Risk of developing colorectal cancer and benign colorectal neoplasm in patients with chronic constipation

Review article: do stimulant laxatives damage the gut? A critical analysis of current knowledge

Stimulant laxatives are well established as first- or second-line treatments for constipation and although they have a reliable therapeutic effect, alleged safety concerns still exist, particularly with long-term use. The potential harmful effects on the gastrointestinal system (including carcinogenicity) of the long-term use of diphenylmethane [bisacodyl, sodium picosulfate (SPS)] and senna stimulant laxatives were assessed in a comprehensive review of the publications identified in literature searches performed in PubMed and Embase up to and including June 2023. We identified and reviewed 43 publications of interest. While stimulant laxatives at supratherapeutic doses have been shown to cause structural alterations to surface absorptive cells in animals and humans, these effects are reversible and not considered clinically relevant. No formal long-term studies have demonstrated morphological changes in enteric neural elements or intestinal smooth muscle with bisacodyl or SPS in humans. Furthermore, there is no convincing evidence that stimulant laxatives are associated with the development of colon cancer, and in fact, chronic constipation itself has been reported to potentially increase the risk of colon cancer, therefore, the use of stimulant laxatives might reduce this risk. Many studies suggesting a possible harmful effect from laxatives were limited by their failure to consider confounding factors such as concomitant neurological disease, metabolic disorders, and age. These findings highlight the lack of evidence for the harmful effects of laxatives on the colon, and thus, the benefits of treatment with stimulant laxatives, even in the long-term, should be reconsidered for the management of patients with constipation.

Derivation and validation of a nomogram incorporating modifiable lifestyle factors to predict development of colorectal adenomas after negative index colonoscopy

This retrospective cohort study aimed to identify baseline patient characteristics involving modifiable lifestyle factors that are associated with the development of colorectal adenomas, and establish and validate a nomogram for risk predictions among high-risk populations with negative index colonoscopy. A total of 83,076 participants who underwent an index colonoscopy at the Tianjin Union Medical Center between 2004 and 2019 were collected. According to meticulous inclusion and exclusion criteria, 249 subjects were enrolled and categorized into the primary and validation cohorts. Based on the primary cohort, we utilized the LASSO-Cox regression and the univariate/multivariate Cox proportional hazards (Cox-PH) regression parallelly to select variables, and incorporated selected variables into two nomogram models established using the multivariate Cox-PH regression. Comparison of the Akaike information criterion and the area under the receiver operating characteristic curve of the two models demonstrated that the nomogram model constituted by four covariates retained by the LASSO-Cox regression, including baseline age, body mass index, physical activity and family history of colorectal cancer (CRC) in first-degree relatives, performed better at predicting adenoma-free survival probabilities. Further validation including the concordance index, calibration plots, decision curve analysis and Kaplan-Meier survival curves also revealed good predictive accuracy, discriminating ability, clinical utility and risk stratification capacity of the nomogram model. Our nomogram will assist high-risk individuals with negative index colonoscopy to prevent colorectal adenoma occurrence and CRC morbidity with improved cost-effectiveness.

The Yield of Colonoscopy in the Evaluation of Constipation: An Age-Based Analysis of Outcome

Background: Chronic constipation, a prevalent gastrointestinal complaint, exhibits rising incidence and diverse clinical implications, especially among the aging population. This study aims to assess colonoscopy performance in chronic constipation across age groups, comprehensively evaluating diagnostic yield and comparing results with average-risk controls. Methods: A retrospective analysis was conducted on 50,578 colonoscopy procedures performed over 12 years, including 5478 constipated patients. An average-risk control group (n = 4100) was included. Data extracted from electronic medical records covered demographics, operational aspects, and colonoscopy findings. The primary outcome measures included the diagnosis rate of colorectal cancer (CRC), polyp detection rate (PDR), and inflammatory bowel disease (IBD) diagnoses in constipated patients versus controls, with age-based and multivariate analyses. Results: Constipated patients exhibiting lower rates of adequate bowel preparation (92.7% vs. 85.3%; p < 0.001) and a lower cecal intubation rate. No significant variances between CRC and PDR were observed between constipated and controls, except for a potential of a slightly elevated CRC risk in constipated patients older than 80 (2.50% vs. 0% in controls; p = 0.07). Multivariate analysis demonstrated, across all age groups, that constipation did not confer an increased risk for CRC or polyp detection. Younger constipated patients exhibited a higher rate of IBD diagnoses (1.7% vs. 0.1% in controls; p < 0.001). Conclusions: Constipation did not confer an increased risk for CRC or polyps, among any age groups, except for a potential signal of elevated CRC risk in patients older than 80; additionally, it was associated with higher rates of IBD in younger patients.

Acacia fiber or probiotic supplements to relieve gastrointestinal complaints in patients with constipation-predominant IBS: a 4-week randomized double-blinded placebo-controlled intervention trial

PURPOSE

To date, no adequate treatment for irritable bowel syndrome with predominant constipation complaints (IBS-C) is available. Fibers with prebiotic properties and probiotic compounds have shown promise in relieving IBS-C-related complaints. We aimed to determine the effects of a 4-week intervention with either an Acacia fiber (AF) with prebiotic properties or a probiotic Bifidobacterium Lactis (BLa80) supplement, compared to a control supplement, on stool pattern, IBS symptoms and Quality of Life (QoL), in IBS-C individuals.

METHODS

A parallel, double-blind, randomized controlled trial involving 180 subjects meeting the ROME IV criteria for IBS-C was conducted. Following a 4-week observation period, subjects received either AF (10 g), Probiotic BLa80 (4 g; 2 × 1011 CFU/g) or a maltodextrin placebo (10 g) daily for 4 weeks. Subjects reported daily information on stool pattern and gastrointestinal complaints. Before and after each 4-week period, questionnaires on symptom severity, constipation symptoms, anxiety and depression and QoL were completed. Stool mass was measured for 5-days before and after the intervention.

RESULTS

Stool frequency significantly improved in the AF and Probiotic BLa80 groups compared to placebo (P < 0.001, P = 0.02, respectively). Probiotic BLa80 showed a significant reduction in IBS symptom severity (P = 0.03), for AF a trend towards decreased constipation symptoms (PAC-SYM, P = 0.10) was observed. No significant changes in stool consistency, stool mass or QoL measures were observed between the AF and Probiotic BLa80 compared to placebo.

CONCLUSION

Daily dietary supplementation with Acacia fiber and probiotic supplements might help IBS-C patients by relieving IBS-related complaints compared to a placebo supplement.

REGISTRATION NUMBER OF CLINICAL TRIAL

The trial is registered at ClinicalTrials.gov: NCT04798417: Study Details | Nutrition to Relieve IBS Constipation | ClinicalTrials.gov.

Sex Difference of Colon Adenoma Pathway and Colorectal Carcinogenesis

Colorectal cancer (CRC) is one of the most common causes of cancer morbidity in both sexes but shows sex differences. First, sex-specific differences in tumor recurrence and survival rates have been reported. For example, the development of CRC is found about 1.5 times higher and 4-8 years earlier in males compared to females, suggesting the protective role of estrogen in the disease. Furthermore, female patients have a higher risk of developing right-sided (proximal) colon cancer than male patients, which is known to have more aggressive clinical character compared to left-sided (distal) colon cancer. That is, left and right CRCs show differences in carcinogenic mechanism, that the chromosomal instability pathway is more common in left colon cancer while the microsatellite instability and serrated pathways are more common in right colon cancer. It is thought that there are sex-based differences on the background of carcinogenesis of CRC. Sex differences of CRC have two aspects, sexual dimorphism (biological differences in hormones and genes) and gender differences (non-biological differences in societal attitudes and behavior). Recently, sex difference of colon adenoma pathway and sexual dimorphism in the biology of gene and protein expression, and in endocrine cellular signaling in the CRC carcinogenesis have been accumulated. In addition, behavioral patterns can lead to differences in exposure to risk factors such as drinking or smoking, diet and physical activity. Therefore, understanding sex/gender-related biological and sociocultural differences in CRC risk will help in providing strategies for screening, treatment and prevention protocols to reduce the mortality and improve the quality of life. In this review, sex/gender differences in colon adenoma pathway and various aspects such as clinicopathological, biological, molecular, and socio-cultural aspects of CRC were described.

Trends in colorectal cancer screening compliance and incidence among 60- to 74-year-olds in China

BACKGROUND

Compliance with colonoscopy among elderly individuals participating in colorectal cancer (CRC) screening programs is unsatisfactory, despite a high detection rate of bowel-related diseases. In this study, our aim was to analyze the impact of risk factors on the trends of compliance and detection rates in colonoscopy among high-risk individuals aged 60-74.

METHODS

A retrospective study was conducted on the high-risk individuals aged 60-74 participating in the 2021 CRC screening program in Tianjin, China. Logistic regression analyses, including both univariate and multivariate analyses, were performed to explore the impact of different risk factors on colonoscopy compliance among the high-risk individuals. Besides, the study investigated the influence of various risk factors on the detection rates of bowel-related diseases among the high-risk individuals who underwent colonoscopy.

RESULTS

A total of 24,064 high-risk individuals were included, and 5478 individuals received a free colonoscopy, with an overall compliance of 22.76%. Among them, the adenoma detection rate was 55.46%. Males and individuals with a positive FIT had high compliance and detection rates for CRC, advanced adenomas (AA), advanced colorectal neoplasia (ACN), and colorectal neoplasm (CN). Individuals aged 70-74 were associated with low compliance but high CRC, ACN, and CN detection rates. Individuals who reported a history of chronic constipation, bloody mucous, and CRC in first-degree relative showed high compliance but no significantwere associated with the detection rates of CRC, AA, and CN.

CONCLUSION

This study reported several risk factors associated with the screening behaviors for CRC. Patterns and trends in CRC, AA, ACN, and CN compliance and detection rates correlate with risk factors.

Lacidophilin tablets alleviate constipation through regulation of intestinal microflora by promoting the colonization of Akkermansia sps

Constipation is a major health problem worldwide that requires effective and safe treatment options. Increasing evidence indicates that disturbances in gut microbiota may be a risk factor for constipation. Administration of lacidophilin tablets shows promising therapeutic potential in the treatment of inflammatory bowel disease owing to their immunomodulatory properties and regulation of the gut microbiota. The focus of this study was on investigating the ability of lacidophilin tablets to relieve constipation by modulating the gut microbiome. Rats with loperamide hydrochloride induced constipation were treated with lacidophilin tablets via intragastric administration for ten days. The laxative effect of lacidophilin tablets was then evaluated by investigating the regulation of intestinal microflora and the possible underlying molecular mechanism. Our results reveal that treatment with lacidophilin tablets increased the intestinal advancement rate, fecal moisture content, and colonic AQP3 protein expression. It also improved colonic microflora structure in the colonic contents of model rats mainly by increasing Akkermansia muciniphila and decreasing Clostridium_sensu_stricto_1. Transcriptome analysis indicated that treatment with lacidophilin tablets maintains the immune response in the intestine and promotes recovery of the intestinal mechanical barrier in the constipation model. Our study shows that lacidophilin tablets improve constipation, possibly by promoting Akkermansia colonization and by modulating the intestinal immune response.

Arecoline alleviated loperamide induced constipation by regulating gut microbes and the expression of colonic genome

This study aimed to investigate the effects of arecoline on constipation by intervening at different times to explore its preventive and therapeutic effects. Symptoms related to constipation, gut microbes, short-chain fatty acid (SCFA) content in the cecum, and gene expression in the colon were measured to examine the effect of arecoline on relieving constipation. The results showed that arecoline intervention alleviated loperamide-induced constipation, as evidenced by significantly shortened intestinal transit time, increased fecal water content, improved small bowel propulsion, and increased defecation frequency. In addition, arecoline significantly reduced the levels of gastrointestinal regulatory peptides such as somatostatin and vasoactive intestinal peptide in the serum, thereby regulating intestinal peristalsis. Histopathological analysis showed that arecoline ameliorated intestinal injury caused by constipation. Gut microbial analysis indicated that arecoline altered the taxonomic composition and levels of its metabolite SCFAs in the gut microbiota. Furthermore, the colonic transcriptome results indicated that genes expression related to intestinal diseases were significantly down-regulated by arecoline intervention. In conclusion, the results of the correlation analysis propose a possible mechanism of arecoline in alleviating constipation by modulating the gut microbes and their metabolites and regulating the gut genome.

Characteristics and risk factors for colorectal polyps among children in an urban area of Wenzhou, China: a retrospective case control study

BACKGROUND

Scarce evidence exists on pediatric colorectal polyp risk factors. This study explored the clinical manifestations, morphological and pathological characteristics of, and risk factors for pediatric colorectal polyps.

METHODS

This retrospective case-control study included children who received colonoscopy, divided into a colorectal polyp group and a normal control group based on colonoscopy results. The risk factors for colorectal polyps in children were analyzed through logistic regression analysis.

RESULTS

The mean age of children with polyps was 6.77 ± 3.44 years. Polyps were detected predominantly in males (72.9%); hematochezia was the primary clinical manifestation (80.25%). Most polyps were juvenile (88.9%) and solitary (87.7%); 50.6% were located in the rectosigmoid area. Univariate analysis showed that gender (P = 0.037), age (P < 0.001), family aggregation (P < 0.001), specific immunoglobulin E (sIgE) (P < 0.001), platelet count (P = 0.001), aspartate aminotransferase (AST) (P = 0.016), meat intake (P = 0.010), and vegetable intake (P < 0.001) were significantly associated with colorectal polyps. Age ≤ 6 years (3-6 years: OR: 26.601, 95% CI: 3.761-160.910; < 3 years: OR: 22.678, 95% CI: 1.873-274.535), positive family aggregation (OR: 3.540, 95% CI: 1.177-10.643), positive sIgE (OR:2.263, 95% CI: 1.076-4.761), and higher meat intake (OR:1.046, 95% CI: 1.029-1.063) were risk factors for pediatric colorectal polyps in logistic regression analysis. Higher vegetable intake (OR: 0.993, 95% CI: 0.986-1.000) was a protective factor against pediatric colorectal polyps. The area under the curve (AUC) of meat intake in the receiver operating characteristic (ROC) curve analysis for predicting colorectal polyps was 0.607; the best cut-off value was 92.14 g/d (P = 0.010, 95% CI: 0.527-0.687). The meat and vegetable intake combination AUC in predicting pediatric colorectal polyps was 0.781 (P < 0.001, 95% CI: 0.718-0.845).

CONCLUSIONS

Juvenile, solitary, and located in the rectosigmoid region polyps are most common in children. Hematochezia is the main clinical manifestation. Most polyps were, but multiple and proximally located polyps were also detected. Age ≤ 6 years, especially 3-6 years, positive family aggregation, positive sIgE, and higher meat intake are risk factors for pediatric colorectal polyps. A higher vegetable intake is a protective factor.

Psychometric evaluation of the Chinese version of the Elderly-Constipation Impact Scale: a translation and validation study

OBJECTIVE

The objective of this study was to translate the Elderly-Constipation Impact Scale into Chinese and to examine its reliability and validity in a population of older people suffering from chronic constipation.

METHODS

In this study, the scale was paraphrased, back-translated, cross-culturally adapted and pre-experimented using the Brislin double translation-back-translation method to create the initial Chinese version of the Elderly-Constipation Impact Scale. A convenience sampling method was used to select 564 study participants who met the inclusion and exclusion criteria in Liaoning and Shanxi, China, to evaluate the reliability and validity of the scale. General information about the study population was using descriptive statistics; item analysis was used to screen the items of the scale. Content validity, exploratory factor analysis, and validation factor analysis were chosen to validate the scales; internal consistency, spilt-half reliability and retest reliability were used determine the reliability of the measurement scales.

RESULTS

The Chinese version of the Elderly-Constipation Impact Scale contains 7 dimensions and 21 items. The Cronbach's alpha coefficient for the total scale was 0.901 and the range of Cronbach's alpha values for each dimension was 0.707 to 0.918. The split-half reliability of the scale was 0.736 and the retest reliability was 0.763. The exploratory factor analysis showed a KMO value of 0.873 and a Bartlett's spherical test X² value of 3499.978 (p < 0.001). A total of seven common factors were extracted, namely daily activities, treatment satisfaction, lack of control of bodily function, diet restriction, symptom intensity, anxiety and preventive actions, with a cumulative variance contribution of 77.813%. Each item had a loading value > 0.4 on its common factor. In the validation factor analysis, the model fit results were X² / df = 1.886, GFI = 0.910, AGFI = 0.874, PGFI = 0.654, IFI = 0.955, TLI = 0.942, CFI = 0.954, RMSEA = 0.056 and PNFI = 0.718. The model fit indicators were all within acceptable limits.

CONCLUSION

The Chinese version of the E-CIS has good reliability and validity in the chronic constipation population of elderly individuals. The results of the questionnaire can effectively and comprehensively reflect the impact of chronic constipation on the quality of life of elderly individuals. It provides a meaningful reference for identifying targets for intervention.

Microbiota regulation in constipation and colorectal cancer

The relevance of constipation to the development and progression of colorectal cancer (CRC) is currently a controversial issue. Studies have shown that changes in the composition of the gut microbiota, a condition known as ecological imbalance, are correlated with an increasing number of common human diseases, including CRC and constipation. CRC is the second leading cause of cancer-related deaths worldwide, and constipation has been receiving widespread attention as a risk factor for CRC. Early colonoscopy screening of constipated patients, with regular follow-ups and timely intervention, can help detect early intestinal lesions and reduce the risks of developing colorectal polyps and CRC. As an important regulator of the intestinal microenvironment, the gut microbiota plays a critical role in the onset and progression of CRC. An increasing amount of evidence supports the thought that gut microbial composition and function are key determinants of CRC development and progression, with alterations inducing changes in the expression of host genes, metabolic regulation, and local and systemic immunological responses. Furthermore, constipation greatly affects the composition of the gut microbiota, which in turn influences the susceptibility to intestinal diseases such as CRC. However, the crosstalk between the gut microbiota, constipation, and CRC is still unclear.

Effects of Bifido, Yijunkang, Siliankang, and Golden Bifid on loperamide induced constipation

BACKGROUND

Constipation is a common gastrointestinal disorder and a risk factor for colorectal cancer. Probiotics are the most widely used microecological agents for the treatment of constipation in clinical practice. Common intestinal microecological drugs include Bifido, Yijunkang, Siliankang, Golden Bifid, etc. They have different composition and may have different therapeutic effects on constipation.

AIM

To compare the effects of the four microecological agents in a rat model of constipation and to assess the effects of these probiotics on constipation-related indicators.

METHODS

Rats were randomly divided into six groups: Control group, model group, Bifido group, Yijunkang group, Siliankang group, and Golden Bifid group, with 10 rats in each group. The body weight, fecal quantity, shape, and water content, and intestinal transit rate of rats in each group were measured. Hematoxylin-eosin staining was performed to observe the pathological changes in the intestine of rats in each group. The expression level of intestinal mucin was analyzed by Alcian blue staining.

RESULTS

There were no significant changes in body weight and fecal water content of rats in each group. Compared to the model group, the quantity of feces (P < 0.01), intestinal transit rate (P < 0.05), intestinal mucosal thickness (P < 0.01), and mucin expression level (P < 0.01) were significantly increased in the Bifido group. Intestinal transit rate (P < 0.05) and mucin expression (P < 0.001) were significantly increased in the Yijunkang group. Increased intestinal transit rate and mucin level were observed in the Siliankang group (P < 0.05), and increased mucin expression was observed in the Golden Bifid group (P < 0.01).

CONCLUSION

The four microecological preparations improve constipation to varying degrees, of which Bifido has the best effect. Bifido can significantly increase the quantity of feces and intestinal transit rate of constipation rats, increase the expression level of mucin, promote the secretion of intestinal mucus, improve gastrointestinal peristalsis, and relieve constipation related symptoms.

Latilactobacillus sakei Furu2019 and stachyose as probiotics, prebiotics, and synbiotics alleviate constipation in mice

Introduction

Slow transit constipation (STC) is a common disorder in the digestive system. This study aimed to evaluate the effects of stachyose (ST) and Latilactobacillus sakei Furu 2019 (L. sakei) alone or combined on diphenoxylate-induced constipation and explore the underlying mechanisms using a mouse model.

Methods

ICR mice were randomly divided into five groups. The normal and constipation model groups were intragastrically administrated with PBS. The ST, L. sakei, and synbiotic groups were intragastrically administrated with ST (1.5 g/kg body weight), alive L. sakei (3 × 10⁹ CFU/mouse), or ST + L. sakei (1.5 g/kg plus 3 × 10⁹ CFU/mouse), respectively. After 21 days of intervention, all mice except the normal mice were intragastrically administrated with diphenoxylate (10 mg/kg body weight). Defecation indexes, constipation-related intestinal factors, serum neurotransmitters, hormone levels, short-chain fatty acids (SCFAs), and intestinal microbiota were measured.

Results

Our results showed that three interventions with ST, L. sakei, and synbiotic combination (ST + L. sakei) all alleviated constipation, and synbiotic intervention was superior to ST or L. sakei alone in some defecation indicators. The RT-PCR and immunohistochemical experiment showed that all three interventions relieved constipation by affecting aquaporins (AQP4 and AQP8), interstitial cells of Cajal (SCF and c-Kit), glial cell-derived neurotrophic factor (GDNF), and Nitric Oxide Synthase (NOS). The three interventions exhibited a different ability to increase the serum excitatory neurotransmitters and hormones (5-hydroxytryptamine, substance P, motilin), and reduce the serum inhibitory neurotransmitters (vasoactive intestinal peptide, endothelin). The result of 16S rDNA sequencing of feces showed that synbiotic intervention significantly increased the relative abundance of beneficial bacteria such as Akkermansia, and regulated the gut microbes of STC mice. In conclusion, oral administration of ST or L. sakei alone or combined are all effective to relieve constipation and the symbiotic use may have a promising preventive effect on STC.

Advancing human gut microbiota research by considering gut transit time

Accumulating evidence indicates that gut transit time is a key factor in shaping the gut microbiota composition and activity, which are linked to human health. Both population-wide and small-scale studies have identified transit time as a top covariate contributing to the large interindividual variation in the faecal microbiota composition. Despite this, transit time is still rarely being considered in the field of the human gut microbiome. Here, we review the latest research describing how and why whole gut and segmental transit times vary substantially between and within individuals, and how variations in gut transit time impact the gut microbiota composition, diversity and metabolism. Furthermore, we discuss the mechanisms by which the gut microbiota may causally affect gut motility. We argue that by taking into account the interindividual and intraindividual differences in gut transit time, we can advance our understanding of diet-microbiota interactions and disease-related microbiome signatures, since these may often be confounded by transient or persistent alterations in transit time. Altogether, a better understanding of the complex, bidirectional interactions between the gut microbiota and transit time is required to better understand gut microbiome variations in health and disease.

Analysis of Key Genes for Slow Transit Constipation Based on RNA Sequencing

Purpose

This study aims to identify key genes in slow transit constipation (STC). We also sought to explore the potential link between STC and colorectal cancer.

Patients and Methods

mRNA expression profiles were obtained by RNA sequencing, and differentially expressed genes were identified. Functional enrichment analysis and a protein–protein interaction (PPI) network was explored, and differentially expressed genes common to STC and colorectal cancer were examined. Analysis of the effect of constipation and colorectal cancer common genes on the overall survival of colorectal cancer patients based on GEPIA database.

Results

Functional enrichment showed that significantly different genes are related to lymphocyte chemotaxis, positive regulation of inflammatory response, cellular response to tumor necrosis factor, extracellular region, extracellular space and chemokine activity. The hub gene for STC was found in the PPI network. In addition, AQP8 and CFD were common differential genes for STC and colorectal cancer. AQP8 affects overall survival in patients with colorectal cancer.

Conclusion

Our findings will contribute to understanding the pathology of STC at the molecular level, with the first discovery that AQP8 may be a hub gene in the transition from STC to colorectal cancer.

Game-theoretic link relevance indexing on genome-wide expression dataset identifies putative salient genes with potential etiological and diapeutics role in colorectal cancer

Diapeutics gene markers in colorectal cancer (CRC) can help manage mortality caused by the disease. We applied a game-theoretic link relevance Index (LRI) scoring on the high-throughput whole-genome transcriptome dataset to identify salient genes in CRC and obtained 126 salient genes with LRI score greater than zero. The biomarkers database lacks preliminary information on the salient genes as biomarkers for all the available cancer cell types. The salient genes revealed eleven, one and six overrepresentations for major Biological Processes, Molecular Function, and Cellular components. However, no enrichment with respect to chromosome location was found for the salient genes. Significantly high enrichments were observed for several KEGG, Reactome and PPI terms. The survival analysis of top protein-coding salient genes exhibited superior prognostic characteristics for CRC. MIR143HG, AMOTL1, ACTG2 and other salient genes lack sufficient information regarding their etiological role in CRC. Further investigation in LRI methodology and salient genes to augment the existing knowledge base may create new milestones in CRC diapeutics.

Chronic Constipation as a Risk Factor for Colorectal Cancer: Results From a Nationwide, Case-Control Study

BACKGROUND & AIMS

Prolonged colon transit times may increase the contact time between potential carcinogens in the stool and the colonic mucosa. Nonetheless, previous studies have yielded conflicting results connecting chronic constipation with the risk of colorectal cancer (CRC). We examined the association between chronic constipation and later CRC.

METHODS

In this nationwide case-control study, we identified 41,299 CRC cases by colorectal biopsy in Sweden between July 2007 and December 2016 and matched them to 203,181 age- and sex-matched controls from the general population. We compared odds of earlier chronic constipation (defined as ≥2 laxative prescriptions in the Prescribed Drug Register with ≥6 months between the first and last prescription) between CRC cases and controls using logistic regression. In separate analyses, we compared odds of earlier constipation between CRC cases and sibling comparators, but also examined earlier risk of having an inpatient/outpatient specialty diagnosis of chronic constipation before CRC.

RESULTS

Overall, 3943 patients with CRC met our criteria for chronic constipation before CRC. The crude proportion of chronic constipation in CRC patients was 9.5% compared with 8.8% in controls. After multivariable adjustment, there was a modest association between chronic constipation and later CRC (odds ratio [OR], 1.10; 95% CI, 1.06-1.14) that vanished using sibling comparators to control for residual confounding (OR, 1.04; 95% CI, 0.97-1.13). In a sensitivity analysis of 126,650 CRC patients diagnosed from 1989 to 2016, we found no association with earlier chronic constipation diagnosed in inpatient/outpatient specialty clinics (OR, 0.88; 95% CI, 0.75-1.04).

CONCLUSIONS

In a nationwide case-control study, chronic constipation was not associated with later CRC.

Biofeedback therapy combined with Baduanjin on quality of life and gastrointestinal hormone level in patients with colorectal cancer

BACKGROUND

With the change in people’s lifestyles, the incidence of colorectal cancer (CRC) is increasing. It is essential to study the efficacy of various treatment methods for CRC patients to prevent and treat CRC.

AIM

To investigate the efficacy of biofeedback therapy combined with Baduanjin in improving the quality of life and gastrointestinal hormone levels of patients with CRC.

METHODS

A total of 120 patients with CRC who were admitted to our hospital from June 2020 to June 2021 were included in the study. They were randomly divided into four groups (n = 30): the control group (group A), the biofeedback therapy intervention group (group B), the Baduanjin exercise intervention group (group C), and the combination group (group D). Patients in group A adopted the standard nursing mode and necessary health education. Patients in group B were treated with biofeedback therapy based on routine nursing care. Patients in group C were given Baduanjin intervention for 12 wk based on conventional drug treatment and care. Patients in group D were treated with biofeedback therapy and Baduanjin exercise. In this study, patients’ quality of life, gastrointestinal hormone levels, and clinical efficacy in the four groups were observed at baseline and 12 wk after intervention. Meanwhile, the correlation between gastrointestinal hormone levels and various functional areas of quality of life was analyzed. By comparing the observed indicators of patients in the four groups, the efficacy of biofeedback therapy combined with Baduanjin in improving the quality of life and gastrointestinal hormone levels of patients with CRC was explored.

RESULTS

At baseline, there were no significant differences in quality of life, gastrointestinal hormone levels, or clinical efficacy among the four groups (P > 0.05). Twelve weeks after the intervention, the combination group’s quality of life, gastrointestinal hormone levels, and clinical effectiveness were better than those of the three other groups.

CONCLUSION

On the basis of routine nursing care, patients with CRC combined with biofeedback therapy and Baduanjin exercise can improve the quality of life of patients with CRC and the efficacy of gastrointestinal hormone levels.

A high-fibre personalised dietary advice given via a web tool reduces constipation complaints in adults

Constipation can greatly impact the quality of life (QoL), which can be relieved by dietary fibres; however, preserving a higher fibre intake remains a challenge. We investigated the effects of a personalised dietary advice (PDA) on fibre intake and mild constipation complaints. A total number of twenty-five adults with mild constipation complaints were included in a 4-week observation period followed by a 4-week personalised intervention. The PDA provided high-fibre alternatives via a web tool. In weeks 1, 4 and 8, dietary intake, constipation complaints and QoL were assessed. Furthermore, participants collected a faecal sample at weeks 1, 4 and 8 to determine microbiota diversity and composition, and short-chain fatty acids (SCFA). Participants completed questions daily for 8 weeks regarding abdominal complaints, stool frequency and stool consistency. Fibre intake in week 8 was significantly higher compared to week 1 (Δ = 5·7 ± 6·7 g, P < 0·001) and week 4 (Δ = 5·2 ± 6·4 g, P < 0·001). Constipation severity and QoL significantly improved at week 8 compared to the observation period (P < 0·001). A higher fibre intake significantly reduced constipation severity (β = -0·031 (-0·05; -0·01), P = 0·001) and the QoL (β = -0·022 (-0·04; -0·01), P = 0·009). Stool consistency (P = 0·040) and abdominal pain (P = 0·030) improved significantly during the intervention period (P = 0·040), but stool frequency did not. Average microbial alpha diversity and composition and SCFA concentrations did not change over time, but indicated individual-specific dynamics. Several SCFAs were associated with constipation complaints. To conclude, a PDA effectively increased fibre intake and subsequently reduced constipation complaints, indicating that guided dietary adjustments are important and feasible in the treatment of mild constipation complaints.

Curative efficiency and adverse events of alternative therapy and medicine for functional constipation in adults: A protocol for systematic review and meta-analysis

BACKGROUND

The efficacy of alternative therapies and medications for functional constipation (FC) in adults is well established, however, the efficacy and safety of different alternative therapies and medications for FC in adults is not fully clarified. Due to there are many different alternative therapies and medications available for the treatment of febrile FC in adults, the selection of appropriate alternative therapies and medications has become an urgent issue. The purpose of this study was to evaluate the effectiveness and safety of alternative therapy and medicine for FC in adults.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library, Embase, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang Data were searched to identify randomized controlled trials which focused on alternative therapy and medicine for FC in adults from December 15, 2020 to July 1, 2021. Subsequently, 2 researchers will be independently responsible for literature screening, data extraction, and assessment of their quality. This study uses The R Programming Language 4.0.2 based on Bayesian framework for NMA. Odds ratios or standardized mean differences will be modeled using Markov chain Monte Carlo methods, both with 95% confidence intervals.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSIONS

The conclusion of this systematic review will provide evidence for selecting an optimal alternative therapy and medicine for patients with FC in adults.

ETHICS AND DISSEMINATION

The protocol of the systematic review does not require ethical approval because it does not involve humans. This article will be published in peer-reviewed journals and presented at relevant conferences.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202210091.

Pharbitis nil extract ameliorates functional constipation and intestinal microflora disorder induced by loperamide in rats

BACKGROUND

Semen pharbitidis can be used for the treatment of constipation; however, the specific pharmacological effect and mechanism of its main pharmacological active ingredient pharbitis nil extract (PN) on functional constipation (FC) are still not clear.

AIM

To investigate the regulatory effect of PN on constipation symptoms, intestinal motility, colonic myoelectric activity, colonic tissue morphology, intestinal microflora and neurotransmitters in FC rats.

METHODS

A rat model of FC was established by intragastric administ-ration of loperamide (Lop) and then treated with PN. The number of fecal pellets within 6 h, fecal water content, intestinal transit rate, and colonic myoelectric activity were observed and recorded. The alteration of intestinal flora was measured by polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE). Hematoxylin-eosin (H&E) staining was used to detect the morphological changes of colon tissues. The expression levels of vasoactive intestinal peptide (VIP), substance P (SP), and 5-hydroxytryptamine (5-HT) were determined by enzyme linked immunosorbent assay (ELISA).

RESULTS

PN could significantly increase the fecal pellet count and water content within 6 h, accelerate the intestinal ink propelling rate, and decrease the frequency and amplitude variation of colon myoelectric activity in FC rats. H&E staining showed that PN improved the colon histological changes induced by Lop. PCR-DGGE demonstrated that PN rectified the abundance of Bacteroidetes and Verrucomicrobia and increased the abundance of Lactobacillaceae and Bifidobacteriaceae in FC rats. ELISA showed that PN significantly increased the SP and 5-HT expression and decreased the expression of VIP in colon tissues of FC rats.

CONCLUSION

PN alleviates FC caused by Lop and improves intestinal microflora and intestinal nervous system.

Bamboo shavings derived O-acetylated xylan alleviates loperamide-induced constipation in mice

BSH-1 is an O-acetylated xylan obtained from bamboo shavings. This study determined the protective effects of BSH-1 against loperamide (Lop)-induced constipation in mice. Mice received BSH-1 by gavage daily for 14 days. In constipated mice, BSH-1 significantly shortened the defecation time and raised the gastrointestinal (GI) transit rate, stool production, and cecal concentration of short-chain fatty acids (SCFAs). BSH-1 regulated the serum levels of gut hormones and neurotransmitters. BSH-1 also significantly altered the cecal microbiota of the constipated mice by increasing the abundance of potentially beneficial bacteria (e.g., Lactobacillus, Roseburia, and Bacteroidales_S24-7) and decreasing potentially pathogenic bacteria (e.g., Alloprevotella and Staphylococcus). Furthermore, colonic transcriptome analysis revealed that BSH-1 significantly reversed the expression changes of genes related to intestinal motility, water and ion transport, inflammation and cancer in constipated mice. Our findings indicated that BSH-1 effectively relieved Lop-induced constipation in mice and could be potentially used for constipation treatment.

Therapeutic effect of Moringa oleifera leaves on constipation mice based on pharmacodynamics and serum metabonomics

ETHNOPHARMACOLOGICAL RELEVANCE

Moringa oleifera is native to India, and has been introduced to China in recent years. Moringa oleifera leaves (MOL), as Ayurvedic medicine, has efficacy of Pachana karma (digestive) and Virechana karma (purgative). Folium Sennae (FS), Rhubarb (RB), Aloe vera (AV), Hemp seed (HS) are commonly used as laxatives in Traditional Chinese Medicine (TCM), which have different characteristics. However, the intensity of the diarrheal effect of MOL and its mechanism of action are unclear.

AIM OF THE STUDY

The methods of pharmacology and omics were used to compare the purgative effects of MOL and FS, RB, AV, HS, and their effects on metabolomics, to analyze the purgative characteristics and related mechanisms of MOL.

MATERIALS AND METHODS

C57BL/6J mouse model of constipation was established by feeding low-fiber food. Feces parameters and colon pathology were used to evaluate the effect of FS, RB, AV, HS and MOL. And mass spectrometry-based serum metabolomics was performed. The differential metabolites of these herbs in the treatment of constipation were obtained by OPLS-DA analysis. Furthermore, pathway analysis was conducted based on different metabolites.

RESULTS

Moringa leaves can adjust the stool number, wet fecal weight and fecal water content to varying degrees to achieve laxative effects, and recover colon muscle thickness and mucus. Analysis of metabolomics results showed that 71 metabolites from LC-MS datasets between model group and control group were obtained. 29, 12, 44, 29 and 20 metabolites were significantly reversed by FS, RB, AV, HS, MOL compared with model group respectively. According to the metabolic pathways, RB and AV may be clustered into a similar category, and MOL, FS and HS showed similarity of metabolic characteristics.

CONCLUSION

The purgative effect of MOL is inferior to that of FS, and stronger than that of AV, RB and HS. The metabolic pathway for constipation is more similar to that of FS. MOL has a long-lasting and mild effect of laxative, increasing defecation volume and water content of feces, and may become a fewer side effects medicine to treat constipation.

Long-Term Risks of Parkinson's Disease, Surgery, and Colorectal Cancer in Patients With Slow-Transit Constipation

BACKGROUND & AIMS

Long-term outcomes of constipation have not been evaluated fully. We investigated the incidence of Parkinson's disease, constipation-related surgery, and colorectal cancer (CRC) in patients with constipation and slow-transit constipation (STC), followed up for up to 20 years.

METHODS

We collected data from 2165 patients (33.1% men; median patient age, 54 y; median symptom duration, 5.0 y) with a diagnosis of constipation (based on Rome II criteria) who underwent an anorectal function test and a colonic transit time study, from 2000 through 2010, at a tertiary university hospital in Seoul, South Korea. The presence of STC was determined from colonic transit time. We used the Kaplan-Meier method to analyze and compare cumulative probabilities of a new diagnosis of Parkinson's disease or CRC according to the presence of STC. The patients were followed up until the end of 2019.

RESULTS

During a median follow-up period of 4.7 years (interquartile range, 0.7-8.3 y), 10 patients underwent constipation-related surgery. The cumulative probabilities of constipation-related surgery were 0.7% at 5 years and 0.8% at 10 years after a diagnosis of constipation. Twenty-nine patients (1.3%) developed Parkinson's disease; the cumulative probabilities were 0.4% at 1 year, 1.0% at 5 years, and 2.6% at 10 years after a diagnosis of constipation. At 10 years, 1.3% of patients with STC required constipation-related surgery and 3.5% of patients with STC developed Parkinson's disease; in contrast, none of the patients without STC required constipation-related surgery (P = .003), and 1.5% developed Parkinson's disease (P = .019). In multivariate analysis, patient age of 65 years or older at the diagnosis of constipation (hazard ratio, 4.834; 95% CI, 2.088-11.190) and the presence of STC (hazard ratio, 2.477; 95% CI, 1.046-5.866) were associated independently with the development of Parkinson's disease. Only 5 patients had a new diagnosis of CRC during the follow-up period. The risk of CRC did not differ significantly between patients with vs without STC (P = .575).

CONCLUSIONS

In a long-term follow-up study of patients with constipation in Korea, most patients had no severe complications. However, patients older than age 65 years with a new diagnosis of STC might be considered for Parkinson's disease screening.

Fruits and their impact on the gut microbiota, gut motility and constipation

Fruits are the seed-bearing product of plants and have considerable nutritional importance in the human diet. The consumption of fruits is among the dietary strategies recommended for constipation due to its potential effects on the gut microbiota and gut motility. Dietary fiber from fruits has been the subject of research on the impact on gut microbiota, gut motility and constipation, however, fruits also contain other components that impact the intestinal luminal environment that may impact these outcomes including sorbitol and (poly)phenols. This review aims to explore the mechanisms of action and effectiveness of fruits and fruit products on the gut microbiota, gut motility and constipation, with a focus on fiber, sorbitol and (poly)phenols. In vitro, animal and human studies investigating the effects of fruits on gut motility and gut microbiota were sought through electronic database searches, hand searching and consulting with experts. Various fruits have been shown to modify the microbiota in human studies including blueberry powder (lactobacilli, bifidobacteria), prunes (bifidobacteria), kiwi fruit (Bacteroides, Faecalibacterium prausnitzii) and raisins (Ruminococcus, F. prausnitzii). Prunes, raisins and apple fiber isolate have been shown to increase fecal weight in humans, whilst kiwifruit to increase small bowel and fecal water content. Apple fiber isolate, kiwifruit, fig paste, and orange extract have been shown to reduce gut transit time, while prunes have not. There is limited evidence on which fruit components play a predominant role in regulating gut motility and constipation, or whether a synergy of multiple components is responsible for such effects.

Prevalence and risk factors of functional constipation in the Rome IV criteria during a medical check-up in Japan

BACKGROUND AND AIM

Functional constipation (FC) is one of the functional bowel disorders with symptoms of constipation in the Rome IV criteria. This study aimed to examine the epidemiology of FC in a large-scale survey of individuals undergoing a medical check-up in Japan.

METHODS

A total of 13 729 subjects who underwent a medical check-up at MedCity21 between April 2018 and March 2019 were given a questionnaire that inquired about bowel habits. Among them, 10 658 subjects participated in this study, and FC was diagnosed based on the Rome IV criteria.

RESULTS

The number of subjects who fulfilled diagnostic criteria of FC was 220, and the prevalence of FC was 2.1%. Compared with subjects with non-FC, those with FC were more complaining of abdominal bloating and distension, feeling stressed, getting annoyed, lack of motivation, fatigue upon waking, and feeling depressed. The risk of FC was significantly lower among subjects who drank alcohol more than 5 days a week, exercised for more than 30 min at least twice a week for more than 1 year, and were getting enough rest by sleeping, whereas it was significantly higher among women and subjects who were eating faster than other people.

CONCLUSIONS

The prevalence of FC in Japanese subjects during a medical check-up was relatively low compared with that in Western countries. Subjects with FC had troublesome symptoms, and it might be suggested that female sex, lack of regular exercise with moderate activity, insufficient rest by sleeping, and eating faster were a risk of FC.

Colorectal Cancer Epidemiology: Recent Trends and Impact on Outcomes

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer related deaths in the world with an estimated number of 1.8 million new cases and about 881,000 deaths worldwide in 2018. The epidemiology of CRC varies significantly between different regions in the world as well as between different age, gender and racial groups. Multiple factors are involved in this variation, including risk factor exposure, demographic variations in addition to genetic susceptibility and genetic mutations and their effect on the prognosis and treatment response. In this mini-review, we discuss the recent epidemiological trend including the incidence and mortality of colorectal cancer worldwide and the factors affecting these trends.

Pediococcus pentosaceus B49 from human colostrum ameliorates constipation in mice

Constipation is a prevalent and burdensome gastrointestinal (GI) disorder that seriously affects the quality of human life. This study evaluated the effects of the P. pentosaceus B49 (from human colostrum) on loperamide (Lop)-induced constipation in mice. Mice were given P. pentosaceus B49 (5 × 109 CFU or 5 × 1010 CFU) by gavage daily for 14 days. The result shows that P. pentosaceus B49 treatment relieved constipation in mice by shortening the defecation time, increasing the GI transit rate and stool production. Compared with the constipation control group, the P. pentosaceus B49-treated groups showed decreased serum levels of inhibitory neurotransmitters (vasoactive intestinal peptide and nitric oxide), increased serum levels of excitatory neurotransmitters (acetylcholinesterase, motilin, and gastrin), and elevated cecal concentration of short chain fatty acids (SCFAs). Analysis of cecal microbiota reveals that P. pentosaceus B49 was colonized in the intestine of constipated mice, and altered the cecal microbiota by increasing beneficial SCFAs-producing bacteria (i.e., Lactobacillus, Ruminococcaceae_UCG-014, and Bacteroidales_S24-7) and decreasing potential pathogenic bacteria (i.e., Staphylococcus and Helicobacter). Moreover, transcriptome analysis of the colon tissue shows that P. pentosaceus B49 partly normalized the expression of genes related to GI peristalsis (i.e., Ache, Chrm2, Slc18a3, Grp, and Vip), water and electrolyte absorption and transport (i.e., Aqp4, Aqp8, and Atp12a), while down-regulating the expression of pro-inflammatory and pro-oncogenic genes (i.e., Lbp, Lgals2, Bcl2, Bcl2l15, Gsdmc2, and Olfm4) in constipated mice. Our findings indicate that P. pentosaceus B49 effectively relieves constipation in mice and is a promising candidate for treating constipation.

Chronic Constipation in Adults: The Primary Care Approach

BACKGROUND

Primary care is normally the initial point of presentation and management of patients with chronic constipation (CC). CC has a prevalence of 3-27%, predominantly amongst females and in the older population, and is associated with a reduced quality of life. Effective management can be a challenge without a structured approach.

SUMMARY

Whilst conventional teaching defines constipation as the number of stools per week, patients complain mainly of other symptoms such as straining and stool consistency rather than frequency. Symptoms need to be correlated with the likely causes, and ruling out secondary causes and treatment should be symptom driven, distinguishing between functional constipation and irritable bowel syndrome with CC. Treatment can be stepwise or involve combinations of therapies. There is a poor evidence base for most common managements, including lifestyle measures, although stimulant laxatives can be effective. Key Messages: Failure of routine treatment and an early consideration of alternative causes should lead to collaboration with a specialist, especially as many problems, such as pelvic floor disorders, gynaecological problems, and dyssynergic defecation, require secondary care investigations and remedies. In light of our ageing population, CC should be considered thoughtfully and the diagnosis and management tailored to the individual, to maintain good quality of life.

Gut bacteria-derived 5-hydroxyindole is a potent stimulant of intestinal motility via its action on L-type calcium channels

Microbial conversion of dietary or drug substrates into small bioactive molecules represents a regulatory mechanism by which the gut microbiota alters intestinal physiology. Here, we show that a wide variety of gut bacteria can metabolize the dietary supplement and antidepressant 5-hydroxytryptophan (5-HTP) to 5-hydroxyindole (5-HI) via the tryptophanase (TnaA) enzyme. Oral administration of 5-HTP results in detection of 5-HI in fecal samples of healthy volunteers with interindividual variation. The production of 5-HI is inhibited upon pH reduction in in vitro studies. When administered orally in rats, 5-HI significantly accelerates the total gut transit time (TGTT). Deciphering the underlying mechanisms of action reveals that 5-HI accelerates gut contractility via activation of L-type calcium channels located on the colonic smooth muscle cells. Moreover, 5-HI stimulation of a cell line model of intestinal enterochromaffin cells results in significant increase in serotonin production. Together, our findings support a role for bacterial metabolism in altering gut motility and lay the foundation for microbiota-targeted interventions.

Sexual Dimorphism in Colon Cancer

A higher incidence of colorectal cancer (CRC) is found in males compared to females. Young women (18-44 years) with CRC have a better survival outcome compared to men of the same age or compared to older women (over 50 years), indicating a global incidence of sexual dimorphism in CRC rates and survival. This suggests a protective role for the sex steroid hormone estrogen in CRC development. Key proliferative pathways in CRC tumorigenesis exhibit sexual dimorphism, which confer better survival in females through estrogen regulated genes and cell signaling. Estrogen regulates the activity of a class of Kv channels (KCNQ1:KCNE3), which control fundamental ion transport functions of the colon and epithelial mesenchymal transition through bi-directional interactions with the Wnt/β-catenin signalling pathway. Estrogen also modulates CRC proliferative responses in hypoxia via the novel membrane estrogen receptor GPER and HIF1A and VEGF signaling. Here we critically review recent clinical and molecular insights into sexual dimorphism of CRC biology modulated by the tumor microenvironment, estrogen, Wnt/β-catenin signalling, ion channels, and X-linked genes.

Chronic Kidney Disease, Gut Dysbiosis, and Constipation: A Burdensome Triplet

Gut dysbiosis has been implicated in the progression of chronic kidney disease (CKD). Alterations in the gut environment induced by uremic toxins, the dietary restriction of fiber-rich foods, and multiple drugs may be involved in CKD-related gut dysbiosis. CKD-related gut dysbiosis is considered to be characterized by the expansion of bacterial species producing precursors of harmful uremic toxins, such as indoxyl sulfate and p-cresyl sulfate, and the contraction of species generating beneficial short-chain fatty acids, such as butyrate. Gut-derived uremic toxins cause oxidative stress and pro-inflammatory responses, whereas butyrate exerts anti-inflammatory effects and contributes to gut epithelial integrity. Gut dysbiosis is associated with the disruption of the gut epithelial barrier, which leads to the translocation of endotoxins. Research on CKD-related gut dysbiosis has mainly focused on chronic inflammation and consequent cardiovascular and renal damage. The pathogenic relationship between CKD-related gut dysbiosis and constipation has not yet been investigated in detail. Constipation is highly prevalent in CKD and affects the quality of life of these patients. Under the pathophysiological state of gut dysbiosis, altered bacterial fermentation products may play a prominent role in intestinal dysmotility. In this review, we outline the factors contributing to constipation, such as the gut microbiota and bacterial fermentation; introduce recent findings on the pathogenic link between CKD-related gut dysbiosis and constipation; and discuss potential interventions. This pathogenic link needs to be elucidated in more detail and may contribute to the development of novel treatment options not only for constipation, but also cardiovascular disease in CKD.

Non-pharmacological interventions to improve constipation amongst older adults in long-term care settings: A systematic review of randomised controlled trials

Constipation is a highly prevalent condition amongst older adults in long-term care settings and laxatives are not always the solution. We aimed to examine the characteristics and the effects of non-pharmacological interventions to improve constipation amongst older adults in long-term care settings. Eligible studies were identified using PubMed, CINAHL, Scopus, Web of Science, Cochrane and EMBASE (up to April 2019). We included 7 studies with a total of 657 patients. Five interventions improved the number of bowel movements (i.e. laxative tea, fermented oat drink, patient education, probiotics and multi-component intervention). The administration of probiotic capsules and fermented oat drinks also improved stool form. Auricular acupressure improved constipation symptoms and constipation-related quality of life. After appraising the trials' methodological quality and risk of bias, we cannot recommend any non-pharmacological interventions to improve constipation amongst older adults in long-term care settings until more robust studies have been conducted.

Astragaloside IV alleviates mouse slow transit constipation by modulating gut microbiota profile and promoting butyric acid generation

Gut microbiota and short‐chain fatty acids (SCFAs) are associated with the development of various human diseases. In this study, we examined the role of astragaloside IV in modulating mouse gut microbiota structure and the generation of SCFAs, as well as in slow transit constipation (STC). An STC model was established by treating mice with loperamide, in which the therapeutic effects of astragaloside IV were evaluated. The microbiota community structure and SCFA content were analysed by 16S rRNA gene sequencing and gas chromatography‐mass spectrometry, respectively. The influence of butyrate on STC was assessed using a mouse model and Cajal cells (ICC). Astragaloside IV promoted defecation, improved intestinal mobility, suppressed ICC loss and alleviated colonic lesions in STC mice. Alterations in gut microbiota community structure in STC mice, such as decreased Lactobacillus reuteri diversity, were improved following astragaloside IV treatment. Moreover, astragaloside IV up‐regulated butyric acid and valeric acid, but decreased isovaleric acid, in STC mouse stools. Butyrate promoted defecation, improved intestinal mobility, and enhanced ICC proliferation by regulating the AKT–NF‐κB signalling pathway. Astragaloside IV promoted intestinal transit in STC mice and inhibited ICC loss by regulating the gut microbiota community structure and generating butyric acid.

Differences in efficacy and safety of lubiprostone used for idiopathic vs opioid-induced constipation: meta-analysis of East Asian and Western populations

Several secretagogues, such as lubiprostone, have been developed for the treatment of constipation in the last 10 years. It is unclear whether the efficacy of lubiprostone for spontaneous bowel movement (SBM) and the adverse events are similar between idiopathic and opioid-induced constipation and between East-Asian and Western populations. We conducted a meta-analysis to compare efficacy and safety of lubiprostone in two populations with idiopathic vs opioid-induced constipation. The PubMed and Cochrane databases were searched for relevant randomized control trials (RCTs) investigating the efficacy and safety that were published in English up to March 2019. Compared with the placebo groups in idiopathic and opioid-induced constipation, the lubiprostone groups significantly improved in 24-h SBM frequency [relative risk: 1.28, 95% confidence interval, 1.11-1.49, and 1.23, 1.14-1.32] and weekly frequency >3 SBM/week (1.68, 1.41-2.01, and 1.43, 1.01-2.04), respectively. Although the incidence of adverse events was similar between idiopathic and opioid-induced constipation, the incidence of nausea in Western populations with idiopathic constipation was significantly higher (29.2%) than that in East-Asian populations (10.0%, p<0.001). In conclusion, lubiprostone effectively improved SBM frequency, irrespective of the etiology of constipation and population. The incidence of nausea was significantly higher in Western populations.

Abnormal bowel movement frequency increases the risk of rectal cancer: evidence from cohort studies with one million people

Previous studies from case-control studies failed to draw reliable conclusions regarding the relationship between bowel movement frequency and the risk of colorectal cancer. To further examine this relationship, we collect the data from cohort studies that make a more accurate estimation. Several online data were searched from inception to February 29, 2020. Ten cohort studies involving 1,038,598 individuals were included in our study. The pooled results indicated that a bowel movement of less than once per day was not associated with the risk of colorectal cancer (relative risk (RR)= 1.00, 95% confidence interval (CI): 0.87-1.16, P = 0.950) compared with that of once per day. Compared with a bowel movement frequency of once per day, a bowel movement of more than once per day was also not related to elevated risk of colorectal cancer (RR = 1.04, 95% CI: 0.91-1.19, P = 0.570). The subgroup analyses indicated a low or high bowel movement frequency did not increase the risk of colon cancer (RR = 0.91, 95% CI: 0.80-1.03, P = 0.130). However, an increased frequency of bowel movements increased the risk of rectal cancer (RR = 1.34, 95% CI: 1.19-1.52, P < 0.001). The sensitivity analysis still supports the results. No significant publication bias existed. The data from cohort indicated that less bowel movement frequency was not associated with the risk of colorectal cancer. The frequency of bowel movement affects the risk of rectal cancer.

Effects of rice-based and wheat-based diets on bowel movements in young Korean women with functional constipation

Background

Although several studies have reported the effects that dietary fiber intake from different types of grains and fiber components have on bowel movements, insufficient attention has been paid to comparing and evaluating the effects of rice-based and wheat-based diets. This study compared and evaluated the effects of ingesting rice-based (brown rice-based diet: BRD; white rice-based diet: WRD) and wheat-based diet (WD) on the bowel movements of young women with functional constipation.

Method

Based on an open, randomized, controlled, and parallel design, 39 subjects were assigned to BRD, WRD, and WD groups (13 in each group). Each participant had received three types of experimental diets over the course of 4 weeks and we recommended that the subjects eat only the test diet provided during the study. Primary outcomes (total colon transit time TCTT) and secondary outcomes (bowel movements, short-chain fatty acid content, and fecal enzyme activity) were compared before and after the 4-week intervention period.

Results

After the 4-week study, the rice-based diet (BRD and WRD) groups and the WD group had a statistically significant difference in TCTT (p = 0.028). The TCTT of the BRD group was significantly reduced (p = 0.028) compared with the WRD group (−16.5 ± 8.1 vs +6.8 ± 2.1), and the TCTT of the WD group was also significantly reduced (p = 0.022) compared with that of the WRD group (−17.1 ± 11.9 vs +6.8 ± 2.1).

Conclusion

Among women with functional constipation, the BRD and WD both improved bowel function by reducing TCTT and increasing the number of bowel movements compared with the WRD group.

The effect of probiotics used as a single therapy on functional constipation: Study protocol for a systematic review and meta-analysis

BACKGROUND

Constipation is a frequent gastrointestinal symptom. It is intimately related to many diseases. 1st-line therapy can not alleviate constipation for some patients. Alternative treatments are therefore commonly used, such as probiotics. Nevertheless, the efficacy and safety of probiotics used as a single treatment are still uncertain. A systematic review and meta-analysis will be carried out to answer the issue.

METHODS

The protocol accompanied Preferred Reporting Items for Systematic Reviews and Protocol Meta-Analysis. PubMed, Cochrane, Embase, and Web of Science databases were practiced for randomized controlled trials without language constraint. In addition, We have also conducted backward (manually) and forward (with Google Scholar) citation checks to identify any additional relevant papers.Two reviewers will conduct studies selection, data extraction, and risk of bias assessment independently. The primary outcome is treatment success (spontaneous bowel movements (sBMs) >3 times per week), defecation frequency. The second result will be consistency, fecal incontinence, other symptoms (e.g. flatulence, abdominal pain), and adverse event rates and types.

RESULTS

This study provides helpful information about whether probiotics can be used as a single therapy on functional constipation CONCLUSION:: The findings of the review will be disseminated through peer-review publications.

Constipation in chronic kidney disease: it is time to reconsider

Constipation is highly prevalent in patients with chronic kidney disease (CKD) and is primarily characterized by decreased intestinal motility. This chronic disorder affects the quality of life of patients. However, nephrologist and dialysis clinicians have long had a disproportionately limited understanding of constipation. Accumulating evidence has revealed a relationship between constipation and cardiovascular disease and CKD. The pathogenesis of constipation in CKD patients is multifactorial: decreased physical activity, comorbidities affecting bowel movement, such as diabetes mellitus, cerebrovascular disease, and hyperparathyroidism, a restricted dietary intake of plant-based fiber-rich foods, and multiple medications, including phosphate binders and potassium-binding resins, have all been implicated. CKD is associated with alterations in the composition and function of the gut microbiota, so-called gut dysbiosis. Recent studies showed that CKD-related gut dysbiosis decreased intestinal motility via intestinal inflammation or the increased generation of gut-derived uremic toxins, such as indoxyl sulfate and p-cresyl sulfate. Furthermore, the gastrointestinal secretion of mucin was found to be decreased in CKD animal models, which may delay colonic transit by diminished lubrication in the alimentary tract. Thus, CKD-related gut dysbiosis may play a role in constipation, but limited information is currently available. Since constipation is often intractable, particularly in CKD patients, every available means needs to be employed in its treatment. The effects of probiotics, prebiotics, and synbiotics on the composition of the gut microbiota and gut-derived uremic toxins have been increasingly reported. However, their effects on stool consistency or frequency in CKD patients remain unclear. Some laxatives may be beneficial for improving not only bowel habits but also gut dysbiosis. Further studies are required to elucidate the CKD-specific pathogenesis of constipation and develop novel effective treatment options.

G protein-coupled estrogen receptor in colon function, immune regulation and carcinogenesis

Estrogens play important roles in the development and progression of multiple tumor types. Accumulating evidence points to the significance of estrogen action not only in tumors of hormonally regulated tissues such as the breast, endometrium and ovary, but also in the development of colorectal cancer (CRC). The effects of estrogens in physiological and pathophysiological conditions are mediated by the nuclear estrogen receptors α and β, as well as the membrane-bound G protein-coupled estrogen receptor (GPER). The roles of GPER in CRC development and progression, however, remain poorly understood. Studies on the functions of GPER in the colon have shown that this estrogen receptor regulates colonic motility as well as immune responses in CRC-associated diseases, such as Crohn’s disease and ulcerative colitis. GPER is also involved in cell cycle regulation, endoplasmic reticulum stress, proliferation, apoptosis, vascularization, cell migration, and the regulation of fatty acid and estrogen metabolism in CRC cells. Thus, multiple lines of evidence suggest that GPER may play an important role in colorectal carcinogenesis. In this review, we present the current state of knowledge regarding the contribution of GPER to colon function and CRC.

Adhesive Bifidobacterium Induced Changes in Cecal Microbiome Alleviated Constipation in Mice

Constipation, which seriously affects living quality of people, is a common gastrointestinal disease. The engagement of the intestinal flora in the development of symptoms of constipation has been frequently hypothesized. In this study, constipated mice induced by loperamide were used to investige the alleviation of constipation by Bifidobacteria. Bifidobacteria was sorted out according to their adhesive properties into two groups. One group combined multiple strains of Bifidobacterium with adhesion property (CMB1), the other combined multiple strains of Bifidobacterium without adhesion property (CMB2). It was found that CMB1 can alleviate constipation more efficiently by improving the water, propionate and butyrate content in feces, and overall gastrointestinal transit time. Meanwhile, from the perspective of fecal microbiota, CMB1 alleviated constipation mainly by increasing the relative abundances of genera (Bifidobacterium, Lactobacillus, and Prevotella) associated with rapid bowel movement. From the perspective of cecal microbiota, CMB1 alleviated constipation mainly by increasing the relative abundances of genera Lactobacillus, Bacteroides, unclassified S24-7, Dorea, Ruminococcus, Coprococcus, and Rikenella, and decreasing the relative abundances of genera Oscillospira, Odoribacter and Unclassified F16, which are associated with methane production and colonic transit. Overall, changes of microbiota in caecum by CMB1 reflect the stage of constipation in mice more comprehensively than that in feces.

Risk of cancer in patients with constipation

Background: It remains unclear whether constipation is associated with cancer. We evaluated the risk of malignancies in patients with constipation requiring hospitalization. Methods: Using Danish medical registries, we calculated cumulative incidences and standardized incidence ratios (SIRs) for cancer. SIRs were computed as the observed number of gastrointestinal (GI) cancers and selected non-GI cancers in patients with constipation compared with the expected number based on national incidence rates by sex, age, and calendar year (1978-2013). Results: We identified 1,75,901 patients with constipation (59% females, median age 54 years). The cumulative incidences of GI cancers and non-GI cancers after 15 years of follow-up were 2.5% and 2.6%, respectively. During the first year of follow-up, the SIR for any GI cancer was 5.0 (95% confidence interval (CI): 4.8-5.3), driven by colon and pancreas cancers and higher for younger age groups. Beyond 1 year of follow-up, the risk declined to near unity for colorectal cancer. The risk of other GI cancers (including cancers of the esophagus, stomach, small intestine, liver, and pancreas) remained moderately increased (overall SIR =1.3, 95% CI: 1.2-1.4). Except for ovarian cancer (SIR =7.3, 95% CI: 6.3-8.4), the risk of non-GI cancers was only slightly increased during the first year of follow-up and declined to unity thereafter. Conclusions: Patients with constipation had increased short-term risk of a diagnosis of GI cancer. Beyond 1 year of follow-up, a moderately elevated risk persisted only for GI cancers other than colorectal cancer. The risk of non-GI cancers was elevated only during the first year of follow-up, particularly for ovarian cancer.

Diet, obesity and colorectal carcinoma risk: results from a national cancer registry-based middle-eastern study

BACKGROUND

Cancer of colon and rectum (colorectal) is one of the most common cancers worldwide. There is a scarcity of published data on the risk factors for colorectal cancer (CRC) from the Middle-Eastern countries specifically in Kuwait. Therefore, this matched case-control study sought to examine the risk factors associated with CRC in Kuwait.

METHODS

One hundred and three histopathologically confirmed colorectal cancer cases were recruited from Kuwait Cancer Control Centre Registry. Two hundred and six controls matched with cases (2:1 ratio) on age, gender and nationality were selected from medical, ophthalmology, orthopedic and/ or surgical out-patient clinics at three main general hospitals in Kuwait. A structured questionnaire was used to collect the data from cases and controls through face-to-face interview. Adjusted matched odds ratios (mOR_adj) and their 95% confidence intervals (CI) were estimated using a multivariable conditional logistic regression model.

RESULTS

Multivariable conditional logistic regression model showed that cases were 4.3 times more likely to have had attainted obesity (BMI ≥ 30) in their lifetime compared to controls (mOR_adj = 4.3; 95% CI: 1.6-11.4). Compared to controls, cases rarely consumed fruits and vegetable (mOR_adj = 20.8; 95% CI: 4.4-99.5), tended to consume red meat 2-3 times a week (mOR_adj = 3.8; 95% CI: 1.6-8.7) or more than 4 times a week (mOR_adj = 9.4; 95% CI: 2.5-35.4). Reportedly cases compared to controls frequently (nearly every week) suffered from constipation (mOR_adj = 5.6; 95% CI: 1.9-16.5). However, CRC cases were less likely than controls to have been diagnosed in the past with hypercholesterolemia (mOR_adj = 0.3; 95% CI: 0.2-0.7) or diabetes mellitus type II (mOR_adj = 0.4; 95% CI: 0.2-0.8).

CONCLUSIONS

Obesity, excessive red meat consumption and infrequent fruits/vegetables intake were associated with an increased CRC risk. Overcoming identified pitfalls in dietary pattern and maintenance of healthy weight may help minimize CRC risk in Kuwait and perhaps other countries in the region. Further studies on genetic basis in conjunction with life styles and dietary factors may unravel their joint contributions to CRC risk and furnish tools for curtailing CRC risk in this and other similar populations.

Elevated serum neopterin levels in children with functional constipation: association with systemic proinflammatory cytokines

BACKGROUND

Functional constipation is a clinical problem with an incompletely understood etiology. Functional bowel diseases have been shown to be related to inflammation in many studies in adults. In this study, we aimed to evaluate leukocytes, C-reactive protein, proinflammatory and anti-inflammatory cytokines, and neopterin levels in children with functional constipation.

METHODS

Seventy-six children with constipation and 71 healthy controls (mean age 7.12 ± 3.46 years and 7.32 ± 4.33 years, respectively, P = 0.991) were included in the study. Leukocytes, C-reactive protein, interleukin (IL)-1β, IL-6, IL-10, IL-12, tumor necrosis factor-alpha (TNF-α) and neopterin levels were assessed in patients and healthy controls. Parameters were measured in the serum using enzyme-linked immunosorbent assay methods.

RESULTS

Mean IL-6 (20.31 ± 12.05 vs. 16.2 ± 10.25 pg/mL, respectively, P = 0.003), IL-12 (181.42 ± 133.45 vs. 135.6 ± 83.67 pg/mL, respectively, P = 0.018) and neopterin levels (2.08 ± 1.12 vs. 1.52 ± 1.02 pg/mL, respectively, P = 0.001) were significantly higher in constipated children than healthy controls. Leukocyte and thrombocyte counts, C-reactive protein, and IL-1β, IL-10 and TNF-α levels did not show any difference between the two groups.

CONCLUSIONS

In this study, IL-6, IL-12 and neopterin levels of constipated patients were found to be higher than those of controls. These results indicate the presence of subclinical inflammation in children with functional constipation.

Do bad habits bring a double constipation risk?

BACKGROUND/AIMS

Good dietary habits, fluid intake, and regular exercise are considered to ease defecation although very few cases of chronic constipation can be managed through these approaches alone. Good defecation habits are recommended to avoid chronic constipation; however, the literature regarding this remains scarce. In this paper, we aimed to assess the association of bad habits concerning defecation, such as postponing, reluctance, or avoiding defecation anywhere but at home, with chronic constipation.

MATERIALS AND METHODS

This was a cross-sectional observational study including subjects from a tertiary hospital taskforce. In total, 415 of 910 eligible subjects were randomly selected. A cluster of questionnaires easy to understand and fill out was distributed. The questionnaires included queries regarding demographic data; past medical history; the presence of constipation; and dietary, other lifestyle, and defecation habits. The Rome III criteria for chronic constipation were also recorded.

RESULTS

In total, 24.3% of the subjects considered themselves constipated, and 26.5% fulfilled the Rome III criteria for constipation. There were obvious differences in constipation prevalence by sex (men 5% vs. women 31%). Fiber-rich diet, fluid intake, and exercise habits were not related to constipation. Defecation habits significantly correlated with the presence or absence of constipation: regular schedule (OR 0.39; CI 95% 0.23-0.67), persistently postponing defecation (OR 1.94; CI 95% 1.13-3.34), or avoiding defecation anywhere but at home (OR 2.38; CI 95% 1.4-4.1).

CONCLUSION

Compared with dietary habits, behavioral aspects surrounding defecation are more related to chronic constipation. Our results indicate that the modification of these bad habits may be the first step in chronic constipation treatment.

Older Adults' Response to Analgesic Adverse Drug Reactions: A Pilot Study

BACKGROUND

Older adults who take analgesics for chronic pain are at increased risk for adverse drug events (ADEs). Aims/Design: The purpose of this descriptive pilot survey was to examine how older adults self-identify analgesic ADEs, and actions they take in response to analgesic ADEs. Setting/Participants/Methods: Twenty-two community dwelling older adults with chronic pain who reported an analgesic ADE associated with their chronic pain management were interviewed and asked to describe their analgesic related ADE. Written responses were content analyzed.

RESULTS

Nineteen opioids were reported by 15, 11 NSAIDs were reported by 8, and acetaminophen was reported by 2 older adults as associated with an ADE. Gastrointestinal ADEs were most common with upset stomach (31.8%) most frequent. Neurological ADEs were also common but more varied with dizziness (27.3%) and headache (13.6%) reported most frequently. A total of 54.5% responded to their ADE by contacting their physician. Three (13.6%) went to the emergency department. A total of 36.4% stopped taking their ADE associated analgesic, 22.7% started taking a different analgesic, and 22.7% started prophylaxis. Three (13.6%) continued their ADE related analgesic. A total of 54.5% reported their symptoms subsided, but 13.6% reported their symptoms remained.

CONCLUSIONS

A significant number of older adults with chronic pain self-manage their analgesic related ADE without contacting their primary care provider. Analgesic related ADE prevention and management should be discussed during primary care visits to reduce ADEs and enhance pain management outcomes for older adults with chronic pain.

Efficacy and Safety of Daikenchuto for Constipation and Dose-Dependent Differences in Clinical Effects

Background

Daikenchuto (DKT) is a Kampo medicine used for the treatment of constipation. In this study, we evaluated the effectiveness of DKT against constipation.

Patients and Methods

Thirty-three patients administered DKT for constipation were selected and divided into low-dose (7.5 g DKT; n = 22) and high-dose (15 g DKT; n = 11) groups. We retrospectively evaluated weekly defaecation frequency, side effects, and clinical laboratory data.

Results

Median defaecation frequencies after DKT administration (5, 5.5, 5, and 8 for the first, second, third, and fourth weeks, resp.) were significantly higher than that before DKT administration (2) in all 33 cases (P < 0.01). One case (3%) of watery stool, one case of loose stools (3%), and no cases of abdominal pain (0%) were observed. Median defaecation frequencies in the high-dose group (7 and 9) were significantly higher than those in the low-dose group (4 and 3) in the first (P = 0.0133) and second (P = 0.0101) weeks, respectively. There was no significant change in clinical laboratory values.

Conclusion

We suggest that DKT increases defaecation frequency and is safe for treating constipation.