Constipation. Pathogenesis and management

Advancement of Traditional Chinese Medicine in Regulation of Intestinal Flora: Mechanism-based Role in Disease Management

Intestinal microecology is the largest and most complex human microecology. The intestinal microflora plays an important role in human health. Imbalance of intestinal microflora contributes to the occurrence and development of many diseases. Recently, the treatment of human diseases by regulating intestinal microflora has become a research topic of interest. Traditional Chinese medicine considers the whole human body as the central concept in disease treatment strategies. It advocates maintaining the coordination and balance of the functions of various organs and systems of the human body, including the intestinal microflora. Traditional Chinese medicine improves the metabolism and immune function of the human body by regulating the intestinal microflora. The intestinal microflora could trigger pharmacological activity or reduce toxicity of drugs through regulating metabolism, which enables traditional Chinese medicine formulations to exert their best therapeutic effects. This review summarized the relationship between the intestinal microflora and digestive system, tumors, and other diseases. Furthermore, the role of traditional Chinese medicine in the treatment of tumors, and other diseases is discussed. The relationship among traditional Chinese medicine and the common intestinal microflora, pathogenesis of human diseases, and effective intervention methods were elaborated. In addition, we explored the research progress of traditional Chinese medicine in the treatment of various human diseases by regulating intestinal microflora to provide new treatment concepts. There is a close relationship between traditional Chinese medicine and the intestinal microflora. Traditional Chinese medicine formulations contribute to maintain the natural balance of the intestinal tract and the intestinal microflora to achieve treatment effects. This paper summarizes the mechanism of action of traditional Chinese medicine formulations in regulating the intestinal microflora in the prevention and treatment of various diseases. Furthermore, it summarizes information on the application of the interaction between traditional Chinese medicine preparations and the regulation of intestinal microflora in the treatment of common human diseases. Intestinal microflora plays a key role in traditional Chinese medicine in maintaining the natural balance of physiology and metabolism of human body. It will provide a theoretical basis for the traditional Chinese medicine preparations in the prevention and treatment of common human diseases, and simulate future research on this aspect.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Chronic constipation in Rome IV era: The Indian perspective

Chronic constipation (CC) is a common problem in the community and in gastroenterology practice all over the world including India. After release of Rome IV guidelines in April 2016, there is increasing interest among gastroenterologists and physicians in India to look into special issues on CC in the Indian perspective. There are important differences in the bowel habit, definition, epidemiology, and pathophysiology including dietary factors and management of CC in India as compared to the West. As severity and frequency of abdominal pain, a symptom essential to diagnose constipation-predominant irritable bowel syndrome (IBS-C) rather than functional constipation (FC), is less common among Indian patients, FC is commoner than IBS-C in India. The pathophysiological mechanisms of CC may include slow colon transit, fecal evacuation disorder (FED), or a combination of these; though CC in a third to half of patients presenting to tertiary care facilities may result from these pathophysiological mechanisms, most patients presenting to primary care may have lifestyle and dietary issues. The current Rome IV algorithm dictates to explore the underlying physiological factors in the pathogenesis of functional gastrointestinal disorders including CC, which may translate to its personalized management. However, the availability of the methods to explore pathophysiological factors and manage CC caused by FED non-pharmacologically (using biofeedback) in India is limited. Though several pharmacological agents are available in India to manage CC, there are several unmet needs in its treatment. This review explores CC in India in relation to these issues, some of which are unique in the Indian perspective.

Chronic constipation: Facilitator factor for development of varicocele

AIM: To evaluate the possible relationship between varicocele and chronic constipation.

METHODS: Between April 2009 and May 2010, a total of 135 patients with varicocele or constipation and 120 healthy controls were evaluated. Patients were divided into two groups. In both groups detailed medical history was taken and all patients were examined physically by the same urologist and gastroenterologist. All of them were evaluated by color Doppler ultrasonography. All patients with constipation, except for the healthy controls of the second group, underwent a colonoscopy to identify the etiology of the constipation. In the first group, we determined the rate of chronic constipation in patients with varicocele and in the second group, the rate of varicocele in patients with chronic constipation. In both groups, the rate of the disease was compared with age-matched healthy controls. In the second group, the results of colonoscopies in the patients with chronic constipations were also evaluated.

RESULTS: In the first group, mean age of the study and control groups were 22.9 ± 4.47 and 21.8 ± 7.21 years, respectively (P < 0.05). In the second group, mean age of the study and control groups were 52.8 ± 33.3 and 51.7 ± 54.3 years, respectively (P < 0.05). In the first group, chronic constipation was observed in 8 of the 69 patients with varicocele (11.6%) and 3 out of 60 in healthy controls (5%), respectively. In this regard, there was no statistical significance between varicocele patients and the healthy control (P = 0.37). In the second group, varicocele was observed in 16 of the 66 patients with chronic constipation (24.24%) and 12 out of 60 in healthy controls (20%) respectively. Similarly, there was no statistical significance between chronic constipation and healthy controls (P = 0.72). Internal/external hemorrhoids were detected in 4 of the 16 patients with chronic constipation and varicocele, in the second group. In the remaining 50 patients with chronic constipation 9 had internal/external hemorrhoids. In this regard, there was no statistical significance between chronic constipation and healthy controls (P = 0.80).

CONCLUSION: Chronic constipation may not be a major predictive factor for the development of varicocele, but it may be a facilitator factor for varicocele.

The older person: management of constipation

Despite being a major concern for the older person, constipation is not given the attention it needs as other conditions are often deemed as more pressing. This article explores the symptom of constipation in the older patient; established management and treatment options are discussed within the context of available evidence together with new constipation management modalities.

Constipation and palliative care - where are we now?

Constipation is an unpleasant and distressing symptom that many palliative care patients may experience, often having a profound effect on their quality of life. The many management options available reflect the multifactorial nature of constipation. The article explores the complexity of constipation in palliative care and highlights the challenge of managing opioid-induced constipation. Advances in the pharmacological and non-pharmacological management of constipation are reviewed and discussed in the light of relevant research. Further discussion includes definitions, incidence and causes of constipation in palliative care.

Chronic constipation as a causative factor for development of varicocele in men: a prospective ultrasonographic study

OBJECTIVE

The purpose of this study was to determine the role of chronic constipation in the etiopathogenesis of varicocele in men.

METHODS

In this prospective study, group 1 included 25 male patients who had symptoms of chronic constipation for a mean duration +/- SD of 17.0 +/- 20.3 months (range, 3-96 months), and group 2 included 26 male subjects without any symptoms associated with constipation. All subjects were evaluated by both physical examination and scrotal ultrasonography. For the plexus pampiniformis (PP) veins, a mean diameter exceeding 2 mm and reflux for more than 1 second were accepted as suggestive findings for varicocele, as described previously.

RESULTS

Left varicocele was detected in 13 (52%) of the 25 patients in group 1 and in 5 (19%) of the 26 subjects in group 2 (P = .02). The mean diameters of the left PP veins were 2.58 +/- 0.97 mm (range, 1.2-4.3 mm) in group 1 and 1.71 +/- 0.53 mm (range, 1.0-3.0 mm) in group 2 (P < .001). A significant difference was detected between the two groups for varicocele prevalence and the mean diameter of the left PP veins.

CONCLUSIONS

Chronic constipation is a significant causative factor for the development of left varicocele, which may be attributable to the accompanying distention of the sigmoid colon and distal part of the descending colon, with resultant compression of the left testicular vein in the retroperitoneum. Therefore, we propose routine ultrasonographic examinations for the possible development of varicocele in men with chronic constipation.

Interstitial cells of cajal in patients with constipation due to total colonic inertia

Colonic wall contains interstitial cells of Cajal. In view of studies demonstrating that Cajal cells generate electric waves which are presumably responsible for colonic motor activity, and that these waves are absent in total colonic inertia, we investigated the hypothesis that colonic Cajal cells might be disordered in patients with total colonic inertia. The study comprised 28 patients (age 41.6 +/- 8.2 SD years, 19 women, 9 men) with total colonic inertia in whom total colectomy was performed. Colonic specimens obtained from normal segments of the excised colon of 24 cancer patients acted as controls. Specimens were subjected to c-kit immunohistochemistry. Controls for antisera specificity consisted of tissue incubated with normal rabbit serum that had been substituted for the primary antiserum. C-kit-positive branched Cajal-like cells were detected in the musculature of the normal colonic segments. They were distinguishable from the C-kit-negative smooth muscle cells and the C-kit-positive but unbranched mast cells. No Cajal cells were detected in colon of total colonic inertia patients. The absence of Cajal cells in patients with total colonic inertia can be assumed to explain the absence of electric waves and motile activity previously reported in these patients. Further studies are needed to investigate the cause of Cajal-cell absence.

Fecoflowmetric evaluation of anorectal function and ability to defecate in children with idiopathic chronic constipation

Idiopathic chronic constipation (ICC) is one of the most common clinical conditions in children. The pathophysiology is multifactorial and differs from case to case. To investigate the relationship between anorectal motility (ARM) and clinical course in children with ICC, anorectal function was evaluated using fecoflowmetry in nine children aged 2-14 years (mean 6.1). Three were boys and six were girls. Pressure fluctuations in the rectum and anal canal were simultaneously recorded during saline (250-500 ml) infusion into the rectum. The dynamics of defecation were evaluated using recordings of the saline evacuation curve from the rectum in each patient. Seven patients showed periodic contractions of the rectum accompanied (five) or unaccompanied (two) by relaxations of the anal canal during saline infusion. These patients achieved comfortable spontaneous defecation during follow-up periods ranging from 5 to 20 months. The other two exhibited no rectal contractions in spite of relaxations of the anal canal, and did not respond well to long-term medical management. In eight patients segmental fecoflowmetric curves showed a significantly lower flow rate and longer evacuation time than those of controls. Fecoflowmetry is a simple and non-invasive technique for evaluation of the ability to defecate. Disturbances of ARM may play an important role in patients with severe ICC. When evaluating anorectal function in children with chronic constipation, more attention should be paid to ARM and fecodynamics.

Self-prescribed laxative use: a drug-utilization review

This study was conducted to determine the reasons for the choice of self-prescribed laxatives and to acquire information on how they were used and tolerated. From November 1999 to February 2000, 70 pharmacies, uniformly located throughout the Campania region of southern Italy, distributed a questionnaire to purchasers of over-the-counter laxatives. The average age of the (mostly female) respondents was 45.9 years; 23.8% were elderly. Among the 7324 individuals who completed the survey, 77.6% selected an oral product; 22.4% preferred rectal administration. A physician influenced the choice of a laxative in 37.7% of the cases, a pharmacist in 20.5%; other suggestions came from relatives (14%), acquaintances (12.1%), advertisements (11.7%), and miscellaneous sources (4%). Only 59.8% of respondents used these drugs correctly, and 58.2% consulted a physician or pharmacist because of constipation. Adverse effects, mainly gastrointestinal symptoms, occurred in 6.1% of those surveyed. The long-term use or abuse of laxatives can cause serious medical consequences, as well as mask diseases, delaying diagnosis and appropriate treatment. Physicians, pharmacists, and other health-care personnel should counsel patients on the proper use of these easily available, ubiquitous drugs.

Evaluation of anorectal functions of children with anorectal malformations using fecoflowmetry

BACKGROUND/PURPOSE

A simple and objective method evaluating the bowel functions of patients with anorectal anomalies is necessary. The authors applied fecoflowmetry and saline enama test for patients with anorectal anomalies to evaluate the fecodynamics and anorectal motilities in these children.

METHODS

The bowel functions of 16 patients who underwent repair for anorectal malformations and 5 normal controls were evaluated by saline enema test and fecoflowmetry. The correlations between the clinical scores for the bowel functions and the parameters in fecodynamic studies were investigated.

RESULTS

Seven of 16 patients exhibited periodical contractions of the rectum synchronized with relaxations of the anal canal during saline infusion as did the controls and had significantly higher clinical scores than the other patients. Two patients with severe chronic constipation lacked rectal contractions. Among the fecoflowmetric parameters, the maximum flow, average flow, and tolerable volume of saline infused into the rectum were significantly lower in the patients with low clinical scores than those of the controls. The maximal squeeze pressure and resting anal pressure were not significantly different between the patients and controls.

CONCLUSION

Fecodynamic studies, such as fecoflowmetry and saline enema test, help in obtaining clinical indicators for the bowel functions of patients with anorectal anomalies.

Study of the motile activity of the colon in rectal inertia constipation

BACKGROUND

We have recently demonstrated that rectal distension effected left colonic contraction, which probably acts to feed the rectum with fecal matter each time the rectum distends and evacuates its contents. This effect was postulated to occur through the recto-colic reflex. As the colonic status in rectal inertia constipation was scarcely addressed in the literature, we investigated this point.

METHODS

The response of the colonic pressure to rectal balloon distension in increments of 10 mL of water was studied in 38 patients with rectal inertia constipation (IC) (age 42.6 +/- 14.3 years, 29 women) and 12 healthy volunteers (40.9 +/- 12.2 years, nine women). The rectal and colonic pressures were measured by saline-perfused tubes connected to a pneumohydraulic infusion system. The rectum was distended by a condom applied to the end of a 10-F catheter.

RESULTS

The rectal and left colonic resting pressures were significantly lower in the patients than in the controls (P < 0.5, P < 0.05, respectively). In the healthy volunteers, rectal distension up to first rectal sensation produced no significant rectal or colonic pressure changes (P > 0.05, P > 0.05). At urge, rectal and left colonic pressures increased significantly (P < 0.001, P < 0.001, respectively), but there were no changes in the right colonic pressure (P > 0.05). The colonic response lasted as long as the rectum was distended. In IC, patients did not perceive the first rectal or urge sensation up to a rectal balloon filling of 300 mL; there was no rectal or colonic pressure response (P > 0.05, P > 0.05).

CONCLUSION

In normal subjects, left colonic contraction on rectal distension probably acts to feed the rectum with fecal material. In IC, the low left colonic resting pressure assumedly points to left colonic hypotonia which appears to aggravate the constipation produced by the inertic rectum. Furthermore, non-response of the left colon to rectal distension probably impedes rectal feeding with fecal matter and enhances constipation.

Low-dose oral naloxone reverses opioid-induced constipation and analgesia

The most common side effect of opioid therapy is constipation. It is often difficult to treat and is believed to be primarily a peripheral effect. Single large doses of oral naloxone have been shown to be efficacious in reversing opioid-induced constipation. However, they often cause the unwanted side effect of analgesia reversal. This study evaluated the effects on constipation and analgesia of low doses of oral naloxone given three times daily. Patients taking stable doses of opioids with complaints of constipation were recruited for this double-blind, randomized, placebo-controlled study. Patients were given 4 mg or 2 mg of oral naloxone, or placebo, three times daily. Stool frequency and symptoms related to constipation were recorded daily. Patients also recorded the daily amount of analgesics required to maintain pain control. Nine patients were recruited for the study. All the patients who received oral naloxone had some improvement in their bowel frequency. Three of the patients also experienced reversal of analgesia, including one who had complete reversal of analgesia. This study demonstrates that reversal of analgesia still occurred despite dividing the oral naloxone into very low doses relative to the total dose of opioid used. Patients using high doses of opioids appear to be the most vulnerable to the analgesic effect of oral naloxone.

Effect of Magnetic Stimulation on the Contractile Activity of the Rectum in Humans

Magnetic stimulation (MS) has been used to activate the neuromuscular tissue by inducing an electric field. Based on the results of a recent study on a canine model (Eur Surg Res 1998;30:268–72), which demonstrated that sacral MS effected a rectal and vesical pressure rise and a drop of rectal neck (anal canal) pressure, thereby achieving evacuation, the test was performed on 28 healthy volunteers (mean age, 36.6 years; 18 men and 10 women). The rectal, rectal neck, and vesical pressures were recorded during sacral MS with a magnetic coil while the rectum was empty and distended by a balloon. Electromyographic activity of the two rectus abdominis muscles was determined to exclude the possible interference of intra-abdominal pressure with the MS recordings. Stimulation parameters were set at 70 per cent intensity, 40-Hz frequency, and 1-to 2-second burst length. Sacral MS effected significant rectal and vesical pressure rise ( P < 0.01 and P < 0.01, respectively) and drop of rectal neck pressure ( P < 0.01). Intermittent stimulation induced balloon expulsion from the rectum. The two rectus abdominis muscles did not show change in electromyographic activity during MS, indicating that the rectal and vesical pressure rise was not due to increased intra-abdominal pressure. Sacral MS induced rectal evacuation with no adverse effects. The method is simple, easy, safe, and noninvasive and is suggested to be applied for the treatment of the inertic or neuropathic rectum. As the vesical pressure proved to be elevated too, MS might also be used for rectal and vesical evacuation in patients with spinal cord lesions.

Diet and chronic constipation in children: the role of fiber

BACKGROUND

Chronic constipation is one of the most common disorders in Western countries and despite numerous clinical, pathophysiologic, and epidemiologic studies its cause is still unclear. Several hypotheses have been proposed and according to experimental studies and clinical observation, fiber intake could play a role in its pathogenesis. The purpose of this case-control study was to examine the possible correlation of idiopathic chronic constipation in children and dietary intake, particularly fiber intake.

METHODS

A randomized sample of children (291 children with constipation and 1602 controls) aged 2 to 14 years was taken from three of the 52 counties of Greece. Stratification was performed on the basis of urban, rural, or suburban location and socioeconomic status. The nutritional data were obtained from a 3-day dietary record and a dietary history. Statistical analysis was performed with multivariate tests, multivariate analysis of variance, discriminant analysis, and chi-square analysis according to the characteristics of the correlated variables.

RESULTS

Constipated children had a lower caloric and nutrient intake (p < 0.001), lower body weight/height (p < 0.001), and higher prevalence of reported anorexia (p < 0.001). Discriminant analysis indicated that dietary fiber alone was independently negatively correlated with chronic constipation, despite the age and the age of onset of constipation. Relative risk also had a negative correlation with fiber intake (p < 0.001). Of the main fiber fractions only cellulose and pentose were independently correlated with chronic constipation.

CONCLUSIONS

Lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children.

Constipation: cause and control in an acute hospital setting

Constipation is not a glamorous subject, but its prevention and management can make a vast difference to patients' quality of life. This literature review identifies causative factors and describes the mode of action, side-effects and contraindications of many remedies currently available. Recommendations include a systematic approach to management in an acute ward setting, based on assessment of risk, maintenance of normal bowel routine and appropriate dietary advice and the use of appropriate pharmaceutical interventions where necessary. To be effective, this process should be underpinned by accurate documentation and the maintenance of a high level of knowledge and awareness among staff.