Current Overview on Clinical Management of Chronic Constipation

The Diagnostic Yield of Laboratory Tests in Chronic Constipation in Adults

BACKGROUND

Chronic constipation is a common gastrointestinal complaint characterized by infrequent or difficult bowel movements, significantly affecting patients' quality of life. Laboratory markers offer potential diagnostic value in identifying physiological changes associated with chronic constipation, yet their effectiveness remains underexplored.

OBJECTIVES

The objective of this study was to evaluate the diagnostic value of various laboratory tests in identifying the underlying causes of chronic constipation among adults.

PATIENTS AND METHODS

A cross-sectional study was conducted at Kurdistan Private Hospital and Jeen Clinics in Duhok, Kurdistan, Iraq, from December 2022 to May 2024. A total of 132 patients meeting the Rome IV criteria for chronic constipation were included. Data collection involved demographic information, lifestyle factors, and laboratory tests, including complete blood count (CBC), thyroid stimulating hormone (TSH), serum calcium, serum potassium, serum glucose, serum creatinine, parathyroid hormone (PTH), and vitamin D levels.

RESULTS

The study population consisted of 56 males (42.4%) and 76 females (57.6%) with a mean age of 46.5 years (SD=17 years) and a range of 18-81 years. Regular exercise was performed by only 56 (42.4%) patients, 85 (64.4%) patients were drinking less than 2 liters of water per day, and 108 (81.8%) were overweight or obese. Of the study population, hypothyroidism was detected in 27 (20.4%), hyperparathyroidism in 27 (20.4%), anemia in 58 (44%), leukocytosis in 24 (18.2%), renal impairment in 48 (36.4%), hypokalemia in four (3%), hyperkalemia in 12 (9.1%), hypocalcemia in 10 (7.6%), hypercalcemia in 12 (9.1%), impaired fasting glucose in 46 (34.8%), hyperglycemia in 21 (15.9%), and vitamin D deficiency in 80 (60.6%). Of the study population, 40 (30%) patients had normal laboratory investigations panel.

CONCLUSION

In chronic constipation, laboratory tests have high diagnostic yield in adults and are essential for ruling out secondary causes of chronic constipation. Unhealthy lifestyles are prevalent in patients with chronic constipation.

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.

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

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

An abdominal vibration combined with walking exercise (AVCWE) program for older patients with constipation: Development and feasibility study

BACKGROUND

Older patients with constipation are at higher risk for inadequate bowel preparation, but there are currently no targeted strategies. This study aims to develop an abdominal vibration combined with walking exercise (AVCWE) program and assess its feasibility among older patients with constipation.

METHODS

Phase I: Using the Delphi technique, eight experts across three professional fields were consulted to develop the AVCWE program. The experts evaluated and provided recommendations on demonstration videos and detailed descriptions of the preliminary protocol. Phase II: A single-arm feasibility study of the AVCWE program was conducted on 30 older patients with constipation undergoing colonoscopy at a tertiary hospital in China. A 10-point exercise program evaluation form and several open-ended questions were used to gather feedback from participants regarding the program. In both phases, content analysis was used to critically analyze and summarize qualitative suggestions for protocol modifications.

RESULTS

Based on feedback from the expert panel, the AVCWE program developed in Phase I included two procedures during laxative ingestion: at least 5,500 steps of walking exercise and two cycles of moderate-intensity abdominal vibration (each cycle consisted of 10 min of vibration and 10 min of rest). The feasibility study in Phase II showed high positive patient feedback scores for the program, ranging from 9.07 ± 0.74 to 9.73 ± 0.52.

CONCLUSION

The AVCWE program was developed by eight multidisciplinary experts and was well accepted by 30 older patients with constipation. Study participants believed that this program was simple, safe, appropriate, and helpful for their bowel preparation. The findings of this study may provide valuable information for optimizing bowel preparation in older patients with constipation.

A survey on functional constipation and its risk factors in older people in Shahreza, Iran

BACKGROUND

Functional constipation is prevalent among older people. It has major effects on the quality of life of them, as well as the high costs of treatment. This study investigated functional constipation and risk factors affecting older people living in Shahreza, Iran.

MATERIALS AND METHODS

This cross-sectional study was performed on 200 older people in Shahreza. They were selected by simple random sampling. We used the Rome III Criteria, the Elderly Physical Activity Questionnaire (PASE), and related questions from the SIB system (integrated health system). After completing the questionnaires, the data were analyzed using the mean and standard deviation, Chi-square test, independent-samples t-test, Fisher's exact test, and Mann-Whitney test.

RESULTS

The prevalence of functional constipation was 45%. There are significant relationships between functional constipation with dental problems (P = 0.02), intake of fluid (P = 0.001), fruits (P = 0.001), and vegetables (P < 0.001), polypharmacy (P = 0.003), and antidepressants (P = 0.008), history of colon (P = 0.003) and anal (P = 0.001) diseases, stroke or mobility disabilities (P = 0.002), the level of physical activity (P = 0.002), and gender (P = 0.04) in older people living in Shahreza.

CONCLUSIONS

According to the high prevalence of functional constipation in the studied older people, it is necessary to focus on controlling risk factors and planning to prevent the destructive effects of social restrictions on older people during the coronavirus disease 2019 (COVID-19) pandemic.

The Potential Application of Aloe Barbadensis Mill. as Chinese Medicine for Constipation: Mini-Review

Aloe barbadensis Mill. has a long history of medicinal use in the annals of traditional Chinese medicine, wherein it has garnered considerable renown. Its multifaceted therapeutic properties, characterized by its anti-inflammatory and antibacterial attributes, alongside its established efficacy as a laxative agent, have been extensively documented. This review commences with an exploration of the nomenclature, fundamental characteristics, and principal constituents of Aloe barbadensis Mill. responsible for its laxative effects. Subsequently, we delve into an extensive examination of the molecular mechanisms underlying Aloe barbadensis Mill.'s laxative properties, types of constipation treatments, commercially available preparations, considerations pertaining to toxicity, and its clinical applications. This review aims to serve as a comprehensive reference point for healthcare professionals and researchers, fostering an enhanced understanding of the optimal utilization of Aloe barbadensis Mill. in the treatment of constipation.

Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management

Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.

Exploring the connection between caffeine intake and constipation: a cross-sectional study using national health and nutrition examination survey data

BACKGROUND

Caffeine has been reported to increase gastrointestinal motility and change intestinal microbiota. Constipation may be caused by colonic motor dysfunction and colonic microbiomeis disturbances. In this study, we aimed to explore the association between caffeine intake and constipation.

METHODS

This was a cross-sectional study based on the National Health and Nutrition Examination Survey (NHANES). Caffeine intake was assessed using 24-h dietary recall method, and constipation was defined based on stool consistency or stool frequency. Logistic regression analysis was used to assess the association between caffeine intake and constipation, and results were expressed as odds ratio (OR) with 95% confidence intervals (95%CI). Subgroup analysis was performed based on age.

RESULTS

A total of 13,816 participants were finally included for analysis. After adjusting potential confounders, high intake of caffeine was found to be associated with the low odds of constipation (Q3: OR = 0.60, 95%CI: 0.49-0.74; Q4: OR = 0.77, 95%CI: 0.59-0.99; Q5: OR = 0.72, 95%CI: 0.56-0.92). The similar association was found in young people and middle-age people (P < 0.05).

CONCLUSION

High caffeine intake was associated with the low odds of constipation. Our finding indicated that individuals should develop consciousness and habit of consuming caffeinated foods and drinks to prevent and relief the constipation.

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.

Modulation of gut microbiota ecosystem by a glucan-rich snail mucin heteropolysaccharide attenuates loperamide-induced constipation

The present study aimed to investigate the effect of oral administration of snail-derived mucin extract (SM) on ameliorating constipation symptoms of loperamide-induced constipated rats (n = 6). The analytical results indicated that SM mainly contains a glucan-rich snail mucin heteropolysaccharide with high molecular weights (108.5-267.9 kDa), comprising primarily of glucose (64.9 %) and galactose (22.4 %) with some deoxyhexoses (5.0 %) and hexosamines (4.9 %). Daily SM administration at doses of 10-40 mg/kg/day to the loperamide-induced constipated rats significantly (p < 0.05) ameliorated the deterioration in fecal parameters, such as numbers and weight of feces, fecal water contents, and gastrointestinal transit ratio. The histomorphometric results showed that the loperamide-induced decreases in the thickness of mucosal and muscularis mucosae layers as well as the distribution of mucin and c-KIT-positive areas were significantly (p < 0.05) improved via SM consumption at all doses tested. SM administration at all doses significantly increased the expression of genes encoding tryptophan hydroxylases (TPH1 and TPH2; p < 0.05), tight junction molecules (OCLN, CLDN1, and TJP1; p < 0.05), and mucin (MUC2 and MUC4; p < 0.05), but significantly decreased the aquaporin-encoding genes (AQP3 and AQP8; p < 0.05). Gut microbial community analysis indicated that SM administration could modulate loperamide-induced dysbiosis by increasing the phyla Actinobacteria (11.72-12.64 % at 10-40 mg/kg doses; p < 0.05) and Firmicutes (79.33 % and 74.24 % at 20 and 40 mg/kg doses; p < 0.05) and decreasing the phyla Bacteroidetes (5.98-12.47 % at 10-40 mg/kg doses; p < 0.05) and Verrucomicrobia (2.21 % and 2.78 % at 20 and 40 mg/kg doses; p < 0.05), suggesting that SM administration is effective in ameliorating constipation by controlling gut microbial communities. These findings can be utilized as fundamental data for developing novel functional materials using SM to prevent or treat constipation.

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery

PURPOSE

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

METHODS

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

RESULTS

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

CONCLUSION

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

Rectal sensitivity and associated factors in patients with different subtypes of functional defecation disorder

OBJECTIVE

To investigate rectal sensitivity and associated factors in patients with different subtypes of functional defecation disorder (FDD).

METHODS

We segregated individuals diagnosed with FDD into two groups based on their defecation patterns: those with dyssynergic defecation and those with inadequate defecatory propulsion. We gathered general information through questionnaires and assessed rectal sensitivity using anorectal manometry. The rectal sensitivity performances of the two groups were compared; the factors related to rectal sensitivity were analyzed to determine the factors associated with rectal sensitivity, and the effect of biofeedback therapy on rectal sensitivity was clarified.

RESULTS

Rectal sensitivity in different subtypes of FDD decreased, and the difference between the two groups was not statistically significant ( P  > 0.05). There were no statistically significant differences in the first constant sensation volume, defecatory desire volume, and maximum tolerable volume between the different subtypes of FDD ( P  > 0.05). Multi-factor binary logistic regression analysis showed that age, constipation symptom score, and diabetes were all independent risk factors for decreased rectal sensitivity ( P  < 0.05). There were no statistically significant differences between the prior- and post-biofeedback therapy in the first constant sensation volume, defecatory desire volume, and maximum tolerable volume ( P  > 0.05).

CONCLUSION

Rectal sensitivity in different subtypes of FDD decreased. Age, constipation symptom score, and diabetes were independent risk factors for decreased rectal sensitivity. Short-term biofeedback therapy did not improve rectal hyposensitivity in patients with FDD.

Gastrointestinal Fermentable Polysaccharide Is Beneficial in Alleviating Loperamide-Induced Constipation in Mice

To investigate the role of gastrointestinal (GI) polysaccharide fermentation in alleviating constipation, two polysaccharide fractions were isolated from a soluble fiber extract with determined anti-constipation activity: a 2.04 kDa neutral fraction (SSP-1) contained 99.29% glucose, and a 41.66 kDa acidic fraction (SSP-2) contained 63.85% uronic acid. After mice were given loperamide for 14 d to induce constipation, the GI transit rate increased significantly in the SSP-1 group (p < 0.05) but not in the SSP-2 group. The stool weight in the SSP-2 group was significantly higher than that in SSP-1 (383.60 mg vs. 226.23 mg) (p < 0.05). Both SSP-1 and SSP-2 groups had significantly increased serum gastrin and motilin levels (p < 0.05) and changes in their fecal short-chain fatty acid (SCFA) profiles, while SSP-1 showed better fermentation properties than SSP-2 in terms of statistically higher fecal contents of acetic acid and total SCFAs (p < 0.05). Bioinformatic analysis indicated that SSP-1 upregulated bacteria such as Oscillibacter to improve SCFA metabolism and stimulate GI hormone secretion, while SSP-2 had less influence on the gut microbiota. These results suggest that the neutral polysaccharide with superior GI fermentation properties exerted beneficial effects on constipation, while the less fermentable pectic fraction might act as a stool-bulking agent.

LimosiLactobacillus pentosus Isolated from Mustard Relieves Drug-induced Constipation in Mice Fed a High-fat Diet by Modulating Enteric Neurotransmitter Function

Functional constipation is one of the most common gastrointestinal disorders. Oxidative stress can aggravate organ dysfunction. Enteric neurotransmitters have significant effects on the regulation of the enteric nervous system and intestinal muscle contraction. Oxidative stress and reduced gastrointestinal motility are considered to be one of the main causes of constipation. This study aimed to investigate whether LimosiLactobacillus pentosus CQZC02 alleviated loperamide hydrochloride (Lop)-induced constipation in mice under high-fat diet (HFD) conditions and to elucidate the underlying mechanism, focusing on enteric neurotransmitters. Four-week-old female BALB/c mice were randomly divided into five groups: normal group (Nor), constipation model group (H-Lop), L. pentosus CQZC02 low-dose group (H-Lop + ZC02L), L. pentosus CQZC02 high-dose group (H-Lop + ZC02H), and LimosiLactobacillus bulgaricus control group (H-Lop + LB). The fecal weight, water content, and total gastrointestinal transit time were measured to determine whether the mice were constipated. Small bowel and colon tissue damage was assessed by hematoxylin and eosin staining, while the degree of damage was determined by double-blind scoring. The levels of serum oxidative stress markers malondialdehyde, superoxide dismutase, glutathione peroxidase, and catalase and neurotransmitters motilin, gastrin, substance P, endothelin, somatostatin, and vasoactive intestinal peptide were measured. The gene expression levels of endothelial nitric oxide synthase, inducible nitric oxide synthase, neuronal nitric oxide synthase, nuclear factor kappa-B, and cyclooxygenase-2 in small intestine tissue were calculated. The constipation symptoms of mice in H-Lop group were manifested by a variety of physiological indicators. In addition, compared with the H-Lop group, H-Lop + ZC02H could effectively relieve the symptoms of constipation in mice. In symptom characterization, the mice in the H-Lop + ZC02H group lost weight and increased feces and water content. In functional experiments, gastrointestinal motility was enhanced; the inflammation score of intestinal tissue was decreased, and gene expression levels were modulated; serum oxidative factor levels were modulated, and oxidative stress levels were decreased.

Management of Constipation in Hospitalized Patients

Constipation is frequently encountered in hospital settings and can have potentially serious consequences yet is often underrecognized and undertreated. Opioid-induced constipation is a common cause of constipation in hospitalized patients. Opioids induce constipation through agonistic effects on enteric µ-opioid receptors. This review aims to provide insight on the identification and management of constipation in inpatient settings, with a particular focus on opioid-induced constipation. Constipation assessment should be routinely initiated at hospital admission and can be facilitated by thorough symptom assessments; relevant patient history, including recent medication use; physical examination; and patient assessment tools developed to evaluate the impact of constipation. Management of opioid-induced constipation should begin with ensuring adequate hydration and electrolyte balance and encouraging patient mobilization. Other treatments may include laxatives, enemas, intestinal secretagogues, peripherally acting µ-opioid receptor antagonists, and manual disimpaction. Surgical intervention may be required for some patients as a salvage therapy in severe, refractory cases.

Association between dietary carotenoids intake and chronic constipation in American men and women adults: a cross-sectional study

BACKGROUND

Dietary carotenoids have been proven to improve intestinal disorders like inflammatory bowel disease and colon cancer, yet little is known about the link between dietary carotenoids and constipation. This study aims to examine the relationship between dietary carotenoids intake and constipation, using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010.

METHODS

A total of 11,722 participants were enrolled. Chronic constipation was defined as type 1 (separate hard lumps, like nuts) and type 2 (sausage-like, but lumpy) in the Bristol stool form scale (BSFS). Carotenoids intake was obtained from the average of two 24-hour dietary recall questionnaires (if only one 24-hour was available, we used it) and divided into quartiles (Q). The prevalence of constipation was calculated across men and women individuals. The relationship between dietary carotenoids intake and constipation in men and women was assessed with weighted logistic regression and smoothed curve fitting after adjusting confounders, with results displayed as weighted odds ratio (OR) with 95% confidence intervals (95% CI). The model was further stratified by age, race, and HEI 2015 scores (with median as cutoff) among men and women.

RESULTS

The total weighted prevalence of chronic constipation in this study was 8.08%, 11.11% in women and 5.18% in men. After multivariable adjustment, compared with the lowest intake, participants with the highest dietary lycopene intake (ORQ4 vs. Q1= 0.55, 95% CI: 0.36-0.84, p for trend = 0.01) and total lycopene intake (ORQ4 vs. Q1 = 0.52, 95% CI: 0.34-0.80, p for trend = 0.01) were negatively associated with the risk of chronic constipation in men, whereas increased dietary α-carotene intake reduced the risk of chronic constipation in women (ORQ4 vs. Q1 = 0.69, 95% CI: 0.48-0.98, p for trend = 0.04). Smoothing curve fitting further supported these results and provided evidence of dose-response effects. No association was found between other types of carotenoids and chronic constipation in men and women.

CONCLUSIONS

Increasing lycopene intake may improve bowel function in men while increased α-carotene intake may reduce the risk of chronic constipation in women. Further studies are essential to explore the role that the intake of carotenoids plays in chronic constipation.

Symptoms and Prevalence of Constipation among Adult Population of Bangladesh

Background

Constipation is one of the most common gastrointestinal disorders. The prevalence of constipation is rapidly increasing globally. It has adverse effects on the patient's quality of life including productivity and results in a high financial hardship on the healthcare system. The aim of the study was to estimate the symptoms and prevalence of constipation among the adult population of Bangladesh.

Materials and methods

It was a cross-sectional observational study based on a structured questionnaire and a checklist. In this study, three criteria were used for the diagnosis of chronic constipation (self-reported perception, Rome III criteria, and Bristol's criteria). The study was conducted among 1,550 population between July 2019 and December 2019.

Result

The study population consisted of 1,550 respondents, among them 41.61% male and 58.39% female, and the mean age was 32.71 ± 9.72 years. In the study, 12.2% of the population was categorized to have constipation according to self-reported perception, 11.2% according to Rome III, and 10.3% reported to have been suffering from constipation according to Bristol chart.Female gender tends to have a greater prevalence than male. In multivariate analysis for constipation, betel nut chewer, alcohol consumer, diabetes mellitus, hypertension, GI surgery, and bronchial asthma were significantly (p < 0.001) associated with constipation. According to Bristol's criteria, the most common stool form was Type III (sausage-shaped with cracked surface) among the Bangladeshi population in this study.

Conclusion

Chronic constipation is a common problem worldwide. The findings of this study suggest that there is a high prevalence of constipation among the general population of Bangladesh. Decreasing modifiable risk factors of constipation can reduce its prevalence and burden of the disease. Bangladesh is markedly deficient in literature citing constipation prevalence and determinants. These findings may commence a call for setting priority as one of the major public health problems and demanding attention for both at the clinical and community levels.

How to cite this article

Ghosh DK, Sarkar DK, Nath M, et al. Symptoms and Prevalence of Constipation among Adult Population of Bangladesh. Euroasian J Hepato-Gastroenterol 2023;13(2):45-49.

Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia

Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.

Cannabis sativa L. alleviates loperamide-induced constipation by modulating the composition of gut microbiota in mice

MaZiRenWan (MZRW) is the most frequently used Traditional Chinese Medicine formula to treat chronic constipation, Cannabis sativa L. is regarded as a monarch drug in MZRW. However, the targets of Cannabis sativa L. that enhance colonic motility and improve constipation symptoms remain unknown. This study was designed to investigate the laxative effect and underlying mechanism of the water extract of Cannabis sativa L. (WECSL) using a loperamide-induced constipation mouse model. We found that WECSL treatment significantly improved intestinal motility and water-electrolyte metabolism, decreased inflammatory responses, prevented gut barrier damage, and relieved anxiety and depression in constipated mice. WECSL also structurally remodeled the composition of the gut microbiota and altered the abundance of bacteria related to inflammation, specifically Butyricicoccus and Parasutterella. Moreover, WECSL failed to relieve constipation symptoms following intestinal flora depletion, indicating that WECSL alleviates constipation symptoms depending on the gut microbiota. Our research provides a basis for WECSL to be further investigated in the treatment of constipation from the perspective of modern medicine.

The effect of probiotics on functional constipation in adults: A randomized, double-blind controlled trial

BACKGROUND

Two formulations were developed in the form of an oral sachet containing probiotics, and their efficacy and safety were evaluated in adults with functional constipation.

METHODS

One formulation with Lactobacillus acidophilus, Bifidobacterium bifidum and Lactobacillus rhamnosus (3 billion Colony Forming Units - CFU); and another with Lactobacillus acidophilus, Bifidobacterium bifidum, Lactobacillus rhamnosus, Lactobacillus paracasei, Bifidobacterium longum, Bifidobacterium lactis, Lactobacillus casei, Bifidobacterium animallis (8 billion CFU). The participants were randomized in a 3-arm parallel study and one oral sachet was auto-administered once a day for 30 days.

RESULTS

Primary outcomes were improvement in increasing the frequency of weekly bowel movements and improvement in stool quality. Secondary outcomes were number of adverse events. In the first week one observed an increase in stool frequency and in the quality of stools, showing an improvement in constipation. No statistically significant differences were observed between the three treatment groups in relation to these outcomes (P ≥ .05). Only one adverse event was observed in a patient of group 2, related to abdominal pain.

CONCLUSION

The two probiotic cocktails were effective in improving the symptoms of functional constipation, by increasing both the weekly frequency of evacuation and stool quality, and were deemed safe. Clinicaltrials.gov number: NCT04437147.

Association between overall dietary quality and constipation in American adults: a cross-sectional study

Background

Constipation seriously affects people’s life quality, and dietary adjustment has been one of the effective methods. Overall dietary quality has been reported to be associated with some diseases, while its association with constipation has not been reported. This study aims to explore the association between overall dietary quality and constipation.

Methods

A cross-sectional study was designed and data were extracted from National Health and Nutrition Examination Survey (NHANES). Overall dietary quality was assessed by healthy eating index-2015 (HEI-2015), and constipation was defined by either stool consistency or stool frequency. The association between overall dietary quality or components of HEI-2015 and constipation was assessed using logistic regression, with results expressed as odds ratio (OR) and 95% confidence intervals (95%CI). Subgroup analysis was conducted according to age and gender.

Results

A total of 13,945 participants were eligible, with 1,407 in constipation group and 12,538 in non-constipation group. Results showed that higher adherence to HEI-2015 was associated with reduced odds of constipation (OR: 0.98, 95%CI: 0.98–0.99) after adjusting potential confounders. Further, we found higher intake of total fruits, whole fruits, total vegetables, greens and beans, whole grains, total protein foods, seafood and plant proteins, and higher fatty acids ratio decreased the odds of constipation, while higher intake of sodium increased the odds (all P < 0.05). We also found negative association between HEI-2015 and constipation in participants with male sex, female sex, age ≥ 65 years, and age < 65 years (all P < 0.05).

Conclusion

We found higher adherence to HEI-2015 decreased the odds of constipation, suggesting that increasing HEI-2015 adherence may be one of effective methods to alleviate constipation.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-14360-w.

Electroacupuncture Improves Intestinal Motility through Exosomal miR-34c-5p Targeting SCF/c-Kit Signaling Pathway in Slow Transit Constipation Model Rats

Background. The pathogenesis of slow transit constipation (STC) is associated with exosomal miR-34c-5p. Electroacupuncture (EA) improves gastrointestinal motility in gastrointestinal disorders, especially STC. Our study aimed to explore the mechanism by which EA improves intestinal motility by modulating the release of exosomes and the transmission of exosomal miR-34c-5p. Methods. Fifty rats were randomly divided into five groups. STC model rats were induced, and GW4869, the exosome release inhibitor, was used to inhibit the release of exosome. The serum exosomes were authenticated under a transmission electron microscope and nanoparticle tracking analysis. RT-qPCR detected the expression of miR-34c-5p in serum exosomes and colonic tissues. The fecal number in 24 hours, Bristol scores, and intestinal transit rates were used to assess intestinal motility. Subsequently, hematoxylin and eosin (H&E) staining was used to examine the colonic mucosal histology. Finally, the expression of stem cell factor (SCF) and receptor tyrosine kinase (c-Kit) protein was measured using immunohistochemistry staining. Results. We found that EA upregulated exosomal miR-34c-5p in serum and downregulated miR-34c-5p in colonic tissues ( $P<0.01$ ). EA improved fecal numbers in 24 hours, Bristol scores, and intestinal transit rates in STC rats ( $P<0.01$ ). EA recovered the colonic histological structure and enhanced the expression of SCF and c-Kit protein ( $P<0.01$ ). The therapeutic effect of EA was attenuated after inhibiting the release of the exosome. Conclusion. Our results indicated that EA improves intestinal motility in STC rats by transporting of exosomal miR-34c-5p targeting the SCF/c-Kit signaling pathway.

Effects of Lactobacillus plantarum P9 Probiotics on Defecation and Quality of Life of Individuals with Chronic Constipation: Protocol for a Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Background

Although probiotics have been shown to improve constipation-related symptoms, a clear consensus on the use of probiotics as a constipation-relieving agent has not been reached, which is attributed to the limited available evidence and inconsistent protocols used in existing studies.

Method

A randomized, double-blind, placebo-controlled clinical trial is designed to study the efficiency and possible mechanism of action of probiotics for chronic constipation, in which 200 eligible volunteers with chronic constipation will be randomly assigned to a probiotic group (oral Lactobacillus plantarum P9 probiotic powder, 100 billion colony-forming units (CFUs)/day) or a placebo group. Volunteers, treatment distributors, data collectors, and data analysts will be blinded. The primary outcome is the weekly mean frequency of complete spontaneous bowel movements (CSBMs), and secondary outcomes include weekly mean frequency of CSBMs ≥3, weekly mean frequency of spontaneous bowel movements (SBMs), weekly mean stool appearance score, weekly mean difficulty of passing stool score, weekly percentage of volunteers who use auxiliary measures to assist with defecation (WPUAMA), quality-of-life (QOL) score, emotional status score, gut microbiome, and faecal metabolome. Each outcome measure will be assessed at the time points of preadministration (day 0), administration (day 14 and/or 28), and postadministration (day 42) to identify inter- and intragroup differences. Adverse events will be recorded to evaluate the safety of L. plantarum P9. Discussion. The protocol will provide methodological guidance for other similar studies, avoiding methodological bias and ultimately facilitating the formulation of consensus on the use of probiotics as a constipation-relieving agent. In addition, the results are more comprehensive than those of existing studies and may objectively and scientifically reflect the effectiveness of L. plantarum P9 on constipation. If the expected study findings are obtained, L. plantarum P9, taken as a probiotic, may become a complementary choice for chronically constipated patients. This trial is registered with Chinese Clinical Trial Registry (ChiCTR) (no. ChiCTR2000038396) registered on November 22, 2020, https://www.chictr.org.cn/showproj.aspx?proj=54024.

Bifidobacterium longum relieves constipation by regulating the intestinal barrier of mice

Constipation is a major health concern worldwide, requiring effective and safe treatment options. This study mainly focused on three species and nine strains of bifidobacteria from different sources to study their abilities to relieve constipation induced by loperamide in BALB/C mice. By monitoring constipation-related indicators, it was found that only Bifidobacterium longum (B. longum) relieved constipation, which indicated that bifidobacteria had inter-species differences in relieving constipation. Furthermore, through the detection of biological, chemical, mechanical, and immune barriers in mice, it was discovered that B. longum upregulates the relative abundance of 22 genera that were positively related to faecal water content, small intestinal propulsion rate, acetate, propionate, and intestinal mechanical barrier and negatively correlated with inflammatory factors, AQP8 and the time of first black stool and downregulates the relative abundance of Akkermansia. Furthermore, it increased the level of acetate in faeces and reduced the expression of AQP8 in the colon. This enhances intestinal motility and improves water and electrolyte metabolism. Meanwhile, it inhibited inflammation and prevented loperamide-induced intestinal barrier damage in constipated mice by upregulating occludin and downregulating IL-1β and TNF-α. In summary, B. longum relieved constipation by regulating the intestinal barrier in constipated mice.

The Anti-Constipation Effects of Raffino-Oligosaccharide on Gut Function in Mice Using Neurotransmitter Analyses, 16S rRNA Sequencing and Targeted Screening

Raffino-oligosaccharide (ROS), the smallest oligosaccharide of the raffinose family, is a novel food ingredient. However, the anti-constipation effects of ROS remain obscure. This study investigates the anti-constipation effects of ROS based on the loperamide-induced mice model and reveals the underlying mechanism using constipation parameters, neurotransmitter level, 16S rRNA sequencing, and the targeted screening strategy. The prevention effects were firstly investigated by the gastro-intestinal transit rate experiment (50 mice) and defecation status experiment (50 mice), which were divided into five groups (n = 10/group): blank, model, and low-, medium- and high-dose ROS. Furthermore, the slow-transit constipation experiment (blank, model, and high-dose ROS, n = 10/group) was conducted to illustrate the underlying mechanism. The results showed that ROS aided in preventing the occurrence of constipation by improving the gastro-intestinal transit rate and the defecation frequency in mice, and ROS significantly reduced the serum levels of vasoactive intestinal peptide (VIP). In addition, ROS regulated the diversity and structure of intestinal flora. Among them, one specific family and six specific genera were significantly regulated in constipated mice. The targeted screening revealed that 29 targets related to the anti-constipation effects of ROS, indicating ROS may play a role by regulating multiple targets. Furthermore, the network pharmacology analysis showed that Akt1, Stat3, Mapk8, Hsp90aa1, Cat, Alb, Icam1, Sod2, and Gsk3b can be regarded as the core anti-constipation targets. In conclusion, ROS could effectively relieve constipation, possibly by inhibiting the level of neurotransmitters and regulating the gut flora in mice. This study also provides a novel network pharmacology-based targeted screening strategy to reveal the anti-constipation effects of ROS.

Effect of Fresh Dendrobe Juice Consumption on Senile Habitual Constipation for Older People: A Four-Week Randomized Controlled Trial

Background: In Chinese medicine, it is believed that fresh dendrobe juice, which is mild in nature, can relieve the symptom of constipation. Methods: A pilot research design was conducted. Fifty-six older people with senile habitual constipation were recruited and randomly enrolled into control or experimental groups, each with 28 people. The control group was offered water routinely in a day. In addition, the experimental group received 125 mL of dendrobe juice twice a day for four weeks. Quality of life for the old people was evaluated by the Patient Assessment of Constipation Quality of Life (PAC-QOL) Score and the symptom of constipation was assessed by Wexner score. Results: The four-week intervention brought significant performance improvement in all the measured parameters in the experimental group in comparison with the control group. These included significantly more frequency and shorter durations of defecation (p < 0.01, respectively), improved quality of life based on constipation score (PAC-QOL) (experimental group: 50.41 ± 3.46 vs. control group: 70.25 ± 2.35; p < 0.05), and improved score on the Wexner constipation scale (experimental group: 6.56 ± 0.89 vs. control group: 15.50 ± 0.64; p < 0.05). Conclusions: Fresh dendrobe beverage therapy is effective in improving stool frequency, reducing duration of defecation, and enhancing quality of life.