Pathophysiology of colonic causes of chronic constipation

Effect of Electroacupuncture with Different Current Intensities on the Serum Metabolomics of Functional Constipation

Objective

The aim of the study is to investigate the serum metabolomics of electroacupuncture (EA) with different current intensities in the treatment of functional constipation (FC).

Methods

The total number of FC patients was 19, (7, 6, 6, in the low current intensity group (LCI), high current intensity group (HCI), and mosapride citrate tablet control group (MC), respectively). Patients in the EA groups received 16 sessions of acupuncture treatments. Patients in the MC group were orally administered 5 mg mosapride citrate tablets 3 times daily, and serum samples were collected from the patients before and after treatment. Orthogonal partial least square-discriminant analysis (OPLS-DA) was used to assess the metabolic data. The significant differences before and after FC treatment are shown in the OPLS-DA score plot. Variable importance plots (VIPs) and T tests were used to identify significant metabolites.

Results

Among the three groups, the number of metabolites with VIP > 1 was 11, 7, and 21 (in LCI, HCI and MC groups, respectively). Compared with those before treatment, the serum metabolites of patients were characterized by increased levels of L-ornithine (p < 0.05) and glyceric acid in the LCI group (p < 0.05), increased levels of vanillic acid in the MC group (p < 0.05), and decreased levels of arabinonic acid in the MC group (p < 0.05).

Conclusions

The effects of EA treatment on the serum metabolomics of FC may involve fatty acid and amino acid metabolism.

Colonic Response to Physiological, Chemical, Electrical and Mechanical Stimuli; What Can Be Used to Define Normal Motility?

The colon plays an important functional role in the bacterial fermentation of carbohydrates, transmural exchange of fluid and short-chain fatty acids, and the formation, storage and evacuation of faeces and gaseous contents. Coordinated colonic motor patterns are essential for these functions to occur. Our understanding of human colonic motor patterns has largely come through the use of various forms of colonic manometry catheters, combined with a range of stimuli, both physiological and artificial. These stimuli are used in patients with colonic disorders such as constipation, irritable bowel syndrome and faecal incontinence to understand the pathophysiology mechanisms that may cause the disorder and/or the associated symptoms. However, our understanding of a "normal" colonic response remains poor. This review will assess our understanding of the normal colonic response to commonly used stimuli in short duration studies (<8 hrs) and the mechanisms that control the response.

Regional Gastrointestinal Motility in Healthy Children

OBJECTIVE

The aim of the study was to evaluate the safety and use of the 3D-Transit system (Motilis SA, Lausanne, Switzerland) and to describe regional gastrointestinal transit times, segmental colonic transit times, and colonic movement patterns in healthy children.

METHODS

Twenty-one healthy children (11 girls, median age 10.5 years, range 7-15 years) were included. For evaluation of gastrointestinal transit times and colonic movement patterns, we used the minimally invasive electromagnetic 3D-Transit system. A small electromagnetic capsule (21.5 mm × 8.3 mm) was ingested and tracked through the gastrointestinal tract by a body-worn detector. Regional gastrointestinal transit times were assessed as time between capsule passage of anatomical landmarks. Colonic movement patterns were described and classified based on capsule movement velocity, direction, and distance.

RESULTS

One child could not swallow the capsule and 20 children completed the study without any discomfort or side-effects. Median whole gut transit time was 33.6 (range 10.7-80.5) hours, median gastric emptying time was 1.9 (range 0.1-22.1) hours, median small intestinal transit time was 4.9 (range 1.1-15.1) hours, and median colonic transit time was 26.4 (range 6.8-74.5) hours. Median ascending colon/cecum transit time was 9.7 (range 0.3-48.1) hours, median transverse colon transit time was 5.6 (range 0.0-11.6) hours, median descending colon transit time was 2.6 (range 0.01-22.3) hours, and median sigmoid colon/rectum transit time was 7.5 (range 0.1-31.6) hours. Colonic movement patterns among children corresponded to those previously described in healthy adults.

CONCLUSIONS

The 3D-Transit system is a well-tolerated and minimally invasive method for assessment of gastrointestinal motility in children.

Novel bionics developments in gastroenterology: fecobionics assessment of lower GI tract function

Biomechatronics (bionics) is an applied science that is interdisciplinary between biology and engineering (mechanical, electrical and electronics engineering). Biomechatronics covers a wide area and is probably best known in development of prosthetic limbs, vision aids, robotics and neuroscience. Although the gastrointestinal tract is difficult to study, it is particularly suited for a bionics approach as demonstrated by recent developments. Ingestible capsules that travel the tract and record physiological variables have been used in the clinic. Other examples include sacral nerve stimulators that seek to restore normal anorectal function. Recently, we developed a simulated stool termed fecobionics. It has the shape of normal stool and records a variety of parameters including pressures, bending (anorectal angle) and shape changes during colonic transit and defecation, i.e. it integrates several current tests. Fecobionics has been used to study defecation patterns in large animals as well as in humans (normal subjects and patient groups including patients with symptoms of obstructed defecation and fecal incontinence). Recently, it was applied in a canine colon model where it revealed patterns consistent with shallow waves originating from slow waves generated by the interstitial cells of Cajal. Furthermore, novel analysis such as the rear-front pressure (preload-afterload) diagram and quantification of defecation indices have been developed that enable mechanistic insight. This paper reviews the fecobionics technology and outlines perspectives for future applications.

Disruption of Circadian Rhythms and Gut Motility: An Overview of Underlying Mechanisms and Associated Pathologies

Circadian rhythms ensure that physiological processes occur at the most biologically meaningful time. The circadian timing in the gastrointestinal tract involves interlocking transcriptional and translational feedback loops that culminate in the rhythmic expression and activity of a set of clock genes and related hormones. The suprachiasmatic nucleus and peripheral core molecular clocks oscillate every 24 hours and are responsible for the periodic activity of various segments and transit along the gastrointestinal tract. Environmental cues may alter or reset these rhythms to align them with new circumstances. Colonic motility also follows a circadian rhythm with reduced nocturnal activity. Healthy humans have normal bowel motility during the day, frequently following awakening or following a meal, with minimal activity during the night. Maladjusted circadian rhythms in the bowel have been linked to digestive pathologies, including constipation and irritable bowel syndrome. Our advanced knowledge of the link between the circadian clock and gastrointestinal physiology provides potential therapeutic approaches for the treatment of gastrointestinal diseases. This review seeks to establish evidence for the correlation between circadian rhythm, bowel movements and digestive health, and examine the implications of disrupted circadian rhythms on gut physiology.

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation

BACKGROUND

Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting.

PURPOSE

This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.

Constipation in ulcerative colitis: pathophysiology and practical management

Clinical experience suggests that there is a cohort of patients with refractory colitis who do have faecal stasis that contributes to symptoms. The underlying physiology is poorly understood, partly because until recently the technology to examine segmental colonic motility has not existed. Patients are given little information on how proximal faecal stasis can complicate colitis. Treatment guidelines are scanty and many patients are offered little apart from laxatives and advice on increasing fibre intake, which often makes symptoms worse. This article aims to review the history, pathology and management, and create impetus for future research on this underappreciated condition.

Mechanisms, Evaluation, and Management of Chronic Constipation

With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.

Normative values for region-specific colonic and gastrointestinal transit times in 111 healthy volunteers using the 3D-Transit electromagnet tracking system: Influence of age, gender, and body mass index

BACKGROUND

The 3D-Transit electromagnet tracking system (Motilis Medica, SA, Lausanne, Switzerland) is an emerging tool for the ambulatory assessment of gastrointestinal (GI) transit and motility. Using this tool, we aimed to derive normative values for region-specific colonic and GI transit times and to assess the influence of age, gender, and body mass index (BMI).

METHODS

Regional and total colonic transit times (CTT), gastric emptying (GET), small intestinal (SITT), and whole gut (WGTT) transit times were extracted from 111 healthy volunteers from the United Kingdom and Denmark (58 female; median age: 40 years [range: 21-88]). The effects of age, gender, and BMI were assessed using standard statistical methods.

KEY RESULTS

The ascending, transverse, descending, and rectosigmoid colon transit times accounted for 32%, 34%, 17%, and 17% of total CTT in females, and 33%, 25%, 14%, and 28% of total CTT in males. CTT and WGTT were seen to cluster at intervals separated by approximately 24 hours, providing further evidence of the non-continuous nature of these measurements. Increasing age was associated with longer CTT (P = .021), WGTT (P < .001) ascending (P = .004), transverse (P < .001), and total right (P < .001) colon transit times, but shorter rectosigmoid (P = .004) transit time. Female gender was significantly associated with longer transverse (P = .049) and descending (P < .001) colon transit times, but shorter rectosigmoid (P < .001) transit time. Increasing BMI was significantly associated with shorter WGTT (P = .012).

CONCLUSIONS AND INFERENCES

For the first time, normative reference values for region-specific colonic transit have been presented. Age, gender, and BMI were seen to have an effect on transit times.

Chronic Constipation

Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Gastrointestinal Transit Time in Parkinson's Disease Using a Magnetic Tracking System

BACKGROUND

Symptoms from the gastrointestinal tract are highly prevalent in Parkinson's disease (PD), but knowledge of the underlying pathology is incomplete and valid objective markers on regional gastrointestinal function are limited.

OBJECTIVE

The aims were to evaluate gastrointestinal transit time and motility in PD patients and controls.

METHODS

Twenty-two PD patients and 15 controls were included. Gastric-, small intestinal-, and caecum-ascending colonic transit times as well as colonic motility, defined as mass- and fast movements, were performed using the ambulatory 3D-Transit system. Gastrointestinal transit time with radio opaque markers, gastric emptying scintigraphy, and subjective non-motor symptoms were also evaluated.

RESULTS

Using the 3D-Transit system, the patient group displayed significantly longer small intestinal- and caecum-ascending transit times (p = 0.030 and p = 0.0063). No between-group difference was seen in gastric transit time (p = 0.91). Time to first mass- and fast colonic movement were significantly increased in PD (p = 0.023 and p = 0.006). Radio opaque marker gastrointestinal transit time was significantly increased in the patient group (p < 0.0001), whereas no difference was seen in scintigraphic gastric emptying time (p = 0.68). Prevalence of constipation symptoms on the NMSQuest was 41% in PD and 7% in controls.

CONCLUSIONS

Significantly increased small intestinal- and caecum-ascending 3D-Transit times were detected in PD patients. Also, time to first propagating colonic movement was increased. Radio opaque marker gastrointestinal transit time was significantly delayed, but no difference was seen in gastric transit time and gastric emptying time. The present findings highlight widespread intestinal involvement in PD increasing throughout the gastrointestinal tract.

Colonic transit time and pressure based on Bernoulli's principle

PURPOSE

Variations in the caliber of human large intestinal tract causes changes in pressure and the velocity of its contents, depending on flow volume, gravity, and density, which are all variables of Bernoulli's principle. Therefore, it was hypothesized that constipation and diarrhea can occur due to changes in the colonic transit time (CTT), according to Bernoulli's principle. In addition, it was hypothesized that high amplitude peristaltic contractions (HAPC), which are considered to be involved in defecation in healthy subjects, occur because of cecum pressure based on Bernoulli's principle.

METHODS

A virtual healthy model (VHM), a virtual constipation model and a virtual diarrhea model were set up. For each model, the CTT was decided according to the length of each part of the colon, and then calculating the velocity due to the cecum inflow volume. In the VHM, the pressure change was calculated, then its consistency with HAPC was verified.

RESULTS

The CTT changed according to the difference between the cecum inflow volume and the caliber of the intestinal tract, and was inversely proportional to the cecum inflow volume. Compared with VHM, the CTT was prolonged in the virtual constipation model, and shortened in the virtual diarrhea model. The calculated pressure of the VHM and the gradient of the interlocked graph were similar to that of HAPC.

CONCLUSION

The CTT and HAPC can be explained by Bernoulli's principle, and constipation and diarrhea may be fundamentally influenced by flow dynamics.

Novel Effects of Traditional Wooden Toothbrush on Bowel Motility Symptoms in Spinal Cord Injury Patients; Findings from a Pilot Quasi-experimental Study

BACKGROUND

The aim of this study was to investigate the therapeutic effect of traditional wooden toothbrush usage on most severe constipation, which usually occurs in spinal cord injury (SCI) patients.

METHODS

In a quasi-experimental study, 61 SCI patients were selected who had injuries in different spinal levels (cervical, thoracic, and lumbar), and severe constipation from one defection in a few days to 3 weeks. They were recommended to use traditional wooden toothbrush for 5 min twice a day, after breakfast and dinner, over a 6 weeks period. Two proper standard scales, called neurogenic bowel dysfunction (NBD), and "Constipation Assessment Scale (CAS)," were used for evaluating the changes in patients' gastrointestinal (GI) habits during the period of using the wooden toothbrush. Through these scales (NBD and CAS), the therapeutic effects of traditional wooden toothbrush usage on the severity of constipation before and after intervention were measured.

RESULTS

The mean of NBD and CAS scores were reduced significantly, from 8.95 ± 0.78 and 3.34 ± 0.28; respectively, to 3.03 ± 0.57 and 1.74 ± 0.25, after 6 weeks using traditional wooden toothbrush (P < 0.0001). There was a significant difference in terms of NBD scores in patients with different levels of injury (P < 0.01), particularly in patients with thoracic injury, before (10.52 ± 0.88) and after (3.13 ± 0.78) treatment, respectively (P < 0.0001). Eventually, all symptoms of bowel problems improved significantly after the intervention (P < 0.05).

CONCLUSIONS

The use of traditional wooden toothbrush lead to the improvement of bowel and defecation problems in SCI patients. Yet more studies, particularly randomized control clinical trials are needed to investigate the effect of using wooden toothbrush on other GI reflexes. In addition, if some clinical trials are devised to study the effects of wooden toothbrush on both conscious and unconscious patients in ICU, best results are expected to be found on keeping their mouth and teeth hygiene, as well as, getting rid of their constipations.

Evaluation of interstitial cells of Cajal in patients with severe colonic inertia requiring surgery: a clinical-pathological study

AIM

Subtotal colectomy is the treatment of last resort in patients with severe colonic inertia (SCI) refractory to laxatives. Some studies have reported hypoplasia of the interstitial cells of Cajal (ICC) using a semi-quantitative analysis. The aims of this study were first to investigate if semi-quantitative analysis or morphometry is better at the quantification of colonic ICC and second to determine whether there is a relationship between the number of ICC and the severity of constipation.

METHOD

Clinical and pathological data from patients with subtotal colectomy for SCI were collected. Quantification of ICC using CD117 immunohistochemistry and morphometric methods was performed at three different colonic sites in patients and controls.

RESULTS

Twenty patients had a colectomy for SCI. All were considered to have failed maximal medical treatment and 45% were hospitalized at least once for colonic obstruction due to faecaloma. Using a semi-quantitative methodology, 30% of patients displayed ICC hypoplasia (< 7 per high power field) and all controls had normal ICC. Using morphometry, the percentage of colonic ICC was significantly less in patients compared with controls with no significant differences between the ascending, transverse and descending colonic segments. Overall 60% of patients had ICC hypoplasia (< 1% vs 20% of controls, P = 0.009). The severity of constipation was not related to the quantity of ICC.

CONCLUSION

In patients with SCI, morphometric analysis is more sensitive than semi-quantitative analysis in the detection of ICC hypoplasia. The severity of constipation was not related to the quantity of ICC.

Inhibitory Effects and Sympathetic Mechanisms of Distension in the Distal Organs on Small Bowel Motility and Slow Waves in Canine

Rectal distension (RD) is known to induce intestinal dysmotility. Few studies were performed to compare effects of RD, colon distension (CD) and duodenal distension (DD) on small bowel motility. This study aimed to investigate effects and underlying mechanisms of distensions in these regions on intestinal motility and slow waves. Eight dogs chronically implanted with a duodenal fistula, a proximal colon fistula, and intestinal serosal electrodes were studied in six sessions: control, RD, CD, DD, RD + guanethidine, and CD + guanethidine. Postprandial intestinal contractions and slow waves were recorded for the assessment of intestinal motility. The electrocardiogram was recorded for the assessment of autonomic functions. (1) Isobaric RD and CD suppressed intestinal contractions (contractile index: 6.0 ± 0.4 with RD vs. 9.9 ± 0.9 at baseline, P = 0.001, 5.3 ± 0.2 with CD vs. 7.7 ± 0.8 at baseline, P = 0.008). Guanethidine at 3 mg/kg iv was able to partially block the effects. (2) RD and CD reduced the percentage of normal intestinal slow waves from 92.1 ± 2.8 to 64.2 ± 3.4 % (P < 0.001) and from 90 ± 2.7 to 69.2 ± 3.7 % (P = 0.01), respectively. Guanethidine could eliminate these inhibitory effects. (3) DD did not induce any changes in small intestinal contractions and slow waves (P > 0.05). (4) The spectral analysis of the heart rate variability showed that both RD and CD increased sympathetic activity (LF) and reduced vagal activity (HF) (P < 0.05). Isobaric RD and CD could inhibit postprandial intestinal motility and impair intestinal slow waves, which were mediated via the sympathetic pathway. However, DD at a site proximal to the measurement site did not seem to impair small intestinal contractions or slow waves.

Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments

Gastrointestinal (GI) side-effects of chemotherapy are a debilitating and often overlooked clinical hurdle in cancer management. Chemotherapy-induced constipation (CIC) and Diarrhea (CID) present a constant challenge in the efficient and tolerable treatment of cancer and are amongst the primary contributors to dose reductions, delays and cessation of treatment. Although prevalence of CIC is hard to estimate, it is believed to affect approximately 16% of cancer patients, whilst incidence of CID has been estimated to be as high as 80%. Despite this, the underlying mechanisms of both CID and CIC remain unclear, but are believed to result from a combination of intersecting mechanisms including inflammation, secretory dysfunctions, GI dysmotility and alterations in GI innervation. Current treatments for CIC and CID aim to reduce the severity of symptoms rather than combating the pathophysiological mechanisms of dysfunction, and often result in worsening of already chronic GI symptoms or trigger the onset of a plethora of other side-effects including respiratory depression, uneven heartbeat, seizures, and neurotoxicity. Emerging treatments including those targeting the enteric nervous system present promising avenues to alleviate CID and CIC. Identification of potential targets for novel therapies to alleviate chemotherapy-induced toxicity is essential to improve clinical outcomes and quality of life amongst cancer sufferers.

Constipation and Outcomes of Cecostomy

Constipation, defined as delay or difficulty in defecation, present for 2 or more weeks, is a common problem encountered by both primary and specialty medical providers. There are no randomized controlled trials on the use of antegrade enemas in the pediatric population. Most published papers are based on the experience at a particular center. The aim of this article is to describe the pathophysiology of constipation, review the contribution of colonic manometry to the diagnosis of constipation, summarize the advancements in the management of constipation through the use of antegrade enemas, and study the outcomes of cecostomy at different centers. This study is a comprehensive literature review generated by computerized search of literature, supplemented by review of monographs and textbooks in pathology, gastroenterology, and surgery. Literature search was performed using the publications from 1997 to 2012. The search included publications of all types presenting or reviewing data on cecostomy. The antegrade continence enema is a therapeutic option for defecation disorders when maximal conventional therapy is not successful. Symptoms of defecation disorders in children with different underlying etiologies improve significantly after a cecostomy is created. In addition, there is a benefit on the patients' physical activity, healthcare utilization, and general well-being. Based on the review of published literature it seems that antegrade enemas are a successful therapeutic option in children with severe constipation and/or fecal incontinence. With the advent of cecostomy buttons, patient compliance and the overall cosmetic appearance have improved.

A study of human colonic motility in healthy and constipated subjects using the wireless capsule

Constipation is a common and distressing condition that has been linked to major morbidity, burdens the health care system, and impacts patients׳ quality of life. However, there is no perfect method for diagnosing and treating constipation. The purpose of this paper is to develop an automatic algorithm to identify patients with constipation from healthy subjects. Data from 12 healthy subjects and 10 patients with constipation were analyzed. The key challenges for data processing were data filtering, feature extraction, information evaluation, and providing the reference conclusion; these were resolved by employing the phase space reconstruction (PSR), independent component analysis (ICA), dynamic feature extraction algorithm, and the Wilcoxon rank sum test. The contractile frequency (Fr), motility index per unit time (MIU), average peak of peristaltic wave (Pave) and variance (Var) were extracted as dynamic parameters and analyzed. Results between groups were compared with the Wilcoxon rank sum test. There were statistically significant differences between healthy subjects and patients with constipation for Fr and MIU (P<0.05), whereas there was no statistically difference for Var. Moreover, the Fr and MIU of patients with normal transit constipation (NTC) are significantly lower compared to healthy subjects, whereas patients with slow transit constipation (STC) did not show significant differences. The proposed algorithms were able to differentiate between healthy subjects and patients with constipation based on the colonic motility profiles.

Regional gastrointestinal transit and pH studied in 215 healthy volunteers using the wireless motility capsule: influence of age, gender, study country and testing protocol

BACKGROUND

The wireless motility capsule (WMC) offers the ability to investigate luminal gastrointestinal (GI) physiology in a minimally invasive manner.

AIM

To investigate the effect of testing protocol, gender, age and study country on regional GI transit times and associated pH values using the WMC.

METHODS

Regional GI transit times and pH values were determined in 215 healthy volunteers from USA and Sweden studied using the WMC over a 6.5-year period. The effects of test protocol, gender, age and study country were examined.

RESULTS

For GI transit times, testing protocol was associated with differences in gastric emptying time (GET; shorter with protocol 2 (motility capsule ingested immediately after meal) vs. protocol 1 (motility capsule immediately before): median difference: 52 min, P = 0.0063) and colonic transit time (CTT; longer with protocol 2: median 140 min, P = 0.0189), but had no overall effect on whole gut transit time. Females had longer GET (by median 17 min, P = 0.0307), and also longer CTT by (104 min, P = 0.0285) and whole gut transit time by (263 min, P = 0.0077). Increasing age was associated with shorter small bowel transit time (P = 0.002), and study country also influenced small bowel and CTTs. Whole gut and CTTs showed clustering of data at values separated by 24 h, suggesting that describing these measures as continuous variables is invalid. Testing protocol, gender and study country also significantly influenced pH values.

CONCLUSIONS

Regional GI transit times and pH values, delineated using the wireless motility capsule (WMC), vary based on testing protocol, gender, age and country. Standardisation of testing is crucial for cross-referencing in clinical practice and future research.

Determination of bioactive components in Chinese herbal formulae and pharmacokinetics of rhein in rats by UPLC-MS/MS

Rhein (4,5-dihydroxy-9,10-dioxoanthracene-2-carboxylic acid, cassic acid) is a pharmacological active component found in Rheum palmatum L. the major herb of San-Huang-Xie-Xin-Tang (SHXXT), a medicinal herbal product used as a remedy for constipation. Here we have determined multiple bioactive components in SHXXT and investigated the comparative pharmacokinetics of rhein in rats. A sensitive and specific method combining liquid chromatography with electrospray ionization tandem mass spectrometry has been developed and validated to simultaneously quantify six active compounds in the pharmaceutical herbal product SHXXT to further study their pharmacokinetics in rats. Multiple reaction monitoring (MRM) was employed for quantification with switching electrospray ion source polarity between positive and negative modes in a single run. There were no significant matrix effects in the quantitative analysis and the mean recovery for rhein in rat plasma was 91.6%±3.4%. The pharmacokinetic data of rhein demonstrate that the herbal formulae or the single herbal extract provide significantly higher absorption rate than the pure compound. This phenomenon suggests that the other herbal ingredients of SHXXT and rhubarb extract significantly enhance the absorption of rhein in rats. In conclusion, the herbal formulae (SHXXT) are more efficient than the single herb (rhubarb) or the pure compound (rhein) in rhein absorption.

Low-resolution colonic manometry leads to a gross misinterpretation of the frequency and polarity of propagating sequences: Initial results from fiber-optic high-resolution manometry studies

BACKGROUND

High-resolution manometry catheters are now being used to record colonic motility. The aim of this study was to determine the influence of pressure sensor spacing on our ability to identify colonic propagating sequences (PS).

METHODS

Fiber-optic catheters containing 72-90 sensors spaced at 1 cm intervals were placed colonoscopically to the cecum in 11 patients with proven slow transit constipation, 11 patients with neurogenic fecal incontinence and nine healthy subjects. A 2 h section of trace from each subject was analyzed. Using the 1 cm spaced data as the gold standard, each data set was then sub-sampled, by dropping channels from the data set to simulate sensor spacing of 10, 7, 5, 3, and 2 cm. In blinded fashion, antegrade and retrograde PS were quantified at each test sensor spacing. The data were compared to the PSs identified in the corresponding gold standard data set.

KEY RESULTS

In all subject groups as sensor spacing increased; (i) the frequency of identified antegrade and retrograde PSs decreased (P < 0.0001); (ii) the ratio of antegrade to retrograde PSs increased (P < 0.0001); and (iii) the number of incorrectly labeled PSs increased (P < 0.003).

CONCLUSIONS & INFERENCES

Doubling the sensor spacing from 1 to 2 cm nearly halves the number of PSs detected. Tripling the sensor spacing from 1 to 3 cm resulted in a 30% chance of incorrectly labeling PSs. Closely spaced pressure recording sites (<2 cm) are mandatory to avoid gross misrepresentation of the frequency, morphology, and directionality of colonic propagating sequences.

Neurogenic and myogenic properties of pan-colonic motor patterns and their spatiotemporal organization in rats

Background and Aims

Better understanding of intrinsic control mechanisms of colonic motility will lead to better treatment options for colonic dysmotility. The aim was to investigate neurogenic and myogenic control mechanisms underlying pan-colonic motor patterns.

Methods

Analysis of in vitro video recordings of whole rat colon motility was used to explore motor patterns and their spatiotemporal organizations and to identify mechanisms of neurogenic and myogenic control using pharmacological tools.

Results

Study of the pan-colonic spatiotemporal organization of motor patterns revealed: fluid-induced or spontaneous rhythmic propulsive long distance contractions (LDCs, 0.4–1.5/min, involving the whole colon), rhythmic propulsive motor complexes (RPMCs) (0.8–2.5/min, dominant in distal colon), ripples (10–14/min, dominant in proximal colon), segmentation and retrograde contractions (0.1–0.8/min, prominent in distal and mid colon). Spontaneous rhythmic LDCs were the dominant pattern, blocked by tetrodotoxin, lidocaine or blockers of cholinergic, nitrergic or serotonergic pathways. Change from propulsion to segmentation and distal retrograde contractions was most prominent after blocking 5-HT₃ receptors. In the presence of all neural blockers, bethanechol consistently evoked rhythmic LDC-like propulsive contractions in the same frequency range as the LDCs, indicating the existence of myogenic mechanisms of initiation and propulsion.

Conclusions

Neurogenic and myogenic control systems orchestrate distinct and variable motor patterns at different regions of the pan-colon. Cholinergic, nitrergic and serotonergic pathways are essential for rhythmic LDCs to develop. Rhythmic motor patterns in presence of neural blockade indicate the involvement of myogenic control systems and suggest a role for the networks of interstitial cells of Cajal as pacemakers.

Classification of normal and abnormal colonic motility based on cross-correlations of pancolonic manometry data

BACKGROUND

Manual analysis of data acquired from manometric studies of colonic motility is laborious, subject to laboratory bias and not specific enough to differentiate all patients from control subjects. Utilizing a cross-correlation technique, we have developed an automated analysis technique that can reliably differentiate the motor patterns of patients with slow transit constipation (STC) from those recorded in healthy controls.

METHODS

Pancolonic manometric data were recorded from 17 patients with STC and 14 healthy controls. The automated analysis involved calculation of an indicator value derived from cross-correlations calculated between adjacent recording sites in a manometric trace. The automated technique was conducted on blinded real data sets (observed) and then to determine the likelihood of positive indicator values occurring by chance, the channel number within each individual data set were randomized (expected) and reanalyzed.

KEY RESULTS

In controls, the observed indicator value (3.2 ± 1.4) was significantly greater than that predicted by chance (0.8 ± 1.5; P < 0.0001). In patients, the observed indicator value (-2.7 ± 1.8) did not differ from that predicted by chance (-3.5 ± 1.6; P = 0.1). The indicator value for controls differed significantly from that of patients (P < 0.0001), with all individual patients falling outside of the range of indicator values for controls.

CONCLUSIONS & INFERENCES

Automated analysis of colonic manometry data using cross-correlation separated all patients from controls. This automated technique indicates that the contractile motor patterns in STC patients differ from those recorded in healthy controls. The analytical technique may represent a means for defining subtypes of constipation.

Opioid-induced bowel dysfunction: pathophysiology and management

Opioids are the most commonly prescribed medications to treat severe pain in the Western world. It has been estimated that up to 90% of American patients presenting to specialized pain centres are treated with opioids. Along with their analgesic properties, opioids have the potential to produce substantial side effects, such as nausea, cognitive impairment, addiction and urinary retention. In the gut, opioids exert their action on the enteric nervous system, where they bind to the myenteric and submucosal plexuses, causing dysmotility, decreased fluid secretion and sphincter dysfunction, which all leads to opioid-induced bowel dysfunction (OIBD). In the clinic, this is reported as nausea, vomiting, gastro-oesophageal reflux-related symptoms, constipation, etc. One of the most severe symptoms is constipation, which can be assessed using different scales for subjective assessment. Objective methods such as radiography and colonic transit time can also be used, together with manometry and evaluation of anorectal function to explore the pathophysiology. Dose-limiting adverse symptoms of OIBD can lead to insufficient pain treatment. Even though several treatment strategies are available, the side effects are still a major challenge. Traditional laxatives are normally prescribed but they are often insufficient to alleviate symptoms, especially those from the upper gastrointestinal tract. Newer prokinetics, such as prucalopride and lubiprostone, may be more effective in alleviating OIBD. Another treatment approach is co-administration of opioid antagonists, which either cannot cross the blood-brain barrier or selectively target opioid receptors in the gastrointestinal tract. However, although these new agents have proved to be more efficacious than placebo, clinical trials still need to prove their superiority to standard co-prescribed laxative regimes.

Insights from a novel model of slow-transit constipation generated by partial outlet obstruction in the murine large intestine

The mechanisms underlying slow-transit constipation (STC) are unclear. In 50% of patients with STC, some form of outlet obstruction has been reported; also an elongated colon has been linked to patients with STC. Our aims were 1) to develop a murine model of STC induced by partial outlet obstruction and 2) to determine whether this leads to colonic elongation and, consequently, activation of the inhibitory "occult reflex," which may contribute to STC in humans. Using a purse-string suture, we physically reduced the maximal anal sphincter opening in C57BL/6 mice. After 4 days, the mice were euthanized (acutely obstructed), the suture was removed (relieved), or the suture was removed and replaced repeatedly (chronically obstructed, over 24-31 days). In partially obstructed mice, we observed increased cyclooxygenase (COX)-2 levels in muscularis and mucosa, an elongated impacted large bowel, slowed transit, nonpropagating colonic migrating motor complexes (CMMCs), a lack of mucosal reflexes, a depolarized circular muscle with slow-wave activity due to a lack of spontaneous inhibitory junction potentials, muscle hypertrophy, and CMMCs in mucosa-free preparations. Elongation of the empty obstructed colon produced a pronounced occult reflex. Removal of the obstruction or addition of a COX-2 antagonist (in vitro and in vivo) restored membrane potential, spontaneous inhibitory junction potentials, CMMC propagation, and mucosal reflexes. We conclude that partial outlet obstruction increases COX-2 leading to a hyperexcitable colon. This hyperexcitability is largely due to suppression of only descending inhibitory nerve pathways by prostaglandins. The upregulation of motility is suppressed by the occult reflex activated by colonic elongation.

Effects of Hange-shashin-to (TJ-14) and Keishi-ka-shakuyaku-to (TJ-60) on contractile activity of circular smooth muscle of the rat distal colon

The Japanese Kampo medicines Hange-shashin-to (TJ-14) and Keishi-ka-shakuyaku-to (TJ-60) have been used to treat symptoms of human diarrhea on an empirical basis as Japanese traditional medicines. However, it remains unclear how these drugs affect smooth muscle tissues in the distal colon. The aim of the present study was to investigate the effects of TJ-14 and TJ-60 on the contractile activity of circular smooth muscle from the rat distal colon. TJ-14 and TJ-60 (both 1 mg/ml) inhibited spontaneous contractions of circumferentially cut preparations with the mucosa intact. Blockade of nitric oxide (NO) synthase or soluble guanylate cyclase activity abolished the inhibitory effects of TJ-60 but only attenuated the inhibitory effects of TJ-14. Apamin (1 μM), a blocker of small-conductance Ca(2+)-activated K(+) channels (SK channels), attenuated the inhibitory effects of 5 mg/ml TJ-60 but not those of 5 mg/ml TJ-14. TJ-14 suppressed contractile responses (phasic contractions and off-contractions) evoked by transmural nerve stimulation and increased basal tone, whereas TJ-60 had little effect on these parameters. These results suggest that 1 mg/ml TJ-14 or TJ-60 likely inhibits spontaneous contractions of the rat distal colon through the production of NO. Activation of SK channels seems to be involved in the inhibitory effects of 5 mg/ml TJ-60. Since TJ-14 has potent inhibitory effects on myogenic and neurogenic contractile activity, TJ-14 may be useful in suppressing gastrointestinal motility.

The physiology of human defecation

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.

The pathophysiology of chronic constipation

Constipation is broadly defined as an unsatisfactory defecation characterized by infrequent stools, difficult stool passage or both. The common approach to the pathophysiology of constipation groups the disorder into primary and secondary causes. Primary causes are intrinsic problems of colonic or anorectal function, whereas secondary causes are related to organic disease, systemic disease or medications. The normal process of colonic transit and defecation is discussed, and the etiology of constipation is reviewed.

What is chronic constipation? Definition and diagnosis

Although chronic constipation is a common complaint, there are no ideal biological markers for its diagnosis. Diagnosis rests on individual patient perception or clinical criteria developed by expert consensus. Investigation options are multiple but often not necessary. When selected, investigations are directed at confirming the absence of a primary underlying disease, differentiating or defining an alteration in colonic motility or identifying an anorectal evacuation disorder.

Chronic constipation: current management and challenges

Many challenges are associated with the diagnosis and management of patients with chronic constipation. Some of these challenges arise from the currently incomplete understanding of what causes constipation and from the difficulties in diagnosing and classifying the heterogeneous group of patients with chronic constipation. Despite the availability of different treatment options for constipation, an unmet need for drugs in the treatment of patients with chronic constipation remains. This holds especially true for patients who fail an initial treatment. With promising novel drugs either close to approval for the Canadian market or on the horizon, many of these unmet needs may be addressed. The present supplement to The Canadian Journal of Gastroenterology provides an educational overview of the current understanding of the diagnosis, epidemiology, pathophysiology and management of chronic constipation, and summarizes current treatment options in light of current and newly available drugs.

Anatomical registration and three-dimensional visualization of low and high-resolution pan-colonic manometry recordings

BACKGROUND

Colonic propagating sequences (PS) are important for the movement of colonic content and defecation, and aberrant PS patterning has been associated with slow transit constipation. However, because these motor patterns are typically recorded over long periods (24 h +), the visualization of PS spatiotemporal patterning is difficult. Here, we develop a novel method for displaying pan-colonic motility patterns.

METHODS

A 3D mesh representing the geometry of the human colon was created as follows: (i) Human colon images from the Visible Human Dataset were digitized to create a 3D data cloud, and (ii) A surface mesh was fitted to the cloud using a least-squares minimization technique. Colonic manometry catheters were placed in the ascending colon of healthy controls and patients with slow transit constipation (STC), with the aid of a colonoscope. The colonic manometry data were interpolated and mapped to the model according to the following anatomical landmarks: cecum, hepatic flexure, splenic flexure, sigmoid-descending junction, and anus.

KEY RESULTS

These 3D images clearly and intuitively communicate characteristics of normal and abnormal colonic motility. Specifically we have shown the reduced amplitude of the antegrade propagating pressure waves (PPW) throughout the colon and reduced frequency of PPWs at the mid-colon in patients with STC.

CONCLUSIONS AND INFERENCES

A novel method for the 3D visualization of PS is presented, providing an intuitive method for representing a large volume of physiological data. These techniques can be used to display frequency, amplitude or velocity data, and will help to convey regions of abnormally in patient populations.

Colonic dysmotility in constipation

Constipation is a common and distressing condition with major morbidity, health care burden, and impact on quality of life. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in the most severe cases of chronic constipation and physiological testing plays a role in identifying the colonic dysmotility and the subsequent patient management. Measurement of colonic motor patterns and transit has enhanced our knowledge of normal and abnormal colonic motor physiology. The scope of this review encompasses the latest findings that improve our understanding of the motility disorders associated with colonic dysfunction in both the paediatric and adult population suffering from constipation.

Accurate localization of a fall in pH within the ileocecal region: validation using a dual-scintigraphic technique

Stereotypical changes in pH occur along the gastrointestinal (GI) tract. Classically, there is an abrupt increase in pH on exit from the stomach, followed later by a sharp fall in pH, attributed to passage through the ileocecal region. However, the precise location of this latter pH change has never been conclusively substantiated. We aimed to determine the site of fall in pH using a dual-scintigraphic technique. On day 1, 13 healthy subjects underwent nasal intubation with a 3-m-long catheter, which was allowed to progress to the distal ileum. On day 2, subjects ingested a pH-sensitive wireless motility capsule labeled with 4 MBq (51)Chromium [EDTA]. The course of this, as it travelled through the GI tract, was assessed with a single-headed γ-camera using static and dynamic scans. Capsule progression was plotted relative to a background of 4 MBq ¹¹¹Indium [diethylenetriamine penta-acetic acid] administered through the catheter. Intraluminal pH, as recorded by the capsule, was monitored continuously, and position of the capsule relative to pH was established. A sharp fall in pH was recorded in all subjects; position of the capsule relative to this was accurately determined anatomically in 9/13 subjects. In these nine subjects, a pH drop of 1.5 ± 0.2 U, from 7.6 ± 0.05 to 6.1 ± 0.1 occurred a median of 7.5 min (1-16) after passage through the ileocecal valve; location was either in the cecum (n = 5), ascending colon (n = 2), or coincident with a move from the cecum to ascending colon (n = 2). This study provides conclusive evidence that the fall in pH seen within the ileocolonic region actually occurs in the proximal colon. This phenomenon can be used as a biomarker of transition between the small and large bowel and validates assessment of regional GI motility using capsule technology that incorporates pH measurement.

Pancolonic spatiotemporal mapping reveals regional deficiencies in, and disorganization of colonic propagating pressure waves in severe constipation

BACKGROUND

The morphology, motor responses and spatiotemporal organization among colonic propagating sequences (PS) have never been defined throughout the entire colon of patients with slow transit constipation (STC). Utilizing the technique of spatiotemporal mapping, we aimed to demonstrate 'manometric signatures' that may serve as biomarkers of the disorder.

METHODS

In 14 female patients with scintigraphically confirmed STC, and eight healthy female controls, a silicone catheter with 16 recording sites spanning the colon at 7.5 cm intervals was positioned colonoscopically with the tip clipped to the cecum. Intraluminal pressures were recorded for 24 h.

KEY RESULTS

Pan-colonic, 24 h, spatiotemporal mapping identified for the first time in STC patients: a marked paucity of propagating pressure waves in the midcolon (P = 0.01), as a consequence of a significant (P < 0.0001) decrease in extent of propagation of PS originating in the proximal colon; an increase in frequency of retrograde PS in the proximal colon; a significant reduction in the spatiotemporal organization among PS (P < 0.001); absence of the normal nocturnal suppression of PS.

CONCLUSIONS & INFERENCES

Pancolonic, 24 h, spatiotemporal pressure mapping readily identifies characteristic disorganization among consecutive PS, regions of diminished activity and absent or deficient fundamental motor patterns and responses to physiological stimuli. These features are all likely to be important in the pathophysiology of slow transit constipation.

Paediatric and adult colonic manometry: A tool to help unravel the pathophysiology of constipation

Colonic motility subserves large bowel functions, including absorption, storage, propulsion and defaecation. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in chronic constipation, a heterogeneous condition which is extremely prevalent in the general population, and has huge socioeconomic impact and individual suffering. Physiological testing plays a crucial role in patient management, as it is now accepted that symptom-based assessment, although important, is unsatisfactory as the sole means of directing therapy. Colonic manometry provides a direct method for studying motor activities of the large bowel, and this review provides a contemporary understanding of how this technique has enhanced our knowledge of normal colonic motor physiology, as well as helping to elucidate pathophysiological mechanisms underlying constipation. Methodological approaches, including available catheter types, placement technique and recording protocols, are covered, along with a detailed description of recorded colonic motor activities. This review also critically examines the role of colonic manometry in current clinical practice, and how manometric assessment may aid diagnosis, classification and guide therapeutic intervention in the constipated individual. Most importantly, this review considers both adult and paediatric patients. Limitations of the procedure and a look to the future are also addressed.

Colonic elongation inhibits pellet propulsion and migrating motor complexes in the murine large bowel

The colonic migrating motor complex (CMMC) is a rhythmically occurring neurally mediated motor pattern. Although the CMMC spontaneously propagates along an empty colon it is responsible for faecal pellet propulsion in the murine large bowel. Unlike the peristaltic reflex, the CMMC is an 'all or none' event that appears to be dependent upon Dogiel Type II/AH neurons for its regenerative slow propagation down the colon. A reduction in the amplitude of CMMCs or an elongated colon have both been thought to underlie slow transit constipation, although whether these phenomena are related has not been considered. In this study we examined the mechanisms by which colonic elongation might affect the CMMC using video imaging of the colon, tension and electrophysiological recordings from the muscle and Ca(2+) imaging of myenteric neurons. As faecal pellets were expelled from the murine colon, it shortened by up to 29%. Elongation of the colon resulted in a linear reduction in the velocity of a faecal pellet and the amplitude of spontaneous CMMCs. Elongation of the oral end of a colonic segment reduced the amplitude of CMMCs, whereas elongation of the anal end of the colon evoked a premature CMMC, and caused the majority of CMMCs to propagate in an anal to oral direction. Dogiel Type II/AH sensory neurons and most other myenteric neurons responded to oral elongation with reduced amplitude and frequency of spontaneous Ca(2+) transients, whereas anal elongation increased their amplitude and frequency in most neurons. The inhibitory effects of colonic elongation were reduced by blocking nitric oxide (NO) production with l-NA (100 mum) and soluble guanylate cyclase with 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ; 10 mum); whereas, l-arginine (1-2 mm) enhanced the inhibitory effects of colonic elongation. In conclusion, polarized neural reflexes can be triggered by longitudinal stretch. The dominant effect of elongation is to reduce CMMCs primarily by inhibiting Dogiel Type II/AH neurons, thus facilitating colonic accommodation and slow transit.

Technical advances in monitoring human motility patterns

Abnormal motor patterns are implicated in many motility disorders. However, for many regions of the gut, our knowledge of normal and abnormal motility behaviors and mechanisms remains incomplete. There have been many recent advances in the development of techniques to increase our knowledge of gastrointestinal motility, some readily available while others remain confined to research centers. This review highlights a range of these recent developments and examines their potential to help diagnose and guide treatment for motility disorders.