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PubMed2002

Introducing abdominal massage in palliative care for the relief of constipation.

Constipation and its associated problems affect approximately 50% of patients admitted to hospices in the United Kingdom. It is common practice in many hospices to offer a range of complementary therapies of which aromatherapy massage is one. Abdominal massage for the relief of constipation was once a commonly practised therapy but its use declined over time, like other complementary therapies there is now a rekindling of interest in the role that abdominal massage may play in relieving constipation. This paper will explain how a safe non-invasive easily learnt technique of abdominal massage was introduced in a palliative care setting to help relieve some of the problems associated with constipation. Despite the number of patients involved in this project being small, relief from some of the symptoms associated with constipation was experienced by some patients. A formal study of the benefits of abdominal massage in palliative care far the relief of constipation is needed.

Abdomen↗
PubMed2001

Motor and sensory function of the rectum in different subtypes of constipation.

BACKGROUND: It is not known whether evaluation of motor and sensory function of the rectum using a barostat may help to distinguish subtypes of constipation. METHODS: Motor and sensory function of the rectum have been evaluated using a barostat in 14 patients with slow transit constipation (STC), 12 patients with constipation-predominant irritable bowel syndrome (IBS) and 18 healthy controls. First minimal distending pressure was determined, after which spontaneous adaptive relaxation of the rectum was monitored. Then a step-wise isobaric distension procedure was performed, during which symptom perception was determined. The distension was followed by a 90-min barostat procedure: for 30 min in the basal state followed by ingestion of a semi-liquid meal (postprandial state). RESULTS: Minimal distending pressure was not different between both patient groups and controls, neither was compliance different between constipated patients and controls. The degree of spontaneous adaptive relaxation was in the same range in all groups. During distensions with high pressures, the perception of urge was significantly reduced in STC patients compared to IBS and controls, while the perception of pain was significantly increased in IBS versus STC and controls. Postprandially, a small decrease of rectal volume was only observed in the control group, but not in the patients. CONCLUSIONS: Rectal motor characteristics are not different between patients with constipation-predominant IBS, patients with STC and healthy controls while during isobaric distensions, sensations of urge were reduced in STC and sensations of pain were increased in IBS. Rectal visceroperception testing may help distinguish groups of patients with different subtypes of constipation.

Adult↗
PubMed2005

Development and validation of the Patient Assessment of Constipation Quality of Life questionnaire.

OBJECTIVE: Chronic constipation is characterized by difficult, infrequent, or seemingly incomplete bowel movements. The Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire was developed to address the need for a standardized, patient-reported outcomes measure to evaluate constipation over time. MATERIAL AND METHODS: Items for the PAC-QOL were generated from the literature, clinical experts, and patients. Following principal components and multi-trait analyses, 28 items were retained forming four subscales (worries and concerns, physical discomfort, psychosocial discomfort, and satisfaction) and an overall scale. Validation studies were conducted in the United States, Europe, Canada, and Australia, to evaluate the internal consistency reliability (Cronbach's alpha), reproducibility (Intraclass Correlation Coefficients (ICCs)), validity (analysis of variance models), and responsiveness (effect size) of the PAC-QOL scales. RESULTS: The PAC-QOL scales were internally consistent (Cronbach's alpha >0.80) and reproducible (ICCs >0.70, except for the satisfaction subscale ICC=0.66). PAC-QOL scale scores were significantly associated with abdominal pain (p<0.001) and constipation severity (p<0.05). Effect sizes in patients reporting improvements in constipation over a 6-week period were moderate to large, with subscale effect sizes ranging from 0.76 to 3.41 and the overall scale effect size=1.77. Similar findings were observed in validation studies conducted in Europe, Canada, and Australia. CONCLUSIONS: The PAC-QOL is a brief but comprehensive assessment of the burden of constipation on patients' everyday functioning and well-being. Multinational studies demonstrate that the PAC-QOL is internally consistent, reproducible, valid, and responsive to improvements over time.

Adult↗
PubMed1998

The intestinal ecosystem in chronic functional constipation.

Chronic functional constipation is common in infants, and the bacterial composition of stools in this condition is not known. The study aims were to: (i) investigate the composition of the intestinal ecosystem in chronic functional constipation; (ii) establish whether the addition of the water-holding agent calcium polycarbophil to the diet induces an improvement in constipation; and (iii) determine the composition of the intestinal ecosystem after the use of this agent. In total, 42 children (20F, 22M; mean age: 8.6 +/- 2.9 y) were studied. Twenty-eight children with functional chronic constipation without anatomical disorders were treated double-blind in random sequence for 1 month with an oral preparation of calcium polycarbophil (0.62 g/twice daily) or placebo. Intestinal flora composition was evaluated by standard microbiological methods and biochemical assays on faecal samples collected before and after treatment. Fourteen healthy children were studied as controls. The results show that (i) the constipated children presented a significant increase in clostridia and bifidobacteria in faeces compared to healthy subjects--different species of clostridia and enterobacteriaceae were frequently isolated; no generalized overgrowth was observed; Clostridia outnumbered bacteroides and E. coli mean counts by 2-3log, while bacteroides and E. coli counts were similar (5-6 log10/g fresh faeces); these intestinal disturbances could be defined as a dysbiosis, i.e. a quantitative alteration in the relative proportions of certain intestinal bacterial species. (ii) Clinical resolution of constipation was achieved only in 43% of treated children and an improvement in 21% (one bowel movement every 2 d). (iii) Calcium polycarbophil treatment induced no significant changes in the composition of the intestinal ecosystem, nor in blood chemistry parameters.

Acrylic Resins↗
PubMed1984

Sensitivity of the sigmoid colon and rectum in children treated for chronic constipation.

Sensations in the sigmoid and rectum and the response of the anal canal to balloon distension were measured with a latex balloon and pressure transducer in 15 chronically constipated and 15 healthy control children. The constipated children received milk of magnesia and bowel training. Thirteen constipated children were restudied 7-12 months later and 11 were restudied 3 years later. Although thresholds of transient sensation and of the rectosphincteric reflex were not different in constipated and control children, the threshold of fullness, the critical volume, and the volume for constant relaxation were significantly higher in constipated than in control children (p less than 0.05), and remained higher 1 year and 3 years later, even in the children who recovered. The initial data support the concept of a sigmoid and rectum so enlarged that a normal fecal bolus may not cause a sensation of fullness or a sensory stimulus for defecation. Despite improvement in clinical manifestations and normal rectal size, the abnormalities in sensitivity of the sigmoid and rectum persisted in five of eight recovered children. This may explain why these children are so vulnerable to recurrence of constipation and fecal soiling.

Anal Canal↗
PubMed1990

Breath methane production in children with constipation and encopresis.

Breath methane excretion is uncommon in children compared with adults. Certain intracolonic conditions, however, have been associated with enhanced methane generation. We hypothesized that encopretic and constipated children, who have abnormal colonic transit times, more likely would excrete methane than healthy children. To determine the prevalence of methane excretion among children with encopresis or simple constipation, we performed breath methane analysis on such patients and age-, race-, and sex-matched control subjects. Encopretic patients (mean age, 8.3 +/- 3.0 years) had daily, involuntary passage of feces and clinical evidence of constipation. Constipated patients (mean age, 7.1 +/- 2.9 years) had a history of hard stools and at least one of the following symptoms: infrequent defecation, dyschezia, hematochezia, difficult stool expulsion, or abdominal pain during bowel movements. Methane excretion was present in 26 of 40 (65%) encopretic patients versus 6 of 40 (15%) control patients (P less than 0.001). In contrast, 3 of 27 (11%) constipated patients were methane excreters, versus 2 of 27 (7%) controls (P = 0.4). Fourteen asymptomatic encopretic patients were retested after successful therapy; eight were methane excreters initially, but five of eight did not excrete methane after treatment. We conclude that methane is produced in a large number of children with encopresis. Treatment appears to alter methanogenesis in such patients. The prevalence of methane producers among constipated children is not different from the prevalence in healthy subjects. Methanogenesis in encopretic patients may be enhanced by prolonged colonic transit time or abnormal intracolonic conditions.

Age Factors↗
PubMed1999

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition.

BACKGROUND: Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. METHODS: The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. RESULTS: The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist. CONCLUSIONS: This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Child↗
PubMed1996

Decreased substance P levels in rectal biopsies from patients with slow transit constipation.

OBJECTIVE: Previous studies in patients with chronic constipation found abnormalities in the nervous tissue of the large intestine, predominantly in the muscularis externa. Since there is evidence that the nervous system of mucosa and submucosa is also involved in the control of colonic motility we investigated the contents of vasoactive intestinal polypeptide (VIP), somatostatin and substance P in rectal biopsies of patients with slow colonic transit constipation. DESIGN AND METHODS: Twenty-two patients (17 females, 5 males) with chronic slow transit constipation (oro-anal transit with radio-opaque markers on high fibre diet > 70 h) and long-term use of laxatives, and 20 controls (12 females, 8 males) with no history of constipation, were included in this study. Large rectal biopsy specimens including the submucosa were obtained from 5 cm above the dentate line and frozen in liquid nitrogen. After microdissection of the biopsies into mucosa and submucosa the neuropeptides were extracted by boiling and homogenizing the tissue in acetic acid and determined using validated radioimmunoassays. RESULTS: Patients with slow transit constipation showed, compared to healthy controls, significantly lower levels of the excitatory neurotransmitter substance P in the mucosa and submucosa of rectal biopsies. There was no difference between the two groups concerning the levels of the inhibitory neurotransmitters, VIP and somatostatin. CONCLUSION: Slow transit constipation is associated with abnormalities of the substance P content of the enteric nervous system of mucosa and submucosa. This seems not to be related to chronic laxative use, since anthranoids cause a reduction in the levels of inhibitory neurotransmitters (VIP, somatostatin), but not of substance P, in the rat colon.

Biopsy↗
PubMed2002

Effects of carbonated water on functional dyspepsia and constipation.

OBJECTIVE: The effects of carbonated beverages on the gastrointestinal tract have been poorly investigated. Therefore, this study aims to assess the effect of carbonated water intake in patients with functional dyspepsia and constipation. METHODS: Twenty-one patients with dyspepsia and secondary constipation were randomized into two groups in a double-blind fashion. One group (10 subjects) drank carbonated water and the other (11 subjects) tap water for almost 15 days. Patients were evaluated for dyspepsia and constipation scores, and underwent a satiety test by a liquid meal, radionuclide gastric emptying, sonographic gallbladder emptying and colonic transit time, using radio-opaque markers. RESULTS: The dyspepsia score was significantly reduced with carbonated water (before = 7.9 +/- 2.8 after = 5.4 +/- 1.7; 0.05) and remained unmodified after tap water (9.7 +/- 5.3 9.9 +/- 4.0). The constipation score also decreased significantly ( 0.05) after carbonated water (16.0 +/- 3.9 12.1 +/- 4.4; 0.05) and was not significantly different with tap water (14.7 +/- 5.1 13.7 +/- 4.7). Satiety was significantly reduced with carbonated water (before = 447 +/- 146 kcal after = 590 +/- 245; 0.01). Gallbladder emptying (delta percent contraction) was significantly improved only with carbonated water (39.9 +/- 16.1% 53.6 +/- 16.7%; 0.01). CONCLUSION: In patients complaining of functional dyspepsia and constipation, carbonated water decreases satiety and improves dyspepsia, constipation and gallbladder emptying.

Adult↗
PubMed2006

Colorectal motor and sensitivity features in patients affected by ulcerative proctitis with constipation: a radiological and manometric controlled study.

BACKGROUND AND AIM: Constipation may be present in ulcerative proctitis (UP), but its pathogenesis has not yet been evaluated. The aim of this article is to investigate functional and morphologic features of the anorectal region in patients with UP and constipation. MATERIALS AND METHODS: Eleven patients with quiescent clinical, endoscopic, and histological UP and constipation and 10 patients with functional constipation (FC) underwent radiologic evaluation of intestinal transit time, anorectal manometry, and defecography. Transit time was measured with radiograms at 72 h after ingestion of radiopaque markers. Manometry was carried out using a continuous perfused catheter and a balloon inflated with increasing volumes of air. Defecography was performed after the injection of a barium-sulfate solution in the rectum, with the registration of videotapes during straining, squeezing, and evacuation. RESULTS: Manometry showed in UP significantly lower values of rectal compliance than those in FC (3.10 and 5 mL/mmHg, respectively) (P = 0.03). Rectal sensitivity threshold was increased but without significant differences in UP and FC (30 and 50 mL air, respectively). At defecography, the median value of rectosacral space was increased in UP in comparison with FC (1.30 vs 0.8; P = 0.002). Lateral rectal diameter in UP was lower than in FC (6 and 8.8 cm, respectively; P = 0.016). Nonsymptomatic rectocele, mucosal prolapse, descending perineum, and abdominopelvic dyssynergy were equally present in UP and FC. The majority of UP patients showed a prolonged intestinal transit time similar to FC patients, and, more frequently, they showed low transit in the left colon in comparison with the right colon in comparison with FC patients. CONCLUSIONS: This study suggests that constipation in UP may be correlated with rectal fibrosis, which reduces the transit of stools from the left colon. The concomitance of asymptomatic anorectal organic or functional alteration may contribute to worsen constipation.

Adult↗
PubMed2005

Breath methane associated with slow colonic transit time in children with chronic constipation.

OBJECTIVE: This study analyzed the relationship between methane production and colonic transit time in children with chronic constipation. METHODOLOGY: Forty children, from 3 to 13 years of age, suffering from chronic constipation were included. Methane production was defined when the breath methane concentration was greater than 3 ppm. The total and segmental colonic transit times were measured with radio-opaque markers. RESULTS: Soiling was present in 34 (85.0%) of 40 patients with constipation. Methane production was present in 25 of 34 (73.5%) patients with constipation and soiling and only in 1 (16.7%) of 6 with constipation but without soiling (P = 0.014). The medians of total colonic transit time were 80.5 and 61.0 hours, respectively (P = 0.04), in methane and nonmethane producers. Segmental colonic transit times were 17.5 and 10.5 hours, respectively (P = 0.580), in right colon, 29.5 and 10.5 hours (P = 0.001), respectively, in left colon, and 31.5 and 27.0 hours (P = 0.202), respectively, in the rectosigmoid. By the sixth week of treatment, the reduction in the total colonic transit time was greater in patients who had become nonmethane producers. CONCLUSION: The presence of breath methane in children with chronic constipation may suggest the possibility of prolonged colonic transit time.

Adolescent↗
PubMed2005

Lack of lasting effectiveness of PEG 3350 laxative treatment of constipation.

PURPOSE: PEG 3350 (MiraLax, Braintree Laboratories Inc., Braintree, MA) 17 g daily has been shown to be safe and effective in a 14-day trial for constipation. This present investigation was designed to extend the treatment and safety experience with PEG 3350 and to evaluate any lasting effectiveness during a 30-day post-treatment observation period. METHODS: Study subjects met Rome II criteria for constipation and reported <3 bowel movements a week. They were treated with PEG 3350 17 g daily for 14 days. Treatment efficacy was defined by resolution of constipation symptoms as determined by the Rome II and stool frequency definitions during the treatment period. RESULTS: Fifty healthy constipated subjects formed the study group. There were 42 females and 8 males. Mean age was 52 +/- 15.5 years (+/-SD). Symptom duration was 22.6 +/- 16.7 months (+/-SD). At baseline, all had <3 bowel movements a week and met Rome II criteria. Two were lost to follow-up. Two took enemas or laxatives and 2 discontinued active treatment because of "gas" and were considered treatment failures. At the end of 14 days, 40 of 48 (83.3%) had >3 stools in the last week and no longer met Rome criteria. Thirty-two of 45 (71.1%) reported satisfaction with the first bowel movement after initiating treatment. Thirty days after active treatment, 29 of 47 (61.7%) responded that they needed laxative treatment. CONCLUSION: PEG 3350 relieved constipation in most treated study subjects. During a 30-day post-treatment observation period, 29 of 47 (61.7%) had additional constipation treatment interventions.

Constipation↗
PubMed2007

Emergency department management and short-term outcome of children with constipation.

BACKGROUND: Constipation is a common diagnosis made in the pediatric emergency department (ED). Specific evidence-based standards for evaluation and treatment are lacking. OBJECTIVE: To describe variation in evaluation and treatment of constipation and characteristics and treatments associated with improvement. METHODS: This single-site descriptive study examined constipated children discharged from the ED. Chart review provided history, examination, evaluation, and treatment. Symptoms and on-going treatment were assessed by telephone interview at 4 to 6 weeks. Patients were dichotomized to poor versus adequate responders. Poor responders had 2 or more of the following: overall constipation, persistent presenting symptom, bowel movement frequency of less than once every other day, painful defecation, and/or abdominal pain. RESULTS: The study group had 121 patients, with mean age of 6.4 years; 54% were female. Abdominal pain was the most common complaint (66%); 46% reported hard/infrequent stools. Most (67%) had symptoms for less than 1 week. Many (41%) previously sought care for the same problem. Most (70%) had abdominal radiographs. One third received an enema in the ED, and most patients were prescribed laxatives, most commonly polyethylene glycol (80%). After an enema, 28% were discharged without constipation medication. At follow-up, 35% were using laxatives, and 27% had sought additional care. Nearly half (42%) were poor responders. Poor responders were younger (5.1 vs. 7.3 years; P < 0.01). There was no difference in response based upon sex, duration of symptoms, or ED treatment. CONCLUSIONS: Although older children are more likely to improve, many constipated children continue to have symptoms. Type of ED therapy is unrelated to on-going symptoms at 4 to 6 weeks.

Chi-Square Distribution↗
PubMed1993

Review article: the management of constipation in adults.

The successful management of constipation depends on defining the patient's symptoms, excluding secondary causes, and characterizing the abnormality of defecation. Constipation without gut dilatation is found commonly in pregnancy, the elderly, and those with the irritable bowel syndrome. In addition, there is a group of patients that has intractable, severe idiopathic constipation. Some have 'slow transit' and open their bowels every 1-4 weeks. Others have a defecatory disorder with normal colonic transit. Constipation with gut dilatation is seen in Hirschsprung's disease, idiopathic megarectum and megacolon, chronic intestinal pseudo-obstruction and Chagas' disease. Constipation can also result from disturbance to the autonomic outflow of the gastrointestinal tract, and colonic function may be also affected by psychological factors. This review article discusses the presentation, investigation and management of patients with constipation.

Adult↗
PubMed2004

Review article: tegaserod for chronic constipation.

Constipation is one of the most common gastrointestinal conditions with limited effective treatment options. Tegaserod, a 5-HT4 receptor agonist has demonstrated efficacy in relieving constipation-related symptoms in patients suffering from irritable bowel syndrome with constipation. This paper reviews two recent reports that have evaluated the efficacy and safety of tegaserod in patients with chronic constipation. Two double-blind, randomized, placebo-controlled trials have been reported; one in Europe and Asia (E2301) the other in North and South America (E2302). After a 2-week baseline period, patients were randomized to treatment with tegaserod 2 mg b.d., tegaserod 6 mg b.d. or placebo for 12 weeks. Two thousand, six hundred and twelve patients were randomized, the majority were white females. In both studies, responder rates during weeks 1-4 were significantly greater in the tegaserod groups compared with placebo. A similar trend was seen over weeks 1-12. Statistically significant improvements over placebo were seen across the majority of secondary efficacy variables. Tegaserod was safe with no consistent differences in the frequency of adverse events among the various groups. In conclusion, treatment of chronic constipation with tegaserod was associated with significant improvement in bowel frequency as well as other constipation symptoms. Tegaserod was also well tolerated in this patient population.

Aged↗
PubMed2005

Review article: The role of serotonergic agents in the treatment of patients with primary chronic constipation.

Chronic constipation is a highly prevalent disorder that is associated with significant direct and indirect costs and has substantial impact on patient quality of life. It is more common among women and non-white populations and is evenly distributed across adult age groups. Constipation is a heterogeneous disorder associated with multiple symptoms and aetiologies. Recent research has increased our understanding of the pathogenesis of this disorder and the central role of the neurotransmitter serotonin in mediating gastrointestinal motility, secretion and sensation. Abnormal serotonin signalling and reuptake appear to play central roles in the symptoms of a subset of patients with chronic constipation. This observation provides a rationale for the use of targeted serotonergic agents for the treatment of chronic constipation. As the role of serotonin in gastrointestinal function is further elucidated and additional candidate drugs are developed, it is likely that serotonergic agents will afford additional treatment options for patients with chronic constipation. This article provides a concise review of the evidence supporting a role for serotonin in the pathogenesis of chronic constipation and a summary of the currently available evidence supporting the use of serotonergic agents for this disorder.

Brain↗
PubMed2005

Decreased density of interstitial cells of Cajal and neuronal cells in patients with slow-transit constipation and acquired megacolon.

BACKGROUND: The pathophysiology of constipation is not clearly identified as yet, and the interstital cells of Cajal (ICC), known to generate the slow wave activity and to be involved in intestinal neurotransmission and the enteric nervous system (ENS), are suspected to play an important role. The aims of the present study were to assess the distribution of ICC and neuronal cells of ENS in patients with slow-transit constipation and acquired megacolon. METHODS: Sigmoid colon specimens were obtained from patients who underwent colectomy due to slow-transit constipation (n = 10), acquired megacolon (n = 9) and non-obstructive colon cancer (n = 10) as a control group. The ICC were visualized by c-Kit immunohistochemistry and neuronal cells of the ENS were demonstrated by protein gene product (PGP) 9.5. Density of cells stained by c-Kit and PGP 9.5 was calculated as percent area (area stained/area of X-Y plane) x 100, when images were collected at a magnification of x40 objective, with maximum area examined in the horizontal X-Y plane of 400 microm x 400 microm using an image analyzer. RESULTS: The densities of ICC and PGP 9.5 reactive neuronal structures were significantly decreased in all layers of sigmoid colon specimens in patients with slow-transit constipation and acquired megacolon, compared with that of the control group. However, there was no statistically significant difference in either the density of ICC or that of neuronal structures between the patients with slow-transit constipation and acquired megacolon. CONCLUSIONS: Slow-transit constipation and acquired megacolon were associated with alteration of ICC and neuronal cells of ENS in the sigmoid colon.

Adolescent↗
PubMedDate not supplied

Chronic constipation in children: organic disorders are a major cause.

Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.

Behavior Therapy↗