The Effects of Conservative Treatment for Constipation on Symptom Severity and Quality of Life in Community-Dwelling Adults

Novel sensory trigger for gastrocolonic response

BACKGROUND

Gastrocolonic response (GCR) is a physiologic increase in motor activity of the colon following meal ingestion. The presence of GCR, in colonic manometry (CM) studies, is used as a marker of normal colonic motor activity. Our aim was to investigate whether GCR could be induced by sensory stimulation (visual or olfactory) prior to food ingestion, and to describe the characteristics of patients with this response.

METHODS

We prospectively marked time of meal presence and initiation on CM tracings of patients with idiopathic constipation. We reviewed electronic medical records and normal CM studies. Presence of sensory GCR was defined as an increase by at least 25% of the baseline motility index (MI) after exposure to meal, prior to food ingestion. Manometry characteristics of patients with a sensory GCR response were compared to those without.

KEY RESULTS

Eighty-nine patients, (47% females, median age 9 years) met the inclusion criteria. Forty-seven (52.8%) patients had a positive sensory GCR. This cohort had a higher proportion of postprandial GCR (93.6% vs. 76.2%, p-value = 0.02) and lower fasting MI (2.08 mm Hg vs. 3.54 mm Hg, p < 0.01). Thirteen (14.6%) patients who had no postprandial GCR had higher baseline MI (median of 3.69 vs. 2.46 mm Hg, p < 0.05).

CONCLUSIONS & INFERENCES

Visualizing or smelling food resulted in a significant increase in baseline MI in more than 50% of patients. Our findings propose a novel, alternate pathway that can induce GCR. This central sensory pathway may have clinical relevance in the diagnosis and management of patients with colonic dysmotility.

Management of Opioid-induced Constipation in Older Adults

Opioid-induced constipation (OIC) is a common condition in older adults who may not be responsive to traditional laxative therapy. OIC is defined as new or worsening constipation symptoms that occur with initiation of or altering the dose of opioid analgesia. For adult patients with OIC and noncancer pain, we recommend considering nonpharmacologic interventions (eg, dietary measures, increased physical activity, and biofeedback training) and over-the-counter laxatives, followed by prescription opioid receptor antagonists (methylnaltrexone, naloxegol, and naldemedine) if traditional over-the-counter laxatives fail. Other options may include lubiprostone, linaclotide, plecanatide, and prucalopride; however, these are not indicated for OIC specifically or studied in older adults. Because of the complex nature of absorption, distribution, metabolism, and excretion in the aging population, all agents used to treat OIC must be evaluated individually and reevaluated as patients continue to age. This review will serve as a guide to managing OIC in older adults.

Gastrocolonic Response

PURPOSE OF REVIEW

The gastrocolonic response (GCR), is a physiologic increase in motor activity of the colon, which usually occurs within minutes following meal ingestion. Over the years several triggers that provoke GCR were recognized including gastric dilation, caloric intake, and fat component of the meal. The response is mediated by the vagal nerve and neurohumoral mechanisms, and it can be modified by several pharmacological factors. Assessment of GCR is part of high-resolution colonic manometry studies, performed in patients with suspected colonic dysmotility. This review highlights the physiologic basis of GCR as well as its clinical and diagnostic features and implementation in variable pathological conditions and clinical practice.

RECENT FINDINGS

GCR has a role in patients with constipation, diabetes, dumping syndrome, bowel hyper and hypomotility and irritable bowel syndrome. Novel sensory triggers for GCR were recently recognized. GCR is a physiological response which is evaluated during colonic manometry studies. Abnormal GCR is a marker of an underlying pathology, which can provide a potential target for treatment.

Urinary Tract Infection in Parkinson's Disease

Urinary tract infection (UTI) is a common precipitant of acute neurological deterioration in patients with Parkinson's disease (PD) and a leading cause of delirium, functional decline, falls, and hospitalization. Various clinical features of PD including autonomic dysfunction and altered urodynamics, frailty and cognitive impairment, and the need for bladder catheterization contribute to an increased risk of UTI. Sepsis due to UTI is a feared consequence of untreated or undertreated UTI and a leading cause of morbidity in PD. Emerging research suggests that immune-mediated brain injury may underlie the pathogenesis of UTI-induced deterioration of PD symptoms. Existing strategies to prevent UTI in patients with PD include use of topical estrogen, prophylactic supplements, antibiotic bladder irrigation, clean catheterization techniques, and prophylactic oral antibiotics, while bacterial interference and vaccines/immunostimulants directed against common UTI pathogens are potentially emerging strategies that are currently under investigation. Future research is needed to mitigate the deleterious effects of UTI in PD.

Surgical treatment of idiopathic megarectum in constipated children

BACKGROUND

Chronic constipation in children is associated with primary megarectum. This study investigated outcomes of surgical treatment of idiopathic megarectum in children.

METHODS

This retrospective comparative study included 52 children with idiopathic megarectum (mean age, 9.4 ± 1.7 years) treated from 2007 to 2016. Patients were divided into 2 groups. Group 1 included 23 patients who underwent a Soave pull-through operation. Group 2 included 29 children who underwent laparoscopic low anterior resection with endorectal stapled anastomosis using laparoscopic ultrasound guidance. All patients had clinical and laboratory evaluations with anorectal manometry, colonoscopy and contrast enema studies.

RESULTS

Six patients (26.1%) in Group 1 and one (3.5%) in Group 2 experienced anastomosis leakage requiring colostomy (χ² = 3.867, P = 0.049). In long-term follow-up, 3 children (13.1%) in Group 1 and 2 (6.9%) in Group 2 had ongoing constipation; this difference was not significant. Frequent loose stools with soiling were significantly more common in Group 1 (14 patients; 60.9%) than in Group 2 (4 patients; 13.8%) (χ² = 10.566, P = 0.001).

CONCLUSIONS

Our experience shows that laparoscopic video-assisted low anterior resection of the colon with endorectal stapled anastomosis under laparoscopic ultrasound guidance to determine the level of colon resection is the better operation then Soave for children with idiopathic megarectum and chronic constipation. This approach provides good functional results and reduces complications.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Constipation in Elderly Patients with Noncancer Pain: Focus on Opioid-Induced Constipation

Constipation is a common and often debilitating condition in the elderly, which may be caused by underlying disease conditions, structural abnormalities in the bowel, and a variety of medications such as anticholinergics, antidepressants, and opiates. In this review, we focus on opioid-induced constipation (OIC), which is often underrecognized and undertreated in the elderly. When opioid therapy is initiated, healthcare providers are encouraged to evaluate risk factors for the development of constipation as part of a thorough patient history. To this end, the patient assessment should include the use of validated instruments, such as the Bristol Stool Scale and Bowel Function Index, to confirm the diagnosis and provide a basis for evaluating treatment outcomes. Healthcare providers should use a stepwise approach to the treatment of OIC in the elderly. Conventional laxatives are a first-line option and considered well tolerated with short-term use as needed; however, evidence is lacking to support their effectiveness in OIC. Moreover, because of the risk of adverse events and other considerations, such as chewing difficulties and swallowing disorders, conventional oral laxatives may be inappropriate for the treatment of OIC in the elderly. Thus, the availability of new pharmacologic agents such as the peripherally acting µ-opioid receptor antagonists methylnaltrexone and naloxegol, which target the underlying causes of OIC, and the secretagogue lubiprostone may provide more effective treatment options for elderly patients with OIC.

Categorization of Functional Constipation in Traditional Persian Medicine: A Descriptive Study

Functional constipation (FC) is a common clinical condition without any specific physiological causes with economic cost and adverse effects on patients' quality of life. The present study aimed to evaluate the causes of nonobstructive constipation in traditional Persian medicine and its prevalence in patients with functional constipation by content analysis of patients' interviews and clinical exams. In this study, almost two thirds of the patients with functional constipation had mild to severe cold distemperament of the gastrointestinal system, and in almost half of them the signs and symptoms were compatible with dry distemperament of the gastrointestinal. This observational study reports high prevalence of gastrointestinal system distemperaments in patients with functional constipation. According to the results, we can consider the proposed management of distemperaments in traditional Persian medicine for functional constipation treatment and pathophysiology explanation. This project is a novel study that provides the opportunity for investigating the epidemiological aspects of these distemperaments and their relationship with functional constipation.

The measures to evaluate constipation: a review article

The aim of this study was to review current constipation assessment scales and clarify (a) the nature of extant measurements and (b) the criteria contained in the measures. A review of relevant literature from inception to 2011 was extracted from PubMed, CINHAL, Cochrane, and MEDLINE databases by searching for the following key words: constipation, scale, measurement, questionnaire, and assessment. Eight scales were reviewed. The scales under review measured constipation from a subjective viewpoint. All measurement criteria included in 8 of the scales were arranged into 51 items and divided into 5 categories. Categories used to measure the severity of constipation were defecation difficulties, abdominal symptoms, emotional effects of constipation, self-treatment strategies, and individual characteristics. Original and suitable scales for the measurement of the severity of constipation based on the review were the Patient-Assessment of Constipation Symptoms scale and the Constipation Assessment Scale. The Patient-Assessment of Constipation Symptoms scale and the Constipation Assessment Scale are reliable, valid, original, and suitable scales to measure the severity of constipation for subjects.

The effect of lifestyle modification on severity of constipation and quality of life of elders in nursing homes at Ismailia city, Egypt

Background:

Constipation has a significant impact on the quality of life (QOL). Lifestyle modification is widely accepted and recommended by experts as first-line therapy.

Aim:

This study aimed at using education on lifestyle modification to improve the QOL of the elderly in nursing homes suffering from functional constipation (FC).

Materials and Methods:

This study was conducted in nursing homes in Ismailia city, Egypt. It involved 23 elderly patients suffering from FC, who were randomly selected according to the sample equation. They fulfilled the inclusion criteria of being ≥60 years age and according to Rome II criteria. Participants completed personal characteristics and lifestyle questionnaire, the Patient Assessment of Constipation Symptom questionnaire (PAC-SYM) to assess the severity of symptoms, and the Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL) to assess pre- and post-intervention. The intervention was conducted in three sessions, of 30 min each, 2 weeks apart using group discussions to educate the sample about dietary pattern, fluid intake, regular physical activity, and the use of laxatives. Statistical analysis: Data were analyzed using a statistical package for social sciences (SPSS version 20).

Results:

The lifestyle modification education on constipation significantly reduced the severity of symptoms as measured by PAC-SYM, including its total score and subscores (P < 0.001). It also improved the QOL of elderly suffering from constipation as measured by PAC-QOL and reduced total scores of dissatisfaction (P = 0.001) with the exception of the psychosocial subscale. It also significantly increased the satisfaction subscale of PAC-SYM (P < 0.001).

Conclusion:

Education on lifestyle modification leads to an improvement in the severity of the symptoms of constipation and the QOL of the elderly in nursing homes.

Increased fluid intake is associated with bothersome bowel symptoms among women with urinary incontinence

OBJECTIVES

To determine the association between the type and volume of fluid intake and bowel symptoms in women with urinary incontinence. We hypothesize that a lower volume of fluid intake would be associated with greater straining with bowel movements in women with urinary incontinence.

METHODS

We performed a cross-sectional study of 256 women presenting with complaints of urinary incontinence from 2009 to 2010. Data on fluid intake, fluid intake behavior, urinary and bowel symptoms were collected using validated questionnaires. The relationship between quartiles of total daily fluid intake and bowel symptoms was analyzed.

RESULTS

The behavior of restricting fluid intake was reported by 32% of the women. Increasing quartiles of total daily fluid intake was significantly associated with greater bother from straining with bowel movements (P = 0.04). Women with no bother from straining with bowel movements had significantly lower median daily fluid intake (2839 mL) than women with quite a bit of bother (3312 mL; P = 0.01). The association between the volume of fluid intake and straining with bowel movements persisted after controlling for age, body mass index, history of prolapse or incontinence surgery, and stage of prolapse (P < 0.05). There was no association between caffeinated fluid intake and any bowel symptom or between the behavior of restricting fluid intake and any bowel symptom.

CONCLUSION

In women with urinary incontinence, higher volume of total fluid intake is reported by women with greater straining with bowel movements. The behavior of fluid restriction is not associated with bothersome bowel symptoms.