Constipation Research: 2002-2006
     
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003448.
Laxatives for the management of constipation in palliative care patients.
Miles CL, Fellowes D, Goodman ML, Wilkinson S.
Royal Free & University College Medical School, Marie Curie Palliative Care R&D unit, Department of Mental Health Services, Hampstead Campus, Rowland Hill Street, London, UK. susie.wilkinson@medsch.ucl.ac.uk

BACKGROUND: Constipation is a common problem for palliative care patients which can generate considerable suffering for patients due to both the unpleasant physical symptoms and psychological preoccupations that can arise. There is uncertainty about the 'best' management of constipation in palliative care patients and variation in practice between palliative care settings. OBJECTIVES: To determine the effectiveness of laxative administration for the management of constipation in palliative care patients, and the differential efficacy of the laxatives used to manage constipation. SEARCH STRATEGY: We searched The Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue four, 2005), MEDLINE (1966 to January 2005), EMBASE (1980 to January 2005), CANCERLIT, PUBMED, Science Citation Index, CINAHL, The Cochrane Library, SIGLE, NTIS, DHSS-DATA, Dissertation Abstracts, Index to Scientific and Technical Proceedings and NHS-NRR and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing laxatives for constipation in palliative care patients. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted patient-reported data measuring changes in stool frequency and ease of passing stools, using objective and validated scales. Tolerance or adverse effects of laxatives used were also sought. The appropriateness of synthesizing data from the controlled trials depended upon the clinical and statistical homogeneity of studies identified. If the controlled trials were homogeneous, a meta-analysis would be attempted. MAIN RESULTS: Four trials involving 280 people were included. Between these trials, the laxatives lactulose; senna; danthron combined with poloxamer (Co-danthramer); Misrakasneham; magnesium hydroxide combined with liquid paraffin (Milpar) were evaluated. All four trials included number and frequency of bowel movements and relative ease of defecation as part of the assessment of laxative efficacy. All of the laxatives demonstrated a limited level of efficacy, although a significant number of participants required rescue laxatives in each of the studies. The only significantly different treatments were in the trial where lactulose plus senna were more effective than danthron combined with poloxamer. Patient preference did not favour either treatment option. Other related systematic reviews have similarly identified that there is a lack of evidence to support the use of one laxative, or combination of laxatives, over another. AUTHORS' CONCLUSIONS: The treatment of constipation in palliative care is based on inadequate experimental evidence, such that there are insufficient RCT data. Recommendations for laxative use can be related to costs as much as to efficacy. There have been few comparative studies, equally there have been few direct comparisons between different classes of laxative and between different combinations of laxatives. There persists an uncertainty about the 'best' management of constipation in this group of patients.

-----

Am J Gastroenterol. 2006 Oct 4; [Epub ahead of print]
Experience with Type A Botulinum Toxin for Treatment of Outlet-Type Constipation.
Maria G, Cadeddu F, Brandara F, Marniga G, Brisinda G.
Department of Surgery, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy.

BACKGROUND: Puborectalis syndrome remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles. METHODS: Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. RESULTS: At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 +/- 24 to 56 +/- 20 mmHg at a 1-month evaluation (p < 0.01) and 56 +/- 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 +/- 9 degrees to 121 +/- 15 degrees (p < 0.01). CONCLUSIONS: Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.

-----

Surgery. 2006 Sep;140(3):435-40.
Is total colectomy the right choice in intractable slow-transit constipation?
Ripetti V, Caputo D, Greco S, Alloni R, Coppola R.
Department of Digestive Diseases, Campus Bio-Medico University of Rome, Italy. v.ripetti@unicampus.it

BACKGROUND: The aim of the study was to evaluate the functional results of surgical treatment for intractable slow-transit constipation and to establish that the importance of correct diagnosis and type of colon resection (total or segmental) is essential to achieve optimal outcome while minimizing side effects. METHODS: Between 1995 and 2004, of the 450 patients presenting with chronic constipation, we further investigated 33 patients with a diagnosis of slow-transit constipation that had not improved with medical or rehabilitative treatment. Preoperative evaluation included a daily evacuation diary compiled using Wexner score, psychologic assessment, Medical Outcomes Study 36-item Short Form Health Survey (SF-36), radiologic investigation of colonic transit time, enema radiograph, colpo-cysto-defecography, anal manometry, and, in selected patients, colonoscopy and pudendal nerve terminal motor latency. In 15 cases, the cause of constipation was colonic slow-transit (with a mean Wexner score of 22), which was always associated with dolichocolon. The other 18 patients presented outlet obstruction, and, therefore, these results are not included in the present report. The 15 patients with slow-transit constipation were submitted to total laparoscopic colectomy (2), total open colectomy (6), and left laparoscopic hemicolectomy for left colonic slow-transit (7). RESULTS: Mean follow-up was 38 months. All patients except 1 presented improvement in symptoms with daily evacuations (P < .01; mean Wexner score, 6). Furthermore, results of the SF-36 test showed an improvement in the perception of physical pain, and the emotional, psychologic, and general health spheres after surgical treatment. CONCLUSIONS: Meticulous preoperative evaluation of intractable slow-transit constipation may discriminate between the different causes of chronic constipation and thus avoid the well-known "Iceberg syndrome," which is responsible for many treatment failures.

-----

Int J Colorectal Dis. 2006 Aug 31; [Epub ahead of print]
Surgery for slow transit constipation: are we helping patients?
Zutshi M, Hull TL, Trzcinski R, Arvelakis A, Xu M.
Department of Colorectal Surgery, Cleveland Clinic Foundation, Desk A-30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA, zutshim@ccf.org.

INTRODUCTION: Long-term outcome after surgery for slow transit constipation is conflicting. The aim of this study was to assess long-term quality of life after surgery. METHODS: The medical records of all patients undergoing colectomy with ileorectal anastomosis between 1983 and 1998 were evaluated. Preoperative, operative, and postoperative details were recorded. A survey was conducted to evaluate current symptoms and health. Quality of life was assessed using the short-form (SF)-36 survey. RESULTS: Sixty-nine (2 male) patients were identified. Five were deceased. Mean age at surgery was 38.6 years (range, 19.7-78.8 years). Median follow-up after surgery was 10.8 years (range, 5.1-18.6 years). Forty-one percent had a family history of constipation. Eleven (16%) had an ileus postoperatively, which responded to medical therapy. One patient had a leak that required temporary diversion. Long-term complications occurred in 32 (46%) patients, which included hernias (3 patients; 4%), pelvic abscess (1 patient; 1.5%), rectal pain (1 patient; 1.5%), small-bowel obstruction (14 patients; 20%, with eight requiring surgery), diarrhea (5 patients; 7%), incontinence (1 patient, 1.5%), and persistent constipation (6 patients; 9%). Fifty-five percent (35/64) responded to a questionnaire. Overall, 25 of 35 (77% of the respondents) stated that surgery was beneficial. Sixty-four percent of patients have semisolid stools, 35% have liquid stools, and 4% reported hard stool. Results of the SF-36 showed the physical component score was comparable with healthy individuals. However, the mental component score was low especially in the areas of vitality (median, 45) and social functioning (median, 37). CONCLUSION: Surgery for constipation is not perfect, and preoperative symptoms may persist after surgery. When assessing long-term quality of life, the mental component of the SF-36 was low compared with the general population, and the physical component was similar. Moreover, because 77% report long-term improvement, surgery is beneficial for appropriate patients.

-----

Pediatrics. 2006 Aug;118(2):528-35.
A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence.
Loening-Baucke V, Pashankar DS.
Division of General Pediatrics, University of Iowa, Iowa City, Iowa, USA. vera-loening-baucke@uiowa.edu

OBJECTIVE: Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes. METHODS: Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests. RESULTS: Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol. CONCLUSIONS: In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

-----

Curr Treat Options Gastroenterol. 2006 Jul;9(4):351-60.
Pacing the gut in motility disorders.
Zhang J, Chen JD.
Division of Gastroenterology, University of Texas Medical Branch, 1108 The Strand, Room 221, Galveston, TX 77555-0632, USA. jianchen@utmb.edu.

Similar to cardiac pacing, gastrointestinal (GI) pacing is an attractive idea and may become a promising therapy, as the GI organs, like the heart, have their own natural pacemakers. Over the past 10 years, electrical stimulation of the gut has received increasing attention among researchers and clinicians. Several clinical studies have shown that gastric electrical stimulation (GES) with short pulses is able to reduce nausea and vomiting in patients with gastroparesis and that GES with long pulses is able to pace the intrinsic gastric slow waves and thus normalize gastric dysrhythmia. However, possible placebo effects cannot be ruled out, although recent animal studies have revealed various peripheral and central mechanisms involved with GES. Electrical stimulation of the small intestine, colon, or anal sphincter also has been reported for the treatment of dumping syndrome, constipation, and fecal incontinency. Similarly, there is a lack of placebo-controlled studies. In our opinion, pacing of the gut has great potential for the treatment of various GI motor disorders. However, none of the commercially available devices is designed for pacing the gut. The lack of well-suited devices and the invasive nature of gut pacing slow down the progress and clinical applications of gut pacing.

-----

Tech Coloproctol. 2006 Jul;10(2):111-4. Epub 2006 Jun 19.
Prospective randomized crossover trial comparing fibre with lactulose in the treatment of idiopathic chronic constipation.
Quah HM, Ooi BS, Seow-Choen F, Sng KK, Ho KS.
Department of Colorectal Surgery, Singapore General Hospital, Singapore.

BACKGROUND: Fibre is often recommended as the first-choice treatment but its effects can be uneven. The aim of the study was to compare the clinical efficacy and tolerability of fibre versus lactulose in outpatients with chronic constipation. METHODS: In a prospective randomized crossover trial, patients were randomized to receive fibre or lactulose for four weeks. Between treatments, patients had at least one week free of laxatives. RESULTS: 50 patients, of median age 50 years (range, 18-85) were recruited and 39 patients completed the trial. Compared to fibre, lactulose resulted in significantly higher mean bowel frequency (7.3, 95% CI 5.7 to 8.9 vs. 5.5, 95% CI 4.4 to 6.5; p=0.001) and stool consistency score (3.4, 95% CI 3.1 to 3.7 vs. 2.9, 95% CI 2.5 to 3.3; p=0.018). Scores for ease of evacuation were similar. The frequencies of adverse effects were not significantly different, but greater in the lactulose group. Mean patients' recorded improvement score was significantly higher after taking lactulose than fibre (6.2, 95% CI 5.5 to 7.0 vs. 4.8, 95% CI 4.0 to 5.9; p=0.017). Of the 39 patients who completed the trial, 24 (61.5%) preferred lactulose and 14 (35.9%) preferred fibre. CONCLUSIONS: Lactulose had better efficacy than fibre for chronic constipation in ambulant patients, although both treatments were equally well tolerated in terms of adverse effects.

-----

J Fam Pract. 2006 Jul;55(7):587-93.
Chronic constipation: let symptom type and severity direct treatment.
Bleser SD.
Bellbrook Medical Center, Inc, 4336 State Route 725, Bellbrook, OH 45305-2742, USA. scottbleser@woh.rr.com

Increased fiber intake through diet or fiber supplements is an appropriate initial therapy for chronic constipation. Osmotic and stimulant laxatives may be administered to patients who do not respond to more conservative measures if the limitations of these agents are explained. Tegaserod, a selective 5-hydroxytryptamine type 4 (5-HT4) receptor partial agonist, is more effective than placebo at relieving symptoms of chronic idiopathic constipation in patients younger than 65 years of age. Patients with suspected defecation disorders and those with treatment-refractory symptoms should be referred to a gastroenterologist for further evaluation.

-----

Pharmacotherapy. 2006 Jul;26(7):896-902.
Pharmacologic management of constipation in the critically ill patient.
Patanwala AE, Abarca J, Huckleberry Y, Erstad BL.
1 Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona.

Study Objective. To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU). Design. Retrospective medical record review. Setting. MICU of an academic medical center. Patients. Ninety-five patients admitted to the MICU from July 1-October 31, 2004. Measurements and Main Results. Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of MICU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% CI 0.59-0.97, p=0.027). Disease severity, as determined by APACHE II score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04). Conclusion. Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population.

-----

Curr Med Res Opin. 2006 Jun;22(6):1227-35.
Long-term efficacy and cost-effectiveness of polyethylene glycol 3350 plus electrolytes in chronic constipation: a retrospective study in a disabled population.
Migeon-Duballet I, Chabin M, Gautier A, Mistouflet T, Bonnet M, Aubert JM, Halphen M.
CHU de Poitiers, Hopital La Miletrie, Poitiers, France.

OBJECTIVES: The efficacy and safety of treatments for constipation in severely intellectually disabled patients and their associated cost-effectiveness are an under-investigated area of clinical practice. Aiming to address this, the objectives of the study were to evaluate the efficacy and tolerability of polyethylene glycol 3350 plus electrolytes (Movicol; PEG+E) by comparing clinical data collected before and after its introduction to a stable population of residents of a mental health care, long-stay institution. The study also attempted an economic evaluation of the use of PEG+E in this setting. RESEARCH DESIGN AND METHODS: This was a retrospective study of 54/66 severely intellectually and physically disabled residents of a specialist unit at La Miletrie University Hospital, Poitiers, France, who suffered regularly from constipation. A total of 54 residents were treated with PEG+E (1-3 sachets a day) for 24 months. The number of stools, episodes of diarrhoea (defined as frequent stools, not necessarily watery), body weights and blood biochemistry were recorded. Data were compared with those recorded during the 21 months preceding the introduction of PEG+E for 16/54 residents who had been treated regularly with a range of other interventions for the relief of constipation. The monthly use and costs of laxatives, enemas and suppositories was obtained from hospital pharmacy records, and the total hospital costs before and after the introduction of PEG+E treatment was calculated. RESULTS: The mean (+/- standard deviation) number of stools per patient per month was significantly greater following the introduction of PEG+E (24.9 +/- 6.3) compared to before its use (12.4 +/- 3.4) (p < 0.001). The mean (+/- standard deviation) monthly number of episodes of diarrhoea per patient before and after the introduction of PEG+E was 0.1 +/- 0.1 and 6.3 +/- 2.9, respectively (p < 0.001). Treatment with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Introduction of PEG+E and its increasing use reduced the total hospital medical ward expenditure on laxatives from 3788 to 1767 Euros per month. CONCLUSIONS: PEG+E is effective in the clinical management of constipation in an institutional setting. Furthermore, long-term intensive therapy with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Although the time periods over which the economic data and the efficacy and safety data were collected did not directly correspond, this study indicates that use of PEG+E in the management of constipation in people with severe intellectual disability may be cost-effective, reducing hospital laxative costs.

-----

Minerva Pediatr. 2006 Jun;58(3):299-304.
Painful defecation and chronic functional constipation in children: diagnosis and treatment.
Sabatino MD, Borrelli M, Cautiero P, Romano M, Parmeggiani P, Marte A.
Dipartimento di Chirurgia Pediatrica , Seconda Universita degli Studi di Napoli, Napoli, Italy.

AIM: The aim of this study was to report our results on the treatment of chronic constipation associated with pain during defecation. METHODS: From January 1999 to January 2004, 60 patients (25 females, 35 males; age range, 6 months to 12 years) who met the ROMA II diagnostic criteria for chronic functional constipation associated with pain on defecation were enrolled in the study. All subjects underwent anorectal manometry to determine rectosphincter inhibitory reflex function. A retraining program for daily defecation, a diet high in fiber and lactulose, and local administration of prilocaine/lidocaine were instituted. At rectal anal endosonography, 7 drug-treatment-resistant patients presented with increased thickness of the internal anal sphincter and received botulin toxin A injection at the sphincter. Because symptoms persisted in 2 of these patients, they received a sphincterectomy. RESULTS: At the end of treatment, 40 (71.4%) of the 56 patients who completed the study had a daily bowel movement without pain; 9 experienced a relapse; in the 2 surgical patients the alveus returned to normal function at 2 and 6 weeks, respectively. CONCLUSIONS: Our treatment strategy breaks the vicious circle of spasm-pain-spasm with use of prolonged analgesic treatment and feces softener over the course of the day. In treatment-resistant patients with functioning rectosphincter reflexes and thickened internal anal sphincter, administration of botulin toxin A may be a valuable aid in place of standard sphincterectomy.

-----

J Gastroenterol. 2006 May;41(5):408-17.
Acupuncture for functional gastrointestinal disorders.
Takahashi T.
Department of Surgery, Duke University Medical Center, Durham, NC 27705, USA.

Functional gastrointestinal (GI) symptoms are common in the general population. Especially, motor dysfunction of the GI tract and visceral hypersensitivity are important. Acupuncture has been used to treat GI symptoms in China for thousands of years. It is conceivable that acupuncture may be effective in patients with functional GI disorders because it has been shown to alter acid secretion, GI motility, and visceral pain. Acupuncture at the lower limbs (ST-36) causes muscle contractions via the somatoparasympathetic pathway, while at the upper abdomen (CV-12) it causes muscle relaxation via the somatosympathetic pathway. In some patients with gastroesophageal reflux disease (GERD) and functional dyspepsia (FD), peristalsis and gastric motility are impaired. The stimulatory effects of acupuncture at ST-36 on GI motility may be beneficial to patients with GERD or FD, as well as to those with constipation-predominant irritable bowel syndrome (IBS), who show delayed colonic transit. In contrast, the inhibitory effects of acupuncture at CV-12 on GI motility may be beneficial to patients with diarrhea-predominant IBS, because enhanced colonic motility and accelerated colonic transit are reported in such patients. Acupuncture at CV-12 may inhibit gastric acid secretion via the somatosympathetic pathway. Thus, acupuncture may be beneficial to GERD patients. The antiemetic effects of acupuncture at PC-6 (wrist) may be beneficial to patients with FD, whereas the antinociceptive effects of acupuncture at PC-6 and ST-36 may be beneficial to patients with visceral hypersensitivity. In the future, it is expected that acupuncture will be used in the treatment of patients with functional GI disorders.

-----

Best Pract Res Clin Gastroenterol. 2006;20(3):575-87.
Nutritional care of the patient with constipation.
Fernandez-Banares F.
Department of Gastroenterology, Hospital Universitari Mutua Terrassa, Plaza Dr Robert 5, 08221 Terrassa, Barcelona, Spain. digestiu@mutuaterrassa.es

Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3 months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. On the other hand, the presence of clinically important abdominal discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating chronic constipation in patients without slow colonic transit or disordered constipation. On the other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and the population being studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic constipation.

-----

Gastroenterology. 2006 Mar;130(3):657-64.
Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia.
Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G.
Gastrointestinal Rehabilitation Division, Valeggio sul Mincio Hospital, Azienda Ospedaliera and University of Verona, Verona, Italy.

Background & Aims: Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education. Methods: Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6-29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months. Results: At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P < .001). Biofeedback's benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P < .01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months. Conclusions: Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

-----

Tech Coloproctol. 2006 Mar 15; [Epub ahead of print]
Biofeedback therapy for rectal intussusception.
Hwang YH, Person B, Choi JS, Nam YS, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA, mcderme@ccf.org.

BACKGROUND: Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception. METHODS: We retrospectively evaluated the results of electromyography (EMG)-based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder. RESULTS: A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean+/-SD) was 2.0+/-6.8 before and 4.1+/-4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8+/-3.5 before to 1.5+/-2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty-three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were consti- pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0+/-0.7 before to 0.07+/-0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1+/-4.2 before to 4.6+/-3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. CONCLUSIONS: Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

-----

Clin Pediatr (Phila). 2006 Mar;45(2):157-64.
Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance.
Reid H, Bahar RJ.
Early Childhood Center, Cedars Sinai Medical Center, Los Angeles, CA.

SUMMARY: To describe the source of and treatment for encopresis in a series of 40 children under age 9 years. Referral for psychological based treatment followed upon limited success of standard gastroenterologic intervention. The treatment provided is defined as interactive parent-child family guidance. This includes a variety of specific psychologically based recommendations offered to parents, and, when indicated, direct interventions with the symptomatic child. These are different from various forms of behavioral corrective reward-punishment interventions frequently recommended for young children with encopresis. The pediatric and the psychological literature offer few reports of successful treatment of young children with this syndrome. Also, there are few specific descriptions of psychologically based interventions. The results reported here are of the successful treatment of 38 of 40 cases referred specifically for psychologically based intervention following the prior limited success of standard gastroenterologic treatment. The interactive parent-child family guidance intervention described in this report, differentiated from typical behavior therapies, is a notably successful mode of psychologically based therapy for these children. It offers an important alternative to standard pediatric gastroenterological treatment for encopresis, as well as to reward-punishment oriented behavioral therapies. Clin Pediatr. 2006;45:157-164.

-----

Digestion. 2006;73 Suppl 1:28-37. Epub 2006 Feb 8.
Pharmacological treatment of the irritable bowel syndrome and other functional bowel disorders.
Mearin F.
Institute of Functional and Motor Digestive Disorders, Centro Medico Teknon, Barcelona, Spain. mearin@dr.teknon.es

Functional digestive disorders constitute one of the main causes of consultation in gastroenterology and primary health care. Is still unclear whether therapy has to be aimed to the gut, to the neural pathways controlling bowel motility and perception, or to the processing mechanisms of symptoms and disease behaviour. It is conceivable that in the next future better understanding of functional bowel disorders pathophysiology will help us to tailor treatment for different patients. At the moment, subclassification of the diverse patterns of symptomatology allows to adjust new treatments for irritable bowel syndrome (IBS) according to the clinical predominance for each patient. The knowledge of motor and sensorial response to different stimuli in IBS patients and the pathways to the central nervous system is an important source of information for the development of new molecules. Fiber-enriched diet is frequently given for constipation-predominant IBS. Loperamide, antispasmodic drugs and tricyclic antidepressants are nowadays the basis for pharmacological treatment of diarrhea- predominant IBS. The scientific evidence supporting this therapeutical approach is however limited. Visceral analgesics and serotonin agonists and antagonists may play an important therapeutical role in the near future. However, it is not likely that one single treatment will help every functional bowel disorder patient and many of them will need a more complex approach with a multidisciplinary therapy (diet, psychotherapy, medications). Copyright 2006 S. Karger AG, Basel.

-----

Acta Paediatr. 2006 Mar;95(3):369-74.
Tap-water enema for children with myelomeningocele and neurogenic bowel dysfunction.
Mattsson S, Gladh G.
Division of Paediatrics, Faculty of Health Sciences, University Hospital, Department of Molecular and Clinical Medicine, Linkoping, Sweden.

Aim: To evaluate the outcome of transrectal irrigation (TRI) using clean tap water without salt in children with myelomeningocele and neurogenic bowel problems. Methods: 40 children (21 boys and 19 girls; aged 10 mo to 11 y) with myelomeningocele and neurogenic bowel dysfunction were treated with TRI given by a stoma cone irrigation set daily or every second day. A questionnaire on the effects on faecal incontinence, constipation and self-management was completed by the parents, 4 mo-8 y (median 1.5 y) after start. Effects on rectal volume, anal sphincter pressure and plasma sodium were evaluated before and after the start of irrigation. Results: At follow-up, 35 children remained on TRI, four had received appendicostomy, while one defecated normally. For all children but five (35/40; 85%) the procedure worked satisfactorily, but a majority found the procedure very time consuming and only one child was able to perform it independently. All children were free of constipation; most (35/40) were also anal continent. Rectal volume and anal sphincter pressure improved, while plasma sodium values remained within the normal range.Conclusion: Transrectal irrigation with tap water is a safe method to resolve constipation and faecal incontinence in children with myelomeningocele and neurogenic bowel dysfunction, but it does not help children to independence at the toilet.

-----

Am Fam Physician. 2006 Feb 1;73(3):469-77.
Evaluation and treatment of constipation in infants and children.
Biggs WS, Dery WH.
Michigan State University College of Human Medicine, East Lansing, Michigan, USA. wendy.biggs@midmichigan.org

Constipation in children usually is functional and the result of stool retention. However, family physicians must be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease (congenital aganglionic megacolon), pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation. Treatment of functional constipation involves disimpaction using oral or rectal medication. Polyethylene glycol is effective and well tolerated, but a number of alternatives are available. After disimpaction, a maintenance program may be required for months to years because relapse of functional constipation is common. Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol. Education of the family and, when possible, the child is instrumental in improving functional constipation. Behavioral education improves response to treatment; biofeedback training does not. Because cow's milk may promote constipation in some children, a trial of withholding milk may be considered. Adding fiber to the diet may improve constipation. Despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement.

-----

Neurogastroenterol Motil. 2006 Feb;18(2):123-8.
A multicentre study of the management of disorders of defecation in patients with spina bifida.
Lemelle JL, Guillemin F, Aubert D, Guys JM, Lottmann H, Lortat-Jacob S, Moscovici J, Mouriquand P, Ruffion A, Schmitt M.
Service de Chirurgie Infantile, Hopital d'Enfants, CHU de Nancy, Vandoeuvre les Nancy, France. jl.lemelle@chu-nancy.fr

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.

-----

Eur J Gastroenterol Hepatol. 2006 Feb;18(2):125-8.
Food allergy and constipation in childhood: how functional is it?
Scaillon M, Cadranel S.
Department of Gastroenterology, Queen Fabiola Children's Hospital, Free University of Brussels, Brussels, Belgium.

An increasing incidence of food allergy, especially to cow's milk proteins, is observed in children living in the industrialized regions of the world. In some cases responding to an eviction diet excluding offending foods, the 'functional' constipation can be caused by inflammation of the intestinal wall infiltrated by eosinophils. Understanding the complex mechanisms involved could help to improve the management of idiopathic functional constipation in children by addressing the aetiology instead of treating the symptoms.

-----

Dig Dis Sci. 2006 Jan;51(1):154-60.
Cecostomy in children with defecation disorders.
Mousa HM, van den Berg MM, Caniano DA, Hogan M, Di Lorenzo C, Hayes J.
Divisions of Pediatric Gastroenterology, Columbus Children's Hospital, Ohio State University College of Medicine and Public Health, Columbus, Ohio 43205, USA. mousah@pediatrics.ohio-state.edu

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n = 9), Hirschsprung's disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

-----

Aliment Pharmacol Ther. 2006 Jan 1;23(1):191-6.
Effect of a laxative with and without tegaserod in adolescents with constipation predominant irritable bowel syndrome.
Khoshoo V, Armstead C, Landry L.
West Jefferson Medical Center, New Orleans, LA 70072, USA. vkhoshoo@sbcglobal.net

AIM: To determine the effect of a laxative alone and in combination with tegaserod in alleviating pain and improving stool frequency in adolescents with constipation predominant irritable bowel syndrome. PATIENTS: Forty-eight postpubertal adolescents of both sexes with constipation predominant irritable bowel syndrome, as defined by Rome II criteria, were randomly allocated to Group A (n = 27) for treatment with a laxative (polyethylene glycol 3350 oral solution) only or Group B (n = 21) for combination therapy with the laxative and tegaserod. Symptoms of abdominal pain (scale 0-10) and frequency of bowel movements were recorded daily in the pre-treatment phase and the post-treatment phase after a 7-day 'washout' period. Patients served as their own controls. RESULTS: Treatment with the laxative alone (Group A) resulted in significant increase in frequency of bowel movements (P < 0.05), but not significant improvement in pain (P > 0.05). Treatment with the combination of the laxative and tegaserod (Group B) led to significant increase in the frequency of bowel movements and also significant reduction in pain (P < 0.05). CONCLUSIONS: The laxative alone improved stooling but not pain in adolescents with constipation predominant irritable bowel syndrome. Addition of tegaserod resulted in alleviation of pain as well.

-----

Aliment Pharmacol Ther. 2005 Nov 15;22(10):997-1003.
Outlet type constipation in Parkinson's disease: results of botulinum toxin treatment.
Cadeddu F, Bentivoglio AR, Brandara F, Marniga G, Brisinda G, Maria G.
Department of Surgery, Catholic School of Medicine, University Hospital Agostino Gemelli, Rome, Italy.

Summary Background : Constipation is one of the most common autonomic dysfunctions observed in Parkinson's disease. Aim : To investigate the efficacy of injections of botulinum toxin in improving rectal emptying in these patients. Methods : Eighteen Parkinson's disease patients with outlet constipation were included in the study. The patients were treated with type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. Results : Symptomatic improvement was noted in 10 patients, at 2 months evaluation. In these subjects, anorectal manometry demonstrated decreased tone during straining from 96.2 +/- 17.1 to 45.9 +/- 16.2 mmHg at 1 month evaluation (P = 0.00001) and to 56.1 +/- 10.7 mmHg at 2 months (P = 0.00001). Pressure during straining was lower than resting anal pressure at the same times in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 99.1 +/- 8.4 degrees to 121.7 +/- 12.7 degrees (P = 0.00001) at 2 months. Conclusions : Botulinum toxin injections may be a useful treatment for Parkinson's disease patients affected by outlet-obstruction constipation. The treatment is safe and simple. However, because the effects of the toxin wear off within 3 months of administration, repeated injections could be necessary to maintain the clinical improvement.

-----

Curr Med Res Opin. 2005 Oct;21(10):1595-602.
Evaluation of polyethylene glycol plus electrolytes in the treatment of severe constipation and faecal impaction in adults.
Chen CC, Su MY, Tung SY, Chang FY, Wong JM, Geraint M.
Taipei Veteran's General Hospital, Taipei 111, Taiwan.

INTRODUCTION: Extreme and severe cases of constipation can lead to faecal impaction. Current therapies are often both ineffective and unpleasant. The objective of this trial was to evaluate the efficacy and safety of Movicol, a polyethylene glycol (PEG) + electrolyte solution (PEG+E), as treatment for severe constipation and faecal impaction. PATIENTS: 56 patients (aged 17 to 88 years) with a history of chronic constipation and presenting with no bowel movement for three to four days (severe constipation), or no bowel movement for at least five days (faecal impaction), were enrolled at three centres in Taiwan. Faecal loading was confirmed in all patients by abdominal and rectal examination or abdominal radiography. Patients were excluded from the study if they had a gastrointestinal obstruction, evidence of delayed gastric emptying, or if their constipation was secondary to severe inflammatory bowel disease. TREATMENT: All patients followed the same regimen: up to eight 13.8 g sachets of PEG+E (two at a time in 250 ml water; maximum of 1L/day) over a 4-6 h period each day, with 1-1.5 h between each dosing. Duration of treatment was for up to three days. EFFICACY ENDPOINTS AND RESULTS: Patients with either improvement (passage of a moderate to large volume of stool within four days of treatment initiation) or complete resolution (passage of moderate to large volumes of faecal matter plus the disappearance of palpable faecal masses in the abdomen and/or rectum) were considered responders. Based on bowel movement data recorded by the patients, an excellent response rate was obtained: 50/56 patients had a successful response to treatment (89.3%; 95% confidence intervals [CIs] 77.4% to 95.6%); there were 39 complete responders and 11 patients showed improvement. Investigator assessment of response was almost the same: 87.5% (95% CIs 75.3% to 94.4%). All bowel movement measurements (stool volume, number of evacuations, stool form and ease of evacuations) showed a positive improvement by Day 2. Median duration of treatment was two days. The incidence of adverse events was low, even for those side-effects such as abdominal pain and bloating, which are known undesirable consequences of PEG+E administration. No patient discontinued from the study because of an adverse event. CONCLUSION: PEG+E, administered orally at a dose equivalent to eight 13.8 g sachets (1 L) per day over three days, was a highly effective and well tolerated therapy for the treatment of severe constipation and faecal impaction.

-----

Acta Paediatr Suppl. 2005 Oct;94(449):120-4.
Advances in the management of digestive problems during the first months of life.
Savino F, Maccario S, Castagno E, Cresi F, Cavallo F, Dalmasso P, Fanaro S, Oggero R, Silvestro L.
Department of Paediatrics, Ospedale Infantile Regina Margherita, University of Turin, Turin, Italy. francesco.savino@unito.it

A study was carried out on 168 full-term infants with digestive problems such as regurgitation and/or constipation to evaluate the efficacy of new infant formulas containing partially hydrolysed whey protein, modified vegetable oil with a high beta-palmitic acid content, prebiotic oligosaccharides and starch. Infants receiving the new formulas had an increase in stool frequency of 0.60 between day 1 and day 7 (95% CI 0.19-1.01; p=0.004) and 0.53 (95% CI 0.11-0.90; p=0.015) between day 7 and day 14. A reduction of 1.06 in the number of regurgitation episodes was reported between day 1 and day 7 (95% CI 0.24-1.88; p=0.012) and 1.31 (95% CI 0.42-2.21; p=0.005) between day 7 and day 14. CONCLUSION: A prebiotic mixture of galacto-/fructo-oligosaccharides with a high beta-palmitic acid content may reduce digestive problems and improve intestinal tolerance in infants during the first months of life.

-----

Nutr Clin Pract. 2005 Oct;20(5):526-35.
Gastrointestinal manifestations of food allergies in pediatric patients.
Garcia-Careaga M Jr, Kerner JA Jr.
Department of Pediatrics, Division of Pediatric Gasteroenterology, Hepatology, and Nutrition, Stanford University Medical Center, 750 Welch Road, Suite 116, Palo Alto, CA 94304, USA.

Foods that account for 90% of allergic reactions in children are cow's milk protein, eggs, peanut, soy, tree nuts, fish, and wheat. Food allergy can manifest as urticaria/angioedema, anaphylaxis, atopic dermatitis, respiratory symptoms, or a gastrointestinal (GI) disorder. GI allergic manifestations can be classified as immunoglobulin E (IgE) mediated (immediate GI hypersensitivity and oral allergy syndrome); "mixed" GI allergy syndromes (involving some IgE components and some non-IgE or T-cell-mediated components) include eosinophilic esophagitis and eosinophilic gastroenteritis. Non-IgE-mediated or T-cell-mediated allergic GI disorders include dietary protein enteropathy, protein-induced enterocolitis, and proctitis. All these conditions share a common denominator: the response of the immune system to a specific protein leading to pathologic inflammatory changes in the GI tract. This immunological response can elicit symptoms such as diarrhea, vomiting, dysphagia, constipation, or GI blood loss, symptoms consistent with a GI disorder. The detection of food allergies can be accomplished by the use of radioallergosorbent (RAST) testing and skin prick tests in helping to assess the IgE-mediated disorders. Patch tests may help evaluate delayed hypersensitivity reactions. Treatment of GI allergic disorders ranges from strict dietary elimination of offending food(s), use of protein hydrolysates, and use of L-amino acid-based formula when protein hydrolysates fail. Treatment with topical (for eosinophilic esophagitis) or systemic steroids is used if all dietary measures are unsuccessful. Maternal breast feeding or the use from birth of hydrolysate formulas (extensive or partial hydrolysates) may be efficacious in the prevention of atopic disease in "high-risk" families (with at least 1 parent or sibling with a history of atopic disease).

-----

Neurogastroenterol Motil. 2005 Oct;17(5):697-704.
Effects of long-term treatment with oxytocin in chronic constipation; a double blind, placebo-controlled pilot trial.
Ohlsson B, Truedsson M, Bengtsson M, Torstenson R, Sjolund K, Bjornsson ES, Simren M.
Department of Medicine Malmo University Hospital, Sweden. bodil.ohlsson@kir.lu.se

BACKGROUND: Oxytocin and its receptor have been found throughout the gastrointestinal (GI) tract, where it affects gut function. Clinically, we have noticed an improvement of bowel habits during lactation in constipated women. The aim of this study was to examine whether oxytocin has an effect on bowel symptoms and psychological well being in women with refractory constipation. METHODS: Fifty-nine women with refractory constipation were included in a double blind, multicentre study. After a 2-week run-in period, they were randomly allocated to nasal inhalation of either placebo or oxytocin treatment twice daily for 13 weeks, followed by a 2 weeks, posttreatment period. The patients completed a questionnaire every day concerning bowel habits, abdominal pain and discomfort, and Gastrointestinal Symptoms Rating Scale (GSRS) and Psychological General Well-being (PGWB) twice during the study; namely, during the baseline period and at the end of the treatment period. RESULTS: Both oxytocin and placebo led to improvement of the constipation according to the GSRS and led to improvement in the sensation of incomplete evacuation and anorectal obstruction, without significant differences between the groups. Abdominal pain and discomfort responded weakly to oxytocin, with no effect of the placebo. In a subgroup of patients with IBS and concomitant depression, a weak improvement in depressed mood was observed after oxytocin administartion. CONCLUSION: Nasal administration of oxytocin had no significant advantage over placebo concerning an effect on constipation. However, it seems to have a positive effect on abdominal pain and discomfort and depressed mood. These findings should be further explored.

-----

Neurogastroenterol Motil. 2005 Oct;17(5):643-53.
Basic and clinical pharmacology of new motility promoting agents.
Galligan JJ, Vanner S.
Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA. galliga1@msu.edu

Recent research has provided new information about drugs that could be used to treat functional motility disorders. Promotility drugs accelerate gastric emptying or colonic transit and these properties may contribute to their efficacy in treating symptoms associated with gastroparesis, functional dyspepsia or constipation. 5-Hydroxytryptamine4 receptors are targets for drugs (tegaserod, renzapride) that treat symptoms in constipated irritable bowel syndrome patients and in gastroparesis. Drugs acting at motilin (erythromycin) and cholecystokinin-1 (dexloxiglumide) receptors accelerate gastric emptying. Dexloxiglumide might be useful in the treatment of functional dyspepsia particularly that associated with lipid intake. Alvimopan is a mu-opioid receptor antagonist that does not cross the blood brain barrier. Alvimopan is effective in treating postsurgical ileus and perhaps opiate-induced bowel dysfunction. Successes and failures of recent efforts to develop promotility agents revealed opportunities and challenges for developing new promotility drugs. The pharmacological properties of partial agonists might be exploited to develop effective promotility drugs. However, opposing actions of promotility agents on motility (increased contraction vs decreased accommodation) limit the clinical efficacy of drugs with these opposing actions. Selection of appropriate patient populations for evaluation of new drugs is also critical.

-----

Am J Hosp Palliat Care. 2005 Sep-Oct;22(5):375-81.
Management of constipation in palliative care patients undergoing opioid therapy: is polyethylene glycol an option?
Wirz S, Klaschik E.
Department of Anesthesiology and Intensive Care Medicine, Outpatient Pain Clinic, University of Bonn, Germany.

This study assessed the efficacy of laxative use for treatment of constipation in patients receiving opioid therapy, with special attention to polyethylene glycol 3350/electrolyte solution (PEG-ES). Computerized data from 206 patients were analyzed using descriptive statistics. Subgroups were analyzed using confirmatory statistics. Constipation occurred in 42.7 percent of patients. Laxatives were administered to 74.3 percent of these patients using a standardized step scheme, with good results in 78.4 percent. As a therapy for constipation, the combined administration of PEG-ES, sodium picosulphate, and liquid paraffin proved most effective, although statistical analysis yielded no significance. Early use of PEG-ES using a step scheme holds promise for treatment of opioid-related constipation in palliative care patients, although further investigation is warranted.

-----

Aliment Pharmacol Ther. 2005 Sep 1;22(5):373-80.
Effect of tegaserod on work and daily activity in irritable bowel syndrome with constipation.
Reilly MC, Barghout V, McBurney CR, Niecko TE.
Margaret Reilly Associates, Inc., New York, New York, USA.

Background : Tegaserod is a promotility agent with proven efficacy and safety in patients with irritable bowel syndrome with constipation. Aim : To assess tegaserod's effect on work productivity and daily activity. Methods : Women, 18-65 years old and meeting Rome II criteria for irritable bowel syndrome with constipation, were randomized to a double-blind, placebo-controlled, multicentre study of tegaserod 6 mg b.d. or placebo. Productivity loss and daily activity impairment because of irritable bowel syndrome were measured with the Work Productivity and Activity Impairment questionnaire for irritable bowel syndrome, modified to exclude diarrhoea as a symptom. Assessments were made at baseline, weeks 2 and 4. Results : A total of 2660 women were randomized and, of these, 1675 [tegaserod (n = 1363), placebo (n = 312)] were employed and completed Work Productivity and Activity Impairment for irritable bowel syndrome questionnaires. Compared with placebo, tegaserod significantly reduced work and daily activity impairment at weeks 2 and 4. Tegaserod reduced absenteeism by 2.6% (P = 0.004), presenteeism by 5.4% (P < 0.0001), overall work productivity loss by 6.3% (P < 0.0001), and activity impairment by 5.8% (P < 0.0001) at week 4 (vs. baseline). Assuming a 40-h workweek, tegaserod reduced work productivity loss by 2.5 h/week. Conclusions : Tegaserod significantly reduced work productivity loss and daily activity impairment at 2 weeks, and this benefit was maintained at 4 weeks.

-----

Gut. 2005 Aug 26; [Epub ahead of print]
A randomised controlled trial assessing the efficacy and safety of repeated tegaserod therapy in women with irritable bowel syndrome with constipation (IBS-C).
Tack J, Muller-Lissner S, Bytzer P, Corinaldesi R, Chang L, Viegas A, Schnekenbuehl S, Dunger-Baldauf C, Rueegg P.
University Hospitals Leuven, Belgium.

BACKGROUND: It has been proposed that treatments for irritable bowel syndrome with constipation (IBS-C) should provide rapid symptomatic relief, be intermittent and effective upon repeated use. AIMS: To evaluate the efficacy and safety of tegaserod on IBS symptoms, and its impact on quality of life and health-economic measures. PATIENTS: Women (>/=18 years of age) with IBS-C according to the Rome II criteria. METHODS: Prospective, double-blind, placebo- controlled, randomised trial. Women with IBS-C either received tegaserod 6 mg b.i.d. or placebo for 1 month. Patients with at least a partial response entered a treatment-free interval. Upon symptom recurrence, tegaserod-treated patients were re-randomised to tegaserod or placebo for an additional month. Primary efficacy variables were response (overall IBS symptoms and abdominal discomfort/pain) to first and repeated treatment. Analysis was by intention-to-treat. RESULTS: 2,660 patients and 1,191 patients were randomised for first and repeated treatment respectively. Tegaserod was superior to placebo for each primary efficacy variable (first treatment: 33.7% vs 24.2% responders respectively for relief of IBS symptoms and 31.3% vs 22.1% for relief of abdominal discomfort/pain; repeated treatment: 44.9% vs 28.7%, and 42.4% vs 27.1%, all p<0.0001). Tegaserod was superior to placebo for every secondary efficacy variable (relief of abdominal discomfort/pain, bloating and constipation; stool frequency and consistency). A response to tegaserod was observed within the first treatment week. Tegaserod produced greater satisfaction, work productivity and improved quality of life than placebo (p<0.05). CONCLUSION: Tegaserod provides rapid and sustained relief of IBS-C symptoms both during first and repeated treatment.

-----

Curr Treat Options Gastroenterol. 2005 Aug;8(4):337-45.
Pelvic outlet obstruction.
Kaidar-Person O, Rosen SA, Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA. mcderme@ccf.org.

Despite the wide variety of definitions and descriptions of constipation, ideally, the diagnostic approach should be uniform. The evaluation process should begin with a careful and thorough patient history and physical exam; appropriate efforts should be made to exclude organic causes of constipation. Patients suffering from pelvic outlet obstruction often respond poorly to conservative treatment. Diagnostic tests include intestinal transit studies, anorectal manometry, defecography, balloon expulsion, and anal sphincter electromyography. For many patients constipation is multifactorial and accordingly, so is the treatment. In our opinion the first line of treatment should be based on conservative measures including adequate intake of fluids, dietary fiber supplementation, and laxatives. Biofeedback training should be offered, particularly to patients with paradoxical puborectalis contraction. Surgical management can, in very limited circumstances, be offered only to those patients with disabling symptoms who have failed other standard therapeutic measures.

-----

J Clin Gastroenterol. 2005 Aug;39(7):600-2.
Lack of lasting effectiveness of PEG 3350 laxative treatment of constipation.
Tran LC, Di Palma JA.
University of South Alabama College of Medicine Mobile, AL 36693, USA.

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.

-----

J Pediatr Surg. 2005 Jul;40(7):1217.
Paediatric constipation for adult surgeons-article 1: Targeting the cause.
Angerpointner TA.

The authors review the potential implications for adult general and colorectal surgeons of recent advances in the diagnosis and management of constipation in childhood. The authors cite data highlighting the high incidence and prevalence of constipation in both children and adults, and how constipation in childhood commonly persists or recurs in adult life. The authors argue that constipation should be regarded as a "collection of symptoms" rather than a diagnosis. Through the use of manometry and colonic transit studies, they suggest that patients may be grouped into those that are constipated as a result of slow colonic transit and those due to ano-rectal disorders, collectively termed functional faecal retention (FFR). FFR may occur as a result of anatomical problems, such as an anal fissure, or non-anatomical problems that include endocrine, metabolic, and neurological disorders. Once an anatomical problem has been excluded, The authors suggest that patients presenting with constipation should be investigated to determine the site of the problem, using both radio-opaque marker studies to determine the transit time and colonic manometry to assess pressure abnormalities. In the authors' experience, 50% of children with chronic constipation will have delayed transit times, indicating slow transit constipation (STC), with failure of markers to progress to the rectosigmoid within 48 hours. Paediatric STC seems to differ from adults with the same condition, in that adult STC is far more common in women, the stools are firm.

-----

Tech Coloproctol. 2005 Jul 8; [Epub ahead of print]
Quality of life after colectomy for colonic inertia.
Thaler K, Dinnewitzer A, Oberwalder M, Weiss EG, Nogueras JJ, Efron J, Vernava AM 3rd, Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA, mcderme@ccf.org.

BACKGROUND: Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome.METHODS: A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was healthrelated quality of life assessed at follow-up using the SF-36 Health Survey.RESULTS: A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations.CONCLUSIONS: After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

-----

Scand J Gastroenterol. 2005 Apr;40(4):422-9.
Effects of regular physical activity on defecation pattern in middle-aged patients complaining of chronic constipation.
De Schryver AM, Keulemans YC, Peters HP, Akkermans LM, Smout AJ, De Vries WR, van Berge-Henegouwen GP.
Gastrointestinal Research Unit, Department of Gastroenterology, University Medical Centre, Utrecht, The Netherlands.

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.

-----

Digestion. 2005;71(4):238-44. Epub 2005 Jul 12.
Tegaserod: long-term treatment for irritable bowel syndrome patients with constipation in primary care.
Layer P, Keller J, Mueller-Lissner S, Ruegg P, Loeffler H.
Israelitisches Krankenhaus, Hamburg University, Hamburg, Deutschland. layer@ik-h.de

BACKGROUND: Tegaserod, a prokinetic 5-HT4 receptor agonist, has demonstrated efficacy and tolerability in irritable bowel syndrome (IBS) patients with constipation (IBS-C) in controlled clinical trials. Its use in primary care has not been investigated. AIM: To determine whether tegaserod is effective and well tolerated by primary care IBS-C patients. METHODS: Patients received tegaserod 6 mg b.i.d. for 12 weeks and were assessed for response, abdominal pain/discomfort, bloating, stool consistency/frequency and straining at weeks 4 and 12. Previous successful treatment with the withdrawn drug, cisapride, was noted. A 9-month study extension was offered to patients completing 12 weeks of tegaserod treatment. RESULTS: 212 patients entered the 12-week treatment period; 166 completed as planned. Response rates were 64.2% at week 4 and 70.3% at week 12. After 12 weeks, abdominal pain/discomfort and bloating were reduced from baseline (p < 0.0001; mean change -1.02 and -0.91 points, respectively), stool frequency increased (0.78-0.97 stools/day) and stool consistency improved (2.45-3.42; lumpy stools became softer). Tegaserod was well tolerated; the most common adverse events were headache (13.2%) and diarrhea (9.4%). One hundred and twenty patients entered the 9-month extension study, 85 completed and tegaserod continued to be well tolerated. CONCLUSIONS: In ambulatory primary care IBS-C patients, tegaserod is an effective and well-tolerated long-term treatment. Copyright (c) 2005 S. Karger AG, Basel.

-----

Colorectal Dis. 2005 May;7(3):224-7.
Ileostomy for constipation: long-term postoperative outcome.
Scarpa M, Barollo M, Keighley MR.
Colorectal Unit, Department of Surgery, Queen Elizabeth Hospital, University of Birmingham, UK.

Abstract Background and aims Idiopathic constipation is a rare indication for ileostomy construction. The aim of the study was to evaluate the success of ileostomy in treatment of severe constipation. Also to analyse the surgical complications and re-operation rate to identify any factors potentially predictive of outcome. Patients and methods This retrospective study analysed the long-term outcome of 24 ileostomies constructed for constipation. The ileostomy construction was performed in 13 patients during large bowel/rectum resection, in 6 after a full laparotomy and in 5 through an abdominal wall trephine alone. We analysed the surgical complications and the re-operation rate according any factors potentially predictive of outcome. Results One (4%) patient had persistent constipation after stoma creation. Surgical complications occurred in 11 (46%): retraction in 6 (25.0%), peristomal sepsis in 3 (12.5%) and parastomal hernia in 2 (8.1%). Refashioning of the stoma was necessary in 7 (29%) patients. Previous abdominal surgery, end ileostomy, ileostomy constructed after large bowel resection or laparotomy were associated with a significantly higher incidence of stomal complications while age, duration of follow up, major complication and ileostomy created after bowel resection were associated to a significantly higher re-operation rate (P < 0.05). Multivariate analysis identified end ileostomy and ileostomy created after bowel resection as independent risk factors for surgical complication and re-operation, respectively (P < 0.05). Conclusions Ileostomies were associated with a high frequency of complications, but most could be managed by minor surgical interventions. Patients who are considered for an ileostomy for severe idiopathic constipation should, where possible, have a loop ileostomy through a trephine rather than a laparotomy.

-----

Chemotherapy. 2005;51 Suppl 1:36-66.
Rifaximin, a poorly absorbed antibiotic: pharmacology and clinical potential.
Scarpignato C, Pelosini I.
Laboratory of Clinical Pharmacology, Department of Human Anatomy, Pharmacology and Forensic Sciences, School of Medicine and Dentistry, University of Parma, Parma, Italy. scarpi@tin.it

Rifaximin (4-deoxy-4'-methylpyrido[1',2'-1,2]imidazo- [5,4-c]-rifamycin SV) is a synthetic antibiotic designed to modify the parent compound, rifamycin, in order to achieve low gastrointestinal (GI) absorption while retaining good antibacterial activity. Both experimental and clinical pharmacology clearly show that this compound is a nonsystemic antibiotic with a broad spectrum of antibacterial action covering Gram-positive and Gram-negative organisms, both aerobes and anaerobes. Being virtually nonabsorbed, its bioavailability within the GI tract is rather high with intraluminal and fecal drug concentrations that largely exceed the minimal inhibitory concentration values observed in vitro against a wide range of pathogenic organisms. The GI tract represents, therefore, the primary therapeutic target and GI infections the main indication. The appreciation of the pathogenic role of gut bacteria in several organic and functional GI diseases has increasingly broadened its clinical use, which is now extended to hepatic encephalopathy, small intestine bacterial overgrowth, inflammatory bowel disease and colonic diverticular disease. Potential indications include the irritable bowel syndrome and chronic constipation, Clostridium difficile infection and bowel preparation before colorectal surgery. Because of its antibacterial activity against the microorganism and the lack of strains with primary resistance, some preliminary studies have explored the rifaximin potential for Helicobacter pylori eradication. Oral administration of this drug, by getting rid of enteric bacteria, could also be employed to achieve selective bowel decontamination in acute pancreatitis, liver cirrhosis (thus preventing spontaneous bacterial peritonitis) and nonsteroidal anti-inflammatory drug (NSAID) use (lessening in that way NSAID enteropathy). This antibiotic has, therefore, little value outside the enteric area and this will minimize both antimicrobial resistance and systemic adverse events. Indeed, the drug proved to be safe in all patient populations, including young children. Although rifaximin has stood the test of time, it still attracts the attention of both basic scientists and clinicians. As a matter of fact, with the advancement of the knowledge on microbial-gut interactions in health and disease novel indications and new drug regimens are being explored. Besides widening the clinical use, the research on rifaximin is also focused on the synthesis of new derivatives and on the development of original formulations designed to expand the spectrum of its clinical use. Copyright (c) 2005 S. Karger AG, Basel.

-----

Pediatrics. 2005 Apr;115(4):873-7.
Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome.
Borowitz SM, Cox DJ, Kovatchev B, Ritterband LM, Sheen J, Sutphen J.
Department of Pediatrics, University of Virginia, Charlottesville, Virginia 22908, USA. witz@virginia.edu

OBJECTIVE: Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are. METHODS: A total of 119 children who were between 2 and 7 years of age (mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians (15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians. RESULTS: After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose (8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes (5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively. CONCLUSION: Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic.

-----

World J Gastroenterol. 2005 Apr 7;11(13):1971-5.
Use of a device that applies external kneading-like force on the abdomen for treatment of constipation.
Mimidis K, Galinsky D, Rimon E, Papadopoulos V, Zicherman Y, Oreopoulos D.
Democritus University of Thrace, Alexandroupolis, Greece. kmimidis@otenet.gr

AIM: To evaluate the efficacy of a recently developed device that applies kneading-like motion on the abdomen in improving constipation in elderly long-term care patients. METHODS: Thirty constipated elderly patients were randomly selected from two nursing homes. They were instructed to use the device once daily for 20 min. Rate of bowel movements, volume and consistency of stool and the use of laxantia were all recorded during a 3-wk baseline period and for 12-wk treatment period. Colonic transit time (CTT) was measured in 13 patients by radiopaque markers during the baseline and at the end of treatment. RESULTS: Bowel movement rate (BM/week) increased from 1.4+/-0.4 BM/wk during baseline to 3.9+/-0.8 BM/wk during treatment (P<5.0x10(-7)). Stool amount that was "low" in 30 patients during baseline increased in 21 patients at the end of the study period (chi2 = 19.048-P = 1.3x10(-5)). Stool consistency, that was "hard" in 25 patients and "soft" in 5 patients during baseline, ameliorated in 23 patients at the end of the study (only 2 patients referred "hard" stool) (chi2 = 21.043-P = 4.0x10(-6)). The mean baseline CTT measured was 92.3+/-32.3 h at baseline and decreased to 49.4+/-31.3 h during the study period (P = 0.000208). No side effects were observed during the study period. CONCLUSION: External mechanical vibration of the abdomen reduced CTT and helped to relieve severe constipation in elderly constipated patients.

-----

Am J Gastroenterol. 2005 Apr;100(4):936-71.
Efficacy and safety of traditional medical therapies for chronic constipation: systematic review.
Ramkumar D, Rao SS.
Division of Gastroenterology, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA.

OBJECTIVES: Constipation is common, and its treatment is unsatisfactory. Although many agents have been tried, there are limited data to support their use. Our aim was to undertake a systematic review of the efficacy and safety of traditional medical therapies for chronic constipation and to make evidence-based recommendations. METHODS: We searched the English literature for drug trials evaluating treatment of constipation by using MEDLINE and PUBMED databases from 1966 to 2003. Only studies that were randomized, conducted on adult subjects, and published as full manuscripts were included. Studies were assigned a quality score based on published methodology. Standard forms were used to abstract data regarding study design, duration, outcome measures, and adverse events. By using the cumulative evidence of published data for each agent, recommendations were made regarding their use following the United States Preventive Services Task Force guidelines. RESULTS: Good evidence (Grade A) was found to support the use of polyethylene glycol (PEG) and tegaserod. Moderate evidence (Grade B) was found to support the use of psyllium, and lactulose. There was a paucity of quality data regarding many commonly used agents including milk of magnesia, senna, bisacodyl, and stool softeners. CONCLUSIONS: There is good evidence to support the use of PEG, tegaserod, lactulose, and psyllium. Surprisingly, there is a paucity of trials for many commonly used agents. These aspects should be considered when designing trials comparing new agents with traditional therapies because their use may not be well validated.

-----

J Pediatr. 2005 Mar;146(3):359-63.
Prevalence, symptoms and outcome of constipation in infants and toddlers.
Loening-Baucke V.
Division of General Pediatrics, University of Iowa, Iowa City 52242-1083, USA. vera-loening-baucke@uiowa.edu

OBJECTIVE: To determine the prevalence of constipation in children <or=2 years, describe the symptoms of constipation, and review how often specific interventions were effective. STUDY DESIGN: Retrospective chart review. RESULTS: Of 4,157 children <2 years of age, 185 children had constipation. The prevalence rate for constipation in the first year of life was 2.9%, and in the second year of life, the rate was 10.1%. Functional constipation was the cause in 97% of the children. Boys and girls were affected with equal frequency. Constipation was caused by an underlying organic disease in 1.6% of cases, and 97% of the children had functional constipation. Dietary changes and corn syrup were the initial treatment suggestions for 116 children; 93% of these children underwent follow-up examinations, and the constipation resolved in 25% of the children. Of 100 children treated with milk of magnesia or polyethylene glycol 3350 without electrolytes, 93 children underwent follow-up examinations, and the constipation was resolved with treatment in 92% of the children. CONCLUSIONS: Dietary changes, corn syrup, or both resolved constipation in 25% of children, and laxatives resolved constipation in 92% of children. Both milk of magnesia and polyethylene glycol were efficient and safe in infants and toddlers.

-----

Scand J Caring Sci. 2005 Mar;19(1):71-6.
Fruit and fibre (Pajala porridge) in the prevention of constipation.
Wisten A, Messner T.
Section of Geriatrics and Rehabilitation, Department of Internal Medicine, Sunderby Hospital, Lulea, Sweden. aasewisten@hotmail.com

BACKGROUND AND AIMS: Constipation is a common problem in geriatric wards and in the elderly population. Although high-fibre diets can help relieve constipation non-pharmacologically in many patients, traditional laxatives still remain the standard treatment. A fibre supplement in the form of raw bran is not always well tolerated. We wanted to study the effects of a daily consumption of a fruit- and fibre-rich porridge on stool frequency, perceived well-being and the costs for laxatives, when compared with traditional treatment with laxatives, in geriatric patients. METHODS: Twenty patients in secondary geriatric wards (hospital rehabilitation wards) were randomized into an intervention group (porridge group) and a control group (standard diet without porridge) for a 1-week run-in and 2-week study, with registration of clinical data, e.g. medical treatment, laxative consumption, stool frequency and perceived well-being. RESULTS: The patients in the porridge group had a daily defaecation without laxatives on average 76% of the time (10.7/14 days) compared with 23% of the time (3.3/14 days) in the non-porridge group (p = 0.003). The discomfort was less in the porridge group (2.5 vs. 6.5 on a 10-degree visual analogue scale, p = 0.008) when compared with the control group. The cost for laxatives was 93% lower in the intervention group (2.5 vs. 37.5) for the 2-week study. CONCLUSIONS: A fibre-rich porridge was effective, well liked and tolerated and reduced the need for laxatives in geriatric patients. We conclude that a daily fibre-rich meal ought to be included in the treatment strategies of constipation in hospital wards.

-----

Am J Gastroenterol. 2005 Feb;100(2):362-72.
Tegaserod for the treatment of chronic constipation: a randomized, double-blind, placebo-controlled multinational study.
Kamm MA, Muller-Lissner S, Talley NJ, Tack J, Boeckxstaens G, Minushkin ON, Kalinin A, Dzieniszewski J, Haeck P, Fordham F, Hugot-Cournez S, Nault B.
Department of Medicine, St. Mark's Hospital, London, United Kingdom.

OBJECTIVES: Chronic constipation is a common, persistent disorder with limited effective treatment options. This study investigated the efficacy, safety, and tolerability of tegaserod in the treatment of chronic constipation. METHODS: After a 2-wk baseline period, patients were randomized to double-blind treatment of 12 wk with tegaserod (2 or 6 mg b.i.d.) or placebo. Response during weeks 1-4 (primary variable) was defined as an increase in complete spontaneous bowel movement (CSBM)/wk. Secondary variables included response during weeks 1-12, patient evaluation of individual symptoms, and global assessment of bowel habits and constipation. RESULTS: One thousand two hundred and sixty-four patients were randomized to tegaserod or placebo. Responder rates for the primary efficacy variable were 35.6% for tegaserod 2 mg b.i.d. (p= 0.0059 vs placebo), 40.2% for 6 mg b.i.d. (p < 0.0001 vs placebo) and 26.7% for placebo. The number needed to treat was 7.3 for the 6 mg b.i.d. dose compared with 11.1 for tegaserod 2 mg b.i.d. Tegaserod 6 mg b.i.d. reduced straining, abdominal bloating/distension, and abdominal pain/discomfort during the 12-wk treatment period compared with placebo (p < 0.05 for all symptoms). Significant improvements were also seen in stool form and in global assessment of bowel habits and constipation. The most common adverse events, headache and abdominal pain, were more frequent with placebo than with tegaserod. CONCLUSIONS: Tegaserod was efficacious in relieving symptoms of chronic constipation and was well tolerated.

-----

Pediatr Int. 2005 Feb;47(1):15-9.
A comparative study: The efficacy of liquid paraffin and lactulose in management of chronic functional constipation.
Urganci N, Akyildiz B, Polat TB.
Clinic of Pediatrics, Sisli Etfal Hospital, Istanbul, Turkey.

Abstract Objectives: To determine and compare efficacy, safety and optimal dose of two laxatives, liquid paraffin and lactulose, in 40 children with chronic functional constipation. Methods: A total of 20 children were treated with liquid paraffin and 20 with lactulose for 8 weeks and at an initial dose of 1 mL/kg per day for both drugs. The dose was adjusted every 3 days as required and a diary was kept to monitor dose, side-effects, stool frequency and consistency, and other symptoms. Results: During first 4 weeks, improvement in stool consistency and frequency was significantly higher in liquid the paraffin group (P < 0.01 and P < 0.05, respectively). Improvement in the number of stools per week was also significantly higher in the liquid paraffin group during the last 4 weeks of therapy (P < 0.05). Compliance rates averaged 95% in the liquid paraffin group and 90% in the lactulose group during the first 4 weeks of therapy and 90% in the liquid paraffin group and 60% in the lactulose group during the last 4 weeks of therapy (chi(2) = 4.8, SD = 1, P = 0.02). During the first 4 weeks of therapy and during the last 4 weeks of therapy, mostly side-effects and poor symptom control, respectively, influenced the compliance in the liquid paraffin group. Conclusions: Liquid paraffin is more effective in the treatment of children with constipation. Patients treated with liquid paraffin responded more rapidly than patients responding to lactulose and showed fewer side-effect. It is considered that late response and side-effects in conjunction with poor symptom control influence the patient compliance and the successful treatment of childhood constipation.

-----

Pediatr Surg Int. 2005 Feb;21(2):100-105. Epub 2005 Jan 21.
Role of anal dilatation in treatment of idiopathic constipation in children: long-term follow-up of a double-blind randomized
controlled study.
Keshtgar AS, Ward HC, Clayden GS, Sanei A.
Guy's and St Thomas' Hospital, NHS Trust and University Hospital Lewisham, NHS Trust, London, UK, ali.keshtgar@uhl.nhs.uk.

Constipation in childhood is a common symptom, with an estimated incidence between 0.3% and 8%. Most of the evidence for the current management of constipation and fecal soiling in children is based on reports of nonrandomized retrospective trials. Anal dilatation has had an established role in the management of idiopathic constipation but has never been evaluated by a randomized study. A double-blind randomized controlled trial was done of children who failed to respond to medical treatment and were admitted for investigation and treatment of idiopathic constipation to Guy's Hospital, London, between April 2001 and April 2003. All children had intestinal transit study on admission. They were randomized, using a computer-generated allocation in sealed envelopes, to receive no anal dilatation (control group) or anal dilatation (anal dilatation group). Anorectal manometry and endosonography were done under ketamine anesthesia followed by anal dilatation if necessary under the same anesthesia. Disimpaction of feces from the rectum was done at the end of the procedure under general anesthesia using propofol muscle relaxant to minimize stretching of anal sphincter muscles in the control group. All children had intensification of medical treatment, toilet training, and monitoring of their response to treatment during their hospital stay, which ranged from 3 to 5 days. Outcome was measured using a parent's questionnaire of symptom severity at 3 and 12 months of follow-up by one of the authors, who was blinded to randomization. The symptom severity score ranged between 0 and 65 and consisted of scores for the following: delay in defecation (score range 0-10), difficulty and pain with passing stool (0-5), soiling problem (0-10), intensity of laxative treatment (0-10), child's general health (0-5), behavior related to the bowel problem (0-5), overall improvement of symptoms (0-12,) and assessment of megarectum on abdominal examination (0-8). Of 60 neurologically normal children, 31 (19 males) were randomized in the control group and 29 (18 males) in the anal dilatation group. All children had findings consistent with idiopathic constipation and positive anorectal reflex on manometry, no anal sphincter damage on endosonography, and no anal fissure on examination under anesthesia. The median age for control and anal dilatation groups was 7.97 (range 4.1-14.25) years and 7.78 (4-13.25) years, respectively. Both groups were also comparable with regard to median of duration of laxative treatment (32 months vs. 31.5 months), internal anal sphincter thickness on endosonography (0.90 mm vs. 0.80 mm), resting anal sphincter pressure on manometry (51 mmHg vs. 51 mmHg), total rectal capacity on manometry (260 mmHg vs. 260 mmHg), and total symptom severity score before admission (33 vs. 29), respectively. At 12-month follow-up, the median pre-admission symptom severity score had improved significantly, from 33 (range 12-49) in the control group and 29 (16-51) in the dilatation group to 15 (0-51, p<0.0001) and 19 (1-46, p<0.0001), respectively. There was no significant difference between the two groups with regard to symptom severity score improvement at 12-month follow-up (p<0.92). We found a significant correlation between total rectal capacity measured on manometry and symptom severity score before admission and at 12-month follow-up (r=0.30, p<0.01 and r=0.25, p<0.05, respectively). Our results indicate that anal dilatation does not contribute to the management of school-aged children with idiopathic constipation. Admission to hospital for clarification of diagnosis and intensification of medical treatment with disimpaction of stool from the rectum is beneficial.

-----

Clin Pediatr (Phila). 2005 Jan-Feb;44(1):63-71.
Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes.
Croffie JM, Ammar MS, Pfefferkorn MD, Horn D, Klipsch A, Fitzgerald JF, Gupta SK, Molleston JP, Corkins MR.
Division of Pediatric Gastroenterology/Hepatology/Nutrition, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.

SUMMARY: The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p </= 0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p </= 0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p </= 0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes. Clin Pediatr. 2005;44:63-71.

-----

Am J Gastroenterol. 2005 Jan;100(1):232-42.
Myths and misconceptions about chronic constipation.
Muller-Lissner SA, Kamm MA, Scarpignato C, Wald A.
Abteilung Innere Medizin, Park-Klinik Weissensee, Schonstrasse 80, 13086 Berlin, Germany.

There are many strongly held beliefs about constipation that are not evidence based. The purpose of this review is to address these beliefs concerning various aspects of constipation. There is no evidence to support the theory that diseases may arise via "autointoxication," whereby poisonous substances from stools within the colon are absorbed. Dolichocolon, defined as an elongated colon, should not be seen as a cause of constipation. The role of sex hormones altering gut function during the menstrual cycle appears to be minimal. During pregnancy they may play a role in slowing gut transit. Hypothyroidism can cause constipation, but among patients presenting with constipation, hypothyroidism is rare. A diet poor in fiber should not be assumed to be the cause of chronic constipation. Some patients may be helped by a fiber-rich diet but many patients with more severe constipation get worse symptoms when increasing dietary fiber intake. There is no evidence that constipation can successfully be treated by increasing fluid intake unless there is evidence of dehydration. In the elderly constipation may correlate with decreased physical activity, but many cofactors are likely to play a role. Intervention programs to increase physical activity as part of a broad rehabilitation program may help. It is unlikely that stimulant laxatives at recommended doses are harmful to the colon. A proportion of patients with chronic constipation is dependent of laxatives to achieve satisfactory bowel function, but this is not the result of prior laxative intake. Tolerance to stimulant laxatives is uncommon. There is no indication for the occurrence of "rebound constipation" after stopping laxative intake. While laxatives may be misused, there is no potential for addiction.

-----

Rocz Akad Med Bialymst. 2004;49:47-52.
Surgical treatment of constipation.
Blachut K, Bednarz W, Paradowski L.
Department of Gastroenterology and Hepatology, Medical University of Wroclaw, Poland.

Constipation is a common symptom in clinical practice. Definition of constipation includes abnormal bowel frequency, difficulty during defecation and abnormal stool consistency. There are many classifications of constipation based on constipation etiology (constipation in healthy people caused by life style, constipation as a symptom of digestive tract diseases, secondary constipation in the course of systemic disorders or associated with drugs) and/or constipation mechanisms (functional, mechanical). The numerous disorders leading to constipation make often diagnostic management difficult and complicated. Treatment of constipation includes dietary and behavioral approaches, pharmacologic therapy and in selected patient surgical treatment. Surgical treatment is recommended in young patients with severe slow transit constipation refractory to conservative treatment. Confirmation of indication to surgical treatment requires studies of colonic and anorectal function (colonic transit studies, anorectal manometry, studies of defecation). Preferred surgical technique is colectomy with ileorectal anastomosis. Authors reported good results and patient satisfaction in 50-100 percent of cases. Postoperative complications include intestinal obstruction, abdominal pain, flatulence, diarrhea.

-----

Aliment Pharmacol Ther. 2004 Nov;20 Suppl 7:20-4.
Review article: tegaserod for chronic constipation.
Johanson JF.
University of Illinois College of Medicine, Rockford, IL, USA.

Summary Constipation is one of the most common gastrointestinal conditions with limited effective treatment options. Tegaserod, a 5-HT(4) 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 pateints 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.

-----

Drugs Aging. 2004;21(14):911-30.
The treatment of chronic constipation in elderly people: an update.
Bosshard W, Dreher R, Schnegg JF, Bula CJ.
Division of Geriatric Medicine and Geriatric Rehabilitation, Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.

Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition.Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives.Several promising compounds such as the new serotonin 5-HT(4) receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified.Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.

-----

Scand J Surg. 2004;93(3):184-90.
The role of biofeedback therapy in functional proctologic disorders.
Kairaluoma M, Raivio P, Kupila J, Aarnio M, Kellokumpu I.
Department of Gastroenterological Surgery Jyvaskyla Central Hospital, Jyvaskyla, Finland. matti.kairaluoma@ksshp.fi

BACKGROUND AND AIMS: The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation. MATERIAL AND METHODS: Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database. RESULTS: Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes. CONCLUSIONS: Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

-----

Gut. 2004 Nov;53(11):1590-4.
PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: a double blind, randomised, controlled, multicentre trial.
Voskuijl W, de Lorijn F, Verwijs W, Hogeman P, Heijmans J, Makel W, Taminiau J, Benninga M.
Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, the Netherlands. w.p.voskuijl@amc.nl.

BACKGROUND: Recently, polyethylene glycol (PEG 3350) has been suggested as a good alternative laxative to lactulose as a treatment option in paediatric constipation. However, no large randomised controlled trials exist evaluating the efficacy of either laxative. AIMS: To compare PEG 3350 (Transipeg: polyethylene glycol with electrolytes) with lactulose in paediatric constipation and evaluate clinical efficacy/side effects. PATIENTS: One hundred patients (aged 6 months-15 years) with paediatric constipation were included in an eight week double blinded, randomised, controlled trial. METHODS: After faecal disimpaction, patients <6 years of age received PEG 3350 (2.95 g/sachet) or lactulose (6 g/sachet) while children > or =6 years started with 2 sachets/day. Primary outcome measures were: defecation and encopresis frequency/week and successful treatment after eight weeks. Success was defined as a defecation frequency > or =3/week and encopresis < or =1 every two weeks. Secondary outcome measures were side effects after eight weeks of treatment. RESULTS: A total of 91 patients (49 male) completed the study. A significant increase in defecation frequency (PEG 3350: 3 pre v 7 post treatment/week; lactulose: 3 pre v 6 post/week) and a significant decrease in encopresis frequency (PEG 3350: 10 pre v 3 post/week; lactulose: 8 pre v 3 post/week) was found in both groups (NS). However, success was significantly higher in the PEG group (56%) compared with the lactulose group (29%). PEG 3350 patients reported less abdominal pain, straining, and pain at defecation than children using lactulose. However, bad taste was reported significantly more often in the PEG group. CONCLUSIONS: PEG 3350 (0.26 (0.11) g/kg), compared with lactulose (0.66 (0.32) g/kg), provided a higher success rate with fewer side effects. PEG 3350 should be the laxative of first choice in childhood constipation.

-----

Ann Chir. 2004 Oct;129(8):400-4.
[Surgical management for slow-transit constipation]
[Article in French]
Alves A, Coffin B, Panis Y.
Service de chirurgie digestive, hopital Lariboisiere, 2, rue Ambroise-Pare, 75010 Paris, France. arnaud.alves@lrb.ap-ho-paris.fr

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.

-----

ANZ J Surg. 2004 Oct;74(10):890-4.
Paediatric constipation for adult surgeons - article 2: new microscopic abnormalities and therapies.
King SK, Sutcliffe JR, Hutson JM, Southwell BR.
Department of General Surgery, Royal Children's Hospital, Parkville, Victoria, Australia.

Chronic constipation is a common condition in both adults and children. Children with chronic constipation frequently have symptoms that continue into adulthood. In the second part of the review we describe advances in the identification of abnormalities in the control of motility. The role of neurotransmitters in both paediatric and adult constipation is examined and the radical rethink of colonic dysmotility caused by the re-emergence of interstitial cells of Cajal is discussed. The recognition of chronic constipation as an heterogenous condition has led to the introduction of new therapies. Antegrade washouts through appendix stomas and an exciting new treatment with electrical interferential therapy may, in the future, result in a less invasive approach to the management of chronic constipation. An improved understanding of the assessment and management of chronic constipation in childhood is also likely to reduce the frequency and morbidity of chronic constipation in adults.

-----

Clin Ther. 2004 Sep;26(9):1479-91.
Open-label, dose-ranging pilot study of 4 weeks of low-dose therapy with sodium phosphate tablets in chronically constipated adults.
Medoff J, Katz S, Malik P, Pambianco D, Pruitt R, Poulos J, Rank J, Rose M.
Vital Re:Search, Greensboro, North Carolina, USA.

BACKGROUND: The tablet formulation of sodium phosphate (NaP) is a prescription osmotic purgative that has been marketed since 2001. The use of NaP tablets in patients with constipation has not been studied previously. OBJECTIVE: This study assessed the tolerability and efficacy of 28 days of therapy with NaP tablets (1.5 g NaP/tablet) in patients with chronic constipation. METHODS: Adults with functional constipation or constipation-predominant irritable bowel syndrome and Z-3 spontaneous bowel movements (BMs) during the 7-day screening/baseline period were eligible for this open-label, dose-ranging study. Patients were randomized to receive starting doses of 4 NaP tablets (group A) or 8 NaP tablets (group B) each morning for 28 days. After a minimum of 48 hours, the NaP dose could be titrated upward (in the case of no BM or no relief of symptoms) or downward (in the case of a predefined excess laxative response) by 2 tablets/d to a minimum of 2 tablets/d or a maximum of 12 tablets/d. Patients kept a diary of their BMs and gastrointestinal symptoms. A serum chemistry panel was obtained weekly. The primary end points were the constipation response (based on the change from baseline in weekly number of BMs) and the global sense response (based on daily scores for the patient's overall sense of change in their bowel problems). RESULTS: At randomization, there were 18 patients in group A and 25 in group B. Of these, 40 patients (16 group A, 24 group B) had > or 7 days of diary information while taking study treatment and were evaluable for efficacy. The constipation response rate was 100% in group A and 95.8% in group B, and the respective global sense response rates were 68.8% and 79.2%. Four patients in group B withdrew due to adverse events, none of which were serious. Five patients had occasional hypokalemia that required no treatment. Changes from baseline in serum concentrations of calcium, inorganic phosphorus, and potassium were not clinically significant and did not require treatment. CONCLUSIONS: In this small study, NaP tablets taken daily were generally well tolerated (particularly in the low-dose group) and produced prompt relief of constipation--generally within the first week of treatment--that was sustained over the 28-day treatment period. A reasonable starting dose appears to be 2 to 4 tablets (3-6 g NaP) daily.

-----

Appl Psychophysiol Biofeedback. 2004 Sep;29(3):153-74.
Biofeedback treatment for functional anorectal disorders: a comprehensive efficacy review.
Palsson OS, Heymen S, Whitehead WE.
Department of Medicine, Center for Functional Gastrointestinal and Motility Disorders, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7080, USA. olafur_palsson@med.unc.edu

This review aimed to critically evaluate the literature on the efficacy of biofeedback for functional anorectal disorders, rate these biofeedback applications according to established guidelines, and make recommendations for this field based on the literature. The Medline and PsychInfo databases were searched to obtain all papers published from 1975 to 2003 that included the terms "biofeedback" and either "constipation" "pelvic floor dyssynergia" "fecal incontinence" or "anorectal pain." Adult and pediatric papers in any language were screened. Prospective studies with five or more participants and a description of the treatment protocol and outcome were selected for review. Seventy-four studies qualified for review: 33 trials on fecal incontinence (FI), 38 on pelvic floor dyssynergia (PFD) or functional constipation, and 3 on anorectal pain. Only 20% of studies were controlled outcome trials. Treatment protocols, etiological subgroups studied and outcome measures varied greatly. The overall average probability of successful treatment outcome for patients treated with biofeedback was 67.2% for functional FI and 62.4% for constipation. There were insufficient data to warrant such calculation for anorectal pain. According to standard efficacy rating criteria, biofeedback treatment is efficacious for functional constipation or PFD in children and probably efficacious in adults; probably efficacious for functional FI; and possibly efficacious for anorectal pain. Utilizing data from all applicable studies, we found that success rate per subject is significantly higher for biofeedback treatment than for standard medical care for PFD/functional constipation, and FI (p < .001 for both). Biofeedback treatment may therefore be viewed as a valuable adjunct to medical management of functional PFD/constipation and incontinence. A number of recommendations for future investigations are made based on the review.

-----

Br J Surg. 2004 Sep 29;91(12):1559-1569 [Epub ahead of print]
Systematic review of sacral nerve stimulation for faecal incontinence and constipation.
Jarrett ME, Mowatt G, Glazener CM, Fraser C, Nicholls RJ, Grant AM, Kamm MA.
Physiology Unit, St Mark's Hospital, Harrow, UK.

BACKGROUND AND METHOD:: This systematic review assesses the efficacy and safety of sacral nerve stimulation (SNS) for faecal incontinence and constipation. Electronic databases and selected websites were searched for studies evaluating SNS in the treatment of faecal incontinence or constipation. Primary outcome measures included episodes of faecal incontinence per week (faecal incontinence studies) and number of evacuations per week (constipation studies). RESULTS:: From 106 potentially relevant reports, six patient series and one crossover study of SNS for faecal incontinence, and four patient series and one crossover study of SNS for constipation, were included. After implantation, 41-75 per cent of patients achieved complete faecal continence and 75-100 per cent experienced improvement in episodes of incontinence. There were 19 adverse events among 149 patients. The small crossover study reported increased episodes of faecal incontinence when the implanted pulse generator was switched off. Case series of SNS for constipation reported an increased frequency of evacuation. There were four adverse events among the 20 patients with a permanent implant. The small crossover study reported a reduced number of evacuations when the pulse generator was switched off. CONCLUSION:: SNS results in significant improvement in faecal incontinence in patients resistant to conservative treatment. Early data also suggest benefit in the treatment of constipation. Copyright (c) 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

-----

Curr Treat Options Gastroenterol. 2004 Aug;7(4):291-298.
Treatment of Severe and Intractable Constipation.
Bharucha AE.
Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA. Bharucha.adil@mayo.edu

A careful clinical evaluation, exclusion of secondary causes (eg, colonic obstruction, metabolic conditions, and drug-induced constipation), and assessments of colonic transit and rectal evacuation are necessary to ascertain whether constipation is attributable to normal colonic transit, delayed colonic transit (ie, slow-transit constipation), or a rectal evacuation disorder (with or without delayed colonic transit). Idiopathic slow-transit constipation is a clinical syndrome predominantly affecting women and is characterized by intractable constipation and delayed colonic transit. This syndrome is attributed to disordered colonic motor function and spans a spectrum of variable severity ranging from patients who have relatively mild delays in transit, but are otherwise indistinguishable from irritable bowel syndrome, at one extreme to patients with colonic inertia or chronic megacolon at the other extreme. Most patients are treated with one or more pharmacological agent. A subtotal colectomy is effective and occasionally indicated for patients with medically refractory severe slow-transit constipation, provided that pelvic floor dysfunction has been excluded or treated. Pelvic floor dysfunction can be diagnosed by the clinical features and anorectal testing. Most patients with pelvic floor dysfunction will respond to pelvic floor retraining by biofeedback therapy.

-----

Am J Clin Nutr. 2004 Aug;80(2):245-56.
Yogurt and gut function.
Adolfsson O, Meydani SN, Russell RM.
Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA 02111, USA.

In recent years, numerous studies have been published on the health effects of yogurt and the bacterial cultures used in the production of yogurt. In the United States, these lactic acid-producing bacteria (LAB) include Lactobacillus and Streptococcus species. The benefits of yogurt and LAB on gastrointestinal health have been investigated in animal models and, occasionally, in human subjects. Some studies using yogurt, individual LAB species, or both showed promising health benefits for certain gastrointestinal conditions, including lactose intolerance, constipation, diarrheal diseases, colon cancer, inflammatory bowel disease, Helicobacter pylori infection, and allergies. Patients with any of these conditions could possibly benefit from the consumption of yogurt. The benefits of yogurt consumption to gastrointestinal function are most likely due to effects mediated through the gut microflora, bowel transit, and enhancement of gastrointestinal innate and adaptive immune responses. Although substantial evidence currently exists to support a beneficial effect of yogurt consumption on gastrointestinal health, there is inconsistency in reported results, which may be due to differences in the strains of LAB used, in routes of administration, or in investigational procedures or to the lack of objective definition of "gut health." Further well-designed, controlled human studies of adequate duration are needed to confirm or extend these findings.

-----

J Pediatr Gastroenterol Nutr. 2004 Aug;39(2):197-199.
Polyethylene Glycol for Constipation in Children Younger Than Eighteen Months Old.
Michail S, Gendy E, Preud'Homme D, Mezoff A.
Wright State University School of Medicine and The Children's Medical Center, Dayton, Ohio, U.S.A.

BACKGROUND:: Polyethylene glycol (PEG) is a safe and effective treatment for constipation in children older than 18 months. Data on its safety and efficacy in infants are lacking. The goal of this study was to determine safety, efficacy, and optimal dose of polyethylene glycol powder for treatment of constipation in patients younger than 18 months. METHODS:: The authors reviewed the charts of patients younger than 18 months treated with PEG 3350 for constipation. The initial dose, effective maintenance dose, response to therapy, duration of therapy, and side effects were recorded. RESULTS:: Twenty-eight patients younger than 18 months of age treated with PEG were identified (3, age 0-5 months; 9, age 6-11 months; 16, age 12-17 months). Mean duration of therapy was 6.2 +/- 5 months (range, 3 weeks-21 months). Mean initial dose was 0.88 g/kg/day (range, 0.26-2.14 g/kg/day). Mean effective maintenance dose was 0.78 g/kg/day (range, 0.26-1.26 g/kg/day). PEG relieved constipation in 97.6% of patients. One infant experienced increased gas per rectum and four others experienced transient diarrhea that resolved after adjusting the dose. CONCLUSION:: Oral powdered polyethylene glycol at a maintenance dose of 0.78 g/kg/day is safe and effective for patients younger than 18 months. Dose and safety profiles are similar for those reported in older children.

-----

Rev Gastroenterol Disord. 2004;4 Suppl 2:S34-42.
Current treatment options for chronic constipation.
DiPalma JA.
Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA.

Various agents are used for the medical management of chronic constipation but few have been carefully studied. This review examines available data concerning several bulk and fiber products, lubricating agents, stimulants, and osmotic laxatives, alone and in combination. Popular therapeutic options for initial treatment of chronic constipation are dietary fiber and medicinal bulk. Subsequent treatments if fiber is not successful or tolerated would include saline osmotic laxatives, lactulose, or stimulants like senna or bisacodyl. Recent data demonstrate polyethylene glycol laxative to be safe and effective as an initial or second-line agent for chronic constipation. Indications and use of surgery and biofeedback are also discussed.

------

J Midwifery Womens Health. 2004 Jul-Aug;49(4):355-8.
Polyethylene glycol electrolyte solution (Isocolan) for constipation during pregnancy: an observational open-label study.
Neri I, Blasi I, Castro P, Grandinetti G, Ricchi A, Facchinetti F.
Clinica Ostetrica, Modena, Italy. neri.Isabella@unimore.it

To evaluate the efficacy of a polyethylene glycol electrolyte solution (PEG-4000) in pregnant women affected by constipation, 40 consecutive pregnant women from 6 to 38 weeks' gestation were enrolled in this preliminary study. Constipation was defined as spontaneous evacuation less than four times a week or the presence of symptoms such as defecation pain, rectal urgency, tenesmus, anal injury, or abdominal pain. A PEG-4000 solution (Isocolan, also marketed in the United States as Golitely/Nulitely) was administered for 15 days at a dose of 250 mL by mouth once or twice a day. The number of bowel movements per week, the presence or absence of liquid stools, tenesmus, urgency, defecation pain, anal lesions, and abdominal pain were evaluated before and after 15 days of treatment. Treatment with PEG-4000 significantly increased the evacuation episodes per week (from 1.66 +/- 0.48 to 3.16 +/- 1.05; P <.01), and constipation was resolved in 27 of 37 women (73%). Defecation pain, anal injury, and abdominal pain significantly improved after PEG-4000 administration. Improvement occurred in both patients with new-onset constipation during pregnancy as well as patients with a history of constipation before pregnancy. These preliminary findings indicate that PEG-4000 may be an effective choice for the treatment of constipation during pregnancy.

-----

Gastrointest Endosc. 2004 Jul;60(1):39-43.
Percutaneous endoscopic colostomy of the left colon: A new technique for management of intractable constipation in children.
Rawat DJ, Haddad M, Geoghegan N, Clarke S, Fell JM.
Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK.

BACKGROUND: The antegrade colonic enema is accepted as effective for management of intractable constipation in children when conventional bowel management has failed. This study describes experience with a new, minimally invasive technique, the distal antegrade colonic enema, which involves percutaneous endoscopic colostomy of the left colon. METHODS: Fifteen children with refractory constipation and soiling who had radiographic evidence of megarectum and/or distal colonic delay were selected for the procedure. The junction of the descending and the sigmoid colon was identified colonoscopically, and the percutaneous endoscopic colostomy tube, through which antegrade distal colonic enema are administered, was inserted. RESULTS: Fourteen children underwent distal percutaneous endoscopic colostomy insertion. The median time required for the procedure was 30 minutes (20-50 minutes). Excluding one child (technical difficulties with percutaneous endoscopic colostomy placement), median post-procedural hospital stay was 4 days (2-27 days). Thirteen children were no longer soiling, and improvement in quality of life was reported at 2 months' follow-up. At 6 months' follow-up, 90% of children were clean during intervals between enemas. All children evaluated at 12 months' follow-up remained clean. Median duration of follow-up was 12.5 months (2-51 months). CONCLUSIONS: The distal percutaneous endoscopic colostomy is a simple alternative to established methods for delivery of antegrade enemas. It is less invasive and on reversal leaves only minor scarring.

------

Arch Surg. 2004 Jul;139(7):775-9.
Colonic pacing: a therapeutic option for the treatment of constipation due to total colonic inertia.
Shafik A, Shafik AA, El-Sibai O, Ahmed I.
Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt. shafik@ahmed-shafik.org

HYPOTHESIS: The treatment of constipation caused by total colonic inertia is problematic and its results are unsatisfactory. We speculated that colonic pacing would initiate electric activity in the inertial colon and effect rectal evacuation. METHODS: Nine patients with constipation due to total colonic inertia (age range, 39-52 years; 7 women, 2 men) were enrolled in the study. One pacing electrode was applied to each of the 4 potential colonic pacemaker sites, and 2 to 3 temporary recording electrodes were applied distally. A stimulator was embedded subcutaneously in the inguinal area. Home pacing was practiced after patients were trained; the recording electrodes were removed before home pacing was started. RESULTS: Colonic pacing evoked electric waves, which effected defecation in 6 of the 9 patients. Three of these 6 patients had spontaneous defecation after a few months of pacing, and their electrodes and stimulators were removed. In the other 3 of these 6 patients, the pacemakers are still in place and continue to effect rectal evacuation. Colonic pacing did not produce rectal evacuation in 3 patients and is believed to have failed because of an advanced stage of colonic inertia. CONCLUSION: Colonic pacing induced rectal evacuation in 66.6% of the patients with total colonic inertia. No complications were encountered. We suggest that colonic pacing be considered as a new therapeutic option in the treatment of total colonic inertia.

------

Gastroenterol Clin Biol. 2004 May;28(5):438-43.
Effect of an oral bulking agent and a rectal laxative administered alone or in combination for the treatment of constipation.
Bouchoucha M, Faye A, Savarieau B, Arsac M.
Hopital Broussais, Laboratoire de physiologie digestive, 96, rue Didot 75014 Paris. michel.bouchoucha@brs.ap-hop-paris.fr

OBJECTIVES: The aim of the present study was to search for a synergetic action between psyllium and a defecation-inducing drug, Eductyl, for symptom relief in patients suffering from chronic constipation. METHODS: Twenty healthy volunteers and 20 patients complaining of chronic constipation were included in a randomized crossover study. The study was divided into four 2-weeks periods: pre-inclusion and three periods of treatment with psyllium, Eductyl, and Eductyl + psyllium respectively. Colonic transit time was determined at the end of each period of treatment. During each of the four periods, a self-administered questionnaire was used to assess symptoms of constipation. RESULTS: For constipated patients, treatment with Eductyl and Eductyl-psyllium improved clinical symptoms of constipation: increased stool frequency, resulted in fewer hard stools and less sensation of incomplete evacuation and less straining to defecate. The improvement was associated with a decrease in total and segmental colonic transit time. The Eductyl-psyllium combination did not exhibit any synergetic effect. CONCLUSION: Treatment with Eductyl alone is more efficient than with psyllium alone in providing symptom relief. Combination with psyllium is not synergetic.

------

Rev Gastroenterol Disord. 2004;4 Suppl 2:S43-51.
New and emerging treatment options for chronic constipation.
Schiller LR.
Baylor University Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Chronic constipation remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, osmotic laxatives, stimulant laxatives, prokinetic agents, biofeedback training, and surgery. These often are tried sequentially and episodically and have little evidence of long-term efficacy. Patients often report inadequate relief of symptoms. There is room for improvement, therefore, in the therapy of chronic constipation. Future advances largely will be based on insights into the enteric nervous system (ENS), the structure and function of which is being revealed in great detail. Manipulating the ENS pharmacologically offers the opportunity to reprogram this key control system to improve bowel function. For example, interneurons in the ENS display 5-HT4 receptors, activation of which enhances the peristaltic reflex. Prokinetic agents that stimulate those receptors, such as tegaserod and prucalopride, have demonstrated efficacy as investigational agents for the treatment of chronic constipation in large studies. Less well studied investigational drugs with presumed activity in the ENS include opiate antagonists and the nerve growth factor neurotrophin-3. Both of these types of agents have been shown to be effective in small groups of patients with constipation. Another approach under development is to stimulate colonic fluid secretion by opening chloride channels in the epithelium pharmacologically. Existing non-pharmacological treatments that can be improved include biofeedback training for pelvic floor dysfunction and surgery. Future developments include investigation of electrical stimulation of the colon and use of stem cells to repopulate degenerated populations of neurons, interstitial cells of Cajal, or smooth muscle cells.

-----

Tidsskr Nor Laegeforen. 2004 Mar 4;124(5):632-3.
[Resection rectopexy for internal rectal intussusception reduces constipation and incomplete
evacuation of stool. ]
[Article in Norwegian]
Johnson E, Carlsen E, Mjaland O, Drolsum A.
Ulleval universitetssykehus 0407 Oslo. egil.johnson@ulleval.no

BACKGROUND:Internal rectal intussusception, usually occurring in women, causes constipation and incomplete evacuation of stool. MATERIALS AND METHODS:Twenty-one women and one man (median age 48) were operated with suture rectopexy and sigmoid resection. The patients were examined with anoscopy and defecography, and symptomatic outcome, patients' satisfaction and morbidity were evaluated. Outcome was based mainly on the validated KESS score for constipation. RESULTS:There was a significant reduction in all ten symptoms. Faecal incontinence improved in the two afflicted patients after operation. The number of patients with constipation was reduced from 20 to 8 (p < 0.01); none became constipated. Mean (95 % CI) colonic transit times in ten constipated patients was reduced from 5.3 (4.1 - 6.4) to 4.0 (2.6 - 5.4) days (p = 0.08); seven of these patients had a reduction of transit time as well as constipation score. INTERPRETATION:Rectopexy with sigmoid resection improved symptoms, including constipation and feeling of incomplete rectal emptying.

-----

Dis Colon Rectum. 2004 Mar;47(3):346-53.
One-year follow-up study on the effects of electrogalvanic stimulation in chronic idiopathic constipation with pelvic floor dyssynergia.
Chiarioni G, Chistolini F, Menegotti M, Salandini L, Vantini I, Morelli A, Bassotti G.
Gastrointestinal Rehabilitation Division, Valeggio sul Mincio Hospital, Azienda Ospedaliera, University of Verona, Verona, Italy. chiarioni@tin.it

BACKGROUND: Constipation is a commonly reported symptom, and pelvic floor dyssynergia is frequently documented in constipated patients. The standard therapeutic approach for pelvic floor dyssynergia is biofeedback training, but long-term studies show that a significant percentage of patients remain symptomatic. Alternative or adjunctive therapeutic options are needed. AIMS: The purpose of this study was to evaluate the long-term effects of electrogalvanic stimulation in patients with pelvic floor dyssynergia and severe constipation, to see whether this treatment may be of some benefit. PATIENTS AND METHODS: Thirty consecutive constipated patients with clinical and instrumental evidence of pelvic floor dyssynergia entered the study and were treated with a standard high-frequency galvanic electrostimulation protocol. Clinical and instrumental (colon transit time, anorectal manometry, defecography, rectal balloon expulsion) assessment evaluations were performed basally and one year after the treatment. RESULTS: Overall, approximately 50 percent of patients showed significant improvement after electrogalvanic treatment, from both a clinical and an instrumental point of view, as shown by the objective measurements obtained through manometry, defecography, and the balloon expulsion test. The benefit was limited to normal transit constipation patients. CONCLUSIONS: Because of the relatively simple, painless and effective nature of electrogalvanic stimulation, we concluded that it may represent a useful adjunct to the therapeutic armamentarium for pelvic floor dyssynergia in normal transit constipation.

-----

Pediatrics. 2004 Mar;113(3 Pt 1):e259-64.
Fiber (glucomannan) is beneficial in the treatment of childhood constipation.
Loening-Baucke V, Miele E, Staiano A.
University of Iowa, Iowa City, Iowa, USA. vera-loening-baucke@uiowa.edu

OBJECTIVE: Constipation and encopresis are common problems in children. Still today, the role of fiber in the treatment of chronic constipation in childhood is controversial. The aim of our study was to evaluate whether fiber supplementation is beneficial in the treatment of children with functional constipation with or without encopresis. We used glucomannan as the fiber supplement. METHODS: We evaluated the effect of fiber (glucomannan, a fiber gel polysaccharide from the tubers of the Japanese Konjac plant) and placebo in children with chronic functional constipation with and without encopresis in a double-blind, randomized, crossover study. After the initial evaluation, the patients were disimpacted with 1 or 2 phosphate enemas if a rectal impaction was felt during rectal examination. Patients continued with their preevaluation laxative. No enemas were given during each treatment period. Fiber and placebo were given as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg for 4 weeks each. Parents were asked to have children sit on the toilet 4 times daily after meals and to keep a stool diary. Age, frequency of bowel movements into the toilet and into the undergarment, presence of abdominal pain, dietary fiber intake, medications, and the presence of an abdominal and/or a rectal fecal mass were recorded on a structured form at the time of recruitment and 4 weeks and 8 weeks later. Children were rated by the physician as successfully treated when they had > or =3 bowel movements/wk and < or =1 soiling/3 weeks with no abdominal pain in the last 3 weeks of each 4-week treatment period. Parents made a global assessments to whether they believed that the child was better during the first or second treatment period. RESULTS: Forty-six chronically constipated children were recruited into the study, but only 31 children completed the study. These 31 children (16 boys and 15 girls) were 4.5 to 11.7 years of age (mean: 7 +/- 2 years). All children had functional constipation; in addition, 18 had encopresis when recruited for the study. No significant side effects were reported during each 4-week treatment period. Significantly fewer children complained of abdominal pain and more children were successfully treated while on fiber (45%) as compared with placebo treatment (13%). Parents rated significantly more children (68%) as being better on fiber versus 13% as being better on placebo. The initial fiber intake was low in 22 (71%) children. There was no difference in the percentage of children with low fiber intake living in the United States (70%) and Italy (71%). Successful treatment (physician rating) and improvement (parent rating) were independent of low or acceptable initial fiber intake. The duration of chronic constipation ranged from 0.6 to 10 years (mean: 4.0 +/- 2.5 years). Duration of constipation did not predict response to fiber treatment. Children with constipation only were significantly more likely to be treated successfully with fiber (69%) than those with constipation and encopresis (28%). CONCLUSION: We found glucomannan to be beneficial in the treatment of constipation with and without encopresis in children. Symptomatic children who were already on laxatives still benefited from the addition of fiber. Therefore, we suggest that we continue with the recommendation to increase the fiber in the diet of constipated children with and without encopresis.

-----

Ann Pharmacother. 2004 Feb 27 [Epub ahead of print]
Pediatric Constipation Therapy Using Guidelines and Polyethylene Glycol 3350 (CE).
Bell EA, Wall GC.
College of Pharmacy and Health Sciences, Drake University, Des Moines, IA.

OBJECTIVE: To review current guidelines on the treatment of functional constipation in pediatric patients, with an emphasis on the role of polyethylene glycol 3350 (PEG 3350). DATA SOURCES: Primary medical literature published in English was identified by MEDLINE search (1980-May 2003). STUDY SELECTION AND DATA EXTRACTION: Recently published treatment guidelines relating to pediatric functional constipation and its pharmacotherapy are assessed and compared. Published trials evaluating PEG 3350 in pediatric subjects are discussed and their results applied to the clinical role and use of this new agent. DATA SYNTHESIS: Constipation is a common disorder among children. A number of factors may play a role. A variety of medications are commonly used for this disorder, although few treatments have undergone evaluation by controlled clinical trials. Consensus guidelines recommend either osmotic laxatives, mineral oil, or their combination for maintenance treatment in concert with patient and parental education and behavioral training. PEG 3350 solution (MiraLax) has been shown in recent clinical studies to be an effective maintenance treatment for pediatric constipation. CONCLUSIONS: PEG 3350 is an effective and well-tolerated treatment choice for pediatric constipation, especially as an adjunct to education and behavioral training. PEG 3350 is an option for children with constipation who have failed or are intolerant of other pharmacotherapies. ((CE)) This article is approved for continuing education ACPE UNIVERSAL PROGRAM NUMBER: 407-000-04-xxx-H01

-----

Appl Nurs Res. 2004 Feb;17(1):48-54.
Effectiveness of lactulose syrup after cardiac surgery.
Van Der Schaaf M, Vermeulen H, Storm-Versloot MN, Goossens A, Simons R, Eijsman L.

Dutch cardiac surgery centers lack consistency in management with respect to the prevention of postoperative constipation. Although not based on any evidence, the administration of lactulose syrup is widely used. Because it often causes intestinal discomfort such as abdominal pain, bowel cramps, and feelings of distention, a study was performed in postoperative cardiac surgery patients who were given either standard care (routine administration of lactulose syrup twice daily) or laxative on indication. Postoperative constipation appeared equally frequent in both groups, and patients who received lactulose had more symptoms of intestinal discomfort. Based on these findings, it is safe to abolish the routine management of postoperative laxatives on a cardiac surgery ward.

-----

Gastroenterology. 2004 Jan;126(1 Suppl 2):S55-63.
Medical management of fecal incontinence.
Scarlett Y.

Diarrhea and constipation are known risk factors for fecal incontinence. This report reviews how to diagnose and medically treat patients with chronic diarrhea, chronic constipation with overflow incontinence, and incontinence resulting from rectal mucosal prolapse secondary to hemorrhoids. Antidiarrheal agents (including loperamide, diphenoxylate, and difenoxin) and the tricyclic antidepressant amitriptyline improve continence in patients with diarrhea-associated incontinence. Other antidiarrheal agents are under investigation. The mechanism is believed to be decreased intestinal motility and stool frequency resulting in more formed stools. Increases in anal canal resting pressure may also contribute to improvement in continence. Adverse effects are constipation from excessive use. In addition to antidiarrheal drugs, fiber supplements may improve incontinence associated with diarrhea. Transient, benign cases of constipation usually respond to increasing fluid intake and dietary fiber, improving mobility, or eliminating the concurrent use of constipating drugs. For mild to moderate constipation, bulking agents, laxatives, and stool softeners are used cautiously so as not to excessively loosen stools and exacerbate anal incontinence. Laxatives have been shown to improve continence, possibly through the mechanism of eliminating fecal impaction. Prolapsing hemorrhoids may partially obstruct defecation and cause soilage from the passage of fecal material, mucus, or blood. With endoscopic banding, a ligator is attached to an endoscope and a tight band is placed around the enlarged vein, causing the hemorrhoid to thrombose.

-----

J Pediatr Gastroenterol Nutr. 2004 Jan;38(1):75-8.
Colostomy for treatment of functional constipation in children: a preliminary report.
Woodward MN, Foley P, Cusick EL.
Department of Paediatric Surgery, Bristol Royal Hospital for Children, United Kingdom. mark.woodward@doctors.org.uk

OBJECTIVES: Surgery is indicated in very few children with intractable functional constipation. A number of operations have been described with unpredictable outcome and significant morbidity. The authors present a series of 10 children who underwent a Hartmann procedure with end colostomy formation. METHOD: Preoperative management, in addition to maximum conservative measures, included psychologic referral, rectal biopsy, transit studies, and contrast enemas. A standard Hartmann procedure was performed with on-table rectal washout, formation of a proximal sigmoid colostomy, limited anterior resection of hypertrophic proximal rectosigmoid, and oversewing of the rectal stump. RESULTS: The series includes 10 pediatric patients (4 female, 6 male), in whom constipation was first reported at a median age of 3 years (range, 2 months-7 years) and surgical referral was made at 8 years (range, 1-14 years). Surgery was performed at a median age of 9.5 years (range, 2-15 years), and the median postoperative stay was 5 days (range, 4-9 days). Complications occurred in four patients (transient mild rectal discharge in 2, stomal prolapse in 1, and an unrelated small bowel obstruction in 1 patient with an additional Mitrofanoff stoma). Median postoperative follow-up was 31 months (range, 9-56 months), and the children and parents were all completely satisfied with the stoma. CONCLUSION: Colostomy formation is a potential surgical option for severe functional constipation with low associated morbidity and high patient satisfaction.

-----

Gastroenterology. 2004 Jan;126(1 Suppl 2):S41-7.
Urinary and fecal incontinence in nursing homes.
Schnelle JF, Leung FW.

Urinary and fecal incontinence affect 50% or more of nursing home residents and frequently occur together because immobility and dementia are primary risk factors for both conditions. Many residents (40%-60%) show immediate improvement when provided with consistent toileting assistance, which compensates for the immobility and dementia risk factors that prevent them from toileting independently. Residents who are responsive to assistance can be identified with a 2-day run-in trial during which prompts are provided every 2 hours to encourage toileting. This run-in trial also provides an opportunity to use protocols to identify and treat other reversible causes of incontinence (e.g., urinary tract infection, fecal impaction) and to diagnose problems with bladder or anorectal functioning. The effects of toileting assistance on the frequency of fecal incontinence, while significant, are less dramatic than those reported for urinary incontinence, primarily because of constipation. Fortunately, noninvasive interventions have been identified that address most of the risk factors common to both constipation and fecal incontinence. Trials are needed to evaluate treatments that integrate noninvasive interventions directed toward the use of laxatives or constipating agents, low toileting frequency, low food and fluid intake, and physical activity to improve constipation and fecal incontinence in nursing home residents. The scientific documentation of the efficacy of such a noninvasive intervention and the labor costs of implementing these measures can lead to major changes in how nursing home care is funded and provided.

-----

J Nutr Health Aging. 2004;8(2):116-21.
Effects of an exercise and scheduled-toileting intervention on appetite and constipation in
nursing home residents.
Simmons SF, Schnelle JF.
Sandra F. Simmons, Ph.D, Jewish Home for the Aging / UCLA Borun Center for Gerontological Research, 7150 Tampa Avenue, Reseda, CA 91335, Phone: (818) 774-3349, Fax: (818) 774-3346, Email: ssimmons@ucla.edu

Purpose: To evaluate the effects of an exercise and scheduled-toileting intervention on appetite and constipation in nursing home (NH) residents. Methods: A controlled, clinical intervention trial with 89 residents in two NHs. Research staff provided exercise and toileting assistance every two hours, four times per day, five days a week for 32 weeks. Oral food and fluid consumption during meals was measured at baseline, eight and 32 weeks. Bowel movement frequency was measured at baseline and 32 weeks. Results: The intervention group showed significant improvements or maintenance across all measures of daily physical activity, functional performance, and strength compared to the control group. Participants in both groups consumed an average of approximately 55% of meals at all three time points (approximately 1100 calories/day) with no change over time in either group. There was also no change in the frequency of bowel movements in either group, which averaged less than one in two days for both groups; and, approximately one-half of all participants had no bowel movement in two days. Conclusions: An exercise and scheduled-toileting intervention alone is not sufficient to improve oral food and fluid consumption during meals and bowel movement frequency in NH residents.

-----

Scand J Gastroenterol. 2004 Jan;39(1):27-31.
Effect of an oats-containing gluten-free diet on symptoms and quality of life in coeliac disease. A randomized study.
Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P.
Dept. of Medicine, Jyvaskyla Central Hospital, Finland.

BACKGROUND: Evidence suggests the acceptability of oats in a gluten-free diet in coeliac disease. We investigated the impact of an oats-containing diet on quality of life and gastrointestinal symptoms. METHODS: Thirty-nine coeliac disease patients on a gluten-free diet were randomized to take either 50 g of oats-containing gluten-free products daily or to continue without oats for 1 year. Quality of life was assessed using the Psychological General Well-Being questionnaire and gastrointestinal symptoms using the Gastrointestinal Symptom Rating Scale. Small-bowel mucosal villous architecture, CD3+, alphabeta+, gammadelta+ intraepithelial lymphocytes, serum endomysial and tissue transglutaminase antibodies were investigated. RESULTS: Twenty-three subjects were randomized to the oats-containing diet and 16 to the traditional gluten-free diet. All adhered strictly to their respective diet. Quality of life did not differ between the groups. In general, there were more gastrointestinal symptoms in the oats-consuming group. Patients taking oats suffered significantly more often from diarrhoea, but there was a simultaneous trend towards a more severe average constipation symptom score. The villous structure did not differ between the groups, but the density of intraepithelial lymphocytes was slightly but significantly higher in the oats group. The severity of symptoms was not dependent on the degree of inflammation. Antibody levels did not increase during the study period. CONCLUSION: The oats-containing gluten-free diet caused more intestinal symptoms than the traditional diet. Mucosal integrity was not disturbed, but more inflammation was evident in the oats group. Oats provide an alternative in the gluten-free diet, but coeliac patients should be aware of the possible increase in intestinal symptoms.

-----

J Pediatr Surg. 2003 Dec;38(12):1778-80.
Left-colon antegrade continence enema (LACE) procedure for fecal incontinence.
Churchill BM, De Ugarte DA, Atkinson JB.
Department of Urology, Clark-Morrison Children's Urological Center, UCLA, Los Angeles, CA 90095-1738, USA.

PURPOSE: Antegrade continence enemas (ACE) are an efficacious therapeutic option for patients with fecal incontinence. The authors review their institution's experience with a variation of the Monti-Malone ACE procedure using the left colon as a source of an intestinal conduit and enema reservoir. METHODS: From 2000 to 2002, 18 patients with fecal incontinence or intractable constipation underwent left-colon ACE (LACE) procedure. Concomitant Mitrofanoff appendicovesicostomy was performed in 15 patients and bladder augmentation in 9. The majority of patients had neural tube defects. A segment of left colon was tubularized, tunneled into the muscular wall of the distal colon, and exteriorized through the left upper quadrant or midabdomen. Stomal catherization and enema installation were started one month postoperatively. RESULTS: Fifteen patients (83%) achieved fecal continence, 2 remain incontinent of stool, and 1 experienced stomal closure (mean follow-up was 24 +/- 9 months). Two patients had stomal stenosis that required revision. The mean enema volume in patient's achieving continence was 360 +/- 216 mL, and the mean transit time was 18 +/- 12 minutes. CONCLUSIONS: LACE is an efficacious procedure for fecal incontinence that can be performed safely at the time of major urologic reconstruction. Administration of enemas into the left colon has several physiologic advantages that result in predictable bowel evacuation.

-----

Postgrad Med J. 2003 Nov;79(937):616-21.
Management of childhood constipation.
Clayden G, Keshtgar AS.
Guy's, King's, St Thomas' School of Medicine, Paediatrics, St Thomas' Hospital, London.

The effective management of constipation in childhood requires an understanding of the ways that the physical and psychological factors interact. The early difficulty with defecation that leads to pain, fear, and refusal to use the pot or lavatory often progresses to the formation of vicious cycles of increasing faecal retention as the rectum increases in capacity and the experience of passing large, hard stools is repeated. There is increasing distress as overflow faecal incontinence compounds the problem for the older child. The medical, psychological, and surgical management strategies are reviewed together with the rationale for their use.

-----

Korean J Gastroenterol. 2003 Oct;42(4):289-96.
[Clinical factors associated with response to biofeedback therapy for patients with chronic constipation]
[Article in Korean]
Park do H, Myung SJ, Yoon IJ, Kwon OR, Ko JE, Chang HS, Yang SK, Kim TH, Song HK, Lee JH, Jung HY, Hong WS, Kim JH, Min YI.
Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

BACKGROUND/AIMS: Biofeedback therapy has been widely used for the treatment of constipated patients. However, there are only a few reports about the clinical factors that can predict the effectiveness of biofeedback therapy. The aim of this study was to evaluate prognostic factors before the initiation of biofeedback treatment in constipated patients. METHODS: Biofeedback treatment was performed in 114 patients with constipation. After classifying the patients into two groups, responder and non-responder by subjective and objective parameters, univariate and multivariate analysis were performed to evaluate the factors associated with effectiveness of biofeedback therapy. RESULTS: Eighty-five patients (74.6%) responded to biofeedback therapy. Pre-treatment balloon expulsion test, paradoxical contraction on manometry, defecation index and anal residual pressure during straining were the factors that influenced the results of biofeedback treatment. On multivariate analysis, defecation index (odds ratio=67.5, p<0.05) and paradoxical contraction on manometry (odds ratio=0.053, p<0.05) were the factors that showed significant difference between the responders and non-responders. CONCLUSIONS: This study suggests that several pre-treatment prognostic factors are associated with response to biofeedback for the constipated patients. Using prognostic factors, we may be able to evaluate the patterns of pelvic floor dysfunction and responsiveness of biofeedback therapy for the patients with constipation.

-----

J Urol. 2003 Oct;170(4 Pt 2):1518-20.
Polyethylene glycol 3350 for constipation in children with dysfunctional elimination.
Erickson BA, Austin JC, Cooper CS, Boyt MA.
Division of Pediatric Urology, Children's Hospital of Iowa, Iowa City, USA.

PURPOSE: Children with daytime wetting often have constipation, and treatment of constipation helps children become dry. Polyethylene glycol 3350 (Miralax, Braintree Laboratories, Braintree, Massachusetts) is a nonaddictive, tasteless powder that can be mixed with any liquid for treatment of constipation. MATERIALS AND METHODS: We review our use of polyethylene glycol 3350 in 35 girls and 11 boys with dysfunctional elimination. Noninvasive urodynamic studies and post-void residual measurement were performed before and during treatment. RESULTS: A significant increase in frequency of bowel movements occurred while taking polyethylene glycol 3350 (p = 0.0001). Average final dose was 0.63 gm/kg. The only reported adverse effect was diarrhea (9 patients). Of the children 18 became dry, 26 had decreased wetting and 2 had no improvement. Voided volume increased (146 vs 210 ml, p <0.0001) and post-void residual decreased significantly (92 vs 48 ml, p <0.0001) while on polyethylene glycol 3350. Ten children were still considered constipated including both patients who experienced no change in wetting. Average final dose in this group (0.69 gm/kg) did not differ significantly from those in whom constipation resolved (0.61 gm/kg). Patients in whom constipation resolved had a significantly lower post-void residual than those who remained constipated (11.8% vs 30.6%, p <0.01) and were significantly more likely to become dry or improved (p = 0.045). CONCLUSIONS: The efficacy, compliance and lack of significant side effects make polyethylene glycol 3350 an ideal substance for treatment of constipation in children with dysfunctional elimination. Persistent constipation was associated with decreased resolution of voiding symptoms and significantly increased post-void residuals.

-----

J Am Diet Assoc. 2003 Sep;103(9):1199-202.
Increased stool frequency occurs when finely processed pea hull fiber is added to usual foods consumed by elderly residents in long-term care.
Dahl WJ, Whiting SJ, Healey A, Zello GA, Hildebrandt SL.
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada.

Dietary fiber fortification of food offers a preventative strategy that is a less invasive alternative to laxatives and enemas in the management of constipation in elderly individuals. To determine if a moderate increase in fiber provided in foods would increase bowel movement frequency among elderly institutionalized residents, data were collected on the same elderly residents (n=114) before and during a 6-week intervention. The intervention consisted of adding finely processed pea hull fiber (1-3 g/serving) to 3 to 4 foods each day. Laxative and enema use was monitored. Mean number of bowel movements/month increased from 18.7+/-9.4 to 20.1+/-9.6 (n=114, P=.034), and in 17 residents with low baseline frequency, the increase was highly significant (8.8+/-1.0 to 12.6+/-3.8 bowel movements/month, P=.001). With treatment, prune-based laxative administration decreased (P<.001). Thus, addition of a moderate amount of finely processed fiber to foods results in increased bowel frequency in institutionalized elderly individuals.

-----

World J Gastroenterol. 2003 Sep;9(9):2109-13.
Prospective study of biofeedback retraining in patients with chronic idiopathic functional constipation.
Wang J, Luo MH, Qi QH, Dong ZL.
Department of Colorectal Surgery, Tianjin Binjiang Hospital, Tianjin 300022, China. chinahcc@vip.sina.com

AIM: To determine the efficacy and long-term outcome of biofeedback treatment for chronic idiopathic constipation and to compare the efficacy of two modes of biofeedback (EMG-based and manometry-based biofeedback). METHODS: Fifty consecutive contactable patients included 8 cases of slow transit constipation, 36 cases of anorectic outlet obstruction and 6 cases of mixed constipation. Two modes of biofeedback were used for these 50 patients, 30 of whom had EMG-based biofeedback, and 20 had manometry-based biofeedback. Before treatment, a consultation and physical examination were done for all the patients, related information such as bowel function and gut transit time was documented, psychological test (symptom checklist 90, SCL90) and anorectic physiological test and defecography were applied. After biofeedback management, all the patients were followed up. The Student's t-test, chi-squared test and Logistic regression were used for statistical analysis. RESULTS: The period of following up ranged from 12 to 24 months (Median 18 months). 70 % of patients felt that biofeedback was helpful, and 62.5 % of patients with constipation were improved. Clinical manifestations including straining, abdominal pain, bloating, were relieved, and less oral laxative was used. Spontaneous bowel frequency and psychological state were improved significantly after treatment. Patients with slow and normal transit, and those with and without paradoxical contraction of the anal sphincter on straining, benefited equally from the treatment. The psychological status rather than anorectal test could predict outcome. The efficacy of the two modes of biofeedback was similar without side effects. CONCLUSION: This study suggests that biofeedback has a long-term effect with no side effects, for the majority of patients with chronic idiopathic constipation unresponsive to traditional treatment. Pelvic floor abnormalities and transit time should not be the selection criteria for treatment.

-----

Gastroenterology. 2003 Jul;125(1):19-31.
Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders.
Drossman DA, Toner BB, Whitehead WE, Diamant NE, Dalton CB, Duncan S, Emmott S, Proffitt V, Akman D, Frusciante K, Le T, Meyer K, Bradshaw B, Mikula K, Morris CB, Blackman CJ, Hu Y, Jia H, Li JZ, Koch GG, Bangdiwala SI.
UNC Center for Functional GI and Motility Disorders, Division of Digestive Diseases, University of North Carolina at Chapel Hill, 27599-7080, USA.

BACKGROUND & AIMS: Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments. METHODS: This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment. RESULTS: The intention-to-treat analysis showed CBT as significantly more effective than EDU (P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis (P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis (P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded (P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression. CONCLUSIONS: For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

-----

Coll Antropol. 2003 Jun;27(1):197-204.
The efficacy of cisapride vs. placebo and diet in patients with chronic constipation.
Altabas K, Bilic A, Jurcic D, Dorosulic Z, Mihanovic M, Sunic-Omejc M, Restek-Petrovic B, Tolj N.
Department of Hepatogastroenterology, University Department of Medicine, General Hospital Sveti Duh, Zagreb, Croatia.

The effects of cisapride (10 mg three times daily) on the stool evacuation characteristics, laxative consumption (symptom diary) and motility pattern (rectoanal manometry) were assessed in patients with chronic idiopathic constipation who fulfilled Rome II criteria. After a 14-day basal period on a diet rich in fiber (phase I), patients were treated with placebo (n = 20) or cisapride (n = 19) (phase II). Anorectal manometry was performed at the end of each phase. The study was controlled, randomized and double blind. Side effects related to the use of cisapride were noted and found to be mild. Cisapride and placebo increased stool frequency from 4 (1-11) to 7 (14-12) (p < 0.001) and from 4 (2-10) to 6 (2-11) (p < 0.05) per week, respectively. Straining was decreased from 69.0% to 39.7% in the cisapride (p < 0.0001) group, and from 79% to 35% (p < 0.0001) in the placebo group. Both cisapride and placebo decreased the feeling of incomplete evacuation from 91.7% to 37.5% (p < 0.0001) and from 82.7% to 39.2% (p < 0.0001), respectively. Cisapride reduced the need of laxatives and showed a tendency to normalize stool consistency but did not influence any other symptom or bowel motility parameter.

-----

Gastroenterol Clin North Am. 2003 Jun;32(2):659-83.
Constipation: evaluation and treatment.
Rao SS.
Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA. satish-rao@uiowa.edu

Constipation is a common clinical problem that comprises a constellation of symptoms that include excessive straining, hard stools, feeling of incomplete evacuation, use of digital maneuvers, or infrequent defecation. Although many conditions, such as metabolic problems, fiber deficiency, anorectal problems, and drugs, can cause constipation, when excluded functional constipation consists of two subtypes: slow-transit constipation and dyssynergic defecation. Some patients with irritable bowel syndrome may exhibit features of both types of constipation. The Rome criteria for functional constipation together with modifications proposed here for dyssynergic defecation may serve as useful guidelines for making a diagnosis. Recent advances in technology, together with a better understanding of the underlying mechanisms, have led to real progress in the diagnosis of this condition. Management options are limited, however, and evidence to support these treatments is only modest. The treatment is primarily medical; surgical options should be reserved for refractory disease and after careful diagnostic work-up. Although laxatives remain the mainstay of therapy, prokinetics that are colon-selective are optimal for treating patients with slow-transit constipation, but they are not yet available for clinical use. Recent controlled trials, however, are promising. Biofeedback therapy is the preferred treatment for patients with dyssynergia, but is not widely available. In the near future, user-friendly biofeedback programs including home therapy may facilitate wider use of these methods for patients with dyssynergic defecation.

-----

Ned Tijdschr Geneeskd. 2003 Jun 28;147(26):1267-71.
[Functional childhood gastrointestinal disorders. III. Constipation and solitary encopresis; diagnostic work-up and therapy]
[Article in Dutch]
van Ginkel R, Buller HA, Heymans HS, Taminiau JA, Boeckxstaens GE, Benninga MA.
Afd. Kindergastro-enterologie en voeding, Academisch Medisch Centrum/Emma Kinderziekenhuis, Meibergdreef 9, 1105 AZ Amsterdam.

A detailed medical history in combination with a thorough physical examination, including rectal examination, form the cornerstone in the diagnostic work-up for children with functional defecation disorders. Additional investigations are often not informative and have only minor diagnostic or therapeutic implications. Medical therapy in children with functional constipation and solitary encopresis is primarily based on clinical experience. In both patient groups, the role of education, the use of diary cards and toilet training is important. In some patients behaviour interventions are important. Oral laxatives are the basis of treatment of children with functional constipation, whereas they are contra-indicated in children with solitary encopresis. In both groups, biofeedback training appears to be of little additional benefit. Long-term follow-up of children with functional defecation disorders shows that complaints continue far beyond puberty in many children.

-----

Pediatr Med Chir. 2003 Mar-Apr;25(2):126-30.
[Success of antegrade enemas in children with functional constipation]
[Article in Italian]
Pensabene L, Youssef NN, Di Lorenzo C.
Dipartimento di Pediatria, Divisione di Gastroenterologia Pediatrica, Children's Hospital di Pittsburgh, 3705 Fifth Avenue at DeSoto Street, Pittsburgh, Pennsylvania 15213, USA.

AIM: To assess the benefit of antegrade enemas via cecostomy in children with functional constipation unresponsive to medical treatment. METHODS: A retrospective chart review identified 19 children (12 male, age 10.4 +/- 4.3 yrs) who from 1998-2001 underwent placement of a cecostomy for administration of antegrade enemas. All children were neurologically normal, suffered from functional constipation; all had a history of using multiple medications, having daily soiling, and 65% had prior hospitalizations due to fecal impaction. Sixteen of 19 children had undergone colonic manometry which ruled out colonic inertia. One of 3 irrigation solutions: polyethylene glycol (65%), saline and glycerin solution mix (10%) and phosphate enema (25%) administered through the cecostomy everyday in 14 children or every other day in 5 children. We used a questionnaire to interview caregivers, a mean of 21.1 +/- 24.9 mo after cecostomy placement. RESULTS: In all patients antegrade enemas led to significant improvement of: bowel movements/wk (7.4 vs. 1.4, p < 0.001), soiling accidents/wk (1.1 vs. 6.1, p < 0.001), emotional health score (3.8 vs. 1.8, p < 0.001), overall health score (3.7 vs. 1.8, p < 0.001), number of medications for constipation (0.8 vs. 4.2, p < 0.001), number of missed school days/mo (1.3 vs. 10.5, p < 0.001), and number of physician office visits/yr (7.7 vs. 24.1, p < 0.002). Eight patients have been able to discontinue the use of the antegrade enemas within a mean of 19.9 +/- 14.2 mo after beginning treatment. CONCLUSION: Antegrade enemas are an alternative effective way for treating severe cases of functional constipation unresponsive to medical management.

-----

Am J Gastroenterol. 2003 Jun;98(6):1338-47.
Neurotrophin-3 improves functional constipation.
Parkman HP, Rao SS, Reynolds JC, Schiller LR, Wald A, Miner PB, Lembo AJ, Gordon JM, Drossman DA, Waltzman L, Stambler N, Cedarbaum JM.
Temple University Hospital, Philadelphia, Pennsylvania, USA

Neurotrophin-3 (NT-3) is a neurotrophic factor involved in the growth, development, and function of the nervous system. In preliminary studies, s.c. recombinant methionyl-human NT-3 enhanced transit throughout the GI tract and increased stool frequency in normal and constipated subjects. Our aim was to assess 1) the dose-related effects of NT-3 on bowel function, colon transit, and symptoms of chronic constipation, and 2) its safety.This was a double-blind, randomized, placebo-controlled phase II study. A total of 107 patients with a diagnosis of functional constipation (Rome II criteria) were randomized to receive 4 wk of double blind, s.c. injections of either placebo, 3 mg, or 9 mg NT-3 once per week (qW) or three times per week (TTW); or 9 mg NT-3 TTW for 1 wk, then qW. The primary endpoint was the change in number of spontaneous, complete bowel movements per week. Colon transit was assessed before and at end of treatment.Compared with placebo, patients who received 9 mg NT-3 TTW showed significant increases in frequency of spontaneous, complete bowel movements and total bowel movements, as well as dose-related softening of stool and improved ease of passage. The number of days per week without a bowel movement also decreased, colon transit improved, as did constipation-related symptoms. Weekly dosing was ineffective. Transient injection-site reactions, seen in one third of patients receiving NT-3 TTW, were the most frequent adverse event.NT-3, administered TTW, increased stool frequency, enhanced colon transit, and improved symptoms of chronic constipation. NT-3 seems to be a novel, safe, and effective agent for the treatment of functional constipation.

-----

Aliment Pharmacol Ther. 2003 Jan;17(1):165-72.
Comparison of efficacy and safety of two doses of two different polyethylene glycol-based laxatives in the treatment of constipation.
Chaussade S, Minic M.
Department for Hepatogastroenterology, Hopital Cochin, Pavillon Achard, 27 rue du faubourg Saint Jacques, 75679 Paris cedex 14, France. chaussade.s@wanadoo.fr

AIM: To compare standard and maximum daily doses of polyethylene glycol 3350 plus electrolytes (Transipeg) and polyethylene glycol 4000 (Forlax) in a multicentre, double-blind, randomized, parallel-group study. METHODS: Ambulatory patients with idiopathic chronic constipation were randomized to receive Forlax (10 or 20 g) or Transipeg (5.9 or 11.8 g) for 1 month. The primary efficacy end-point was stool frequency. Secondary efficacy parameters included stool consistency, date of occurrence of first motion, straining on defecation, rectal evacuation, abdominal pain and distension. Adverse events were recorded. RESULTS: Stool frequency was significantly increased compared with baseline in all treatment groups (P = 0.0001). Most patients (> or = 67.3%) had their first stool within 1 day of starting treatment. Stool consistency significantly improved compared with baseline in all treatment groups (P = 0.0001). The percentage of patients with normal stool consistency was significantly higher for standard-dose Transipeg vs. both maximum-dose treatments (P < 0.01). Other secondary parameters were also significantly improved compared with baseline in all treatment groups (P = 0.0001). All medications were well tolerated. CONCLUSIONS: Standard-dose Transipeg (5.9 g) normalized stool consistency with less semi-liquid or liquid stools than maximum-dose Transipeg and Forlax, with a non-significant trend towards less semi-liquid or liquid stools than standard-dose Forlax.

-----

Am J Gastroenterol. 2003 May;98(5):1112-6.
Treatment of chronic constipation with colchicine: randomized, double-blind, placebo-controlled, crossover trial.
Verne GN, Davis RH, Robinson ME, Gordon JM, Eaker EY, Sninksy CA.
Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA.

OBJECTIVE: Refractory constipation is a common GI complaint seen by physicians in all practice settings. We have previously shown that p.d. colchicine (0.6 mg t.i.d.) increases the number of spontaneous bowel movements, hastens GI transit, and improves GI symptoms in patients with chronic constipation during an 8-wk, open-label therapeutic trial. The aim of this study was to determine if p.d. colchicine will increase spontaneous bowel movements and accelerate colonic transit in patients with idiopathic chronic constipation in a randomized, placebo-controlled, crossover trial. METHODS: A total of 16 patients (15 women, one man) with a mean age of 47 yr (age range 25-89) with chronic idiopathic constipation who were refractory to standard medical therapy participated in the study. Patients randomly received either colchicine 0.6 mg p.o. t.i.d. or an identical placebo p.o. t.i.d. for a total of 4 wk in a double-blind, crossover fashion. Patients recorded their daily number of bowel movements and daily symptoms of daily nausea, abdominal pain, and bloating. Mean colonic transit was calculated at baseline, weeks 6 and 12. RESULTS: Colchicine increased the number of bowel movements and accelerated colonic transit compared with baseline and placebo conditions. There were no significant differences between conditions on ratings of nausea and bloating. During colchicine administration, mean abdominal pain was greater than the baseline or placebo conditions, however, the pain decreased significantly by the last week the patient was on colchicine. CONCLUSION: Colchicine increases the frequency of bowel movements and hastens colonic transit in patients with chronic constipation. Colchicine may be an effective agent available to practitioners to treat a subset of patients with chronic constipation who are refractory to standard medical therapy.

-----

Colorectal Dis. 2003 Jul;5(4):288-96.
Chronic idiopathic slow transit constipation: pathophysiology and management.
El-Salhy M.
Section for Gastroenterology and Hepatology, Department of Medicine, Institute of Public Health and Clinical Medicine, University Hospital, Umea, Sweden.

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.

-----

Dis Colon Rectum. 2003 Apr;46(4):433-40.
Quality of life after subtotal colectomy for slow-transit constipation: both quality and quantity count.
FitzHarris GP, Garcia-Aguilar J, Parker SC, Bullard KM, Madoff RD, Goldberg SM, Lowry A.
University of Minnesota, St. Paul, MN, USA.

PURPOSE: Subtotal colectomy reliably increases bowel-movement frequency in patients with slow-transit constipation, but its impact on quality of life is unknown. The purpose of this study was to assess the relationship between functional outcomes and quality of life after subtotal colectomy for slow-transit constipation. METHODS: We reviewed the charts and operative reports of all patients who underwent subtotal colectomy for slow-transit constipation from January 1992 to June 2001. We sent them a 54-question survey that inquired about bowel function and included a modified 36-item gastrointestinal quality-of-life index. Using Pearson's R, we correlated gastrointestinal quality-of-life index scores with specific functional outcomes. RESULTS: Of 112 patients (109 females), 28 had been lost to follow-up and 2 had died. In all, 75 surveys (67 percent) were returned. Most of these 75 patients (81 percent) were at least somewhat pleased with their bowel-movement frequency, but 41 percent cited abdominal pain; 21 percent, incontinence; and 46 percent, diarrhea at least some of the time. The overall mean gastrointestinal quality-of-life index score was 103 +/- 22 of a maximum possible score of 144 (mean score for healthy controls, 126 +/- 13). We found no correlation between frequency of bowel movements and gastrointestinal quality-of-life index score (R = -0.03). Abdominal pain, diarrhea, and incontinence each had a statistically significant negative impact on gastrointestinal quality-of-life index scores (P = 0.01). Patients who required permanent ileostomy had low gastrointestinal quality-of-life index scores (68 +/- 24). The vast majority (93 percent) of patients stated they would undergo subtotal colectomy again if given a second chance. CONCLUSION: Subtotal colectomy for slow-transit constipation increases bowel-movement frequency; however, the persistence of abdominal pain and the development of postoperative incontinence or diarrhea adversely affect quality of life. Although most patients in the present study were satisfied with their results, quality-of-life scores should be used to assess postoperative outcome.

-----

Drugs. 2003;63(7):649-71.
Opioid-induced bowel dysfunction: pathophysiology and potential new therapies.
Kurz A, Sessler DI.
Department of Anesthesiology, OUTCOMES RESEARCH Institute, Washington University School of Medicine, St Louis, Missouri, USA.

Opioid treatment for postoperative or chronic pain is frequently associated with adverse effects, the most common being dose-limiting and debilitating bowel dysfunction. Postoperative ileus, although attributable to surgical procedures, is often exacerbated by opioid use during and following surgery. Postoperative ileus is marked by increased inhibitory neural input, heightened inflammatory responses, decreased propulsive movements and increased fluid absorption in the gastrointestinal tract. The use of opioids for chronic pain is characterised by a constellation of symptoms including hard dry stools, straining, incomplete evacuation, bloating, abdominal distension and increased gastroesophageal reflux. The current management of opioid-induced bowel dysfunction among patients receiving opioid analgesics consists primarily of nonspecific ameliorative measures. Intensive investigations into the mode of action of opioids have characterised three opioid receptor classes -mu, delta and kappa- that mediate the myriad of peripheral and central actions of opioids. Activation of mu-opioid receptors in the gastrointestinal tract is responsible for inhibition of gut motility, whereas receptors in the central nervous system mediate the analgesic actions of opioids. Blocking peripheral opioid receptors in the gut is therefore a logical therapeutic target for managing opioid-induced bowel dysfunction. Available opioid antagonists such as naloxone are of limited use because they are readily absorbed, cross the blood-brain barrier, and act at central opioid receptors to reverse analgesia and elicit opioid withdrawal. Methylnaltrexone and alvimopan are recently developed opioid antagonists with activity that is restricted to peripheral receptors. Both have recently shown the ability to reverse opioid-induced bowel dysfunction without reversing analgesia or precipitating central nervous system withdrawal signs in non-surgical patients receiving opioids for chronic pain. In addition, recent clinical studies with alvimopan suggest that it may normalise bowel function without blocking opioid analgesia in abdominal laparotomy patients with opioid-related postoperative ileus.

-----

Int J Clin Pharmacol Ther. 2003 Jan;41(1):14-21.
Differential therapy of constipation--a review.
Wanitschke R, Goerg KJ, Loew D.
I. Medizinische Klinik und Poliklinik, Johannes Gutenberg-Universitat, Mainz, Germany.

Constipation is a common condition occurring with increasing frequency in advanced age. As a symptom, it is not always dealt with directly by the physician, but is often left to the care of nurses. Many patients rely on self-medication. Constipation not only interferes with the quality of life, but often has the rank of a syndrome requiring competent medical intervention. This is of clinical importance, because a thorough understanding of the pathophysiology of constipation enables the clinician to identify the potential causes and, if necessary, initiate a differentiated therapy with the aid of only simple additional investigations. This review outlines a clinical approach including medical history, spectrum of causes, radiopaque pellets method to differentiate between slow transit constipation and defecation disturbances for the differential diagnosis of constipation. The mechanisms of action of laxatives (anti-absorptive, secretagogue, osmotic, filling and swelling agents) are further components and important for the individual therapy. Based on this fundamental information, a differentiated therapy is possible in each specific case such as coprostasis. Chronic symptomatic constipation reduces the quality of life and should be evaluated by physicians. If situations such as drug-induced constipation or hypothyroidism which have to be treated causally can be ruled out, laxative treatment according to the clinical picture, mode of action of drug used and side effects of the laxative can be initiated. Laxative abuse due to chronic constipation is rare and almost always associated with psychosomatic-psychiatric disorders.

-----

Paediatr Nurs. 2003 Apr;15(3):20-1.
Reflexology in the management of encopresis and chronic constipation.
Bishop E, McKinnon E, Weir E, Brown DW.

Encopresis or faecal incontinence in children is an extremely distressing condition that is usually secondary to chronic constipation/stool withholding. Traditional management with enemas may add to the child's distress. This study investigated the efficacy of treating patients with encopresis and chronic constipation with reflexology. An observational study was carried out of 50 children between three and 14 years of age who had a diagnosis of encopresis/chronic constipation. The children received six sessions of 30-minutes of reflexology to their feet. With the help of their parents they completed questionnaires on bowel motions and soiling patterns before, during and after the treatment. A further questionnaire was completed by parents pre and post treatment on their attitude towards reflexology. Forty-eight of the children completed the sessions. The number of bowel motions increased and the incidence of soiling decreased. Parents were keen to try the reflexology and were satisfied with the effect of reflexology on their child's condition. It appears that reflexology has been an effective method of treating encopresis and constipation over a six-week period in this cohort of patients.

-----

Am J Gastroenterol. 2002 Dec;97(12):3154-9.
Psychological state and quality of life in patients having behavioral treatment (biofeedback) for intractable constipation.
Mason HJ, Serrano-Ikkos E, Kamm MA.
St. Mark's Hospital, Middlesex, London, United Kingdom.

OBJECTIVE: Behavioral techniques, including biofeedback, improve symptoms in a majority of patients with intractable idiopathic constipation. However, it is unknown whether there is also improvement in patients' psychological well-being and quality of life (QOL). It is also unknown whether psychological or QOL factors can be used to predict the response to treatment. We aimed to assess these factors prospectively. METHODS: Thirty-one consecutive patients (median age 36 yr) receiving biofeedback retraining for idiopathic constipation were studied. A bowel symptom record, the General Health Questionnaire-28 (GHQ-28) (n = 31) and Hospital Anxiety and Depression Scale (n = 20), both psychological measures, and the Short Form-36 (SF-36) (n = 22), a generic QOL measure, were recorded before and after treatment. RESULTS: Twenty-two of the patients felt subjectively symptomatically improved. When considering all patients, treatment resulted in decreased depression (p < 0.05), anxiety (p < 0.05), and somatic symptoms (p < 0.01) (psychological measures: GHQ-28), and improved general health (p < 0.05) and vitality (p < 0.05) (QOL measures: SF-36). Patients who improved symptomatically showed significantly higher scores on the GHQ-28 and SF-36, in contrast to the unchanged scores in patients who did not symptomatically improve. Pretreatment GHQ-28 did not predict who would benefit from treatment, but patients in whom pain, emotional problems, or low vitality interfered with daily living (SF-36 pain subscales) were significantly (p < 0.05) less likely to respond to treatment. CONCLUSIONS: The symptomatic improvement produced by biofeedback in constipated patients is associated with improved psychological state and QOL. Some of the psychological morbidity in these patients is reversible. QOL parameters may be useful for predicting a likely response to treatment.

-----

Ostomy Wound Manage. 2002 Dec;48(12):30-41.
When fiber is not enough: current thinking on constipation management.
Doughty DB.
Emory University Wound Ostomy Continence Nursing Education Center, Atlanta, GA 30322, USA. ddoughty@emory.edu

Constipation is a common disorder and many patients fail to respond to the simple constipation remedies of increased fiber and fluid intake. When secondary to other conditions, medications, or disease processes, the focus of constipation management is correction of causative factors. However, primary constipation - ie, constipation with no identifiable causative factor - is very common. Patients generally present with one of three patterns: constipation-predominant irritable bowel syndrome, slow transit constipation, or pelvic floor dysfunction resulting in dyssynergic defecation. Baseline evaluation for patients with chronic constipation includes a careful history, focused physical examination, and limited laboratory studies. Patients with dyssynergic defecation usually respond best to biofeedback therapy and pelvic muscle re-education. Constipation-predominant irritable bowel syndrome is best managed with dietary monitoring and modifications, fiber therapy, and education regarding self-monitoring and self-care. Patients with slow transit constipation may benefit from fiber therapy and increased activity, but most also will require laxative therapy. Current guidelines for prescribing laxatives suggest bulk agents as first line and osmotic agents as second line therapy. Stimulant laxatives should generally be reserved for PRN use. Current understanding about the etiology, pathology, and classification of different types of constipation are summarized and a stepwise approach to evaluation and management is presented.

-----

Eur J Nutr. 2002 Nov;41 Suppl 1:I17-25.
Medical, nutritional and technological properties of lactulose. An update.
Schumann C.
Solvay Pharmaceuticals GmbH, Postfach 220, 30002 Hannover, Germany.

The undigestable disaccharide lactulose has been in medical use for over 40 years, mainly in the treatment of portosystemic encephalopathy and of constipation. Pharmacodynamics of lactulose make it an efficacious and safe drug in these indications. But the reason for its numerous potential benefits are under research now. The major principle of action is the promotion of growth and activity of lactic acid bacteria in the gut which counteract detrimental species such as clostridia or salmonellae. This shows that prebiotic action, if used accordingly, can have medically significant effects. The mechanism of action, medical and prebiotic effects, veterinary uses, and technological properties of lactulose, e. g. in yoghurt production are reviewed.

-----

J Gastrointest Surg. 2002 Sep-Oct;6(5):738-44.
Long-term response to subtotal colectomy in colonic inertia.
Verne GN, Hocking MP, Davis RH, Howard RJ, Sabetai MM, Mathias JR, Schuffler MD, Sninsky CA.
Malcom Randall Veterans Affairs Medical Center, Gastroenterology Section, Department of Medicine, University of Florida, Gainesville, Florida 32608, USA. verneegn@medicine.ufl.edu

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia. Copyright 2002 The Society for Surgery of the Alimentary Tract, Inc.

-----

Aliment Pharmacol Ther. 2002 Nov;16(11):1877-88.
A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation.
Novick J, Miner P, Krause R, Glebas K, Bliesath H, Ligozio G, Ruegg P, Lefkowitz M.
Charles City Research, Towson, MD, USA.

BACKGROUND: Irritable bowel syndrome is a common functional gastrointestinal disorder which affects up to 20% of the population, with a predominance in females. AIM: To evaluate the efficacy and safety of tegaserod in female patients with irritable bowel syndrome characterized by symptoms of abdominal pain/discomfort and constipation. METHODS: In a randomized, double-blind, multicentre study, 1519 women received either tegaserod, 6 mg b.d. (n = 767), or placebo (n = 752) for 12 weeks, preceded by a 4-week baseline period without treatment and followed by a 4-week open withdrawal period. The primary efficacy evaluation was the patient's symptomatic response as measured by the Subject's Global Assessment of Relief. Other efficacy variables included abdominal pain/discomfort, bowel habits and bloating. RESULTS: Tegaserod produced significant (P < 0.05) improvements in the Subject's Global Assessment of Relief and other efficacy variables. These improvements were seen within the first week, and were maintained throughout the treatment period. After withdrawal of treatment, the symptoms rapidly returned. Overall, tegaserod was well tolerated. Diarrhoea was the most frequent adverse event; however, this led to discontinuation in only 1.6% of tegaserod-treated patients. CONCLUSIONS: Tegaserod, 6 mg b.d., produced rapid and sustained improvement of symptoms in female irritable bowel syndrome patients and was well tolerated.

-----

J Feline Med Surg. 2002 Sep;4(3):129-38.
Surgical management of constipation.
White RN.
Davies White Veterinary Specialists, Higham Gobion, Hitchin, Hertfordshire.

There are many recognised causes of constipation in the cat and the management of the condition depends on the clinician's ability to recognise the appropriate aetiology in each case. Most surgery therapies for constipation in the cat are related to the management of idiopathic megacolon, although causes such as pelvic outlet obstruction, complications of neutering surgery, perineal herniation, and malunion pelvic fractures may also require surgical intervention. Currently, the surgical management of megacolon consists of subtotal colectomy with the recommendation that the ileocolic junction be preserved. The procedure, in general, is associated with few life-threatening complications although the majority of individuals will experience a transient period of loose stool formation in the immediate post-operative period. In the majority of cases, the long-term outcome following subtotal colectomy is considered excellent. Copyright 2002 ESFM and AAFP

-----

Br J Surg. 2002 Oct;89(10):1270-4.
Outcome of segmental colonic resection for slow-transit constipation.
Lundin E, Karlbom U, Pahlman L, Graf W.
Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden. erik.lundin@kirurgi.uu.se

BACKGROUND: The standard surgical treatment for slow-transit constipation (STC) is subtotal colectomy and ileorectal anastomosis. A segmental resection may serve the same purpose, but with a reduced risk of side-effects such as diarrhoea or incontinence. The aim of this study was to evaluate the functional results following segmental resection in a consecutive series of patients with STC. METHODS: Selection criteria included prolonged segmental transit on oral 111In-labelled diethylene triamine penta-acetic acid scintigraphic transit study, and disabling symptoms resistant to medical therapy and treatment of outlet obstruction. Twenty-eight patients (26 women, median age 52 years) were treated with segmental resection and followed prospectively with a validated questionnaire. RESULTS: After a median of 50 (range 16-78) months, 23 patients were pleased with the outcome. The median (range) stool frequency increased from 1 (0-7) to 7 (0-63) per week (P < 0.001). The number of patients passing hard stools and straining excessively decreased (P = 0.016 and P = 0.041, respectively). The median incontinence score was unchanged. Rectal sensory thresholds were higher in patients in whom the treatment failed (P < 0.001). CONCLUSION: With a symptomatic relief comparable to that after ileorectal anastomosis and less severe side-effects, segmental colectomy may be a better alternative for selected patients with STC. Thorough preoperative evaluation is important and impaired rectal sensation may predict a poor outcome.

-----

Aliment Pharmacol Ther. 2002 Oct;16(10):1701-8.
Long-term safety of tegaserod in patients with constipation-predominant irritable bowel syndrome.
Tougas G, Snape WJ Jr, Otten MH, Earnest DL, Langaker KE, Pruitt RE, Pecher E, Nault B, Rojavin MA.
Medicine and Gastroenterology, McMaster University Medical Center, Hamilton, Canada.

BACKGROUND: Tegaserod is a 5-hydroxytryptamine-4 receptor partial agonist. Oral administration causes gastrointestinal effects resulting in increased gastrointestinal motility and attenuation of visceral sensation. AIM: : To determine the long-term safety and tolerability of tegaserod in patients suffering from irritable bowel syndrome with constipation as the predominant symptom of altered bowel habits. METHOD: A multicentre, open-label study with flexible dose titration of tegaserod in out-patients suffering from constipation-predominant irritable bowel syndrome. RESULTS: A total of 579 patients with constipation-predominant irritable bowel syndrome were treated with tegaserod. Of these, 304 (53%) completed the trial. The most common adverse events, classified as related to tegaserod for any dose, were mild and transient diarrhoea (10.1%), headache (8.3%), abdominal pain (7.4%) and flatulence (5.5%). Forty serious adverse events were reported in 25 patients (4.4% of patients) leading to discontinuation in six patients. There was one serious adverse event, acute abdominal pain, classified as possibly related to tegaserod. There were no consistent differences in adverse events between patients previously exposed to tegaserod and those treated de novo. No pattern-forming tegaserod-related abnormalities in haematological and biochemical laboratory tests, urinalysis, blood pressure, pulse rate or electrocardiograms were found. CONCLUSIONS: Tegaserod appears to be well tolerated in the treatment of patients with constipation-predominant irritable bowel syndrome. The adverse event profile, clinical laboratory evaluations, vital signs and electrocardiogram recordings revealed no evidence of any unexpected adverse events, and suggest that treatment is safe over a 12-month period.

-----

Rev Med Chil. 2002 Jul;130(7):803-8.
[Severe chronic constipation. Is it a problem of surgery?]
[Article in Spanish]
Bannura G.
Servicio y Departamento de Cirugia, Hospital Clinico San Borja-Arriaran, Campus Centro, Facultad de Medicina, Universidad de Chile, Santiago de Chile. gbannura@rdc.cl

Severe chronic constipation is defined as less than two bowel movements per week, hard stools, non productive urgency and the need of digital maneuvers in more than 25% of bowel evacuations. The best studied causes of chronic severe constipation are slow bowel transit constipation and pelvic floor dysfunction. However, there are mixed forms that cross link with irritable colon syndrome. The main diagnostic tests are anorrectal manometry, bowel evacuation, X-ray studies and anorrectal sphincteromyomectomy, that can be therapeutic. Five percent of patients are surgical candidates. In cases of slow bowel movement, total colectomy with ileorectal anastomosis has satisfactory results in 80 to 90% of patients. Some patients with pelvic floor dysfunction have an occult rectal prolapse, rectocele or sigmoidocele and obtain benefits with the correction of these conditions. The remaining patients require a training of bowel evacuation, known as biofeedback. We have performed a total colectomy in 10 patients with slow bowel movements with good functional results in 80%. After 56 months of follow-up, a mean 2.6 bowel movements per day is reported by the patients. Four patients were also operated due to a solitary rectal ulcer and two patients due to a sigmoidocele, with satisfactory results.

-----

Complement Ther Nurs Midwifery. 2002 May;8(2):101-5.
Introducing abdominal massage in palliative care for the relief of constipation.
Preece J.
Hospiscare, Exeter, Devon, UK.

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.

-----

Ann Nutr Metab. 2002;46(3-4):159-62.
Effect of probiotics on constipation, fecal azoreductase activity and fecal mucin content in the elderly.
Ouwehand AC, Lagstrom H, Suomalainen T, Salminen S.
Department of Biochemistry and Food Chemistry, University of Turku, Finland. arthur.ouwehand@utu.fi

BACKGROUND: Constipation is a common problem in elderly subjects, probiotics have been suggested to improve intestinal motility and reduce fecal enzyme activity. METHODS: Elderly subjects (n = 28) were enrolled in an open parallel study. The subjects were divided into 3 groups: 1 control group receiving juice; 1 group receiving juice supplemented with Lactobacillus reuteri, and 1 group receiving juice supplemented with Lactobacillus rhamnosus and Propionibacterium freudenreichii. During the first 3 weeks all subjects consumed unsupplemented juice. In the subsequent 4 weeks, the subjects received their designated juice. During the last 3 weeks, all subjects again received unsupplemented juice. From the subjects, defecation frequency, laxative use, fecal pH, mucin content and azoreductase activity were assessed during the last week of each period. RESULTS: The subjects receiving the L. rhamnosus/P. freudenreichii-supplemented juice exhibited a 24% increase in defecation frequency. However, no reduction in laxative use was observed. The fecal azoreductase activity was also significantly reduced in this group. No changes in fecal pH or mucin excretion were observed. CONCLUSION: Some relief from constipation may be observed with the combination of L. rhamnosus/P. freudenreichii. This probiotic combination also reduced fecal enzyme activity. The tested probiotics did not affect the mucosal barrier. Copyright 2002 S. Karger AG, Basel

-----

Br J Surg. 2002 Jul;89(7):882-8.
Permanent sacral nerve stimulation for treatment of idiopathic constipation.
Kenefick NJ, Nicholls RJ, Cohen RG, Kamm MA.
St Mark's Hospital, Watford Road, Harrow HA1 3UJ, UK.

BACKGROUND: Constipation can usually be managed using conservative therapies. A proportion of patients require more intensive treatment. Surgery provides variable results. This paper describes an alternative approach, in which the neural control of the bowel and pelvic floor is modified, using permanent sacral nerve stimulation. METHODS: Four women (aged 27-36 years), underwent temporary and then permanent stimulation. All had idiopathic constipation, resistant to maximal therapy, with symptoms for 8-32 years. Clinical evaluation, bowel diary, Wexner constipation score, symptom analogue score, quality of life questionnaire and anorectal physiology were completed. RESULTS: There was a marked improvement in all patients with temporary, and in three with permanent, stimulation. Median follow-up was 8 (range 1-11) months. Bowel frequency increased from 1-6 to 6-28 evacuations per 3 weeks. Improvement occurred, at longest-follow-up, in median (range) evacuation score (4 (0-4) versus 1 (0-4)), time with abdominal pain (98 (95-100) versus 12 (0-100) per cent), time with bloating (100 (95-100) versus 12 (5-100) per cent), Wexner score (21 (20-22) versus 9 (1-20)), analogue score (22 (16-32) versus 80 (20-98)) and quality of life. Maximum anal resting and squeeze pressures increased. Rectal sensation was altered. Transit time normalized in one patient. CONCLUSION: Permanent sacral nerve stimulation can be used to treat patients with resistant idiopathic constipation.

-----

Front Biosci. 2002 Jun 1;7:b6-13.
The motor efficacy of the artificial colonic pacemaker in colonic inertia patients.
Shafik A, El-Sibai O, Shafik AA, Ahmed I.
Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt. ashafik@ahmedshafik.org

We have recently demonstrated that the colon possesses at least 4 pacemakers which presumably generate electric waves and that colonic pacing evokes electric activity in colonic inertia. We tested the hypothesis that electric waves produced by artificial colonic pacing in colonic inertia patients may initiate colonic motilitiy and effect evacuation. 17 patients with constipation due to total colonic inertia were divided into 2 groups: 10 (age 45.6 ( 6.3 years, 7 women) in the study group and 7 (age 43.7 ( 5.8 years, 5 women) as controls. 7 healthy volunteers were included in the study. Colonic pacing was tested at 2 sites of pacemakers: mid-transverse colon and colosigmoid junction. A stimulating electrode was hooked to the colonic mucosa at the pacemaker site and 2-3 recording electrodes distally to it. Healthy volunteers showed resting electric waves in the form of pacesetter and action potentials which increased significantly on colonic pacing. Inertia patients exhibited no basal electric activity. Colonic pacing in the study group evoked electric waves and caused expulsion of small volume balloon. Balloon distension at pacemaker site produced mass movement of balloon, while away from pacemaker site step-wise movement. In conclusion, colonic pacing evoked electric waves in colonic inertia patients and effected balloon expulsion. We postulate that the pacemaker generates electric waves which spread along pacemaker branches that are composed of interstitial cells of Cajal and nerve fibers of the enteric nervous plexus and effect colonic mass contraction. Ex-pacemaker stimulation presumably leads to local activation of interstitial cells of Cajal and segmental step-wise contraction.

-----

Scand J Gastroenterol. 2002 Apr;37(4):431-6.
Efficacy and tolerability of prucalopride in patients with constipation due to spinal cord injury.
Krogh K, Jensen MB, Gandrup P, Laurberg S, Nilsson J, Kerstens R, De Pauw M.
Surgical Research Unit, Arhus Amtssygehus, Denmark.

BACKGROUND: Chronic constipation (CC) often occurs after spinal cord injury (SCI). Prucalopride is a novel, highly selective, specific serotonin4 receptor agonist with enterokinetic properties. We evaluate the tolerability and pilot efficacy of prucalopride in the treatment of CC due to SCL. METHODS: Double-blind, placebo-controlled, pilot, phase 11, dose-escalation study. After 4 weeks' run in, patients received prucalopride 1 mg (n = 8) or placebo (n = 4); 11 new patients were randomized to prucalopride 2 mg (n = 8) or placebo (n = 3) once daily for 4 weeks. Patients recorded bowel function (diary) and assessed constipation severity and treatment efficacy (visual analogue scale (VAS) 0-100 mm). Colonic transit times were determined. RESULTS: Compared with run in. mean changes in constipation severity (VAS) increased with placebo, but decreased with prucalopride 1 and 2 mg. The VAS score for treatment efficacy showed a clear dose response (medians 4, 52 and 73 for placebo, 1 and 2 mg, respectively). Diary data showed an improvement in average weekly frequency of all bowel movements over 4 weeks within the 2 mg group (median 0.6; 95% CI 0.2; 1.2). There was a significant reduction in median colonic transit time with 2 mg (n = 4; -38.5 h (95% CI -80; -5)). Four patients (2 mg) reported moderate/severe abdominal pain, and two of these discontinued treatment. There were no clinically relevant effects on any of the safety parameters. CONCLUSION: This pilot study indicates that prucalopride can play an important role in the management of patients with CC due to SCI.

-----

Aliment Pharmacol Ther. 2002 Apr;16(4):759-67.
Effects of prucalopride on colonic transit, anorectal function and bowel habits in patients with chronic constipation.
Sloots CE, Poen AC, Kerstens R, Stevens M, De Pauw M, Van Oene JC, Meuwissen SG, Felt-Bersma RJ.
Department of Gastroenterology, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands.

BACKGROUND: There is a need for better tolerated drugs to normalize bowel function in chronic constipation. Prucalopride is a highly selective, specific, serotonin4 receptor agonist with enterokinetic properties. AIM: To evaluate the effects of prucalopride on bowel function, colonic transit and anorectal function in patients with chronic constipation. METHODS: Twenty-eight patients were enrolled in this double-blind, placebo-controlled, crossover study (prucalopride: 1 mg, n=12; 2 mg, n=16). Patients kept a bowel function diary. Colonic transit times and anorectal function (anal manometry, rectal sensitivity and rectal compliance) were assessed. RESULTS: Prucalopride (1 mg) compared to placebo significantly increased the mean number of spontaneous complete, spontaneous and all bowel movements per week. Prucalopride (1 mg) significantly decreased the percentage of bowel movements with hard/lumpy stools and straining and increased the urge to defecate. Prucalopride (1 and 2 mg) decreased the mean total colonic transit time by 12.0 h (prucalopride 42.8 h vs. placebo 54.8 h; P=0.074). No statistically significant effects were found in any of the anorectal function parameters. Prucalopride was well tolerated. There were no clinically relevant changes in standard safety parameters. CONCLUSIONS: Prucalopride significantly improves stool frequency and consistency, and the urge to defecate, and may decrease colonic transit times in patients with chronic constipation.

-----

World J Surg. 2002 Feb;26(2):166-70. Epub 2001 Dec 04.
Short-term effects of sacral nerve stimulation for idiopathic slow transit constipation.
Malouf AJ, Wiesel PH, Nicholls T, Nicholls RJ, Kamm MA.
St. Mark's Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.

This study assessed the short-term clinical and physiological effect of continuous sacral nerve stimulation in patients with slow transit constipation. Some patients with idiopathic slow transit constipation are unresponsive to conservative treatments, while colectomy has a variable and poorly predictable outcome. Sacral nerve stimulation is a less invasive and reversible procedure that enables direct neuromodulation of the pelvic floor and hindgut. It has been used successfully in the treatment of urologic disorders and fecal incontinence, and some of these patients with concurrent constipation have also noted improved stool frequency and rectal evacuation. Eight women (median age 47 years, median symptom duration 31 years, median stool frequency once per 6 days) were implanted with a temporary percutaneous stimulating S3 electrode for 3 weeks, attached to an external stimulator (Medtronic, Minneapolis,USA). A bowel symptom diary card, anorectal physiological studies, and a radiopaque marker transit study were completed before and during stimulation. Two patients had cessation or marked diminution of symptoms, including normalization of bowel frequency. Colonic transit did not return to normal in any patient. Rectal sensory threshold to distension was decreased during stimulation. Percutaneous temporary sacral nerve stimulation symptomatically improved a minority of patients with resistant idiopathic slow transit constipation. Sensory function was altered by stimulation. Further studies are required to identify patients who may benefit and to assess a range of stimulation parameters.

-----

Curr Womens Health Rep. 2002 Aug;2(4):280-4.
Constipation overview: evaluation and management.
Douglas J.
Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA. jennifer.m.douglas@medstar.net

Constipation is variably defined, but usually refers to persistent, difficult, infrequent, or seemingly incomplete defecation. An exhaustive list of possible factors may contribute to chronic constipation. Most patients are successfully treated without elaborate, expensive diagnostic procedures, by implementing simple alterations in diet and lifestyle. In the small percentage of patients in whom this fails, a more in-depth analysis of the problem may lead to more specialized forms of therapy. Bowel retraining, or biofeedback, often serves as a foundation for further therapy, but pharmacologic aids or surgery may also be necessary. Unfortunately, results in these patients are not universally optimistic, but patient selection is the key.

-----

Aliment Pharmacol Ther. 2002 Jul;16(7):1347-56.
Prucalopride, a systemic enterokinetic, for the treatment of constipation.
Emmanuel AV, Roy AJ, Nicholls TJ, Kamm MA.
St. Mark's Hospital, Harrow, Middlesex, UK.

BACKGROUND: Laxatives are frequently ineffective in treating constipation. An alternative therapeutic approach is to target serotonin-4 receptors, which are involved in initiating peristalsis. AIM: In a double-blind, placebo-controlled trial, to assess the efficacy and safety of a systemically active serotonin-4 agonist, prucalopride. METHODS: Seventy-four women with constipation were stratified into slow or normal transit groups, and each group was randomized to receive either placebo or 1 mg prucalopride daily for 4 weeks. A bowel function diary was maintained. Whole-gut and orocaecal transit, visceral sensitivity, quality of life and psychological state were assessed before and after treatment. RESULTS: Prucalopride, not placebo, increased spontaneous stool frequency (P=0.008) and reduced time to first stool (P < 0.001). Prucalopride reduced the number of retained markers in all patients compared to placebo (P=0.004). Prucalopride reduced the mean number of retained markers in slow transit (P=0.069), but did not alter the marker count in normal transit (P=0.86). Orocaecal transit was accelerated by prucalopride, not placebo (P=0.004). Prucalopride, notplacebo, increased rectal sensitivity to distension (urge volume, P=0.01) and electrical stimulation (P=0.001). Prucalopride significantly improved several domains of the Short Form Health Status Survey and the disease-specific quality of life. Adverse effects were similar for prucalopride and placebo. CONCLUSIONS: Prucalopride improves symptoms, upper gut transit and gut sensitivity in constipated patients with both slow and normal transit. It improves transit in patients with slow transit. These changes are associated with improved well-being.

-----

Am J Gastroenterol. 2002 Jul;97(7):1776-9.
Overnight efficacy of polyethylene glycol laxative.
Di Palma JA, Smith JR, Cleveland M.
Division of Gastroenterology, University of South Alabama, Mobile 36693, USA.

OBJECTIVES: Clinical studies in constipated adult patients have shown that a 17- or 34-g daily dose of polyethylene glycol (PEG) 3350 (MiraLax) is safe and effective for the treatment of constipation, with the best efficacy seen in wk 2 of treatment. The purpose of this study was to determine an optimal dose of PEG to provide satisfactory relief of constipation within 24 h. METHODS: A total of 24 adult study subjects who met Rome II criteria for constipation were randomized in a double-blind, parallel pilot study to receive a single dose of placebo or PEG laxative at doses of 51, 68, or 85 g in 500 ml of flavored water. Over a 72-h period, subjects rated bowel movements (BM), completeness of evacuation, and satisfaction. RESULTS: The 68-g dose seemed to be most satisfactory. Five of six subjects had a BM within 24 h. The time to first BM was 14.8 h for 68 g versus 27.3 h for placebo (p = NS). The time to second BM was 19.2 h versus 47.2 h for 68 g and placebo, respectively (p = 0.003). Of the subjects receiving 68 g of PEG, 50% and 100% reported complete evacuation for the first and second BM, respectively. The average number of BMs in 24 h for placebo, 51 g, 68 g, and 84 g were 0.5, 2.2, 2.2, and 4.2, respectively (p = 0.004). There were no adverse reactions, and no patient reported incontinence or complained of cramps or diarrhea at any dose. There were no changes in measured electrolytes, calcium, glucose, BUN, creatinine, or serum osmolality. CONCLUSIONS: A 68-g dose of PEG laxative seems to provide safe and effective relief in constipated adults within a 24-h period.

-----

Colorectal Dis. 2001 Nov;3(6):392-5.
Long-term results of subtotal colectomy for severe slow-transit constipation in patients with normal
rectal function.
Aldulaymi BH, Rasmussen OO, Christiansen J.
Department of Surgery, D Herlev Hospital, University of Copenhagen.

OBJECTIVE: The outcome of subtotal colectomy for severe constipation may be difficult to predict. One factor, which probably is of major importance for the functional outcome, is rectal function. The aim of the study has been to evaluate long-term results after subtotal colectomy with ileo-rectal anastomosis in a group of patients with severe slow-transit constipation but without evidence of impaired rectal emptying. PATIENTS AND METHODS: Of 273 patients with constipation referred for surgical evaluation 18 (7%) fulfilled our criteria for subtotal colectomy. Slow-transit was confirmed by radio-opaque marker studies and normal rectal function by emptying of viscous fluid and normal emptying at defecography. RESULTS: At follow up between 3 and 9 years 15 patients had a bowel frequency between 2 and 6 daily. One patient, who had an ileostomy because of anastomotic leak, had not wanted bowel continuity restored. One patient with opiate abuse became less constipated with 2-3 bowel movements a week. One patient was still constipated one year after the operation and subsequently had an ileal pouch-anal anastomosis. This patient who had normal rectal emptying had a very high volume tolerability with a maximum tolerable volume of 700 ml. In 4 of 7 patients abdominal pain persisted after the operation, and 3 developed diarrhoea, which required daily intake of loperamide. CONCLUSION: Subtotal colectomy for severe slow-transit constipation is justified provided anorectal function is normal. In spite of normal rectal emptying very high rectal volume tolerability may be an indicator of functional megarectum and impaired rectal emptying postoperatively.

-----

Rev Gastroenterol Disord. 2001;1(4):187-98.
Tegaserod for the treatment of constipation-predominant irritable bowel syndrome.
Baker DE.
Drug Information Center, College of Pharmacy, Washington State University, Spokane, WA, USA.

Tegaserod, a potent, partial serotonin 4 receptor (5-HT4) agonist, is an effective agent for the treatment of females with constipation-predominant irritable bowel syndrome. Tegaserod enhances gastric motility, stimulates peristaltic reflux and intestinal secretion, inhibits visceral sensitivity, and/or shortens colonic transit time. This agent may help women who have failed to respond to diet and exercise, laxatives, and other forms of therapy. The optimal dose of tegaserod is 6 mg twice daily and results in decreased number of days per month with pain, bloating, and days without bowel movements. Tegaserod is less effective in males than females in the treatment of constipation-predominant irritable bowel syndrome. Tegaserod is well tolerated. Diarrhea is the most frequent adverse effect. The diarrhea tends to occur most frequently during the first few months of therapy and decreases with continued administration.

The Constipation FileSM Compiled and Maintained by    The Center for Current Research, Inc. 708 Aubrey Avenue • Ardmore PA USA 19003 Phone: 610-649-3165 Email: customerservice@lifestages.com Website: www.lifestages.com

©Copyright 1992-date by The Center for Current Research. The Constipation File is a proprietary compilation of the Center for Current Research. The information in the File is solely for your use, and the use of your family, friends, and doctors. The information is the property of the individual researchers and institutions that produced it. It is an infringement of copyright law to attempt to "resell" the information as it is presented here.