The Cost of Chronic Constipation

Colonic electrical stimulation promotes colonic motility through regeneration of myenteric plexus neurons in slow transit constipation beagles

Slow transit constipation (STC) is a common disease characterized by markedly delayed colonic transit time as a result of colonic motility dysfunction. It is well established that STC is mostly caused by disorders of relevant nerves, especially the enteric nervous system (ENS). Colonic electrical stimulation (CES) has been regarded as a valuable alternative for the treatment of STC. However, little report focuses on the underlying nervous mechanism to normalize the delayed colonic emptying and relieve symptoms. In the present study, the therapeutic effect and the influence on ENS triggered by CES were investigated in STC beagles. The STC beagle model was established by oral administration of diphenoxylate/atropine and alosetron. Histopathology, electron microscopy, immunohistochemistry, Western blot analysis and immunofluorescence were used to evaluate the influence of pulse train CES on myenteric plexus neurons. After 5 weeks of treatment, CES could enhance the colonic electromyogram (EMG) signal to promote colonic motility, thereby improving the colonic content emptying of STC beagles. HE staining and transmission electron microscopy confirmed that CES could regenerate ganglia and synaptic vesicles in the myenteric plexus. Immunohistochemical staining showed that synaptophysin (SYP), protein gene product 9.5 (PGP9.5), cathepsin D (CAD) and S-100B in the colonic intramuscular layer were up-regulated by CES. Western blot analysis and immunofluorescence further proved that CES induced the protein expression of SYP and PGP9.5. Taken together, pulse train CES could induce the regeneration of myenteric plexus neurons, thereby promoting the colonic motility in STC beagles.

Differential Effects of Lactobacillus casei Strain Shirota on Patients With Constipation Regarding Stool Consistency in China

Background/Aims

Probiotics are expected to confer benefits on patients with constipation, but how probiotics act on constipated patients with variable stool consistencies remains unclear. We investigated the effect of Lactobacillus casei strain Shirota (LcS) on constipation-related symptoms, especially stool consistency, of constipated patients.

Methods

Constipated patients meeting the Rome III criteria were divided into 3 groups according to the Bristol Stool Form Scale (BSFS): hard (hard stool [HS], BSFS < 3), normal (normal stool [NS], ≤ 3 BSFS ≤ 4), and soft (soft stool [SS], 4 < BSFS ≤ 5) stools. Subjects in each group consumed a probiotic beverage containing 10¹⁰ colony-forming units of LcS daily for 28 days.

Results

LcS intervention significantly alleviated constipation-related symptoms and increased defecation frequency in all subjects. Four weeks of LcS supplementation softened the hard stools in HS, hardened the soft stools in SS, and did not alter the ideal stool consistency in NS. The short-chain fatty acid (SCFA) concentrations were highest in SS, followed by NS and HS. LcS intervention increased the stool SCFA levels in HS but reduced or did not alter the levels in NS and SS. LcS intervention increased the Pseudobutyrivibrio and Roseburia abundances in HS and decreased the Pseudobutyrivibrio abundance in SS.

Conclusions

LcS supplementation improved the constipation-related symptoms in constipated subjects. Differences in baseline stool consistency could result in different anti-constipation effects of LcS intervention. LcS balanced the stool consistency—softened the HS and hardened the SS. These effects could be associated with modulation of the gut microbiota and SCFA production.

Constipation and Laxative Use among Nursing Home Patients: Prevalence and Associations Derived from the Residents Assessment Instrument for Long-Term Care Facilities (interRAI LTCF)

Introduction. Constipation is a common, bothersome, and potentially dangerous condition among nursing home (NH) patients. Between 50 and 74% of NH patients use laxatives. Objective. To study prevalence and associations of laxative use and constipation using the comprehensive Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities. Methods. Cross-sectional study. Patients from 20 NH units were included. Logistic regression was used to analyze the results. Data collected in NHs might be clustered. Consequently, the multivariable models were tested against a mixed effects regression model to investigate variance both on the level of patients and on the level of NH units. Results. In all, 261 patients were included. The prevalence of constipation was 23.4%, and 67.1% used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson's disease were associated with constipation. Reduced ability to communicate and number of drugs were associated with laxative use. Antidementia-drugs and being involved in activities 1/3 to 2/3 of daytime were protective factors for laxative use. Mixed effects analyses identified variance on the level of NH units as nonsignificant. Conclusion. Constipation and laxative use are common. Variance is mainly explained by different patient characteristics/health deficiencies. Hence, patients might benefit from individualized care to compensate for deficiencies.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial

BACKGROUND

Constipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.

METHODS

Seventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants' symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.

RESULTS

After 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.

CONCLUSION

The psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640).

The measures to evaluate constipation: a review article

The aim of this study was to review current constipation assessment scales and clarify (a) the nature of extant measurements and (b) the criteria contained in the measures. A review of relevant literature from inception to 2011 was extracted from PubMed, CINHAL, Cochrane, and MEDLINE databases by searching for the following key words: constipation, scale, measurement, questionnaire, and assessment. Eight scales were reviewed. The scales under review measured constipation from a subjective viewpoint. All measurement criteria included in 8 of the scales were arranged into 51 items and divided into 5 categories. Categories used to measure the severity of constipation were defecation difficulties, abdominal symptoms, emotional effects of constipation, self-treatment strategies, and individual characteristics. Original and suitable scales for the measurement of the severity of constipation based on the review were the Patient-Assessment of Constipation Symptoms scale and the Constipation Assessment Scale. The Patient-Assessment of Constipation Symptoms scale and the Constipation Assessment Scale are reliable, valid, original, and suitable scales to measure the severity of constipation for subjects.

Economic burden attributable to functional bowel disorders in Iran: a cross-sectional population-based study

OBJECTIVE

While few population-based studies on the economic burden of functional bowel disorders (FBD) have been published from developing countries like Iran, this study aimed to estimate their direct and indirect costs for five groups of patients: irritable bowel syndrome (IBS), functional constipation (FC), unspecified-FBD (U-FBD), functional abdominal bloating (FAB) and functional diarrhea (FD).

METHODS

Up to 18,180 adults randomly sampled from Tehran, Iran (2006-2007) were interviewed using two questionnaires based on the Rome III criteria to detect FBD patients and to estimate their medical expenses (such as visiting the doctor, drugs, hospitalization and laboratory tests) and productivity loss in the previous 6 months. All costs were converted to dollar purchasing power parity (PPP$) to facilitate cross-country comparisons.

RESULTS

The mean total 6-month costs were approximately: 160, 147, 103, 96 and 42 PPP$ for IBS, FC, U-FBD, FAB and FD, respectively. The highest proportion of drug consumption was found in IBS patients. The highest mean duration of absence from work was seen in IBS patients (2.26 days). Overall, doctor visit costs accounted for approximately 1/3 of the total costs for FBD, followed by hospitalization. A higher indirect cost of illness was found in IBS (54 PPP$), whereas it was zero in FD.

CONCLUSION

The economic burden of FBD seems to be moderately high in Iran and it imposes a relatively heavy financial burden on the Iranian national health system because of its high prevalence and its impact on quality of life, productivity and waste of resources.

Electrical colonic stimulation reduces mean transit time in a porcine model

Electrical stimulation is a new way to treat digestive disorders such as constipation. Colonic propulsive activity can be triggered by battery operated devices. This study aimed to demonstrate the effect of direct electrical colonic stimulation on mean transit time in a chronic porcine model. The impact of stimulation and implanted material on the colonic wall was also assessed. Three pairs of electrodes were implanted into the caecal wall of 12 anaesthetized pigs. Reference colonic transit time was determined by radiopaque markers for each pig before implantation. It was repeated 4 weeks after implantation with sham stimulation and 5 weeks after implantation with electrical stimulation. Aboral sequential trains of 1-ms pulse width (10 V; 120 Hz) were applied twice daily for 6 days, using an external battery operated stimulator. For each course of markers, a mean value was computed from transit times obtained from individual pig. Microscopic examination of the caecum was routinely performed after animal sacrifice. A reduction of mean transit time was observed after electrical stimulation (19 +/- 13 h; mean +/- SD) when compared to reference (34 +/- 7 h; P = 0.045) and mean transit time after sham stimulation (36 +/- 9 h; P = 0.035). Histological examination revealed minimal chronic inflammation around the electrodes. Colonic transit time measured in a chronic porcine model is reduced by direct sequential electrical stimulation. Minimal tissue lesion is elicited by stimulation or implanted material. Electrical colonic stimulation could be a promising approach to treat specific disorders of the large bowel.

Electrical stimulation induces propagated colonic contractions in an experimental model

BACKGROUND

Direct colonic electrical stimulation may prove to be a treatment option for specific motility disorders such as chronic constipation. The aim of this study was to provoke colonic contractions using electrical stimulation delivered from a battery-operated device.

METHODS

Electrodes were inserted into the caecal seromuscular layer of eight anaesthetized pigs. Contractions were induced by a neurostimulator (Medtronic 3625). Caecal motility was measured simultaneously by video image analysis, manometry and a technique assessing colonic transit.

RESULTS

Caecal contractions were generated using 8-10 V amplitude, 1000 micros pulse width, 120 Hz frequency for 10-30 s, with an intensity of 7-15 mA. The maximal contraction strength was observed after 20-25 s. Electrical stimulation was followed by a relaxation phase of 1.5-2 min during which contractions propagated orally and aborally over at least 10 cm. Spontaneous and stimulated caecal motility values were significantly different for both intraluminal pressure (mean(s.d.) 332(124) and 463(187) mmHg respectively; P < 0.001, 42 experiments) and movement of contents (1.6(0.9) and 3.9(2.8) mm; P < 0.001, 40 experiments).

CONCLUSION

Electrical stimulation modulated caecal motility, and provoked localized and propagated colonic contractions.

A cost analysis of functional bowel disorders in Iran

BACKGROUND AND AIMS

The objective of this work is to evaluate the health care utilization and cost of different types of functional bowel disorder (FBD) in a population of Iranian patients and compare the costs in consulters and non-consulters.

MATERIALS AND METHODS

A consecutive sample of 1,023 patients in an outpatient gastroenterology clinic in central Tehran were interviewed, using two questionnaires based on the Rome II criteria, from December 2004 to May 2005 to detect FBD patients and to determine the frequency of health resource utilization (physician visit, hospitalization, laboratory tests, imaging studies, and drugs) and productivity loss (days off work or with low functionality) due to FBD symptoms in the past 12 months. Societal perspective was used and cost per person per year was estimated in purchasing power parity dollars (PPP$).

RESULTS

The direct costs (for consulters, non-consulters; data presented in this order) were: irritable bowel syndrome (IBS; $92.04, $1.04), unspecified functional bowel disorder (FBD; $100.94, $0.39), functional constipation ($57.23, $1.04), and functional abdominal bloating ($71.35, $0.63). Indirect costs (for consulters, non-consulters) were: IBS ($811.85, $669.09), unspecified FBD ($705.85, $263.47), functional constipation ($587.48, $97.49), and functional abdominal bloating ($147.88, $38.60). Total yearly costs of IBS and functional constipation for urban adult population of Iran were roughly estimated at 2.94 billion PPP$ and 89.2 million PPP$, respectively.

CONCLUSIONS

As proven in developed countries, FBD and especially IBS seem to put a heavy burden on the economy of a developing country like Iran. Further population-based studies are needed for more precise estimations.

Management of constipation in residents with dementia: sorbitol effectiveness and cost

OBJECTIVE

The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia.

DESIGN

We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose.

SETTING

The study was conducted at a dementia special care unit at a Veterans Administration hospital.

MEASUREMENT

We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function.

RESULTS

There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature.

CONCLUSION

Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

The treatment of chronic constipation in elderly people: an update

Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition. Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives. Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified. Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.