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PubMed2004

[Surgical management for slow-transit constipation].

Less than 10% of patients with slow-transit constipation require surgical management after failure of medical treatment. Preoperative clinical, psychological and colorectal routine investigations (ie colonic transit test, anorectal manometry and defecography) are mandatory in order to highly select the patients. To day, the surgical management of slow-transit constipation consists of subtotal colectomy with ileorectal anastomosis, eventually by laparoscopic approach. Although, surgical management improves slow-transit constipation in two thirds of the patients, small bowel obstruction, abdominal pain and constipation recurrence can occur in 25%, 50%, and 10% of the patients respectively.

Constipation↗
PubMed2004

Constipation, laxative use and risk of colorectal cancer: The Miyagi Cohort Study.

The objective of this study was to investigate the association between constipation or laxative use and the risk of colorectal cancer in Japanese men and women. In 1990, we delivered a self-administered questionnaire to 41670 subjects who were 40-64 years old. During the seven years of follow-up, 251 incident cases of colorectal cancer were documented. Constipation was defined as a bowel movement frequency of less than daily. The multivariate relative risk (RR) of colorectal cancer for constipated subjects compared with those with daily bowel movements was 1.35 (95% Confidence Interval: 0.99-1.84). The RR for laxative users over non-users was 1.31 (0.88-1.95), and for frequent users (twice a week or more) it was 2.75 (1.48-5.09). When colorectal cancers were divided into colon cancers or rectal cancers, a significant association was found with colon cancer alone. Our results support the hypothesis that constipation or laxative use increases the risk of colon cancer.

Adult↗
PubMed2006

Enteric neuropathology of the terminal ileum in patients with intractable slow-transit constipation.

Slow-transit constipation is usually considered a colonic motor disorder. However, there is some evidence that abnormalities may be present in locations other than the colon. In particular, several studies have reported abnormal motor activity of the small bowel in these patients. We evaluated the neuropathological aspects of the terminal ileum in patients with slow-transit constipation to see whether abnormalities are present that may explain an abnormal motility of the small intestine. Specimens of the terminal ileum were obtained from 16 female patients (age range, 42-76 years) with slow-transit constipation undergoing surgery for intractable symptoms. Fifteen age- and sex-matched controls were used for comparison. Histologic and immunohistochemical evaluation of the myenteric plexus and the smooth muscle of the proximal ileal resection margin was carried out by means of hematoxylin and eosin, trichrome and periodic acid-Schiff stain, neuron-specific enolase, S-100, CD117, CD34, anti-alpha-actin, desmin, and vimentin antibodies. The patient group displayed a significantly reduced number of glial cells, compared with controls, in both the submucosal and the myenteric plexus. Only 1 of the 3 populations of interstitial cells of Cajal (that associated with the deep muscular plexus) was decreased in patients. No differences were found between patients and controls concerning ganglia neurons, fibroblast-like cells, enteric neurons, apoptotic phenomena, and smooth muscle. Patients with slow-transit constipation display neuropathological abnormalities of the terminal ileum to a lesser extent than those we previously found in the colon, which might explain the abnormal motor aspects sometimes found in these patients.

Adult↗
PubMedDate not supplied

Management of constipation in residents with dementia: sorbitol effectiveness and cost.

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

Aged↗
PubMed2006

Efficacy of an herbal dietary supplement (Smooth Move) in the management of constipation in nursing home residents: A randomized, double-blind, placebo-controlled study.

OBJECTIVE: To investigate the efficacy and cost effectiveness of an herbal tea, Smooth Move, in nursing home residents with chronic constipation. DESIGN: Double-blind, placebo-controlled, 2-armed, parallel-group clinical trial. SETTING: A 483-bed nursing home in Allentown, Pennsylvania, operated by Lehigh County Government. PARTICIPANTS: A total of 86 nursing home residents with chronic constipation. INTERVENTIONS: Participants (n = 86) were randomly assigned to receive Smooth Move (n = 42) or a placebo (n = 44), once daily, in addition to standard treatment for chronic constipation. The study period was 28 days. MEASUREMENTS: The primary efficacy parameter was the difference in total number of bowel movements. Secondary parameters included the difference in average number of standard treatment doses dispensed, and the difference in total medication costs. RESULTS: Compared to placebo, in the intention to treat (ITT analysis) there was a statistically significant increase in the number of bowel movements in the Smooth Move group. The Smooth Move group (n = 42) compared with the placebo group (n = 44) experienced an average of 4.14 more bowel movements during the 28-day study period versus the 28-day pre-study period (P = .017). CONCLUSION: Smooth Move herbal tea, when added to the standard treatment regimen for nursing home residents with chronic constipation, increased the average number of bowel movements compared to the addition of a placebo tea.

Beverages↗
PubMed2005

Functional constipation in infants: a follow-up study.

Our objective of this study was to describe the clinical course of severe functional constipation in early childhood. Eligible patients were 47 children (60% boys; median age, 3.5 months) who had constipation in their first year of life. Follow-up data were obtained through a standardized questionnaire. Success was defined as a period of at least 4 weeks with > or =3 painless bowel movements per week. Six months after initial evaluation, 69% of the children were recovered. After initial success, a relapse occurred in 15% of the children within 3 years. A duration of symptoms <3 months before referral correlated significantly with better outcome. We conclude that most infants with severe constipation evaluated at a tertiary center are recovered after 6 months. Early therapeutic intervention may beneficially contribute to the resolution of constipation.

Cathartics↗
PubMed2006

An association of multiple endocrine neoplasia 2B, a RET mutation; constipation; and low substance P-nerve fiber density in colonic circular muscle.

BACKGROUND: Multiple endocrine neoplasia (MEN) 2B is a rare hereditary syndrome that results from an activating mutation of the RET proto-oncogene. The RET gene is involved in the development of the enteric nervous system. Patients with MEN 2B have enlarged enteric ganglia and may be affected by gastrointestinal dysmotility. A deficiency of the neurotransmitter substance P (SP) has been identified in both pediatric and adult patients with chronic constipation. METHODS: Three patients, in whom constipation was the presenting symptom and MEN 2B had been provisionally diagnosed, underwent genetic analysis. Seromuscular colonic biopsies were taken for immunofluorescence imaging in all 3 patients. A retrospective review of the patient notes was undertaken. RESULTS: All 3 patients had constipation refractory to conservative treatment. Genetic analyses in the 3 patients confirmed an identical RET mutation (Met918Thr). Immunofluorescence imaging in all 3 patients identified grossly enlarged myenteric plexus ganglia but surprisingly a low density of SP-labeled nerve fibers in the colonic circular muscle. Nitric oxide synthase and vasoactive intestinal peptide labeling were not reduced. CONCLUSION: The results show an association between MEN 2B and its most common RET mutation, colonic dysmotility, and low density of SP in the colonic circular muscle. Larger numbers of patients need to be studied to investigate whether low SP is primarily associated with the constipation or RET mutation and if it is a common feature of MEN 2B.

Colon↗
PubMed2005

Neuromodulation for constipation and fecal incontinence.

The evidence is consistent with permanent SNM substantially improving continence in patients with severe fecal incontinence resistant to medical treatment. This treatment has been used in patients in whom a major surgical intervention would normally have been the next stage in treatment and the option of a minimally invasive treatment, with the added advantage of testing before definitive implantation, has the potential to have a major impact on this patient group. The results of the early case series examining the use of SNM for constipation are encouraging. Patients who have failed maximal medical treatment for constipation pose considerable clinical difficulties, with current surgical treatments requiring a bowel resection or stoma formation. If SNM proves to be of benefit to a proportion of these patients, this will be of considerable importance in terms of their future treatment options. Fecal incontinence and idiopathic constipation are both conditions in which conservative treatment is the mainstay of treatment in most cases,but for a small proportion surgical intervention is warranted. The surgical procedures available,however, have a considerable invasive component with often little guarantee of symptom resolution. SNM is becoming more widely used for patients with fecal incontinence as series sizes get larger and follow-up longer. Its potential benefit in constipation has been shown in pilot studies but larger trials are still required.

Constipation↗
PubMed2000

Decreased interstitial cell of cajal volume in patients with slow-transit constipation.

BACKGROUND & AIMS: The cause of slow-transit constipation is incompletely understood. Recent observations suggest a central role for interstitial cells of Cajal in the control of intestinal motility. The aim of this study was to determine the volume of interstitial cells of Cajal in the normal sigmoid colon and in the sigmoid colon from patients with slow transit constipation. METHODS: Sigmoid colonic samples were stained with antibodies to protein gene product 9.5, c-Kit, and alpha-smooth muscle actin. Three-dimensional reconstruction of regions of interest was performed using consecutive images collected on a laser scanning confocal microscope and ANALYZE software. RESULTS: Volume of interstitial cells of Cajal was significantly decreased in all layers of sigmoid colonic specimens from patients with slow-transit constipation compared with normal controls. Neuronal structures within the colonic circular smooth muscle layer were also decreased. CONCLUSIONS: A decrease in the volume of interstitial cells of Cajal may play an important role in the pathophysiology of slow-transit constipation.

Adult↗
PubMed1997

Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter.

This study was undertaken to search for a rational basis for the use of anal dilatation and internal sphincterotomy as the treatment for chronic intractable constipation in children. Sixteen children, age 5 months to 13 years, who had constipation resistant to conservative treatment were compared with 39 age-matched controls. History and current symptoms were assessed using a standard questionnaire. Internal and external and sphincter morphology was assessed on clinical examination and by anal endosonography, using a 10-MHz rotating endoprobe to provide accurate measurement of the various components of the anal canal. The control group showed a linear correlation between the thickness of the internal anal sphincter and both age and weight, increasing from 0.4 mm in infancy to 0.9 mm in adolescence. Children who had constipation displayed significant thickening of the internal sphincter (range, 0.5 to 1.9 mm, P = .005) which was independent of the length of the history (P = .103). There was no difference in the morphology of the external anal sphincters between the groups. The finding of a hypertrophied internal anal sphincter could provide a rational basis for anal dilatation and internal sphincterotomy as treatment for idiopathic constipation.

Adolescent↗
PubMed1997

The Pediatric Bowel Management Clinic: initial results of a multidisciplinary approach to functional constipation in children.

The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective. The authors tested this hypothesis in a newly created pediatric Bowel Management Clinic (BMC). Detailed data were collected prospectively on all patients seen in the clinic over the first 16 months. Both quantitative and qualitative analyses were performed to describe the index population and to demonstrate the impact of the intervention. Satisfaction with care in the clinic was measured using the Measure of Processes of Care tool, then compared with a normative sample. One hundred fourteen patients, all previously treated unsuccessfully for constipation, were referred to a team comprised of a physician, nurse practitioner, nurse educator, dietitian, and psychosocial nurse specialist. The mean age was 5.4 years with equal gender distribution. Between the first and last visits recorded, several variables including stool consistency and frequency, soiling frequency, abdominal pain, rectal pain, and rectal bleeding all showed statistically significant (P < .05) improvement. Qualitative data analysis showed the significant psychosocial impact of constipation on patients and their families. In the Measures of Processes of Care questionnaire, scores for the BMC were higher than normal on all scales except in provision of information. A multidisciplinary approach to functional constipation leads to both patient and parent satisfaction and significant short-term improvement. Further studies will examine the long-term impact of the clinic.

Adolescent↗
PubMed1997

Decreased substance P content in the rectal mucosa of diabetics with diarrhea and constipation.

Substance P (SP), vasoactive intestinal polypeptide (VIP), and somatostatin content in rectal mucosa were determined by radioimmunoassay (RIA) in 38 diabetic patients (12 with normal bowel function, 13 with diabetic diarrhea, and 13 with constipation) and in 10 nondiabetic controls with normal bowel function. SP content (picograms per milligram) in the rectal mucosa of diabetics with normal bowel function was significantly higher than that of nondiabetic controls (P < .05). SP content in the rectal mucosa of diabetics with diabetic diarrhea and constipation was significantly lower than in diabetics with normal bowel habits and nondiabetic controls (P < .05). No differences were found in the rectal mucosa content of VIP and somatostatin between the different groups of diabetics and controls. Diabetic diarrhea is a condition with an intermittent nature and frequently alternates with constipation. Our findings showing low levels of rectal mucosa SP in both conditions suggest a possible common role of SP in the pathogenesis of diabetic diarrhea and constipation.

Adult↗
PubMed1999

Reduction in constipation and laxative requirements following opioid rotation to methadone: a report of four cases.

Constipation is a common symptom in cancer patients, especially in those who are receiving opioid analgesics for pain. Although several articles have recently examined constipation with respect to causation and treatment, little research has been done to elucidate the effects of different opioids on the bowel. Recent research has found that laxative doses may be lower in patients using methadone as an analgesic, but changes in constipation were not measured. We report here on four cases in which patients had improvement in constipation and decreased laxative requirements following opioid rotation to methadone.

Analgesics, Opioid↗
PubMed1999

[Management of chronic constipation in the infant].

Constipation is a common symptom of various pathologies with dysfunction of the intestinal motricity which largely differ in their expression and severity. However chronic idiopathic constipation is by far the most frequent condition. Only constipations associated with symptoms such as poor nutritional status, failure to thrive, signs of upper intestinal tract obstruction (gross abdominal distention), or showing resistance to the usual therapeutic approach, justify investigations looking for an organic disease, mainly Hirschsprung disease. Treatment of chronic idiopathic constipation requires, first to evacuate the fecal mass, then to prevent its reconstitution mainly by dietetic measures, regular large hydration, stool modifying therapy, daily bowel habit, and regular physical activities; in addition it is important that clear and reassuring explanations be given to the parents.

Child↗
PubMed2001

Use of isomalto-oligosaccharide in the treatment of lipid profiles and constipation in hemodialysis patients.

Chronic constipation and hyperlipidemia, one of the many atherogenic risk factors, were common complications in hemodialysis (HD) patients. The present trial evaluates the therapeutic efficacy of isomaltose-oligosaccharide (IMO) in the treatment of chronic severe constipation and its effect on lipid profiles in 20 HD patients. After a 2-week basal period, these patients were allocated to receive 30 g of IMO for a 4-week period. After the study period, these patients were observed for another 4 weeks. Bowel frequency, gastrointestinal symptomatology, biochemical parameters, and lipid profiles were assessed. All patients completed this study. IMO induced a significant increase in number of bowel movements and hence improvement of constipation in 76.3% + 30.9% of patients during the 4-week treatment. Some, but well-tolerated gastrointestinal side effects were noted. Statistically significant decreases in total cholesterol and triglycerides (TG) and increases in high density lipoprotein-cholesterol (HDL-C) were noted after IMO treatment (P <.05 compared with baseline and controls). After the study period, those patients receiving IMO had reductions in levels of total cholesterol -17.6%, TG -18.4%, and elevations of levels of HDL-C by +39.1%. In conclusion, IMO once a day is well tolerated and effective in increasing bowel frequency and improving constipation in HD patients. In addition, IMO treatment was effective in lowering total cholesterol and triglycerides and in raising HDL-C in HD patients.

Adult↗
PubMed1999

Relationship of gynecologic surgery to constipation.

STUDY OBJECTIVE: To determine if women undergoing presacral neurectomy, hysterectomy, or other gynecologic surgery experience a greater frequency of constipation than those having no surgery. DESIGN: Concurrent, nonrandomized, retrospective study (Canadian Task Force classification II-2). SETTING: Tertiary medical care center with referral-based practice for the treatment of chronic pelvic pain. PATIENTS: Two hundred fifty-six women forming four groups based on surgical procedure: presacral neurectomy (66), hysterectomy (65), other gynecologic surgery (68), and no surgery (57). INTERVENTIONS: Laparoscopic presacral neurectomies. Other gynecologic surgery included laparoscopy, dilatation and curettage, laparoscopic resection of endometriosis, or any combination of these procedures. MEASUREMENTS AND MAIN RESULTS: Constipation was defined as decrease in frequency of spontaneous bowel movements. A statistically significant greater percentage of patients undergoing surgical procedures were more constipated than those having no surgery: presacral neurectomy, 31.8%; hysterectomy, 27.7%; other gynecologic surgery, 25%; and no gynecologic surgery, 10.5%. CONCLUSION: Pelvic surgery may cause parasympathetic nerve dysfunction leading to constipation. (J Am Assoc Gynecol Laparosc 6(1):75-78, 1999)

Adult↗
PubMed1997

Constipation. Diagnosis and treatment.

Chronic constipation, the number one gastrointestinal complaint in the United States, is a serious condition that affects patient quality of life and accounts for the annual expenditure of millions of dollars by affected individuals, many of whom attempt to self-manage their condition. Because constipation has varied etiologies and treatment modes, it is imperative for the family nurse practitioner to know options for patients. Constipation complaints can indicate multiple diseases, and such patients can be among the most difficult diagnostic and therapeutic problems in clinical practice. Two of the primary care provider's duties to these patients are to educate them about bowel habits and to explain how different medications may either aid or exacerbate their symptoms. Constipation is a universal affliction of Western civilization. In the United States, this malady accounts for more than 2.5 million physician visits per year, is among the most frequent reasons for self-medication, and is particularly troublesome in the elderly population. Americans spend more than $725 million annually on over-the-counter (OTC) laxatives in an attempt to self-treat the most common gastrointestinal complaint in the country.

Cathartics↗
PubMed2000

Function of hollow viscera in children with constipation and voiding difficulties.

We wished to investigate the urodynamic characteristics and colonic motility in a group of children with severe chronic constipation and lower urinary tract symptoms. We performed colonic manometry using an endoscopically placed catheter. The urodynamic studies consisted of cystometry, electromyography of the external urethral sphincter, measurement of urinary flow rate, and urethral pressure profile. We found abnormal colonic motility in all patients. Findings included: absent gastrocolonic response (N = 8), absent high-amplitude propagated contractions (HAPCs) (N = 4), and abnormal propagation of HAPCs (N = 7). Urodynamic features were abnormal in 10 children. Findings included: uninhibited bladder contractions (N = 6), hypertonic bladder (N = 2), sphincter dyssynergy (N = 2), small capacity bladder (N = 1). In all children constipation improved, in three after a partial colectomy. Urinary symptoms persisted. We conclude that some children with severe constipation may have a neuropathy affecting both the colonic and lower urinary tracts systems. In this group of patients treatment of constipation does not result in resolution of urinary symptoms.

Adolescent↗