Stimulant Laxatives Research Articles

Improving Bowel Management in Children With Spina Bifida.

In individuals with spina bifida (SB), bowel incontinence is associated with lower quality of life and lower likelihood of employment. In an effort to maximize bowel continence in children and adolescents, we created a bowel management assessment and follow-up protocol in a multidisciplinary clinic. Here we report the results of this protocol using quality-improvement methodology. Continence was defined as no unplanned bowel movements. Our protocol involved: (1) a standardized 4-item questionnaire about bowel continence and consistency; (2) if the patient was not achieving continence, an intervention starting with oral medication (stimulant and/or osmotic laxatives), and/or suppositories (glycerin or bisacodyl) followed by an escalation to trans-anal irrigation, or continence surgery; and (3) follow-up phone calls at regular intervals to monitor progress and make changes as needed. Results are summarized with descriptive statistics. We screened 178 eligible patients in the SB clinic. Eighty-eight agreed to participate in the bowel management program. Of those who did not participate, the majority (68/90, 76%) were already achieving continence with their bowel regimen. Of children in the program, most (68/88, 77%) had a diagnosis of meningomyelocoele. At 1 year, the proportion of patients who were bowel accident free improved to 46% (vs 22% initially, P = 0.0007). A standardized bowel management protocol, primarily the use of suppositories and trans-anal irrigation to achieve social continence, as well as frequent telephone follow-up, can reduce bowel incontinence in children and adolescents with SB.

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation.

Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.

A Nationwide Hospital Claims Database Analysis of Real-World Patterns of Laxative Use for Opioid-Induced Constipation in Japanese Patients with Cancer.

Opioid-induced constipation (OIC) is one of the most common side effects in patients with cancer treated with opioid analgesics. The actual use of laxatives for OIC in Japan remains unelucidated. This study aimed to investigate the real-world patterns of laxative use for patients with cancer who newly initiated opioid analgesic therapy. We used a Japanese nationwide hospital claims database (January 2018-December 2019). Patients with cancer newly receiving opioid analgesic therapy were included and classified on the basis of opioid classes (weak or strong) and route of administration (oral or transdermal) at initiation. The patients were divided into two groups on the basis of whether they received early medication (starting laxatives within 3days after initiating opioid analgesic therapy), and patterns of laxative use were analyzed. There were 26,939 eligible patients, with 50.7% of them initiated with strong opioids. The proportion of patients who received early medication was 25.0% for weak opioids and 57.3% for strong opioids. Osmotic laxatives were most frequently used as first-line therapy in the early medication group (oral weak opioids: 12.3%, oral strong opioids: 29.4%, transdermal strong opioids: 12.8%). Stimulant laxatives were frequently used as first-line therapy, to the same extent or more than osmotic laxatives in the non-early medication group (oral weak opioids: 13.7%, oral strong opioids: 7.7%, transdermal strong opioids: 15.1%). Peripherally acting μ-opioid receptor antagonists were the second most frequently used in the early medication group for those on oral strong opioids (9.4%). This study demonstrated for the first time that the patterns of laxative use for OIC in Japanese patients with cancer were different, depending on the opioid types at initiation and the timing of laxative medication.

An Update of Pharmacological Management in Children with Functional Constipation.

Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.

Association of laxatives use with incident dementia and modifying effect of genetic susceptibility: a population-based cohort study with propensity score matching

BackgroundConstipation was associated with incidence of dementia and cognitive decline. Laxatives are the mainstay of constipation management and are commonly used among older populations for both treatment and prevention of constipation. However, the association between use of laxatives and incident dementia, and whether laxatives use may modify the effect of genetic predisposition on dementia remains unclear.MethodsWe applied 1:3 propensity score matching to balance the baseline characteristics of the laxative users versus non-users and to reduce potential confounders using multi-variates adjusted Cox hazards regression models. We categorized genetic risk into three groups (low, middle, and high) through a genetic risk score of common genetic variants. Information on laxatives use was assessed at baseline and categories into four varieties, including bulk forming laxatives, softeners and emollients, osmotic laxatives, and stimulant laxatives.ResultsOf 486,994 participants, there were 14,422 laxatives users in UK Biobank. After propensity score matching, participants with use of laxatives (n = 14,422) and matched non-laxative (n = 43,266) exposed individuals were enrolled. Over follow-up to 15 years, there were 1377 participants developed dementia (539 for Alzheimer’s disease, and 343 for vascular dementia). The use of laxatives had greater risk of dementia (HR, 1.72; 95% CI:1.54–1.92), Alzheimer’s disease (HR, 1.36; 95% CI: 1.13–1.63), and vascular dementia (HR, 1.53; 95% CI: 1.23–1.92). Compared to non-laxative exposed participants, those with use of softeners and emollients drugs, stimulant laxatives, and osmotic laxatives were associated with 96% (HR, 1.96; 95 CI: 1.23–3.12; P = 0.005), 80% (HR, 1.80; 95% CI: 1.37–2.37; P < 0.001), and 107% (HR, 2.07; 95% CI: 1.47–2.92; P < 0.001) higher risk of developed incident dementia, respectively. In joint effect analysis, compared to participants with low/middle genetic susceptibility and non-laxatives use, the HR (95% CIs) of dementia was 4.10 (3.49–4.81) for those with high genetic susceptibility plus use of laxatives. There was an additive interaction between laxatives use and genetic susceptibility on dementia (RERI: 0.736, 95% CI: 0.127 to 1.246; AP: 0.180, 95% CI: 0.047 to 0.312).ConclusionsUse of laxatives was associated with higher risk of dementia and modify the effect of genetic susceptibility on dementia. Our findings suggested that attention should be paid to the relationship between laxatives use and dementia, especially in people at high genetic susceptibility.

Bifidobacterium bifidum CCFM1163 Alleviated Cathartic Colon by Regulating the Intestinal Barrier and Restoring Enteric Nerves.

Cathartic colon (CC), a type of slow-transit constipation caused by the long-term use of stimulant laxatives, does not have a precise and effective treatment. This study aimed to evaluate the ability of Bifidobacterium bifidum CCFM1163 to relieve CC and to investigate its underlying mechanism. Male C57BL/6J mice were treated with senna extract for 8 weeks, followed by a 2-week treatment with B. bifidum CCFM1163. The results revealed that B. bifidum CCFM1163 effectively alleviated CC symptoms. The possible mechanism of B. bifidum CCFM1163 in relieving CC was analyzed by measuring the intestinal barrier and enteric nervous system (ENS)-related indices and establishing a correlation between each index and gut microbiota. The results indicated that B. bifidum CCFM1163 changed the gut microbiota by significantly increasing the relative abundance of Bifidobacterium, Faecalibaculum, Romboutsia, and Turicibacter as well as the content of short-chain fatty acids, especially propionic acid, in the feces. This increased the expression of tight junction proteins and aquaporin 8, decreased intestinal transit time, increased fecal water content, and relieved CC. In addition, B. bifidum CCFM1163 also increased the relative abundance of Faecalibaculum in feces and the expression of enteric nerve marker proteins to repair the ENS, promote intestinal motility, and relieve constipation.

Chronic constipation: from pathophysiology to management.

Chronic constipation (CC) is one of the most common conditions found in gastrointestinal clinical practice and defined by the presence of fewer than 3 bowel movements per week and/or more than one fourth of bowel movements with Bristol stool form types 1 or 2. CC affects people regardless of race, age, or sex, although it is most common in women and in elderly. It is associated with relevant disease burden, including significant impairment of patients' quality of life. In the absence of alarm features, patients should receive a symptom-based diagnosis. Treatment options include lifestyle and general measures, bulking agents, in particular dietary fiber supplementation. Osmotic laxatives are currently considered the first-line gold-standard pharmacological treatment of CC together with stimulant laxatives which are often used as a rescue therapy. When necessary, prokinetic agents and/or intestinal secretagogues can be used. Biofeedback may be indicated in patients with functional defecation disorders. In this review, we will briefly summarize the current understanding on epidemiology, classification, pathophysiology and clinical evaluation of CC and discuss in depth the pharmacological and not pharmacological management of patients with this disorder.

Clinical Characteristics of Adult Functional Constipation Patients with Rectoanal Areflexia and Their Response to Biofeedback Therapy.

The London Classification for anorectal physiological dysfunction specifically proposes rectoanal areflexia (RA), which means the absence of a rectoanal inhibitory reflex (RAIR) based on a manometric diagnosis. Although RA is not observed in healthy people, it can be found in adult patients with functional constipation (FC). This study describes the clinical manifestations of adult patients with FC and RA and their response to biofeedback therapy (BFT). This retrospective study reviewed the reports of high-resolution anorectal manometry (HR-ARM) and the efficacy of BFT in adult patients with FC. In addition, the Constipation Scoring System (CSS) scale, Patient Assessment of Constipation Symptoms (PAC-SYM) scale, Patient Assessment of Constipation Quality of Life (PAC-QOL) scale, Zung's Self-Rating Anxiety Scale (SAS), Zung's Self-Rating Depression Scale (SDS), balloon expulsion test (BET), and the use of laxatives were assessed. A total of 257 adult patients diagnosed with FC were divided into the RA group (n = 89) and the RAIR group (n = 168). In the RA and RAIR groups, 60 (67.4%) and 117 (69.6%) patients, respectively, had dyssynergic defecation (DD) during simulated defecation. Type II pattern of dyssynergia was most frequently observed in both groups. Compared with the RA group, the RAIR group showed a higher CSS score, physical discomfort score, and prevalence of inadequate relaxation of the anal sphincter (p &lt; 0.001, p = 0.036, and p = 0.017, respectively). The anxiety and depression scores were not different between the two groups. The proportion of patients using volumetric and stimulant laxatives and their combination was significantly higher in FC patients with RA, whereas the efficacy of BFT was significantly lower (p&amp;nbsp;= 0.005, p &lt; 0.001, p = 0.045, and p = 0.010, respectively). Adult FC patients with RA may suffer more severe constipation and have a lower efficacy of BFT compared with those with RAIR.

Response Rates to Methylnaltrexone in Hospitalized Cancer Patients.

Context: Methylnaltrexone is a peripherally-acting mu-opioid receptor antagonist studied in both cancer and non-cancer patients with opioid-induced constipation (OIC), but mostly in the outpatient setting. For adult hospitalized cancer patients with OIC, its effectiveness is unknown. Objectives: Describe the efficacy of methylnaltrexone for OIC in the inpatient setting, defined as bowel movement (BM) within 24hours of methylnaltrexone administration. Methods: We performed a single-center, retrospective chart review of all hospitalized, adult patients with a cancer diagnosis who received methylnaltrexone from the palliative care team between January 1st, 2012 and July 1st, 2019. Results: We identified 194 patients. The mean age was 59, 50.5% were male and 88% were white. 192 patients (98%) received the 8mg dose subcutaneously. The median oral morphine equivalent (OME) was 135mg (IQR 70-354mg). 45% (95% confidence interval, 38-53%) had a BM within 24hours. Higher OME was correlated with successful BM, with a response in 93% (86/92) of patients receiving ≥150 OME and 2% (2/102) of patients receiving <150 OME (P < .0001). Prior laxative use did not predict response at 24hours whether these were osmotic laxatives (40.7% vs 47.1%, P = .52), stimulant laxatives (45.7% vs 45.2%, P > .99), or stool softeners (44.7% vs 46.1%, P = .89). Conclusion: Methylnaltrexone has a high response rate when used as treatment for OIC in hospitalized adult cancer patients, especially for patients taking ≥150 OME.

Efficient methods of therapy of pediatric functional constipation

Constipation holds an important place among the functional gastrointestinal disorders. The following are among the main reasons for the development of functional constipation: alimentary factors, impaired nervous and endocrine regulation (functional immaturity of the colon, perinatal injury of the central nervous system, endocrine disease), psychosomatic factors, hypodynamia, previous intestinal infections, iatrogenic effects, food allergies and anorectal pathology, genetic predisposition. Treatment of constipation should be comprehensive and include lifestyle maneuvers, dietary recommendations, dietary fibres and water schedule, pharmacotherapy, biofeedback, and surgical methods. Stimulant laxatives (sodium picosulfate, bisacodyl) are effective drugs among the medications used to treat constipation. A sodium picosulfate drug is an effective stimulant laxative, which has a triple effect: stimulation of bowel movements, reduction of the evacuation time and softening stools. The efficacy and safety of the drug was studied in a multicenter, parallel, double-blind, randomized, placebo-controlled study in patients with chronic constipation. The article presents our own experience – a clinical observation – of the use of sodium picosulfate. 26 children with chronic constipation aged from 1 to 7 years, who had stool retention from 3 to 7 days, were observed. The inclusion of a stimulant sodium picosulfate laxative in the comprehensive functional chronic constipation therapy in children aged 1 to 7 years at age-specific dosage variances for 7 days showed high clinical efficacy, which resulted in the normalization of stool in 76.9% of children, facilitating bowel movements and improvement of children’s well-being. This drug can be recommended in the comprehensive therapy of functional constipation in children.

S2517 Pill Prep Problems? Erosive Gastritis and Peptic Ulcers due to Sodium Sulfate-Based Tablet Bowel Prep

Introduction: SUTAB is the second ever tablet formulation for bowel preparation. It became FDA approved in 2020 based on 2 randomized studies in which SUTAB provided noninferior bowel cleansing when compared to other commonly used FDA approved preparations. These randomized studies focused only on colonoscopies, possibly ignoring SUTAB’s effects on the upper GI tract. Endoscopists have recently been noticing significant adverse side effects from SUTAB, notably erosive gastritis and peptic ulcers in patients scheduled for same day bidirectional endoscopy. These findings were not noted by the studies used for FDA approval. SUTAB is a sodium sulfate based tablet composed of 3 main active ingredients: sodium sulfate, magnesium sulfate, and potassium chloride. SUTAB is taken as a 2-day split dose regimen of 24 tablets with large volumes of water. The most common adverse side effects published for SUTAB include nausea, abdominal distension, vomiting, and abdominal discomfort. Any mention of mucosal ulcerations focused on colonic ulcerations in patients with suspected inflammatory bowel disease or in concurrence with the use of stimulant laxatives. Case Description/Methods: 5 cases of same day bidirectional endoscopy were examined from 9/2/2021 to 11/15/2021. Indications for upper endoscopy included a history of Barrett’s esophagus and/or gastroesophageal acid reflux disease and all patients used SUTAB as the sole bowel preparation. In all cases there was no previous history of erosive gastritis or peptic ulcer disease, however, all upper endoscopies noted signs of moderate to severe erosive gastritis. Two of the cases also noted similarly appearing linear gastric ulcers with black eschars. All patients were subsequently placed on antacid therapy and follow-up endoscopies were performed to assess ulcer healing, which was noted at the time. Discussion: SUTAB is a relatively new bowel preparation on the market with very little published data on its known side effects. The convenience of a tablet formulation for a bowel preparation that achieves successful bowel cleansing attracts patients and doctors, but it comes with the cost of possible adverse side effects in the upper GI tract. The ingredients in SUTAB are corrosive agents, specifically, potassium chloride has been linked to erosions that are found in the mucosa of the GI tract with prolonged exposure. To better understand this recently noted phenomena, more research is needed to help prevent these unwanted and potentially dangerous side effects.

Constipation Severity and Quality of Life among Patients with Cancer Who Received Prophylactic Laxatives: Quasi-Experimental Study.

Prophylactic laxatives were associated with decreasing the incidence of Opioid-induced constipation among patients with cancer. This study aims to evaluate the effectiveness of early prophylactic laxatives therapy on the severity of constipation and quality of life among patients with cancer receiving opioids. Using a quasi-experimental design with 64 patients assigned to control group and 66 patients assigned to intervention group. The final sample was composed from 112 patients (57 in control group and 55 in intervention group), who were selected from an oncology clinic. Patients in the intervention group have received prophylactical laxatives The intervention included an oral colonic stimulant laxative (i.e., Bisacodyl, Dose= 3 tab/ day and/or Senna 6.8 mg twice daily) and an oral colonic osmotic laxative (i.e., Lactulose, Dose = 15 ml three times per day). Patients in the control group continue to receive their routine care without laxatives. Patients in the intervention group have reported a significant reduction in the severity of constipation symptoms at eight weeks post the intervention (p &lt; 0.001). Furthermore, the patients in the intervention group have revealed a significant improvement in their quality of life (QoL) (p&lt; 0.001). Patients with cancer need to use the first line of laxatives as prophylactic alongside with opioids to minimize the severity of Opioid-induced constipation symptoms and to enhance the QoL.

The success rate of antegrade enemas for the management of idiopathic constipation.

Most patients with idiopathic constipation achieve daily voluntary bowel movements with stimulant laxatives after a "Structured Bowel Management Program" (BMP). A small percentage require rectal enemas. One week in a BMP to find the right enema recipe results in a success rate great than 95%. Once the enema is radiologically and clinically effective, antegrade continent enema procedures (ACE) can afford patients an alternative route of enema administration. This study summarized the outcomes of children with idiopathic constipation who receive antegrade enemas (AE) with or without a prior BMP. This was a single institution, retrospective cohort study of children with idiopathic constipation who underwent ACE procedures indicated by different providers from 2015-2020. We categorized the outcomes with AE after the ACE procedure as: "successful outcome" when the AE produced a daily bowel movement, no involuntary bowel movements, and no more fecal impactions, "unsuccessful outcome" was defined when the patient continued having involuntary bowel movements or fecal impaction requiring cleanouts despite a daily AE, and "unnecessary outcome" was defined when the patient was no longer doing AE, but had daily bowel movements, and no involuntary bowel movements or fecal impactions. Thirty-eight children with idiopathic constipation had an ACE. The most frequent indication for ACE was a failure of medical treatment. The most common medical treatment was polyethylene glycol. Before ACE, 34 (89%) patients did not have a BMP; 18 patients were on rectal enemas and 16 on laxatives. All four with BMP (100%) had a successful rectal enema. After ACE, 12 (31%) patients had successful antegrade enemas, including the four with previous successful BMP with rectal enemas. Twenty patients (52%) had unsuccessful antegrade enemas, and in 6 (15%), the ACE was unnecessary (Fig. 1). Using antegrade enemas without a previously successful formula for rectal enemas has resulted in a high rate of unsuccessful and unnecessary procedures. BMP for children with idiopathic constipation who needs rectal enemas offers a high possibility to find the proper rectal enema recipe and ensures higher rates of successful AE.

A sensitive and quantitative immunochromatographic assay for simultaneous detection of three stimulant laxatives in slimming food

Bisacodyl, sodium picosulfate and their metabolite bis-(p-hydroxyphenyl)-pyridyl-2-methane (BHPM) are clinically used to treat constipation. In this study, with the rational hapten design, a broad-specific and highly sensitive monoclonal antibody (mAb) was obtained with half of inhibitory concentrations of 0.16, 0.18 and 0.65 ng/mL for bisacodyl, sodium picosulfate and BHPM, respectively. Based on this mAb, a rapid and sensitive lateral flow immunochromatographic assay toward bisacodyl, sodium picosulfate and BHPM in slimming foods was developed. This method can qualitatively and quantitatively screen three stimulant laxatives with cut-off values of 3–6 ng/mL by naked eye and quantitative detection limits of 0.14–0.41 ng/mL by reader. The acceptable recoveries of spiked samples (78.00 %–120.12 %) and consistent results with liquid chromatography with tandem mass spectrometry (LC-MS/MS) in real sample detection confirmed the accuracy of the method. The established method provides a technique for multiplex, sensitive, fast, and on-site detection of three stimulant laxatives in slimming food.

Expert opinion on the habit forming properties of laxatives in patients with constipation

Constipation is a commonly reported disorder in many patients. Constipation treatment using laxatives on a regular and long term basis can lead to patient dependence, especially among the elderly. However, there is scanty data on the habit-forming potential of laxatives in Indian constipated patients. This review has explored literature evidence and expert opinion on patients’ experience regarding habit-forming attributes of stimulant and osmotic laxatives. Additionally, structured face-to-face discussions were conducted with 2 key opinion leaders to understand their clinical experience on the habit-forming aspects stimulant and osmotic laxatives in patients with constipation. Based on literature evidence, lactulose is not known to lead to any habit-forming behaviors in patients. Furthermore, experts pointed out that dependence on stimulant laxatives is common, but not on osmotic laxatives, and emphasized that milk of magnesia is not habit forming. In conclusion, no habit-forming characteristics or dependence was observed with the use of osmotic laxatives in India. Nevertheless, real-world, studies exploring patient and physician perspectives are warranted to establish the dependence and habit forming attributes of laxatives.

Effects of Aqueous-Methanol Bulb Extract of Allium sativum on Gastric Ulcer and Gastrointestinal Motility

This research work evaluated the ulcer protective effects of aqueous-methanol bulb extract of Allium sativum in rats using acetylsalicylic acid and cold-stress induced ulceration model. Adult Wistar rats were grouped into 5 (consisting of 5 rats each). Rats in group A were administered normal saline (30 ml/kg P.O) to serve as negative control. Rats in groups. B, C and D were pretreated with graded doses of the extract (50, 100, and 200 mg/kg P.O). Rats in group E were treated with Cimetidine (50 mg/kg P.O) to serve as the positive control. Ulceration was induced in all groups afterwards and gross examination of the excised stomach revealed a dose-dependent decrease in ulcer indices in groups treated with the extract. The highest reduction in ulceration was observed in the group treated with 200 mg/kg of the extract, although statistically insignificant but comparable to the cimetidine treated group. This suggests that Allium sativum extract possesses antiulcer properties. Another aspect of this research work evaluated the effect of the same extract (50, 100 and 200 mg/kg P.O) on gastrointestinal motility in mice using activated charcoal meal model. Normal saline (20 ml/kg P.O) was used as the negative control. The results obtained from the study revealed a dose-dependent increase in intestinal motility which is suggestive of stimulant laxative mechanism of action. This validates its traditional use as a treatment for constipation and aid in digestion.

Mechanisms of Action of Current Pharmacologic Options for the Treatment of Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation.

Multiple therapeutic agents are currently available for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation. A better understanding of the mechanism of action of each treatment provides important insights into expected responses and is key to optimizing treatment outcomes. Some constipation treatments, such as stimulant laxatives, may increase bowel movement frequency but are ineffective at relieving, and may even exacerbate, abdominal symptoms. On the contrary, prescription treatments, such as the guanylyl cyclase-C agonists, for example, may improve bowel symptoms and reduce visceral hypersensitivity. This review summarizes the mechanisms of action of commonly used over-the-counter and prescription therapies for chronic idiopathic constipation and irritable bowel syndrome with constipation, outlining how these mechanisms contribute to the efficacy and safety of each treatment option.

Iatrogenic constipation in gastrointestinal surgery.

Postoperative constipation occurs relatively frequently, and can involve drug-related, surgical and lifestyle and dietary factors. Gastrointestinal motility can be altered by inflammation, surgery, opioid medications, hypnotics, anti-secretory or anesthetic drugs or by functional modifications for which the physiopathology is not well defined. There are a number of laxatives available. These include bulk laxatives, osmotic laxatives and locally acting laxatives such as suppositories and enemas. Stimulant laxatives have a role to play in the short-term management of persistent constipation. 5-HT4 receptor antagonists are recommended in refractory constipation. Other specific therapeutic laxatives can be proposed such as methylnaltrexone in opioid-induced constipation or neostigmine in Ogilvie's syndrome. The prevention and/or early detection of iatrogenic constipation, whether postoperative or not, is essential and the knowledge how to improve patient comfort and reduce the duration of gastrointestinal motor disorders with specific drugs or other means is essential, particularly the postoperative period.

Saudi Experts Consensus on Diagnosis and Management of Pediatric Functional Constipation.

Although functional gastrointestinal disorders (FGIDs) are very common in pediatric patients, there is a scarcity of published epidemiologic data, characteristics, and management patterns from Saudi Arabia, which is the 2nd largest Arabic country in terms of area and the 6th largest Arabic country in terms of population, with 10% of its population aged <5 years. Functional constipation (FC) is an FGID that has shown a rising prevalence among Saudi infants and children in the last few years, which urges us to update our clinical practices. Nine pediatric consultants attended two advisory board meetings to discuss and address current challenges, provide solutions, and reach a Saudi national consensus for the management of pediatric constipation. The pediatric consultants agreed that pediatricians should pay attention to any alarming signs (red flags) found during history taking or physical examinations. They also agreed that the Rome IV criteria are the gold standard for the diagnosis of pediatric FC. Different therapeutic options are available for pediatric patients with FC. Dietary treatment is recommended for infants with constipation for up to six months of age. When non-pharmacological interventions fail to improve FC symptoms, pharmacological treatment with laxatives is indicated. First, the treatment is aimed at disimpaction to remove fecal masses. This is achieved by administering a high dose of oral polyethylene glycol (PEG) or lactulose for a few days. Subsequently, maintenance therapy with PEG should be initiated to prevent the re-accumulation of feces. In addition to PEG, several other options may be used, such as Mg-rich formulas or stimulant laxatives. However, rectal enemas and suppositories are usually reserved for cases that require acute pain relief. In contrast, infant formulas that contain prebiotics or probiotics have not been shown to be effective in infant constipation, while the use of partially hydrolyzed formula is inconclusive. These clinical practice recommendations are intended to be adopted by pediatricians and primary care physicians across Saudi Arabia.

Circadian rhythm and its potential influence on gut motility

The gastrointestinal system exhibits circadian fluctuations in activity that are under control of central and peripheral mechanisms. Disturbance of such rhythms may be associated with symptoms like constipation. Available evidence shows that stimulant laxatives such as bisacodyl can act synchronized on circadian colonic fluctuations helping to restore physiological gut rhythms.