Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations

Laxative Properties of Microencapsulated Oleic Acid Delivered to the Distal Small Intestine in Patients with Constipation after Bariatric Surgery or Treatment with Glucagon-Like- Peptide 1 Analogues

BACKGROUND

Constipation is prevalent after bariatric surgery and glucagon-like-peptide 1 (GLP-1) analogues. Increasing fat content in the distal small intestine and colon can enhance colonic peristalsis, potentially alleviating symptoms of constipation.

AIM

We investigated whether oleic acid can ameliorate constipation in patients undergoing bariatric surgery or receiving GLP-1 analogues.

METHODOLOGY

Fourteen adults with chronic constipation according to Rome IV criteria following bariatric surgery or GLP-1 analogues were on stable treatment for constipation for more than 4 weeks. This randomized double-blind crossover trial compared microcapsules containing 21.25 g of oleic acid delivered in the distal small intestine or the stomach. The primary outcome was changed in the number of bowel motions over 24 h. Exploratory endpoints included alterations in straining, diarrhoea, faecal leakage over 24 h and hunger, fullness, nausea and calorie intake for the 3 h after ingesting the microcapsules.

FINDINGS

Receiving oleic acid into the distal small intestine increased number of bowel movements per day (2.5 vs 1.1, p = 0.009) and caused softer stool consistency (p = 0.03). 9/14 of the control group passed motions and 13/14 of the intervention group passed motions in 24 h (p = 0.059). No significant differences were observed in straining (p = 0.65), rapid bowel movements (p = 0.08), accidental leakage (p = 0.32), hunger, fullness, nausea or food intake between the groups (all p > 0.05). There were no disparities in safety profile between groups.

CONCLUSION

Microcapsules containing oleic acid delivered to the distal small intestine appear to be a safe and effective relief from chronic constipation in patients undergoing bariatric surgery and/or receiving GLP-1 analogues.

Multikingdom and functional gut microbiota markers for autism spectrum disorder

Associations between the gut microbiome and autism spectrum disorder (ASD) have been investigated although most studies have focused on the bacterial component of the microbiome. Whether gut archaea, fungi and viruses, or function of the gut microbiome, is altered in ASD is unclear. Here we performed metagenomic sequencing on faecal samples from 1,627 children (aged 1-13 years, 24.4% female) with or without ASD, with extensive phenotype data. Integrated analyses revealed that 14 archaea, 51 bacteria, 7 fungi, 18 viruses, 27 microbial genes and 12 metabolic pathways were altered in children with ASD. Machine learning using single-kingdom panels showed area under the curve (AUC) of 0.68 to 0.87 in differentiating children with ASD from those that are neurotypical. A panel of 31 multikingdom and functional markers showed a superior diagnostic accuracy with an AUC of 0.91, with comparable performance for males and females. Accuracy of the model was predominantly driven by the biosynthesis pathways of ubiquinol-7 or thiamine diphosphate, which were less abundant in children with ASD. Collectively, our findings highlight the potential application of multikingdom and functional gut microbiota markers as non-invasive diagnostic tools in ASD.

Evaluating the Effect of Lacticaseibacillus paracasei Strain Shirota on the Physical Consistency of Stool in Healthy Participants with Hard or Lumpy Stools: A Double-Blind, Randomized, Placebo-Controlled Study

We have earlier established a direct measurement method for assessing stool physical consistency using a texture analyzer (TAXT). The present study aimed to evaluate the stool softening effect of Lacticaseibacillus paracasei strain Shirota (LcS) using TAXT in a double-blind, randomized, placebo-controlled study. Sixty-four healthy participants with a Bristol stool form scale (BSFS) 1/2 ≥ 50% during screening consumed fermented milk containing LcS or a placebo beverage daily for 8 weeks. Stool consistency and water content were determined using TAXT and a lyophilizer, respectively. Participants evaluated their defecation using the BSFS. Stool consistency evaluated by a texture analyzer (TAXT) in the LcS group tended to be softer than that in the placebo group (p = 0.052). Subgroup analyses (TAXT value at baseline ≥ 4.5) showed that stool consistency was significantly softer in the LcS group (p = 0.014). Stool water content was also significantly higher in the LcS group than in the placebo group, but the proportion of normal stools was not statistically significant. We were unable to find evidence for the softening effect of LcS under the present study's conditions. However, its efficacy may be confirmed by targeting participants with physically hard stools and TAXT values ≥ 4.5.

Estimating minimal clinically important difference (MCID) for gastrointestinal symptoms in cystic fibrosis

BACKGROUND

Minimal clinically important difference (MCID) is important to establish as a meaningful outcome in research when using patient reported outcome measures (PROMs). We determined the MCID using the distribution-based approach for three measurements used as part of the GALAXY study, which is an observational prospective study on gastrointestinal (GI) symptoms in cystic fibrosis (CF).

METHODS

Four hundred and two persons with cystic fibrosis (PwCF) participated in the GALAXY study, all with baseline values available for all questionnaires. Mean age was 20.9 years (2.1- 61.1) with 75 females and 94 males under the age of 18 (42.04 %) and 118 females and 115 males aged 18 or older (57.99 %). MCID was measured for Patient Assessment of Constipation Symptoms (PAC-SYM), Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM), Patient Assessment of Constipation-Quality of Life (PAC-QOL) and their subscales. Two distribution-based approaches, defined as multiplications of the standard deviation (SD) or standard error of the mean (SEM), were used to approximate the MCID.

RESULTS

The two distribution-based approaches for determining the MCID estimates produced comparable results in trends in MCIDs across the subscales and total scores. In general, MCID estimates of subscales for all three measurements were higher than their total score MCIDs. The one-half SD- and SEM-based MCID estimates for total scores of each questionnaire are as follows: PAC-SYM: 0.26 and 0.14; PAGI-SYM: 0.32 and 0.15; PAC-QOL: 0.27 and 0.18, respectively.

CONCLUSION

This paper establishes initial MCIDs estimated by the distribution-based approach for the PAC-SYM, PAGI-SYM and PAC-QOL that can now be used to evaluate interventional studies that may impact gastrointestinal symptoms in PwCF.

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.

Exploring the Impact of Short Term Travel on Gut Microbiota and Probiotic Bacteria Mediated Stability

Although travelers are frequently accompanied by abdominal discomfort and even diarrhea, not every trip can cause this issue. Many studies have reported that intestinal microbes play an important role in it. However, little is known about the reason for the dynamics of these intestinal microbes. Here, we delved into the effects of short-term travel on the gut microbiota of 12 healthy individuals. A total of 72 fecal samples collected before and after one-week travel, alongside non-traveling controls, underwent amplicon sequencing and a series of bioinformatic analyses. We found that travel significantly increased intra-individual gut microbiota fluctuations without diarrhea symptoms. In addition, the initial composition of the gut microbiota before travel emerged as a crucial factor in understanding these fluctuations. Travelers with stable microbiota exhibited an enrichment of specific probiotic bacteria (Agathobaculum, Faecalibacterium, Bifidobacterium, Roseburia, Lactobacillus) before travel. Another batch of data validated their predictive role in distinguishing travelers with and without the gut microbial disorder. This work provided valuable insights into understanding the relationship between gut microbiota and travel. It offered a microbiota-centric perspective and a potential avenue for interventions to preserve gut health during travel.

A Decrease in the Hardness of Feces with Added Glucosylceramide Extracted from Koji In Vitro-A Working Hypothesis of Health Benefits of Dietary Glucosylceramide

Skin barrier function, prevent colon cancer, head and neck cancer, and decrease liver cholesterol. However, the mechanism of action has not yet been elucidated. In this study, we propose a new working hypothesis regarding the health benefits and functions of glucosylceramide: decreased fecal hardness. This hypothesis was verified using an in vitro hardness test. The hardness of feces supplemented with glucosylceramide was significantly lower than that of the control. Based on these results, a new working hypothesis of dietary glucosylceramide was conceived: glucosylceramide passes through the small intestine, interacts with intestinal bacteria, increases the tolerance of these bacteria toward secondary bile acids, and decreases the hardness of feces, and these factors synergistically result in in vivo effects. This hypothesis forms the basis for further studies on the health benefits and functions of dietary glucosylceramides.

Effectiveness of physiotherapy in children with functional constipation

PURPOSE

The objective was to compare the immediate effects of pharmacological versus physiotherapy intervention versus a combination of physiotherapy and pharmacological treatment, as well as the quality of life and the recurrence of symptoms in children with functional constipation after 3 months.

METHODS

A total of 69 children with functional constipation between the ages of 5 and 14 years of either gender were assessed and randomly assigned to one of three groups: Group A, B, and C. Visual Analogue Scale, Bristol Stool Form Scale, frequency of defecation, PedsQL GI symptom scale, and PedsQL Generic Core Scale were used as outcome measures. Pharmacology was used to treat Group A, physiotherapy was used to treat Group B, and a combination of both was used to treat Group C.

RESULTS

The study revealed statistically significant results on Visual Analogue Scale, Bristol Stool Form Scale, and frequency of defecation in all groups. However, no significant changes were observed on the PedsQL GI symptom scale and the Generic Core scale in Group A, whereas significant changes were observed in Groups B and C.

CONCLUSION

In this study, we found that there were significant differences in the short- and long-term effects across all groups. More changes occurred in Group C than in Groups A and B.

A randomized, double-blinded, placebo-controlled clinical trial on Lactobacillus-containing cultured milk drink as adjuvant therapy for depression in irritable bowel syndrome

Irritable bowel syndrome (IBS) is frequently linked with coexisting mental illnesses. Our previous study discovered that 32.1% of IBS patients had subthreshold depression (SD), placing them at higher risk of developing major depression. Gut microbiota modulation through psychobiotics was found to influence depression via the gut-brain axis. However, the efficacy of lessening depression among IBS patients remains ambiguous. The study's aim was to investigate the roles of cultured milk drinks containing 109 cfu Lactobacillus acidophilus LA-5 and Lactobacillus paracasei L. CASEI-01 on depression and related variables among IBS participants with SD. A total of 110 IBS participants with normal mood (NM) and SD, were randomly assigned to one of four intervention groups: IBS-NM with placebo, IBS-NM with probiotic, IBS-SD with placebo, and IBS-SD with probiotic. Each participant was required to consume two bottles of cultured milk every day for a duration of 12 weeks. The following outcomes were assessed: depression risk, quality of life, the severity of IBS, and hormonal changes. The depression scores were significantly reduced in IBS-SD with probiotic and placebo from baseline (p < 0.001). Only IBS-SD with probiotic showed a significant rise in serotonin serum levels (p < 0.05). A significantly higher life quality measures were seen in IBS-SD with probiotic, IBS-SD with placebo, and IBS-NM with placebo (p < 0.05). All groups, both placebo and probiotic, reported significant improvement in IBS severity post-intervention with a higher prevalence of remission and mild IBS (p < 0.05). Dual strains lactobacillus-containing cultured milk drink via its regulation of relevant biomarkers, is a potential anti-depressive prophylactic agent for IBS patients at risk.

The prevalence of constipation in adult psychiatric out-patients on clozapine treatment at a regional public hospital in Hong Kong

OBJECTIVE

To determine the occurrence of constipation in local patients on clozapine treatment, and to compare the demographical and clinical characteristics of patients on clozapine treatment with or without constipation.

METHODS

This is a cross-sectional, observational study. All adult psychiatric out-patients on clozapine treatment attending follow-up at a regional hospital were recruited for clinical interview and medical record review. The Enhanced Asian Rome III Questionnaire (EAR3Q) was used to define patients with constipation. The Bristol Stool Form Scale (BSFS) was used to assess stool form. The Brief Psychiatric Rating Scale-Anchored (BPRS-A) was used to measure psychiatric symptoms. The Brief Medication Adherence Scale (BMAS) was used to assess treatment adherence. Logistic regression was conducted to identify independent associating factors of constipation in patients on clozapine treatment.

RESULTS

The prevalence of constipation in patients on clozapine treatment was 26.3%, (95% CI [21.5%, 31.6%]). Independent associating factors included disorder of psychological development (aOR = 6.98, 95% CI [1.24, 39.18]), anxiety (very mild: aOR = 9.23, 95% CI [2.59, 32.87]; mild: aOR = 2.66, 95% CI [1.26, 5.62]), prescription with combination of laxatives (aOR = 0.40, 95% CI [0.17, 0.95]), and concomitant use of amisulpride (aOR = 2.52, 95% CI [1.09, 5.82]), quetiapine (aOR = 5.92, 95% CI [1.11, 31.56]) and metamucil (aOR = 9.30, 95% CI [1.53, 56.58]).

CONCLUSION

This study examined the prevalence of clozapine-associated constipation in Hong Kong using a validated questionnaire. The identification of independent factors associated with constipation could facilitate better risk stratification and risk modification in clinical practice.

Clinical Relevance of Pathological Diagnosis of Hirschsprung's Disease with Acetylcholine-Esterase Histochemistry or Calretinin Immunohistochemistry

INTRODUCTION

Hirschsprung disease (HD) manifests as a developmental anomaly affecting the enteric nervous system, where there is an absence of ganglion cells in the lower part of the intestine. This deficiency leads to functional blockages within the intestines. HD is usually confirmed or ruled out through rectal biopsy. The identification of any ganglion cells through hematoxylin and eosin (H&E) staining rules out HD. If ganglion cells are absent, further staining with acetylcholine-esterase (AChE) histochemistry or calretinin immunohistochemistry (IHC) forms part of the standard procedure for determining a diagnosis of HD. In 2017, our Institute of Pathology at University Hospital of Heidelberg changed our HD diagnostic procedure from AChE histochemistry to calretinin IHC. In this paper, we report the impact of the diagnostic procedure change on surgical HD therapy procedures and on the clinical outcome of HD patients.

METHODS

We conducted a retrospective review of the diagnostic procedures, clinical data, and postoperative progress of 29 patients who underwent surgical treatment for HD in the Department of Pediatric Surgery, University of Heidelberg, between 2012 and 2021. The patient sample was divided into two groups, each covering a treatment period of 5 years. In 2012-2016, HD diagnosis was performed exclusively using AChE histochemistry (AChE group, n = 17). In 2017-2021, HD diagnosis was performed exclusively using calretinin IHC (CR group, n = 12).

RESULTS

There were no significant differences between the groups in sex distribution, weeks of gestation, birth weight, length of the aganglionic segment, or associated congenital anomalies. Almost half of the children in the AChE group, twice as many as in the CR group, required an enterostomy before transanal endorectal pull-through procedure (TERPT). In the AChE group, 4 patients (23.5%) required repeat bowel sampling to confirm the diagnosis. Compared to the AChE group, more children in the CR group suffered from constipation post TERPT.

DISCUSSION

Elevated AChE expression is linked to hypertrophied extrinsic cholinergic nerve fibers in the aganglionic segment in the majority of patients with HD. The manifestation of increased AChE expression develops over time. Therefore, in neonatal patients with HD, especially those in the first 3 weeks of life, an increase in AChE reaction is not detected. Calretinin IHC reliably identifies the presence or absence of ganglion cells and offers multiple benefits over AChE histochemistry. These include the ability to perform the test on paraffin-embedded tissue sections, a straightforward staining pattern, a clear binary interpretation (negative or positive), cost-effectiveness, and utility regardless of patient age.

CONCLUSIONS

The ability of calretinin IHC to diagnose HD early and time-independently prevented repeated intestinal biopsies in our patient population and allowed us to perform a one-stage TERPT in the first months of life, reducing the number of enterostomies and restoring colonic continuity early. Patients undergoing transanal pull-through under the age of 3 months require a close follow-up to detect cases with bowel movement problems.

Amylose content controls the V-type structural formation and in vitro digestibility of maize starch-resveratrol complexes and their effect on human gut microbiota

The chain structure of starch affects its interaction with polyphenol molecules which in turn determines the nutritional function of starch. In this study, starch with different amylose content including waxy maize starch (WMS), normal maize starch (NMS) and G50 high-amylose maize starch (G50) were selected to complex with resveratrol (RA) in high-pressure homogenization (HPH) environment, and structural changes of the complexes, together with their effects on in vitro digestibility and gut microbiota were discussed. The results showed that with increasing amylose content, RA could form more inclusion complex with starch through non-covalent bonds accompanied by the increased single helix structure, V-type crystalline structure, compact nano-aggregates and total ordered structure content, which thus endowed the complex lower digestibility and intestinal probiotic function. Notably, when RA addition reached 3 %, the resistant starch (RS) content of HP-G50-3 % rose to 29.2 %, correspondingly increased the relative abundance of beneficial gut microbiota such as Megamonas and Bifidobacterium, as well as the total short-chain fatty acids (SCFAs) content. Correlation analysis showed that V-type crystalline structure positively correlated with the growth of Pediococcu and Blautia (p < 0.05) for producing SCFAs. These findings provided feasible ideas for the development of personalized nutritional starch-based foods.

OAGB Bowel Function in Patients With up to 5 Years Follow-Up: Updated Outcomes

OBJECTIVE

One-anastomosis gastric bypass (OAGB) is considered an effective technique in weight reduction and remission of comorbidities. However, in common with many bariatric and metabolic/bariatric procedures, gastrointestinal side effects are frequently reported, but clinical experience varies. The objective of this study was to analyze the bowel function of patients who undergo OAGB looking at 5-year postoperative outcomes.

METHOD

This study is cross-sectional, descriptive and analytical, developed with individuals undergoing OAGB (n = 208) in yhe period between 2015 and 2020. The time periods evaluated were 1 to 6 months (T1), 6 to 12 months (T2), and 1 to 5 years (T3). Data analysis was performed using SPSS v.28.0, considering a significance level p ≤ 0.05.

RESULTS

114 participants (54.8%), 79.8% women, mean age 47.0 ± 12.6 years, and BMI 40.1 ± 5.6 kg/m2, 51.9% dyslipidemia, 43.6% arterial hypertension, and 19.1% diabetes mellitus. The T1 group had more severe symptoms/nausea than the T2 group. The T2 group had a significantly lower defecation frequency than the T1 and T3 groups. As for the occurrence of diarrhea, associations were not found in the considered groups. The T3 group had a greater severity of constipation associated with greater difficulty in consuming red meat, white meat, rice, vegetables, and salads.

CONCLUSIONS

Gastrointestinal symptoms are prevalent in the first postoperative months. However, diarrhea was not common. The patient selection policy and surgical technique were decisive in this result. Constipation was prevalent in patients between 1 and 5 postoperative years. It was also prevalent in those who had food intolerance, which from a nutritional point of view is an adverse factor for optimal bowel function.

Prevalence of Blastocystis and Dientamoeba fragilis in diarrheal patients in Corum, Türkiye

To investigate the prevalence of Blastocystis and Dientamoeba fragilis in diarrhea patients and healthy individuals in Corum, Türkiye, fecal samples from 92 diarrhea patients and 50 healthy individuals were collected and evaluated using direct microscopy and molecular methods to screen for bacteria, protozoa, and viruses. The prevalence of Blastocystis was 24.6% in total and more frequent in the healthy group (30.0%). The commonly detected STs (subtypes) were ST3 (40.0%) and ST2 (34.2%). The distribution of Blastocystis STs in the healthy and diarrheal groups did not show any difference in sex and age, but ST3 was detected more frequently in patients aged from 40 to 59 years (p < 0.05). Alleles 4 (8/12) and 2 (4/12) were present in ST1; 9 (3/5) and 12 (2/5) in ST2; 34 (9/14), 36 (3/14), and 38 (2/14) in ST3; and only allele 42 (2/2) in ST4. D. fragilis was present in 8.4% of the population. However, there was no statistically significant difference between the healthy and diarrheic groups (12.0% and 6.5%, respectively), neither with respect to age nor sex. Co-infection was 58.3% and was more frequent in healthy individuals (33.3%) than in diarrhea patients (25.0%). Blastocystis ST3 was the most common subtype detected, with D. fragilis at 33.3%. Salmonella, Shigella, or helminth eggs were not observed in all groups, but Entamoeba histolytica, Giardia intestinalis, Cryptosporidium, Rotavirus, Adenovirus, and Clostridium difficile toxin were found only in diarrhea patients. These findings support the hypothesis that Blastocystis and D. fragilis may be part of the healthy human gut microbiome.

Effect of acupressure on alleviating constipation among inpatients with stroke during the acute phase: A randomized controlled trial

BACKGROUND AND PURPOSE

This study aimed to explore the effects of acupressure in alleviating constipation among inpatients with stroke in neurological departments.

MATERIAL AND METHODS

This was a two-arm, parallel, randomized, controlled trial conducted between September 2020 and August 2021. In total, 128 inpatients with stroke at the acute phase from neurological departments were randomly assigned at a 1:1 ratio to either an acupressure group (ST25, CV12, and CV6) or a sham acupressure group for twice-daily therapy at 4 min per intervention for 7 days. The Bristol Stool Form Scale and Constipation Assessment Scale (CAS) were assessed at the beginning and completion of the study. A generalized estimating equation was used for data analyses.

RESULTS

The mean ages were 63.8 ± 19.1 and 66.2 ± 16.0 years, and the average National Institutes of Health Stroke Scale scores were 7.2 ± 5.6 and 8.1 ± 6.3 points for the acupressure and sham acupressure groups, respectively. The acupressure group demonstrated gradually lower scores on the CAS over time than the sham acupressure group. Patients who received acupressure had a lower likelihood of requiring defecation medication and were more likely to have normal bowel movements and a decreased risk of their stool appearing as a hard lump than those who received sham acupressure over time.

CONCLUSION

Traditional Chinese medicine-based acupressure can help alleviate constipation and reduce the use of defecation medication among inpatients with stroke who have been admitted to neurological departments.

TRIAL AND PROTOCOL REGISTRATION

ClinicalTrials.gov, NCT05612646.

Bowel dysfunctions after acquired brain injury: a scoping review

Bowel dysfunction is a common consequence of neurological diseases and has a major impact on the dignity and quality of life of patients. Evidence on neurogenic bowel is focused on spinal cord injury and multiple sclerosis; few studies have focused on patients with acquired brain injury (ABI). Neurogenic bowel dysfunction is related to a lifelong condition derived from central neurological disease, which further increases disability and social deprivation. The manifestations of neurogenic bowel dysfunction include fecal incontinence and constipation. Almost two out of three patients with central nervous system disorder have bowel impairment. This scoping review aims to comprehend the extent and type of evidence on bowel dysfunction after ABI and present conservative treatment. For this scoping review, the PCC (population, concept, and context) framework was used: patients with ABI and bowel dysfunction; evaluation and treatment; and intensive/extensive rehabilitation path. Ten full-text articles were included in the review. Oral laxatives are the most common treatment. The Functional Independence Measure (FIM) subscale is the most common scale used to assess neurogenic bowel disease (60%), followed by the Rome II and III criteria, and the colon transit time is used to test for constipation; however, no instrumental methods have been used for incontinence. An overlapping between incontinence and constipation, SCI and ABI increase difficulties to manage NBD. The need for a consensus between the rehabilitative and gastroenterological societies on the diagnosis and medical care of NBD.

Systematic review registration

Open Science Framework on August 16, 2022 https://doi.org/10.17605/OSF.IO/NEQMA.

How to use the Bristol Stool Chart in childhood constipation

Constipation in children is common and is a frequent cause for healthcare attendances in both primary and secondary care. The Bristol Stool Chart has become ubiquitous as an aid in the diagnosis and treatment of constipation, but many clinicians may not be aware of its origins or strengths and weaknesses. In this article, we outline the history and rationale behind the development of the Bristol Stool Chart and how it should be used in childhood constipation.

Application of non-invasive neuromodulation in children with neurodevelopmental disorders to improve their sleep quality and constipation

BACKGROUND

Children with neurodevelopmental disorders have a very wide clinical variability. A common prevalent factor is problems with stool and sleep quality. Currently, there are multiple studies related to their evaluation, but not so much related to a specific intervention. The aim was to evaluate the effectiveness and safety of the application of non-invasive neuromodulation as a treatment in children with neurodevelopmental disorders to improve constipation and quality of sleep.

METHODS

A total of 23 minors aged between 2 and 16 were included in this cross-sectional study. All participants were applied the microcurrent device for 60 min, 3 times per week for a total of 4 weeks. The technique was based on non-invasive neuromodulation using a surface-applied microcurrent electrostimulation device that administers an external, imperceptible, pulsed electrical stimulation. It is applied to the extremities, in a coordinated manner, using gloves and anklets connected with electrodes to a control console. Sleep latency and microarousals were evaluated through a sleep diary. To assess the evolution and type of defecation, the adapted and validated version in Spanish of the Bristol Stool Form Scale was used.

RESULTS

No adverse events occurred during the study and no incidences were registered. Clinically relevant improvements were registered in defecation frequency and type as well as in sleep related parameters. An increase in the hours of sleep was registered, from 7,35 (0,83) to 9,09 (1,35), and sleep interruptions decreased from 3,83 (1,95) to 1,17 (1,11), (p < .001).

CONCLUSION

Microcurrents can be used as an effective and safe treatment to improve quality of sleep and constipation in children with neurodevelopmental disorders. More studies are needed in order to obtain statistically significant results.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05265702.

FIRST REGISTRATION

03/03/2022 PROTOCOL: https://clinicaltrials.gov/ct2/show/NCT05265702?term=baez+suarez&draw=2&rank=4.

A Double-Blind, Randomized, Placebo-Controlled Trial of the Effect of 1-Kestose on Defecation Habits in Constipated Kindergarten Children: A Pilot Study

Constipation is common in children and can significantly affect quality of life. Prebiotics are reportedly helpful for constipation in adults, but few studies have examined their use in young children. In this study, the effect of 1-kestose (kestose), which has excellent bifidobacterial growth properties, on constipation in kindergarten children (n = 11) was compared with that of maltose (n = 12) in a randomized, double-blind study. Three grams of kestose per day for 8 weeks did not affect stool properties, but significantly increased the number of defecations per week (Median; 3 → 4 times/week, p = 0.017, effect size = 0.53). A significant decrease in Intestinibacter, a trend toward increased bifidobacteria, and a trend toward decreased Clostridium sensu stricto were observed after kestose ingestion, while concentrations of short-chain fatty acids in stools were unchanged.

Exploring the Potential of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 as Promising Psychobiotics Using SHIME

Psychobiotics are probiotics that have the characteristics of modulating central nervous system (CNS) functions or reconciled actions by the gut-brain axis (GBA) through neural, humoral and metabolic pathways to improve gastrointestinal activity as well as anxiolytic and even antidepressant abilities. The aim of this work was to evaluate the effect of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 on the gut microbiota of mildly anxious adults using SHIME^®. The protocol included a one-week control period and two weeks of treatment with L. helveticus R0052 and B. longum R0175. Ammonia (NH4+), short chain fatty acids (SCFAs), gamma-aminobutyric acid (GABA), cytokines and microbiota composition were determined. Probiotic strains decreased significantly throughout the gastric phase. The highest survival rates were exhibited by L. helveticus R0052 (81.58%; 77.22%) after the gastric and intestinal phase when compared to B. longum (68.80%; 64.64%). At the genus level, a taxonomic assignment performed in the ascending colon in the SHIME^® model showed that probiotics (7 and 14 days) significantly (p < 0.005) increased the abundance of Lactobacillus and Olsenella and significantly decreased Lachnospira and Escheria-Shigella. The probiotic treatment (7 and 14 days) decreased (p < 0.001) NH₄⁺ production when compared to the control period. For SCFAs, we observed after probiotic treatment (14 days) an increase (p < 0.001) in acetic acid production and total SCFAs when compared to the control period. Probiotic treatment increased (p < 0.001) the secretion of anti-inflammatory (IL-6 and IL-10) and decreased (p < 0.001) pro-inflammatory cytokines (TNF-alpha) when compared to the control period. The gut-brain axis plays an important role in the gut microbiota, producing SCFAs and GABA, stimulating the production of anti-anxiety homeostasis. The signature of the microbiota in anxiety disorders provides a promising direction for the prevention of mental illness and opens a new perspective for using the psychobiotic as a main actor of therapeutic targets.

Ozone therapy: protocol for treating canine parvovirus infection

Canine Parvovirus infection is a disease caused by Canine Parvovirus (CPV) that results in hemorrhagic gastroenteritis and secondary infections, mainly in puppies between six weeks and six months old that are not immunized. Since there is no specific treatment for the condition, supportive therapy based on antibiotics, antiemetics, and non-steroidal anti-inflammatory drugs is traditionally used. Ozone therapy is an economical treatment that has bactericidal, fungicidal, and antiviral properties, besides promoting oxygenation and tissue regeneration, as well as anti-inflammatory and analgesic effects, and was used as a complementary therapy in this study. Therefore, four mixed-breed dogs, aged between 2 and 3 months, with no previous immunization against CPV and testing positive for the virus in a rapid test were selected. The animals were randomly distributed into two groups, being 1: the control group (n=2) that received only supportive treatment; and 2: the experimental group (n=2), that in addition to conventional therapy received intravenously 500 mL of ozonized Ringer's Lactate solution. Before treatment and after 24 and 48 hours, the following clinical signs were evaluated: episodes of emesis and diarrhea, weight, hydration, blood glucose level, abdominal pain, and blood count. One control group animal died within the first hours of hospitalization. Both animals in the experimental group presented faster resolution of diarrheal episodes and shorter hospitalization time when compared to the surviving animal that received only supportive treatment. Although further studies are needed, ozone therapy showed promising results for the treatment of canine parvovirus.

Effects of acupressure on intestinal function in patients with coronary artery bypass graft surgery: a randomized clinical trial

Aim

This study aimed to determine the effects of acupressure on the intestinal function of patients undergoing Coronary Artery Bypass Graft (CABG) surgery.

Background

Studies indicated that cardiovascular patients are prone to constipation. Acupressure is one of the therapeutic and palliative approaches that can be used by doctors, nurses, and even patients themselves.

Methods

The present three-group randomized clinical trial study was conducted on 90 patients undergoing CABG surgery. In the intervention group, 48 hours after surgery the patients received acupressure points LI4 and ST25 twice a day (10 am and 6 pm) for three sequential days. In the sham group, the patients received acupressure at a 1.5 cm distance from the LI4-ST25 points, and the patients in the control group received only the usual care. This research used a demographic and medical information questionnaire, Rome IV scale, Bristol stool scale, symptom registration checklist, and daily excretion assessment checklist. The intestinal function indices were completed 24 hours after surgery (before intervention), 48, 72, 96, and 120 hours after surgery.

Results

All three intervention, sham, and control groups were without defecation in 24 hours (before intervention) and 48 hours after surgery. There was a significant difference between the three intervention, sham, and control groups in the number of stools after 72 hours, 96 hours, and 120 hours after the intervention (p<0.001). Also, a significant difference was observed among the three groups in terms of stool consistency 96 hours after the start of the intervention (p=0.032) and 120 hours after the start of the intervention (p<0.001).

Conclusion

The results showed that patients had a significant improvement in the number of bowel movements and stool consistency in the intervention group. In acute conditions, acupressure on LI4-ST25 points can positively affect intestinal function when patients are hospitalized in the intensive care unit.

Development of a new version of the Bristol Stool Form Scale: translation, content validity, face validity, and reliability of the Persian version

OBJECTIVES

The Bristol Stool Form Scale (BSFS) is the most widely used scale for stool form assessment. This study aimed to translate the BSFS into the Persian version and determine its content validity, face validity, and reliability.

DESIGN

Following permission, a forward-backward translation procedure was applied to translate the scale from English into Persian. A cross-sectional study was conducted on a sample of 210 participants from the general and gastrointestinal clinics of a teaching hospital affiliated with the Tehran University of Medical Sciences, Tehran, Iran, from January 2020 to August 2020. The samples were selected using convenience sampling. A group of 10 experts and 10 adults assessed content and face validity, respectively. The kappa index evaluated the reliability of the instruments.

RESULTS

Participants' mean (±SD) age was 37.62 (±8.87) years. Most of the participants (65.7%) were women. The highest percentage of concordance was 100% for stool type 7, and stool type 5 had the lowest concordance percentage (78.1%). The overall kappa index was 0.79.

CONCLUSION

The Persian version of the BSFS is a valid and reliable measure for assessing stool form, and now it can be used in research and clinical practice.

Associations of Mucosal Nerve Fiber Innervation Density with Hirschsprung-Associated Enterocolitis: A Retrospective Three-Center Cohort Study

OBJECTIVE

 Hirschsprung's disease (HSCR) is a congenital intestinal neurodevelopmental disorder characterized by the absence of enteric ganglion cells in the distal colon. Although Hirschsprung-associated enterocolitis (HAEC) is the most frequent life-threatening complication in HSCR, to date reliable biomarkers predicting the likelihood of HAEC are yet to be established. We established a three-center retrospective study including 104 HSCR patients surgically treated between 1998 and 2019.

MATERIALS AND METHODS

 Patient-derived cryopreserved or paraffin-preserved colonic tissue at surgery was analyzed via βIII-tubulin immunohistochemistry. We subsequently determined extrinsic mucosal nerve fiber density in resected rectosigmoid specimens and classified HSCR patients accordingly into nerve fiber-high or fiber-low groups. We compared the distribution of clinical parameters obtained from medical records between the fiber-high (n = 36) and fiber-low (n = 68) patient groups. We assessed the association between fiber phenotype and enterocolitis using univariate and multivariate logistic regression adjusted for age at operation.

RESULTS

 Enterocolitis was more prevalent in patients with sparse mucosal nerve fiber innervation (fiber-low phenotype, 87%) compared with the fiber-high phenotype (13%; p = 0.002). In addition, patients developing enterocolitis had a younger age at surgery (3 vs. 7 months; p = 0.016). In the univariate analysis, the odds for enterocolitis development in the fiber-low phenotype was 5.26 (95% confidence interval [CI], 1.67-16.59; p = 0.005) and 4.01 (95% CI, 1.22-13.17; p = 0.022) when adjusted for age.

CONCLUSION

 Here, we showed that HSCR patients with a low mucosal nerve fiber innervation grade in the distal aganglionic colon have a higher risk of developing HAEC. Consequently, histopathologic analysis of the nerve fiber innervation grade could serve as a novel sensitive prognostic marker associated with the development of enterocolitis in HSCR patients.

Association Between Food Intake and Gastrointestinal Symptoms in Patients With Obesity

BACKGROUND AND AIMS

Hunger, satiation, postprandial satiety, and hedonic eating constitute key food intake parameters. We aim to study whether these symptoms are associated with gastrointestinal symptoms (GIS) in patients with obesity.

METHODS

This is a cross-sectional study of patients with obesity. Patients completed the following validated biomarkers and questionnaires: hunger was measured via visual analog scale (100 mm) following a standard meal, satiation was measured via ad libitum meal (calories to fullness; kcal), postprandial satiety was measured via gastric emptying scintigraphy (T1/2; mins), and hedonic eating was measured via the Hospital Anxiety and Depression Scale questionnaire. Participants completed the abridged Bowel Disease Questionnaire to evaluate their GIS. We calculated the odds ratios (ORs) adjusted for sex, weight, and age between food intake parameters <25th or >75th percentile observed in a prior cohort of 450 participants with obesity and GIS.

RESULTS

A total of 274 participants (41 ± 10 [SD] years, 75% females, body mass index 39 ± 8 kg/m2) were included in the analysis. Increased hunger was associated with a lower prevalence of lumpy stools (OR = 0.18, P = .02). Satiation was associated with abdominal pain/discomfort (relieved by defecation [OR = 2.4, P = .02] or associated with change in stool consistency [OR = 2.92, P < .01]), loose/watery stools (OR = 2.09, P = .02), and bloating (OR = 2.49, P < .01). Abnormal postprandial satiety was associated with bloating (OR = 2.26, P < .01) and loose/watery stools (OR = 1.84, P = .04). Hedonic eating was associated with abdominal pain/discomfort with stool frequency change (OR = 2.4, P = .02), >3 bowel movements per day (OR = 1.93, P = .048), bloating (OR = 2.49, P = .01), abdominal pain after meals >1 per month (OR = 4.24, P < .01), and nausea >1 per week (OR = 4.51, P < .01).

CONCLUSION

Alterations in hunger, satiation, postprandial satiety, and hedonic eating are associated with GIS in patients with obesity.

Abnormal bile acid metabolism is an important feature of gut microbiota and fecal metabolites in patients with slow transit constipation

Destructions in the intestinal ecosystem are implicated with changes in slow transit constipation (STC), which is a kind of intractable constipation characterized by colonic motility disorder. In order to deepen the understanding of the structure of the STC gut microbiota and the relationship between the gut microbiota and fecal metabolites, we first used 16S rRNA amplicon sequencing to evaluate the gut microbiota in 30 STC patients and 30 healthy subjects. The α-diversity of the STC group was changed to a certain degree, and the β-diversity was significantly different, which indicated that the composition of the gut microbiota of STC patients was inconsistent with healthy subjects. Among them, Bacteroides, Parabacteroides, Desulfovibrionaceae, and Ruminiclostridium were significantly upregulated, while Subdoligranulum was significantly downregulated. The metabolomics showed that different metabolites between the STC and the control group were involved in the process of bile acids and lipid metabolism, including taurocholate, taurochenodeoxycholate, taurine, deoxycholic acid, cyclohexylsulfamate, cholic acid, chenodeoxycholate, arachidonic acid, and 4-pyridoxic acid. We found that the colon histomorphology of STC patients was significantly disrupted, and TGR5 and FXR were significantly downregulated. The differences in metabolites were related to changes in the abundance of specific bacteria and patients’ intestinal dysfunction. Analysis of the fecal genomics and metabolomics enabled separation of the STC from controls based on random forest model prediction [STC vs. control (14 gut microbiota and metabolite biomarkers)—Sensitivity: 1, Specificity: 0.877]. This study provided a perspective for the diagnosis and intervention of STC related with abnormal bile acid metabolism.

A Smartphone Application Using Artificial Intelligence Is Superior To Subject Self-Reporting When Assessing Stool Form

INTRODUCTION

Stool form assessment relies on subjective patient reports using the Bristol Stool Scale (BSS). In a novel smartphone application (app), trained artificial intelligence (AI) characterizes digital images of users' stool. In this study, we evaluate this AI for accuracy in assessing stool characteristics.

METHODS

Subjects with diarrhea-predominant irritable bowel syndrome image-captured every stool for 2 weeks using the app, which assessed images for 5 visual characteristics (BSS, consistency, fragmentation, edge fuzziness, and volume). In the validation phase, using 2 expert gastroenterologists as a gold standard, sensitivity, specificity, accuracy, and diagnostic odds ratios of subject-reported vs AI-graded BSS scores were compared. In the implementation phase, agreements between AI-graded and subject-reported daily average BSS scores were determined, and subject BSS and AI stool characteristics scores were correlated with diarrhea-predominant irritable bowel syndrome symptom severity scores.

RESULTS

In the validation phase (n = 14), there was good agreement between the 2 experts and AI characterizations for BSS (intraclass correlation coefficients [ICC] = 0.782-0.852), stool consistency (ICC = 0.873-0.890), edge fuzziness (ICC = 0.836-0.839), fragmentation (ICC = 0.837-0.863), and volume (ICC = 0.725-0.851). AI outperformed subjects' self-reports in categorizing daily average BSS scores as constipation, normal, or diarrhea. In the implementation phase (n = 25), the agreement between AI and self-reported BSS scores was moderate (ICC = 0.61). AI stool characterization also correlated better than subject reports with diarrhea severity scores.

DISCUSSION

A novel smartphone application can determine BSS and other visual stool characteristics with high accuracy compared with the 2 expert gastroenterologists. Moreover, trained AI was superior to subject self-reporting of BSS. AI assessments could provide more objective outcome measures for stool characterization in gastroenterology.

Bowel Health in U.S. Shift Workers: Insights from a Cross-Sectional Study (NHANES)

Working outside of regular daytime hours is increasingly common in current societies and poses a substantial challenge to an individual’s biological rhythm. Disruptions of the gastrointestinal tract’s circadian rhythm and poor dietary choices subsequent to shiftwork may predispose the shift workforce to an increased risk of gastrointestinal disorders, including constipation, peptic ulcer disease, and erosive gastritis. We investigated bowel health in a US population of shift workers, using data from the National Health and Nutrition Examination Survey, and compared bowel movement (BM) frequency and defecation patterns between 2007 day workers and 458 shift workers (representing 55,305,037 US workers). Using bivariate and multivariate logistic regression techniques, our results suggested no association between shiftwork status and BM frequency, bowel leakage of gas, and stool consistency. Constipation prevalence was high but comparable in both groups (6.90% vs. 7.09%). The low fiber intake observed in both groups (15.07 vs. 16.75 g/day) could play a potential role here. The two groups did not differ with regard to other nutrients that may influence BM frequency and stool consistency (e.g., carbohydrate or caffeine intake). Additional studies including food group analyses and fecal biomarkers are warranted for a better understanding of GI health in shift workers.

Bowel Health in U.S. Vegetarians: A 4-Year Data Report from the National Health and Nutrition Examination Survey (NHANES)

Dietary fiber is of paramount importance in the prevention of large-bowel diseases, yet fiber intake in many high income countries is well below daily recommendations. Vegetarian diets high in fiber-rich plant-foods have been associated with a higher frequency of bowel movements and softer stools. Thus, vegetarians appear to suffer less frequently from constipation and other bowel disorders. The number of studies investigating these associations, however, is limited. The present study sought to investigate bowel health and constipation prevalence in a self-identified vegetarian population from the U.S. National Health and Nutrition Examination Survey (2007−2010). Bowel health assessment included Bristol Stool Scale (BSS), Bowel Movement (BM) frequency and Fecal Incontinence Severity Index (FISI). The present study included 9531 non-vegetarians and 212 vegetarians. We found no associations between vegetarian status and all examined bowel health items (BM frequency, BSS and FISI). Vegetarians consumed significantly more fiber than omnivores (21.33 vs. 16.43 g/d, p < 0.001) but had a lower moisture intake (2811.15 vs. 3042.78 g/d, p = 0.045). The lack of an association of vegetarian status and bowel health is surprising, and may be a result of the relatively low fiber intake in this particular vegetarian cohort, which did not meet the daily fiber recommendations.

Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography

Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient’s colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.

Multispecies probiotics promote perceived human health and wellbeing: insights into the value of retrospective studies on user experiences

When taking a broader perspective on the societal impact of probiotics, engagement of end-users is important to discover unmet needs, define relevant health benefits and identify key considerations for successful implementation in daily practice. This study therefore takes a retrospective approach and analyses a database of user experiences to review the effects of four multispecies probiotic formulations. The user experiences were analysed in a dependent sample manner (without control group) and complement previous randomised controlled trials that have been performed with the formulations. The database consisted of 584 evaluable user experiences regarding the impact of probiotic supplementation on perceived quality of life (QoL), gastrointestinal (GIT) symptoms and reported stool consistency after two weeks of consumption. Two different scales were used (n=344 in a 5-point scale; n=240 in a 10-point scale), which are presented as separate analyses. In the combined population of the 5-point-scale questionnaire, a significant increase in perceived QoL and a significant reduction in perceived GIT symptoms was observed. Descriptive summaries also indicate that diarrhoea- and constipation-like stool patterns are reduced following supplementation. Moreover, half of participants indicated that probiotic supplementation had a positive effect on their unmet medical need, and 64% of users were likely to continue using the product. Similar results were observed in the 10-point scale questionnaire. Considering the clinical relevance of probiotic supplementation in specific target groups, subgroup analyses were performed on participants who consumed the products for diarrhoea, constipation, Inflammatory Bowel Disease, Irritable Bowel Syndrome, and antibiotic usage. Overall, findings support the potential of probiotics to advance perceived human health and support the daily wellbeing of users. This systematic analysis of user experiences thereby contributes to the external validity of studies evaluating clinical effects of probiotics and increases knowledge on their societal impact.

Investigation of neglected protists Blastocystis sp. and Dientamoeba fragilis in immunocompetent and immunodeficient diarrheal patients using both conventional and molecular methods

Introduction

The clinical significance of Blastocystis sp. and Dientamoeba fragilis in patients with gastrointestinal symptoms is a controversial issue. Since the pathogenicity of these protists has not been fully elucidated, testing for these organisms is not routinely pursued by most laboratories and clinicians. Thus, the prevalence of these organisms and the subtypes of Blastocystis sp. in human patients in Turkey are not well characterized. This study aimed to determine the prevalence of Blastocystis sp. and D. fragilis in the diarrheic stool samples of immunodeficient and immunocompetent patients using conventional and molecular methods and to identify Blastocystis sp. subtypes using next generation sequencing.

Material and methods

Individual stool specimens were collected from 245 immunodeficient and 193 immunocompetent diarrheic patients between March 2017 and December 2019 at the Gazi University Training and Research Hospital in Ankara, Turkey. Samples were screened for Blastocystis sp. and D. fragilis by conventional and molecular methods. Molecular detection of both protists was achieved by separate qPCRs targeting a partial fragment of the SSU rRNA gene. Next generation sequencing was used to identify Blastocystis sp. subtypes.

Results

The prevalence of Blastocystis sp. and D. fragilis was 16.7% and 11.9%, respectively as measured by qPCR. The prevalence of Blastocystis sp. and D. fragilis was lower in immunodeficient patients (12.7% and 10.6%, respectively) compared to immunocompetent patients (21.8% and 13.5%, respectively). Five Blastocystis sp. subtypes were identified and the following subtype distribution was observed: ST3 54.4% (n = 37), ST2 16.2% (n = 11), ST1 4.4% (n = 3), ST6 2.9% (n = 2), ST4 1.5% (n = 1), ST2/ST3 11.8% (n = 8) and ST1/ST3 8.8% (n = 6). There was no statistically significant difference in the distribution of Blastocystis sp. subtypes between immunocompetent and immunodeficient patients.

Conclusion and recommendation

Our findings demonstrated that Blastocystis sp. and D. fragilis are commonly present in immunocompetent and immunodeficient patients with diarrhea. This study is the first to use next generation sequencing to address the presence of Blastocystis sp. mixed subtypes and intra-subtype variability in clinical samples in Turkey.

Blastocystis sp. and Dientamoeba fragilis are single-cell parasites of the human intestine which are common worldwide and reported in cases with gastrointestinal symptoms. However, the role of Blastocystis sp. and D. fragilis in patients with gastrointestinal symptoms is still controversial because their presence is not always associated with symptoms. As some intestinal parasitic infections can cause severe illness in immunocompromised individuals careful consideration of intestinal protist infection is warranted. However, testing for Blastocystis sp. and D. fragilis is not routinely carried out by most laboratories and clinicians. Therefore, this study aimed to determine the prevalence of Blastocystis sp. and D. fragilis in immunocompetent and immunosuppressed patients with diarrhea by conventional and molecular methods. Both Blastocystis sp. and D. fragilis were detected more frequently by quantitative polymerase chain reaction than by conventional methods. Next generation sequencing was used to characterize the diversity and frequency of Blastocystis sp. subtypes and mixed subtypes in patients in Turkey. Five Blastocystis sp. subtypes (ST1, ST2, ST3, ST4 and ST6) were detected. ST3 was the most frequent subtype in both immunocompetent and immunosuppressed patients. Mono-infections were more common than mixed subtype infections. Our findings showed that Blastocystis sp. and D. fragilis are commonly present in immunocompetent and immunodeficient patients with diarrhea.

My Treatment Approach to Clostridioides difficile Infection

Clostridioides difficile infection is the most common cause of infectious diarrhea in hospitals with an increasing incidence in the community. Clinical presentation of C difficile infection ranges from diarrhea manageable in the outpatient setting to fulminant infection requiring intensive care admission. There have been significant advances in the management of primary and recurrent C difficile infection including diagnostics, newer antibiotics, antibody treatments, and microbiome restoration therapies. Because of the risk of clinical false-positive results with the polymerase chain reaction test, a two-step assay combining an enzyme immune assay for glutamate dehydrogenase and the C difficile toxin is being used. Cost permitting, I treat a first episode of C difficile infection preferably with fidaxomicin over vancomycin but not metronidazole. The most common complication after C difficile infection is recurrence. I manage a first recurrence with a vancomycin taper and pulse or fidaxomicin and recommend a single dose of intravenous bezlotoxumab (a monoclonal antibody against the toxin B) to reduce recurrence rates for those patients at high risk. Patients with multiply recurrent C difficile infection are managed with a course of antibiotics such as vancomycin or fidaxomicin followed by microbiota restoration. The success of fecal microbiota transplantation is greater than 85%, compared with the 40% to 50% success rate of antibiotics in this situation. Fecal microbiota transplantation is heterogeneous and has rare but serious risks such as transmission of infections. Standardized microbiota restoration therapies are in clinical development and have completed phase III clinical trials. This review answers common clinical questions in the management of C difficile infection.

Melanosis coli in a peritoneal dialysis patient: a case report

BACKGROUND

Patients who undergo peritoneal dialysis (PD) are at risk of gut bacteria translocation leading to peritonitis when there is chronic diarrhea. Chronic diarrhea is defined as any course of diarrhea that lasts at least 4 weeks, which can be continuous or intermittent. Chronic diarrhea of any duration may cause dehydration, electrolyte imbalance, and life-threatening hypovolemic shock. In PD patients, excessive ultrafiltration from the exchanges, combined with severe gastrointestinal loss, may cause hypovolemic shock, electrolyte imbalance, and metabolic acidosis. There are multiple causes of chronic diarrhea in PD patients including infective causes, mitotic lesions, and rarely the regular and excessive use of laxatives, which is a diagnosis of exclusion.

CASE PRESENTATION

We report a case of Melanau lady with chronic diarrhea secondary to laxative usage in a patient being treated with automated peritoneal dialysis (APD). The patient went into hypovolemic shock, but luckily did not contract peritonitis. A colonoscopy revealed brown to black discoloration of the colon, a feature suggestive of melanosis coli. A biopsy of the intestine further confirmed the diagnosis by histopathological examination. Withdrawal of laxatives and the introduction of probiotics improved the symptoms tremendously.

CONCLUSIONS

The chronic use of laxatives in PD patients can potentially lead to a devastating problem; thus, the management team must monitor treatment commencement appropriately.

Effect of Low FODMAPs Diet on Irritable Bowel Syndromes: A Systematic Review and Meta-Analysis of Clinical Trials

We conducted a meta-analysis exploring the effect of a low fermentable oligo-, di-, monosaccharides, and polyols diet (LFD) on the overall symptoms, quality of life, and stool habits of irritable bowel syndrome (IBS) patients. The meta-analysis was performed using a random-effects method. The effect size was presented as weighted standardized mean difference (SMD) and 95% confidence interval (CI). Subgroup analyses were conducted to determine the potential effects of covariates on the outcome. Twenty-two papers were included. The LFD group showed a moderate reduction in symptom severity and a slight improvement in quality of life compared to the control group (SMD, −0.53 and 0.24; 95% CI, −0.68, −0.38 and 0.02, 0.47, respectively). IBS symptom improvement was consistent between subgroups stratified according to proportions of female patients, study durations, IBS subtypes, assessment methods, and control interventions. Three studies regarding stool habits change in IBS-D patients showed a significant decrease in stool frequency (mean differences [MD], −5.56/week; 95% CI, −7.40, −3.72) and a significant improvement in stool consistency (MD, −0.86; 95% CI, −1.52, −0.19) in the LFD group compared to the control group. This is the most updated meta-analysis including studies that adopted diverse control interventions such as dietary interventions, supplementation, habitual diets, and lifestyle changes.

Technician-Scored Stool Consistency Spans the Full Range of the Bristol Scale in a Healthy US Population and Differs by Diet and Chronic Stress Load

BACKGROUND

Prior studies of adults with constipation or diarrhea suggest that dietary intake, physical activity, and stress may affect stool consistency. However, the influence of these factors is unresolved and has not been investigated in healthy adults.

OBJECTIVES

We assessed the relations of technician-scored stool consistency in healthy adults with self-reported diet, objectively monitored physical activity, and quantifiable markers of stress.

METHODS

Stool consistency was scored by an independent technician using the Bristol Stool Form Scale (BSFS) to analyze samples provided by healthy adults, aged 18-65 y, BMI 18-44 kg/m2, in the USDA Nutritional Phenotyping Study (n = 364). A subset of participants (n = 109) were also asked to rate their sample using the BSFS. Dietary intake was assessed with two to three 24-h recalls completed at home and energy expenditure from physical activity was monitored using an accelerometer in the 7-d period preceding the stool collection. Stress was measured using the Wheaton Chronic Stress Inventory and allostatic load (AL). Statistical and machine learning analyses were conducted to determine which dietary, physiological, lifestyle, and stress factors differed by stool form.

RESULTS

Technician-scored BSFS scores were significantly further (P = 0.003) from the central score (mean ± SEM distance: 1.41 ± 0.089) than the self-reported score (1.06 ± 0.086). Hard stool was associated with higher (P = 0.005) intake of saturated fat (13.8 ± 0.40 g/1000 kcal) than was normal stool (12.5 ± 0.30 g/1000 kcal). AL scores were lower for normal stool (2.49 ± 0.15) than for hard (3.07 ± 0.18) (P = 0.009) or soft stool (2.89 ± 0.18) (P = 0.049). Machine learning analyses revealed that various dietary components, physiological characteristics, and stress hormones predicted stool consistency.

CONCLUSIONS

Technician-scored stool consistency differed by dietary intake and stress hormones, but not by physical activity, in healthy adults.This trial was registered at clincialtrials.gov as NCT02367287.

Prevalence and predictors of laxatives use in clozapine-related constipation: an observational study

Clozapine-induced constipation is a frequently overlooked side effect that can prove fatal. This study aimed to investigate the prevalence of constipation and the breakdown of laxatives, and to identify whether use of laxative may be predicted by demographics or baseline metabolic markers in 53 Japanese treatment-resistant schizophrenia inpatients switched to clozapine. Differences of present age, onset age and duration of illness, previous antipsychotic dose using the chlorpromazine equivalent, and 10-items of metabolic markers, including fasting plasma glucose and ratio of triglyceride to high-density lipoprotein cholesterol levels were compared between the laxative and nonlaxative user groups. Sequential changes of defecation scores using Bristol stool form scale, and clozapine dosage at 1, 2 and 3 months were evaluated within each group. Multiple linear stepwise regression analysis was performed to assess the predicting use of laxatives. Half of subjects required treatment with laxative, were significantly older and had longer durations of illness than nonlaxative users. Magnesium oxide and lubiprostone were mainly used singly or in combination. Longer disease duration, and lower levels of fasting blood glucose and insulin resistance were predicting the use of laxatives. Screening and preventive strategies for minimizing clozapine-related constipation should be established in future study.

Gastrointestinal adverse reactions reduce the success rate of Helicobacter pylori eradication therapy: A multicenter prospective cohort study

BACKGROUND

The screening and treatment of Helicobacter pylori infection for all junior high students in Saga Prefecture, Japan, were started in 2016. The present study aims to evaluate the influence of adverse reactions on the success of the eradication therapy.

METHODS

From 2017 to 2019, 25,006 third-grade junior high school students were tested for urinary anti-H. pylori antibodies. Positive cases were confirmed by H. pylori stool antigen tests. Of the 531 students who were found to be H. pylori-positive, 390 (358 in first-line and 32 in second-line therapy) underwent eradication therapy, and 274 (242 in first-line and 32 in second-line) students actually completed a self-reported form to rate stool consistency (based on the Bristol Stool Scale), the maximum number of bowel movements, and abdominal symptoms during the 7 days of treatment.

RESULTS

Among the 274 students, the total of primary and secondary eradication success rates was 87% (95% confidential interval: 82.9-90.1) in intention-to-treat analysis. On days 4, 5, and 6, stool consistency was looser in the primary eradication failure group than in the success group (p < .05). Looser stool consistencies were observed in male students with abdominal pain compared to those who did not experience pain (p < .05). Abdominal pain and diarrhea were detected in 28.5% and 42.7% of the subjects, respectively. The overall incidence of other adverse events was low (n = 8/274, 2.9%), and only two students discontinued treatment because of adverse events.

CONCLUSIONS

Softening of the stool was related to the eradication failure in the junior high school students, especially in males with abdominal pain. Adverse effects did not induce discontinuation of the eradication treatment.

The Importance of Objective Stool Classification in Fecal 1H-NMR Metabolomics: Exponential Increase in Stool Crosslinking Is Mirrored in Systemic Inflammation and Associated to Fecal Acetate and Methionine

Past studies strongly connected stool consistency-as measured by Bristol Stool Scale (BSS)-with microbial gene richness and intestinal inflammation, colonic transit time and metabolome characteristics that are of clinical relevance in numerous gastro intestinal conditions. While retention time, defecation rate, BSS but not water activity have been shown to account for BSS-associated inflammatory effects, the potential correlation with the strength of a gel in the context of intestinal forces, abrasion, mucus imprinting, fecal pore clogging remains unexplored as a shaping factor for intestinal inflammation and has yet to be determined. Our study introduced a minimal pressure approach (MP) by probe indentation as measure of stool material crosslinking in fecal samples. Results reported here were obtained from 170 samples collected in two independent projects, including males and females, covering a wide span of moisture contents and BSS. MP values increased exponentially with increasing consistency (i.e., lower BSS) and enabled stratification of samples exhibiting mixed BSS classes. A trade-off between lowest MP and highest dry matter content delineated the span of intermediate healthy density of gel crosslinks. The crossectional transects identified fecal surface layers with exceptionally high MP and of <5 mm thickness followed by internal structures with an order of magnitude lower MP, characteristic of healthy stool consistency. The MP and BSS values reported in this study were coupled to reanalysis of the PlanHab data and fecal 1H-NMR metabolomes reported before. The exponential association between stool consistency and MP determined in this study was mirrored in the elevated intestinal and also systemic inflammation and other detrimental physiological deconditioning effects observed in the PlanHab participants reported before. The MP approach described in this study can be used to better understand fecal hardness and its relationships to human health as it provides a simple, fine scale and objective stool classification approach for the characterization of the exact sampling locations in future microbiome and metabolome studies.

Transcutaneous Acupoint Electrical Stimulation on Chemotherapy-Induced Constipation for Non-Small Cell Lung Cancer Patients: A Randomized Controlled Trial

Objective:

Chemotherapy-induced constipation (CIC) adversely affects the quality of life of non-small cell lung cancer (NSCLC) patients. This study aimed to investigate the clinical effects of transcutaneous acupoint electrical stimulation (TAES) on CIC.

Methods:

Sixty NSCLC patients who received chemotherapy at Hunan Cancer Hospital, Changsha, China, were assigned to the TAES (n = 30) or control (n = 30) group using Research Randomizer. In the TAES group, four acupoints, namely Tianshu, Quchi, Zusanli, and Shangjuxu, were stimulated six times a week, lasting for 4 weeks, while the control group received the usual care. The Bristol Stool Form Scale (BSFS) and the Constipation Assessment Scale (CAS) were used.

Results:

Both the BSFS and CAS scores for the experimental group were significantly higher than that for the control group (P = 0.004 and P < 0.001 separately).

Conclusions:

TAES was effective for alleviating constipation in NSCLC patients receiving chemotherapy and was a safe and practical nursing intervention.

Brazilian Portuguese version of the Amsterdam infant stool scale: a valid and reliable scale for evaluation of stool from children up to 120 days old

BACKGROUND

For newborns and infants wearing diapers the difficulties in characterizing the appearance of the stool are significant, since the changes in consistency, quantity, and color of the stool are higher than in other age groups. The Amsterdam Infant Stool Scale (AISS) was created and validated in 2009, providing a specific tool for the evaluation of the stool of children up to 120 days old. However, to be used in clinical practice and scientific investigations in Brazil, it is mandatory to perform the translation and cross-cultural adaptation process for Brazilian Portuguese language. Thus, we aim to perform the translation and cross-cultural adaptation of AISS into Brazilian Portuguese and to evaluate the psychometric properties of the translated version.

METHODS

The process of translation and cross-cultural adaptation was performed according to the internationally accepted methodology, including: translation, summary of translations, backtranslation, preparation of the pre-final version, application of the pre-test and determination of the final version. The evaluation of the psychometric properties was performed through the application of Brazilian Portuguese AISS, by five examiners (including child health field specialists and a literate adult lay on the subject), analyzing 238 stool photographs of children under 120 days old. The intra and inter-examiner agreement values were determined using kappa statistic. The validity of the criterion was investigated through correlation analysis (Kendall's coefficient) between the classifications determined by the non-specialist examiner and the expert examiners.

RESULTS

In all 30 tests performed between different examiners, there was an agreement considered as at least moderate (kappa values above 0.40). The intra-examiner reliability was considered as substantial (kappa> 0.6). There was a statistically significant correlation (p <  0.05) between the classifications determined by the examiners considered as specialists and the examiner considered as non-specialist.

CONCLUSION

The Brazilian Portuguese AISS version proved to be valid and reliable to be used by healthcare professionals and the general public in the evaluation of stool from children up to 120 days old.

Gut Microbiome Changes with Osteopathic Treatment of Constipation in Parkinson's Disease: A Pilot Study

INTRODUCTION

The gut microbiome appears to be predictive of Parkinson's disease (PD) with constipation. Chronic constipation frequently manifests prior to motor symptoms and impairs quality of life. An osteopathic manipulative medicine (OMM) sequence used physical exam assessment and manual treatment of neuromusculoskeletal dysfunctions pertinent to constipation in PD for this prospective ABA-design study, IRB-NYITBHS1065. The effects of 4 weekly treatments on the gut microbiome among men and women over 40 years old with chronic constipation and PD were investigated. Severity of PD was rated with the Movement Disorders Society-Unified PD rating scale (UPDRS) in six subjects with constipation. Also, the Bristol stool scale and questionnaires validated for constipation were administered for diagnosis, symptom severity, and quality of life during a 4-week control-period (A), 4-weekly OMM-treatments (B), and 2-weeks no-intervention (A). Biweekly stool samples were assessed for normalized microbiota abundance.

RESULTS

The mean Bristol rating improved from type 2 (± 1) Pre-OMM to 3 (± 1; p = .167; d = 0.677) Post-OMM. Mean constipation severity significantly decreased (p = .010; d = 1.508) Post-OMM. Mean quality of life significantly improved (p = .041; d = 1.072) Post-OMM. The Pre-OMM mean number of families within the phylum Firmicutes decreased by 3 (p = .043; d = 1.177) Post-OMM. There were significant changes in the normalized abundance of phyla Actinobacteria (p = .040; d = 0.845) and Verrucomicrobia (p = .024; d = 0.675) as well as in genus Roseburia (p = .033; d = 1.109), Intestinimonas (p = .035; d = 0.627) and Anaerotruncus (p = .004) Post-OMM.

CONCLUSION

The gut microbiome shifted among individuals with constipation and PD after four weekly treatments with the OMM-sequence. Changes in the gut microbiome Post-OMM were associated with UPDRS results and constipation measures. Clinical trials and studies to develop the gut microbiome into a validated biomarker for PD are necessary to understand the impact of OMM in patients with PD and constipation.

Direct measurement of stool consistency by texture analyzer and calculation of reference value in Belgian general population

Stool consistency is evaluated mainly in reference to indirect indicators such as water content or the appearance of stool forms using Bristol Stool Form Scale (BSFS). Methods of measurement are limited. We thus aimed to develop a simple protocol for direct measurement of stool consistency using the TA.XTExpress Texture Analyser (Stable Micro Systems Ltd.). We developed a protocol which enables mechanical quantification of the gram-force against a cylindrical probe (ø 6 mm) pushed into the stool surface at 2.0 mm/s to 5 mm depth. The consistency of 252 stools collected from 40 healthy Belgians was evaluated by the direct method and by the indirect indicators (water content and BSFS) for comparison. The log-transformed stool consistency values measured by the texture analyzer had a negative linear correlation with the stool water contents (rrm = - 0.781) with homoscedastic variance, suggesting the appropriateness of the new protocol. They showed a similar correlation with the BSFS, but with a large variance in the consistency values of normal stool forms. This correlation was much smaller for BSFS scored by subjects (rrm = - 0.587) than by experts (rrm = - 0.789), collectively indicating BSFS as a rough indicator of stool consistency susceptible to subjective bias despite its effectiveness in clinical use. The optimized direct method using the texture analyzer enables the accurate quantification of stool consistency, which facilitates understanding of the intestinal environment and function and thus may enhance the value of the stool as a predictor of human health.

Deficiency of complement component 3 may be linked to the development of constipation in FVB/N-C3em1Hlee /Korl mice

Alterations in complement component 3 (C3) expression has been reported to be linked to several bowel diseases including Crohn's disease, inflammatory bowel disease, and ulcerative colitis; however, the association with constipation has never been investigated. In this study, we aimed to investigate the correlation between C3 regulation and constipation development using a C3 deficiency model. To achieve these, alterations in stool excretion, transverse colon histological structure, and mucin secretion were analyzed in FVB/N-C3em1Hlee /Korl (C3 knockout, C3 KO) mice with the deletion of 11 nucleotides in exon 2 of the C3 gene. The stool excretion parameters, gastrointestinal transit, and intestine length were remarkably decreased in C3 KO mice compared with wild-type (WT) mice, although there was no specific change in feeding behavior. Furthermore, C3 KO mice showed a decrease in mucosal and muscle layer thickness, alterations in crypt structure, irregular distribution of goblet cells, and an increase of mucin droplets in the transverse colon. Mucin secretion was suppressed, and they accumulated in the crypts of C3 KO mice. In addition, the constipation phenotypes detected during C3 deficiency were confirmed in FVB/N mice treated with C3 convertase inhibitor (rosmarinic acid (RA)). Similar phenotypes were observed with respect to stool excretion parameters, gastrointestinal transit, intestine length, alterations in crypt structure, and mucin secretion in RA-treated FVB/N mice. Therefore, the results of the present study provide the first scientific evidence that C3 deficiency may play an important role in the development of constipation phenotypes in C3 KO mice.

Randomised clinical trial: significant biochemical and colonic transit effects of the farnesoid X receptor agonist tropifexor in patients with primary bile acid diarrhoea

BACKGROUND

In primary bile acid diarrhoea, feedback by farnesoid X receptor (FXR) and fibroblast growth hormone 19 (FGF19) on hepatic bile acid production is impaired.

AIMS

To evaluate the safety, mechanisms and efficacy of negative feedback by FXR activation with tropifexor, a non-bile acid FXR agonist, in patients with primary bile acid diarrhoea.

METHODS

In this double-blind, multicentre, randomised, cross-over study, patients received tropifexor 60 µg or placebo once daily for 14 days in each of two treatment periods. Primary objectives included tropifexor safety and tolerability, and on stool frequency and form. Other assessments included pharmacokinetic and pharmacodynamic measures, biochemical markers and gastrointestinal transit.

RESULTS

Twenty patients (tropifexor 60 µg/placebo [N = 10]; placebo/tropifexor 60 µg [N = 10]) were enrolled. Adverse event rates were lower with tropifexor vs placebo (52.9% vs 73.7%). No patient had pruritus during tropifexor intake. There were no significant differences in stool frequency, stool form or loperamide use between treatments. Tropifexor increased FGF19 and decreased 7α-hydroxy-4-cholesten-3-one (C4) levels for up to 8 h. Plasma tropifexor concentrations peaked at 5 hours post-dose on days 1 and 12. At day 12, tropifexor caused reduction in peak total bile acid concentration (33%, P = 0.032) and exposure (36%, P = 0.005). Moreover, tropifexor showed a significant increase in ascending colon half-emptying time (P = 0.036).

CONCLUSIONS

Tropifexor 60 µg once daily had acceptable safety and tolerability. Changes in FGF19 and C4 showed effective target engagement; however, higher doses may be required to observe stool frequency changes. Slowing of ascending colon emptying suggests therapeutic potential of tropifexor in patients with primary bile acid diarrhoea. ClinicalTrials.gov number: NCT02713243.

Increased diversity and novel subtypes among clinical Cryptosporidium parvum and Cryptosporidium hominis isolates in Southern Ireland

Reported incidence rates of cryptosporidiosis in Ireland are consistently among the highest in Europe. Despite the national prevalence of this enteric parasite and the compulsory nature of incidence surveillance and reporting, in-depth analyses seeking to genotype clinical isolates of Cryptosporidium on an intra-species level are rarely undertaken in Ireland. This molecular epidemiology study of 163 clinical Cryptosporidium isolates was conducted in Southern Ireland, from 2015 to 2018, in order to ascertain population subtype heterogeneity. Analysis was conducted via real-time PCR amplification and gp60 gene sequencing, which successfully determined the subtype designation of 149 of the 163 (91.4%) tested isolates. Overall, 12 C. parvum and five C. hominis subtypes were identified, with the incidence of the regionally predominant C. parvum species found to primarily occur during springtime months, while C. hominis incidence was largely confined to late summer and autumnal months. Additionally, one C. parvum and four C. hominis subtypes were newly reported by this study, having not been previously identified in clinical or livestock infection in Ireland. Overall, these data give insight into the diversification of the Cryptosporidium population and emergent subtypes, while also allowing comparisons to be made with clinical epidemiological profiles reported previously in Ireland and elsewhere.

How adding the abdominal massage to polyethylene glycol can improve symptom and quality of life in patients with functional constipation in comparison with each one of the treatment modalities alone: A randomized clinical trial

BACKGROUND

A variety of medical and non-medical treatments have been introduced for functional constipation relief. Here, we aimed to compare the efficacy of a combination of polyethylene glycol (PEG) and abdominal massage with each one of the treatments alone.

MATERIALS AND METHODS

Patients with functional constipation based on Rome IV criteria were randomly assigned into the three treatment groups: group A (abdominal massage for 15 min daily), group B (PEG 20 g daily), and group C (PEG 20 g plus abdominal massage for 15 min daily) for 14 days. PAC-QOL questionnaire, Bristol stool scale were evaluated at baseline and two weeks after treatment. Constipation-associated symptom scores were recorded at baseline, two weeks and four weeks after treatment beginning. Descriptive statistics were provided as the mean ± standard deviation or number and percentage. P-value<0.05 was considered statistically significant.

RESULTS

Forty eight, 47 and 48 patients in group A, B, and C completed the study, respectively. PAC-QOL, Bristol and Constipation-associated symptom scores showed a significant improvement in all study groups two weeks after the treatment compared to the baseline. At the end of treatment, the rate of straining, incomplete evacuation sensation, finger evacuation and the number of defecation was significantly lower in the group C (P < 0.04). Bristol score were significantly improved in group B (P = 0.029) in compare to other groups. The total quality of life score was also significantly improved in the group C (P = 0.028).

CONCLUSION

A combination of abdominal massage and PEG is safe, tolerable and more effective than each one of the treatments alone.