The health-related quality of life and economic burden of constipation

Cost drivers and feasibility of a hospital-at-home programme for geriatric care in northeastern Mexico: a retrospective observational study

OBJECTIVE

The primary objective was to evaluate factors influencing the cost of a 'hospital at home' (HAH) for geriatric patients in a Northeastern Mexican hospital. Secondarily to evaluate the per capita global cost-effectiveness compared with traditional hospital care.

DESIGN

This retrospective analysis examined the costs incurred by geriatric patients in an HAH programme from February to December 2022 SETTING: We collected data from clinical records and assessed medication and procedure costs through the hospital's financial department. Costs for traditionally hospitalised patients were reviewed for comparison.

PARTICIPANTS

Subjects of both genders aged 70 and older who were treated in HAH during 2022 and hospitalised subjects with the same age and gender treated in the same period.

INTERVENTION

NA PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: factors that influence costs in HAH. Secondary, global per capita cost comparison between HAH and hospital care.

RESULTS

We examined the expenses associated with 416 home visits to 49 patients in the HAH programme. The main factors influencing the programme's overall cost were medical care and procedure-related disorders (β=0.333, p=0.002), sleep-regulators (β=0.561, p<0.001), laxatives (β=0.330, p=0.001) and anticoagulants (β=0.228, p=0.025). The HAH programme's per capita cost was three times lower compared with that of traditional hospital care and resulted in a 40% reduction in hospitalisation days.

CONCLUSIONS

This study highlights that the main factors influencing the HAH programme's costs include medical care and procedure-related disorders, as well as medication extensively used in the elderly population. Additionally, we demonstrated the cost-effectiveness of the HAH programme, which produces substantial savings and is a financially viable alternative to traditional hospital care.

Efficacy of anal botulinum toxin injection in children with functional constipation

OBJECTIVES

Functional constipation (FC) is a common diagnosis in the pediatric age group. In addition to laxative regimens and behavioral interventions, some have reported the use of anal botulinum toxin (BTX) injections to treat FC, with limited data regarding its efficacy.

METHODS

This is a retrospective, multicenter study including patients who received BTX for FC refractory to medical therapy. Demographic data, results of anorectal manometry, and BTX data (number of sessions, dose, and side effects) were collected. Patients were divided into three groups based on the indication for BTX: group 1 (FC with FI [fecal incontinence]), group 2 (FC without FI), and group 3 (FI alone). Response to therapy was assessed for whole cohort and for each group based on improvement in weekly frequency of BM (bowel movements) to 3 or more per week and/or resolution of FI. We also compared the response to therapy to the parental and provider report.

RESULTS

A total of 63 patients were included in the study. Median age was 6.4 years and 32 (51%) were female. The median dose of BTX was 100 units, and most patients (55/63) received a single BTX injection. Medical therapy was continued after BTX injections in most patients (60/63 or 95%). After BTX, the frequency of BM increased to >3/week in 29/56 (52%) and FI improved in 8/47 (17%) for the whole cohort. We observed a response rate of 10% in group 1, 50% in group 2 and 14% in group 3. No factors (age, gender, anal resting pressure) were associated with BTX response except for prolonged time of therapy before BTX and shorter median follow up after BTX. Parents/primary provider reported improvement in 44/63 (70%) after BTX, which was significantly higher than the actual observed response to therapy (70% vs. 21%, p = 0.003, kappa = 0.202). We found no association between response to BTX and presence of developmental delay and/or behavioral disorders (p = 0.531). Side effects were minimal and noted in seven (11%) patients, mainly FI. No factors were associated with the development of side effects.

CONCLUSIONS

Anal BTX injections improved BM frequency with minimal effect on FI with an overall symptom resolution in 21% of patients. BTX does not seem to have a notable effect in patients with FC and developmental delay and/or behavioral disorders. Provider and parental reported success were significantly higher than the actual observed response.

Daily alcohol intake and its negative association with constipation based on NHANES data 2005-2010

Constipation is a common gastrointestinal disorder that causes both physical and psychological distress to many patients, significantly affecting their daily lives and quality of life. Alcohol consumption is often considered a potential factor in various health issues; however, its association with constipation has not been adequately studied in large-scale population research. This study aims to investigate the association between daily alcohol intake and constipation in adults by analyzing data from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). Data from NHANES participants aged over 20 years from 2005 to 2010 were analyzed. Weighted logistic regression models were used to assess the association between daily alcohol intake and constipation, calculating odds ratios (OR) and 95% confidence intervals (CI) while adjusting for potential confounders. Additionally, restricted cubic splines (RCS) were applied to explore potential nonlinear patterns in the alcohol-constipation relationship, and subgroup analyses were conducted to assess effect differences across various population groups. Potential interaction factors within different subgroups were also examined. A total of 14,465 participants were included in the study. After adjusting for multiple confounders, a significant inverse association was found between daily alcohol intake (as a continuous variable) and constipation, with an OR of 0.98 (95% CI: 0.96-0.99, P = 0.005). Compared to non-drinkers (Q1), the risk of constipation progressively decreased among light (Q2), moderate (Q3), heavy (Q4), and very heavy drinkers (Q5). In our analysis, the OR for the heaviest drinkers (Q5) was 0.24 (95% CI: 0.11-0.52, P < 0.001), with a significant trend test (P = 0.001). RCS analysis revealed a significant nonlinear inverse relationship between alcohol intake and constipation (P = 0.016). No significant interactions were observed in the subgroup analysis (all P-values > 0.05). This study identified a significant inverse association between daily alcohol intake and constipation. Future research should employ more rigorous designs, such as prospective cohort studies, to confirm the association between alcohol intake and gut health and to elucidate the underlying biological mechanisms to assess the potential benefits and risks of alcohol consumption.

The Effect of Biofeedback on Constipation, Sleep, Depression, Anxiety and Quality of Life in Patients with Dyssynergic Defecation: a QUASI Experimental Study (Before and After Study)

Dyssynergic defecation(DD) is the inability to coordinate abdominal and anorectal muscle contraction during defecation. Patients with constipation often report poor quality of life, sleep issues, and increased risk of mood disorders. Biofeedback is a recommended treatment for DD. we evaluated the effect of EMG-biofeedback on constipation symptoms as the primary outcome and also on insomnia, mood disorders (depression and anxiety), and quality of life as secondary outcomes in patients with dyssynergic defecation. Thirty-one patients with DD (74.2% women, mean age 46.23 ± 13.42 years), diagnosed using Rome IV criteria, Bristol Stool Form Scale, and anorectal manometry, were included. Patients underwent six to ten sessions of EMG-based biofeedback. We evaluated symptoms using the Wexner constipation questionnaire, Visual Analog Scale (VAS), SF-36 for quality of life, Insomnia Severity Index (ISI), and Hamilton questionnaires for anxiety and depression (HAM-A and HAM-D) before and after treatment. As consistent with study hypotheses, the Wexner scores significantly improved after biofeedback (p < 0.0001, t = 6.98). ISI scores improved (p = 0.01, t = 2.74), as did VAS scores (p < 0.0001, t = 5.14). HAM-A and HAM-D scores showed significant reductions (HAM-A: p = 0.0001, t = 5.01; HAM-D: p = 0.003, t = 2.17). However, SF-36 did not show significant improvement in quality of life (p > 0.05, t = -0.93). Biofeedback effectively improved constipation symptoms, insomnia, and mood disorders but did not impact quality of life.

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

Background

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

Methods

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

Results

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

Conclusion

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

Economic Impact of Daily Bowel Management Regimens

BACKGROUND

Chronic constipation and fecal incontinence are devastating problems for patients with anorectal malformations, Hirschsprung's disease, idiopathic constipation, and spina bifida/spinal cord injuries. Finding the proper regimen allows these patients to be out of diapers and free of stool accidents. A typical bowel management regimen consists of daily laxatives or enemas; because these products are sold over the counter, insurance companies do not cover them. This study reviews the cost of bowel regimens and analyzes their economic impact on the families we treat.

METHODS

A retrospective review of patients undergoing bowel management between January 2016 and September 2023 was done. The mean annual income of families was calculated using their zip codes.

RESULTS

Upon review, 430 patients met inclusion criteria; 167 were on laxatives, and 263 were using enemas. There was significant variation in the cost of medications based on the distributors they were bought from and the dose of the medication in their regimen. The cost of laxatives ranged from $15.70 to $2938.10 annually. The cost of enemas containing glycerin ranged from $29.20 to $4380.00 annually. In comparison, diapers/incontinence briefs ranged from $131.40 to $4343.50 annually. The median annual income of patients across 41 states ranged from $32,192 to $225,119.

CONCLUSIONS

Our findings emphasize the importance of proper counseling families regarding medication costs in the market, intending to promote long-term treatment adherence. They also serve as a data source to advocate for improved insurance coverage of the medications required to manage these chronic conditions successfully.

LEVEL OF EVIDENCE

IV.

Cost-Effectiveness of Vibrant System vs. Linaclotide in Chronic Idiopathic Constipation

INTRODUCTION

Chronic idiopathic constipation (CIC) is a common disorder that has a large unmet clinical need, affecting 8.0-12.0% of the US population and disproportionately affecting female individuals more than male individuals. Patients and physicians are equally dissatisfied with over-the-counter and prescription treatments. Physician dissatisfaction is at 78%. CIC has a significant negative impact on quality of life (QoL). The objective of this analysis was to compare the total cost and QoL of the Vibrant System vs. linaclotide, over 1-3 years of treatment.

METHODS

Markov models were utilized to project 1-3-year US costs and health outcomes (quality adjusted life years, QALYs) comparing the Vibrant System to the current standard of care pharmacologic therapy (linaclotide). One model examined direct (D) costs plus QALYs. Direct (D) costs included list price of product and medical treatment costs due to adverse events. Costs (D) were as of 2024; derived from the medical literature. A second model examined D as well as indirect (I) costs (absenteeism, presenteeism) [D + I] and QALYs. Longitudinal 12-month persistence prescription data for linaclotide was obtained from IQVIA claims data. The Vibrant System persistence data was derived from post market collection. One-way sensitivity analyses were also performed.

RESULTS

Years 1-3 direct costs were lower with Vibrant System with improved QALYs. Cumulative D + I data analysis for the Vibrant System at 12 months, and for years 2 and 3 show increased cost savings from $345 to $3866 with improved effectiveness.

CONCLUSION

On the basis of lower costs and improved QALYs, the Vibrant System should be considered a first-line therapy for CIC and should be covered by insurers.

Understanding constipation as a geriatric syndrome

Constipation is common among older adults and significantly impacts their quality of life (QoL). Prior studies have extensively detailed constipation, but conceptualization of constipation as a geriatric syndrome is lacking. In this review, we provide an overview of constipation in the geriatric population and conceptualize constipation as a geriatric syndrome given its high prevalence, under-recognized status, and association with poor QoL and adverse outcomes among older adults. The conceptualization of constipation as a geriatric syndrome, as with frailty and delirium, highlights its importance and need for a multi-faceted approach. Future research is needed to 1) better define constipation, 2) explore the multifactorial nature of constipation in older adults and relationship with other geriatric syndromes, 3) include more older adults in pharmacological and non-pharmacological interventions for constipation, and 4) curate multidisciplinary care models. Appreciating constipation as a geriatric syndrome will yield tailored management strategies, ensure timely intervention, and avoid adverse outcomes.

Risk factors for constipation during pregnancy: a multicentre prospective cohort study

BACKGROUND

Constipation is frequently encountered in the population of pregnant women. Physical activity and nutritional factors are considered common causes of constipation; however, their impact on this population has not yet been evaluated precisely. This study aimed to assess the prevalence of constipation and its risk factors during pregnancy and postpartum.

METHODS

A prospective observational cohort study was conducted in 3 hospitals in Lithuania, including women with early viable pregnancies using questionnaires on demographic, obstetric, nutrition, behaviour, peri-anal disease, and birth data. All women with an early viable pregnancy (<12 weeks' gestation) aged 18 - 45 years who gave written informed consent were included. The Rome III criteria defined constipation. Independent risk factors were identified using multivariate analysis.

RESULTS

In all, 263 (55.9%) women developed constipation. Multivariate analysis identified haemorrhoidal disease during pregnancy (OR 8.25, 95% CI 4.41-15.4, p < 0.001), inadequate physical activity (OR 1.66, 95% CI 1.03-2.69, p=0.038), not participating in sports (OR 1.98, 95% CI 1.24-3.17, p=0.004), and monthly income 300-500 euros (OR 1.97, 95% CI 1.22-3.19, p=0.006) as significant predictors of constipation during pregnancy. Lower education was defined as a protective factor (retrospectively, secondary education by 2.2 times (OR 0.45, 95% CI 0.22-0.89, p=0.022) and unfinished secondary - by 1.84 times (OR 0.20, 95% CI 0.05-0.90, p=0.036) reduced the possibility of constipation development).

CONCLUSIONS

In conclusion, haemorrhoidal disease during pregnancy, low physical activity, and low monthly income are independent risk factors for constipation during pregnancy. Lower education significantly reduces the incidence of this condition.

Fructooligosaccharides for Relieving Functional Constipation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Fructooligosaccharides (FOS) are prebiotics with great potential to improve constipation. This study set out to investigate the usefulness of consuming FOS as a dietary supplement on bowel movement frequency, stool consistency, abundance of Bifidobacteria, gastrointestinal transit time, and gastrointestinal symptoms through a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases up to 2 March 2024. Randomized controlled trials reporting the use of FOS as a supplement by participants were included. Bias risk was assessed using the Cochrane Risk of Bias assessment tool. Results were synthesized using a random-effects model or fixed-effects model, combining outcomes using odds ratios (OR), weighted mean differences (MD), or standardized mean differences (SMD) with 95% confidence intervals (CI). The meta-analysis encompassed 17 randomized controlled trials, involving a total of 713 study participants. Overall, the intake of FOS significantly increased bowel movement frequency (95% CI: 0.80, 1.50, p < 0.00001) and positively affected stool consistency, softening the stool (SMD: 0.36, 95% CI: 0.12, 0.60, p = 0.76). It also reduced the effort and pain during defecation (SMD: -0.60, 95% CI: -0.85, -0.34, p = 0.12). At the same time, mild bloating was noted as an adverse event associated with FOS ingestion (OR: 10.36, 95% CI: 3.32, 33.23, p = 0.24). No reports of serious adverse events were documented. Overall, FOS may enhance bowel movement frequency, stool consistency, and overall constipation symptoms, suggesting cautious optimism regarding their use as a dietary treatment alternative. Nevertheless, further robust and definitive randomized controlled trials are required to more accurately determine the most effective dosage and duration of use. Additional research and evidence are necessary before the efficacy of FOS as a therapeutic method for treating functional constipation can be firmly established.

Efficacy of acupuncture for functional constipation in elderly: a systematic review and meta-analysis

Background

Numerous clinical studies have shown that patients suffering from functional constipation can benefit by combining medication with acupuncture. There have been no published reviews or meta-analyses regarding the use of acupuncture in treating functional constipation in older adults. Therefore, we carried out a meta-analysis to assess the impact of acupuncture on elderly patients dealing with functional constipation.

Methods

This study retrieved randomized controlled trials (RCTs) on acupuncture therapy for functional constipation in the elderly from several electronic databases, including Embase, PubMed, Cochrane Library, Wanfang Database, Chinese BioMedical Literature Database, and China National Knowledge Infrastructure. In these databases, clinical investigators evaluated the effectiveness of acupuncture as a primary treatment for elderly people with functional constipation. The Cochrane Handbook for Systematic Reviews of Interventions was used by researchers to evaluate the quality of the study.

Results

A total of 469 elderly individuals were included in 8 RCTs. The meta-analysis yielded compelling findings: the application of acupuncture has significantly elevated the rates of treatment effectiveness compared to the control group. Compared with the control group, the treatment group exhibited a statistically significant difference in complete spontaneous bowel movements after treatment. The two groups showed no significant difference in spontaneous bowel movements. However, there was a significant difference in the Bristol Stool Scale scores. The Defecation Difficulty Score and Patient Assessment of Constipation Quality of Life (PAC-QOL) showed p-values that indicated no significant effect. However, acupuncture improved bowel movements, demonstrating a significant difference in the Clinic Constipation Score (CCS) when comparing the two groups. The Nitric Oxide Synthase (NOS) and 5-Hydroxytryptamine (5-HT) contents changed significantly after intervention in both groups. An article reported that the improvement of traditional Chinese medicine (TCM) symptom scores was better in the treatment group than in the control group.

Conclusion

The analysis results indicated that acupuncture can be beneficial for elderly people with functional constipation; however, strong and comprehensive data are not yet obtainable. Given that our study is based on evidence that is of a low-to-moderate quality, further high-quality research is necessary to enhance the feasibility and practicability of this treatment.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024533215.

Physical activity and constipation: A systematic review of cohort studies

Background

Constipation significantly impacts quality of life and is a common public health issue. For affected individuals, especially those who are inactive and experience constipation symptoms, it is recommended to engage in physical activity (PA) to improve their condition. However, the relationship between PA and improvement in constipation remains unclear. We performed this systematic review of cohort studies to evaluate this potential association.

Methods

We systematically searched the Embase, Cochrane Library, PubMed, and CINAHL databases for all cohort studies examining the relationship between PA and constipation from the inception of the databases up to 5 November 2023. We calculated the reported risk ratios (RRs) and 95% confidence intervals (CIs), conducted a random effects model, and performed a subgroup analysis based on factors such as gender, geographic region, and PA intensity to comprehensively explore the link between PA and constipation. Furthermore, we used the Newcastle-Ottawa Scale to evaluate the quality of the studies included in our analysis.

Results

The analysis included 13 studies with 119 426 participants and 63 713 cases. The results indicated that higher levels of PA were associated with a decreased risk of constipation compared with lower levels of PA (RR = 0.69; 95% CI = 0.88-0.83) and moderate levels of PA (RR = 0.87; 95% CI = 0.79-0.95). Furthermore, adherence to international PA guidelines was correlated with a significantly reduced risk of constipation (RR = 0.87; 95% CI = 0.81-0.93). Notably, the risk of constipation was lowered among Asian populations (RR = 0.67; 95% CI = 0.56-0.79) and Oceanian populations (RR = 0.72; 95% CI = 0.63-0.83) who engaged in regular PA. Moreover, when comparing the risk of constipation between men and women collectively, PA was associated with a 34% lower risk (RR = 0.66; 95% CI = 0.55-0.80).

Conclusions

The study findings indicated that moderate to high levels of PA significantly reduced the risk of constipation, showing a negative correlation between PA and constipation.

Registration

PROSPERO: CRD42023479653.

Can depression lead to chronic constipation, or does chronic constipation worsen depression? NHANES 2005-2010 and bidirectional mendelian randomization analyses

BACKGROUND

Depression and chronic constipation often co-occur, but the reciprocal influence between the two remains unclear. The purpose of this study is to explore the potential association between depression and chronic constipation.

METHODS

This study initially utilized data from National Health and Nutrition Examination Survey (NHANES) 2005-2010 to explore the correlation between depression scores and chronic constipation, assessing the non-linear relationship between the two. Subsequently, we conducted a two-sample Mendelian randomization (MR) analysis to evaluate the causal relationship between depression and major depression with chronic constipation. The Inverse Variance Weighting (IVW) method served as the primary reference, supplemented by sensitivity tests. Finally, a reverse MR analysis was performed to assess the presence of any reverse causation. The STROBE-MR checklist for the reporting of MR studies was used in this study.

RESULTS

In the NHANES analysis, survey-weighted logistic regression revealed a significantly positive correlation between depression scores and chronic constipation (OR = 1.04, 95% CI = 1.02-1.07, p = 0.002), even after adjusting for the included covariates. The nonlinear analysis using Restricted Cubic Splines (RCS) enhanced the robustness of the association (P-non-liner = 0.01). The MR analysis also confirmed the causal relationship between depression (OR = 11.43, 95% CI = 1.85-70.67, p = 0.008) and major depression (OR = 1.12, 95% CI = 1.03-1.22, p = 0.007) with chronic constipation, passing rigorous sensitivity tests. No evidence of reverse causation was observed in the reverse MR analysis (P > 0.05).

CONCLUSIONS

Depression is positively correlated with the risk of chronic constipation. Therefore, enhancing attention to chronic constipation in patients with depression may be effective in clinical practice.

Association between bowel movement disorders and depressive symptoms: a cross-sectional study

Objectives

This study aimed to explore the association between bowel movement disorders and depression in adults.

Method

A cross-sectional study was conducted using data from the National Health and Nutritional Examination Survey (NHANES), 2005-2010. Depression, constipation, diarrhea, and fecal incontinence were self-reported via questionnaires. Weighted logistic regression and subgroup analyses were performed to explore the association between bowel movement disorders and the risk of depression. Restricted cubic spline (RCS) was also conducted to investigate the association between bowel movements disorder and depression.

Results

A total of 13,820 participants were collected. Compared to the participants with normal bowel movements, the full-adjusted depression model ORs for constipation and diarrhea were 2.28 (95%CI,1.78-2.92), 1.75 (95%CI,1.31-2.31), respectively. Any kind of bowel leakage were associated with depression. The RCS showed the possible nonlinear association between bowel movement frequency/stool shape and depression.

Conclusions

Constipation, diarrhea, and bowel leakage are associated with an increased risk of depression.

Association between physical activity and risk of gastroesophageal reflux disease: A systematic review and meta-analysis

BACKGROUND

Lifestyle plays an important role in preventing and managing gastroesophageal reflux disease (GERD). In response to the conflicting results in previous studies, we performed a systematic review and meta-analysis to investigate this association.

METHODS

Relevant studies published until January 2023 were retrieved from 6 databases, and the prevalence of symptomatic gastroesophageal reflux (GER) or GERD was determined from the original studies. A random effects model was employed to meta-analyze the association by computing the pooled relative risk (RR) with 95% confidence intervals (95%CIs). Furthermore, subgroup and dose-response analyses were performed to explore subgroup differences and the association between cumulative physical activity (PA) time and GERD.

RESULTS

This meta-analysis included 33 studies comprising 242,850 participants. A significant negative association was observed between PA and the prevalence of symptomatic GER (RR = 0.74, 95%CI: 0.66-0.83; p < 0.01) or GERD (RR = 0.80, 95%CI: 0.76-0.84; p < 0.01), suggesting that engaging in PA might confer a protective benefit against GERD. Subgroup analyses consistently indicated the presence of this association across nearly all subgroups, particularly among the older individuals (RR<40 years:RR≥40 years = 0.85:0.69, p < 0.01) and smokers (RRsmoker:RRnon-smoker = 0.67:0.82, p = 0.03). Furthermore, a dose-response analysis revealed that individuals who engaged in 150 min of PA per week had a 72.09% lower risk of developing GERD.

CONCLUSION

Maintaining high levels of PA decreased the risk of GERD, particularly among older adults and smokers. Meeting the recommended PA level of 150 min per week may significantly decrease the prevalence of GERD.

Review article: advances in the diagnosis and management of anorectal motility disorders

BACKGROUND

Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field.

AIMS

To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach.

METHODS

We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review.

RESULTS

A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe.

CONCLUSIONS

Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients.

Effect of thumbtack needle on functional constipation: A pragmatic randomized controlled trial

OBJECTIVE

Thumbtack Needling (TN) has been employed in the treatment of functional constipation (FC), although the existing evidence supporting its effectiveness is limited. This study is to evaluate the efficacy of TN in ameliorating FC.

METHOD

A total of 482 eligible patients were recruited and randomly assigned to the TN group or the Mosapride Citrate (MC) group. The TN was buried once for three days, rest for one day after two consecutive burials, followed by a 4-week follow-up. The primary outcome measure was the score for Complete and spontaneous bowel movement score (CSBMs). Secondary outcome measures included the Bristol Stool Form Scale (BSFS), Cleveland Clinic Score (CCS), and the Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL).

RESULTS

Out of the 482 patients randomized, 241 were allocated to each group. Of these, 216 patients (89.6 %) in both groups completed the intervention and follow-up. Compared with the baseline, the differences of CSBMs in TN group [1.76(95 % CI, 1.61 to 1.91)] and MC group [1.35(95 % CI, 1.20 to 1.50)] at week 4 meet the threshold for minimal clinically important difference (MCID). However, there were no clinical difference from baseline at week 2 and week 8 in both groups. Mean CSBMs at week 4 was 3.35 ± 0.99 in the TN group and 3 ± 1.03 in the MC group (adjusted difference between groups, 0.37 points [95 % CI, 0.18 to 0.55]; P < 0.001), although differences between the two groups did not meet the MCID threshold.

CONCLUSION

Compared with mosapride citrate, thumbtack needling produced a greater improvement in CSBMs, although the difference from control was not clinically significant.

CLINICALTRIALS

GOV IDENTIFIER

ChiCTR2100043684.

Association between Constipation and the Risk of Parkinson's Disease among Participants in the UK Biobank

INTRODUCTION

Constipation is common in patients with Parkinson's disease (PD), but its impact on incident PD remains uncertain. We aimed to prospectively investigate constipation symptoms and the risk of PD.

METHODS

Participants without PD at baseline from the UK Biobank were included in the study. Information on the regular use of laxatives, bowel movement frequency, and the frequency of hard or lumpy stools was collected. Incident PD was defined by the ICD-10 code. Cox proportional hazards models were used to assess the association between constipation symptoms and incident PD.

RESULTS

In the analysis of regular laxative use and PD, 490,797 participants were included and 2,735 incident PD were detected. The multivariable adjusted HR of PD in participants who regularly used laxatives was 1.99 (95% confidence interval [CI], 1.70-2.33) compared with those who did not. In the analysis of bowel movement frequency and hard or lumpy stools and PD, 170,017 participants were included and 519 incident PD were detected. The multivariable adjusted HRs were 2.16 (95% CI, 1.74-2.68) and 2.57 (95% CI, 2.00-3.31) for participants with a bowel movement frequency of 3-6 times/week and <3 times/week, respectively, compared with those with a bowel movement frequency of ≥7 times/week; compared with participants who never had hard or lumpy stools, multivariable adjusted HRs were 1.31 (95% CI, 1.07-1.60), 2.32 (95% CI, 1.77-3.05), and 2.94 (95% CI, 2.14-4.05) for those who sometimes had hard or lumpy stools, often had hard or lumpy stools, and most of time/always had hard or lumpy stools, respectively.

CONCLUSIONS

Constipation measured by the regular use of laxatives, bowel movement frequency, and the frequency of hard or lumpy stools was significantly associated with an increased risk of incident PD.

Transanal proximal rectosigmoidectomy: a single-center experience in surgically treated severe medically refractory idiopathic constipation

PURPOSE

To present the functional results after a transanal proximal rectosigmoidectomy in patients with severe idiopathic constipation in which medical treatment has failed.

METHODS

Patients with severe idiopathic constipation who underwent transanal proximal rectosigmoidectomy (TPRS) at Children's Hospital Colorado between June 2019 and March 2024 were included in the study. We compared multiple pre- and post-operative outcome measures and the patient's bowel regimen before and after resection.

RESULTS

Fourteen patients underwent TPRS, 10 of whom were male. The average age at the time of surgery was 10.1 years (range 5-19). Seven patients have moderate to severe autism. Constipation-related clinic visits, family calls, procedural intervention, emergency room visits, and hospitalizations notably decreased frequency after TPRS. Laxative dosages and enema volume requirements were also reduced after surgery. Before surgery, all the patients suffered from daily fecal accidents, while post-operatively, all were completely free of stool accidents.

CONCLUSION

In our experience, for patients who suffer from severe medically refractory idiopathic constipation, TPRS has provided improvement in their symptoms and decreased the complications inherent to this chronic disease. Parents and patients attest to a profound positive transformation in their quality of life after surgery.

The human colon: Evidence for degenerative changes during aging and the physiological consequences

BACKGROUND

The incidence of constipation increases among the elderly (>65 years), while abdominal pain decreases. Causes include changes in lifestyle (e.g., diet and reduced exercise), disease and medications affecting gastrointestinal functions. Degenerative changes may also occur within the colo-rectum. However, most evidence is from rodents, animals with relatively high rates of metabolism and accelerated aging, with considerable variation in time course. In humans, cellular and non-cellular changes in the aging intestine are poorly investigated.

PURPOSE

To examine all available studies which reported the effects of aging on cellular and tissue functions of human isolated colon, noting the region studied, sex and age of tissue donors and study size. The focus on human colon reflects the ability to access full-thickness tissue over a wide age range, compared with other gastrointestinal regions. Details are important because of natural human variability. We found age-related changes within the muscle, in the enteric and nociceptor innervation, and in the submucosa. Some involve all regions of colon, but the ascending colon appears more vulnerable. Changes can be cell- and sublayer-dependent. Mechanisms are unclear but may include development of "senescent-like" and associated inflammaging, perhaps associated with increased mucosal permeability to harmful luminal contents. In summary, reduced nociceptor innervation can explain diminished abdominal pain among the elderly. Degenerative changes within the colon wall may have little impact on symptoms and colonic functions, because of high "functional reserve," but are likely to facilitate the development of constipation during age-related challenges (e.g., lifestyle, disease, and medications), now operating against a reduced functional reserve.

Agave tequilana Fructans Versus Psyllium plantago for Functional Constipation : Randomized Double-blind Clinical Trial

GOAL

The aim of this study was to evaluate the efficacy of supplementation with Agave tequilana Weber blue variety fructans (Predilife) in the improvement of symptoms in functional constipation.

BACKGROUND

Fiber supplementation is the first-line treatment for constipation. Fibers-like fructans have a known prebiotic effect.

MATERIALS AND METHODS

A randomized, double-blind, study comparing agave fructans (AF) against psyllium plantago (PP). Four groups were randomized. Group 1: AF 5 g (Predilife), group 2: AF 10 g (Predilife), group 3: AF 5 g (Predilife)+10 g maltodextrin (MTDx), and group 4: PP 5 g+10 g MTDx. The fiber was administered once daily for 8 weeks. All fibers were similarly flavored and packaged. Patients kept their usual diet and fiber sources were quantified. Responders were defined as ≥1 complete spontaneous bowel movement from baseline to 8 weeks. Adverse events were reported. The study was registered in Clinicaltrials.gov with registration number NCT04716868.

RESULTS

Seventy-nine patients were included (group 1: 21, group 2: 18, group 3: 20, and group 4: 20), of which 62 (78.4%) were women. The responders were similar across groups (73.3%, 71.4%, 70.6%, and 69%, P >0.050). After 8 weeks, all groups significantly increased complete spontaneous bowel movements, showing the greatest increase in spontaneous bowel movements in group 3 ( P =0.008). All groups improved in symptoms, stool consistency, and quality of life. Diet and fiber intake were similar between groups. Adverse events were mild and similar between groups.

CONCLUSIONS

AF (Predilife) are as effective at different doses and combined with MTDx as PP and are a feasible option for the treatment of functional constipation.

Nocebo effects and influencing factors in the randomized clinical trials of chronic constipation: A systematic review and meta-analysis

BACKGROUND

Nocebo effects are unavoidable in randomized clinical trials. We aimed to assess the magnitude of nocebo effects and explore the influencing factors in chronic constipation.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases up to July 2022. Randomized, placebo-controlled trials investigating interventions in chronic constipation were included. We conducted a random effects meta-analysis of the proportion of adverse events (AEs) in placebo-treated participants and evaluated the effect of trial characteristics on nocebo effects.

KEY RESULTS

We identified 20,204 studies from the databases, of which 61 were included in the final analysis. The pooled placebo AE rate was 30.41%, and AE-related withdrawal rate was 1.53%. The most commonly reported AEs were headache (5.67%), diarrhea (4.45%), abdominal pain (3.98%), nasopharyngitis (3.39%), nausea (3.36%), and flatulence (2.95%). The placebo AE rate was lower in trials conducted in Asia compared to those in Europe, North America, and international trials. It was also lower in trials diagnosed by Rome III compared to clinician's opinion and Rome II. Additionally, the placebo AE rate was lower in single-center trials compared to multicenter trials, lower in 5-8 weeks therapy compared to 9-12 weeks therapy, lower in participants with FC compared to those with IBS-C and CC, lower in trials with 2 arms compared to 3 arms, and higher in trials with prokinetic drugs compared to secretagogues and laxatives.

CONCLUSIONS & INFERENCES

The placebo AE rate was 30.41% in patients with chronic constipation. Based on our findings, we recommend that researchers take the nocebo effects into consideration when designing and conducting clinical trials and adopt specific measures to mitigate the negative influence of nocebo effects.

Prevalence and associated factors of chronic constipation among Japanese university students

BACKGROUND

Chronic constipation (CC) is one of the most frequently reported gastrointestinal disorders in the general population and a prominent problem among university students. The study aimed to evaluate the prevalence and the associated factors of CC among Japanese university students.

METHODS

This cross-sectional study was conducted among university students at Hiroshima University, Japan. Students answered the web questionnaire when making a web reservation for the health checkup (April 1 to May 31, 2023). The web questionnaire consisted of four sections, including baseline characteristics, lifestyle factors, family history of CC, and three scales to assess depression and eating disorders: the Beck Depression Inventory (BDI), Eating Attitudes Test (EAT)-26 and Bulimic Investigatory Test (BITE). CC was diagnosed using Rome IV criteria. The multivariate logistic regression model was used to determine CC-related factors.

RESULTS

Out of 10,500 individuals who participated in the annual health checkup, 7,496 participants answered the web questionnaire, of whom 5,386 answered all the survey questions. The mean age of the students was 21.1 ± 4.1 years. The male-to-female ratio was 1:1.17. The prevalence of CC was 13.7%. Factors significantly associated with CC in the multivariate model were first-degree family members with CC [Odd ratio (OR): 2.77, 95% confidence interval (CI): 2.31-3.31], severe depression according to BDI scale (OR: 2.59, 95% CI: 1.96-3.43), female sex (OR: 2.00, 95% CI: 1.69-2.36), and short sleep duration of 6 hours or less per day (OR: 1.28, 95% CI: 1.09-1.50). Lack of physical exercise tended to be associated with CC (OR: 1.19, 95% CI: 1.00-1.40).

CONCLUSIONS

CC is prevalent among Japanese university students. Significant risk factors for CC included the first-degree family history of CC, severe depression, female sex, and short sleep duration. Lack of physical exercise tended to be associated with CC. This may contribute to implementing suitable education health programs, health care professionals, and public health policies to identify individuals at risk for CC to prevent and treat CC effectively.

Comparative profiles of lubiprostone, linaclotide, and elobixibat for chronic constipation: a systematic literature review with meta-analysis and number needed to treat/harm

OBJECTIVE

To comprehensively evaluate the efficacy, safety, patient symptoms, and quality-of-life (QoL) of lubiprostone, linaclotide, and elobixibat as treatment for chronic constipation (CC).

DESIGN

Systematic literature review (SLR) and meta-analysis (MA). Literature searches were conducted on PubMed and Embase using the Ovid platform.

METHODS

SLR including randomized controlled trials (RCTs) and observational studies was conducted to identify the overall efficacy and safety of lubiprostone, linaclotide, and elobixibat. Thereafter, MA was performed using only RCTs. The number needed to treat (NNT) and number needed to harm (NNH) analyses were additionally conducted.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was efficacy regarding change in spontaneous bowel movements. Secondary outcomes included safety, constipation-related symptoms, and QoL.

RESULTS

Twenty-four studies met the inclusion criteria for the SLR: 17 RCTs, 4 observational studies, and 3 single-arm trials. Feasibility assessment for the MA resulted in 14 studies available for safety data analysis, and 8 available for efficacy analysis, respectively. Three drugs showed similar efficacy in the MA and NNT analysis. However, the NNH analysis revealed distinct safety profiles: lubiprostone, linaclotide, and elobixibat were linked to the highest risk of nausea, diarrhea, and abdominal pain, respectively.

CONCLUSION

The current study provides an updated overview of the efficacy, safety, patient symptoms, and QoL of the three drugs with different mechanisms of action for CC treatment.The findings could help physicians adopt an individualized approach for treating patients with CC in clinical practice.

Adult patients with constipation presenting to the emergency department: Can care be improved?

OBJECTIVE

This study aimed to establish the demographic profile of adult patients presenting with constipation and constipation-related issues to an Australian tertiary hospital ED, investigate ED management and referral pathways in this cohort and determine satisfaction of these aspects of care from a patient's perspective.

METHODS

This is a single-centre study conducted in an Australian tertiary hospital ED which sees 115 000 presentations annually. ED presentations of adults aged 18-80 years with symptoms of constipation were evaluated through retrospective electronic medical record audit and follow-up by survey 3-6 months after their ED presentation.

RESULTS

The patients presenting to the ED with constipation had a median age of 48 years (IQR 33.5-63.5) and arrived self-referred by private transport. Median length of stay was 292 min. 22% of patients reported they had previously attended the ED for the same issue within the previous year. Diagnosis of chronic constipation was inconsistent, with limited supporting documentation. Constipation was largely managed with aperients. Four in five patients were satisfied with ED care; however, 3-6 months post-ED visit, 92% of patients reported ongoing bowel-related issues, reflecting the chronic course of functional constipation.

CONCLUSION

This is the first study to investigate the management of constipation in adult patients in an Australian ED setting. It is important that ED clinicians recognise that functional constipation is a chronic condition and many patients have persistent symptoms. There are opportunities for quality-of-care improvements including diagnostics, treatment, and referral post-discharge to allied health, nursing and medical specialist services.

Involving patients in the process: Development of a constipation patient-reported outcome measure for symptoms and quality of life

Objective

Patient-reported outcome measures (PROMs) are useful standardized tools to measure current patient health status and well-being. While there are existing constipation-related PROMs, the majority of PROMs were not developed with adequate patient involvement and few examined content validity. Accordingly, the current study aimed to develop a constipation PROM with multiple phases of patient and clinician involvement.

Methods

To generate PROM items, 15 patients with chronic constipation (age range =28-79 years, 10 females) underwent a qualitative interview exploring their experiences with chronic constipation. Following that, eight clinical experts completed the content validity index (CVI) ratings of all the items generated to assess content validity. Based on results of the content validity assessment, relevant items were maintained and 12 participants with chronic constipation were re-interviewed to obtain feedback about comprehensibility, comprehensiveness and relevance.

Results

Six themes and 25 sub-themes emerged from the qualitative interview, and an initial list of 33 symptom items and 18 quality of life (QoL) items were generated. Based on the CVIs calculated, 11 symptom items and nine QoL items were maintained with the scale-content validity index indicating excellent content validity. Overall, participants indicated the PROM to be relevant, comprehensive and easy to understand however, minor amendments were made to improve the three qualities of interest.

Conclusion

The current study developed a constipation PROM that measures both symptom severity and constipation-related QoL, with supporting evidence for relevance, comprehensiveness and comprehensibility. Further prioritization should be given to validating and exploring new digital modalities of PROM administration.

Effects of acupuncture on gut microbiota and short-chain fatty acids in patients with functional constipation: a randomized placebo-controlled trial

Objective: To comprehensively evaluate the effect of acupuncture on gut microbiota, identify specific microbes closely related to the clinical efficacy of acupuncture, and explored the role of short-chain fatty acids (SCFAs). Methods: A randomized placebo-controlled trial was conducted with 80 FC patients and 28 healthy controls (HCs). FC patients randomly received 16 acupuncture (n = 40) or sham acupuncture (n = 40) sessions over 4 weeks; HCs received no treatment. The change in the proportion of patients with mean weekly complete spontaneous bowel movements (CSBMs) was considered as the primary outcome measure. Moreover, the composition and the predictive metabolic function of the gut microbiota from feceal samples were analyzed by 16S rRNA gene sequencing, while feceal SCFAs were identified via gas chromatography-mass spectrometry (GC-MS). Results: Compared to sham acupuncture, acupuncture significantly increased the proportion of CSBM responders, and improved spontaneous bowel movements (SBMs), straining, stool consistency, and quality of life. Moreover, Sequencing of 16S rRNA genes revealed that acupuncture improved β-diversity and restored the composition of gut microbiota. Specifically, the abundance of beneficial bacteria such as g_Lactobacillus increased while that of pathogenic bacteria such as g_Pseudomonas decreased after acupuncture, which were significantly correlated with alleviated symptoms. Moreover, ten microbes including g_Coprobacter, g_Lactobacillus, and g_Eubacterium_coprostanoligenes_group might be considered acupuncture-specific microbes, and formed a stable interaction network. Additionally, GC-MS analysis indicated that acupuncture increased the content of butyrate acid in the gut, which was positively correlated with an increase in defecation frequency and a decrease in acupuncture-related pathogens. Finally, acupuncture specific-microbes including g_Coprobacter, g_Lactobacillus, g_Pseudomonas, g_Eubacterium_coprostanoligenes_group, g_Erysipelotrichaceae_UCG.003, g_Prevotellaceae_UCG.001, and g_Rolstonia could accurately predict the clinical efficacy of acupuncture (AUC = 0.918). Conclusion: Acupuncture could effectively improve clinical symptoms in FC patients, and was associated with gut microbiota reshaping and increased butyrate acid levels. Moreover, key microbial genera such as g_Coprobacter and g_Lactobacillus was predictive of acupuncture efficacy in treating FC. Future studies are required to validate the causal relationship between key microbial genera and acupuncture clinical efficacy, and should explore further metabolic pathways for designing personalized treatment strategies. Clinical Trial Registration: http://www.chictr.org.cn, Identifier: ChiCTR2100048831.

Osmotic pressure induces translocation of aquaporin-8 by P38 and JNK MAPK signaling pathways in patients with functional constipation

BACKGROUND

Aquaporins (AQPs) maintain fluid homeostasis in the colon. The role of colonic AQPs in the pathophysiology of functional constipation (FC) remains largely unknown.

AIM

To explore variations in aquaporins and investigate their underlying mechanisms.

METHODS

Colonic biopsies were collected from patients with FC and healthy controls. The expression and localization of AQPs were evaluated using quantitative real-time polymerase chain reaction (qRT-PCR), western blot analysis, and immunofluorescence assays. Furthermore, osmotic pressure-induced cell model was used in vitro to investigate the potential relationship between AQP8 and osmotic pressure, and to reveal the underlying mechanisms.

RESULTS

Upregulation of AQP3 and AQP8, and downregulation of AQP1, AQP7, AQP9, AQP10, and AQP11 were observed in the patients with functional constipation. Furthermore, cellular translocation of AQP8 from the cytoplasm to the plasma membrane was observed in patients with FC. Mechanistically, the increase in osmotic pressure could activate the Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) signaling pathways, and subsequently promote the upregulation and translocation of AQP8.

CONCLUSION

Upregulation of AQP8 and AQP3, and translocation of AQP8 were observed in colon biopsies from patients with FC. The p38 and JNK MAPK signaling pathways are involved in the regulation of osmotic pressure-induced AQP8 variation.

Analysis of the economic burden of docusate sodium at a United States tertiary care center

OBJECTIVES

The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate.

METHODS

The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed.

RESULTS

Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium.

CONCLUSION

A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Factors associated with long-term efficacy of lubiprostone for chronic constipation

The prevalence of chronic constipation in Japan is increasing, and is presently almost 1 in 5 people. Because constipation is common, especially in older patients, to avoid adverse events and polypharmacy, simple treatments at low doses are generally desired. Although the chloride channel activator lubiprostone is candidate drug that may solve these problems, factors associated with the long-term efficacy of lubiprostone monotherapy for chronic constipation in treatment-naive patients remain unclear. We here retrospectively investigated the clinical characteristics and factors of patients who achieved long-term constipation improvement with lubiprostone monotherapy. Seventy-four patients with chronic constipation treated with lubiprostone monotherapy (24 or 48 μg/day) from January 2017 to August 2018 were reviewed. Patient characteristics and clinical time-courses were compared between those who sustained improvement for 6 months, and those who became refractory to treatment. In 54 patients (76.1%), constipation improved by lubiprostone administration for 6 months. On multivariate analysis, a significant clinical factor associated with sustained improvement was a starting lubiprostone dose of 24 μg/day (odds ratio: 5.791; 95% confidence interval: 1.032-32.498; p = 0.046). A starting lubiprostone dose of 24 μg/day has efficacy to improve chronic constipation and to prevent adverse events of nausea and diarrhea in Japanese patients.

Rectal Perforation Secondary to a Self-Administered Water-Hose Enema: A Case Report and Literature Review

Chronic functional constipation is a common condition that can have a significant impact on a patient's quality of life and healthcare costs. Hydrostatic enemas are a commonly observed practice among patients with chronic constipation. Rectal perforation is a rare yet serious complication that can be fatal if not diagnosed and treated promptly. Here, we present the case of an elderly lady with Parkinson's disease who presented with upper rectal perforation after using a hydrostatic enema and was treated with Hartmann's procedure. This case highlights the importance of having a low threshold for suspecting and diagnosing colorectal perforation in patients presenting with abdominal pain after receiving a hydrostatic enema.

State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation

BACKGROUND

Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC.

METHODS

A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years.

RESULTS

The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test.

CONCLUSION

Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.

Daikenchuto significantly improves stool consistency and lower gastrointestinal symptoms in patients with chronic constipation

BACKGROUND AND AIM

A number of basic and clinical studies have confirmed that the traditional Japanese herbal medicine, Daikenchutou (DKT) has a pharmacological effect on cholinergic and serotonergic mechanisms with a favorable safety profile and an improving effect on lower gastrointestinal (GI) symptoms including abdominal pain or bloating. The purpose of this study is to evaluate the efficacy and safety of DKT on chronic constipation.

METHODS

This multicenter, randomized, placebo-controlled, double-blinded clinical trial enrolled 67 patients with chronic constipation fulfilling Rome III criteria. After a 2-week observation period, 63 patients with persistent symptoms were finally randomized to a 4-week course of treatment with DKT or placebo. The primary endpoint consisted of a global assessment of overall treatment effect (OTE), while the secondary endpoints consisted of improvements in stool consistency, spontaneous bowel movements, lower GI symptoms related to constipation, and quality of life. Factors associated with OTE were also investigated.

RESULTS

After 4 weeks administration of DKT, OTE was significantly higher than placebo. No side effects were observed. Significant improvement in stool consistency and lower GI symptoms was observed in the DKT group. The improvements in lower GI symptoms as well as stool consistency were associated with OTE. OTE was higher in patients with greater improvement in lower GI symptoms with mental component summary scores close to normal before treatment.

CONCLUSION

DKT was effective and safe in treating chronic constipation, especially in patients having symptoms related to constipation with no impaired mental component summary score.

Prevention of Postoperative Constipation in Urogynecology Patients: A Systematic Review

IMPORTANCE

Constipation is common after pelvic surgery, and studies suggest that surgeons underestimate the negative impact of constipation on patients. Patients undergoing pelvic reconstructive surgery are a unique population requiring special consideration in the prevention and management of constipation.

OBJECTIVE

This study aimed to systematically review the literature to identify evidence for prevention of postoperative constipation with medications or fiber in patients undergoing reconstructive pelvic surgery.

STUDY DESIGN

A structured literature search was performed of five databases (MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library) from inception to June 2022 for studies of postoperative laxative or fiber use in adult patients undergoing benign pelvic reconstructive surgery. Studies of preoperative bowel preparation and nonsurgical patients were excluded. Data on postoperative constipation were extracted for a qualitative analysis of the literature. Grading of Recommendations Assessment, Development, and Evaluation methodology was applied to assess the quality of evidence.

RESULTS

We identified 86 references after deduplication. Only 4 studies with a total of 344 patients were eligible for inclusion in the review. The included studies were all randomized controlled trials assessing time to first bowel movement with the earliest published in 2010. Laxative use decreased constipation more than placebo. Multiple-agent laxative use appeared to decrease bothersome constipation more than single-agent docusate. Preoperative fiber did not decrease constipation. By Grading of Recommendations Assessment, Development, and Evaluation criteria, all four studies provide moderate-quality evidence.

CONCLUSIONS

Few studies have investigated laxative regimens in patients after urogynecologic surgery. The available literature is moderate quality and suggests benefit of multiple-agent treatment over docusate only or no treatment.

Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery

PURPOSE

Fecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation.

METHODS

A multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests.

RESULTS

458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients.

CONCLUSION

We observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care.

LEVEL OF EVIDENCE

Level III.

Efficacy of AI-Assisted Personalized Microbiome Modulation by Diet in Functional Constipation: A Randomized Controlled Trial

Background: Currently, medications and behavioral modifications have limited success in the treatment of functional constipation (FC). An individualized diet based on microbiome analysis may improve symptoms in FC. In the present study, we aimed to investigate the impacts of microbiome modulation on chronic constipation. Methods: Between December 2020−December 2021, 50 patients fulfilling the Rome IV criteria for functional constipation were randomized into two groups. The control group received sodium picosulfate plus conventional treatments (i.e., laxatives, enemas, increased fiber, and fluid intake). The study group underwent microbiome analysis and received an individualized diet with the assistance of a soft computing system (Enbiosis Biotechnology®, Sariyer, Istanbul). Differences in patient assessment constipation−quality of life (PAC-QoL) scores and complete bowel movements per week (CBMpW) were compared between groups after 6-weeks of intervention. Results: The mean age of the overall cohort (n = 45) was 31.5 ± 10.2 years, with 88.9% female predominance. The customized diet developed for subjects in the study arm resulted in a 2.5-fold increase in CBMpW after 6-weeks (1.7 vs. 4.3). The proportion of the study group patients with CBMpW > 3 was 83% at the end of the study, and the satisfaction score was increased 4-fold from the baseline (3.1 to 10.7 points). More than 50% improvement in PAC-QoL scores was observed in 88% of the study cohort compared to 40% in the control group (p = 0.001). Conclusion: The AI-assisted customized diet based on individual microbiome analysis performed significantly better compared to conventional therapy based on patient-reported outcomes in the treatment of functional constipation.

Efficacy of Electroacupuncture Compared With Transcutaneous Electrical Stimulation for Severe Chronic Constipation: A Randomized Controlled Pilot Trial

BACKGROUND

To treat severe chronic constipation, both electroacupuncture (EA) therapy and transcutaneous electrical stimulation (TES) are safe and effective, but there is a lack of comparison between the 2 treatments. We sought to compare the therapeutic effect of EA relative to TES for the treatment of severe chronic constipation.

METHODS

We conducted a pilot randomized controlled trial. Seventy participants with severe chronic constipation were randomly allocated to the EA group or TES group. The acupoints in both groups are bilateral Tianshu (stomach 25), Fujie (spleen 14), and Shangjuxu (stomach 37). Each participant received 24 sessions of EA or TES during the treatment period of 8 weeks. Outcome measures were the proportion of participants with an increase from baseline of 1 or more complete spontaneous bowel movements (CSBMs) at week 8 and changes in the number of CSBMs and spontaneous bowel movements, stool character, difficulty in defecation, Patient Assessment of Constipation Quality of Life (PAC-QOL); the proportion of participants using rescue medicine and adverse reactions. Participants were followed for 24 weeks after the treatment.

RESULTS

Sixty of the 70 eligible participants completed the whole trial, 32 participants (91.43%) in the EA group and 28 participants (80.00%) in the TES group. There were 10 participants (14.29%) who dropped out during the whole study, 3 (8.57%) in the EA group, and 7 (20.00%) in the TES group. At weeks 20 and 32, 22 of 32 (68.75%) and 19 of 32 (59.38%) in the EA group met the clinical outcome of an increase of 1 or more CSBMs from the baseline, compared with 10 of 28 (35.71%) and 9 of 28 (32.14%) in the TES group ( P =0.019 and 0.042, respectively). At the same time, the proportions of participants having 3 or more CSBMs per week were 18 of 32 (56.25%) and 15 of 32 (46.88%) in the EA group, respectively, compared with 6 of 28 (21.43%) and 5 of 28 (17.86%) in the TES group ( P =0.008 and 0.027, respectively). Statistical differences between the 2 groups were maintained in the change from baseline in CSBMs during the follow-up period ( P =0.007 and 0.013, at week 20 and 32, respectively) and in the change from baseline in spontaneous bowel movements at week 20 ( P =0.007). Statistical significance was also observed in the decrease of PAC-QOL score after 8 weeks of treatment (mean±SD, EA: 19.06±14.41 vs. TES: 12.48±9.13, P =0.031). No significant difference was noted between the 2 groups in defecation difficulty, stool character, and the use of rescue medicine.

CONCLUSIONS

For the treatment of severe chronic constipation, EA performed better than TES in long-term follow-up and improving the quality of life. TES could be a better choice for patients with severe chronic constipation who are afraid of acupuncture because it is noninvasive. Well-designed and more rigorous clinical trials with larger sample sizes are needed.

Comparison of two questionnaires to diagnose obstructive defecation syndrome during pregnancy and post-natally

INTRODUCTION AND HYPOTHESIS

Obstructive defecation syndrome (ODS) is a common urogynaecology presentation. This study compares two questionnaires, the electronic Personal Assessment Questionnaire (e-PAQ), used in urogynaecology clinics, with the ODS-Score (ODS-S), a simple validated scoring system used in colorectal clinics for diagnosing ODS, to identify patients with an ODS-S cut-off ≥9.

METHODS

A total of 221 paired ODS-S and e-PAQ questionnaires were completed; 80 during the second trimester of pregnancy, 73 during the third and 68 post-natally, including women sustaining obstetric anal sphincter injury (OASI). e-PAQ score and ODS-S were compared and Pearson's correlation coefficient calculated. Areas under the curve assessed the diagnostic ability of e-PAQ scores to identify patients with ODS-S of ≥9.

RESULTS

The e-PAQ and ODS-S scores showed a positive correlation in the second and third trimesters of pregnancy, post-natally and following OASI. Pearson's correlation coefficient was calculated (0.77; p < 0.001, 0.79; p < 0.001, 0.66; p = 0.001 and 0.79; p < 0.001 respectively). An e-PAQ evacuatory domain score of ≥33 identified women with an ODS score of ≥9 with a sensitivity and specificity of 71% and 94% in the second trimester, 86% and 95% third trimester and 78% and 97% in the OASI group respectively. Area under the curve was >0.90 for all groups.

CONCLUSIONS

Comparison of e-PAQ evacuatory domain scores and ODS-S show a strong correlation, with an e-PAQ score of ≥33 promising for identifying women with an ODS score of ≥9, indicating ODS. This study will enable us to identify women during pregnancy and post-natally with ODS for whom early recognition and intervention may be beneficial.

The effect of Cassia fistula L. syrup in geriatrics constipation in comparison with the lactulose: A randomized clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Cassia fistula is widely used in traditional Persian Medicine as a mild laxative. The rate of chronic constipation increases above the age of 60.

AIM OF THE STUDY

This study aimed to investigate the effect of Cassia fistula syrup (CFS) on geriatric constipation.

MATERIALS AND METHODS

This clinical trial study was performed on 70 aged patients who were referred to the clinic of gastroenterology of Rouhani Hospital, Babol, North of Iran. Patients were randomly divided into two groups of CFS or Lactulose with a dose of 30 ccs/day. Patients were visited two weeks after entering the study to evaluate the frequency of defecation, feeling of incomplete emptying after defecation, manual maneuver, consistency of stool, and also the quality of life.

RESULTS

The frequency of defecation per week varied from 1.82 ± 1.16 to 8.36 ± 3.44 in the CFS group after 2 weeks of intervention that was significantly more than the Lactulose that changed from 2.16 ± 1.46 to 5.66 ± 2.96 (P-value = 0.023, partial eta square = 0.079, NNT = 4). The quality of life, the percent of straining, lumpy or hard stool, pain during defecation, and the consistency of stool based on VAS were significantly better in the CFS group. The sensation of incomplete defecation, anorectal obstruction, and manual maneuvering were not different significantly between groups.

CONCLUSION

CFS can be more effective than Lactulose on geriatric constipation.

Health-Related Quality of Life in Pediatric Inflammatory Bowel Disease Patients: A Narrative Review

Inflammatory bowel disease (IBD) is a chronic autoimmune condition that can have a wide range of symptoms among pediatric patients. Although clinical symptoms like hematochezia, diarrhea, and abdominal pain are commonly addressed, health-related quality of life (HRQOL) is often overlooked in patients with IBD and pediatric patients with chronic disease in general. Examining HRQOL can help improve patient outcomes, but it has been studied sparingly. In this review, we aim to compare HRQOL between pediatric patients suffering from IBD and healthy children, as well as those suffering from other illnesses. We searched through peer-reviewed primary literature related to IBD and HRQOL and selected 10 articles from the PubMed database to be reviewed. Our inclusion criteria included articles published after the year 2000 in English, primary studies, and those that corresponded to the aim of this review. Case reports and secondary and tertiary articles were excluded from our review. We found that patients with IBD reported worse HRQOL in terms of overall health and in various subdomains, including physical health and fatigue, compared to their healthy counterparts. However, children with IBD demonstrated a comparable HRQOL with children suffering from functional abdominal pain (FAP) and obesity. Additionally, children with IBD displayed a greater HRQOL than pediatric patients with gastroesophageal reflux disease (GERD) and chronic constipation. In addressing the aim of this review, we found that children with IBD had a lower HRQOL when compared to healthy children, but a comparable or greater HRQOL than other sick children. Some factors associated with a reduced HRQOL include disease activity, age, fatigue, gender, psychological variables, and associated symptoms. Going forward, HRQOL should be considered by practitioners when caring for pediatric IBD patients in a clinical setting as it can help improve patient care. More studies need to be conducted to further explore HRQOL in pediatric patients. This can help implement early psychosocial interventions in children to reduce the disease burden.

The relation between second-generation antipsychotics and laxative use in elderly patients with schizophrenia

BACKGROUND

We aimed to investigate factors associated with concomitant laxative use among elderly patients with schizophrenia, discharged on second-generation antipsychotics (SGAs), from two large public psychiatric hospitals in Taiwan.

METHODS

Elderly patients with schizophrenia who were discharged between 2006 and 2019 and received SGA monotherapy at discharge were included in the analysis. Multivariate logistic regression was used to identify factors associated with regular laxative use at discharge. The Cochrane-Armitage trend test was used to evaluate whether significant time trends existed for rates of laxative use at discharge.

RESULTS

A total of 2591 elderly patients with schizophrenia were discharged during the study period, and 1727 of 2591 patients who met the inclusion criteria were included for analysis. Of these 1727 patients, 732 (42.4%) also received concomitant laxatives. Female gender, mood stabiliser use and concomitant diabetes mellitus were found to be associated with increased laxative use. Among SGAs, clozapine was associated with the highest rate of laxative use, followed by zotepine, quetiapine, olanzapine and risperidone. Additionally, risperidone, amisulpride, aripiprazole, paliperidone and sulpiride were associated with comparable rates of laxative use. Laxative use rates grew over time from 30.8% in 2006 to 46.6% in 2019 (z = 4.83, P < 0.001).

CONCLUSIONS

Laxative use is common in elderly schizophrenia patients treated with SGAs. In cases of clinically significant constipation, switching to an SGA with a lower risk for constipation, or discontinuing the use of mood stabilisers should be considered, if clinically feasible.

Mechanistic Prediction of Chinese Herb Compound (Zhi Zhu Ma Ren Pill) in the Treatment of Constipation Using Network Pharmacology and Molecular Docking

Background: Constipation is one of the most prevalent chronic gastrointestinal diseases. Notably, previous studies have demonstrated that Chinese herbal compounds may exert effects on constipation. The present study aimed to predict the mechanisms underlying the effects of Zhi Zhu Ma Ren Pill (ZZMRP), which includes Aurantii Fructus Immaturus, Atractylodis Macrocephalae Rhizoma, Fructus Cannabis, Paeonia lactiflora and Radix Asteris in the treatment of constipation, using network pharmacology and molecular docking. Methods: The components and target information of ZZMRP were accessed using the Traditional Chinese Medicine Systems Pharmacology database and analysis platform, and the associated targets of constipation were obtained from the GeneCards, Disgenet, Online Mendelian Inheritance in Man, DrugBANK and Therapeutic Target Database databases. The major targets were subsequently selected using a Venn diagram and network topology analysis, which was followed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. Molecular docking was performed to authenticate the binding activity between active components and core targets. Results: A total of 44 active components, 249 targets of ZZMRP and 1501 targets associated with constipation were acquired. A total of 122 intersection targets were discovered between ZZMRP and constipation. Subsequently, 18 key targets were authenticated, including tumor protein 53, RAC-alpha serine/threonine-protein kinase, JUN and caspase-3. GO and KEGG pathway enrichment analysis indicated that mitogen-activated protein kinase, tumor necrosis factor, and phosphoinositide 3-kinase/protein kinase B signaling pathways may be involved in the treatment of constipation using ZZMRP. Molecular docking suggested that quercetin, kaempferol, and luteolin exhibited high binding affinities with several of the primary targets. Conclusions: The active components, core targets, and signaling pathways of ZZMRP in the treatment of constipation were predicted, which may be applicable to the development of treatments for constipation and application of ZZMRP.

Short-term acute constipation and not short-term acute diarrhea altered cardiovascular variables in male Wistar rats

Gastrointestinal dysmotility is a substantial public health challenge globally. Based on previous findings in developed countries, it has been observed that there is an association between diarrhea, constipation, and some cardiovascular variables. This study investigated the effects of experimentally-induced short-term acute constipation and short-term acute diarrhea on certain cardiovascular variables in rats. Thirty (30) male Wistar rats (150 -180 g) were divided into three groups; Control, Diarrhoea, and Constipation. The experiment was carried out in 2 phases, the period after induction and the recovery period, and 5 animals per group were used for each phase. The control group received an equivalent amount of distilled water while Diarrhoea and the Constipation group were induced by oral administration of 2ml Castor oil and administration of Loperamide (3mg/kg, b.d, orally x 3 days), respectively. Cardiovascular variables were assessed using the Edan Scientific® Electrocardiography and  Heart Rate Variability machine. Recovery was allowed for 4 days after the onset of the procedure and cardiovascular parameters were reassessed. Post-induction Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) and Heart Rate (HR) significantly increased in constipated rats (153.2 ± 2.9 mmHg; 109.0 ± 3.7 mmHg;     123.7 ± 3.2 mmHg; 123.4±5.6 bpm) when compared with the control values (95.5±4.8 mmHg; 61.2 ± 3.5 mmHg; 72.6 ± 3.6 mmHg; 72.3 ± 5.2 bpm), respectively. The recovery SBP, DBP, MAP, and Heart Rate in the constipated group remained significantly higher compared to the control. Diarrhea had no significant effect on the parameters determined in both post-induction and recovery phases. The electrical activities did not change in both experimental groups compared to the control. This study revealed increased SBP, DBP, MAP, and HR in short-term acute constipated rats but not so with short-term acute experimental diarrhea.

A Systematic Review of the Development and Psychometric Properties of Constipation-Related Patient-Reported Outcome Measures: Opportunities for Digital Health

Background/Aims

Constipation can be a chronic condition that impacts daily functioning and quality of life (QoL). To aid healthcare providers in accurately assessing patient symptoms and treatment outcomes, patient-related outcome measures (PROMs) have been increasingly adopted in clinical settings. This review aims to (1) evaluate the methodological quality and measurement properties of constipation-related PROMs, using the COnsensus-based Standards for the selection of health Measurement INtruments (COSMIN) criteria; and (2) assess the modes of digital dissemination of constipation-related PROMs.

Methods

PubMed, Embase, and PsycINFO databases were searched and 11 011 records ranging from 1989 to 2020 were screened by 2 independent reviewers. A total of 26 studies (23 PROMs; 18 measuring symptom-related items and 5 measuring constipation-related QoL items) were identified for the review and assessed.

Results

There were multiple variations between PROMs, including subtypes of constipation, methods of administration, length of PROM and recall period. While no PROM met all the COSMIN quality standards for development and measurement properties, 5 constipation-related PROMs received at least 4 (out of 7) sufficient ratings. Only 2 PROMs were developed in Asia. Five PROMs were administered through digital methods during the validation process but methods of adapting the PROMs into digital formats were not reported.

Conclusions

The constipation-related PROMs identified in this review present varying quality of development and validation, with an overall need for improvement. Further considerations should be given towards more consistent methodology and reporting of PROM development, increase in culturally-specific PROMs, and better reporting of protocol for the digitisation of PROMs.

Epidemiology of Constipation in Elderly People in Parts of China: A Multicenter Study

Purpose

To investigate the epidemiological characteristics of constipation in people aged 65 years and older in several regions of China.

Patients and Methods

A cross-sectional study based on a cluster sampling design was conducted in four cities of China: Tianjin, Xiamen, Cangzhou and Harbin. A total of 5,222 cases (age ≥ 65 years) were recruited, and the survey was conducted via centralized and household questionnaires that included the following: basic demographic characteristics such as sex, age, education, marital status, living status and occupation; social activities; duration of sleep at night; duration of menstruation and delivery times (in females); and if the participant had constipation symptoms, the severity of constipation. Constipation was diagnosed according to the Rome IV criteria.

Results

Of the 5,222 participants, 919 were diagnosed with constipation. The prevalence of constipation was 17.60% in elderly people ≥65 years old. Prevalence increased with age and was significantly higher in females than males (P < 0.05). Prevalence was lower in the manual compared to the non-manual worker group, and significantly increased with decreasing duration of night sleep (P < 0.05). Older age, female sex and shorter sleep duration at night were risk factors for constipation in elderly people.

Conclusion

The prevalence of constipation in the elderly people in four cities of China was 17.60%, and was significantly affected by age, sex and sleep duration at night.

Effects of Lactobacillus plantarum P9 Probiotics on Defecation and Quality of Life of Individuals with Chronic Constipation: Protocol for a Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Background

Although probiotics have been shown to improve constipation-related symptoms, a clear consensus on the use of probiotics as a constipation-relieving agent has not been reached, which is attributed to the limited available evidence and inconsistent protocols used in existing studies.

Method

A randomized, double-blind, placebo-controlled clinical trial is designed to study the efficiency and possible mechanism of action of probiotics for chronic constipation, in which 200 eligible volunteers with chronic constipation will be randomly assigned to a probiotic group (oral Lactobacillus plantarum P9 probiotic powder, 100 billion colony-forming units (CFUs)/day) or a placebo group. Volunteers, treatment distributors, data collectors, and data analysts will be blinded. The primary outcome is the weekly mean frequency of complete spontaneous bowel movements (CSBMs), and secondary outcomes include weekly mean frequency of CSBMs ≥3, weekly mean frequency of spontaneous bowel movements (SBMs), weekly mean stool appearance score, weekly mean difficulty of passing stool score, weekly percentage of volunteers who use auxiliary measures to assist with defecation (WPUAMA), quality-of-life (QOL) score, emotional status score, gut microbiome, and faecal metabolome. Each outcome measure will be assessed at the time points of preadministration (day 0), administration (day 14 and/or 28), and postadministration (day 42) to identify inter- and intragroup differences. Adverse events will be recorded to evaluate the safety of L. plantarum P9. Discussion. The protocol will provide methodological guidance for other similar studies, avoiding methodological bias and ultimately facilitating the formulation of consensus on the use of probiotics as a constipation-relieving agent. In addition, the results are more comprehensive than those of existing studies and may objectively and scientifically reflect the effectiveness of L. plantarum P9 on constipation. If the expected study findings are obtained, L. plantarum P9, taken as a probiotic, may become a complementary choice for chronically constipated patients. This trial is registered with Chinese Clinical Trial Registry (ChiCTR) (no. ChiCTR2000038396) registered on November 22, 2020, https://www.chictr.org.cn/showproj.aspx?proj=54024.

The quality of life and comfort levels of hemodialysis patients with constipation: A descriptive and cross-sectional study

INTRODUCTION

This study was conducted to determine the constipation-related quality of life, bowel habits, and comfort levels of constipated hemodialysis patients. It is known that the prevalence of constipation is high in hemodialysis patients.

METHODS

This was a cross-sectional and correlational study. The study included 164 hemodialysis patients who were determined to have constipation by examining the constipation statuses of 385 patients based on the Rome-IV criteria. The study was reported according to the STrengthening the Reporting of OBservational studies in Epidemiology Declaration.

FINDINGS

It was determined that as the constipation-related quality of life of the patients increased, their comfort levels also increased. Constipation-related quality of life increased in parallel with an increasing Bristol Stool Scale (BSS) score and an increasing number of bowel movements. The BSS scores of the patients were found to have a significant positive correlation with the patients' bowel movement frequencies and a significant negative correlation with their constipation frequencies. There was a negative correlation between years of dialysis and bowel movement frequencies. The presence of a previous gastrointestinal system complaint, the presence of an impact of constipation on the patient's dialysis session, and comfort levels were determined to be significant predictors of constipation-related quality of life that explained 26.3% of the total variance in constipation-related quality of life.

DISCUSSION

In patients receiving hemodialysis treatment, constipation is an important and frequently encountered problem. Constipation leads to a reduction in quality of life and hemodialysis-related comfort.

Prevalence and Risk Factors of Functional Constipation According to the Rome Criteria in China: A Systematic Review and Meta-Analysis

BACKGROUND

Functional constipation (FC) is a common bowel disorder that prevails worldwide. In China, although a heterogeneous prevalence of constipation is expected, it is currently not demonstrated. In this study, we aimed to evaluate the prevalence and related risk factors of FC in the Chinese population, according to the Rome criteria.

METHODS

We searched the PubMed, the Embase, the Cochrane Library, the Web of Science, the China National Knowledge Infrastructure (CNKI), the Wanfang data knowledge service platform, the VIP information resource integration service platform, and the Chinese Biomedical Literature Service System (SinoMed) databases from the inception of database to July 2021. Population-based cross-section studies that enrolled adults with FC, diagnosed by the Rome criteria, were deemed eligible. We summarized the overall prevalence and detected the subgroup effect per the Rome I, Rome II, Rome III, and Rome IV criteria. We used the generalized linear mixed model (GLMM) with a random-effect intercept to pool the prevalence and performed pairwise meta-analyses for prevalence comparisons by risk factors.

RESULTS

We identified 3,213 records through our database search, and 39 studies from China, comprising 1,240,79 participants, met the eligibility criteria for our study. The pooled overall prevalence of FC using the Rome criteria was 8.5% in China. Heterogeneous prevalence was detected within the Rome criteria (Rome II: 10.6%, 95% CI: 7.2-15.4; Rome III: 6.5%, 95% CI: 3.4-12.0; Rome IV: 8.1%, 95% CI: 5.6-11.8). The prevalence increased between 1991 and 2020 (from 5.5% with 95% CI: 3.6-8.2 between 1991 and 2000 to 10.9% with 95% CI: 5.5-20.4 between 2011 and 2020). Higher prevalence was found in women [odds ratio (OR) = 1.53, 95% CI: 1.31-1.78] and the elderly (≥70 years vs. ≤ 29 years: OR = 3.38, 95% CI: 2.16-5.30) than in men and the younger population. A high-fiber diet was associated with lower prevalence (OR = 0.33, 95% CI: 0.15-0.75), whereas irregular bowel habit and inactivity were associated with higher prevalence (OR = 3.64, 95% CI: 2.64-5.03; OR = 1.97, 95% CI: 1.14-3.43). Unhealthy mental states, such as anxiety and depression, and poor sleep quality led to high prevalence (OR = 3.16, 95%C I: 1.96-5.11; OR = 2.74, 95% CI: 1.76-4.26; OR = 2.14, 95% CI: 1.69-2.72, respectively).

CONCLUSION

Various types of FC prevail in China based on the different Rome criteria, personal characteristics, and habits. The prevalence also increased over the past three decades. The FC should be included under the primary care setting with uniform diagnosis criteria in China.

SYSTEMATIC REVIEW REGISTRATION

http://www.crd.york.ac.uk/PROSPERO, CRD42021277172.

Effects of Reversal Technique for Neuromuscular Paralysis on Time to Recovery of Bowel Function after Craniotomy

Background

Non-depolarizing neuromuscular blockade can be reversed with neostigmine/glycopyrrolate or sugammadex. We test the hypothesis that sugammadex is associated with earlier postoperative recovery of bowel function (first bowel movement, BM).

Methods

In adult patients undergoing craniotomy from 2016 to 2019, we identified time of first postoperative BM after receiving neostigmine/glycopyrrolate or sugammadex to reverse neuromuscular blockade. Logistic and proportional hazard regression, with and without inverse probability of treatment weighting (IPTW), were used to assess whether sugammadex is associated with earlier recovery of bowel function.

Results

Seven hundred and thirty-one patients underwent craniotomy, 323 (44.2%) received neostigmine/glycopyrrolate, and 408 (55.8%) sugammadex. From logistic regression analysis, the proportion of patients having a BM within the first 24 and 48 hours was higher in sugammadex group (unadjusted OR [95% CI]) 1.79 [1.16 to 2.77] P = .009; and 1.45 [1.08 to 1.94] P = .014; IPTW adjusted OR [95% CI]) 1.58 [.95, 2.61] P = .078; and 1.38 [.95 to 2.02] P = .095 for 24 and 48 h, respectively). From proportional hazards regression, sugammadex was associated with improved bowel function recovery (unadjusted hazard ratio (HR) [95% CI] 1.35 [1.08, 1.68], P = .008; IPTW adjusted HR 1.29 [.97 to 1.71], P = .076).

Conclusion

Patients undergoing craniotomy who had neuromuscular blockade reversed with sugammadex may have earlier recovered bowel function compared to patients reversed with neostigmine/glycopyrrolate.