Evaluation of the Symptom of Constipation in Indian Patients

Defaecation disorders among information technology personnel: A cross-sectional study

Background Individuals working in the information technology (IT) industry are likely to develop lifestyle disorders. We aimed to determine the presence of defaecation-related disorders in IT personnel in Chennai. Methods This cross-sectional, questionnaire-based study was done from June to December 2018. We included employees between 18 and 60 years of age and excluded those with <1 year stay in Chennai, pregnancy and those who sent incomplete responses. The cohort was classified as normal, irritable bowel syndrome (IBS), faecal evacuation disorder (FED) and a combination of the latter two. Results The overall response rate was 95.6%. The study included 54.7% of men, and the median age was 31 years. The majority of respondents used an Indian toilet (554; 58%). Almost all (96.2%) passed stools daily, and stool consistency was soft in 59%. Based on the study criteria, 180 (18.8%) had FED, 56 (5.9%) had IBS and a small group had a combination of symptoms of IBS and FED (20; 2.1%). Respondents with symptoms of IBS had a higher proportion of comorbid states (p<0.0001), lesser stool frequency (p<0.0001) and required more toilet time (p<0.00001). Conclusion Over one-fourth (26.7%) of the respondents had defaecation-related issues, 18.8% had symptoms suggestive of FED and 5.6% that of IBS, often above 30 years of age.

A cross-sectional study of stool form (using Bristol stool chart) in an urban South Indian population

BACKGROUND

There is paucity of data on Bristol stool form (BSF) in healthy South Indian residents.

AIM

To determine the BSF types and associated factors in an urban bowel health noncomplainant population.

METHODS

This cross-sectional study, performed using a self-administered questionnaire among adult Chennai residents, compared BSF types by gender for various factors (age, occupation, bowel frequency, and defecation-related abdominal pain). BSF types 1/2 and 6/7 were grouped as hard and loose stools, respectively. The statistical tests used were proportion test, χ 2, and Kruskal-Wallis tests (P < 0.05 deemed significant).

RESULTS

The study cohort of 1402 subjects included 748 (53.3%) men and a third each of professionals, semiprofessionals, and "non-office goers" (homemakers, retirees, students, and unemployed). A total of 97% had daily bowel movement, and 8.5% reported defecation associated abdominal pain. The BSF types in decreasing prevalence were: Type 3 (35.6%), Type 4 (32.5%), Types 1 or 2 (20.5%), Type 5 (6.9%), and Types 6 or 7 (4.5%). On gender comparison, significantly more men passed hard (P = 0.03) or loose stools (P = 0.001), while more women passed Type 3 (P = 0.0002). Loose stools in men were associated with abdominal pain (P = 0.0035). Women passing hard or loose stool types were slightly older (median age in 30s vs. 20s in Types 3-5) and had reduced stool frequency (P = 0.026: hard; P = 0.006: loose).

CONCLUSIONS

This South Indian noncomplainant cohort's most common stool types were BSF Types 3 and 4, with few gender variations in extreme stool types.

Clinical and anorectal manometry profile of patients with functional constipation and constipation-predominant irritable bowel syndrome

BACKGROUND

Functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C) have significant healthcare impact. Clinical and investigative data of patients with these disorders in Indian population is scarce. We aimed to compare the clinical and anorectal manometric profile of patients with FC and IBS-C.

METHODS

Consecutive patients with chronic constipation undergoing anorectal manometry (ARM) and balloon expulsion test (BET) were enrolled. Thirty healthy volunteers served as controls (HC). Functional defecatory disorder (FDD) was diagnosed according to ROME IV criteria if both ARM and BET were abnormal.

RESULTS

Of the 231 patients enrolled (median age 47 years, 87.8% males), FC and IBS-C were diagnosed in 132 (57.1%) and 99 (42.9%) patients, respectively. Significant clinical differences between FC and IBS-C patients included older age, lower stool frequency/week, higher frequency of straining, and greater frequency  of incomplete evacuation (p < 0.001). ARM revealed abnormal defecatory pattern in 55.3% (n = 73) FC patients and 47.5% (n = 47) IBS-C patients. Of them, 54.7% (40/73) of FC patients had inadequate defecatory propulsion while 89.4% (42/47) of the IBS-C patients had dyssynergic defecation (p < 0.001). Abnormal BET was seen in 67.4% of FC patients and 43.4% of IBS-C patients. Thus, FDD was diagnosed in 55.3% and 46.5% of FC and IBS-C patients, respectively. Rectal hyposensitivity was present in 60.6% of FC patients compared with 2% of IBS-C patients (p < 0.001).

CONCLUSIONS

There were significant differences in clinical and manometric profile of FC and IBS-C patients. Compared with IBS-C patients, FC patients were older, had higher prevalence of FDD, less often had dyssynergic defecation, and had higher prevalence of rectal hyposensitivity.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Chronic constipation in Rome IV era: The Indian perspective

Chronic constipation (CC) is a common problem in the community and in gastroenterology practice all over the world including India. After release of Rome IV guidelines in April 2016, there is increasing interest among gastroenterologists and physicians in India to look into special issues on CC in the Indian perspective. There are important differences in the bowel habit, definition, epidemiology, and pathophysiology including dietary factors and management of CC in India as compared to the West. As severity and frequency of abdominal pain, a symptom essential to diagnose constipation-predominant irritable bowel syndrome (IBS-C) rather than functional constipation (FC), is less common among Indian patients, FC is commoner than IBS-C in India. The pathophysiological mechanisms of CC may include slow colon transit, fecal evacuation disorder (FED), or a combination of these; though CC in a third to half of patients presenting to tertiary care facilities may result from these pathophysiological mechanisms, most patients presenting to primary care may have lifestyle and dietary issues. The current Rome IV algorithm dictates to explore the underlying physiological factors in the pathogenesis of functional gastrointestinal disorders including CC, which may translate to its personalized management. However, the availability of the methods to explore pathophysiological factors and manage CC caused by FED non-pharmacologically (using biofeedback) in India is limited. Though several pharmacological agents are available in India to manage CC, there are several unmet needs in its treatment. This review explores CC in India in relation to these issues, some of which are unique in the Indian perspective.

Management of chronic constipation in patients with diabetes mellitus

AIM

The aim of this review is to provide an overview of the clinical assessment and evidence-based treatment options for managing diabetes-associated chronic constipation.

METHODS

A literature search of published medical reports in English language was performed using the OVID Portal, from PUBMED and the Cochrane Database of Systematic Reviews, from inception to October 2015. A total of 145 abstracts were identified; duplicate publications were removed and 95 relevant full-text articles were retrieved for potential inclusion.

RESULTS

Chronic constipation is one of the most common gastrointestinal symptoms in patients with diabetes, and occurs more frequently than in healthy individuals. Treatment goals include improving symptoms and restoring bowel function by accelerating colonic transit and facilitating defecation. Based on guidelines and data from published literature, food and dietary change with exercise and lifestyle change should be the first step in management. For patients recalcitrant to these changes, laxatives should be the next step of treatment. Treatment should begin with bulking agents such as psyllium, bran or methylcellulose followed by osmotic laxatives if response is poor. Lactulose, polyethylene glycol and lactitol are the most frequently prescribed osmotic agents. Lactulose has a prebiotic effect and a carry-over effect (continued laxative effect for at least 6 to 7 days, post cessation of treatment). Stimulants such as bisacodyl, sodium picosulphate and senna are indicated if osmotic laxatives are not effective. Newer agents such as chloride-channel activators and 5-HT4 agonist can be considered for severe or resistant cases.

CONCLUSION

The primary aim of intervention in diabetic patients with chronic constipation is to better manage the diabetes along with management of constipation. The physician should explain the rationale for prescribing laxatives and educate patients about the potential drawbacks of long-term use of laxatives. They should contact their physician if short-term use of prescribed laxative fails to provide relief.

Normative values for stool frequency and form using Rome III diagnostic criteria for functional constipation in adults: systematic review with meta-analysis

When designing clinical trials focused on functional constipation therapies, understanding the normative values of populations selected using the Rome III criteria is important for estimating baseline symptom severity, and for power analysis and sample size calculations. The objective of this review was to determine normative ranges for stool frequency and form in adults with functional constipation (Rome III criteria). Eligible studies reported stool frequency or form; random effects meta-analysis was performed with subgroup analyses to explore sources of heterogeneity. A total of 25 studies (43 groups, 2292 subjects) were included. Pooled estimates were 2.7 (95% CI 2.4-3.0) for weekly stools and 2.4 (95% CI 2.1-2.6) for stool form (Bristol scale). Heterogeneity was high for both outcomes (both I²=96%, P<0.001). Subgroup analysis revealed that weekly bowel movement frequency was higher in larger than in smaller studies (3.1 vs. 2.3, P<0.001) and in studies conducted in Europe compared with those in the Americas (3.1 vs. 2.2, P=0.02). For stool form, the use of a daily diary versus subject recall was the sole explanatory variable (2.5 vs. 2.1, P<0.05). We conclude that adults with functional constipation have significant variation in stool frequency and form, explained in part by geography and study design.