Improvement In Constipation Symptoms Research Articles

Comparison of the effects of abdominal massage and osteopathic manipulative treatment home program on constipation in children with cerebral palsy.

The aim of this study is to compare the effects of osteopathic manipulative therapy home program (OMT-H) versus abdominal massage home program (AMHP) in treating constipation in children with cerebral palsy (CP). Twenty-nine children with CP with a mean age of 12.2 ± 3.76 years, who were constipated and were not on medication, were divided into three randomized groups: (i) control group (n = 10), (ii) AMHP (n = 10), and (iii) OMT-H (n = 9). In AMHP and OMT-H groups, treatment was applied as 20-min sessions every other day for 10 sessions for 3 weeks. Modified Constipation Assessment Scale (MCAS), Rome III criteria, and the Bristol Stool Form Scale (BSFS) were used for evaluation before treatment and once a week during treatment. While there was no change in constipation symptoms in the control group, there was an improvement in constipation symptoms after treatment in the AMHP and OMT-H groups (AMHP, P = 0.003; OMT-H, P = 0.000014). While the treatment showed to be effective from the first week in the OMT-H group, the change in BSFS (P = 0.026) and MCAS sub-parameters was found to be superior. AMHP and OMT-H are effective and beneficial in treating constipation. In children with CP, OMT-H was found to be quicker and more successful compared with AMHP. The OMT-H can be effectively used in clinical practice in relieving constipation in CP.

Capsules for the Diagnosis and Treatment of Gastrointestinal Motility Disorders- A Game Changer.

Over the last few decades, there have been remarkable strides in endoscopy and radiological imaging that have advanced gastroenterology. However, the management of neurogastroenterological disorders has lagged behind, in part handicapped by the use of catheter-based manometry that is both non-physiological and uncomfortable. The advent of capsule technology has been a game changer for both diagnostic and therapeutic applications. Here, we discuss several capsule devices that are available or under investigation. There are three technologies that are FDA approved. Wireless motility capsule measures pH and pressure and provides clinically impactful information regarding gastric, small intestine and colonic transit, without radiation that has been demonstrated to guide management of gastroparesis, dyspepsia and constipation. Wireless ambulatory pH monitoring capsule is currently the gold standard for assessing gastroesophageal acid reflux. In the therapeutics arena, an orally ingested vibrating capsule has been recently FDA approved for the treatment of chronic constipation, supported by a robust phase 3 clinical trial which showed significant improvement in constipation symptoms and quality of life. There are several capsules currently under investigation. Smart capsule bacterial detection system and Capscan® are capsules that can sample fluid in the small or large bowel and provide microbiome analysis for detection of small intestinal bacterial (SIBO) or fungal overgrowth (SIFO). Another investigational gas sensing capsule analyzing hydrogen, CO2, volatile fatty acids and capsule orientation, can measure regional gut transit time and luminal gas concentrations and assess gastroparesis, constipation or SIBO. Therapeutically, other vibrating capsules are in development. Innovations in capsule technology are poised to transform our ability to investigate gut function physiologically, and non-invasively deliver targeted treatment(s), thereby providing both accurate diagnostic information and luminally-directed, safe therapy.

Different microbial ecological agents change the composition of intestinal microbiota and the levels of SCFAs in mice to alleviate loperamide-induced constipation.

Probiotics exert beneficial effects by regulating the intestinal microbiota, metabolism, immune function and other ways of their host. Patients with constipation, a common gastrointestinal disorder, experience disturbances in their intestinal microbiota. In the present study, we investigated the effectiveness of two microbial ecological agents (postbiotic extract PE0401 and a combination of postbiotic extract PE0401 and Lacticaseibacillus paracasei CCFM 2711) in regulating the makeup of the intestinal microbiota and alleviating loperamide hydrochloride-induced constipation in mice. We also preliminarily explored the mechanism underlying their effects. Both microbial ecological agents increased the abundance of the beneficial bacteria Lactobacilli and Bifidobacterium after administration and were able to relieve constipation. However, the degree of improvement in constipation symptoms varied depending on the makeup of the supplement. The postbiotic extract PE0401 increased peristalsis time and improved faecal properties throughout the intestinal tract of the host. PE0401 relieved constipation, possibly by modulating the levels of the constipation-related gastrointestinal regulatory transmitters mouse motilin, mouse vasoactive intestinal peptide, and 5-hydoxytryptamine in the intestinal tract of the host and by increasing the levels of the short-chain fatty acids (SCFAs) acetic acid, propionic acid, and isovaleric acid. It also increased the relative abundance of Lactobacillus and Bifidobacterium and reduced that of Faecalibaculum, Mucispirillum, Staphylococcus, and Lachnoclostridium, which are among the beneficial microbiota in the host intestine. Furthermore, PE0401 decreased the levels of constipation-induced host inflammatory factors. Therefore, the two microbial ecological agents can regulate the intestinal microbiota of constipation mice, and PE0401 has a stronger ability to relieve constipation.

Retrospective Analysis of Acupuncture Combined with Warm Acupuncture in The Treatment of Constipation With Defecation Disorder

Background: To compare the clinical efficacy of acupuncture combined with warm acupuncture and moxibustion and conventional acupuncture in the treatment of constipation with defecation disorder.Methods: By retrospective analysis, 60 patients with constipation with defecation disorder admitted to the Department of Acupuncture and Moxibustion in Daxing Hospital, Capital Medical University from January 2020 to March 2022 were selected. According to whether the treatment was combined with warm acupuncture therapy, 60 patients were divided into two groups, conventional acupuncture group and acupuncture combined with warm acupuncture group, with 30 cases in each group. The conventional acupuncture group was given conventional acupuncture treatment, and the acupoints were selected as follows: 1. Abdomen: Zhongwan, Qihai, Guanyuan, Tianshu (Shuang), abdominal knot (Shuang) 2. Limbs: branch groove (double), Zusanli (double), Juxu (double),Taichong (double); 3. Waist and back: Pishu (double), Danshu (double), middle (double), lower (double), needle 30min, 1 time a day. Each course was treated for 5 days with a rest for 2 days, and a total of 4 courses were treated. On the basis of the treatment in the conventional acupuncture group, warm acupuncture and moxibustion therapy was performed on the middle and lower scales (Shuang) at 1d, 3d and 5d of each course. Wexner scale and PAC-QOL scale were used to compare the constipation symptom score, quality of life score, in the two groups after treatment were lower than those before treatment (P < 0.05), and the scores in the acupuncture combined with warm acupuncture group were more ideal than those in the conventional acupuncture group (P < 0.05). After treatment, both groups achieved certain clinical efficacy, and the acupuncture combined with warm acupuncture group was better than the conventional acupuncture group (P < 0.05). Conclusion: Acupuncture combined with warm acupuncture is better than conventional acupuncture in the improvement of constipation symptoms, quality of life and effective rate.

Probiotics, prebiotics, and synbiotics in chronic constipation: Outstanding aspects to be considered for the current evidence.

This integrative aimed to evaluate the effects and the potential mechanism of action of prebiotics, probiotics, and synbiotics on constipation-associated gastrointestinal symptoms and to identify issues that still need to be answered. A literature search was performed in the PubMed database. Animal models (n = 23) and clinical trials (n = 39) were included. In animal studies, prebiotic, probiotic, and synbiotic supplementation showed a decreased colonic transit time (CTT) and an increase in the number and water content of feces. In humans, inulin is shown to be the most promising prebiotic, while B. lactis and L. casei Shirota probiotics were shown to increase defecation frequency, the latter strain being more effective in improving stool consistency and constipation symptoms. Overall, synbiotics seem to reduce CTT, increase defecation frequency, and improve stool consistency with a controversial effect on the improvement of constipation symptoms. Moreover, some aspects of probiotic use in constipation-related outcomes remain unanswered, such as the best dose, duration, time of consumption (before, during, or after meals), and matrices, as well as their effect and mechanisms on the regulation of inflammation in patients with constipation, on polymorphisms associated with constipation, and on the management of constipation via 5-HT. Thus, more high-quality randomized control trials (RCTs) evaluating these lacking aspects are necessary to provide safe conclusions about their effectiveness in managing intestinal constipation.

The effects of synbiotics on indoxyl sulphate level, constipation, and quality of life associated with constipation in chronic haemodialysis patients: a randomized controlled trial

BackgroundGut microbiota dysbiosis in patients with chronic kidney disease on haemodialysis (CKD-HD) creates an increase in proteolytic bacteria activity, leading to an increase in the production of uraemic toxins, such as indoxyl sulphate, worsening of constipation symptoms and reducing patients’ quality of life. Improving gut microbiota dysbiosis is expected to improve this condition. This study aimed to evaluate the effect of synbiotics on indoxyl sulphate levels, constipation symptoms, and constipation-related quality of life in haemodialysis patients.MethodsThis was a double-blinded randomized controlled clinical trial with a parallel design involving haemodialysis patients. We included chronic haemodialysis patients with gastrointestinal complaints, difficulty defecating, faeces with hard consistency, or a bowel movement frequency of fewer than three times per week. Patients were randomly divided into two groups (synbiotics (Lactobacillus acidophilus and Bifidobacterium longum 5x109 CFU) and placebo) for 60 days of oral intervention. All participants, caregivers, and outcome assessors were blinded to group assignment. The primary outcome was a decrease in indoxyl sulphate toxin levels. Meanwhile, improvement in constipation symptoms (measured using the Patient Assessment of Constipation: Symptoms (PAC-SYM) questionnaire) and improvement in constipation-related quality of life (measured using the Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire) were assessed as secondary outcomes.ResultsWe included 60 patients (30 intervention; median age of 51.23 (13.57) years, 33.3% male; 30 control; median age of 52.33 (11.29) years, 36.7% male). There was no significant difference in terms of pre- and postintervention indoxyl sulphate toxin levels in the synbiotics group compared to the placebo group (p=0.438). This study found an improvement in constipation symptoms (p = 0.006) and constipation-related quality of life (p=0.001) after synbiotic administration.ConclusionTwo months of synbiotic supplementation did not lower indoxyl sulphate toxin levels. Nevertheless, it had a major effect in improving constipation and quality of life affected by constipation in patients undergoing chronic haemodialysis.Trial registrationNCT04527640 (date of first registration: 26/08/2020)

Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis.

Obstructed Defecation Syndrome (ODS) is a rather complex entity concerning mainly females and causing primarily constipation. Surgical treatment in the form of Ventral Prosthesis Rectopexy (VPR) has been proposed and seems to have the best outcomes. However, the selection criteria of patients to undergo this kind of operation are not clear and the reported outcomes are mainly short-term and data on long-term outcomes is scarce. This study assesses new evidence on the efficacy of VPR for the treatment of ODS, specifically focusing on inclusion criteria for surgery and the long-term outcomes. A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VPR for ODS from 2000 to March 2020. No language restrictions were made. All studies on VPR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers. Fourteen studies including 963 patients were eligible for analysis. The immediate postoperative morbidity rate was 8.9%. A significant improvement in constipation symptoms was observed in the 12-month postoperative period for ODS (p < 0.0001). Current evidence shows that VPR offers symptomatic relief to the majority of patients with ODS, improving both constipation-like symptoms and faecal incontinence for at least 1-2years postoperatively. Some studies report on functional results after longer follow-up, showing sustainable improvement, although in a lesser extent.

478-P: Effect of Nonpharmacological Management of Chronic Constipation in Diabetic Patients

Background: Chronic constipation is highly prevalent in diabetic patients. The treatment of chronic constipation in general patients is mainly lifestyle modification and pharmacological therapy. The efficacy of non-pharmacological treatment, i.e., behavioral therapy to improve lifestyle and defecation habits, for chronic constipation in diabetic patients is not well known. This study aimed to determine the efficacy of non-pharmacological management for chronic constipation in diabetic patients. Methods: We conducted a questionnaire on defecation for diabetic patients aged 20 to 75 years at Asama General Hospital outpatient clinic. Patients diagnosed with chronic constipation according to Rome IV criteria were randomly assigned to two groups. The intervention group instructed behavior therapy to improve constipation. Specifically, we provided guidance on defecation behavior, exercise, water and dietary fiber intake, and guidance on a defecation diary recording daily defecation status. The other group received usual medical care as a control group. The questionnaire was conducted again at the next outpatient clinic. Results: Eighty of 545 diabetic patients (14.7%) had chronic constipation. The average age of constipated patients was 59.3 years, frequency of defecation 3.7 times/week, stool form (Bristol Stool Form Scale) 2.8, straining during defecations 78,8% and sensation of incomplete evacuation of defecations 42.5%. After the intervention, there was a significant increase in the frequency of defecation (4.8 vs. 3.9 times/week, P=0.008) and improvement in constipation symptoms (P=0.018) in the intervention group compared to the control group. In addition, stool form and straining during defecations were significantly improved before and after comparison within the intervention group (P &amp;lt;0.05). Conclusion: Our findings suggest that non-pharmacological management, including behavioral therapy for chronic constipation in diabetic patients, was effective. Disclosure E. Nishimori: None. M. Naka: None.

The Efficacy of Short-Duration Polyethylene Glycol plus Electrolytes for Improving Bowel Preparation of Colonoscopy in Patients with Chronic Constipation.

Materials and Methods This multicenter retrospective study was conducted from September 2019 to September 2020 at 5 related institutions among patients ≥ 20 years old diagnosed with chronic constipation whose previous colonoscopic BP had had a fair or poor Aronchick score. Two or four sachets of PEG+E (13.7 or 27.4 g/day) were prescribed for 1 week before colonoscopy. We analyzed the rate of improvement in BP, effect-related factors, spontaneous bowel movements (SBMs), stool consistency, improvement of constipation symptoms, and adverse events. Results We evaluated 106 cases (56 males) with an average age of 69.5 ± 9.4 years old (≤74 years old: 68 cases, ≥75 years old: 38 cases). The improvement rate of BP was 72.6%, and the insertion time and pain score also improved. A performance status of 1 or 2 was associated with poor BP. SBMs (times/week) increased from 4.0 ± 1.9 to 6.1 ± 2.6 (p < 0.001). The overall improvement rates of SBMs, stool consistency, symptoms of constipation, and rate of adverse events were 58.5%, 90.6%, 59.4%, and 6.6%, respectively, showing no significant differences with regard to age or gender. Conclusions Short-duration PEG+E was effective for improving poor BP and chronic constipation.

Effect of Foot Reflexology on Constipation: A Systematic Review and Meta-Analysis

Context: Constipation is a prevalent symptom of gastrointestinal disorders, which has an annoying impact on health and quality of life. On the other hand, reflexology is a popular type of complementary and alternative medicine in medical practices. Objectives: The present study aimed to assess the effect of foot reflexology on constipation symptoms. Methods: Nine databases were systematically searched to detect relevant Randomized Clinical Trials. The current used the Cochrane Risk of Bias tool to evaluate the methodological quality of the included articles. The primary outcome was the improvement of constipation symptoms. The Standardized Mean Difference (SMD) was measured, and random effects were reported instead of the fixed effects due to the high heterogeneity. Results: Out of the 693 articles retrieved from the databases and eight additional records identified through other sources, 496 titles, 48 abstracts, and 16 full-texts were reviewed, and 11 articles were included in this study, out of which nine articles entered the meta-analysis. The findings of the meta-analysis indicated that foot reflexology had a significant effect on the constipation score (SMD: -0.82; 95% CI: -1.47 to -0.17; P value = 0.0001; I2 = 93%) Conclusions: Foot reflexology can effectively improve constipation symptoms; however, clinical trials with better designs are recommended.

Impact of treatment for fecal incontinence on constipation symptoms

Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2× 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P= .17) or placebo plus biofeedback (P= .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

Benefit of Pelvic Floor Physical Therapy in Pediatric Patients with Dyssynergic Defecation Constipation

Objectives: Chronic constipation is a common childhood problem and often caused or worsened by abnormal dynamics of defecation. The aim of this study was to assess the benefit of pelvic floor physical therapy (PFPT), a novel treatment in pediatrics for the treatment of chronic constipation with dyssynergic defecation. Methods: This was a retrospective study of 69 children seen at a pediatric neurogastroenterology program of a large tertiary referral center for chronic constipation and dyssynergic defecation, determined by anorectal manometry and balloon expulsion testing. We compared the clinical outcome of patients who underwent PFPT (n = 49) to control patients (n = 20) whom received only medical treatment (laxatives/stool softeners). Additionally, characteristics of the treatment group were analyzed in relation to therapeutic response. Results: Thirty-seven (76%) of the patients who received physical therapy had improvement in constipation symptoms, compared to 5 (25%) of the patients on conservative treatment (p < 0.01). Additionally, patients who received pelvic physical therapy had fewer hospitalizations for cleanouts (4 vs. 25%, p = 0.01) and ­colonic surgery than those that were treated with medical therapy exclusively (0 vs. 10%, p = 0.03). Among the patients who received physical therapy, those that suffered from anxiety and/or low muscle tone had a higher response rate (100%). There were no adverse effects from the intervention. Conclusion: The new field of pediatric PFPT is a safe and effective intervention for children with dyssynergic defecation causing or contributing to chronic constipation, particularly in children whose comorbidities include anxiety and low ­muscle tone.

Current State of Neuromodulation for Constipation and Fecal Incontinence in Children: A Systematic Review.

Neuromodulation is the application of electrical stimulation on nerve fibers to modulate the neuronal activity. Its use for chronic constipation and fecal incontinence has increased in popularity over the past few years. Invasive and noninvasive techniques are currently available. We reviewed the current literature on the application of the neuromodulation techniques in the management of chronic constipation and fecal incontinence in children. A search of Healthcare Database Advanced Search, Embase, Medline, and Cochrane database was performed in accordance with PRISMA guideline. Terms used in the search included neuromodulation, nerve stimulation, fecal/fecal incontinence, incontinence, constipation, children, and pediatric/pediatric. Two-hundred forty-one papers were screened. Fourteen papers were included for the systematic review: seven were selected for the ISNM (implantable sacral nerve modulation) technique, one for the transcutaneous tibial nerve stimulation), one for the transcutaneous sacral nerve modulation), and five for the transcutaneous interferential sacral nerve stimulation. Results showed an overall improvement in constipation symptoms in 79 to 85.7% of patients, resolution of symptoms in 40%, reduced use of ACE stoma/transanal irrigation system in 12.5 to 38.4%, and improvement in incontinence symptoms in 75%. High complication rate was reported (17-50%) in the ISNM group. No complications were reported in the non-invasive group. Neuromodulation is a promising tool in the management of constipation refractory to medical treatment and fecal incontinence in children. Noninvasive techniques provide good results with no complications. A longer term follow-up will provide more information regarding patient compliance and sustainability of benefits of these new techniques.

Effects of psyllium vs. placebo on constipation, weight, glycemia, and lipids: A randomized trial in patients with type 2 diabetes and chronic constipation

ObjectiveTo compare the effects of baked psyllium supplementation versus those who received a placebo on constipation symptoms, body weight, glycemic and lipids control in patients with type 2 diabetes (T2D) and chronic constipation. MethodsIn a single-blinded, randomized controlled trial, 51 patients with T2D and chronic constipation with body mass index (BMI) 20–47 kg/m2 received either 10 g of psyllium pre-mixed in cookies twice per day or placebo cookies for 12 weeks. Constipation symptoms, body mass index (BMI), fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), and lipid profile were determined at the beginning and end of 4, 8, and 12-week period. Constipation was evaluated with a stool diary (ROME III). ResultsThe psyllium group showed improvement in constipation symptoms, body weight, glucose and lipid values compared with the baseline and the placebo group. Body weight and FPG decreased from baseline in the psyllium group (P < 0.001 and P = 0.056, respectively). The differences (95% CI) of absolute change of body weight (−2.0 (−3.0, −1.0) kg; P < 0.001), FPG (−13.6 (−24.3, −2.9) mg/dl; P = .040), and HbA1c (−1.7 (−2.9, −0.5)); P = 0.002) between the groups were statistically significant. Cholesterol (−21.5 (−25.6, −14.4); P < 0.001), triglycerides (−20.0 (−32.3, −7.7); P = 0.021) and constipation symptoms (1.5 (0.4, 2.3); P < 0.001) decreased in the psyllium group. The compliance was good and no adverse effects were observed. ConclusionIn patients with T2D and chronic constipation, psyllium supplementation decreased constipation symptoms, body weight, glycemic, cholesterol, and increased HDLC levels.

When all seems lost: management of refractory constipation-Surgery, rectal irrigation, percutaneous endoscopic colostomy, and more.

While the pharmacological armamentarium for chronic constipation has expanded over the past few years, a substantial proportion of constipated patients do not respond to these medications. This review summarizes the pharmacological and behavioral options for managing constipation and details the management of refractory constipation. Refractory constipation is defined as an inadequate improvement in constipation symptoms evaluated with an objective scale despite adequate therapy (ie, pharmacological and/or behavioral) that is based on the underlying pathophysiology of constipation. Minimally invasive (ie, rectal irrigation and percutaneous endoscopic colostomy) and surgical therapies are used to manage refractory constipation. This review appraises these options, and in particular, percutaneous endoscopic colostomy, which as detailed by an article in this issue, is a less invasive option for managing refractory constipation than surgery. While these options benefit some patients, the evidence of the risk: benefit profile for these therapies is limited.

Advancements in the Treatment of Constipation in Hospitalized Older Adults: Utilizing Secretagogues and Peripherally Acting Mu-Opioid Receptor Antagonists

Background: Despite its prevalence among hospitalized older adults, constipation is frequently treated with ineffective agents. Areas of Uncertainty: Although data exist to support the use of bulk and osmotic laxatives in geriatric patients, commonly used medications, such as docusate sodium, have been shown to lack clear benefit. Therapeutic Advances: Recently, investigators have developed novel agents that rely on alternative mechanisms of action to promote bowel motility. These innovative agents are rapidly becoming powerful tools in the management of constipation in older adults. Randomized control trials have demonstrated that secretory agents, including lubiprostone and linaclotide, are quite effective in the general population for the management of constipation. Limited subgroup analyses of geriatric subjects in these trials did reveal statistically significant improvement in constipation symptoms with minimal adverse effects. Additionally, with the widespread use of opioids to manage chronic pain in the geriatric population, new pharmacologic interventions have entered the market to counter the frequently encountered adverse effect of opioid-induced constipation. These compounds are known as peripherally acting mu-opioid receptor antagonists (PAMORAs) based on their mechanism of action in the gastrointestinal tract. Compounds such as methylnaltrexone and naloxegol are increasingly being used in the hospital setting for elderly patients with constipation associated with the use of opioids; however, further studies are needed to make specific recommendations regarding its use in older adults. Finally, serotonergic agents have also been extensively studied for their potential to augment gut motility, but many have been associated with an increased risk of cardiovascular events and are thus at this time not recommended as first-line therapy. Conclusions: Although promising new agents are becoming available for the treatment of this highly prevalent condition, both traditional and innovative therapies for constipation need additional study for their efficacy and safety in the elderly population.

INFLUENCE OF DRINKING A PROBIOTIC FERMENTED MILK BEVERAGE CONTAINING BIFIDOBACTERIUM ANIMALIS ON THE SYMPTOMS OF CONSTIPATION.

Constipation is a chronic problem in many patients all over the world. - To evaluate the effect of consumption of a probiotic fermented milk beverage containing Bifidobacterium animalis on the symptoms of constipation. - This randomized, double-blind controlled trial included 49 female patients aged 20 to 50 years and diagnosed with constipation according to the ROME III criteria (Diagnostic Criteria for Functional Gastrointestinal Disorders) and the Bristol Stool Form Scale. The patients were randomized into two groups: the intervention group received the probiotic fermented milk beverage and the control group received non-probiotic milk. Participants were instructed to ingest 150 mL of the beverages during 60 days. At the end of this period, patients were assessed again by the ROME III criteria and Bristol scale. The Wilcoxon test was used to evaluate pre and post-intervention results of the ROME III criteria and Bristol scale. The statistical significance level was considered as 5% ( P ≤0.05). - The intervention group showed improvement in the following criteria: straining during a bowel movement ( P <0.001), feeling of incomplete evacuation ( P <0.001) and difficulty in passing stool ( P <0.014), in addition to Bristol scale results ( P <0.001). In the control group, improvements were observed in the following criteria: straining during a bowel movement ( P <0.001), feeling of incomplete evacuation ( P <0.001) and difficulty in passing stool ( P <0.025), in addition to Bristol scale results ( P <0.001). No statistically significant post-intervention differences were observed between the two groups for the Rome III criteria and Bristol scale. - The results show that the consumption of milk resulted in the improvement of constipation symptoms, regardless of the probiotic culture.

Outcome of Biofeedback Therapy in Dyssynergic Defecation Patients With and Without Irritable Bowel Syndrome

The Rome II and III diagnostic criteria for dyssynergic defecation require the exclusion of irritable bowel syndrome (IBS). To prospectively study whether the presence of IBS affects the outcome of biofeedback therapy in dyssynergic defecation patients. Consecutive patients with dyssynergic defecation underwent biofeedback therapy. Dyssynergic defecation was diagnosed based on symptoms, anorectal manometries, balloon expulsion tests, and colonic transit studies. The defecation dynamics and balloon expulsion time were evaluated at the end of the biofeedback therapy in all patients. IBS symptoms were graded before and 4 weeks after the biofeedback therapy using a 4-point Likert scale. Failure of the biofeedback therapy was defined as <50% improvement of constipation symptoms, which were evaluated using a 10 cm long visual analog scale before and 4 weeks after biofeedback therapy. Fifty patients completed the study. The biofeedback therapy was successful in 30 patients. Twenty-nine patients fulfilled the Rome II criteria for IBS. Patients with or without IBS demonstrated similar responses to the biofeedback therapy (16 of 29 vs. 14 of 21, P>0.05). The disappearance of IBS symptoms was observed more frequently in patients with an improved defecation index compared with those with no improvement (8 of 12 vs 4 of 17, P<0.05). A high pretreatment constipation symptom score, a high rectal sensory threshold, and a delayed colonic transit time were associated with a poor treatment outcome. The presence of IBS in dyssynergic defecation did not affect the outcome of biofeedback therapy. In addition, treating dyssynergic defecation patients with IBS by biofeedback therapy improved both constipation and IBS symptoms.

Constipation symptoms before and after vaginal and abdominal pelvic reconstructive surgery

This article aims to evaluate how constipation symptoms change after pelvic reconstructive surgery using the Patient Assessment of Constipation Symptom Questionnaire (PAC-SYM). Our primary hypothesis was that constipation would improve after surgery. Ninety-four subjects completed the PAC-SYM before and 7 weeks after pelvic reconstructive surgery from 2007 through 2009 inclusive. PAC-SYM scores were compared for the cohort before and 7 weeks post-surgery and based on route of surgery: vaginal or abdominal. Baseline PAC-SYM scores between those undergoing abdominal or vaginal reconstructive surgery were not significantly different (0.76 versus 0.83, respectively; p = 0.586). Subjects in the vaginal surgery group had a significant reduction in PAC-SYM scores, 0.83 to 0.62 (p = 0.049). After abdominal surgery, subjects had an increase in abdominal subscale scores, 0.69 to 1.03 (p = 0.012). Women undergoing vaginal prolapse surgery may have a short-term improvement in constipation symptoms, while those undergoing abdominal surgery have worsening of abdominal constipation symptoms.

Effect of subcutaneous methylnaltrexone on patient-reported constipation symptoms

Background Methylnaltrexone, a selective peripheral acting mu-opioid receptor antagonist, alleviates the constipating effects of opioids without affecting centrally mediated analgesia. Objectives To assess the effect of subcutaneous (SC) methylnaltrexone injection on patient-reported constipation symptoms and pain scores. Methods A total of 469 subjects on opioids for chronic non-malignant pain with opioid-induced constipation were randomized to methylnaltrexone SC with once daily (QD) or every other day (QOD) dosing or placebo for 4 weeks. Constipation symptoms and pain were assessed using the patient assessment of constipation–symptoms (PAC-SYM) questionnaire and a 11-point scale, respectively, at baseline, Day 14 and Day 28. Change from baseline in PAC-SYM and pain scores were compared between methylnaltrexone and placebo arms at Day 28 using analysis of covariance, with treatment group as factor and baseline score as covariate. Results A majority of patients were women (60%), average age was 49 years old, and back pain (60%) was the primary pain condition. At Day 28, the methylnaltrexone SC QD group showed a significant improvement over placebo for rectal symptoms (−0.56 vs. –0.30; P < 0.05), stool symptoms (−0.76 vs. –0.43; P < 0.001) and global scores (−0.62 vs. –0.37; P < 0.001). Improvement in stool symptoms (−0.69 vs.−0.43; P < 0.05) and the global scores (−0.52 vs. –0.37; P < 0.05) were significantly greater than placebo in the methylnaltrexone QOD group. Differences in change from baseline in abdominal symptoms and pain scores between the methylnaltrexone SC QD or QOD dosing arms and placebo were not significant. Conclusion The results of our study indicate significant improvement in constipation symptoms with methylnaltrexone QD or QOD dosing compared to placebo without a significant effect on pain scores.