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PubMed2004

Effect of tegaserod in chronic constipation: a randomized, double-blind, controlled trial.

BACKGROUND AND AIMS: Chronic constipation is a common gastrointestinal disorder. The aim of this study was to evaluate the efficacy, safety, and tolerability of tegaserod, a serotonin subtype 4 receptor partial agonist in patients with chronic constipation. METHODS: This was a randomized, double-blind, placebo-controlled study. After a 2-week baseline, patients received tegaserod 2 mg twice daily (n = 450), tegaserod 6 mg twice daily (n = 451), or placebo (n = 447) for 12 weeks, followed by a 4-week withdrawal period. Responders were those patients having been treated for at least 7 days with an increase of > or =1 complete spontaneous bowel movement/week vs. baseline during weeks 1-4 (primary variable) and weeks 1-12 (secondary variable). Other secondary variables included patient assessment of constipation symptoms (number of bowel movements, stool form, abdominal bloating/distention, straining, and abdominal pain/discomfort), and global assessment of constipation and bowel habits. RESULTS: Responder rates for complete spontaneous bowel movement during weeks 1-4 were significantly greater ( P < 0.0001) in the tegaserod 2 mg twice daily (41.4%) and 6 mg twice daily groups (43.2%) vs. placebo (25.1%). This effect was maintained over 12 weeks. Statistically significant improvements over placebo were observed across the majority of secondary variables for both tegaserod doses. No rebound effect was observed after treatment withdrawal. Tegaserod was well tolerated; headache and nasopharyngitis, the most frequent adverse events, were more common in the placebo group than in either tegaserod group. CONCLUSIONS: Over 12 weeks, tegaserod treatment produced significant improvements in chronic constipation symptoms and was also safe and well tolerated.

Chronic Disease↗
PubMed2003

Are colonic regular contractile frequency patterns in slow transit constipation a relevant pathophysiological phenomenon?

BACKGROUND: Pathogenesis of slow transit constipation still remains elusive. Some studies have shown several colonic motor abnormalities; however, it is not easy to understand the relative importance of the single ones. AIMS: Since it has been hypothesized that an excess of periodic distal motor activity may be of pathophysiological importance in patients with slow transit constipation, we evaluated regular colonic contractile frequencies in a homogeneous cohort of these patients. PATIENTS: A total of 26 female patients (age range 34 to 67 years) fulfilling the Rome II criteria for constipation entered the study. No patient had evidence of secondary forms of constipation and distal obstruction. METHODS: Twenty-four hour colonic manometric studies were obtained for each patient. Regular contractile patterns (with frequencies ranging from 2 to 8 cycles/min) were calculated for the entire recording period and in single colonic segments. RESULTS: Overall, regular patterns accounted for about 3% of the total colonic motor activity (average 30 min/day per subject), with the 3 cycles/min being the predominant contractile rhythm. Most of this activity was present in the sigmoid colon, accounting for >50% of the total amount of motility, and it was more prevalent than in the descending and transverse colon; no differences were revealed in the descending with respect to the transverse colon. No daily fluctuations of regular contractile activity, nor a cyclic pattern, nor migration between recording points were observed. CONCLUSIONS: Regular colonic frequency patterns are probably of minor pathophysiological importance in slow transit constipation, even in the light of the scant amount of such phenomena previously documented in healthy subjects.

Adult↗
PubMed2006

Pathophysiology, diagnosis and current management of chronic constipation.

Chronic constipation is prevalent in Western countries and is a complaint that is commonly seen in clinical practice. Only a relatively small percentage of constipated patients seek medical evaluation and most can be managed satisfactorily with first-line, conservative therapy. In patients with severe, refractory constipation, additional studies of colonic and anorectal function have clinical utility, as such patients are candidates for therapies not given to most constipated patients. This article reviews the modern principles and therapies used to manage chronic constipation of varying severities.

Chronic Disease↗
PubMed1998

Constipation and other chronic gastrointestinal problems in spinal cord injury patients.

From a questionnaire sent to 90 spinal cord injury (SCI) patients it is concluded that 58% of patients with a complete SCI above L2 suffer from constipation, defined as two or fewer bowel movements per week, or the use of aids such as laxatives, manual evacuation or enemas. Tetraplegic patients had the highest prevalence of constipation, while patients with low paraplegia were less prone to constipation. The use of anticholinergic drugs was found to predispose to constipation. Preserved rectal sensation did not influence the presence of constipation. Faecal incontinence was rare. Regular abdominal pain was present in one third of SCI patients and might be caused by an irritable bowel syndrome in 62% of these.

Abdominal Pain↗
PubMed1998

Malone antegrade continence enema for faecal incontinence and constipation in adults.

BACKGROUND: In the Malone antegrade continence enema (ACE) technique the appendix or a 'neoappendix' created from the caecum is brought to the abdominal wall creating a small stoma. Thereby, antegrade enemas can be administered to empty the colorectum and prevent faecal incontinence or constipation in children with congenital malformations. The aim of this study was to describe the results of the ACE in adults suffering from faecal incontinence or constipation. METHODS: In 16 adult patients (ten women and six men) suffering from severe faecal incontinence (ten patients) or constipation (six patients) the ACE procedure was performed; the appendix was used in 12 and a 'neoappendix' was created in four. Patient records were used for the description of surgical procedures and complications. Results were evaluated by a structured telephone interview. RESULTS: After a follow-up of 1-39 (mean 17) months, four patients had stopped using the stoma because of abdominal pain or lack of effect. Among the other 12 patients overall satisfaction with the stoma was high or very high. In constipated patients mean time for defaecation was reduced from 170 to 45 min. Faecal incontinence was much reduced in eight patients; the impact on social activities and quality of life caused by bowel dysfunction was reduced in all 12 patients. CONCLUSION: The ACE technique can be used to treat selected adult patients suffering from faecal incontinence or constipation.

Adult↗
PubMed2003

A 6-year follow-up study of chronic constipation and soiling in a specialist paediatric service.

OBJECTIVE: Constipation and soiling is a relatively common condition in childhood and its course is often chronic. This study investigated long-term outcome of children with chronic constipation and soiling by following up a cohort of children 6 years after their presentation to a specialist paediatric gastroenterology clinic with chronic constipation and soiling. DESIGN: Retrospective postal survey. SETTING/SAMPLE: All children referred in 1991 to a specialist paediatric gastroenterology clinic accepting both secondary and tertiary referrals. MEASURES: A semi-structured postal questionnaire was sent to all families, and the Strengths and Difficulties Questionnaire (SDQ) was sent to a random sample. RESULTS: The response rate (of those who could be traced) was 89%. Of these, over a third (36%) still had a problem with constipation and soiling and 17% were using regular laxatives. Three people still having problems with constipation and soiling in the sample were aged over 18 years. No significant difference was found with regard to age, sex or age at referral between the group that improved and the group that did not. Both groups felt they had suffered a high degree of distress because of the problem, with parents highlighting their powerlessness to help their child and the child identifying the embarrassment caused by the problem. CONCLUSIONS: A significant number of children presenting to a specialist paediatric clinic continue to have problems for several years. Further research is needed to identify these cases and to identify which factors promote resolution of the problem.

Adolescent↗
PubMed2000

Proximal and distal gut hormone secretion in slow transit constipation.

BACKGROUND: It has been suggested that slow transit constipation might be part of a panenteric disorder. Gastrointestinal peptides are involved in regulation of motility. DESIGN: In the present study we have evaluated whether plasma levels of proximal and distal gut hormones in the fasting state, and for 120 min after a solid meal in 29 patients with slow transit constipation are different from those obtained from 29 healthy controls. Plasma levels of the gut hormones cholecystokinin, gastrin, pancreatic polypeptide, motilin, neurotensin and peptide YY were determined using sensitive radioimmunoassays. In the patient group, oro-caecal transit time was determined by means of the hydrogen breath test on a separate test day. The results of transit were related with postprandial hormone secretion. RESULTS: Fasting plasma levels of cholecystokinin and pancreatic polypeptide were significantly (P < 0.05) increased in constipated patients. Postprandially, secretion of pancreatic polypeptide and cholecystokinin was significantly (P < 0.05) increased in the patients, while secretion of peptide YY was significantly (P < 0.05) reduced. Plasma motilin levels were not different between patients and controls. Altered postprandial hormone secretion was mainly observed in constipated patients with prolonged oro-caecal transit time. CONCLUSIONS: In patients with slow transit constipation, fasting and postprandial secretion of proximal gut hormones apart from motilin is increased and of distal gut hormones decreased, especially in those with severely delayed intestinal transit.

Adult↗
PubMed2001

Slow transit constipation in children.

Patients with chronic constipation that fails to respond to treatment remain a challenge for paediatricians and surgeons. Ongoing work in our institution suggests that a number of children with intractable symptoms have slow transit constipation, which has only been described recently in paediatrics. Common features of slow transit are: delayed passage of the first meconium stool beyond 24 h of age, symptoms of severe constipation within a year, or treatment-resistant 'encopresis' at 2-3 years, soft stools despite infrequent bowel actions, and delay in colonic transit on a transit study. A proportion of children with slow transit constipation have an abnormality of intestinal innervation associated with the dysfunctional colonic motility, recognized as intestinal neuronal dysplasia (IND). Intestinal neuronal dysplasia type B, the most common variant of IND, is defined on rectal biopsy by hyperplasia of the submucosal plexus. On laparoscopic colon muscle biopsy, many specimens show reduced numbers of excitatory substance P-immunoreactive nerve fibres in the circular muscle. Functional markers of the nerves allow new diagnostic criteria to be developed which may also allow a more rational approach to treatment. The aetiology remains obscure and the optimal management poorly defined, although subtotal colectomy, proximal colostomy or appendicostomy (for antegrade enemas) have been tried. Once the anatomy and physiology of the colon in children with slow colonic transit is better understood, we will have defined not only a new form of constipation, but also will be able to consider new therapies.

Child↗
PubMed2003

Chronic idiopathic slow transit constipation: pathophysiology and management.

OBJECTIVE: Patients with idiopathic slow-transit constipation comprise a small proportion of the total population complaining of constipation. The purpose of this review is to present an update of pathophysiology of this disorder and its application in clinical management. METHODS: Medline was used to search English language articles published up to the end of September 2002 on the subject of slow-transit constipation. RESULTS AND CONCLUSIONS: Patients with idiopathic slow-transit constipation can be divided into 2 subgroups: 1. patients with normal proximal gastrointestinal motility and with onset of constipation in connection with childbirth or pelvic surgery. This subgroup may benefit from consideration of surgical treatment; 2. patients who have a dysfunctional enteric nervous/neuroendocrine system and exhibit colonic dysmotility as part of a generalised gastrointestinal dysmotility. Surgical approach in this subgroup seems to be unhelpful and medical treatment appears to be a better approach.

Autonomic Nervous System↗
PubMed2000

Recombinant human neurotrophic factors accelerate colonic transit and relieve constipation in humans.

BACKGROUND & AIMS: The aim of this study was to assess the effects of recombinant human brain-derived neurotrophic factor (r-metHuBDNF) and recombinant human neurotrophic factor 3 (r-metHuNT-3) on gastrointestinal motor functions in healthy people and in patients with constipation. METHODS: Gastrointestinal and colonic transit was measured by scintigraphy before and after 2 weeks of treatment. Daily diaries documented symptoms over 6 weeks before, during, and after treatment. In a randomized study of healthy subjects, 40 received 100 microg/kg r-metHuBDNF or placebo subcutaneously (SC) daily. In a separate study, 8 healthy subjects and 8 patients with constipation received 300 microg/kg r-metHuNT-3 SC thrice weekly. RESULTS: r-met-HuBDNF accelerated overall and proximal colonic emptying (P<0.05) in health. r-metHuNT-3 accelerated overall colonic transit in health and constipation (all P<0.05) and gastric and small bowel transit (both P<0.05) in health. r-metHuBDNF tended to increase stool frequency compared with placebo in health (P = 0.09). r-metHuNT-3 increased stool frequency (P = 0.05) and facilitated passage of stool (P < 0.01) in constipated patients. The effects on stool frequency started within 3 days of the beginning of neurotrophin administrations and lasted up to 5 days after treatment ended. r-metHu neurotrophic factors were well tolerated, although half of the participants in the 2 studies developed injection site reactions or paresthesiae. CONCLUSIONS: Exogenous neurotrophic factors stimulate human gut motility in health and constipation.

Adult↗
PubMed2002

A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation.

BACKGROUND: The self-reported bowel habits and the prevalence of faecal incontinence and constipation in men and women between the ages of 31 and 76 are assessed. METHODS: A postal questionnaire was sent to a random sample (n = 2000) of the total population of persons between the ages of 31 and 76 living in the County of Ostergötland, Sweden. RESULTS: The response rate was 80.5%. Overall, 67.8% reported one bowel movement per day and 4.4% had more than 21 or less than 3 bowel movements per week. This means that 95.6% had between 3 bowel movements a day to 3 bowel movements a week. Among women, 4.3%, and among men. 1.7%, reported less than 3 bowel movements per week. Women and men used the same terms to describe the definition of constipation. Women had a significantly higher self-reported prevalence of constipation than men (P < 0.0001). About 20% of all women considered themselves constipated. The use of laxatives increased with age and 22% and 10% of elderly women and men, respectively, used laxatives including bulking agents for at least every fourth toilet procedure. About 10% reported leakage of faeces more often than once a month in the case of loose stools. With solid faeces, the rate of leakage was 1.4% and 0.4% for women and men, respectively. Soiling of underclothes more than once a month occurred in 21% of men and in 14.5% of women (P = 0.006) and involuntary daily leakage of gas in 5.9% of men and 4.9% of women (n.s.). CONCLUSIONS: Constipation and faecal incontinence are common problems in a general Swedish population.

Adult↗
PubMed2005

Effects of regular physical activity on defecation pattern in middle-aged patients complaining of chronic constipation.

OBJECTIVE: It is not well known whether physical activity (PA) is useful in the management of patients complaining of constipation. The aim of this study was to test the influence of regular PA on colonic transit time and defecation in middle-aged inactive patients suffering from chronic idiopathic constipation. MATERIAL AND METHODS: Forty-three subjects (> 45 years) were randomly divided into group A (n = 18, 16 F, 2 M) and group B (n = 25, 20 F, 5 M). Group A subjects maintained their normal lifestyle during 12 weeks, followed by a 12-week PA programme. Group B performed a 12-week PA programme after randomization. PA comprised 30 min of brisk walking and a daily 11-min home-based programme. Both groups received dietary advice. Colonic transit time was measured using a radiographic multiple marker single film technique. RESULTS: Despite dietary advice, mean fibre and fluid intake did not change. In group B a significant reduction in 3 out of 4 of the Rome I criteria for constipation was observed, i.e. percentage of incomplete defecations, percentage of defecations requiring straining and percentage of hard stools (p < 0.05). As a consequence, the number of fulfilled Rome criteria for constipation decreased (2.7 to 1.7; p < 0.05). Furthermore, the rectosigmoid and total colonic transit time decreased (17.5 to 9.6 h and 79.2 to 58.4 h, respectively; p < 0.05). After PA the number of fulfilled Rome criteria also decreased in group A (2.6 to 1.7; p < 0.05). CONCLUSIONS: In middle-aged inactive subjects with symptoms of chronic constipation, it is advisable to promote regular physical activity since it improves both the defecation pattern and rectosigmoid or total colonic transit time.

Age Factors↗
PubMed1998

Antroduodenal manometry findings in patients with slow-transit constipation.

BACKGROUND: The results of subtotal colectomy for slow-transit constipation are unpredictable. Abdominal pain, distension, and bloating often persist after operation. To ascertain whether patients with slow-transit constipation may have a generalized intestinal motor disorder, we studied the antroduodenal motor activity in 20 consecutive patients with slow-transit constipation. METHODS: All patients underwent symptom registration, whole-gut transit time, anorectal manometry, electromyography of the anal sphincter, the balloon expulsion test, and defecography to characterize their constipation. The motor activity of the the gastric antrum and the proximal small bowel was monitored for 5 h, using a pneumohydraulic water-perfused manometry system with six channels. RESULTS: Twelve patients (60%) had abnormal patterns of motor activity: abnormal propagation or configuration of phase III in 9 of 12 patients, bursts of non-propagated phasic activity in 8 of 12 patients, and sustained periods of intense phasic activity in 3 of 12 patients. One patient had generalized hypomotility with low-amplitude contractions. In addition, an abundance of so-called discrete clustered contractions was found in 6 of 20 patients. CONCLUSION: A significant proportion of patients with slow-transit constipation have manometric findings that indicate a generalized motor disorder of the gut. The clinical significance of this finding is still unclear.

Adolescent↗
PubMed1999

Abnormal colonic endocrine cells in patients with chronic idiopathic slow-transit constipation.

BACKGROUND: The aim of the present study was to investigate the colonic endocrine cells in patients with slow-transit constipation, to ascertain the presence of a possible abnormality. METHODS: Ten patients with chronic slow-transit constipation were investigated. As controls, macroscopically and histologically normal tissues from the colon of 12 patients were examined. These patients had polyps, prolapsis, chronic diverticulitis, volvulus, and haemorrhoids. The endocrine cells were stained by immunocytochemistry and quantified by computerized image analysis. RESULTS: There were significantly fewer enteroglucagon- and serotonin-immunoreactive cells in patients with chronic slow-transit constipation. There was no statistically significant difference between patients and controls with regard to the number of peptide YY (PYY)-, pancreatic polypeptide (PP)-, and somatostatin-immunoreactive cells. The cell secretory indexes (CSI) of enteroglucagon- and somatostatin-immunoreactive cells were significantly decreased. There was no statistically significant difference in the CSI between the patients and controls with regard to PYY-, PP-, and serotonin-immunoreactive cells. CONCLUSION: The changes in colonic endocrine cells in patients with slow-transit constipation may be one cause of the decreased motility in the colon and consequent development of constipation.

Adult↗
PubMed2000

Empirically supported treatments in pediatric psychology: constipation and encopresis.

OBJECTIVE: To review the empirical research examining behavioral and medical treatments for constipation and fecal incontinence. METHOD: Sixty-five articles investigating intervention efficacy were identified and reviewed. Twenty-three of the studies were excluded because they were case studies or were less well-controlled single-case designs. The intervention protocol for each study was identified and coded, with studies employing the same interventions matched and evaluated according to the Chambless criteria. RESULTS: From the literature base to date, no well-established interventions have emerged. However, four probably efficacious treatments and three promising interventions were identified. Two different medical interventions plus positive reinforcement fit the criteria for the probably efficacious category (one with fiber recommendation and one without). Three biofeedback plus medical interventions fit efficacy category criteria: one probably efficacious for constipation with abnormal defecation dynamics (full medical intervention plus biofeedback for paradoxical contraction), and two fit the promising intervention criteria for constipation and abnormal defecation dynamics (full medical intervention plus biofeedback for EAS strengthening, correction of paradoxical contraction and home practice; and biofeedback focused on correction of paradoxical contraction, medical intervention without fiber recommendation, and positive reinforcement). Two extensive behavioral interventions plus medical intervention also met efficacy criteria for constipation plus incontinence (medical intervention without laxative maintenance plus positive reinforcement, dietary education, goal setting, and skills building presented in a small-group format fits criteria for a promising intervention; and positive reinforcement and skills building focused on relaxation of the EAS during defecation, but without biofeedback, plus medical intervention meets the probably efficacious criteria). CONCLUSIONS: A discussion of the current weaknesses in this research area follows. Specific recommendations for future research are made including greater clarity in treatment protocol and sample descriptions, reporting cure rates rather than success rates, utilization of adherence checks, and investigation of potential differential outcomes for subgroups of children with constipation and incontinence.

Behavior Therapy↗
PubMed2001

Colchicine for persistent constipation after total abdominal colectomy with ileorectostomy for colonic inertia.

Severe constipation caused by colonic inertia may be associated with a generalized gastrointestinal dysmotility syndrome. Patients with severe constipation pose a significant challenge in terms of management. Failure of medical therapy usually leads to surgery in the form of a subtotal colectomy. Most patients develop diarrhea after the surgery, but a subgroup of patients continue to experience constipation. We report the case of such a patient who underwent a total abdominal colectomy and ileorectostomy for intractable constipation. He continued to have constipation after the surgery that was responsive only to a gallon of bowel-cleansing solution. A treatment trial of colchicine was partially unsuccessful when used on its own, but a combination of colchicine and a lesser dose of Colyte was found to be effective in maintaining regular bowel movements.

Adult↗
PubMed2002

Early constipation and toilet training in children with encopresis.

OBJECTIVE: To evaluate the frequency of predisposing factors for encopresis before and during toilet training, comparing children with primary and secondary encopresis. METHODS: In this retrospective study, questionnaires from the initial evaluation at an encopresis clinic at a tertiary care pediatric hospital were reviewed for the presence or absence of factors in the first 2 years of life, for toilet training practices, and for disruptive events during the training process. Children younger than 48 months or those with organic defecation disorders were excluded. RESULTS: In 411 children with encopresis, the reported frequency of predisposing factors included constipation in 35%, and previous treatment for constipation in 24%. Toilet training was initiated before age 2 years in 26% and after age 3 years in 14%. Interruption of toilet training and punishment were seen more in primary encopresis than in secondary encopresis (50% versus 23%; P < 0.05) and (52% versus 26%; P < 0.05) respectively. Constipation (30% versus 18%; P < 0.05) and abdominal pain (23% versus 9%; P <0.0:5) during toilet training were more common in primary encopresis as was fear of the toilet (47% versus 10%; P < 0.05). CONCLUSIONS: In children with encopresis, early difficult defecation, previous treatment for constipation, and early initiation of toilet training were less common than expected. Children with primary encopresis did not have an increased incidence of early constipation or invasive treatments compared with those with secondary encopresis. However, children with primary encopresis did have more difficult and disruptive toilet training experiences.

Adolescent↗
PubMed2002

Total and segmental colonic transit time and anorectal manometry in children with chronic idiopathic constipation.

BACKGROUND: Constipation is a frequent symptom in pediatric clinical practice, although the underlying pathogenesis is not fully understood. Estimating the colonic transit time may help identify subgroups of patients with different physiopathologic mechanisms. METHODS: Thirty children with normal bowel habits and 38 children with chronic idiopathic constipation, aged 2 to 14 years, were studied. The total and segmental colonic transit times were estimated by administering multiple radiopaque markers for 6 days and performing a single abdominal radiograph on day 7. Anorectal function was evaluated using manometry with an Arhan probe. RESULTS: The observed upper reference values were 19.02 hours for the right colon, 19 hours for the left colon, 32 hours for the rectosigmoid colon, and 45.7 hours for the total colon. Fifty percent of the children with chronic idiopathic constipation had colonic transit times within reference values, whereas 37% had left colonic and rectosigmoid delays and 13% had global delay in all colonic segments (colonic inertia). Paradoxic anal contraction was observed in 64% of the constipated children with distal delay but in none of the subjects with colonic inertia. CONCLUSIONS: Estimating colonic transit time is a simple and noninvasive technique for classifying patients with constipation. Colonic inertia may be a manifestation of global motility dysfunction. Children with delayed distal colonic transits are more likely to have abnormal defecation dynamics.

Adolescent↗