Chronic constipation and treatment options (Review)

Shouhui Tongbian Capsules induce regression of inflammation to improve intestinal barrier in mice with constipation by targeted binding to Prkaa1: With no obvious toxicity

Constipation arising from the poor bowel movement is a rife enteric health problem. Shouhui Tongbian Capsule (SHTB) is a traditional Chinese medicine (TCM) which effectively improve the symptoms of constipation. However, the mechanism has not been fully evaluated. The purpose of this study was to evaluate the effect of SHTB on the symptoms and intestinal barrier of mice with constipation. Our data showed that SHTB effectively improved the constipation induced by diphenoxylate, which was confirmed by shorter first defecation time, higher internal propulsion rate and fecal water content. Additionally, SHTB improved the intestinal barrier function, which was manifested by inhibiting the leakage of Evans blue in intestinal tissues and increasing the expression of occludin and ZO-1. SHTB inhibited NLRP3 inflammasome signaling pathway and TLR4/NF-κB signaling pathway, reduced the number of proinflammatory cell subsets and increased the number of immunosuppressive cell subsets to relieve inflammation. The photochemically induced reaction coupling system combined with cellular thermal shift assay and central carbon metabolomics technology confirmed that SHTB activated AMPKα through targeted binding to Prkaa1 to regulate Glycolysis/Gluconeogenesis and Pentose Phosphate Pathway, and finally inhibited intestinal inflammation. Finally, no obvious toxicity related to SHTB was found in a repeated drug administration toxicity test for consecutive 13 weeks. Collectively, we reported SHTB as a TCM targeting Prkaa1 for anti-inflammation to improve intestinal barrier in mice with constipation. These findings broaden our knowledge of Prkaa1 as a druggable target protein for inflammation inhibition, and open a new avenue to novel therapy strategy for constipation injury.

Exploring Molecular Mechanisms of Aloe barbadmsis Miller on Diphenoxylate-Induced Constipation in Mice

Aloe barbadensis Miller (Aloe) known as a common succulent perennial herb had been traditionally used in constipation for more than 1,000 years. Aloe contained anthraquinones and other active compounds which had laxative effect and could modulate constipation. However, the therapeutic effects and mechanisms of aloe in constipation were still unclear. To explore the therapeutic effects and mechanisms of aloe in treating constipation, we employed network pharmacology, molecular docking, and mice experiments in this study. Our network pharmacology indicated that beta-carotene, sitosterol, campest-5-en-3beta-ol, CLR, arachidonic acid, aloe-emodin, quercetin, and barbaloin were the main active ingredients of aloe in treating constipation. Besides, the MAPK signaling pathway was the principal pathway utilized by aloe in treating constipation. Molecular docking results revealed that beta-carotene and sitosterol were acting as interference factors in attenuating inflammation by binding to an accessory protein of ERK, JNK, AKT, and NF-κB p65. Otherwise, in vivo experiments, we used diphenoxylate-induced constipation mice model to explore the therapeutic effects and mechanisms of aloe. Results showed that aloe modulated the constipation mice by reducing the discharge time of first melena, improving the fecal conditions, increasing the gastric intestinal charcoal transit ratio, and improving the intestinal secretion in small intestine. Besides, aloe played an important regulation in promoting intestinal motility sufficiency and the levels of neurotransmitters balance with 5-HT, SP, and VIP on constipation mice. Moreover, aloe significantly inhibited the mRNA and proteins expressions of ERK, JNK, AKT and NF-κB p65 in colon. Our study proved that aloe could reverse diphenoxylate-induced changes relating to the intestinal motility, intestinal moisture, and inhibition of the MAPK (ERK, JNK)/AKT/NF-κB p65 inflammatory pathway. Our study provided experimental evidences of the laxative effect of aloe, which was beneficial to the further research and development of aloe.

Effect of biofeedback combined with high-quality nursing in treatment of functional constipation

BACKGROUND

Functional constipation (FC) is a common functional gastrointestinal disease with various clinical manifestations. It is a physical and mental disease, which seriously affects patient physical and mental health and quality of life. Biofeedback therapy is the treatment of choice for FC, especially outlet obstructive constipation caused by pelvic floor dysfunction. High-quality nursing is a new nursing model in modern clinical work and a new concept of modern nursing service.

AIM

To explore the effect of biofeedback combined with high-quality nursing in the treatment of FC.

METHODS

A total of 100 patients with FC admitted to our hospital from March 2015 to July 2019 were selected for clinical observation. These patients were randomly divided into two groups of 50: Experimental group (biofeedback combined with high-quality nursing treatment group) and control group (biofeedback group).

RESULTS

The constipation symptom score of the experimental group was significantly lower than that of the control group, and the difference was statistically significant (P < 0.05). The anal canal resting pressure and initial defecation threshold of the experimental group were significantly lower than those of the control group, and the maximum squeeze systolic pressure of the anal canal of the experimental group was significantly higher than that of the control group (P < 0.05). The Self-Rating Anxiety Scale and Zung’s Self-Rating Depression Scale scores of the two groups were significantly lower than before treatment. The Self-Rating Anxiety Scale and Self-Rating Depression Scale scores of the experimental group were significantly lower than those of the control group (P < 0.05). The patient satisfaction score of the experimental group was significantly higher than that of the control group (P < 0.05).

CONCLUSION

The application of biofeedback combined with high-quality nursing in the treatment of FC has significant advantages over pure biofeedback treatment, and it is worthy of promotion in clinical work.

Distinctive Pathophysiology Underlying Constipation in Parkinson's Disease: Implications for Cognitive Inefficiency

Depression is associated with constipation within and outside Parkinson’s disease (PD). Since inefficient cognitive-processing (bradyphrenia) features in PD and an enterokinetic agent improved cognitive performance in healthy individuals, bradyphrenia may be associated with constipation. We aim to define the archetypical bowel function of PD, and its association with cognition, mood, and motor features within and outside PD. We assessed colonic transit time (oral radio-opaque markers over 6 days), bowel function and psychometric questionnaires and measures of PD facets, including bradyphrenia, in 58 participants with diagnosed PD, and 71 without (controls). The best abdominal X-ray (day 7) predictors of PD status were total retained marker count and transverse colon segmental delay. However, Rome functional constipation status complemented segmental delay better, giving good specificity (85%) but low sensitivity (56%). Transverse colon marker count appeared to be age-associated only in PD. In PD, those correctly classified by bowel dysfunction had higher depression scores (p = 0.02) and longer cognitive-processing times than the misclassified (p = 0.05). Controls misclassified as PD by bowel dysfunction had higher depression and anxiety scores than the correctly classified (p = 0.002 and 0.003, respectively), but not slower cognitive processing. Measures of motor features were independent of sub-classification by bowel function in PD and in controls. In conclusion, constipation in PD has distinct localized pathophysiology, and is associated with bradyphrenia.

Comparative pharmacodynamic, pharmacokinetic and tissue distribution of Dahuang-Gancao decoction in normal and experimental constipation mice

Dahuang-Gancao decoction (DGD) is a classical formula, which is commonly used for reliving constipation in Chinese clinic. The aim of this study was to investigate the pharmacodynamic, pharmacokinetic and tissue distribution alternations of DGD in normal and constipation mice. DGD exhibited stronger purgative effect in constipation mice by the increased fecal excretion and reduced first defection time compared with normal mice. The C_max, AUC_0-t and MRT_0-t of rhein, aloe-emodin, rhein-8-O-β-D-glucoside, sennoside A, and glycyrrhizic acid as main bio-active components in DGD were markedly increased in constipation mice. The tissue distribution of the analytes in constipation mice were higher than those in normal mice with rhein > rhein-8-O-β-D-glucoside > aloe-emodin > glycyrrhizic acid > emodin in liver, and glycyrrhizic acid > rhein-8-O-β-D-glucoside > liquitin > sennoside A > rhein > aloe-emodin > emodin in colon. The kidney concentrations of the analytes showed a descending order of rhein > rhein-8-O-β-D-glucoside > sennoside A > glycyrrhizic acid > aloe-emodin > emodin, most of them were higher while rhein was lower in constipation mice than normal mice. The higher exposure of the anthraquinones in plasma, liver and colon may result in the stronger purgative effect in the constipation mice than normal mice. Rhein is mainly excreted through the kidney, the decreased level of rhein in constipation mice may explain the alleviated side effects. Accumulation of glycyrrhizic acid in colon may related with the moderate property of licorice. These results provided the experimental basis for understanding the therapeutic effects and metabolite profile of DGD.

Sacral nerve stimulation with appropriate parameters improves constipation in rats by enhancing colon motility mediated via the autonomic-cholinergic mechanisms

Although sacral nerve stimulation (SNS) has been applied for treating constipation, its parameters were adopted from SNS for fecal incontinence, its effects are limited, and mechanisms are largely unknown. We investigated the effects and mechanism of SNS with appropriate parameters on constipation in rats treated with loperamide. First, using rectal compliance as an outcome measure, an experiment was performed to derive effective SNS parameters. Then, a 7-day SNS was performed in rats with constipation induced by loperamide. Autonomic functions were assessed by spectral analysis of heart rate variability (HRV) derived from an electrocardiogram. Serum levels of pancreatic polypeptide (PP), norepinephrine (NE), and acetylcholine (ACh) in colon were assessed. 1) Acute SNS at 5 Hz, 100 µs was found effective in enhancing rectal compliance and accelerating distal colon transit (P < 0.05 vs. sham SNS). 2) The 7-day SNS normalized loperamide-induced constipation, assessed by the number, weight, and water content of fecal pellets, and accelerated the distal colon transit (29.4 ± 3.7 min with sham SNS vs. 16.4 ± 5.3 min with SNS but not gastric emptying or intestinal transit. 3) SNS significantly increased vagal activity (P = 0.035) and decreased sympathetic activity (P = 0.012), assessed by spectral analysis of HRV as well as by the serum PP. 4) SNS increased ACh in the colon tissue; atropine blocked the accelerative effect of SNS on distal colon transit. We concluded that SNS with appropriate parameters improves constipation induced by loperamide by accelerating distal colon motility, mediated via the autonomic-cholinergic function.NEW & NOTEWORTHY Although sacral nerve stimulation (SNS) has been applied for treating constipation, its parameters were adopted from SNS for fecal incontinence, effects are limited, and mechanisms are largely unknown. This paper shows that SNS with appropriate parameters improves constipation induced by loperamide by accelerating distal colon motility mediated via the autonomic-cholinergic function.

Comparison of laparoscopic selective colectomy based on barium-strip examination and subtotal colectomy for adult slow-transit constipation

BACKGROUND

Surgical management of adult slow-transit constipation (ASTC) can be effective for patients with intractable symptoms. This study aimed to evaluate whether barium-strip examination and selective colectomy improved post-operative outcomes in ASTC patients in comparison with subtotal colectomy.

METHODS

A retrospective cohort study of 53 cases with refractory ASTC was conducted between June 2008 and June 2014. Patients were evaluated by the barium-strip technique, colonoscopy, defecography and anorectal manometry. Patients in the standard group underwent laparoscopic subtotal colectomy and patients in the laparoscopic selective colectomy (LSC) group underwent LSC at the precise location identified by barium strip. Spontaneous bowel movements, the Wexner Constipation Scale and the Gastrointestinal Quality of Life Index (GIQLI) were assessed post-operatively at 3, 6, 12 and 24 months.

RESULTS

A total of 49 patients were included in the analysis. The median follow-up was 37 months (range, 26-60 months). The mean post-operative hospital stay was 12 days and similar between groups (P = 0.071). The length of colon resection, operative time and intra-operative blood loss were reduced in the LSC group (all P < 0.05). No major complications occurred. A similar number of patients (24 in the standard group and 25 in the LSC group) exhibited hypoganglionosis or aganglionosis in the colon-wall muscle layer (P = 0.986). Although there were no significant differences in post-operative spontaneous bowel movements and the Wexner Constipation Scale between the two groups, the mean GIQLI of the LSC group was significantly higher at 3, 6 and 24 months post-operatively (all P < 0.05).

CONCLUSIONS

LSC based on barium-strip examination is an appropriate modality for treating ASTC.

Regulation of gastrointestinal hormones during laxative activity of gallotannin-enriched extract isolated from Galla Rhois in loperamide-induced constipation of SD rats

Regulation of gastrointestinal hormones have been reported in animal models for constipation undergoing laxative therapy when administered herbal products. We undertook to investigate whether the laxative activity of gallotannin-enriched extracts isolated from Galla Rhois (GEGR) affects the regulation of gastrointestinal hormones, by examining the concentration of four hormones and the activation of their receptors in the loperamide (Lop)-induced constipation model. Stool parameters, including number, weight and water content, were significantly recovered in the Lop+GEGR treated group, relative to the Lop+vehicle treated group; however, food intake and water consumption were maintained at a constant level. Also, a similar recovery was detected for thickness of mucosa, muscle and flat luminal surface in the Lop+GEGR treated group. Furthermore, concentration of the four gastrointestinal hormones evaluated, namely, cholecystokinin (CCK), gastrin (GAS), somatostatin (SS) and motilin (MTL), were lower in the Lop+vehicle treated group than the No treated group, but were remarkably enhanced in the Lop+GEGR treated group. Moreover, the downstream signaling pathway of MTL and SS receptors were recovered after GEGR administration. Results of the present study therefore indicate that the laxative effects of GEGR treatment may be tightly related with the regulation of gastrointestinal hormones in the Lop-induced constipation model.

Effects of a proposed physical activity and diet control to manage constipation in middle-aged obese women

BACKGROUND

Obesity is very common worldwide and is related to critical morbidity and mortality. It has a large number of impacts on the human body. Constipation has a prevalence from 4% to 29% in various parts of the world and is considered to be a major health problem, with an estimated incidence of 5% in males and 15% in females. There is a strong association between obesity and constipation. This study aimed to investigate the effect of physical activity and a low-calorie diet on constipation in middle-aged obese women.

METHODS

This study included 125 obese women (age 20-40 years) who had chronic constipation. Participants were randomly assigned to two groups. Group A included 62 women who received a suggested protocol of physical activity, a low-calorie diet, and the routine standard care for constipation, whereas Group B included 63 women who received only the standard medical care for constipation and a low-calorie diet. Both groups followed the program for 12 weeks. Changes in the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment Quality of Life (PAC-QOL) scores, and in the body mass index (BMI) were recorded in study subjects, both at baseline and at the end of the study program.

RESULTS

There were no statistically significant differences in the baseline characteristics of patients in the two groups. After 12 weeks of intervention, both groups showed significant intra-group differences (p < 0.05) in all of the measured variables, except the BMI which showed a nonsignificant difference (p > 0.05) in Group B. Between-groups comparison showed significant differences (p < 0.05) in all of the measured parameters in favor of Group A.

CONCLUSION

Physical activity and weight reduction improve PAC-SYM and PAC-QOL scores in middle-aged, premenopausal women with constipation in the short term (up to 12 weeks).

Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group

Background and aims

Opioid-induced bowel dysfunction (OIBD) is an increasing problem due to the common use of opioids for pain worldwide. It manifests with different symptoms, such as dry mouth, gastro-oesophageal reflux, vomiting, bloating, abdominal pain, anorexia, hard stools, constipation and incomplete evacuation. Opioid-induced constipation (OIC) is one of its many symptoms and probably the most prevalent. The current review describes the pathophysiology, clinical implications and treatment of OIBD.

Methods

The Nordic Working Group was formed to provide input for Scandinavian specialists in multiple, relevant areas. Seven main topics with associated statements were defined. The working plan provided a structured format for systematic reviews and included instructions on how to evaluate the level of evidence according to the GRADE guidelines. The quality of evidence supporting the different statements was rated as high, moderate or low. At a second meeting, the group discussed and voted on each section with recommendations (weak and strong) for the statements.

Results

The literature review supported the fact that opioid receptors are expressed throughout the gastrointestinal tract. When blocked by exogenous opioids, there are changes in motility, secretion and absorption of fluids, and sphincter function that are reflected in clinical symptoms. The group supported a recent consensus statement for OIC, which takes into account the change in bowel habits for at least one week rather than focusing on the frequency of bowel movements. Many patients with pain receive opioid therapy and concomitant constipation is associated with increased morbidity and utilization of healthcare resources. Opioid treatment for acute postoperative pain will prolong the postoperative ileus and should also be considered in this context. There are no available tools to assess OIBD, but many rating scales have been developed to assess constipation, and a few specifically address OIC. A clinical treatment strategy for OIBD/OIC was proposed and presented in a flowchart. First-line treatment of OIC is conventional laxatives, lifestyle changes, tapering the opioid dosage and alternative analgesics. Whilst opioid rotation may also improve symptoms, these remain unalleviated in a substantial proportion of patients. Should conventional treatment fail, mechanism-based treatment with opioid antagonists should be considered, and they show advantages over laxatives. It should not be overlooked that many reasons for constipation other than OIBD exist, which should be taken into consideration in the individual patient.

Conclusion and implications

It is the belief of this Nordic Working Group that increased awareness of adverse effects and OIBD, particularly OIC, will lead to better pain treatment in patients on opioid therapy. Subsequently, optimised therapy will improve quality of life and, from a socio-economic perspective, may also reduce costs associated with hospitalisation, sick leave and early retirement in these patients.

Constipation and Botanical Medicines: An Overview

Constipation affects 14% of the adult population globally, mainly women, and significantly impacts on health-related quality of life. The causes of constipation are mainly three: lifestyle related (functional constipation), disease related, and drug induced. Constipation can generate considerable suffering, including abdominal pain and distension, anorexia, and nausea. The value of some therapeutic measures such as increased fluid intake, physical activity, diet rich in fiber, and nutritional supplements recommended for the relief of constipation is still questionable. The treatment of constipation can be carried out not only with traditional drugs but also with herbal medicines or with nutraceuticals, which are used to prevent or treat the disorder. We have reviewed the most common botanical laxatives such as senna, cascara, frangula, aloe, and rhubarb and their use in the treatment of constipation.

Efficacy of Adaptive Biofeedback Training in Treating Constipation-Related Symptoms

Biofeedback therapy is a well-known and effective therapeutic treatment for constipation. A previous study suggested that adaptive biofeedback (ABF) training was more effective than traditional (fixed training parameters) biofeedback training. The aim of this study was to verify the effectiveness of ABF in relieving constipation-related symptoms. We noticed that in traditional biofeedback training, a patient usually receives the training twice per week. The long training sessions usually led to poor compliance. This study proposes an intensive biofeedback therapy and compares intensive therapy with nonintensive therapy in patients with constipation-related symptoms. Methods. 63 patients with constipation-related symptoms were treated with ABF between 2012 and 2013. These patients were further divided into the intensive therapy and nonintensive therapy groups. Results. A total of 63 patients were enrolled in the study, including 24 in the nonintensive therapy group and 39 in the intensive therapy group. 100% (N = 21) of constipation patients achieved the primary efficacy endpoint (≥3 bowel movements/week). There was significant improvement in constipation-related symptoms after adaptive biofeedback. The intensive biofeedback therapy did not show better performance compared to nonintensive biofeedback therapy. Conclusions. This investigation provides support for the efficacy of biofeedback for constipation-related symptoms. The efficacy of intensive therapy is similar to nonintensive therapy.

Comparison of psychological characteristics between patients with irritable bowel syndrome with constipation and those with functional constipation

AIM: To explore the difference in psychological characteristics between patients with irritable bowel syndrome with constipation (IBS-C) and those with functional constipation (FC), to seek the role of psychological factors in the pathogenesis of the two diseases, and to provide a theoretical basis for the development of individualized treatments for them.

METHODS: We retrospectively compared the psychological characteristics (depression, anxiety profiles and score for life quality) between patients with IBS-C vs those with FC using validated questionnaires. Subjects rated the intensity of digestive symptoms experienced using visual analogue scales and questionnaires. Colonic transit time measurements and anorectal manometry were performed.

RESULTS: Of the 208 consecutive constipated patients included, 102 suffered from IBS-C and 106 from FC. Demographic and physiological traits were similar between the two groups. Levels of the common symptoms such as constipation, bloating, abdominal pain and diarrhea in patients with IBS-C were higher than those in patients with FC (P < 0.05), although there was no significant difference in Bristol stool form scale or constipation symptom score (P > 0.05). Patients with FC had higher transit time in the recto-sigmoid area than IBS-C patients, although transit time in other regions was similar between the two groups. There was no significant difference in anorectal manometry measures between the two groups. Patients suffering from IBS-C reported significantly higher depression score (18.156 ± 1.476 vs 11.902 ± 1.351, P < 0.01), and high depression scores were found more frequently in the IBS-C group as compared to the FC group, although trait anxiety and state anxiety were similar between the two groups (P > 0.05). Multiple linear regression showed a positive correlation between symptom intensity and depression and anxiety scores only for FC patients.

CONCLUSION: IBS-C and FC have some differences in the psychological aspects. IBS-C patients are more depressed than patients with FC. There is a correlation between depression, anxiety and levels of symptoms in FC patients.

Transcutaneous Neuromodulation at Posterior Tibial Nerve and ST36 for Chronic Constipation

The aims of this study were to investigate the effects and possible mechanisms of transcutaneous neuromodulation (TN) in patients with chronic constipation. Twelve patients were recruited. The treatment consisted of 2-week TN and 2-week sham-TN which was performed in a crossover design. Bowel habit diary, Patient Assessment of Constipation Symptom (PAC-SYM), Patient Assessment of Constipation Quality of Life (PAC-QOL), and anorectal motility were evaluated. Electrocardiogram was recorded for the assessment of autonomic function during acute TN therapy. It was found that (1) TN improved the frequency of spontaneous defecation. After 2-week TN therapy, 83% patients had more than 3 times bowel movements per week which was significantly different from sham-TN (P = 0.01). (2) TN improved PAC-SYM and PAC-QOL scores (P < 0.001, resp.). (3) TN significantly decreased the threshold volume to elicit RAIR (P < 0.05), ameliorated rectal sensory threshold (P = 0.04), and maximum tolerance (P = 0.04). (4) TN, but not sham-TN, increased the vagal activity (P = 0.01 versus baseline) and decreased the sympathetic activity (P = 0.01, versus baseline). It was concluded that needleless TN at posterior tibial nerve and ST36 using a watch-size stimulator is effective in chronic constipation, and the effect was possibly mediated via the autonomic mechanism.

Irritable bowel syndrome: recent developments in diagnosis, pathophysiology, and treatment

The diagnosis of irritable bowel syndrome (IBS) remains a diagnosis of exclusion, whereby an extensive investigation is performed to exclude other organic diseases that may explain the symptoms of patients. Attempts to have a positive diagnosis based on symptom assessments failed to achieve widely use in clinical practice. Abnormalities in the gastrointestinal endocrine cells in IBS patients have been reported recently, providing evidence that IBS is an organic disorder, and opening the door to the use of these abnormalities as markers for a positive diagnosis of IBS. New and promising drugs for the treatment of IBS with constipation as the predominant symptom are currently on the market, and the treatment results have been satisfactory thus far.