Chronic Constipation in the Community: A National Survey of Australian Adults

The prevalence of constipation in adult psychiatric out-patients on clozapine treatment at a regional public hospital in Hong Kong

OBJECTIVE

To determine the occurrence of constipation in local patients on clozapine treatment, and to compare the demographical and clinical characteristics of patients on clozapine treatment with or without constipation.

METHODS

This is a cross-sectional, observational study. All adult psychiatric out-patients on clozapine treatment attending follow-up at a regional hospital were recruited for clinical interview and medical record review. The Enhanced Asian Rome III Questionnaire (EAR3Q) was used to define patients with constipation. The Bristol Stool Form Scale (BSFS) was used to assess stool form. The Brief Psychiatric Rating Scale-Anchored (BPRS-A) was used to measure psychiatric symptoms. The Brief Medication Adherence Scale (BMAS) was used to assess treatment adherence. Logistic regression was conducted to identify independent associating factors of constipation in patients on clozapine treatment.

RESULTS

The prevalence of constipation in patients on clozapine treatment was 26.3%, (95% CI [21.5%, 31.6%]). Independent associating factors included disorder of psychological development (aOR = 6.98, 95% CI [1.24, 39.18]), anxiety (very mild: aOR = 9.23, 95% CI [2.59, 32.87]; mild: aOR = 2.66, 95% CI [1.26, 5.62]), prescription with combination of laxatives (aOR = 0.40, 95% CI [0.17, 0.95]), and concomitant use of amisulpride (aOR = 2.52, 95% CI [1.09, 5.82]), quetiapine (aOR = 5.92, 95% CI [1.11, 31.56]) and metamucil (aOR = 9.30, 95% CI [1.53, 56.58]).

CONCLUSION

This study examined the prevalence of clozapine-associated constipation in Hong Kong using a validated questionnaire. The identification of independent factors associated with constipation could facilitate better risk stratification and risk modification in clinical practice.

Prevalence and associated factors of chronic constipation among Japanese university students

Background

Chronic constipation (CC) is one of the most frequently reported gastrointestinal disorders in the general population and a prominent problem among university students. The study aimed to evaluate the prevalence and the associated factors of CC among Japanese university students.

Methods

This cross-sectional study was conducted among university students at Hiroshima University, Japan. Students answered the web questionnaire when making a web reservation for the health checkup (April 1 to May 31, 2023). The web questionnaire consisted of four sections, including baseline characteristics, lifestyle factors, family history of CC, and three scales to assess depression and eating disorders: the Beck Depression Inventory (BDI), Eating Attitudes Test (EAT)-26 and Bulimic Investigatory Test (BITE). CC was diagnosed using Rome IV criteria. The multivariate logistic regression model was used to determine CC-related factors.

Results

Out of 10,500 individuals who participated in the annual health checkup, 7,496 participants answered the web questionnaire, of whom 5,386 answered all the survey questions. The mean age of the students was 21.1 ± 4.1 years. The male-to-female ratio was 1:1.17. The prevalence of CC was 13.7%. Factors significantly associated with CC in the multivariate model were first-degree family members with CC [Odd ratio (OR): 2.77, 95% confidence interval (CI): 2.31-3.31], severe depression according to BDI scale (OR: 2.59, 95% CI: 1.96-3.43), female sex (OR: 2.00, 95% CI: 1.69-2.36), and short sleep duration of 6 hours or less per day (OR: 1.28, 95% CI: 1.09-1.50). Lack of physical exercise tended to be associated with CC (OR: 1.19, 95% CI: 1.00-1.40).

Conclusions

CC is prevalent among Japanese university students. Significant risk factors for CC included the first-degree family history of CC, severe depression, female sex, and short sleep duration. Lack of physical exercise tended to be associated with CC. This may contribute to implementing suitable education health programs, health care professionals, and public health policies to identify individuals at risk for CC to prevent and treat CC effectively.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

Purpose

A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation.

Methods

The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed.

Results

A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors.

Conclusion

A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Using a footstool does not aid simulated defecation in undifferentiated constipation: A randomized trial

INTRODUCTION

The use of a footstool has been advocated to optimize posture when sitting on the toilet and thus facilitate bowel evacuation. We aimed to assess the alterations in defecatory posture, and the changes in simulated defecation with use of a footstool in patients with constipation.

METHODS

Forty-one patients (female 93%, mean 52 year, SD 14 year) with constipation referred to a tertiary neurogastroenterology unit were enrolled. A bowel questionnaire, Hospital Anxiety and Depression Scale, and Rome questionnaire were administered prior to anorectal manometry. Each patient underwent three rectal balloon expulsion tests in randomized order with no footstool, a 7-inch, and a 9-inch footstool. Additional assessments included angle between spine and femur, and visual analogue scales assessing ease of evacuation, urge to defecate, and discomfort with expulsion.

KEY RESULTS

Defecatory posture was significantly altered by footstool use, with progressive narrowing of the angle between the spine and femur as footstool height increased (p < 0.001 for all comparisons). Compared with no footstool, the use of a footstool was not associated with a change in balloon expulsion time and there was no difference between the two footstool heights. Subjectively, no significant change was identified in any of the three perceptions of balloon expulsion between no footstool and footstool use.

CONCLUSIONS AND INFERENCES

Although the use of a footstool led to changes in defecatory posture, it did not improve subjective or objective measures of simulated defecation in patients with undifferentiated constipation. Therefore, the recommendation for its use during evacuation cannot be applied to all patients with constipation.

Effects of Lactobacillus plantarum P9 Probiotics on Defecation and Quality of Life of Individuals with Chronic Constipation: Protocol for a Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Background

Although probiotics have been shown to improve constipation-related symptoms, a clear consensus on the use of probiotics as a constipation-relieving agent has not been reached, which is attributed to the limited available evidence and inconsistent protocols used in existing studies.

Method

A randomized, double-blind, placebo-controlled clinical trial is designed to study the efficiency and possible mechanism of action of probiotics for chronic constipation, in which 200 eligible volunteers with chronic constipation will be randomly assigned to a probiotic group (oral Lactobacillus plantarum P9 probiotic powder, 100 billion colony-forming units (CFUs)/day) or a placebo group. Volunteers, treatment distributors, data collectors, and data analysts will be blinded. The primary outcome is the weekly mean frequency of complete spontaneous bowel movements (CSBMs), and secondary outcomes include weekly mean frequency of CSBMs ≥3, weekly mean frequency of spontaneous bowel movements (SBMs), weekly mean stool appearance score, weekly mean difficulty of passing stool score, weekly percentage of volunteers who use auxiliary measures to assist with defecation (WPUAMA), quality-of-life (QOL) score, emotional status score, gut microbiome, and faecal metabolome. Each outcome measure will be assessed at the time points of preadministration (day 0), administration (day 14 and/or 28), and postadministration (day 42) to identify inter- and intragroup differences. Adverse events will be recorded to evaluate the safety of L. plantarum P9. Discussion. The protocol will provide methodological guidance for other similar studies, avoiding methodological bias and ultimately facilitating the formulation of consensus on the use of probiotics as a constipation-relieving agent. In addition, the results are more comprehensive than those of existing studies and may objectively and scientifically reflect the effectiveness of L. plantarum P9 on constipation. If the expected study findings are obtained, L. plantarum P9, taken as a probiotic, may become a complementary choice for chronically constipated patients. This trial is registered with Chinese Clinical Trial Registry (ChiCTR) (no. ChiCTR2000038396) registered on November 22, 2020, https://www.chictr.org.cn/showproj.aspx?proj=54024.

Global prevalence of functional constipation according to the Rome criteria: a systematic review and meta-analysis

BACKGROUND

Functional constipation is a common functional bowel disorder in the community, which has a varying prevalence across cross-sectional surveys. We did a contemporaneous systematic review and meta-analysis of studies using comparable methodology and all iterations of the Rome criteria to estimate the global prevalence of functional constipation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, and Embase Classic from Jan 1, 1990, to Dec 31, 2020, to identify population-based cross-sectional studies comprising at least 50 participants that reported the prevalence of functional constipation in adults (age 18 years and older) according to Rome I, II, III, or IV criteria. We excluded studies that reported the prevalence of functional constipation in convenience samples. We extracted prevalence estimates of functional constipation from eligible studies, according to the study criteria used to define it. For each study, we extracted data for country; method of data collection; criteria used to define functional constipation; whether the study used the Rome I, II, III, or IV diagnostic questionnaires or approximated these definitions of the condition using another questionnaire; the total number of participants providing complete data; age; the number of participants with the condition; the number of male and female participants; and the number of male and female participants with the condition. We calculated pooled prevalence, odds ratios (OR), and 95% CIs.

FINDINGS

Of 8174 citations evaluated, 45 studies fulfilled the eligibility criteria, representing 80 separate populations and comprising 275 260 participants. The pooled prevalence of functional constipation was 15·3% (95% CI 8·1-24·4, I²=99·4%) in studies using the Rome I criteria, 11·2% (7·9-14·9; I²=99·6%) in studies that used Rome II criteria, 10·4% (6·5-14·9; I²=99·8%) in those that used Rome III criteria, and 10·1% (8·7-11·6; I²=98·2%) when Rome IV criteria were used. Prevalence of functional constipation was higher in women, irrespective of the Rome criteria used (OR 2·40 [95% CI 2·02-2·86] for Rome I, 1·94 [1·46-2·57] for Rome II, and 2·32 [1·85-2·92] for Rome III; no studies using Rome IV criteria reported prevalence by sex). There was significant heterogeneity between studies in all of our analyses, which persisted even when the same criteria were applied and similar methodologies used.

INTERPRETATION

Even when uniform symptom-based criteria are used to define the presence of functional constipation, prevalence varies between countries. Thus, environmental, cultural, ethnic, dietary, or genetic factors can influence reporting of symptoms. Future studies should aim to elucidate reasons for this geographical variability.

FUNDING

None.

Factors associated with laxative use in schizophrenia patients treated with second-generation antipsychotics

The aim of this study was to investigate factors associated with concomitant laxative use among schizophrenia patients discharged on second-generation antipsychotics (SGAs) at two large psychiatric hospitals in Taiwan. Patients with schizophrenia who were discharged between 2006 and 2017 and received SGA monotherapy at discharge were included in the analysis. Multivariate logistic regression was used to identify factors associated with regular laxative use at discharge. Multivariate Cox regression was used to determine the effect of laxative use at discharge on time to rehospitalization within one year. The Cochran-Armitage trend test was used to evaluate whether significant time trends existed for rates of laxative use at discharge during the study period. Among patients discharged on SGAs (n = 11,861), 3,336 (28.1%) also received concomitant laxatives. Advanced age and higher antipsychotic or anticholinergic doses were found to be associated with an increase in laxative use. Among SGAs, clozapine was associated with the highest rate of laxative use, followed by zotepine, quetiapine, olanzapine and risperidone. Additionally, risperidone, amisulpride, aripiprazole, paliperidone and ziprasidone were associated with comparable rates of laxative use. In contrast, sulpiride was least associated with laxative use among all SGAs. Regular laxative use at discharge was found to be significantly associated with psychiatric rehospitalization. Also, rate of laxative use at discharge increased significantly during the study period. Laxative use is common in schizophrenia patients treated with SGAs. For clinically significant constipation, switching to an SGA with a lower risk for constipation, and decreasing the doses of SGAs and anticholinergics should be considered.