Chronic Constipation: Gastroenterohepatologist's Approach

Constipation and colonoscopy

Constipation is a significant sociomedical problem, which can be caused by various reasons. In the diagnostic approach to patients with constipation, the following data are usually sufficient: History, complete physical examination (including rectal examination), and additional diagnostic tests. A colonoscopy is not a necessary diagnostic method for all patients with constipation. However, if patients have alarm symptoms/signs, that suggest an organic reason for constipation, a colonoscopy is necessary. The most important alarm symptoms/signs are age > 50 years, gastrointestinal bleeding, new-onset constipation, a palpable mass in the abdomen and rectum, weight loss, anemia, inflammatory bowel disease, and family history positive for colorectal cancer. Most endoscopists do not like to deal with patients with constipation. There are two reasons for this, namely the difficulty of endoscopy and the adequacy of preparation. Both are adversely affected by constipation. To improve the quality of colonoscopy in these patients, good examination techniques and often more extensive preparation are necessary. Good colonoscopy technique implies adequate psychological preparation of the patient, careful insertion of the endoscope with minimal insufflation, and early detection and resolution of loops. Bowel preparation for colonoscopy often requires prolonged preparation and sometimes the addition of other laxatives.

Yiqi Kaimi prescription regulates protein phosphorylation to promote intestinal motility in slow transit constipation

ETHNOPHARMACOLOGICAL RELEVANCE

The clinical efficacy of the Yiqi Kaimi prescription has been confirmed in slow transit constipation. However, the effects and biological mechanism of Yiqi Kaimi prescription are still unclear.

AIMS OF THE STUDY

To identify the effects of Yiqi Kaimi prescription on intestinal motility; To reveal the potential key targets and pathways of Yiqi Kaimi prescription for the treatment of slow transit constipation.

MATERIALS AND METHODS

The effects of Yiqi Kaimi prescription on slow transit constipation were investigated in a mouse model. The terminal ink propulsion experiment and fecal indocyanine green imaging was used to measure the intestinal transit time. Protein phosphorylation changes in colon tissues treated with Yiqi Kaimi prescription were detected using a Phospho Explorer antibody microarray. Bioinformatic analyses were performed using the Database for Annotation Visualization and Integrated Discovery (DAVID) and the Search Tool for the Retrieval of Interacting Genes (STRING). Western blot analysis and immunohistochemistry confirmed the observed changes in phosphorylation.

RESULT

s: Yiqi Kaimi prescription significantly increased the intestinal transit rate (P < 0.05 vs. model) and reduced the time to first discharge of feces containing fecal indocyanine green imaging in mice (P < 0.05 vs. model). The administration of Yiqi Kaimi prescription induced phosphorylation changes in 41 proteins, with 9 upregulated proteins and 32 downregulated proteins. Functional classification of the phosphorylated proteins with DAVID revealed that the critical biological processes included tyrosine protein kinases, positive regulation of calcium-mediated signaling and response to muscle stretch. The phosphorylation of the spleen tyrosine kinase (SYK) at Tyr348 increased 2.19-fold, which was the most significant change. The phosphorylation level of the transcription factor p65 (RELA) at Thr505 was decreased 0.57-fold. SYK was a hub protein in the protein-protein interaction network and SYK and RELA formed the core of the secondary subnetwork. The key protein phosphorylation after treatment with Yiqi Kaimi prescription were verified by Western blot analysis and immunohistochemistry.

CONCLUSION

Yiqi Kaimi prescription significantly enhanced intestinal motility. This effect was attributed to alterations in the phosphorylation levels of various target proteins. The observed changes in protein phosphorylation, including SYK and RELA, may serve as crucial factors in the treatment of slow transit constipation.

Nobiletin, an active component of Wenyang Yiqi formula, alleviates constipation associated depression through targeting MAPT to inhibit the MAPK signaling pathway

BACKGROUND

Slow transit constipation (STC) is a common gastrointestinal disorder that is often accompanied by depression. Nobiletin is a natural compound that has been shown to have anti-inflammatory and anti-depressant effects.

PURPOSE

To study the effects of nobiletin extracted from Wenyang Yiqi Formula 19 (WYF) on STC accompanied by depression and the related mechanism in STC mouse models.

METHODS

In this study, the effects of nobiletin on STC accompanied by depression were investigated in both an STC animal model and an in vitro study. The animal model was induced by loperamide, and the in vitro study used Interstitial cells of Cajal (ICCs) isolated from STC mice. The efficacy of nobiletin was assessed by comparing various parameters, including stool particle counts, moisture content, intestinal propulsive rate, colon histopathology, microtubule-associated protein-tau (MAPT) expression in colon tissue, serum levels of TNF-α, IL-1β, IL-6, IFN-γ, and the levels of MAPK pathway-related proteins among three experimental groups.

RESULTS

Nobiletin treatment significantly improved stool particle counts, moisture content, intestinal propulsive rate, and colon histopathology in the STC animal model. Nobiletin also decreased MAPT expression in colon tissue and serum levels of TNF-α, IL-1β, IL-6, IFN-γ, and the levels of MAPK pathway-related proteins. In the in vitro study, nobiletin treatment reversed the increased cell proliferation and cell apoptosis observed in ICC isolated from the STC model.

CONCLUSION

The findings of this study indicate that nobiletin exhibits promising therapeutic potential in addressing STC accompanied by depression. This potential may be attributed to its ability to regulate the function of ICC by targeting MAPT.

Overlap Between Gastroesophageal Reflux Disease and Functional Constipation and Associated Risk Factors Among the General Population in Saudi Arabia

Introduction

Gastroesophageal reflux disease (GERD) and functional constipation (FC) are two common gastrointestinal disorders that affect many age groups in the community. A few studies were conducted to find the association between GERD and FC, but no study had been conducted in Saudi Arabia. Therefore, this study aims to find the overlap between GERD and FC and associated risk factors among the general population in the Eastern Province, Saudi Arabia.

Methods

A cross-sectional study was conducted in the eastern province of Saudi Arabia between August and September 2022. GERDQ and Rome IV criteria were used to collect the data with participants' characteristics through an online questionnaire.

Results

Out of 2007 respondents, 1481 filled the required criteria, among them 320 (21.6%) had GERD, and 1292 (87.2%) respondents had FC based on the listed criteria. Eighty percent of respondents with GERD had overlapping FC. Men were more likely than women to experience this significant relationship (53.1% versus 46.9%).

Conclusion

There is a significant relationship between GERD and FC among the general population of the eastern province of Saudi Arabia. Consequently, this study could be used to improve the understanding of the overlapping between these gastrointestinal disorders and further new guidelines could be carried out to find the best treatment for these patients.

Abdominal massage for chronic constipation in the elderly: a systematic review and meta-analysis protocol

INTRODUCTION

Chronic constipation (CC) is a highly prevalent health challenge that is particularly challenging to treat in elderly patients. Although lifestyle guidance and laxative therapy often yield positive outcomes, patients occasionally struggle with maintaining dietary control. Therefore, identifying an economical and safe alternative therapy to the existing treatment methods documented in the international literature is necessary. This systematic review and meta-analysis aims to evaluate the efficacy and safety of abdominal massage in elderly patients with CC to provide a basis for future mechanistic research.

METHODS AND ANALYSIS

Electronic searches will be conducted to identify clinical randomised controlled trials in various databases, including Web of Science, PubMed, Cumulated Index to Nursing and Allied Health Literature, Cochrane Library, Embase, Airiti Library, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Periodical Database (VIP), Chinese Biomedical Literature Database and Wan Fang Database. Relevant data will be extracted, and a meta-analysis will be conducted using Reviewer Manager V.5.4. Quality and risk assessments of the included studies will be performed, and the outcome indicators of the trials will be observed. This review will evaluate abdominal massage as a treatment option for relieving symptoms and improving quality of life in elderly patients with CC. Moreover, it will provide additional insights for clinical treatment and mechanistic studies. The search will be performed following the publication of this protocol (estimated to occur on 30 December 2023).

ETHICS AND DISSEMINATION

As this is a literature review, ethics approval will not be required. We will disseminate the findings of this study to publications in peer-reviewed journals as well as presentations at relevant national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42023408629.

Coadministration of Lactulose with Probiotics Ameliorates Loperamide-Induced Constipation in Mice

We evaluated the efficacy of mixtures of lactulose with probiotic strains to ameliorate constipation and to identify suitable probiotic strains. Constipation was induced in Institute of Cancer Research mice (6-week-old, male) by the administering loperamide (5 mg/kg, twice a day) orally for 5 days, whereas the control group was not treated. To evaluate the laxative effects of the lactulose-probiotic and lactulose-magnesium hydroxide mixtures, fecal parameters, the gastrointestinal (GI) transit ratio, and fecal short-chain fatty acid (SCFA) content were analyzed. The administration of lactulose and Bacillus licheniformis or Saccharomyces boulardii significantly improved stool number and water content, which were reduced by loperamide. The GI transit ratio was significantly increased compared with that of the control group. The combined administration of lactulose and probiotics (B. licheniformis or S. boulardii) increased total SCFA content, including that of acetate, more effectively compared with lactulose alone. Similarly, coadministration of lactulose and magnesium hydroxide improved the loperamide-induced changes in fecal parameters and GI transit as well as increased total SCFA content. Overall, the combination of lactulose and probiotics relieves the symptoms of constipation by increasing SCFA content and is more effective compared with lactulose alone.

Incidence of constipation and associated factors in the period of lockdown during COVID-19 pandemic: protocol for a systematic review and meta-analysis

INTRODUCTION

The lifestyle and habit changes that have emerged as a result of quarantine measures may have had a negative impact on defecation habits. However, there is a lack of data on combined estimates of its occurrence and prevalence.

METHODS AND ANALYSIS

We will conduct a systematic search for observational studies on PubMed/MEDLINE, Web of Science, Cochrane Library, EMBASE, CNKI, SinoMed, VIP China Science and Technology Journal database, Chinese Biomedical Databases and Wanfang Data. The search will include literature published from the inception of the databases to September 2022. Two authors will independently screen articles and extract data based on predefined inclusion and exclusion criteria. The risk of bias in the included studies will be evaluated using the Newcastle-Ottawa Scale for observational studies. Statistical analysis will be performed using Review Manager software V.5.4 and STATA V.16.0 software. Heterogeneity among studies will be assessed using the Q statistical test and I2 statistical tests. In case of significant heterogeneity, subgroup analysis and sensitivity analysis will be conducted to explore the source of heterogeneity. Sensitivity analyses will also be performed to assess the reliability of the study findings. If feasible, a meta-analysis will be conducted. Otherwise, a descriptive synthesis will be performed using a best-evidence synthesis approach. The primary outcome of interest will be the prevalence of constipation. The secondary outcomes will involve examining the association of risk factors. To evaluate potential publication bias, we will use both the Begg funnel plot and Egger's weighted regression statistics. Furthermore, to accurately assess the quality of evidence for our primary outcome, we will employ the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

This systematic review protocol will only consider published studies available in databases and will not include individual patient data. Therefore, ethical approval is not required, and the findings will be published in a peer-reviewed journal.

PROSPER REGISTRATION NUMBER

CRD42022366176.

Effect of the probiotic strain, Lactiplantibacillus plantarum P9, on chronic constipation: a randomized, double-blind, placebo-controlled study

Chronic constipation (CC) is a common gastrointestinal condition associated with intestinal inflammation, and the condition considerably impairs patients' quality of life. We conducted a large-scale 42-day randomized, double-blind, placebo-controlled trial to investigate the effect of probiotics in alleviating CC. 163 patients diagnosed with CC (following Rome IV criteria) were randomly divided into probiotic (n = 78; received Lactiplantibacillus plantarum P9 [P9]; 1×10¹¹ CFU/day) and placebo (n = 85; received placebo material) groups. Ingesting P9 significantly improved the weekly mean frequency of complete spontaneous bowel movements (CSBMs) and spontaneous bowel movements (SBMs), while significantly reducing the level of worries and concerns (WO; P < 0.05). Comparing with the placebo group, P9 group was significantly enriched in potentially beneficial bacteria (Lactiplantibacillus plantarum and Ruminococcus_B gnavus), while depriving of several bacterial and phage taxa (Oscillospiraceae sp., Lachnospiraceae sp., and Herelleviridae; P < 0.05). Interesting significant correlations were also observed between some clinical parameters and subjects' gut microbiome, including: negative correlation between Oscillospiraceae sp. and SBMs; positive correlation between WO and Oscillospiraceae sp., Lachnospiraceae sp. Additionally, P9 group had significantly (P < 0.05) more predicted gut microbial bioactive potential involved in the metabolism of amino acids (L-asparagine, L-pipecolinic), short-/medium-chain fatty acids (valeric acid and caprylic acid). Furthermore, several metabolites (p-cresol, methylamine, trimethylamine) related to the intestinal barrier and transit decreased significantly after P9 administration (P < 0.05). In short, the constipation relief effect of P9 intervention was accompanied by desirable changes in the fecal metagenome and metabolome. Our findings support the notion of applying probiotics in managing CC.

Simo decoction curing spleen deficiency constipation was associated with brain-bacteria-gut axis by intestinal mucosal microbiota

Background

Simo decoction (SMD) is a traditional prescription for treating gastrointestinal diseases. More and more evidences prove that SMD can treat constipation by regulating intestinal microbiota and related oxidative stress indicators, but the specific mechanism is still unclear.

Methods

A network pharmacological analysis was used to predict the medicinal substances and potential targets of SMD to alleviate constipation. Then, 15 male mice were randomly divided into normal group (MN group), natural recovery group (MR group), and SMD treatment group (MT group). Constipation model mice were constructed by gavage of Folium sennae decoction and control of diet and drinking water, and SMD was used for intervention after successful modeling. The levels of 5-hydroxytryptamine (5-HT), vasoactive intestinal peptide (VIP), superoxide dismutase (SOD), malondialdehyde (MDA), and fecal microbial activities were measured, and the intestinal mucosal microbiota was sequenced.

Result

Network pharmacology analysis showed that a total of 24 potential active components were obtained from SMD, and 226 target proteins were obtained after conversion. Meanwhile, we obtained 1,273 and 424 disease-related targets in the GeneCards database and the DisGeNET database, respectively. After combination and deduplication, the disease targets shared 101 targets with the potential active components of SMD. When the mice were intervened with SMD, the 5-HT, VIP, MDA, SOD content, and microbial activity in MT group were close to MN group, and Chao 1 and ACE in MT group were significantly higher than that in MR group. In the Linear discriminant analysis Effect Size (LEfSe) analysis, the abundance of beneficial bacteria such as Bacteroides, Faecalibacterium, Alistipes, Subdoligranulum, Lactiplantibacillus, and Phascolarctobacterium in MT group increased. At the same time, there were some associations between microbiota and brain-gut peptides and oxidative stress indicators.

Conclusion

SMD can promote intestinal health and relieve constipation through brain-bacteria-gut axis associating with intestinal mucosal microbiota and alleviate oxidative stress.

Probiotics, prebiotics, and synbiotics in chronic constipation: Outstanding aspects to be considered for the current evidence

This integrative aimed to evaluate the effects and the potential mechanism of action of prebiotics, probiotics, and synbiotics on constipation-associated gastrointestinal symptoms and to identify issues that still need to be answered. A literature search was performed in the PubMed database. Animal models (n = 23) and clinical trials (n = 39) were included. In animal studies, prebiotic, probiotic, and synbiotic supplementation showed a decreased colonic transit time (CTT) and an increase in the number and water content of feces. In humans, inulin is shown to be the most promising prebiotic, while B. lactis and L. casei Shirota probiotics were shown to increase defecation frequency, the latter strain being more effective in improving stool consistency and constipation symptoms. Overall, synbiotics seem to reduce CTT, increase defecation frequency, and improve stool consistency with a controversial effect on the improvement of constipation symptoms. Moreover, some aspects of probiotic use in constipation-related outcomes remain unanswered, such as the best dose, duration, time of consumption (before, during, or after meals), and matrices, as well as their effect and mechanisms on the regulation of inflammation in patients with constipation, on polymorphisms associated with constipation, and on the management of constipation via 5-HT. Thus, more high-quality randomized control trials (RCTs) evaluating these lacking aspects are necessary to provide safe conclusions about their effectiveness in managing intestinal constipation.

Sargassum plagiophyllum Extract Enhances Colonic Functions and Modulates Gut Microbiota in Constipated Mice

Constipation is a symptom that is widely found in the world’s population. Various dietary supplementations are used to relieve and prevent constipation. Seaweed is widely used for its health benefits. In this study, we aimed to investigate the effects of Sargassum plagiophyllum extract (SPE) on functions of the gastrointestinal tract and gut microbiota. The results show that SPE pretreatment increased the frequency of gut contraction, leading to reduce gut transit time. SPE pretreatment also significantly increased the secretion of Cl− and reduced Na+ absorption, increasing fecal water content in constipated mice (p < 0.05). In addition, the Bifidobacteria population in cecal contents was significantly higher in constipated mice pretreated with 500 mg/kg SPE for 14 days than in untreated constipated mice (p < 0.05). Our findings suggest that SPE can prevent constipation in loperamide-induced mice. This study may be useful for the development of human food supplements from S. plagiophyllum, which prevent constipation.