Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

Multi-omics combined to explore the purging mechanism of Rhei Radix et Rhizoma and Magnoliae Officinalis Cortex

Rhei Radix et Rhizoma and Magnoliae Officinalis Cortex have been used together to treat constipation in the clinical practices for more than 2000 years. Nonetheless, their compatibility mechanism is still unclear. In this study, the amelioration of Rhei Radix et Rhizoma combined with Magnoliae Officinalis Cortex on constipation was systematically and comprehensively evaluated. The results showed that their compatibility could markedly shorten gastrointestinal transport time, increase fecal water content and frequency of defecation, improve gastrointestinal hormone disorders and protect colon tissue of constipation rats compared with the single drug. Furthermore, according to 16S rRNA sequencing in conjunction with UPLC-Q-TOF/MS, the combination of two herbal medications could greatly raise the number of salutary bacteria (Lachnospiraceae, Romboutsia and Subdoligranulum) while decreasing the abundance of pathogenic bacteria (Erysipelatoclostridiaceae). And two herb drugs could markedly improve the disorder of fecal metabolic profiles. A total of 7 different metabolites associated with constipation were remarkably shifted by the compatibility of two herbs, which were mainly related to arachidonic acid metabolism, alpha-linolenic acid metabolism, unsaturated fatty acid biosynthesis and other metabolic ways. Thus, the regulation of intestinal microbiome and its metabolism could be a potential target for Rhei Radix et Rhizoma and Magnoliae Officinalis Cortex herb pair to treat constipation. Furthermore, the multi-omics approach utilized in this study, which integrated the microbiome and metabolome, had potential for investigating the mechanism of traditional Chinese medicines.

Plecanatide Improves Abdominal Bloating and Bowel Symptoms of Irritable Bowel Syndrome with Constipation

BACKGROUND

Bloating is a bothersome symptom in irritable bowel syndrome with constipation (IBS-C).

AIM

To evaluate plecanatide efficacy in patients with IBS-C stratified by bloating intensity.

METHODS

Pooled phase 3 data (2 randomized, controlled IBS-C trials) from adults treated with plecanatide 3 mg or placebo for 12 weeks were analyzed. Patients were stratified post-hoc by baseline bloating severity (11-point scale: mild [≤ 5] and moderate-to-severe [> 5]). Assessments included change from baseline in bloating, abdominal pain, and complete spontaneous bowel movement (CSBM) frequency. Abdominal pain and bloating composite responders were defined as patients with ≥ 30% improvement from baseline in both bloating and abdominal pain at Week 12.

RESULTS

At baseline, 1104/1436 patients with IBS-C (76.9%) reported moderate-to-severe bloating. In the moderate-to-severe bloating subgroup, plecanatide significantly reduced bloating severity versus placebo (least-squares mean change [LSMC]: - 1.7 vs - 1.3; P = 0.002), reduced abdominal pain (- 1.7 vs - 1.3; P = 0.006), and increased CSBM frequency (1.4 vs 0.8; P < 0.0001). In the mild bloating subgroup, significant improvements were observed with plecanatide versus placebo for abdominal pain (LSMC: - 1.3 vs - 1.0; P = 0.046) and CSBM frequency (2.0 vs 1.2; P = 0.003) but not bloating (- 0.9 vs - 0.8; P = 0.28). A significantly greater percentage of patients were abdominal pain and bloating composite responders with plecanatide versus placebo (moderate-to-severe bloating: 33.6% vs 26.8% [P = 0.02]; mild bloating: 38.4% vs 27.2% [P = 0.03]).

CONCLUSION

Plecanatide treatment improved IBS-C abdominal and bowel symptoms, including in those who present with moderate-to-severe bloating.

Evaluation of bidirectional gut-brain axis and anorectal function in Parkinson's disease with constipation

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative movement disorder with prodromal and highly prevalent gastrointestinal (GI) symptoms, especially constipation. Although PD models suggest gut-brain axis dysfunction, the mechanistic underpinnings and their correlation with GI symptoms are poorly understood.

AIM

To examine the bidirectional gut-brain axis function in PD and correlate it with constipation severity, PD duration, and severity.

METHODS

Rectal sensory thresholds and afferent cortical evoked potentials (CEP) were assessed using a 4-ring EMG electrode probe. Efferent anal and rectal motor evoked potentials (MEPs) were obtained following transcranial and lumbosacral magnetic stimulation. Bowel symptoms were assessed by prospective stool diary. The CEP and MEP latencies, rectal sensory thresholds, and anorectal sensorimotor data were compared between PD subjects and age-adjusted healthy subjects.

KEY RESULTS

Twenty-five PD subjects with constipation (F/M = 6/19) and 20 healthy subjects (F/M = 14/6) were enrolled. The first and pain sensation thresholds were higher in PD subjects than healthy subjects (p < 0.002) but lost significance after adjustment for age. Age-adjusted rectal CEP and right-sided cortico-anal MEP latencies were prolonged in PD subjects compared to healthy subjects (p < 0.04). Also, half (4 of 8) age-adjusted spino-anal and rectal MEP latencies in PD subjects were significantly longer. In multivariate linear analysis, first rectal sensation and right-sided MEP latencies showed moderate correlation with constipation severity.

CONCLUSIONS & INFERENCES

Parkinson's disease is associated with significant bidirectional gut-brain axis dysfunction as evidenced by prolonged afferent and efferent neuronal signaling. Constipation severity in PD is correlated to abnormal rectal sensation and lateralized disturbance of efferent brain-gut signaling.

Efficacy in bowel movement and change of gut microbiota on adult functional constipation patients treated with probiotics-containing products: a systematic review and meta-analysis

OBJECTIVES

This study aimed to pool the efficacy in bowel movement and explore the change of gut microbiota on adult functional constipated patients after probiotics-containing products treatment.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Cochrane Library for published studies and ClinicalTrials.gov for 'grey' researches were independently investigated for randomised controlled trials up to November 2022.

ELIGIBILITY CRITERIA, DATA EXTRACTION AND SYNTHESIS

The intervention was probiotics-containing product, either probiotics or synbiotics, while the control was placebo. The risk of bias was conducted. The efficacy in bowel movement was indicated by stool frequency, stool consistency and Patient Assessment of Constipation Symptom (PAC-SYM), while the change of gut microbiota was reviewed through α diversity, β diversity, change/difference in relative abundance and so on. The subgroup analysis, sensitivity analysis and random-effect meta-regression were conducted to explore the heterogeneity. The Grading of Recommendations Assessment Development and Evaluation was conducted to grade the quality of evidence.

RESULTS

17 studies, comprising 1256 participants, were included with perfect agreements between two researchers (kappa statistic=0.797). Compared with placebo, probiotics-containing products significantly increased the stool frequency (weighted mean difference, WMD 0.93, 95% CI 0.47 to 1.40, p=0.000, I²=84.5%, 'low'), improved the stool consistency (WMD 0.38, 95% CI 0.05 to 0.70, p=0.023, I²=81.6%, 'very low') and reduced the PAC-SYM (WMD -0.28, 95% CI: -0.45 to -0.11, p=0.001, I²=55.7%, 'very low'). In subgroup analysis, synbiotics was superior to probiotics to increase stool frequency. Probiotics-containing products might not affect α or β diversity, but would increase the relative abundance of specific strain.

CONCLUSIONS

Probiotics-containing products, significantly increased stool frequency, improved stool consistency, and alleviated functional constipation symptoms. They increased the relative abundance of specific strain. More high-quality head-to-head randomised controlled trials are needed.

Altered gut microbial profile is associated with differentially expressed fecal microRNAs in patients with functional constipation

While dysbiosis within the intestinal ecosystem has been associated with functional constipation (FC), the mechanisms underlying the interactions between FC and the microbiome remain poorly elucidated. Recent investigations suggested that host microRNAs (miRNAs) can modulate bacterial growth and influence the composition of the gut microbiome. To explore the connection between gut microbiota and fecal miRNAs in FC patients, we initially employed 16S rRNA sequencing to assess the gut microbial landscape in 30 FC patients and 30 healthy controls (HCs). The α-diversity within the FC group exhibited some alterations, and the β-diversity significantly differed, signifying distinctive variations in gut microbiota composition between FC patients and HCs. Subsequently, we identified 44 differentially expressed (DE) miRNAs in feces from FC patients and HCs. Through correlation analysis between DE miRNAs and FC-associated microbiota, we detected an interaction involving nine DE miRNAs (miR-205-5p, miR-493-5p, miR-215-5p, miR-184, miR-378c, miR-335-5p, miR-514a-3p, miR-141-3p, and miR-34c-5p) with seven bacterial genera (Oscillibacter, Escherichia.Shigella, UCG.002, Lachnospiraceae_NK4A136_group, Lachnospiraceae_UCG.010, Eubacterium_ruminantium_group and Megamonas), as evidenced by a co-occurrence network. Further, a comprehensive panel of seven diagnostic biomarkers (Oscillibacter, Escherichia.Shigella, UCG.002, miR-205-5p, miR-493-5p, miR-215-5p, and Lachnospiraceae_NK4A136_group) demonstrated robust discriminatory capacity in predicting FC status when integrated into a random forest model (AUC = 0.832, 95% CI: 65.73-98.88). Microbiomes correlating with DE miRNAs exhibited enrichment in distinct predicted metabolic categories. Moreover, miRNAs correlated with FC-associated bacteria were found to be enriched in signaling pathways linked to colonic contractility, including Axon guidance, PI3K-Akt signaling pathway, MAPK signaling pathway, and Hippo signaling pathway. Our study offers a comprehensive insight into the global relationship between microbiota and fecal miRNAs in the context of FC, presenting potential targets for further experimental validation and therapeutic interventions.

A Novel Vibrating Capsule Treatment for Constipation: A Review of the Literature

Constipation is a pretty common and sometimes complicated health condition around the world which is characterized by an inability to have regular bowel movements. In response to this worrying trend, various pharmacological and non-pharmacological interventions have been embraced to seek to produce promising outcomes, yet patient dissatisfaction continues to be reported. The main aim of this review paper was to determine the effectiveness and safety of the vibrating capsule in treating constipated patients. The key databases that were consulted to get articles on this subject include Google Scholar, Embase, and PubMed. Specific keywords were used in the database search to get the relevant articles. Based on the exclusion criterion, articles that were excluded include conference abstracts, commentaries, preclinical research articles, articles where full texts were inaccessible, and those that had been published in a language other than English. From the results, the safety profile of the vibrating capsule suggests that the intervention is generally well-tolerated, with only mild and transient side effects or adverse events noted, including abdominal discomfort and sensations of mild vibration. However, the impact of these adverse events (although mild to moderate) on the efficacy of the capsule remains unknown, an area requiring further scholarly attention in the future. Concerning the efficacy of the intervention, most studies were found to affirm that the vibrating capsule enhances the physiologic effects of meals and waking on bowel movements, but the need for providers in clinical environments to note the interplay between the number of vibrations and the effectiveness of the capsule or onset of complete spontaneous bowel movements could not be overemphasized. In conclusion, this paper established that the vibrating capsule is an effective and promising technology through which constipated patients could be treated while experiencing minimal or no adverse events, but future research efforts ought to seek to uncover the interplay between the mechanism of action of the capsule and any moderating role played by factors internal or external to patients, including their emotional, mental, and psychological statuses, as well as the type and quantity of food consumed before and after the vibration sessions.

Step on the accelerator: modern treatment of constipation

PURPOSE OF REVIEW

This review aims to explore effective management of constipation, examine challenges in making a positive diagnosis, and highlights the significance of a positive patient-provider relationship and emerging treatments.

RECENT FINDINGS

Less than one-fifth of patients feel satisfied with treatment of their constipation. Sixty percent of patients with functional dyspepsia and gastroparesis have severe to very severe constipation that correlates with their upper gastrointestinal symptom severity. Two gold kiwifruits are noninferior to 10 g of psyllium in the treatment of constipation. More than 40% of patients undergoing lumbar fusion continue to fill opioid prescriptions 90 days after surgery, contributing to 80 000 chronic opioid users annually. Most patients are using over-the-counter (OTC) treatments for constipation with greater than 60% dissatisfied. Pharmacologic management involves the use of GCC agonists and emerging drug classes such as bile acid transport inhibitors and sodium hydrogen exchanger isoform 3 (NHE3) inhibitors. Nonpharmacologic treatments, including neuromodulation and FDA-approved vibrating capsule, show promise in improving symptoms and quality of life.

SUMMARY

Constipation significantly impacts patients' quality of life and well being and the majority of patients are refractory to conservative measures and OTC treatments. Both pharmacologic and nonpharmacologic treatments hold promise for improving constipation and quality of life.

Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Herbal Remedies for Constipation-Predominant Irritable Bowel Syndrome: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Constipation-predominant irritable bowel syndrome (IBS-C) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits. Conventional treatments for IBS-C often provide limited efficiency, leading to an increasing interest in exploring herbal remedies. This systematic review aims to evaluate the efficacy and safety of herbal remedies in the management of IBS-C.

MATERIALS AND METHODS

A comprehensive search of PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library was conducted to identify relevant studies published up to July 2023 and data extraction was performed independently by two reviewers.

RESULTS

Overall, the included studies demonstrated some evidence of the beneficial effects of herbal remedies on IBS-C symptoms, including improvements in bowel frequency, stool consistency, abdominal pain, and quality of life. However, the heterogeneity of the interventions and outcome measures limited the ability to perform a meta-analysis.

CONCLUSION

This systematic review suggests that herbal remedies may have potential benefits in the management of IBS-C. However, the quality of evidence is limited, and further well-designed, large-scale RCTs are needed to establish the efficacy and safety of specific herbal remedies for IBS-C. Clinicians should exercise caution when recommending herbal remedies and consider individual patient characteristics and preferences.

Incidence of constipation and associated factors in the period of lockdown during COVID-19 pandemic: protocol for a systematic review and meta-analysis

INTRODUCTION

The lifestyle and habit changes that have emerged as a result of quarantine measures may have had a negative impact on defecation habits. However, there is a lack of data on combined estimates of its occurrence and prevalence.

METHODS AND ANALYSIS

We will conduct a systematic search for observational studies on PubMed/MEDLINE, Web of Science, Cochrane Library, EMBASE, CNKI, SinoMed, VIP China Science and Technology Journal database, Chinese Biomedical Databases and Wanfang Data. The search will include literature published from the inception of the databases to September 2022. Two authors will independently screen articles and extract data based on predefined inclusion and exclusion criteria. The risk of bias in the included studies will be evaluated using the Newcastle-Ottawa Scale for observational studies. Statistical analysis will be performed using Review Manager software V.5.4 and STATA V.16.0 software. Heterogeneity among studies will be assessed using the Q statistical test and I2 statistical tests. In case of significant heterogeneity, subgroup analysis and sensitivity analysis will be conducted to explore the source of heterogeneity. Sensitivity analyses will also be performed to assess the reliability of the study findings. If feasible, a meta-analysis will be conducted. Otherwise, a descriptive synthesis will be performed using a best-evidence synthesis approach. The primary outcome of interest will be the prevalence of constipation. The secondary outcomes will involve examining the association of risk factors. To evaluate potential publication bias, we will use both the Begg funnel plot and Egger's weighted regression statistics. Furthermore, to accurately assess the quality of evidence for our primary outcome, we will employ the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

This systematic review protocol will only consider published studies available in databases and will not include individual patient data. Therefore, ethical approval is not required, and the findings will be published in a peer-reviewed journal.

PROSPER REGISTRATION NUMBER

CRD42022366176.

Altered intrinsic functional brain architecture in patients with functional constipation: a surface-based network study

Background

Functional constipation (FCon) is a common functional gastrointestinal disorder (FGID). Studies have indicated a higher likelihood of psychiatric disorders, such as anxiety, depression, sleep disturbances, and impaired concentration, among patients with FCon. However, the underlying pathophysiological mechanisms responsible for these symptoms in FCon patients remain to be fully elucidated. The human brain is a complex network architecture with several fundamental organizational properties. Neurological interactions between gut symptoms and psychiatric issues may be closely associated with these complex networks.

Methods

In the present study, a total of 35 patients with FCon and 40 healthy controls (HC) were recruited for a series of clinical examinations and resting-state functional magnetic imaging (RS-fMRI). We employed the surface-based analysis (SBA) approach, utilizing the Schaefer cortical parcellation template and Tikhonov regularization. Graph theoretical analysis (GTA) and functional connectivity (FC) analysis of RS-fMRI were conducted to investigate the aberrant network alterations between the two groups. Additionally, correlation analyses were performed between the network indices and clinical variables in patients with FCon.

Results

At the global level, we found altered topological properties and networks in patients with FCon, mainly including the significantly increased clustering coefficient (CP), local efficiency (Eloc), and shortest path length (LP), whereas the decreased global efficiency (Eglob) compared to HC. At the regional level, patients with FCon exhibited increased nodal efficiency in the frontoparietal network (FPN). Furthermore, FC analysis demonstrated several functional alterations within and between the Yeo 7 networks, particularly including visual network (VN), limbic network (LN), default mode network (DMN), and somatosensory-motor network (SMN) in sub-network and large-scale network analysis. Correlation analysis revealed that there were no significant associations between the network metrics and clinical variables in the present study.

Conclusion

These results highlight the altered topological architecture of functional brain networks associated with visual perception abilities, emotion regulation, sensorimotor processing, and attentional control, which may contribute to effectively targeted treatment modalities for patients with FCon.

Plecanatide for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation: Post hoc analyses of placebo-controlled trials in adults with severe constipation

BACKGROUND

Patients with chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) often experience severe symptoms. The current aim was to evaluate plecanatide in adults with CIC or IBS-C with severe constipation.

METHODS

Data were analyzed post hoc from randomized, placebo-controlled trials (CIC [n = 2], IBS-C [n = 2]) of plecanatide 3 mg, 6 mg, or placebo administered for 12 weeks. Severe constipation was defined as no complete spontaneous bowel movements (CSBMs) and an average straining score ≥3.0 (CIC; 5-point scale) or ≥8.0 (IBS-C; 11-point scale) during a 2-week screening. Primary efficacy endpoints were durable overall CSBM responders (CIC: ≥3 CSBMs/week, plus increase from baseline of ≥1 CSBM/week, for ≥9 of 12 weeks, including ≥3 of the last 4 weeks) and overall responders (IBS-C: ≥30% reduction from baseline in abdominal pain and ≥1 CSBM/week increase for ≥6 of 12 weeks).

KEY RESULTS

Severe constipation was observed in 24.5% (646/2639) and 24.2% (527/2176) of CIC and IBS-C populations, respectively. The CIC durable overall CSBM response rate (plecanatide 3 mg, 20.9%; plecanatide 6 mg, 20.2%; placebo, 11.3%) and IBS-C overall response rate (plecanatide 3 mg, 33.0%; plecanatide 6 mg, 31.0%; placebo, 19.0%) were significantly greater with plecanatide versus placebo (p ≤ 0.01 for all). Median time to first CSBM in CIC and IBS-C populations were significantly shorter with plecanatide 3 mg versus placebo (p = 0.01 for both).

CONCLUSIONS AND INFERENCES

Plecanatide was effective in the treatment of severe constipation in adults with CIC or IBS-C.

Efficacy of washed microbiota transplantation for therapeutic targets of refractory functional constipation and the influencing factors: a single-center, retrospective, 24-week follow-up study

BACKGROUND

The efficacy of washed microbiota transplantation (WMT) in terms of refractory functional constipation (FC)-related therapeutic targets and influencing factors have not been elucidated. This study aimed to assess the efficacy and influencing factors of WMT in treating refractory FC-related therapeutic targets.

METHODS

The clinical data of patients diagnosed with refractory FC and received with WMT were retrospectively collected. The therapeutic targets included straining, hard stools, incomplete evacuation, a sense of anorectal obstruction, manual maneuvers, and decreased stool frequency. Each target was recorded as 1 (yes) or 0 (no). All patients were followed up for approximately 24 weeks from the end of the first course of WMT. The primary outcomes were the improvement rates for the individual therapeutic targets and the overall response in respect of the therapeutic targets decreased by 2 at weeks 4, 8, and 24. The secondary outcomes were the clinical remission rate (i.e., the proportion of patients with an average of 3 or more spontaneous complete bowel movements per week), clinical improvement rate (i.e., the proportion of patients with an average increase of 1 or more SCBMs/week or patients with remission), stool frequency, Wexner constipation score, Bristol Stool Form Scale (BSFS) score, and adverse events. The factors influencing the efficacy were also analyzed.

RESULTS

Overall, 63 patients with 112 WMT courses were enrolled. The improvement rates at weeks 8 and 24 were 45.6% and 35.0%, 42.9% and 38.6%, 45.0% and 35.7%, 55.6% and 44.4%, and 60.9% and 50.0%, respectively, for straining, hard stools, incomplete evacuation, a sense of anorectal obstruction, and decreased stool frequency. The overall response rates were 49.2%, 50.8%, and 42.9%, respectively, at weeks 4, 8, and 24. The rates of clinical remission and clinical improvement were 54.0% and 68.3%, respectively, at weeks 4. The stool frequency, BSFS score, and Wexner constipation score tended to improve post-WMT. Only 22 mild adverse events were observed during the 112 WMT courses and the follow-up. The number of WMT courses was identified to be the independent factor influencing the efficacy.

CONCLUSIONS

WMT is efficacious in improving refractory FC-related therapeutic targets. The effectiveness of WMT in the management of FC is enhanced with the administration of multiple courses.

Tenapanor in the Treatment of Irritable Bowel Syndrome with Constipation: Discovery, Efficacy, and Role in Management

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction (DGBI). IBS significantly impacts the quality of life of patients. Since its pathogenesis is unclear and can be multifactorial, it highlights the need for new and improved pharmaceutical drugs that not only improve bowel symptoms, but also address global IBS symptoms, such as abdominal pain. Tenapanor, a recently Food & Drug Administration (FDA)-approved medication for IBS with constipation (IBS-C), is a small molecule inhibitor of the sodium/hydrogen exchanger isoform 3 (NHE₃) that inhibits the absorption of sodium and phosphate in the gastrointestinal tract, resulting in fluid retention and softer stool. Furthermore, tenapanor reduces intestinal permeability to improve visceral hypersensitivity and abdominal pain. Due to its recent approval, tenapanor was not included in the recent IBS guidelines, however, it may be considered for IBS-C patients failing first-line treatment of soluble fiber. In this review article, we aim to provide in-depth information to the reader regarding the design of tenapanor, its development through Phase I, II and III randomized clinical trials, and its role in the treatment of IBS-C.

Parkinson's Disease and Diabetes Mellitus: Synergistic Effects on Pathophysiology and GI Motility

PURPOSE OF REVIEW

Parkinson's disease and diabetes affect an increasing proportion of the aging global population. Both conditions extensively affect gastrointestinal (GI) motility with similar and differing clinical symptoms. Nonetheless, GI symptoms in Parkinson's disease and diabetes pose significant morbidity and impairment of quality of life. Their pathophysiology is poorly understood, and therefore, effective treatment options are lacking.

RECENT FINDINGS

Parkinson's disease patients have oropharyngeal dysphagia and constipation. They also have mild or absent upper GI symptoms associated with delayed gastric emptying, which is prevalent in 70% of patients. Delayed gastric emptying in Parkinson's disease leads to erratic medication absorption and fluctuating motor symptoms. Half of diabetics have upper GI symptoms, which correlate to gastric emptying and changes in brain activity of the insular cortex. The majority of diabetics also have constipation. Diabetics have an increased risk for developing Parkinson's disease and anti-diabetic medications are associated with risk reduction of developing Parkinson's disease. Hyperglycemia is associated with advanced glycated end products formation and acceleration of α-synuclein aggregation. GLP-1 receptor agonists have also demonstrated efficacy in improving motor symptoms and cognition in Parkinson's disease patients with diabetes. Parkinson's disease and diabetes are pan-enteric disorders with significant GI symptoms and impairment of gut motility. Both conditions have synergistic pathophysiologies that propagate neurodegenerative changes. Treatment options for GI symptoms in diabetic and Parkinson's disease patients are lacking. Anti-diabetic treatment improves motor symptoms in Parkinson's disease, however, its effect on GI symptoms is unclear.

Aberrant intrinsic functional brain networks in patients with functional constipation

PURPOSE

Patients with functional constipation (FCon) often suffer from mental and psychological problems. To explore the possible neurological interaction, we used resting-state functional magnetic imaging (RS-fMRI) to compare the alterations in intrinsic brain functional networks at multiple levels between patients with FCon and healthy controls (HC).

METHODS

Twenty-eight patients with FCon and twenty-nine HC were recruited for a series of examinations and RS-fMRI. Both graph theory analysis and functional connectivity (FC) analysis were used to investigate brain functional alterations between the two groups. Correlation analyses were performed among neuropsychological scores, clinical indexes, and neuroimaging data.

RESULTS

Compared with the HC, the assortativity showed significantly increased in global level in patients with FCon. In regional level, we found obviously increased nodal degree and nodal efficiency in somatosensory network (SMN), decreased nodal degree, and increased nodal efficiency in default mode network (DMN) in the FCon group. Furthermore, FC analysis demonstrated several functional alterations within and between the networks, particularly including the SMN and visual network (VN) in sub-network and large-scale network analysis. Moreover, correlation analysis indicated that nodal metrics and aberrant FC among functional brain networks were associated with emotion and scores of constipation in patients with FCon.

CONCLUSION

All these findings reflect the differences in intrinsic brain functional networks between FCon and HC. Our study highlighted SMN, DMN, and VN as critical network and may be involved in the neurophysiology of FCon, which may contribute to improve personalized treatment in patients with FCon.

Subtyping intractable functional constipation in children using clinical and laboratory data in a classification model

Background

Children with intractable functional constipation (IFC) who are refractory to traditional pharmacological intervention develop severe symptoms that can persist even in adulthood, resulting in a substantial deterioration in their quality of life. In order to better manage IFC patients, efficient subtyping of IFC into its three subtypes, normal transit constipation (NTC), outlet obstruction constipation (OOC), and slow transit constipation (STC), at early stages is crucial. With advancements in technology, machine learning can classify IFC early through the use of validated questionnaires and the different serum concentrations of gastrointestinal motility-related hormones.

Method

A hundred and one children with IFC and 50 controls were enrolled in this study. Three supervised machine-learning methods, support vector machine, random forest, and light gradient boosting machine (LGBM), were used to classify children with IFC into the three subtypes based on their symptom severity, self-efficacy, and quality of life which were quantified using certified questionnaires and their serum concentrations of the gastrointestinal hormones evaluated with enzyme-linked immunosorbent assay. The accuracy of machine learning subtyping was evaluated with respect to radiopaque markers.

Results

Of 101 IFC patients, 37 had NTC, 49 had OOC, and 15 had STC. The variables significant for IFC subtype classification, according to SelectKBest, were stool frequency, the satisfaction domain of the Patient Assessment of Constipation Quality of Life questionnaire (PAC-QOL), the emotional self-efficacy for Functional Constipation questionnaire (SEFCQ), motilin serum concentration, and vasoactive intestinal peptide serum concentration. Among the three models, the LGBM model demonstrated an accuracy of 83.8%, a precision of 84.5%, a recall of 83.6%, a f1-score of 83.4%, and an area under the receiver operating characteristic curve (AUROC) of 0.89 in discriminating IFC subtypes.

Conclusion

Using clinical characteristics measured by certified questionnaires and serum concentrations of the gastrointestinal hormones, machine learning can efficiently classify pediatric IFC into its three subtypes. Of the three models tested, the LGBM model is the most accurate model for the classification of IFC, with an accuracy of 83.8%, demonstrating that machine learning is an efficient tool for the management of IFC in children.

Alteration of the faecal microbiota composition in patients with constipation: evidence of American Gut Project

There is limited information is known about the composition difference of the gut microbiota in patients with constipation and healthy controls. Here, the faecal 16S rRNA fastq sequence data of microbiota from the publicly available American Gut Project (AGP) were analysed. The tendency score matching (PSM) method was used to match in a 1:1 manner to control for confounding factors age, gender, body mass index (BMI), and country. A total of 524 participants including 262 patients with constipation and 262 healthy controls were included in this analysis. The richness and evenness of the gut microbiota in the constipation group were significantly lower than those in the control group. The dominant genera in the constipation group include Escherichia_Shigella, Pseudomonas, and Citrobacter. The dominant genera in the control group include Faecalibacterium, Prevotella, Roseburia, Clostridium_XlVa, and Blautia. The abundance of three butyrate production-related pathways were significantly higher in the constipation group than in the control groups. There was no significant difference in the diversity and gut microbiota composition in patients with constipation at different ages. In conclusion, patients with constipation showed gut microbiota and butyrate metabolism dysbiosis. This dysbiosis might provide a reference for the diagnosis and clinical therapy of diseases.

Biofeedback pelvic floor muscle training versus posterior tibial nerve electrostimulation in treatment of functional obstructed defecation: a prospective randomized clinical trial

Background

Functional obstructed defecation is a common anorectal problem among adult population. The objective was to compare the short-term efficacy of biofeedback pelvic floor muscle training versus transcutaneous posterior tibial nerve electrostimulation in treatment of patients with functional obstructed defecation.

Results

There were 41 patients completed the study. There were no statistical significant differences between biofeedback pelvic floor muscle training group and transcutaneous posterior tibial nerve electrostimulation group regarding different clinical characteristics, as well as, electrophysiological findings. There was statistically significant reduction in all outcome measures after intervention in both groups. The primary outcome measure was Modified obstructed defecation score. Secondary outcome measures were Patient Assessment of Constipation-Quality of Life questionnaire, time of toileting, and maximum anal pressure during straining to evacuate. No significant differences were present between both groups regarding different outcome measures in the pretreatment and post-treatment assessments. Successful outcome was reported in 81% of patients in biofeedback pelvic floor muscle training group in comparison to 40% of patients in the posterior tibial nerve electrostimulation group according to the Modified obstructed defecation score which was the primary outcome measure.

Conclusions

Both biofeedback pelvic floor muscle training and posterior tibial nerve electrostimulation are considered effective methods in the treatment of functional obstructed defecation. However, biofeedback pelvic floor muscle training seems to be more effective and superior in comparison to posterior tibial nerve electrostimulation. Posterior tibial nerve electrostimulation could be combined with biofeedback pelvic floor muscle training or considered as a second line therapy after failure of biofeedback pelvic floor muscle training.

Trial registration

Pan African Clinical Trials Registry, PACTR202009762113535. Registered 2 September 2020—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12321.

Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test

BACKGROUND

Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions.

PURPOSE

This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.

Chronic constipation that resulted in fecal impaction and colon perforation: A case report

RATIONALE

Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ.

PATIENT CONCERNS

A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids.

DIAGNOSIS

An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying.

INTERVENTIONS

Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed.

OUTCOMES

The patient had an uneventful postoperative course and was discharged in good condition.

LESSONS

Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

Preclinical Studies to Evaluate the Gut Stimulatory Activity of Aloe Musabbar

Background

Constipation is a common functional gastrointestinal disorder. Medicines derived from nature are routinely used to treat it. The present study evaluates the gut stimulatory activity of Aloe musabbar (processed powder of Aloe vera) using in vitro and in vivo models for gut stimulatory activity.

Materials and Methods

In vitro tests were conducted on isolated rat colon, guinea pig ileum, and rabbit jejunum, while in vivo study was performed using mice intestinal transit time. Aloe musabbar (A. musabbar) was tested at doses 0.2–200 mg/mL (in-vitro study) and 86.6 mg/kg (in vivo study). In vitro studies were done in the presence and absence of atropine sulphate (1 ng/ml). The results were statistically analyzed, and p < 0.05 was considered to indicate the significance.

Results

A. musabbar exhibited dose-dependent increase in the smooth muscle contraction of isolated gut tissues. Presence of atropine minimized the contractile responses and shifted the dose-response curves towards the right-hand side. The intestinal transit time in mice was observed to be increased significantly (p < 0.01) in A. musabbar-treated animals, when compared with normal animals.

Conclusion

A mild smooth muscle contraction induced by A. musabbar suggests that it can stimulate intestinal bowel movement without causing spasms. The diminished responses in the presence of atropine indicated that the gut stimulatory activity could be mediated partially through parasympathetic innervations. More studies are needed to determine the precise mechanism of action including the specific active ingredient responsible for the gut stimulatory activity.

Current Treatment Options and Therapeutic Insights for Gastrointestinal Dysmotility and Functional Gastrointestinal Disorders

Functional gastrointestinal disorders (FGIDs) have been re-named as disorders of gut-brain interactions. These conditions are not only common in clinical practice, but also in the community. In reference to the Rome IV criteria, the most common FGIDs, include functional dyspepsia (FD) and irritable bowel syndrome (IBS). Additionally, there is substantial overlap of these disorders and other specific gastrointestinal motility disorders, such as gastroparesis. These disorders are heterogeneous and are intertwined with several proposed pathophysiological mechanisms, such as altered gut motility, intestinal barrier dysfunction, gut immune dysfunction, visceral hypersensitivity, altered GI secretion, presence and degree of bile acid malabsorption, microbial dysbiosis, and alterations to the gut-brain axis. The treatment options currently available include lifestyle modifications, dietary and gut microbiota manipulation interventions including fecal microbiota transplantation, prokinetics, antispasmodics, laxatives, and centrally and peripherally acting neuromodulators. However, treatment that targets the pathophysiological mechanisms underlying the symptoms are scanty. Pharmacological agents that are developed based on the cellular and molecular mechanisms underlying pathologies of these disorders might provide the best avenue for future pharmaceutical development. The currently available therapies lack long-term effectiveness and safety for their use to treat motility disorders and FGIDs. Furthermore, the fundamental challenges in treating these disorders should be defined; for instance, 1. Cause and effect cannot be disentangled between symptoms and pathophysiological mechanisms due to current therapies that entail the off-label use of medications to treat symptoms. 2. Despite the knowledge that the microbiota in our gut plays an essential part in maintaining gut health, their exact functions in gut homeostasis are still unclear. What constitutes a healthy microbiome and further, the precise definition of gut microbial dysbiosis is lacking. More comprehensive, large-scale, and longitudinal studies utilizing multi-omics data are needed to dissect the exact contribution of gut microbial alterations in disease pathogenesis. Accordingly, we review the current treatment options, clinical insight on pathophysiology, therapeutic modalities, current challenges, and therapeutic clues for the clinical care and management of functional dyspepsia, gastroparesis, irritable bowel syndrome, functional constipation, and functional diarrhea.

Review article: irritable bowel syndrome: natural history, bowel habit stability and overlap with other gastrointestinal disorders

Symptoms of irritable bowel syndrome (IBS) characteristically fluctuate over time. We aimed to review the natural history of IBS and IBS subgroups including bowel habit disturbances, and the overlap of IBS with other gastrointestinal disorders. The community incidence of IBS is approximately 67 per 1000 person years. The prevalence of IBS is stable over time because symptoms fluctuate and there is a portion who experience resolution of their GI symptoms similar in number to those developing new-onset IBS. The proportion who report resolution of symptoms varies amongst population-based studies from 17% to 55%. There is evidence of substantial movement between subtypes of IBS. For example in a clinical trial cohort, only one in four patients retained their baseline classification throughout the study periods, two in three moved between IBS-C (constipation) and IBS-M (mixed), while over half switched between IBS-D (diarrhoea) and IBS-M. The least stable group was IBS-M. There are very limited data on drivers of bowel habit change in IBS. There are emerging evidence fluctuations in intestinal immune activity might account for symptom variability over time. It is of clinical importance to recognise the substantial overlap of IBS symptoms with other gastrointestinal syndromes including gastro-oesophageal reflux disease. This is important to ensure the correct clinical diagnosis of IBS is made and patients are not over investigated. Knowledge of the natural history, stability of subgroups and overlap of IBS with other gastrointestinal conditions should be considered in therapeutic decision making.

Chronic Idiopathic Constipation in Adults: A Review on Current Guidelines and Emerging Treatment Options

Chronic idiopathic constipation (CIC) is a common functional bowel disorder characterized by difficult, infrequent, and/or incomplete defecation. It has a great impact on the quality of life and on health care system and represents a heavy economic burden. The diagnosis is based on symptoms, classified by the Rome IV criteria. The aim of this review was to evaluate the current therapeutic guidelines for adult CIC and highlight new emerging treatments. In detail, European, French, Spanish and Korean guidelines have been identified and compared. Osmotic laxatives, and in particular polyethylene glycol, represent the first-line therapeutic approach. Stimulant laxatives are recommended as a second-line therapy. Pelvic floor rehabilitation is recommended in patients with ano-rectal dyssynergia. In patients who fail to improve with pharmacological therapies sacral nerve stimulation is considered as last chance before surgery. Surgical approach has however limited indications in selected cases. Inertia coli refractory to any approach and obstructed defecation are two subtypes which can benefit from surgery. Among emerging agents, prucalopride, a prokinetic agent, is recommended as a second-line treatment in refractory CIC patients. In addition, the secretagogues linaclotide and plecanatide and the bile acid transported inhibitor elobixibat can be effective in patients not responsive to a second-line therapeutic regimen, although they are not worldwide commercially available.