American Gastroenterological Association technical review on constipation

Association Between Caffeine Intake and Stool Frequency- or Consistency-Defined Constipation: Data From the National Health and Nutrition Examination Survey 2005-2010

Background/Aims

The association between caffeine intake and constipation remains inconclusive. This study aims to investigate whether caffeine intake is associated with constipation.

Methods

This cross-sectional study included 13 941 adults from the 2005-2010 National Health and Nutrition Examination Survey. The weighted logistic regression analyses were exerted to evaluate the association between caffeine intake and constipation. Besides, stratified analyses and interaction tests were conducted to determine the potential modifying factors.

Results

After adjusting for confounders, increased caffeine intake by 100 mg was not associated with constipation, as defined by stool frequency (OR, 1.01; 95% CI, 0.94-1.10) or stool consistency (OR, 1.01; 95% CI, 0.98-1.05). Subgroup analyses showed that cholesterol intake modified the relationship between increased caffeine by 100 mg and stool frequency-defined constipation (P for interaction = 0.037). Each 100 mg increase in caffeine intake was associated with a 20% decreased risk of constipation defined by stool frequency in participants who consumed high cholesterol (OR, 0.80; 95% CI, 0.64-1.00), but no association in the other 2 cholesterol level groups. Furthermore, the association between caffeine intake and stool consistency-defined constipation was not found in different cholesterol groups.

Conclusions

Caffeine consumption is not associated with stool frequency or consistency-defined constipation. Nevertheless, increased caffeine intake may decrease the risk of constipation (defined by stool frequency) among participants in the high-cholesterol intake group.

Clinical practice guidelines for the diagnosis of constipation-predominant irritable bowel syndrome and functional constipation in adults: a scoping review

BACKGROUND

Constipation-predominant irritable bowel syndrome (IBS-C) and functional constipation (FC) are prevalent disorders with overlapping and fluctuating symptoms, which pose challenges for accurate diagnosis. This study aimed to assess the consistency of diagnostic criteria for IBS-C and FC in adults across clinical practice guidelines (CPGs).

METHODS

We conducted a scoping review of relevant CPGs by searching electronic databases (MEDLINE and CNKI) and the webpages of Health and Care Excellence (NICE), World Health Organization (WHO), World Gastroenterology Organization (WGO), the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), Chinese Society of Gastroenterology (CSGE) from Jan 2012 to July 2024. The included CPGs should contain the diagnostic criteria for IBS-C, FC, or both.

RESULTS

We identified 27 CPGs, 14 for IBS-C diagnostic criteria, 9 for FC, and 4 for both IBS-C and FC. The Rome IV criteria were the most commonly applied by the included CPGs (59.3%), followed by the Rome III criteria (22.2%), and pathophysiology classification criteria (7.4%). Abdominal pain was emphasized in IBS-C CPGs (71.4%) but not in any FC CPGs, while spontaneous bowel movement (SBM) frequency was commonly used for FC (88.9%) but not mentioned in any IBS-C CPGs. While 40.7% CPGs acknowledged the similarity between IBS-C and FC, one CPG addressed abdominal pain intensity as a diagnostic criterion, using the 0-9 Likert scale to define painful constipation as a score greater than 4. 71.4% IBS-C CPGs recommended a positive symptom-based diagnosis, versus 11.1% of FC CPGs. Geographical differences were observed, Asian-based CPGs (14.3% of IBS-C CPGs and 11.1% of FC/IBS-C CPGs) recommended stool form type 3 on the Bristol Stool Form Scale (BSFS) and abdominal bloating as diagnostic features. 81.5% CPGs recommended colonoscopy based on alarm symptoms or age.

CONCLUSION

Inconsistent and regional variations of existing diagnostic criteria for IBS-C/FC were identified. Future improvements should focus on comprehensive characterizations of pain and constipation in both IBS-C and FC. Long-term advancements in understanding the underlying mechanisms, including gut microbiota and related metabolites, are essential for identifying objective biomarkers to improve differential diagnosis and reduce reliance on symptom-based criteria.

Effect of Daily Consumption of a Fermented Milk Containing Lacticaseibacillus paracasei Strain Shirota (LcS) on Stool Consistency in United States Adults with Hard or Lumpy Stools: A Randomized Controlled Trial

BACKGROUND

Lacticaseibacillus paracasei strain Shirota (LcS) has shown benefits for stool consistency in populations with certain bowel complaints (e.g., constipation), but data in a United States population are limited.

OBJECTIVES

This study evaluated the effects of LcS on hard or lumpy stools (HLS) in an otherwise healthy population that generally represents the United States adult demographic.

METHODS

In this randomized, controlled, open-label study, 50 participants (41 females, 9 males) with HLS in ≥25% of bowel movements (BMs) during a 14-d run-in period were randomly assigned to receive either 80 mL fermented milk containing 8.0 × 109 colony forming units LcS/mL for 28 d (active group) or no intervention (control group) followed by a 14-d postintervention period. Bowel habits were recorded daily using a novel smartphone application. The primary endpoint was the presence of HLS in ≥25% of the participant-rated BMs using the Bristol Stool Form Scale over the 28-d intervention. Secondary endpoints included the presence of reduced frequency of BMs with HLS from baseline, stool frequency, straining, incomplete evacuation, artificial intelligence-derived stool image scores, and Patient Assessment of Constipation Quality of Life (PAC-QOL) scores.

RESULTS

The active group showed a significantly lower proportion of participants with HLS in ≥25% of BMs [odds ratio: 0.34; 95% confidence interval (CI): 0.14, 0.80; P = 0.014] along with a higher proportion of participants with a reduced frequency of BMs with HLS from baseline (odds ratio: 2.86; 95% CI: 1.03, 7.92; P = 0.043). The active group also demonstrated positive improvements in total PAC-QOL scores (P = 0.003).

CONCLUSIONS

Daily consumption of LcS-containing fermented milk significantly reduced constipation symptoms and improved quality of life in an otherwise generally healthy United States adult population with a history of intermittent BMs producing HLS. The intervention was well tolerated, with no serious adverse events related to the product, suggesting its safety and potential as a dietary strategy for managing constipation.

TRIAL REGISTRATION NUMBER

This trial was registered at clinicaltrials.gov as NCT06014008 (https://clinicaltrials.gov/study/NCT06014008).

The impact of sugar-sweetened beverages consumption on constipation: evidence from NHANES

BACKGROUND

The consumption of sugar-sweetened beverages (SSBs) has increased substantially over recent decades, raising concerns about its various physiological effects on bodily function. However, the relationship between SSBs intake and constipation remains insufficiently understood.

METHODS

Data from 7,979 participants sourced from the National Health and Nutrition Examination Survey (NHANES) were analyzed in this study. Dietary intake of SSBs was assessed using two 24-hour dietary recall interviews, and constipation was defined according to the Bristol Stool Form Scale (BSFS) Cards. We employed weighted logistic regression analysis to examine the relationship between SSBs consumption (quantified in grams and kilocalories) and the risk of constipation, while stratified and restricted cubic spline (RCS) analyses explored population variability.

RESULTS

After adjusting for all relevant variables, SSBs quantified in grams (SSBs-grams) (ORQ3 vs. Q1 = 1.419, 95% CI: 1.064-1.893, p = 0.019; p for trend = 0.02) and SSBs quantified in kilocalories (SSBs-kcal) (ORQ4 vs. Q1 = 1.567, 95% CI: 1.100-2.234, p = 0.015; p for trend = 0.016) showed a significant positive association with constipation. Furthermore, the weighted RCS and stratified analyses indicated that the association varied among subgroups, with a non-linear relationship between SSBs-kcal and constipation (SSBs-grams: p non-linear = 0.100, SSBs-kcal: p non-linear = 0.026).

CONCLUSIONS

Our findings indicated that increased SSBs consumption is associated with a higher risk of constipation. The results underscore the need for public health interventions aimed at reducing the intake of SSBs and promoting healthier alternatives.

Association between dietary oxidative balance score and constipation: evidence from National Health and Nutrition Examination Survey

Background

Numerous researches have revealed a correlation between dietary factors and the development of constipation. This study aimed to investigate the association between dietary oxidative balance score (DOBS) and constipation.

Materials and methods

A cross-sectional study was conducted by us based on the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2010 including 31,034 individuals who completed a constipation questionnaire. The DOBS was calculated based on 16 dietary factors, containing 14 antioxidants and two prooxidants. Multiple logistic regression and restricted cubic spline (RCS) analyses were employed to examine the correlation between DOBS and constipation. Meanwhile, propensity score matching (PSM) was chosen to eliminate the effect of confounding variables.

Results

A total of 11,019 participants were identified as constipation. After adjusting for potential confounding variables, multiple logistic regression analysis indicated that decreasing DOBS (OR = 0.977, 95% CI: 0.966-0.987, p < 0.001) was apparently associated with increased risk of constipation incidence. Notably, the occurrence of constipation increased with reduced level of DOBS, as compared to Q1 (Q2, OR = 0.820, 95% CI, 0.682-0.988, p = 0.037; Q3, OR = 0.797, 95% CI, 0.653-0.973, p = 0.026; Q4, OR = 0.648, 95% CI, 0.528-0.797, p < 0.001).

Conclusion

Low levels of DOBS were positively associated with the risk of constipation development, demonstrating that DOBS could be employed as a dietary indicator of constipation prevention.

Efficacy and safety of elobixibat in patients with chronic constipation-A randomized, multicenter, double-blind, placebo-controlled, parallel-group study from India

BACKGROUND

Elobixibat is a locally acting ileal bile acid transporter (IBAT) inhibitor that relieves functional constipation in patients by accelerating colonic transit. In this study, we aimed at determining the efficacy and safety of elobixibat for short-term treatment (two weeks) of chronic constipation in Indian patients.

METHODS

The present study was a randomized, double-blind, parallel-group, placebo-controlled, phase III study to evaluate efficacy and safety of elobixibat. The study planned to enroll patients with chronic constipation of at least six months' duration, satisfying Rome IV criteria for functional constipation. Following a run-in of approximately 14 days to confirm eligibility and determine baseline frequency of spontaneous bowel movements (SBMs), eligible patients were randomized 1:1 either to elobixibat or to placebo groups. The change in weekly frequency of spontaneous bowel movements (SBMs) at the end of treatment (week two) over baseline was the primary efficacy endpoint in this trial. Primary efficacy analyses were based on the modified intention-to-treat (mITT) population. This trial is registered at CTRI (Clinical Trial Registry of India).

RESULTS

Between April 2023 and December 2023, 150 patients were randomized into the two-week trial. In mITT population (n = 146 [elobixibat = 75 and placebo = 71]), the least square mean (LSM) difference between elobixibat (3.83) and placebo (2.68) was 1.15 (95% CI, 0.31, 1.99) demonstrating a statistically significant improvement (p = 0.008) in weekly frequency of SBMs (week two over baseline) with the use of elobixibat. The proportions of patients with a complete spontaneous bowel movement (CSBM) "response" was significantly higher with elobixibat (49.33%) compared to the placebo (26.76%) treatment (difference 22.57% [95% CI, 8.36%, 36.78%] [p = 0.005]). The most common adverse event (AE) was abdominal pain (elobixibat = 6 patients [7.89%] vs. placebo = 3 patients [4.05%]).

CONCLUSIONS

Elobixibat was well tolerated and improved bowel movement frequency within two weeks of treatment in Indian patient population with chronic constipation.

CLINICAL TRIAL REGISTRY NUMBER

CTRI/2022/10/046690.

Insoluble dietary fibers from Hancornia speciosa alleviates chronic constipation on experimental loperamide-induced model

Constipation is one of the most prevalent intestinal disorders and is characterized by the presence of hard and dry stools, excessive effort, infrequent bowel movements, abdominal distension and pain, and others. Low fiber consumption may be one of the nutritional factors that greatly influence the development of constipation. Previous studies have observed the laxative effect of Hancornia speciosa fruit pulp. So, this study aims to extract and characterize the dietary fibers from H. speciosa fruit pulp and evaluate the laxative effect of both soluble (SDF) and insoluble (IDF) fractions on an experimental model of loperamide-induced chronic constipation. Monosaccharide and NMR analyses showed that SDF and IDF fractions were mainly composed of arabinose, indicating the presence of pectic arabinans. No changes on food and water intake and weight gain were observed. IDF fraction induced a threefold increase in number, weight and water content of fecal pellets and doubled small intestine transit rate. Similar results were obtained for SDF in a smaller intensity. Both fractions decreased the number of leukocytes in small and large intestines, suggesting a potential anti-inflammatory effect. Thus, the dietary fiber fractions from H. speciosa were effective in improving fecal parameters and alleviating constipation symptoms in the evaluated model.

Association between constipation and the urine albumin-to-creatinine ratio in adults: the NHANES 2009-2010

Objective

This study aimed to analyze the association between constipation and the urine albumin-to-creatinine ratio (ACR) using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2010.

Methods

In this cross-sectional study, a sample of 4,282 adults aged 20 and older was selected from the NHANES 2009-2010. Constipation was defined as having fewer than three bowel movements per week. The average of the two ACR measurements was used as the outcome variable. Logistic regression models (non-adjusted and multivariate adjusted models) were used to examine the relationship between constipation and ACR. Subgroup and interaction analyses related to gender, age, smoking, alcohol consumption, body mass index (BMI), hypertension, and diabetes were also conducted to assess the stability of the association between constipation and ACR.

Results

In this study population of 4,282 individuals, 352 individuals with an ACR of 30 mg/g or higher were considered to have albuminuria. The prevalence of constipation was higher in the albuminuria group compared to the non-albuminuric group (6.4% vs. 3.5%, p = 0.002). The unadjusted model (Model I) showed an increased risk of ACR associated with constipation (OR 1.81, 95% CI 1.13-2.91, p = 0.014). After controlling for gender, age, race/ethnicity, marital status, and education level in Model II, the association between constipation and ACR remained significant (OR 2.20, 95% CI 1.34-3.60, p = 0.002). Upon further adjustment for BMI, smoking status, alcohol consumption, diabetes, hypertension, arthritis, asthma, coronary heart disease, liver disease, cancer, blood urea nitrogen (BUN), serum creatinine (Scr), uric acid (UA) and estimated glomerular filtration rate (eGFR) in Model III, the positive association between constipation and ACR was still significant (OR 1.88, 95% CI 1.09-3.23, p = 0.023). Subgroup analyses, stratified by gender, age, smoking status, alcohol consumption, BMI, hypertension, and diabetes, showed no statistically significant interactions (p > 0.05).

Conclusion

In summary, this study found a positive association between constipation and urinary albumin excretion rate. The significant association between constipation and ACR highlights the need for clinicians to monitor urinary albumin levels in patients with constipation.

Theaflavin-3,3'-digallate (TF3) attenuated constipation by promoting gastrointestinal motility and modulating the gut microbiota: A comparative study of TF3 and the anti-constipation drug mosapride in mice

TF3 is a functional pigment formed during the process of black tea. This study aims to explore the anti-constipation effects of TF3 and compare its efficacy with the anti-constipation drug mosapride. Result showed that both TF3 and mosapride increased fecal water content and promoted gastrointestinal (GI) motility, but TF3 was more effective in restoring excitatory neurotransmitters like gastrin (Gas), motilin (MTL), and substance P (SP). TF3 uniquely altered the gut microbiota profile and restored the bacterial community at the phylum level. TF3 targeted specific bacteria such as Alloprevotella, Bacteroides, and Parabacteroides, while mosapride affected different bacterial groups. Significant changes in Bacteroides and Prevotellaceae UCG-001 were linked to constipation improvement. Importantly, TF3 did not synergize with mosapride in alleviating constipation. These findings highlight TF3's unique role in modulating gut microbiota to relieve constipation and suggest great potential to develop functional foods with anti-constipation properties using tea-derived polyphenols.

Efficacy of an Iranian herbal medicine formula for postoperative constipation in trauma patients with hip and lower limb fractures: A triple-blind, placebo-controlled randomized clinical trial

AIM OF THE STUDY

This trial aimed to evaluate the efficacy of the "Herbal Laxative Capsule" (HLC) formulation in alleviating symptoms of postoperative constipation (POC) in patients undergoing surgeries for traumatic fractures of the hip or lower extremities. The HLC is a novel polyherbal formulation that integrates both scientifically validated botanicals, such as Cassia angustifolia and Aloe barbadensis, with traditionally employed herbs like Foeniculum vulgare, Coriandrum sativum, and Carum carvi, all of which are recognized for their laxative properties.

MATERIALS AND METHODS

A triple-blind, placebo-controlled, randomized clinical trial was conducted at an academic hospital in Kashan, Iran. A total of 61 orthopedic patients with POC were randomized to receive either HLC (n = 31) in the treatment group or a placebo (n = 30) in the placebo group. Both were administered as 520 mg capsules, taken twice daily for one week. The primary outcomes included assessments of constipation severity and stool consistency, while the secondary outcomes evaluated patient satisfaction using validated clinical scales.

RESULTS

The treatment group demonstrated a statistically significant reduction in constipation severity and improvement in stool consistency compared with the placebo group (P < 0.001). No significant adverse effects were reported. Additionally, patient satisfaction was notably higher in the treatment group (P < 0.001).

CONCLUSION

The HLC formulation demonstrated significant efficacy in effectively managing POC, which is often opioid-induced constipation (OIC), in orthopedic patients. These findings suggest that HLC could serve as a promising alternative to conventional laxatives, warranting further investigation in larger-scale clinical trials.

Impact of comorbid constipation on the survival of patients with heart failure: a multicenter, prospective cohort study conducted in Japan

Background

Constipation frequently affects heart failure patients because of medication side effects and physiological effects of the condition. Although recent speculation suggests that comorbid constipation may affect cardiovascular disease onset and survival rates, this relationship remains unclear. We examined the effect of comorbid constipation on the survival of patients with heart failure.

Methods

We conducted a multicenter prospective cohort study (the Kochi YOSACOI study) of patients hospitalized for acute decompensated heart failure. The influence of comorbid constipation on survival was evaluated using Cox regression analysis with 2-year survival as the index. Patients were divided into two groups based on the presence of comorbid constipation. The patient background was adjusted using propensity score matching, and the evaluation included assessing the 2-year survival and cardiovascular mortality occurrence using the log-rank test.

Results

Among 1,061 patients hospitalized for acute decompensated heart failure, 715 with complete data (124 with comorbid constipation and 591 without) were analyzed. Comorbid constipation was identified as a risk factor for poorer survival in the Cox regression model (hazard ratio: 1.90, 95% confidence interval: 1.3-2.8, P < 0.001). Propensity score matching included 104 patients in each group. Survival analysis using the log-rank test indicated worse survival (P = 0.023) and higher cardiovascular mortality (P = 0.043) in the comorbid constipation group.

Conclusion

Constipation can negatively affect the survival of patients with heart failure. Although the causal link between constipation and decreased survival remains unclear, identifying comorbid constipation is essential for identifying heart failure patients at a higher risk of poor outcomes.

Bifidobacterium longum subsp. longum relieves loperamide hydrochloride-induced constipation in mice by enhancing bile acid dissociation

Bifidobacterium species are known for their efficacy in alleviating constipation. This study aimed to compare the constipation-relieving effects of different Bifidobacterium species (Bifidobacterium longum subsp. longum, Bifidobacterium bifidum, Bifidobacterium animalis, Bifidobacterium breve, Bifidobacterium longum subsp. infantis, and Bifidobacterium adolescentis) and to explore the underlying mechanisms from both the bacterial and host perspectives. We evaluated six Bifidobacterium species for their physiological properties, including growth rate, oligosaccharide utilization, osmotic pressure resistance, cell adhesion, and bile acid dissociation capability. Mice with severe constipation induced by loperamide hydrochloride were treated with these bacteria at a density of 109 CFU per mL for 17 days. Gastrointestinal indices such as fecal water content, time to first black stool defecation, and small intestine propulsion rate were measured to assess constipation relief. Microbiome and metabolome (bile acid and tryptophan) analyses were conducted to elucidate the differences in constipation relief among the species. Our results demonstrated that Bifidobacterium longum subsp. longum exhibited superior physiological traits, including rapid growth, extensive oligosaccharide utilization, and high bile salt dissociation capacity. Notably, only Bifidobacterium longum subsp. longum significantly ameliorated constipation symptoms in the mouse model. Furthermore, this strain markedly restored bile acid and short-chain fatty acid levels in the intestines of constipated mice and altered the composition of the intestinal microbiota. These findings suggest that the enhanced efficacy of Bifidobacterium longum subsp. longum in relieving constipation is associated with its ability to modulate intestinal physiology and microbiota structure and metabolism.

Constipation and risk of death and cardiovascular events in patients on hemodialysis

BACKGROUND

Constipation is a common gastrointestinal disorder and is often accompanied by alteration in the gut microbiota. Recently, several studies have disclosed its association with an increased risk of cardiovascular disease and mortality in the general population. Despite the high prevalence of constipation, data on the clinical impact of constipation in patients with chronic kidney disease are limited. We aimed to explore the prevalence of constipation and its association with cardiovascular disease in chronic kidney disease using a nationally representative cohort of hemodialysis patients.

METHODS

This study used hemodialysis quality assessment and health insurance claims data from patients undergoing maintenance hemodialysis in South Korea. Chronic constipation was defined using the total number of laxatives prescribed during the 1-year baseline period. The primary outcome was a composite of acute ischemic stroke, hemorrhagic stroke, myocardial infarction, or all-cause death. Secondary outcomes were the individual components of the primary outcome.

RESULTS

Among 35,230 patients on hemodialysis, 9,133 (25.9%) were identified as having constipation. During a median follow-up of 5.4 years, patients with constipation had a 15% higher incidence of the composite outcome, 16% higher incidence of ischemic stroke, and 14% higher all-cause mortality, after multivariate adjustment.

CONCLUSION

Chronic constipation requiring laxatives was associated with a higher risk of the composite outcome of cardiovascular events or all-cause death in patients on hemodialysis. Further studies are needed to confirm whether constipation is an independent predictor or a possible causal factor of cardiovascular disease.

Seasonal variations and a demographic analysis of digital evacuation incidence for constipation management: A Japanese population-based cohort study

Objective Digital evacuation (DE) is an intervention used to address severe constipation. Literature exists on easily administered laxatives; however, reports on mildly invasive DE usage are limited. This study aimed to elucidate the fundamental data regarding constipation management using a comprehensive national database of DE incidence. Methods This observational epidemiological study analyzed the age- and sex-stratified DE incidence per 1,000 person-years during 2014-2021 using the medical receipt database in Japan. The annual trends were evaluated using Poisson regression models. We examined the month-stratified incidence during 2019-2021 to assess potential seasonal variations using a one-way analysis of variance and unpaired t-tests with the Bonferroni correction for comparisons across the four seasons. Correlation coefficients were calculated to determine the relationship between the meteorological variables and DE incidence. Results Over the 8-year period, the DE incidence amounted to 32,361,846 procedures, with a median of 10.3 procedures per 1,000 person-years. A demographic analysis revealed a minor peak, nadir, and progressive increase peaking in the 0-4-year (22.1 procedures), 5-9-year (1.5 procedures), and ≥90-year (370.7 procedures) age groups, respectively. The age-adjusted DE incidence across all age groups per 1,000 person-years showed a declining annual trend [incidence rate ratio: 0.971 (P<0.0001)]. A seasonal analysis revealed a significant increase in DE procedures during winter compared with summer (P<0.0125). A correlation was observed between the DE incidence and certain meteorological variables, particularly the temperature. Conclusion This study highlights the notable demographic patterns and the impact of seasonal and meteorological factors on the DE incidence.

Association of Ultra-processed Food and Unprocessed or Minimally Processed Food Consumption With Bowel Habits Among U.S. Adults

BACKGROUND & AIMS

Ultra-processed foods (UPFs) may have a negative impact on bowel habits. We aimed to assess the association between UPF and unprocessed or minimally processed food (MPF) intake and bowel habits among adults in the United States (U.S.).

METHODS

We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (2005-2010). We used two 24-hour dietary recalls and, based on the Nova classification, calculated intakes of UPFs and MPFs. Constipation and diarrhea were defined using the Bristol Stool Form Scale and stool frequency. We performed survey-weighted logistic regression and substitution analysis to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among 12,716 U.S. adults, there were 1290 cases of constipation and 1067 cases of diarrhea. Median UPF and MPF intakes were 26.5% and 66.2% of total grams per day, respectively. Greater UPF consumption (in % gram/d) was associated with higher odds of constipation (adjusted OR [aORQ4 vs Q1], 2.20; 95% CI, 1.76-2.74) (Ptrend < .001) but not diarrhea (aORQ4 vs Q1, 0.82; 95% CI, 0.62-1.09) (Ptrend = .12). Increased MPF consumption was associated with lower odds of constipation (aORQ4 vs Q1, 0.46; 95% CI, 0.370-0.57) (Ptrend < .001). Associations with constipation were attenuated after adjusting for diet quality (aORQ4 vs Q1, UPF, 1.53; MPF, 0.69). Substituting 10% of UPF intake with an equivalent proportion of MPFs was associated with lower odds of constipation (aOR, 0.90; 95% CI, 0.87-0.93).

CONCLUSIONS

UPF intake was associated with higher odds of constipation, whereas the odds were lower with greater MPF consumption. The effect of food processing on bowel habits was independent of diet quality.

Denoising method for colonic pressure signals based on improved wavelet threshold

The colonic peristaltic pressure signal is helpful for the diagnosis of intestinal diseases, but it is difficult to reflect the real situation of colonic peristalsis due to the interference of various factors. To solve this problem, an improved wavelet threshold denoising method based on discrete wavelet transform is proposed in this paper. This algorithm can effectively extract colonic peristaltic pressure signals and filter out noise. Firstly, a threshold function with three shape adjustment factors is constructed to give the function continuity and better flexibility. Then, a threshold calculation method based on different decomposition levels is designed. By adjusting the three preset shape factors, an appropriate threshold function is determined, and denoising of colonic pressure signals is achieved through hierarchical thresholding. In addition, the experimental analysis of bumps signal verifies that the proposed denoising method has good reliability and stability when dealing with non-stationary signals. Finally, the denoising performance of the proposed method was validated using colonic pressure signals. The experimental results indicate that, compared to other methods, this approach performs better in denoising and extracting colonic peristaltic pressure signals, aiding in further identification and treatment of colonic peristalsis disorders.

The magnitude of chronic constipation and associated factors among type 2 diabetic patients in Harar, Eastern Ethiopia

BACKGROUND

Constipation, which affects 16% of adults worldwide, is a chronic health problem characterized by unsatisfactory frequency of bowel movements, causing pain, bloating or incomplete bowel movements. The study aims to assess the magnitude of chronic constipation and associated factors among T2DM patients attending the endocrinology outpatient clinic at Hiwot Fana Comprehensive Specialized University Hospital from January 1 to May 30, 2023.

METHODS

Hospital-based cross-sectional study design was carried out to assess the magnitude and associated factors of chronic constipation among T2DM patients at Hiwot Fana Comprehensive Specialized University Hospital. Using a single population formula 300 T2DM patients were enrolled in this study. The data was analyzed by using the Epi-Data 4.6 and SPSS version 25. Descriptive, bivariate, multivariate, and logistic regression were used. P < 0.05 was used to declare association.

RESULTS

300 T2DM patients participated in this survey. Of these 137 (45.7%) were male and 163 (54.3%) were female and the mean age was 58.57 ± 11.09 SD years, the range from 35 to 85 years. The prevalence of constipation was 73 (24.3%) (95% CI: 0.196-0.296). Education status above high school (AOR: 0.151.95% CI: 0.032-0.718), less than 7 h of sleep per day (AOR: 12.39.95% CI: 2.712-56.69), frequent depression (AOR: 6, 84, 95% CI: 2.639-17.743), parents with constipation (AOR: 6.843.95% CI: 2.639-17.743), daily water intake < 1300 ml (AOR: 4.760.95% CI: 1.146-19.773), TAG levels below 150 mg/dl (AOR: 0.050, 95% CI: 0.015-0.166), HbAlc between 6 and 7% (AOR: 0.013.95% CI: 0.001-0.132) ,HbAlc between 7.1 and 8% (AOR: 0.006, 95% CI: 0.001-0.067), and LDL levels were significantly associated with chronic constipation in T2DM patients.

CONCLUSIONS

The prevalence of chronic constipation was considerable in T2DM patients. Education level above high school, less than 7 h of sleep per day, frequent depression, parents with constipation, daily water intake < 1300 ml, TAG and HbAlc play a significant role in the development of chronic constipation in T2DM patients. T2DM patients can reduce the extent of constipation by treating the above problem in a timely and timely manner.

The impact of small intestinal bacterial overgrowth on the efficacy of fecal microbiota transplantation in patients with chronic constipation

To investigate the impact of Small Intestinal Bacterial Overgrowth (SIBO) on the efficacy of Fecal Microbiota Transplantation (FMT) in patients with chronic constipation, our research team included 218 patients with chronic constipation treated with FMT. Based on the results of the SIBO breath test, the patients were divided into two groups: the constipation with SIBO group (SIBO) and the constipation without SIBO group (non-SIBO). The efficacy of the two groups was evaluated using constipation-related scoring scales. At the same time, feces and small intestinal fluid samples were collected from both groups before and after FMT to compare the changes in the intestinal microbiota through 16S rRNA sequencing. In this study, it was found that the clinical efficacy of FMT in the SIBO group was superior to that in the non-SIBO group. After FMT treatment, both groups showed a significant increase in bowel frequency and improvement in stool characteristics. Abdominal symptoms, rectal symptoms, and defecation symptoms were significantly alleviated (P < 0.05), and patients' quality of life was significantly enhanced (P < 0.05). After FMT, except for the Constipation Assessment Scale scores, other scale scores showed significant differences between the two groups, the SIBO group scoring significantly better than the non-SIBO group (P < 0.05). After FMT, there were minor changes in the colonic microbiota but more substantial changes in the small intestinal microbiota. At baseline, the SIBO group had a higher abundance of Veillonella, and lower abundances of Escherichia-Shigella and Acinetobacter compared to the non-SIBO group. Chronic constipation patients with SIBO have a better response to FMT than those without SIBO.

IMPORTANCE

Existing studies have rarely considered the impact of the small intestine's microbial state on the efficacy of fecal microbiota transplantation (FMT), nor have they extensively explored the effect of the small intestine's microbial state on the recovery of colonic motility. Therefore, this study investigates the influence of small intestinal bacterial overgrowth (SIBO) on the efficacy of FMT in treating constipation, specifically the impact of the microbial state of the small intestine on the restoration of colonic homeostasis, and consequently on the recovery of colonic motility.

Review document of the Spanish Association of Neurogastroenterology and Motility on the management of opioid-induced constipation

Opioid-induced constipation (OIC) is a rising problem due to the progressive increase in opioid prescription. In contrast to functional constipation, opioid-induced constipation is not a functional gut disorder but a side effect of opioid use. Opioids produce constipation due to a decrease in gastrointestinal motility and a reduction in gastrointestinal secretions. The treatment of OIC focuses on three basic pillars: optimizing opioid drug indication, preventing constipation onset, and treating constipation should it develop. As with any other cause of constipation, lifestyle adjustments and laxatives should be the first-line option in the pharmacological management of OIC. Osmotic laxatives such as polyethylene glycol (PEG) are the agents of choice. PEG is inert and is neither fermented nor absorbed in the gastrointestinal tract. Furthermore, it has broad clinical applicability due to its favourable safety profile. If first-line treatments fail, peripheral μ-opioid receptor antagonists (PAMORA) are the drugs of choice. They reduce the peripheral effects of OIC with a minimal potential to diminish analgesia or induce a centrally mediated withdrawal syndrome. Different PAMORA are available in the market both for oral and subcutaneous administration, with demonstrated efficacy for the management of OIC in different clinical trials.

Constipation-associated factors in outpatients with schizophrenia: A multicenter questionnaire survey

Constipation is a prevalent gastrointestinal disorder that affects people globally, decreasing their quality of life and life expectancy. Individuals with schizophrenia often suffer from constipation, which could be a result of the illness itself or the side effects of psychotropic medications. However, little research has been conducted on factors contributing to constipation in individuals with schizophrenia. To address this issue, we conducted a survey using self-administered questionnaires and medical records to identify factors associated with constipation in psychiatric outpatients. This study included 399 patients with schizophrenia, resulting in a high prevalence of constipation (43.4%). The analysis suggested that female gender, the doses of antiparkinsonian medications, and benzodiazepine sleeping pills may be associated with constipation.

Preclinical pharmacokinetic studies and prediction of human PK profiles for Deg-AZM, a clinical-stage new transgelin agonist

Introduction

Deglycosylated azithromycin (Deg-AZM), a newly developed Class I drug with good therapeutic effects on slow transit constipation, is a small-molecule transgelin agonist that has been approved for clinical trials in 2024. The preclinical pharmacokinetic profile of Deg-AZM was investigated to support further development.

Methods

A LC-MS/MS method was established and validated to detected the concentration of Deg-AZM in various biological samples. In vivo tests such as pharmacokinetic studies in rats and dogs, tissue distribution studies in rats, and extraction studies in rats were conducted to investigated the preclinical pharmacokinetic behaviors of Deg-AZM comprehensively. The plasma protein rate of Deg-AZM was determined by rapid equilibrium dialysis method in vitro. The metabolic stability and metabolite profile of Deg-AZM was assessed using pooled mice, rats, dogs, monkeys and humans microsomes in vitro. The PK profiles of Deg-AZM in human was predicted based on physiologically based pharmacokinetic (PBPK) models.

Results

The plasma protein binding rates of Deg-AZM were lower in mice and rats, higher in dogs, and moderate in humans. The metabolic process of Deg-AZM was similar in rat and human liver microsomes. From Pharmacokinetic studies in rats and dogs, Deg-AZM was rapidly absorbed into the blood and then quickly eliminated. Plasma exposure of Deg-AZM was dose dependent with no accumulation after continuous gavage administration. In addition, there is no significant gender difference in the pharmacokinetic behavior of Deg-AZM. Deg-AZM was widely distributed in the tissues without obvious accumulation, and mainly excreted from the urinary excretion pathway. Furthermore, the pharmacokinetic profiles of Deg-AZM in humans showed dose dependency.

Conclusion

The pharmacokinetic profiles of Deg-AZM was fully explored, these results could provide valuable information to support the first-in-human dosage prediction and phase I clinical design.

Evidence-Based Clinical Guidelines for Chronic Constipation 2023

The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide. The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide.

Post-infection gastrointestinal disorders and treatment options

The development of post-infectious pathology is determined by the type of pathogen, the genesis of damage to the intestinal barrier and the premorbid background of the child. On the scale of recent epidemiological events, attention is drawn to the SARS-CoV-2 virus, which has tropism for cells of the gastrointestinal tract, distorts the composition and function of the intestinal microbiome. The importance of the functions of intestinal microbes in the genesis and outcome of SARS-CoV-2 infection has been highlighted. It has been proven that a microbiota disorder with a new coronavirus infection affects not only the duration and severity of the infectious process, but also the risk of the formation of systemic diseases and malignant neoplasms. After the acute phase of SARS-CoV-2 infection, post-COVID-19 syndrome may occur, the pathophysiology of which has not yet been fully established. Although it is believed that the main reason for its appearance is the diversification of the intestinal microbial landscape against the background of the direct effect of SARS-CoV-2 on the ACE2 receptors of intestinal epitheliocytes, followed by a pathoimmune response and impaired hemostasis. Established post-COVID-19 dysbiosis underlies functional gastrointestinal disorders with pronounced impairment in the brain-gut-microbiota axis and imbalance of the migrating motor complex, leading to the development of constipation. Post-infectious constipation debut within the first 3 months after an acute infection. The main goal of therapy for post-infectious constipation is to achieve regular painless defecation with soft-consistency stool and prevent feces. Numerous foreign studies and clinical guidelines indicate that stimulating laxatives are effective and safe in the treatment of constipation, include the children’s practice. Sodium picosulfate is considered one of the topical drugs of this group of laxatives.

Effective process quality control management for constipation prevention in hospitalized patients with acute coronary syndrome: An observational study

Objective

To evaluate the effectiveness of monitoring and managing process quality control indicators in the prevention of constipation among hospitalized patients with acute coronary syndrome (ACS).

Methods

A total of 512 hospitalized patients diagnosed with ACS between January and June 2022 were screened for inclusion in the study. Ultimately, 456 eligible participants were enrolled and divided into two groups based on the chronological order of admission: the control group and the observation group. Upon admission, both groups of patients received routine constipation prevention measures in the department. However, the observation group was subjected to targeted process quality control management, which included monitoring and managing five indicators related to constipation prevention: correctness of bowel movement recording; usage rate of laxatives; execution rate of physical interventions; implementation rate of constipation prevention education; completion rate of dietary structure and habit assessments. Data were analyzed using SPSS, with t tests and χ 2 tests for group comparisons.

Results

In comparison to the control group, the observation group demonstrated significant advantages in terms of constipation incidence, completion rates of the five process quality control indicators, occurrence rates of adverse cardiac events during defecation, and PHQ-9 scores before discharge. These disparities demonstrated statistical significance with a p value < 0.05.

Conclusion

Target-oriented process quality control management is shown to be effective in reducing constipation incidence and adverse cardiac events during constipation episodes, as well as alleviating depressive symptoms among ACS patients, thus providing a safe and effective approach to constipation prevention.

A Handheld Ultrasound Device Can Predict Constipation with Rectal Fecal Retention in a Palliative Care Setting

Although handheld ultrasound devices (HUDs) are commonplace, their ability to diagnose fecal retention (FR) remains unclear. This prospective observational study examined HUDs' usefulness in diagnosing FR in patients with constipation in a palliative care setting. Between 10 December 2020 and 30 June 2022, we compared rectal ultrasonographic findings obtained using HUDs with clinical manifestations in 64 males and 70 females (48%, 52%, 68 ± 11 years old) with constipation who had undergone computed tomography (CT). FR was diagnosed using a HUD and compared with CT and digital rectal examination (DRE) results. In total, 42 (31%), 42 (31%), and 41 (31%) patients were diagnosed using HUDs, CT, and DRE, respectively. Thirty-nine (93%) patients in the CT group were also diagnosed with FR using HUDs. A total of 89 of 92 patients with a negative CT diagnosis also had a negative HUD diagnosis. Among the 41 patients in the DRE group, 37 were also diagnosed with FR using HUDs. Among 93 patients with a negative DRE diagnosis, 86 had a negative HUD diagnosis. The sensitivity, specificity, positive predictive value, and negative predictive value of HUDs for CT were 93%, 97%, 93%, and 97%, respectively. Those of HUDs for DRE were 88%, 94%, 86%, and 95%, respectively. The concordance rates for FR diagnosis were 128/134 for CT and HUDs and 123/134 for DRE and HUDs. HUD was useful for diagnosing FR in this setting. HUDs could provide valuable support for appropriate treatment selection. Developing a constipation treatment algorithm based on rectal ultrasonographic findings is warranted in the future.

A randomized, double-blind, placebo-controlled clinical study to evaluate the efficacy and safety of Weizmannia coagulans BC99 in the treatment of chronic constipation in adults

Introduction

Weizmannia coagulans has emerged as a promising candidate for the management of gastrointestinal ailments. The novel strain of Weizmannia coagulans, Weizmannia coagulans BC99 (BC99), displays robust pathogen-inhibiting capabilities, susceptibility to various antibiotics, and a high level of biosafety. Nevertheless, additional research is necessary to fully understand its effectiveness in managing chronic constipation.

Methods

This study investigates the role of BC99 in alleviating chronic constipation in a double-blind, placebo-controlled, randomized trial, and participants were divided into BC99 (2 billion CFU/d) or placebo (maltodextrin) groups for a 4-week period.

Results and discussion

Results showed that significant improvements were noted in the BC99 group, with an increase in complete spontaneous bowel movements (CSBM) after 4-week treatment compared to the placebo (p = 0.002). The BC99 group also showed significantly lower Quality of Life (PAC-QOL) scores and reduced Constipation Symptoms (PAC-SYM) scores after 4 weeks of treatment (p < 0.001), indicating symptomatic relief. Notably, BC99 effectively modulated key gut microbiota such as Bifidobacterium and Ruminococcus, linked to crucial metabolic pathways like glutathione metabolism. In all, BC99 is confirmed to be an effective and safe therapeutic option for the relief of adult chronic constipation, enhancing gut microbiota balance and influencing critical metabolic pathways.

Clinical trial registration

ChiCTR2200065493.

Constipation prevalence and risk from prescribed medications in people with intellectual disability: Findings from an English mortality programme

Constipation is common in people with intellectual disability, with case reports of associated deaths. Risk factors include lifestyle factors, health conditions, and certain medications. We aimed to explore constipation in a sample of people with intellectual disability who died in 2021. We described prevalence of constipation, causes of death and the risk of secondary constipation from prescribed medications. Medications were scored based on the risk of constipation indicated in the drug profile. Forty-eight percent of the sample had constipation. Half of the sample were prescribed at least two medications that are commonly associated with side effects of constipation. There were high rates of antipsychotic (30%) and laxative (40%) drug prescription. Five people with a history of constipation died of causes of death associated with constipation. Our findings highlight the risk of secondary constipation due to prescribed medication and the seriousness of the condition in people with intellectual disability.

Aberrant bowel movement frequencies coincide with increased microbe-derived blood metabolites associated with reduced organ function

Bowel movement frequency (BMF) directly impacts the gut microbiota and is linked to diseases like chronic kidney disease or dementia. In particular, prior work has shown that constipation is associated with an ecosystem-wide switch from fiber fermentation and short-chain fatty acid production to more detrimental protein fermentation and toxin production. Here, we analyze multi-omic data from generally healthy adults to see how BMF affects their molecular phenotypes, in a pre-disease context. Results show differential abundances of gut microbial genera, blood metabolites, and variation in lifestyle factors across BMF categories. These differences relate to inflammation, heart health, liver function, and kidney function. Causal mediation analysis indicates that the association between lower BMF and reduced kidney function is partially mediated by the microbially derived toxin 3-indoxyl sulfate (3-IS). This result, in a generally healthy context, suggests that the accumulation of microbiota-derived toxins associated with abnormal BMF precede organ damage and may be drivers of chronic, aging-related diseases.

Expert Consensus Document: An Algorithm for the Care and Treatment of Patients with Constipation Based on Ultrasonographic Findings in the Rectum

Chronic constipation is a common gastrointestinal disorder, and its management is critical. However, it is extremely difficult to assess its subjective symptoms when patients are unable to report them due to cognitive or physical disabilities, especially in cases of patients with incurable geriatric, pediatric, palliative, psychiatric, or neurological diseases. We had previously established a protocol for observing and assessing rectal fecal retention using ultrasonography and for classifying cases into three categories based on the rectal findings: no fecal retention, fecal retention without hard stools, and fecal retention with hard stools. However, although the detection of rectal fecal retention using ultrasonography would be expected to lead to better therapeutic management, there is no standard algorithm for selecting specific treatments and defecation care options based on ultrasonographic findings. Therefore, we organized an expert consensus meeting of multidisciplinary professionals to develop such an algorithm based on rectal ultrasonography findings for patients with constipation in both residential and hospital settings.

Association of maternal constipation and risk of atopic dermatitis in offspring

Objectives: Atopic dermatitis (AD) is a chronic and relapsing dermatologic disease that can affect individuals of all ages, including children and adults. The prevalence of AD has increased dramatically over the past few decades. AD may affect children's daily activities, increase their parents' stress, and increase health expenditure. Constipation is a worldwide issue and may affect the gut microbiome. Some research has indicated that constipation might be associated with risk of atopic disease. The primary objective of this retrospective cohort study was to extend and to explore the link between maternal constipation and risk of atopic dermatitis in offspring. Methods: Using the Longitudinal Health Insurance Database, a subset of Taiwan's National Health Insurance Research Database, we identified 138,553 mothers with constipation and 138,553 matched controls between 2005 and 2016. Propensity score analysis was used matching birth year, child's sex, birth weight, gestational weeks, mode of delivery, maternal comorbidities, and antibiotics usage, with a ratio of 1:1. Multiple Cox regression and subgroup analyses were used to estimate the adjusted hazard ratio of child AD. Results: The incidence of childhood AD was 66.17 per 1,000 person-years in constipated mothers. By adjusting child's sex, birth weight, gestational weeks, mode of delivery, maternal comorbidities, and received antibiotics, it was found that in children whose mother had constipation, there was a 1.26-fold risk of AD compared to the children of mothers without constipation (adjusted hazard ratio [aHR]: 1.26; 95% CI, 1.25-1.28). According to subgroup analyses, children in the maternal constipation group had a higher likelihood of AD irrespective of child's sex, birth weight, gestational weeks, mode of delivery, and with or without comorbidities, as well as usage of antibiotics during pregnancy. Compared to the non-constipated mothers, the aHR for the constipated mothers with laxative prescriptions <12 and ≥12 times within one year before the index date were 1.26; 95% CI, 1.24 -1.28 and 1.40; 95% CI, 1.29-1.52, respectively. Conclusion: Maternal constipation was associated with an elevated risk of AD in offspring. Clinicians should be aware of the potential link to atopic dermatitis in the children of constipation in pregnant women and should treat gut patency issues during pregnancy. More study is needed to investigate the mechanisms of maternal constipation and atopic diseases in offspring.

Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis

Chronic kidney disease (CKD) affects 9.1% of the population worldwide. CKD may lead to structural and functional gastrointestinal alterations, including impairment in the intestinal barrier, digestion and absorption of nutrients, motility, and changes to the gut microbiome. These changes can lead to increased gastrointestinal symptoms in people with CKD, even in early grades of kidney dysfunction. Gastrointestinal symptoms have been associated with lower quality of life and reduced nutritional status. Therefore, there has been considerable interest in improving gastrointestinal health in this clinical population. Gastrointestinal health can be influenced by lifestyle and medications, particularly in advanced grades of kidney dysfunction. Therapies focused on gastrointestinal health have been studied, including the use of probiotics, prebiotics, and synbiotics, yielding limited and conflicting results. This review summarizes the alterations in the gastrointestinal tract structure and function and provides an overview of potential nutritional interventions that kidney disease professionals can provide to improve gastrointestinal health in individuals with CKD.

Examining linaclotide for the treatment of chronic idiopathic constipation

INTRODUCTION

Chronic idiopathic constipation (CIC) is characterized by infrequent bowel movements and hard stools lasting for at least three months or longer. This disease affects 8-12% of the US population and 10-17% of the world population. Treatment and management involve identifying the primary cause, changing dietary habits, and adequate physical activity. Linaclotide is a guanylate cyclase-agonist acting locally in the luminal surface of the intestinal enterocyte leading to a signal transduction cascade, activation of the cystic fibrosis transmembrane conductance regulator (CFTR), thus increasing secretion of chloride and bicarbonate into the intestinal lumen with eventual increased intestinal fluid and faster transit time.

AREAS COVERED

We reviewed multiple studies and did a thorough literature review on CIC including its pathophysiology. Through this literature review, we were able to discuss and give the context and rationale for drug regimens indicated for CIC.

EXPERT OPINION

The era we live in right now is akin to nutrient-rich and fertilized soil as knowledge and resources are abundant. The opportunities and potential are endless. Constipation being more extensively studied, our understanding of medications and diseases broadens, leading to novel medications being discovered. Linaclotide is a pioneer in this aspect and can pave the way for future generations.

Evaluating Accuracy of Rectal Fecal Stool Assessment Using Transgluteal Cleft Approach Ultrasonography

BACKGROUND

Transabdominal ultrasound is used to detect fecal impaction, but the rectum is difficult to visualize without bladder urine or with gastrointestinal gas.

OBJECTIVE

We developed a transgluteal cleft approach that is unaffected by these factors and sought to determine if our ultrasound method could detect and classify fecal matter in the lower rectum using this approach.

METHODS

We classified ultrasound images from hospitalized patients into four groups: Group 1 (bowed and rock-like echogenic areas), Group 2 (irregular and cotton candy-like hyperechoic areas), Group 3 (flat and mousse-like hyperechoic areas), and Group 4 (linear echogenic areas in the lumen). Stool characteristics were classified as hard, normal, and muddy/watery. Sensitivity and specificity were determined based on fecal impaction and stool classification accuracy.

RESULTS

We obtained 129 ultrasound images of 23 patients. The sensitivity and specificity for fecal retention in the rectum were both 100.0%. The recall rates were 71.8% for Group 1, 93.1% for Group 2, 100.0% for Group 3, and 100.0% for Group 4. The precision rates were 96.6% for Group 1, 71.1% for Group 2, 88.9% for Group 3, and 100.0% for Group 4. Our method was 89.9% accurate overall.

CONCLUSION

Transgluteal cleft approach ultrasound scanning can detect and classify fecal properties with high accuracy.

Effects of Dietary Fiber Intake and the Prevalence of Constipation Among Patients With End-Stage Renal Disease (ESRD) in Jeddah, Saudi Arabia: A Cross-Sectional Observational Study

RATIONALE/BACKGROUND

Hemodialysis (HD) patients with end-stage renal disease (ESRD) are particularly prone to constipation, which has become a growing public health issue. Nutritional therapy, such as fiber intake, significantly influences the management of constipation. In Saudi Arabia, there is limited data on fiber consumption and its correlation with constipation management in HD patients.

AIMS

The study aimed to investigate the correlation between dietary fiber intake and its effect on the prevalence of constipation in HD patients.

MATERIALS AND METHODS

This cross-sectional observational study of 77 ESRD patients on HD aged 18+ was conducted in a single dialysis center over six months. A questionnaire was employed to diagnose constipation (as defined by the Rome IV criteria of constipation), and seven-day food records were used to evaluate dietary fiber intake.

RESULTS

A study found a high prevalence of constipation (53%) among participants, with a lower daily fiber intake than recommended. However, a significant relationship was found between fiber intake and constipation (p < 0.05) with lower fiber intake in constipated patients compared to non-constipated (p = 0.001).

CONCLUSION

The study highlights a significant link between fiber intake and constipation in HD patients, suggesting adequate daily intake of fiber was effective in preventing constipation and that nutritional counseling should include adequate daily fiber intake in medical therapy management.

Association between dietary protein intake and constipation: Data from the National Health and nutrition examination survey 2005-2010

BACKGROUND

The association between dietary protein intake and constipation remains inconclusive. The aim of this study was to investigate whether dietary protein intake is associated with constipation.

METHODS

This cross-sectional study included 13,941 adults from the 2005 to 2010 National Health and Nutrition Examination Survey. A weighted logistic regression analysis was used to control for confounding factors. In addition, weighted interaction and stratified analyses were conducted to ascertain the potential modifying factors.

RESULTS

The prevalence of constipation was 7.5% when constipation was defined by stool consistency and 3.5% when constipation was defined by stool frequency. After adjusting for covariates, an increase in dietary protein intake of 10 g was not associated with constipation, as defined by stool frequency (OR = 0.94, 95% CI = 0.54, 1.62) or stool consistency (OR = 1.02, 95% CI = 0.75, 1.39). Subgroup analyses revealed that dietary protein intake was associated with an increase in constipation defined by stool consistency risk in participants who consumed a low amount of carbohydrates (OR = 1.08, 95% CI = 1.02-1.14 for every 10-g increase in protein intake), but a decrease in risk in participants in the moderate-carbohydrate group (OR = 0.94, 95% CI = 0.89-0.99 for every 10-g increase in protein intake), suggesting a significant interaction (p = 0.001).

CONCLUSION & INFERENCES

Dietary protein intake is not associated with stool consistency or frequency-defined constipation. However, the association between dietary protein intake and constipation defined by stool consistency in participants with a low carbohydrate intake differed from that in participants with a moderate carbohydrate intake.

Recommendations for the management of gastrointestinal comorbidities with or without trofinetide use in Rett syndrome

INTRODUCTION

Although gastrointestinal (GI) comorbidities are experienced by over 90% of individuals with Rett syndrome (RTT), a neurodevelopmental disorder associated with mutations in the MECP2 gene, many neurologists and pediatricians do not rank the management of these comorbidities among the most important treatment goals for RTT. Trofinetide, the first approved pharmacologic treatment for RTT, confers improvements in RTT symptoms but is associated with adverse GI events, primarily diarrhea and vomiting. Treatment strategies for GI comorbidities and drug-associated symptoms in RTT represent an unmet clinical need.

AREAS COVERED

This perspective covers GI comorbidities experienced by those with RTT, either with or without trofinetide treatment. PubMed literature searches were undertaken on treatment recommendations for the following conditions: constipation, diarrhea, vomiting, aspiration, dysphagia, gastroesophageal reflux, nausea, gastroparesis, gastritis, and abdominal bloating.

EXPERT OPINION

The authors recommend a proactive approach to management of symptomatic GI comorbidities and drug-associated symptoms in RTT to enhance drug tolerance and improve the quality of life of affected individuals. Management strategies for common GI comorbidities associated with RTT are reviewed based on authors' clinical experience and augmented by recommendations from the literature.

Factors Associated with Defecation Satisfaction among Japanese Adults with Chronic Constipation

Background: Constipation causes substantial morbidity worldwide. Methods: This survey assessed constipation-related factors in Japan using the Japanese version of the Irritable Bowel Syndrome Quality of Life (IBS-QOL-J) instrument. We also examined the relationship among laxative type, Bristol Stool Form Scale (BSFS) scores, and treatment cost. Finally, we examined differences in satisfaction scores according to laxative type, treatment type, treatment cost, and BSFS score. Results: IBS-QOL-J was higher among those taking salt and/or irritation laxatives. Those paying >JPY 5000 (USD 50.00) had the lowest IBS-QOL-J. IBS-QOL-J was significantly lower among those with a BSFS score of 1 or 2 (severe constipation). Conclusions: This study's findings suggest that a variety of factors, including treatment type and cost, are associated with defecation satisfaction. Those who had hard stools, used multiple laxatives, or spent more on treatment were less satisfied. Future strategies should target therapies that do not require multiple laxatives with lower treatment costs. Adequate defecation with a small number of appropriate laxatives at minimal cost appears to improve defecation satisfaction. It is desirable to identify appropriate laxatives and improve dietary habits and exercise routines. It is also necessary to stop blindly increasing laxative usage and properly diagnose constipation disorders such as anatomical abnormalities other than functional constipation.

Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement

Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.

Opioid-induced Constipation: Old and New Concepts in Diagnosis and Treatment

Daily use of opioid analgesics has significantly increased in recent years due to an increasing prevalence of conditions associated with chronic pain. Opioid-induced constipation (OIC) is one of the most common, under-recognized, and under-treated side effects of opioid analgesics. OIC significantly reduces the quality of life by causing psychological distress, lowering work productivity, and increasing access to healthcare facilities. The economic and social burden of OIC led to the development of precise strategies for daily clinical practice. Key aspects are the prevention of constipation through adequate water intake and fiber support, avoidance of sedentariness, and early recognition and treatment of cofactors that could worsen constipation. Recommended first-line therapy includes osmotic (preferably polyethylene glycol) and stimulant laxatives. Peripherally acting μ-opioid receptor antagonists, such as methylnaltrexone, naloxegol, or naldemedine, should be used in patients that have not responded to the first-line treatments. The bowel functional index is the main tool for assessing the severity of OIC and for monitoring the response. The paper discusses the recent literature on the pathophysiology, clinical evaluation, and management of OIC and provides a pragmatic approach for its assessment and treatment.

The Management of Opioid-Induced Constipation in Cancer and Advanced Illness: A Meta-Analysis

CONTEXT

Constipation is a common problem among patients with cancer. By some accounts, about 60% of cancer patients experience constipation. There is limited empirical evidence of the clinical effectiveness of pharmacologic agents in opioid-induced constipation in advanced diseases.

OBJECTIVES

We sought to quantitatively summarize the therapeutic effectiveness of the pharmacologic means of managing opioid-induced constipation.

METHODS

Randomized control trials (RCTs) identified from medical literature databases that reported quantitative measures of the effect of pharmacotherapeutic agents to treat opioid induced constipation in patients with cancers and other advanced illnesses were included in this study. A conventional random effects meta-analysis was conducted including >3 trials with the same exposure and outcome assessed, and a network-meta-analysis was conducted for all placebo-controlled trials.

RESULTS

Eighteen studies that examined the effect of various pharmacotherapeutic agents were included. The medications were Methylnatrexone (N = 5), Naldemedine (N = 5), other conventional agents (N = 4) and herbal medicines (N = 4). In conventional meta-analysis, methylnaltrexone increased the proportion achieving rescue-free laxation by 2.68 fold (95% CI: 1.34, 5.37; P = 0.0054) within 4 hours of the administration compared to placebo. In network meta-analysis, the pooled RR of the pharmacotherapeutic agents on rescue-free bowel movements as 2.26 (95% CI: 1.52, 3.36) for methylnaltrexone, 1.58 (95% CI: 0.94, 2.66) for naldemedine, and 0.74 (95% CI: 0.45, 1.23) for polyethylene glycol, compared to placebo.

CONCLUSION

Methylnatrexone and Naldemedine have currently shown promise in randomized trials concerning opioid-induced constipation in cancer and advanced illness. It is imperative that future research ascertain not just the relative therapeutic efficacy but also the cost-benefit analyses of these newer regimens with more commonly used and accessible laxatives.

The rhizomes of Atractylodes macrocephala relieve loperamide-induced constipation in rats by regulation of tryptophan metabolism

ETHNOPHARMACOLOGICAL RELEVANCE

Constipation is one of the most prevalent gastrointestinal tract diseases that seriously affects health-related quality of human life and requires effective treatments without side effect. The rhizome of Atractylodes macrocephala Koidz. (Compositae), called Atractylodes Macrocephala Rhizome (AMR), a commonly used traditional Chinese medicine, has been used to relieve the clinical symptoms of patients with constipation.

AIM OF THE STUDY

To reveal the dose-dependent laxative effect and potential mechanism of AMR on loperamide-induced slow transit constipation (STC) rats.

MATERIALS AND METHODS

Loperamide-induced constipation rat model was established and the dose-dependent laxative effect of AMR was investigated. Untargeted metabolomics based on an UPLC-Q/TOF-MS technique combined with western blot analysis was used to explain the potential mechanism of AMR relieve loperamide-induced constipation in rats.

RESULTS

The results showed that medium dose of AMR (AMR-M, 4.32 g raw herb/kg) and high dose of AMR (AMR-H, 8.64 g raw herb/kg) treatments significantly increased the fecal water content, Bristol score, gastrointestinal transit rate, and recovered the damaged colon tissues of constipated rats, but low dose of AMR (AMR-L, 2.16 g raw herb/kg) did not show laxative effect. Both AMR-M and AMR-H treatments also remarkably reduced the serum levels of vasoactive intestinal peptide (VIP), somatostatin (SS) and dopamine (DA), and increased the levels of motilin (MTL), gastrin (GAS) and 5-hydroxytryptamine (5-HT). Urine metabolomics revealed that constipation development was mainly ascribed to the perturbed tryptophan metabolism, and AMR-M and AMR-H markedly corrected the abnormal levels of five urine tryptophan metabolites, namely 4,6-dihydroxyquinoline, indole, 4,8-dihydroxyquinoline, 5-hydroxytryptamine, and kynurenic acid. Additionally, western blot analysis confirmed that the abnormal expression of rate-limiting enzyme involving in tryptophan metabolism, including tryptophan hydroxylase (TPH), monoamine oxidase (MAO) and indoleamine-2,3-dioxygenase (IDO) in the colon of constipated rats, were mediated by AMR-M and AMR-H.

CONCLUSIONS

The findings provide insight into the mechanisms of STC and AMR could be developed as new therapeutic agent for prevention or healing of constipation.

Generally-healthy individuals with aberrant bowel movement frequencies show enrichment for microbially-derived blood metabolites associated with reduced kidney function

Bowel movement frequency (BMF) has been linked to changes in the composition of the human gut microbiome and to many chronic conditions, like metabolic disorders, neurodegenerative diseases, chronic kidney disease (CKD), and other intestinal pathologies like irritable bowel syndrome and inflammatory bowel disease. Lower BMF (constipation) can lead to compromised intestinal barrier integrity and a switch from saccharolytic to proteolytic fermentation within the microbiota, giving rise to microbially-derived toxins that may make their way into circulation and cause damage to organ systems. However, the connections between BMF, gut microbial metabolism, and the early-stage development and progression of chronic disease remain underexplored. Here, we examined the phenotypic impact of BMF variation in a cohort of generally-healthy, community dwelling adults with detailed clinical, lifestyle, and multi-omic data. We showed significant differences in microbially-derived blood plasma metabolites, gut bacterial genera, clinical chemistries, and lifestyle factors across BMF groups that have been linked to inflammation, cardiometabolic health, liver function, and CKD severity and progression. We found that the higher plasma levels of 3-indoxyl sulfate (3-IS), a microbially-derived metabolite associated with constipation, was in turn negatively associated with estimated glomerular filtration rate (eGFR), a measure of kidney function. Causal mediation analysis revealed that the effect of BMF on eGFR was significantly mediated by 3-IS. Finally, we identify self-reported diet, lifestyle, and psychological factors associated with BMF variation, which indicate several common-sense strategies for mitigating constipation and diarrhea. Overall, we suggest that aberrant BMF is an underappreciated risk factor in the development of chronic diseases, even in otherwise healthy populations.

Factors associated with the initiation of laxative use in the same patients with schizophrenia over a 20-year period: Retrospective cohort study

BACKGROUND

Constipation is a common adverse effect of antipsychotics, but little investigation has been conducted. We aimed to address the factors associated with the initiation of laxative use in the same patients with schizophrenia over a 20-year period.

METHODS

We enrolled patients with schizophrenia attending each hospital (n = 14) from April 1, 2021, and retrospectively examined all prescriptions as of April 1, 2016, 2011, 2006, and 2001, every 5 years starting in 2021, for this population. 716 participants with complete data were included in the analysis. The Cochran Q test followed by Bonferroni correction and the Cochran-Armitage trend test were used to determine the differences and trends of the frequency of each laxative. Multivariate logistic regression analysis was performed to assess the factors on the initiation of laxative use over a 20-year period.

RESULTS

Of the patients, 25.1% were treated with laxatives in 2001, and 34.1% were treated in 2021. The numbers of patients treated with any laxatives significantly differed over the 20-year period, with a significant increasing trend. In all laxatives, the numbers of patients treated with magnesium oxide, lubiprostone and elobixibat differed with a significant increasing trend. Female sex, age, the total DZP equivalent dose, and the doses of levomepromazine maleate, olanzapine, quetiapine, zotepine, lithium, and carbamazepine in 2021 were significant factors associated with the initiation of laxative use over the 20-year period.

CONCLUSIONS

Careful monitoring is needed for patients treated with levomepromazine maleate, olanzapine, quetiapine and zotepine. Optimizing prescriptions according to treatment guidelines could reduce antipsychotic-induced constipation.

Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group

Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.

Nomogram for soiling prediction in postsurgery hirschsprung children: a retrospective study

PURPOSE

The aim of this study was to develop a nomogram for predicting the probability of postoperative soiling in patients aged greater than 1 year operated for Hirschsprung disease (HSCR).

MATERIALS AND METHODS

The authors retrospectively analyzed HSCR patients with surgical therapy over 1 year of age from January 2000 and December 2019 at our department. Eligible patients were randomly categorized into the training and validation set at a ratio of 7:3. By integrating the least absolute shrinkage and selection operator [LASSO] and multivariable logistic regression analysis, crucial variables were determined for establishment of the nomogram. And, the performance of nomogram was evaluated by C-index, area under the receiver operating characteristic curve, calibration curves, and decision curve analysis. Meanwhile, a validation set was used to further assess the model.

RESULTS

This study enrolled 601 cases, and 97 patients suffered from soiling. Three risk factors, including surgical history, length of removed bowel, and surgical procedures were identified as predictive factors for soiling occurrence. The C-index was 0.871 (95% CI: 0.821-0.921) in the training set and 0.878 (95% CI: 0.811-0.945) in the validation set, respectively. And, the AUC was found to be 0.896 (95% CI: 0.855-0.929) in the training set and 0.866 (95% CI: 0.767-0.920) in the validation set. Additionally, the calibration curves displayed a favorable agreement between the nomogram model and actual observations. The decision curve analysis revealed that employing the nomogram to predict the risk of soiling occurrence would be advantageous if the threshold was between 1 and 73% in the training set and 3-69% in the validation set.

CONCLUSION

This study represents the first efforts to develop and validate a model capable of predicting the postoperative risk of soiling in patients aged greater than 1 year operated for HSCR. This model may assist clinicians in determining the individual risk of soiling subsequent to HSCR surgery, aiding in personalized patient care and management.

Management of Gastrointestinal Symptoms in Parkinson's Disease: A Comprehensive Review of Clinical Presentation, Workup, and Treatment

Gastrointestinal symptoms in Parkinson's disease (PD) are among the most prevalent and debilitating of complications and present unique diagnostic and management challenges. Patients with PD commonly experience dysphagia, nausea, bloating, and constipation related to pathologic involvement of the enteric nervous system. In turn, gastrointestinal complications may impact motor fluctuations and the efficacy of levodopa therapy. This review will explore the common gastrointestinal manifestations of PD with an emphasis on clinical presentation, workup, and treatment strategies.

Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis

INTRODUCTION

Anorectal function testing is traditionally relegated to subspecialty centers. Yet, it is an office-based procedure that appears capable of triaging care for the many patients with Rome IV functional constipation that fail empiric over-the-counter therapy in general gastroenterology, as an alternative to empirical prescription drugs. We aimed to evaluate cost-effectiveness of routine anorectal function testing in this specific population.

METHODS

We performed a cost-effectiveness analysis from the patient perspective and a cost-minimization analysis from the insurer perspective to compare 3 strategies: (i) empiric prescription drugs followed by pelvic floor physical therapy (PFPT) for drug failure, (ii) empiric PFPT followed by prescription drugs for PFPT failure, or (iii) care directed by up-front anorectal function testing. Model inputs were derived from systematic reviews of prospective clinical trials, national cost data sets, and observational cohort studies of the impact of chronic constipation on health outcomes, healthcare costs, and work productivity.

RESULTS

The most cost-effective strategy was upfront anorectal function testing to triage patients to appropriate therapy, in which the subset of patients without anal hypocontractility on anorectal manometry and with a balloon expulsion time of at least 6.5 seconds would be referred to PFPT. In sensitivity analysis, empiric PFPT was more cost effective than empiric prescription drugs except for situations in which the primary goal of treatment was to increase bowel movement frequency. If adopted, gastroenterologists would refer ∼17 patients per year to PFPT, supporting feasibility.

DISCUSSION

Anorectal function testing seems to be an emergent technology to optimize cost-effective outcomes, overcoming testing costs by phenotyping care.