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Bassotti G, Usai Satta P, Berti G, Lai M, Villanacci V, Bellini M. Pharmacotherapeutic advances for chronic idiopathic constipation in adults. Expert Opin Pharmacother 2022; 23:2053-2078. [PMID: 36408585 DOI: 10.1080/14656566.2022.2150076] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Gabrio Bassotti
- Gastroenterology, Hepatology & Digestive Endoscopy Section, Department of Medicine and Surgery, University of Perugia
- Gastroenterology & Hepatology Unit, Perugia General Hospital, Perugia, Italy
| | | | - Ginevra Berti
- Gastrointestina Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Mariantonia Lai
- Gastroenterology Unit, University of Cagliari, Monserrato, Italy
| | | | - Massimo Bellini
- Gastrointestina Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Soh AYS, Kang JY, Siah KTH, Scarpignato C, Gwee KA. Searching for a definition for pharmacologically refractory constipation: A systematic review. J Gastroenterol Hepatol 2018; 33:564-575. [PMID: 28960557 DOI: 10.1111/jgh.13998] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/24/2017] [Accepted: 09/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Surgery and other non-pharmacological treatments such as sacral nerve stimulation are used for the treatment of difficult-to-treat chronic constipation. Novel pharmacological therapeutic agents are also being introduced. To evaluate the efficacy of these treatments, it is imperative to have a consistent definition of pharmacologically refractory constipation. A systematic review of studies on refractory, difficult-to-treat or surgically treated constipation was carried out to determine the criteria that various authors used to define this group of patients. METHODS A systematic review was performed for literature published from June 2005 to June 2015 using PubMed, Cochrane, and Scopus databases, as well as manual searches. Studies on patients with refractory or intractable constipation were extracted. Criteria used for defining refractory constipation, as well as pharmacological agents tried including dosage, frequency, and duration, were reviewed. RESULTS Sixty-one studies were included in this review. Forty-eight involved surgical treatment of constipation, while 13 examined non-surgical therapies for refractory constipation. There is no generally accepted definition of refractory constipation. Authors consider constipation to be refractory when response to management is suboptimal, but there is no consensus on the choice of drug, order of usage, and dosage or treatment duration. Prior medical therapy was not mentioned at all in five studies. CONCLUSIONS There is need for a detailed definition of pharmacologically refractory constipation before submitting patients to invasive treatments and to evaluate new pharmacological agents.
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Affiliation(s)
- Alex Yu Sen Soh
- Department of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Jin-Yong Kang
- Department of Gastroenterology, St George's Hospital, London, UK.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kewin Tien Ho Siah
- Department of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Carmelo Scarpignato
- Clinical Pharmacology and Digestive Pathophysiology Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Kok-Ann Gwee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Brosens E, Burns AJ, Brooks AS, Matera I, Borrego S, Ceccherini I, Tam PK, García-Barceló MM, Thapar N, Benninga MA, Hofstra RMW, Alves MM. Genetics of enteric neuropathies. Dev Biol 2016; 417:198-208. [PMID: 27426273 DOI: 10.1016/j.ydbio.2016.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 12/23/2022]
Abstract
Abnormal development or disturbed functioning of the enteric nervous system (ENS), the intrinsic innervation of the gastrointestinal tract, is associated with the development of neuropathic gastrointestinal motility disorders. Here, we review the underlying molecular basis of these disorders and hypothesize that many of them have a common defective biological mechanism. Genetic burden and environmental components affecting this common mechanism are ultimately responsible for disease severity and symptom heterogeneity. We believe that they act together as the fulcrum in a seesaw balanced with harmful and protective factors, and are responsible for a continuum of symptoms ranging from neuronal hyperplasia to absence of neurons.
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Affiliation(s)
- Erwin Brosens
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Alan J Burns
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands; Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ivana Matera
- UOC Medical Genetics, Istituto Giannina Gaslini, Genova, Italy
| | - Salud Borrego
- Department of Genetics, Reproduction and Fetal Medicine, Institute of Biomedicine of Seville (IBIS), Seville, Spain; Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain
| | | | - Paul K Tam
- Division of Paediatric Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine of the University of Hong Kong, Hong Kong, China
| | - Maria-Mercè García-Barceló
- State Key Laboratory of Brain and Cognitive Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Centre for Reproduction, Development, and Growth, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Marc A Benninga
- Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Robert M W Hofstra
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands; Stem Cells and Regenerative Medicine, Birth Defects Research Centre, UCL Institute of Child Health, London, UK
| | - Maria M Alves
- Department of Clinical Genetics, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
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Liu X, Liu S, Xu Y, Liu X, Sun D. Bone morphogenetic protein 2 regulates the differentiation of nitrergic enteric neurons by modulating Smad1 signaling in slow transit constipation. Mol Med Rep 2015; 12:6547-54. [PMID: 26352281 PMCID: PMC4626182 DOI: 10.3892/mmr.2015.4297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 08/17/2015] [Indexed: 01/30/2023] Open
Abstract
Bone morphogenetic proteins (BMPs) belong to the transforming growth factor superfamily and have been implicated in chondrogenesis and neuronal differentiation. In order to examine the function of bone morphogenetic protein 2 (BMP‑2) on the differentiation of nitrergic enteric neurons in slow transit constipation (STC), the expression of BMP‑2 and neuronal nitric oxide synthase (nNOS) was investigated in the myenteric nerve plexus in STC and control tissues by immunohistochemical assays. The present study demonstrated that BMP‑2 and nNOS were expressed in the myenteric nerve plexus and their levels were differentially altered in the STC group and control group. In addition, the effect of BMP‑2 on primary myenteric neurons was investigated by measuring the neurite length. The results demonstrated that BMP‑2 regulated the differentiation of primary enteric neurons and increased the length of neurites compared with the control group. In addition, the effect of BMP‑2 on the expression of nNOS was also investigated in primary enteric neurons and the Smad1 signal transduction pathway by western blot analysis, reverse transcription quantitative polymerase chain reaction and immunofluorescence assay. The results suggested that BMP‑2 promoted the expression of nNOS in primary myenteric neurons and induced phosphorylation of Smad1. These data indicate a new role for BMP‑2 as an important transcriptional cofactor that regulates the differentiation of nitrergic enteric neurons through the Smad1 pathway. Intervention of BMP‑2 may be useful for the treatment of STC.
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Affiliation(s)
- Xuliang Liu
- Department of General Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
| | - Shangming Liu
- Department of Histology and Embryology, Shandong University School of Medicine, Jinan, Shandong 250012, P.R. China
| | - Yanan Xu
- Department of Health Care For Cadre, Qingdao Municipal Hospital, Qingdao, Shandong 266011, P.R. China
| | - Xiuqin Liu
- Department of Internal Pediatrics, Qingdao Municipal Hospital, Qingdao, Shandong 266011, P.R. China
| | - Daqing Sun
- Department of General Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
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Bassotti G, Villanacci V, Creƫoiu D, Creƫoiu SM, Becheanu G. Cellular and molecular basis of chronic constipation: Taking the functional/idiopathic label out. World J Gastroenterol 2013; 19:4099-4105. [PMID: 23864772 PMCID: PMC3710411 DOI: 10.3748/wjg.v19.i26.4099] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 04/22/2013] [Accepted: 05/19/2013] [Indexed: 02/06/2023] Open
Abstract
In recent years, the improvement of technology and the increase in knowledge have shifted several strongly held paradigms. This is particularly true in gastroenterology, and specifically in the field of the so-called “functional” or “idiopathic” disease, where conditions thought for decades to be based mainly on alterations of visceral perception or aberrant psychosomatic mechanisms have, in fact, be reconducted to an organic basis (or, at the very least, have shown one or more demonstrable abnormalities). This is particularly true, for instance, for irritable bowel syndrome, the prototype entity of “functional” gastrointestinal disorders, where low-grade inflammation of both mucosa and myenteric plexus has been repeatedly demonstrated. Thus, researchers have also investigated other functional/idiopathic gastrointestinal disorders, and found that some organic ground is present, such as abnormal neurotransmission and myenteric plexitis in esophageal achalasia and mucosal immune activation and mild eosinophilia in functional dyspepsia. Here we show evidence, based on our own and other authors’ work, that chronic constipation has several abnormalities reconductable to alterations in the enteric nervous system, abnormalities mainly characterized by a constant decrease of enteric glial cells and interstitial cells of Cajal (and, sometimes, of enteric neurons). Thus, we feel that (at least some forms of) chronic constipation should no more be considered as a functional/idiopathic gastrointestinal disorder, but instead as a true enteric neuropathic abnormality.
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Histopathology in gastrointestinal neuromuscular diseases: methodological and ontological issues. Adv Anat Pathol 2013; 20:17-31. [PMID: 23232568 DOI: 10.1097/pap.0b013e31827b65c0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastrointestinal neuromuscular diseases (GINMDs) comprise a heterogenous group of chronic conditions associated with impaired gut motility. These gastrointestinal (GI) disorders, differing for etiopathogenic mechanisms, pathologic lesions, and region of gut involvement, represent a relevant matter for public health, because they are very common, can be disabling, and determine major social and economic burdens. GINMDs are presumed or proven to arise as a result of a dysfunctioning GI neuromuscular apparatus, which includes myenteric ganglia (neurons and glial cells), interstitial cells of Cajal and smooth muscle cells. Despite the presence of symptoms related to gut dysmotility in the clinical phenotype of these patients, in the diagnostic setting scarce attention is usually paid to the morphologic pattern of the GI neuromuscular apparatus. It is also objectively difficult to collect full-thickness gut tissue samples from patients with GINMDs, because their disease, which can be only functional in nature, may not justify invasive diagnostic procedures as a first-line approach. As a consequence, whenever available, bioptic gut specimens, retrieved from these patients, must be regarded as a unique chance for obtaining relevant diagnostic information. On the basis of these arguments, there is an urgent need of standardized and validated histopathologic methods, aiming at overcoming the discrepancies affecting current approaches, which usually lead to conflicting definitions of normality and hamper the identification of disease-specific pathologic patterns. This review article intends to address current methodological and ontological issues in the histopathologic diagnosis of GINMDs, to foster the debate on how to discriminate normal morphology from abnormalities.
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Beyond hematoxylin and eosin: the importance of immunohistochemical techniques for evaluating surgically resected constipated patients. Tech Coloproctol 2011; 15:371-5. [PMID: 21766200 DOI: 10.1007/s10151-011-0721-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 06/30/2011] [Indexed: 12/18/2022]
Abstract
Chronic constipation requiring surgical ablation for intractability is often a frustrating condition from the pathologist's point of view. In fact, limiting the histological examination to only hematoxylin-eosin staining usually yields only the information that there are no abnormalities. By employing some simple and widely available immunohistochemical methods, discussed in this review, it is possible to gather data that may help in explaining the pathophysiological basis of constipation in these patients.
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Hu XD, Li XL, Sha J, Zhang AQ, Lin L. Effect of subcutaneous injection of [Ala] 16-aFGF(1-29) on slow transit constipation in mice. Shijie Huaren Xiaohua Zazhi 2011; 19:1251-1256. [DOI: 10.11569/wcjd.v19.i12.1251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the potential therapeutical effect of a new acidic fibroblast growth factor (aFGF) fragment - [Ala]16-aFGF(1-29) against slow transit constipation (STC) in mice and to explore possible mechanisms involved.
METHODS: Sixty ICR mice were divided randomly and equally into test group and control group. A mouse model of STC was established by subcutaneous injection (SC) of morphine [2.5 mg/(kg•d)] for 45 days. The control group was treated with normal saline for the same duration. The fecal character was observed according to the Bristol Stool Form Scale (BSFS), and only mice producing stools conforming to BSFS 1 and 2 were used as STC models. On day 45, six mice were chosen randomly from each group and used to confirm if STC was successfully induced by charcoal propulsion test. The rest mice in each group were divided into test group 1, test group 2, control group 1, and control group 2 (n = 12 each). The test group 1 and control group 1 were treated with [Ala]16-aFGF(1-29) (300 µg/kg each time, SC) twice per week for 8 weeks, while the test group 2 and control group 2 were treated with the same volume of vehicle. Fecal character was observed in all mice. Eight weeks later, the intestinal propulsion rate (IPR) in mice of each group was measured and the expression of neuron-specific enolase (NSE, a neuronal maker) in the colon was detected by immunohistochemistry and Western blot.
RESULTS: On day 45, the feces in the test group was drier and harder (BSFS 1 and 2) than the control group (BSFS 4 and 5). Both the IPR and expression level of NSE in the test group were significantly lower than those in the control group (63.422% ± 1.791% vs 55.702% ± 1.806%, 1.18800 ± 0.03176 vs 0.88730 ± 0.03554, 0.90520 ± 0.02268 vs 0.71300 ± 0.01654, all P < 0.05 or 0.01). Eight weeks after treatment, the feces in the test group 1 gradually became as smooth and soft (BSFS 4 and 5) as that in the control groups 1 and 2; the IPR and expression level of NSE in colonic tissue in the test group 1 were obviously improved compared to the test group 2 (62.250% ± 5.283% vs 57.190% ± 4.291%, 0.6543 ± 0.0069 vs 0.4193 ± 0.0158, 0.5823 ± 0.019 vs 0.5171 ± 0.0124, all P < 0.05) but showed no significant difference with those in the control groups 1 and 2.
CONCLUSION: Treatment with [Ala]16-aFGF (1-29) improved constipation symptoms and IPR in STC mice at least partially by protection of the enteric nervous system.
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Peeters B, Benninga MA, Hennekam RC. Childhood constipation; an overview of genetic studies and associated syndromes. Best Pract Res Clin Gastroenterol 2011; 25:73-88. [PMID: 21382580 DOI: 10.1016/j.bpg.2010.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/03/2010] [Accepted: 12/13/2010] [Indexed: 01/31/2023]
Abstract
Constipation is a common problem in children but little is known about its exact pathophysiology. Environmental, behavioural but also genetic factors are thought to play a role in the aetiology of childhood constipation. We provide an overview of genetic studies performed in constipation. Until now, linkage studies, association studies and direct gene sequencing have failed to identify mutations in specific genes associated with constipation. We show that along with functional constipation, there are numerous clinical syndromes associated with childhood constipation. These syndromic forms of constipation appear to be the result of mutations in genes affecting all aspects of the normal physiology of human defecation. We stress that syndromic causes of childhood constipation should be considered in the evaluation of a constipated child.
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Affiliation(s)
- B Peeters
- Department of Paediatric Gastrointestinal Motility and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
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Bassotti G, Villanacci V. Can "functional" constipation be considered as a form of enteric neuro-gliopathy? Glia 2010; 59:345-50. [PMID: 21264943 DOI: 10.1002/glia.21115] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 11/03/2010] [Indexed: 12/12/2022]
Abstract
Constipation has been traditionally viewed and classified as a functional or idiopathic disorder. However, evidence has been accumulating that suggests how constipation might be considered as due to abnormalities of the enteric nervous system, since alterations of this system, not evident in conventional histological examination, may be present in these patients. These abnormalities often consist in decrease or loss of the enteric glial cells, a pathological finding present in most types of constipation so far investigated. In this article we will discuss these evidences, and will try to consider constipation no more as a simple functional or idiopathic disorder but as a form of enteric neuro-gliopathy.
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Affiliation(s)
- Gabrio Bassotti
- Department of Clinical and Experimental Medicine, Gastroenterology and Hepatology Section, University of Perugia, Italy.
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Bassotti G, Villanacci V, Antonelli E, Morelli A, Salerni B. Enteric glial cells: new players in gastrointestinal motility? J Transl Med 2007; 87:628-32. [PMID: 17483847 DOI: 10.1038/labinvest.3700564] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The enteric glial cells, in addition to being support structures for the enteric nervous system, have many other additional roles, such as modulators for the homeostasis of enteric neurons, cells involved in enteric neurotransmission and antigen-presenting cells. Moreover, in the last years, data have been accumulating that demonstrate a possible active role of these cells in the pathophysiology of gastrointestinal motor activity. Thus, as also shown by recent evidence in both experimental animal models, and in some human diseases, alterations of enteric glial cells might have some role in the development of intestinal motor abnormalities.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
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