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Valiyeva S, Tiso D, Cerri P, Pisciaroli A, Pietroletti R. Results of medical treatment with psyllium, lactobacillus, and tryptophan (Plurilac® Trio) in obstructive defecation syndrome. Front Surg 2024; 11:1361049. [PMID: 38650661 PMCID: PMC11033349 DOI: 10.3389/fsurg.2024.1361049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/26/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction The term "obstructive defecation syndrome" (ODS) describes a complex condition characterized by defecatory disorders. Such a condition represents a significant proportion of patients, which is estimated to be up to 30% of patients affected by chronic constipation. Presently, a broad agreement has been reached on diagnostic studies, whereas the choice of treatment that aims to improve the quality of life and/or correct the prevalent abnormalities or all anatomical abnormalities remains controversial. Methods This was a retrospective cohort study on 174 patients out of a total of 232 with ODS who were observed in a specialized university unit of surgical coloproctology between 2018 and 2022. Clinical assessment included examining the values of the Agachan-Wexner constipation score and Patient Assessment of Constipation (PAC)-quality of life (QoL) scores, a full digital anorectal examination, anoscopy, RX defecography, and a urogynecological consultation; a functional anorectal test, an endoanal ultrasound, and colonoscopy were performed in select patients. The patients were reevaluated after an 8-10-week course of medical treatment based on a high-fiber diet and fluid intake and 6 g of psyllium combined with lactobacillus and tryptophan b.i.d. The results were analyzed by means of the Wilcoxon rank-sum test, comparing pretreatment scores with the results at the first follow-up visit. Results After 8-10 weeks of conservative treatment, 128 patients declared full satisfaction, 29 reported moderate satisfaction, and 17 (9.7%) declared no improvement. Among these 17, there were 5 patients with paradoxical puborectal contractions. The value of the Agachan-Wexner constipation score after treatment decreased from the pretreatment Agachan-Wexner constipation score mean value of 23.4 ± 3.7 (mean ± SD range 15-27) to a mean value of 5.3 ± 0.7 (range 3-8, p < 0.001). The quality of life improved, as shown by the PAC-QoL score, indicating great improvement in social relationships. Conclusions Given the benefits of conservative therapies, they represent a cornerstone in the treatment of ODS, a complex disorder. Diet and bulking agents are mandatory forms of treatment prior to making any surgical attempt, also considering the fact that the psychosomatic component of ODS is an essential prerequisite to match patient expectations.
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Affiliation(s)
- Sayali Valiyeva
- Department of Applied Clinical and Biotechnological Sciences, University of L’Aquila, L'Aquila, Italy
| | - Domenico Tiso
- Clinical Nutrition, “Villa Maria” Hospital, Rimini, Italy
| | - Paolo Cerri
- General Surgery Department, Val Vibrata Hospital, Sant’Omero, Italy
| | | | - Renato Pietroletti
- Department of Applied Clinical and Biotechnological Sciences, University of L’Aquila, L'Aquila, Italy
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Mihara H, Uchida K, Watanabe Y, Nanjo S, Sakumura M, Motoo I, Ando T, Minemura M, Muhammad JS, Yamamoto H, Itoh F, Yasuda I. Colonic TRPV4 overexpression is related to constipation severity. BMC Gastroenterol 2023; 23:13. [PMID: 36639736 PMCID: PMC9838009 DOI: 10.1186/s12876-023-02647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic constipation is prevalent and involves both colon sensitivity and various changes in intestinal bacteria, particularly mucosa-associated microflora. Here we examined regulatory mechanisms of TRPV4 expression by co-culturing colon epithelial cell lines with intestinal bacteria and their derivatives. We also investigated TRPV4 expression in colon epithelium from patients with constipation. METHODS Colon epithelial cell lines were co-cultured with various enterobacteria (bacterial components and supernatant), folate, LPS, or short chain fatty acids. TRPV4 expression levels and promoter DNA methylation were assessed using pyrosequencing, and microarray network analysis. For human samples, correlation coefficients were calculated and multiple regression analyses were used to examine the association between clinical background, rectal TRPV4 expression level and mucosa-associated microbiota. RESULTS Co-culture of CCD841 cells with P. acnes, C. perfringens, or S. aureus transiently decreased TRPV4 expression but did not induce methylation. Co-culture with clinical isolates and standard strains of K. oxytoca, E. faecalis, or E. coli increased TRPV4 expression in CCD841 cells, and TRPV4 and TNF-alpha expression were increased by E. coli culture supernatants but not bacterial components. Although folate, LPS, IL-6, TNF-alpha, or SCFAs alone did not alter TRPV4 expression, TRPV4 expression following exposure to E. coli culture supernatants was inhibited by butyrate or TNF-alphaR1 inhibitor and increased by p38 inhibitor. Microarray network analysis showed activation of TNF-alpha, cytokines, and NOD signaling. TRPV4 expression was higher in constipated patients from the terminal ileum to the colorectum, and multiple regression analyses showed that low stool frequency, frequency of defecation aids, and duration were associated with TRPV4 expression. Meanwhile, incomplete defecation, time required to defecate, and number of defecation failures per 24 h were associated with increased E. faecalis frequency. CONCLUSIONS Colon epithelium cells had increased TRPV4 expression upon co-culture with K. oxytoca, E. faecalis, or E. coli supernatants, as well as TNFα-stimulated TNFαR1 expression via a pathway other than p38. Butyrate treatment suppressed this increase. Epithelial TRPV4 expression was increased in constipated patients, suggesting that TRPV4 together with increased frequency of E. faecalis may be involved in the pathogenesis of various constipation symptoms.
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Affiliation(s)
- Hiroshi Mihara
- grid.267346.20000 0001 2171 836XCenter for Medical Education and Career Development, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan ,grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Kunitoshi Uchida
- grid.418046.f0000 0000 9611 5902Department of Physiological Science and Molecular Biology, Fukuoka Dental College, Fukuoka, Japan
| | - Yoshiyuki Watanabe
- Department of Internal Medicine, Kawasaki Rinko General Hospital, Kawasaki, Japan ,grid.412764.20000 0004 0372 3116Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sohachi Nanjo
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Miho Sakumura
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Iori Motoo
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Takayuki Ando
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Masami Minemura
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Jibran Sualeh Muhammad
- grid.412789.10000 0004 4686 5317Department of Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Hiroyuki Yamamoto
- grid.26999.3d0000 0001 2151 536XDepartment of Bioinformatics, St. Marianna University Graduate School of Medicine, Kawasaki, Japan
| | - Fumio Itoh
- grid.412764.20000 0004 0372 3116Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ichiro Yasuda
- grid.267346.20000 0001 2171 836XDepartment of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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Jiang Y, Wang Y, Wang M, Lin L, Tang Y. Clinical significance and related factors of rectal hyposensitivity in patients with functional defecation disorder. Front Med (Lausanne) 2023; 10:1119617. [PMID: 36895717 PMCID: PMC9988933 DOI: 10.3389/fmed.2023.1119617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/26/2023] [Indexed: 02/23/2023] Open
Abstract
Background Rectal hyposensitivity (RH) is not uncommon in patients with functional defecation disorder (FDD). FDD patients with RH are usually unsatisfied with their treatment. Aims The aim of this study was to find the significance of RH in patients with FDD and the related factors of RH. Methods Patients with FDD first completed clinical questionnaires regarding constipation symptoms, mental state, and quality of life. Then anorectal physiologic tests (anorectal manometry and balloon expulsion test) were performed. Rectal sensory testing (assessing rectal response to balloon distension using anorectal manometry) was applied to obtain three sensory thresholds. Patients were separated into three groups (non-RH, borderline RH, and RH) based on the London Classification. The associations between RH and clinical symptoms, mental state, quality of life, and rectal/anal motility were investigated. Results Of 331 included patients with FDD, 87 patients (26.3%) had at least one abnormally elevated rectal sensory threshold and 50 patients (15.1%) were diagnosed with RH. Patients with RH were older and mostly men. Defecation symptoms were more severe (p = 0.013), and hard stool (p < 0.001) and manual maneuver (p = 0.003) were more frequently seen in the RH group. No difference in rectal/anal pressure was found among the three groups. Elevated defecatory desire volume (DDV) existed in all patients with RH. With the number of elevated sensory thresholds increasing, defecation symptoms got more severe (r = 0.35, p = 0.001). Gender (male) (6.78 [3.07-15.00], p < 0.001) and hard stool (5.92 [2.28-15.33], p < 0.001) were main related factors of RH. Conclusion Rectal hyposensitivity plays an important role in the occurrence of FDD and is associated with defecation symptom severity. Older male FDD patients with hard stool are prone to suffer from RH and need more care.
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Affiliation(s)
- Ya Jiang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Meifeng Wang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yurong Tang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
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Cap-assisted endoscopic sclerotherapy is effective for rectal mucosal prolapse associated outlet obstructive constipation. Arab J Gastroenterol 2022:S1687-1979(22)00087-9. [DOI: 10.1016/j.ajg.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/09/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
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Transcutaneous Electrical Acustimulation Improves Irritable Bowel Syndrome With Constipation by Accelerating Colon Transit and Reducing Rectal Sensation Using Autonomic Mechanisms. Am J Gastroenterol 2022; 117:1491-1501. [PMID: 35973183 DOI: 10.14309/ajg.0000000000001882] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/14/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Slow colon transit and visceral hypersensitivity are recognized as major pathophysiological mechanisms in irritable bowel syndrome with constipation (IBS-C). However, there is a lack of therapies targeting both abdominal pain and colonic motility. This study was designed to investigate the long-term effects and possible mechanisms of transcutaneous electrical acustimulation (TEA) in patients with IBS-C. METHODS Fifty-two patients with IBS-C were randomized into 2 groups: daily TEA for 4 weeks (n = 26) and daily sham-TEA for 4 weeks (n = 26). The number of complete spontaneous bowel movements per week (CSBMs/week, primary outcome), Irritable Bowel Syndrome Severity Scoring System, Patient Assessment of Constipation Quality of Life, visual analog scale (VAS) pain score, colonic transit time, and anorectal physiology were evaluated before treatment and at the end of the treatment. Colonic transit was assessed with radiopaque markers. Electrocardiograms were recorded for assessing autonomic functions. RESULTS (i) TEA improved constipation and abdominal pain. After the treatment, the number of CSBMs/week during the last week in the TEA group was higher than that in the sham-TEA group (3.5 ± 1.6 vs 2.3 ± 0.6, P = 0.002). Similar effects were also noted in the visual analog scale pain score ( P = 0.002) and Irritable Bowel Syndrome Severity Scoring System score ( P = 0.025). In addition, there was a significant improvement in the quality of life of patients with constipation. The Patient Assessment of Constipation Quality of Life total score was significantly decreased in the TEA group ( P = 0.004). (ii) Compared with sham-TEA, TEA improved colon transit ( P = 0.002) and increased the threshold of rectal sensation (desire to defecate, P = 0.004; maximum tolerability, P < 0.001). (iii) TEA increased vagal activity, compared with sham-TEA ( P < 0.05); at the end of the treatment, the vagal activity was significantly correlated with colon transit and the CSBMs/week. DISCUSSION TEA improves constipation and symptoms of IBS by accelerating colon transit and reducing rectal sensation, possibly mediated by using the autonomic mechanisms.
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Xiao Y, Xu F, Lin L, Chen JD. Transcutaneous Electrical Acustimulation Improves Constipation by Enhancing Rectal Sensation in Patients With Functional Constipation and Lack of Rectal Sensation. Clin Transl Gastroenterol 2022; 13:e00485. [PMID: 35347091 PMCID: PMC9132522 DOI: 10.14309/ctg.0000000000000485] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/15/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Reduced rectal sensation is involved in the pathophysiology of constipation. The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) at acupuncture point ST36 on constipation and rectal sensation as well as autonomic functions in patients with constipation and reduced rectal sensation. METHODS In an acute study, anorectal motility and sensation tests were performed in constipation patients (N = 53) who were treated with TEA at ST36 or sham points. In a chronic study, patients (N = 18) underwent 2 weeks of TEA or sham-TEA in a crossover design. RESULTS Chronic TEA increased spontaneous bowel movements (3.72 vs 2.00 per week with sham-TEA, P < 0.0001) and significantly reduced constipation symptoms and increased quality of life in comparison with sham-TEA (P < 0.05). Acute TEA reduced the sensation threshold in response to rectal distention for the urge of defecation and maximum tolerable volume (P < 0.05, vs baseline); chronic TEA reduced the sensation thresholds for first sensation and desire of defecation, and decreased the threshold volume to an elicit rectal anal inhibitory reflex (P < 0.05). Both acute and chronic TEA increased parasympathetic activity (P < 0.05). DISCUSSION TEA at ST36 improves chronic constipation by enhancing rectal sensation possibly mediated by the reinforcement of parasympathetic activity in patients with functional constipation and reported lack/absence of rectal sensation.
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Affiliation(s)
- Ye Xiao
- Division of Gastroenterology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Division of Gastroenterology, Xuzhou Medical University, Xuzhou, China
| | - Feng Xu
- Division of Gastroenterology, Yinzhou Hospital Affiliated to Medical School of Ningbo, University, Ningbo, China
| | - Lin Lin
- Division of Gastroenterology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiande D.Z. Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Neshatian L, Williams MJOU, Quigley EM. Rectal Distension Increased the Rectoanal Gradient in Patients with Normal Rectal Sensory Function. Dig Dis Sci 2021; 66:2345-2352. [PMID: 32761289 DOI: 10.1007/s10620-020-06519-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/23/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Frequent observation of abnormal manometric patterns consistent with dyssynergia in healthy volunteers has warranted the need for reassessment of the current methods to enhance the diagnostic value of anorectal manometry in functional defecatory disorders. Whether rectal distention at simulated evacuation will affect anorectal pressure profile and increase rectoanal gradient is not known. METHODS One hundred and eight consecutive patients with chronic constipation, 93 females, median age 53 years (interquartile range: 40-65), were studied. Simulated evacuation was performed firstly with empty balloon and subsequently after balloon distention to 50 and 100 ml. Anorectal pressures were compared. We also performed subgroup analysis in relation to outcome of balloon expulsion test (BET). In addition, we studied the effect of rectal distension on the rectoanal pressure gradient with respect to rectal sensory function. RESULTS Rectal balloon distension at simulated evacuation improved rectoanal gradient and decreased the rate of dyssynergia during high-resolution anorectal manometry. In subgroup analysis, the increase in rectoanal gradient and correction of dyssynergia with rectal distension was limited to the patients who had normal BET and normal rectal sensory function. Rate of anal relaxation, residual anal pressures, and rectoanal gradient were significantly different between patients with and without normal BET at 50 ml of rectal distension. Rectoanal gradient recorded only after rectal distension, along with BMI and maximum tolerable volumes, could predict BET results independently in patients with chronic constipation. CONCLUSIONS Rectal distension during simulated evacuation will affect the anorectal pressure profile. Increase in rectoanal gradient and correction of dyssynergia was only significant in patients with normal rectal sensory function and normal BET.
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Affiliation(s)
- Leila Neshatian
- Lynda K and David M Underwood Center for Digestive Disorders Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, 6550 Fannin St Suite 1201, Houston, TX, 77030, USA.
- Stanford University, 430 Broadway, Pavilion C, 3rd floor, Redwood City, CA, 94063, USA.
| | - Mary-Jane O U Williams
- Department of Internal Medicine, Sunrise Health GME Consortium, Mountain View Hospital, Las Vegas, NV, USA
| | - Eamonn M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, 6550 Fannin St Suite 1201, Houston, TX, 77030, USA
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8
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Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil 2021; 33:e14050. [PMID: 33263938 DOI: 10.1111/nmo.14050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting. PURPOSE This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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Affiliation(s)
- S Mark Scott
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam D Farmer
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Institute of Applied Clinical Science, University of Keele, Keele, UK
| | - Philip G Dinning
- College of Medicine and Public Health, Flinders Medical Centre, Flinders University & Discipline of Gastroenterology, Adelaide, SA, Australia
| | - Emma V Carrington
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Gastroenterology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karen Nugent
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Clinical Impact of Rectal Hyposensitivity: A Cross-Sectional Study of 2,876 Patients With Refractory Functional Constipation. Am J Gastroenterol 2021; 116:758-768. [PMID: 33982946 DOI: 10.14309/ajg.0000000000001039] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Normal bowel function requires intact sensory pathways. Diminished rectal sensation (rectal hyposensitivity [RH]) is associated with constipation, although its clinical importance remains unclear. METHODS Consecutive patients (aged 18-80) attending a tertiary center (2004-2016) for investigation of refractory functional constipation (Rome IV core criteria defined, applied post hoc) were included. Patients completed a clinical symptom questionnaire and underwent anorectal physiologic investigations, including rectal sensory testing (balloon distension) to determine 3 well-established sensory thresholds. Multivariate regression analyses were performed to evaluate associations between RH, symptomology, and allied physiologic investigations. RESULTS Of 2,876 patients meeting inclusion criteria, 722 (25%) had RH based on ≥1 elevated sensory thresholds (0: n = 2,154 [74.9%]; 1: n = 327 [11.4%]; 2: n = 209 [7.3%]; and 3: n = 186 [6.5%]). A linear relationship existed between increasing number of elevated sensory thresholds and constipation severity (Cleveland Clinic constipation score: mean difference per threshold [95% confidence interval] 0.69 [0.48-0.90]; P < 0.001). Several symptoms were significantly (P < 0.05) associated with RH including: infrequent defecation (odds ratio 1.29 [1.17-1.42]), painful evacuation (1.15 [1.05-1.27]), prolonged toileting (1.14 [1.05-1.24]), and digitation or enema use (1.18 [1.08-1.30]). On defecography, a "functional" evacuation disorder was also associated with RH (1.37 [1.25-1.50], P < 0.001), as was megarectum (2.52 [2.08-3.05], P < 0.001). DISCUSSION RH occurs in 25% of patients with refractory functional constipation. Increased number of elevated sensory thresholds is associated with more severe constipation phenotype. These data, in the largest study to date, provide for the first time evidence to show that RH is a major pathophysiologic mechanism in constipation, with recognized clinical impact (http://links.lww.com/AJG/B765).(Equation is included in full-text article.).
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Ohkubo H, Takatsu T, Yoshihara T, Misawa N, Ashikari K, Fuyuki A, Matsuura T, Higurashi T, Yamamoto K, Matsumoto H, Odaka T, Lembo AJ, Nakajima A. Difference in Defecation Desire Between Patients With and Without Chronic Constipation: A Large-Scale Internet Survey. Clin Transl Gastroenterol 2020; 11:e00230. [PMID: 32858571 PMCID: PMC7455223 DOI: 10.14309/ctg.0000000000000230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Defecation desire (DD) is an important physiological component of normal defecation. However, knowledge of DD in the general population and in individuals with chronic constipation (CC) is lacking. We aimed to assess the prevalence of DD in the general population and individuals with CC and to understand the impact of treatment on DD among individuals with CC. METHODS We conducted an online questionnaire survey targeting the Japanese general population in 2019. DD was reported as never, rarely, usually, or always. Individuals who self-reported constipation and met the Rome IV criteria for functional constipation but did not for irritable bowel syndrome were included in the CC group, while the same number of age-/sex-matched controls who met neither functional constipation nor irritable bowel syndrome criteria was included in the non-CC group. Individuals who reported DD as rarely or never were defined as having loss of DD (LODD). RESULTS Of the 20,986 participants, 2,587 were included in the CC group (12.3%). LODD was significantly higher in the CC individuals than in the non-CC controls (57.4% vs 8.3%, respectively, P < 0.001, odds ratio 14.84 [95% confidence interval 12.65-17.42]). Satisfaction with treatment for constipation was lower in individuals with persistent LODD (25.9%) compared with those with improved LODD (56.5%) on treatment (P < 0.001, odds ratio 2.48 [1.39-4.43]). DISCUSSION LODD is common in CC and is associated with decreased satisfaction to treatment. Greater attention should be paid to DD when treating patients with CC.
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Affiliation(s)
- Hidenori Ohkubo
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Tomohiro Takatsu
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Tsutomu Yoshihara
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Noboru Misawa
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Keiichi Ashikari
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Akiko Fuyuki
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Tetsuya Matsuura
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Takuma Higurashi
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan;
| | | | | | - Anthony J. Lembo
- Gastroenterology, Beth Israel Deaconess Med Ctr, Boston Massachusetts, USA.
| | - Atsushi Nakajima
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan;
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Transcutaneous Neuromodulation at ST36 (Zusanli) is More Effective than Transcutaneous Tibial Nerve Stimulation in Treating Constipation. J Clin Gastroenterol 2020; 54:536-544. [PMID: 30720579 DOI: 10.1097/mcg.0000000000001184] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND GOALS Combined transcutaneous neuromodulation (TN) at acupoint ST36 (Zusanli) and TN at the posterior tibial nerve (PTN) has been reported effective in treating functional constipation. This study was designed to compare the effectiveness of TN between these 2 points. MATERIALS AND METHODS Eighteen functional constipation patients (M/F: 9/9) were recruited to participate in a cross-over study with a 2-week TN at ST36 and a 2-week TN at PTN. A bowel movement diary, and the questionnaires of Patient Assessment of Constipation Symptom (PAC-SYM) and Constipation Quality of Life (PAC-QoL) were completed; anorectal manometry and spectral analysis of heart rate variability for assessing the autonomic function were performed. RESULTS (1) Both TN at ST36 and TN at PTN improved constipation-related symptoms (PAC-SYM scores on pre-TN vs. post-TN: 1.4±0.1 vs. 0.6±0.1 for ST36, 1.4±0.1 vs. 0.9±0.1 for PTN, both P≤0.001). (2) TN at ST36, but not TN at PTN, increased the number of weekly spontaneous bowel movements (0.9±0.2 pre-TN vs. 3.5±0.7 post-TN, P<0.001) and decreased the total PAC-QoL score. TN at ST36 was more potent than TN at PTN in improving the PAC-SYM score (decrement 0.8±0.1 vs. 0.5±0.1, P<0.05). (3) TN at ST36 rather than TN at PTN resulted in a reduction in sensation thresholds, including rectal distention for urge (134.1±14.3 mL pre-TN vs. 85.6±6.5 mL post-TN, P<0.01) and maximum tolerance (P<0.05). (4) Both TN at ST36 and TN at PTN significantly increased vagal activity and decreased sympathetic activity (P<0.05). CONCLUSIONS TN at ST36 is more potent than TN at PTN in treating constipation and improving constipation-related symptoms and rectal sensation.
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Abstract
PURPOSE OF REVIEW To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research. RECENT FINDINGS The diagnostic utility of high-resolution anorectal manometry (ARM), which has emerged as a promising tool for the diagnosis of defecatory dysfunction, appears to be questionable in differentiating disease from normal physiology. There also seems to be discrepancy between results of various tests of anorectal function in the diagnosis of defecatory dysfunction. New revisions in diagnostic criteria for defecatory dysfunction by Rome IV consortium, may enhance its diagnostic yield. Biofeedback remains to be the most effective evidence-based treatment option for patients with defecatory dysfunction. Anorectal pressure profile cannot predict or mediate the success of biofeedback. Biofeedback may improve the symptoms through central effects. SUMMARY Despite the advances in the ARM and defecography techniques, no one test has been able to be considered as the 'gold standard' for diagnosis of defecatory dysfunction. The mechanism of action of biofeedback in defecatory dysfunction remains poorly understood.
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