Difficult defecation in constipated patients and its relationship to colonic disorders

Improvement Effect of Bifidobacterium animalis subsp. lactis MH-02 in Patients Receiving Resection of Colorectal Polyps: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Postoperative symptoms, bowel dysfunction and recurrence are common problems after resection of colorectal polyps. We aimed to evaluate the efficacy of Bifidobacterium in the postoperative patients.

Methods

In this single-center, randomized, double-blind, placebo-controlled trial, adults (≥ 18 years) undergoing endoscopic resection of colorectal polyps were treated with probiotics (Bifidobacterium animalis subsp. lactis MH-02, 2 × 10⁹ colony-forming units per packet) or placebo once daily for 7 days. The primary clinical endpoint was a reduction in the mean total postoperative symptoms score within 7 days postoperatively. Secondary clinical endpoints were the single symptom scores, time to recovery of bowel function, and changes in the intestinal microbiota. This study is registered with the number ChiCTR2100046687.

Results

A total of 100 individuals were included (48 in probiotic group and 52 in placebo group). No difference was seen in the mean scores between the two groups (0.29 vs. 0.43, P = 0.246). Colorectal polyps size (P = 0.008) and preoperative symptoms (P = 0.032) were influential factors for the primary endpoint. Besides, MH-02 alleviated difficult defecation (P = 0.045), and reduced the time to recovery of bowel function (P = 0.032). High-throughput analysis showed that MH-02 can help restore the diversity of intestinal microbiota, and increased the relative abundance of Bifidobacterium, Roseburia, Gemmiger, Blautia and Ruminococcus, while reduced the relative abundance of Clostridium at genus level (P < 0.05).

Conclusion

In this prospective trial, MH-02 showed efficacy in patients with resection of colorectal polyps, particularly in the recovery of bowel function, and the changes in the intestinal microbiota may provide evidence for further exploration of the therapeutic mechanisms.

Characteristics of patients with overlap functional gastrointestinal disorders

BACKGROUND AND AIM

Functional gastrointestinal disorders (FGIDs) are frequently overlapped. The present study was designed to (i) search the clinical differences between patients with single FGID and overlap FGIDs and (ii) define the most common FGIDs associations to identify homogenous subgroups of patients.

METHODS

A total of 3555 outpatients with FGID filled out the Rome III adult diagnostic questionnaire, Bristol stool form, and four 10-point Likert scales to report the severity of constipation, diarrhea, bloating, and abdominal pain. An unsupervised algorithm was used to estimate the number of groups directly from the data. A classification tree separated patients into different subgroups, according to FGIDs. Multinomial logistic regression was used to characterize the groups of patients with overlap disorders.

RESULTS

Patients reported 3.3 ± 1.9 FGIDs (range 1-10, median = 3); 736 reported only one FGID, while 2819 reported more than one FGID (3.8 ± 1.7). Patients with single FGID had higher body mass index (P < 0.001), never report irritable bowel syndrome (IBS), and rarely report fecal incontinence and anorectal pain (< 1% for each disorder). The non-supervised clustering of the 2819 patients with overlap FGIDs divided this population into 23 groups, including five groups associated with only one disorder (IBS-diarrhea, dysphagia, functional constipation, levator ani syndrome, and IBS-unspecified). Ten groups were related to two overlap disorders and eight groups to three or more disorders. Three disorders were not explicitly associated with a given group: IBS-mixed, proctalgia fugax, and nonspecific anorectal pain.

CONCLUSION

Patients with FGID mostly report overlap disorders in a limited number of associations, each significantly associated with a few disorders.

Constipation in CKD

Constipation is one of the most common gastrointestinal disorders among patients with chronic kidney disease (CKD) partly because of their sedentary lifestyle, low fiber and fluid intake, concomitant medications (e.g., phosphate binders), and multiple comorbidities (e.g., diabetes). Although constipation is usually perceived as a benign, often self-limited condition, recent evidence has challenged this most common perception of constipation. The chronic symptoms of constipation negatively affect patients' quality of life and impose a considerable social and economic burden. Furthermore, recent epidemiological studies have revealed that constipation is independently associated with adverse clinical outcomes, such as end-stage renal disease (ESRD), cardiovascular (CV) disease, and mortality, potentially mediated by the alteration of gut microbiota and the increased production of fecal metabolites. Given the importance of the gut in the disposal of uremic toxins and in acid-base and mineral homeostasis with declining kidney function, the presence of constipation in CKD may limit or even preclude these ancillary gastrointestinal roles, potentially contributing to excess morbidity and mortality. With the advent of new drug classes for constipation, some of which showing unique renoprotective properties, the adequate management of constipation in CKD may provide additional therapeutic benefits beyond its conventional defecation control. Nevertheless, the problem of constipation in CKD has long been underrecognized and its management strategies have scarcely been documented. This review outlines the current understanding of the diagnosis, prevalence, etiology, outcome, and treatment of constipation in CKD, and aims to discuss its novel clinical and therapeutic implications.

Clinical and psychological characteristics of patients with globus

BACKGROUND/AIMS

Psychological factors are involved in many functional gastrointestinal disorders including globus. The aim of the present study was to assess the clinical and psychological correlates associated with globus.

PATIENTS AND METHODS

707 patients (69% female, 45.2 ± 16.5 years, BMI 27.2 ± 11.7 kg/m²) filled an MMPI-2 questionnaire and a standard Rome III clinical questionnaire and were included in this cross sectional study. Data analysis was performed using a univariate analysis and a multivariate logistic regression with a backwards selection procedure on significant scales after a univariate analysis.

RESULTS

140 patients (20%) reported suffering from globus. Globus appeared to be associated with older age (P = 0.001; OR = 1.022; 95% CI = [1.009-1.035]), increased BMI (P = 0.007; OR = 1.029; 95% CI = [1.008-1.051]), higher prevalence of regurgitations (P = 0.008; OR = 2.189; 95% CI = [1.228-3.902]), heartburn (P = 0.001 OR = 2.227; 95% CI = [1.406-3.530]), dysphagia (P < 0.001; OR = 2.399; 95% CI = [1.500-3.837]), epigastric pain (P < 0.001; OR = 3.768; 95% CI = [1.880-7.552]) and nonspecific dyspepsia (P = 0.018; OR = 1.786; 95% CI = [1.106-2.881]), and a higher score of hysteria (P = 0.008 OR = 1.034; 95% CI = [1.009-1.059]). By comparison with patients who reported globus and scores of hysteria in the normal range (n = 73), patients complaining of globus associated with high scores of hysteria (n = 67) have high scores of hypochondriasis (P < 0.001; OR = 1.235; 95% CI = [1.142-1.336]), high levels of Psychopathic deviate (P = 0.005; OR = 1.091; 95% CI = [1.026-1.161]) and a higher, but not significant, prevalence of complaints of regurgitation (P = 0.052; OR = 4.022; 95% CI = [0.989-16.351]).

CONCLUSION

Approximately 50% of the patients complaining of globus have a high score of hysteria associated with other personality disorders, and complain more frequently of regurgitation than other patients complaining of globus. These results tend to confirm that globus has a strong, although not systematic, connections with some specific personality disorders.

Constipation in Peritoneal Dialysis Patients

Constipation in peritoneal dialysis (PD) is an infrequent but potentially serious condition affecting the mechanical properties of dialysis techniques and predisposing to bacterial intestinal translocation and eventual enteric peritonitis. Despite the importance of the problem, published literature is scarce, consisting mostly of uncontrolled single-center trials. This inconsistency may be attributed to the large number of clinical, radiological, and endoscopic tools that have been used in the studies with a lack of generally accepted core primary outcomes.

The current narrative review discusses the pathophysiological associations between chronic kidney disease, PD, and constipation with related complication.

Biomarkers to distinguish functional constipation from irritable bowel syndrome with constipation

Treatments for functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) differ, but symptom criteria do not reliably distinguish between them; some regard FC and IBS-C as parts of a single constipation spectrum. Our goal was to review studies comparing FC and IBS-C to identify possible biomarkers that separate them. A systematic review identified 15 studies that compared physiologic tests in FC vs IBS-C. Pain thresholds were lower in IBS-C than FC for 3/5 studies and not different in 2/5. Colonic motility was decreased more in FC than IBS-C for 3/3 studies, and whole gut transit was delayed more in FC than IBS-C in 3/8 studies and not different in 5/8. Pelvic floor dyssynergia was unrelated to diagnosis. Sympathetic arousal, measured in only one study, was greater in IBS-C than FC. The most reliable separation of FC from IBS-C was shown by a novel new magnetic resonance imaging technique described in this issue of the journal. These authors showed that drinking one liter of polyethylene glycol laxative significantly increased water content in the small intestine, volume of contents in the ascending colon, and time to first evacuation in FC vs IBS-C; and resulted in less colon motility and delayed whole gut transit in FC compared to IBS-C. Although replication is needed, this well-tolerated, non-invasive test promises to become a new standard for differential diagnosis of FC vs IBS-C. These data suggest that FC and IBS-C are different disorders rather than points on a constipation spectrum.