Refractory Constipation: What is the Clinician to Do?

Influencing Factors of Constipation in Elderly Patients With Intracerebral Hemorrhage: Implication for Clinical Care

Background: Constipation is common in elderly inpatients with intracerebral hemorrhage. This study aimed to construct a model for predicting the risk of constipation in elderly inpatients with intracerebral hemorrhage and to provide reference for formulating targeted intervention measures. Methods: Elderly patients with intracerebral hemorrhage who were treated in the department of Neurosurgery of a third-class hospital in Suzhou from January 2018 to September 2023 were included. Clinical data of patients with and without constipation were compared. Logistic regression analysis was used to explore the influencing factors of constipation in elderly patients with intracerebral hemorrhage, and R software was used to construct a line chart model to verify its predictive effect. Results: A total of 504 elderly patients with intracerebral hemorrhage were included. The incidence of constipation in elderly patients with cerebral hemorrhage was 63.9%. Logistic regression analysis showed that GCS score (OR = 1.094, 95%CI: 1.019∼1.174), hypertension (OR = 2.911, 95%CI: 1.797∼4.715), use of dehydrating agent (OR = 3.794, 95%CI: 2.337∼6.158), surgical treatment (OR = 3.986, 95%CI: 2.339∼6.793), use of sedative drugs (OR = 4.212, 95%CI:2.386-7.435), and limb paralysis (OR = 6.313, 95%CI:3.689∼10.803) were the independent risk factors for constipation in elderly patients with intracerebral hemorrhage. The area under the ROC curve of the prediction model was 0.872 (95%CI: 0.8401∼0.9033), the best critical value was 0.705, the sensitivity was 0.748, and the specificity was 0.857. Conclusion: The constipation risk prediction model of elderly patients with cerebral hemorrhage has good differentiation and calibration, which is helpful for health care providers to identify the risk of constipation in elderly patients with intracerebral hemorrhage.

Characteristics of the Cajal interstitial cells and intestinal microbiota in children with refractory constipation

BACKGROUND

Children with refractory constipation experience intense and persistent symptoms that greatly diminish their quality of life. However, the underlying pathophysiological mechanism responsible for this condition remains uncertain. Our objective was to evaluate characteristics of colonic motor patterns and interstitial cells of Cajal (ICCs) to refractory constipation children, as well as intestinal microbiota compositions.

METHODS

Colonic manometry (CM) was conducted on a cohort of 30 patients with refractory constipation to assess colonic motility, and 7 of them underwent full-thickness colon biopsy specimens. Another 5 colonic specimens from nonconstipation patients were collected to identify the ICCs by immunohistochemistry. Fecal samples from 14 children diagnosed with refractory constipation and subjecting 28 age-matched healthy children to analysis using high-throughput sequencing of 16S rRNA.

RESULTS

According to CM results, dividing 30 children with refractory constipation into 2 groups: normal group (n = 10) and dysmotility group (n = 20). Dysmotility subjects showed lower colonic motility. Antegrade propagating pressure waves, retrograde propagating pressure waves, and periodic colonic motor activity were common in normal subjects and rare in dysmotility subjects (32.7 ± 8.9 vs 20.7 ± 13.0/17 h, P < 0.05, 11.5 ± 2.3 vs 9.6 ± 2.3/17 h, P < 0.05, and 5.2 ± 8.9 vs 3.5 ± 6.8 cpm, P < 0.005, respectively), whereas periodic rectal motor activity was more common in dysmotility subjects (3.4 ± 4.8 vs 3.0 ± 3.1 cpm, P < 0.05). Dysmotility subjects exhibited a significantly greater number of preprandial simultaneous pressure waves compared to the normal subjects (32.3 ± 25.0 vs 23.6 ± 13.2/1 h, P < 0.005). Dysmotility subjects displayed a notable decrease in postprandial count of antegrade propagating pressure waves and high amplitude propagating pressure waves when compared to normal subjects (3.9 ± 2.9 vs 6.9 ± 3.5/1 h and 2.3 ± 1.5 vs 5.4 ± 2.9/1 h, respectively, P < 0.05). The number, distribution, and morphology of ICCs were markedly altered in refractory constipation compared children to the controls (P < 0.05). Children diagnosed with refractory constipation displayed a distinct dissimilarity in composition of their intestinal microbiota comparing with control group (P < 0.005). In genus level, Bacteroidetes represented 34.34% and 43.78% in the refractory constipation and control groups, respectively. Faecalibacterium accounted for 3.35% and 12.56%, respectively (P < 0.005). Furthermore, the relative abundances of Faecalibacterium (P < 0.005), Lachnospira (P < 0.05), and Haemophilus (P < 0.05) significantly decreased, whereas those of Parabacteroides (P < 0.05), Alistipes (P < 0.005), Prevotella_2 (P < 0.005), [Ruminococcus]_torques_group (P < 0.005), Barnesiella (P < 0.05), Ruminococcaceae_UCG-002 (P < 0.005), and Christensensenellaceae_R-7_group (P < 0.05) were markedly increased in children with refractory constipation.

CONCLUSIONS

Dysmotility subjects showed lower colonic motility and an impaired postprandial colonic response. The decreased number and abnormal morphology of colonic ICCs may contribute to the pathogenesis of refractory constipation. Children with refractory constipation exhibited significant variations in microbiota composition across various taxonomic levels compared to the healthy control group. Our findings contribute valuable insights into pathophysiological mechanism underlying refractory constipation and provide evidence to support the exploration of novel therapeutic strategies for affected children.

Relief from behind: enemas, the back door enforcement to help treating chronic constipation in adults

INTRODUCTION

Chronic constipation is a frequent symptom encountered in the daily clinical practice. The treatment of this condition mainly relies on the use of laxatives. However, patients' satisfaction with this approach is limited, and alternative measures are often added to the treatment. Among these, particularly frequent worldwide is the use of enemas, even though literature data on its scientific validity are scarce.

AREAS COVERED

In this article, by an extensive online search of Medline (through PubMed), Scopus, Cochrane CENTRAL, EMBASE, and the Science Citation Index, the available literature data on the use of enemas in adult patients with chronic constipation, also in the perspective of available guidelines on treatment of this pathological condition, were analyzed.

EXPERT OPINION

Although the use of enemas remains a frequently employed method and it is considered as useful by many physicians as an adjunctive support for the treatment of chronic constipation in adults, this practice is not substantiated by rigorous scientific data, and some studies are available only for specific instances (fecal impaction, transanal irrigation). Thus, waiting for more robust scientific data, enemas treatment should be carried out on an individual patient's basis, according to the experience of the caring physicians.

Assessment and management of disorders of gut-brain interaction in patients with eating disorders

Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).

Electroacupuncture Improves Intestinal Motility through Exosomal miR-34c-5p Targeting SCF/c-Kit Signaling Pathway in Slow Transit Constipation Model Rats

Background. The pathogenesis of slow transit constipation (STC) is associated with exosomal miR-34c-5p. Electroacupuncture (EA) improves gastrointestinal motility in gastrointestinal disorders, especially STC. Our study aimed to explore the mechanism by which EA improves intestinal motility by modulating the release of exosomes and the transmission of exosomal miR-34c-5p. Methods. Fifty rats were randomly divided into five groups. STC model rats were induced, and GW4869, the exosome release inhibitor, was used to inhibit the release of exosome. The serum exosomes were authenticated under a transmission electron microscope and nanoparticle tracking analysis. RT-qPCR detected the expression of miR-34c-5p in serum exosomes and colonic tissues. The fecal number in 24 hours, Bristol scores, and intestinal transit rates were used to assess intestinal motility. Subsequently, hematoxylin and eosin (H&E) staining was used to examine the colonic mucosal histology. Finally, the expression of stem cell factor (SCF) and receptor tyrosine kinase (c-Kit) protein was measured using immunohistochemistry staining. Results. We found that EA upregulated exosomal miR-34c-5p in serum and downregulated miR-34c-5p in colonic tissues ( $P<0.01$ ). EA improved fecal numbers in 24 hours, Bristol scores, and intestinal transit rates in STC rats ( $P<0.01$ ). EA recovered the colonic histological structure and enhanced the expression of SCF and c-Kit protein ( $P<0.01$ ). The therapeutic effect of EA was attenuated after inhibiting the release of the exosome. Conclusion. Our results indicated that EA improves intestinal motility in STC rats by transporting of exosomal miR-34c-5p targeting the SCF/c-Kit signaling pathway.

Diverting Loop Ileostomy in the Management of Medically Refractory Constipation Cases Not Falling Into Classical Categories

BACKGROUND

The approach to constipation refractory to medical management does not necessarily follow classical teaching and is challenging. Although the role of surgery is unclear, diverting loop ileostomy may be offered to gauge symptom response followed by colectomy for appropriate patients.

OBJECTIVE

Our goal was to examine outcomes in patients with constipation not falling into classical subtypes who underwent diverting loop ileostomy creation as the initial surgical intervention. Our secondary aim was to offer patients colectomy and anastomosis and examine their outcome if they improved after ileostomy.

DESIGN

The study design was a retrospective review.

SETTINGS

This study was conducted in the pelvic floor center of our colorectal surgery department from January 2006 to December 2018.

PATIENTS

Patients with medically refractory constipation referred for surgical consideration and not falling into classical constipation categories (slow transit, normal transit, or pelvic floor dysfunction) underwent evaluation with transit marker study, cinedefecography, and anal physiology and were offered ileostomy as initial surgical management.

MAIN OUTCOME MEASURES

The primary measures were symptom improvement and self-reported quality of life improvement with increased patient satisfaction.

RESULTS

Eighty-seven patients underwent diverting loop ileostomy as initial surgical therapy. Group 1 had 54 (62%) patients who self-reported symptom improvement, discontinued anticonstipation medication, and had ileostomy output >200 mL/day. Of these 54 patients, 25 had colectomy with anastomosis, 16 (64%) of whom had symptom improvement, stayed off bowel medication, and had >1 bowel movement daily. Group 2 had 33 patients who did not meet the above criteria after initial ileostomy. Nine patients in group 2 elected colectomy with anastomosis after intensive counseling; 6 (66%) reported the same positive results above.

LIMITATIONS

The study limitations included: 1) no objective outcome measures of patient's perceived symptom improvement and satisfaction and 2) retrospective review.

CONCLUSION

Initial creation of diverting loop ileostomy may be offered to a subset of refractory constipation patients not falling into classical categories after thorough workup. Patients who self-report symptom improvement, have ileostomy output >200 mL/day, and do not require bowel medication may have acceptable results with subsequent colectomy and ileorectal anastomosis. See Video Abstract at http://links.lww.com/DCR/B854.

ILEOSTOMA EN ASA DERIVATIVA EN CASOS DE ESTREIMIENTO REFRACTARIOS AL TRATAMIENTO MDICO, QUE NO PERTENECEN A LAS CATEGORAS CLSICAS

ANTECEDENTES:El enfoque del estreñimiento refractario al tratamiento médico, que no siempre se presenta como las formas descritas clasicamente, es un desafío. Si bien el papel de la cirugía no está claro, se puede ofrecer una ileostomía en asa para medir la respuesta de los síntomas, seguida de colectomía en pacientes seleccionados.OBJETIVO:Evaluar los resultados de pacientes con estreñimiento, que no pertenecen a las formas clásicas de presentación, que se les realizó una ileostomía en asa de derivación, como intervención quirúrgica inicial. El objetivo secundario fue ofrecer a los pacientes una colectomía con anastomosis primaria y evaluar si mejoraban sus resultados después de la ileostomía.DISEÑO:El diseño del estudio fue una revisión retrospectiva.MARCO:Este estudio se realizó en el centro del piso pélvico de nuestro departamento de cirugía colorrectal, e incluyo los pacientes atendidos entre enero de 2006 y diciembre de 2018.PACIENTES:Se incluyeron los pacientes con estreñimiento refractario al tratamiento médico, derivados para evaluación quirúrgica, que no presentaban las formas clásicas de presentación (tránsito lento, tránsito normal, disfunción del suelo pélvico). Estos se sometieron a evaluación con estudio de tránsito colónico, cinedefecografía y fisiología anal, y se les ofreció una ileostomía en asa como tratamiento quirúrgico inicial.PRINCIPALES MEDIDAS DE RESULTADO:Las primeras medidas fueron la mejora de los síntomas y la calidad de vida informado por el paciente.RESULTADOS:Ochenta y siete pacientes fueron sometidos a ileostomía en asa como tratamiento quirúrgico inicial. El grupo 1 tenía 54 (62%) pacientes que informaron mejoría de los síntomas, interrumpieron la medicación proquinética y tuvieron un débito por la ileostomía >200 cc/día. De estos 54 pacientes, 25 se sometieron a colectomía más anastomosis primaria y 16 (64%) tuvieron una mejoría de los síntomas, dejaron de tomar medicamentos proquinéticos y tuvieron más de una evacuación al día. El grupo 2 tenía 33 pacientes que no cumplían con los criterios de mejoría de los síntomas después de la ileostomía inicial. Nueve pacientes del grupo 2 eligieron colectomía con anastomosis después de un asesoramiento intensivo, 6 (66%) informaron resultados positivos de mejoría de los síntomas.LIMITACIONES:Las limitaciones del estudio incluyeron 1) ninguna medida de resultado objetiva de la mejora y satisfacción de los síntomas percibidos por el paciente 2) revisión retrospectiva.CONCLUSIÓNES:La creación inicial de una ileostomía en asa de derivación se puede ofrecer a un subgrupo de pacientes con estreñimiento refractario que no entran en las categorías clásicas después de un estudio exhaustivo. La mejoría de los síntomas, informado por los pacientes, producción de ileostomía >200 cc/día y que no requieren medicación proquinética, pueden tener resultados aceptables con colectomía y anastomosis ileorrectal. Consulte Video Resumen en http://links.lww.com/DCR/Bxxx. (Traducción-Dr. Rodrigo Azolas).

Cecorectal (CRA) versus ileorectal (IRA) anastomosis after colectomy for slow transit constipation (STC): a meta-analysis

INTRODUCTION

We conducted this meta-analysis, to compare cecorectal (CRA) and ileorectal anastomosis (IRA), regarding perioperative safety and efficacy, in patients submitted to colectomy for refractory slow transit constipation (STC).

METHODS

This study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. To identify all eligible records, a systematic literature search in the electronic scholar databases (Medline, Scopus, Web of Science) was performed.

RESULTS

Overall, 5 trials and 291 patients were included in this meta-analysis. Pooled comparisons confirmed the comparability of the two techniques regarding perioperative complications (p = 0.55). CRA was associated with a shorter operation (p = 0.0004) and hospitalization duration (p = 0.001). Although there was no difference in terms of gastrointestinal symptoms, functional outcomes, and patient satisfaction, CRA resulted in lower long-term Wexner scores (p < 0.0001).

CONCLUSION

Due to several study limitations, further large-scale RCTs are required to verify the findings of the present meta-analysis.

Current Overview on Clinical Management of Chronic Constipation

Constipation is one of the major gastrointestinal disorders diagnosed in clinical practice in Western countries. Almost 20% of population suffer from this disorder, which means constipation is a substantial utilization of healthcare. Pathophysiology of constipation is complex and multifactorial, where aspects like disturbance in colonic transit, genetic predisposition, lifestyle habits, psychological distress, and many others need to be taken into consideration. Diagnosis of constipation is troublesome and requires thorough accurate examination. A nonpharmacological approach, education of the patient about the importance of lifestyle changes like diet and sport activity state, are the first line of therapy. In case of ineffective treatment, pharmacological treatments such as laxatives, secretagogues, serotonergic agonists, and many other medications should be induced. If pharmacologic treatment fails, the definitive solution for constipation might be surgical approach. Commonness of this disorder, costs of medical care and decrease in quality life cause constipation is a serious issue for many specialists. The aim of this review is to present current knowledge of chronic constipation and management of this disorder.

Unexpected High Prevalence of Lymphocytic Infiltrates in Myenteric Ganglions in Intestinal Inertia

Intestinal inertia is a severe form of gut dysmotility that may require surgical resection. Loss of myenteric ganglion cells has been proposed as a possible etiology. Preclinical models have also suggested that virus infection-associated ganglionitis may be an alternative pathogenic factor. We determined to the extent intestinal inertia is associated with the lack of myenteric ganglion cells or ganglionitis using resection specimens from 27 intestinal inertia and 28 colon cancer patients. A hot spot approach with 5 HPFs was used for quantifying inflammatory cells. CD3, CD8, and CD20 immunohistochemistry was used to quantify T and B lymphocytes, along with subtyping the T-lymphocyte population by CD8. None of the intestinal inertia nor control cases showed the absence of myenteric ganglion cells. A total of 15 (55.6%) of the intestinal inertia cases showed inflammatory cell infiltration in the myenteric ganglion cells, compared with only 1 of 28 (3.6%) control cases (P<0.0001 by Fisher exact test). The inertia cases with inflammatory infiltrates were all associated predominantly with lymphocytes, including 3 cases (11.1%) with concurrent eosinophil infiltration, and 1 case (3.7%) with concurrent neutrophil infiltration. Furthermore, all 15 inertia cases with myenteric lymphocytic ganglionitis were associated with T lymphocytes (100%), including 1 case with a subset of concurrent B lymphocytes. The average CD3 count was 3.8 cells/HPF. CD8 immunohistochemical stain showed positive staining in 12 of the 15 cases (80%) with CD8-positive cells ranging from 1 to 8/HPF. In contrast, the only control case with lymphocytic ganglionitis showed mixed B and T lymphocytes and eosinophils. The high prevalence of T-lymphocyte infiltration in the myenteric ganglion in intestinal inertia cases suggests a possible pathogenic role.

Frequency of Eating Disorder Pathology Among Patients With Chronic Constipation and Contribution of Gastrointestinal-Specific Anxiety

BACKGROUND & AIMS

Individuals with eating disorders (EDs) frequently have constipation-related symptoms, although the mechanisms of this relationship are not clear. We examined the frequency of and relation between EDs and constipation in patients with chronic constipation referred for anorectal manometry.

METHODS

We analyzed data from 279 patients with chronic constipation (79.2% female) evaluated at a tertiary center from June 2017 through September 2018. Participants completed a standardized psychometric assessment (patient assessment of constipation symptoms questionnaire and hospital anxiety and depression scale and visceral sensitivity index analyses) and anorectal manometry. A subset of patients completed colonic transit testing. Participants with clinically significant ED pathology were identified based on scores of 20 or higher on the Eating Attitudes Test-26. We performed a logistic regression analysis to examine factors associated with the likelihood of having ED pathology. Odds ratios were calculated based on continuous variables. We examined the contribution of anxiety to the relationship between severity of ED pathology and symptoms of constipation (such as abdominal pain) using a regression-based bootstrapping approach.

RESULTS

Of the study participants, 53 (19.0%) had clinically significant ED pathology. The presence of ED pathology was associated with greater general anxiety scores, based on the hospital anxiety and depression scale (odds ratio, 1.20; 95% CI, 1.05-1.38), and greater gastrointestinal-specific anxiety scores, based on the visceral sensitivity index (odds ratio, 1.06; 95% CI, 1.03-1.09). Gastrointestinal-specific anxiety fully mediated the relationship between the severity of ED pathology and constipation (standardized β, 0.11-0.16; P = .026-.024). We found no differences in anorectal manometry or colonic transit between patients with vs without ED pathology.

CONCLUSIONS

In an analysis of patients with chronic constipation, we found that 19% had clinically significant ED pathology. Our preliminary finding indicated that ED pathology might contribute to constipation via gastrointestinal-specific anxiety. Clinicians should consider screening patients with chronic constipation for EDs-especially patients who report symptoms such as bloating and abdominal pain.