Functional constipation and the effect of prebiotics on the gut microbiota: a review.

Functional constipation is a significant health issue impacting the lives of an estimated 14 % of the global population. Non-pharmaceutical treatment advice for cases with no underlying medical conditions focuses on exercise, hydration and an increase in dietary fibre intake. An alteration in the composition of the gut microbiota is thought to play a role in constipation. Prebiotics are non-digestible food ingredients that selectively stimulate the growth of a limited number of bacteria in the colon with a benefit for host health. Various types of dietary fibre, though not all, can act as a prebiotic. Short-chain fatty acids produced by these microbes play a critical role as signalling molecules in a range of metabolic and physiological processes including laxation, although details are unclear. Prebiotics have a history of safe use in the food industry spanning several decades and are increasingly used as supplements to alleviate constipation. Most scientific research on the effects of prebiotics and gut microbiota has focussed on inflammatory bowel disease rather than functional constipation. Very few clinical studies evaluated the efficacy of prebiotics in the management of constipation and their effect on the microbiota, with highly variable designs and conflicting results. Despite this, broad health claims are made by manufacturers of prebiotic supplements. This narrative review provides an overview of the literature on the interaction of prebiotics with the gut microbiota and their potential clinical role in the alleviation of functional constipation.

A systematic review examining the impact of blended diets on the gastrointestinal symptoms of people who are enterally fed.

BACKGROUND: Adults and children who are enterally tube-fed can experience adverse gastrointestinal symptoms (GIS). Observational data suggests that blended diets (BD) could mitigate such symptoms, with potential to improve quality of life and clinical outcomes. We present a novel systematic review examining the impact of BD, compared to commercial feeds, on GIS of adults and children who are tube-fed. METHODS: The protocol was registered with PROSPERO (CRD42021261147). Four electronic databases were searched from inception to August 2021. Search terms included 'tube-fed', 'blended diet' and 'formula'. Inclusion criteria were intervention studies comparing blended and commercial feeds using quantitative measures of GIS. Heterogeneity of outcome measures precluded meta-analysis; therefore, a narrative synthesis was conducted. RESULTS: Six papers (n = 219), including two randomised control trials (RCT) and four single arm pre-post studies, were identified. Equal numbers studied in- and out-patients, adults and children. Risk of bias was notable for all studies. Equivocal and insufficient evidence prevented consensus on outcomes of vomiting, gagging, oral intake, bloating and constipation. However, one RCT and two single arm pre-post studies suggest that diarrhoea symptoms may be improved on BD. CONCLUSIONS: Diarrhoea is prevalent in tube-fed populations and associated with adverse outcomes. Improvements in diarrhoea symptoms attributed to BD may be clinically important. Our findings are congruous with the wider observational evidence base, and support recommendations of the British Dietetic Association. BD may pose a viable alternative to commercial formula, and may mitigate symptoms of diarrhoea for adults and children who are tube-fed.

The value of preventing constipation in patients treated with peritoneal dialysis: an advanced practice nursing study / Intérêt de la prévention de la constipation des patients traités par la dialyse péritonéale : une recherche de pratique infirmière avancée

Introduction: In 1989, experts developed the Rome criteria classification coupled with the use of the Bristol scale, to objectify the condition of functional constipation.Background Nowadays, little is documented in the literature about transit disorders in patients with End-Stage Chronic Renal Failure treated with peritoneal dialysis, even though this causes non-negligible complications on the patient’s morbidity, comfort and quality of life. Objective: The main objective of our study was to evaluate the prevalence of constipation in CKD patients. Material and method: We conducted a retrospective multicenter data-driven study. Results: 74 patient records were analyzed. We found a prevalence of constipation of 58 % in patients with CKD. Discussion: Our results showed that the prevalence of constipation is frequent in patients with CKD. It leads to a significant discomfort for the patient, an additional cost in terms of care and technical procedures and a failure of the peritoneal dialysis technique. Conclusion: Thus, the prevention of constipation in CKD patients would be relevant to limit complications and ensure a better quality of life.

Introduction: En 1989, des experts ont mis au point la classification des critères de Rome couplée à l'utilisation de l'échelle de Bristol, afin d'objectiver l'état de constipation fonctionnelle. Contexte: Aujourd'hui, la littérature documente peu les troubles du transit des patients en Insuffisance rénale chronique terminale (IRCT) traités par la Dialyse péritonéale (DP), alors même que cela engendre des complications non négligeables sur la morbidité, le confort et la qualité de vie du patient. Objectif: L'objectif principal de notre étude était d'évaluer la prévalence de la constipation des patients en IRCT. Matériel et méthode: Nous avons réalisé une étude rétrospective multicentrique sur données. Résultats: 74 dossiers patients ont été analysés. Nous avons mis en évidence une prévalence de la constipation de 58 % chez des patients atteints d'une IRCT. Discussion: Nos résultats ont démontré que la prévalence de la constipation est fréquente chez les patients atteints d'une IRCT. Elle entraîne un inconfort notable chez le patient, un surcoût au niveau des soins et des actes techniques, et un échec de la technique de dialyse péritonéale. Conclusion: Ainsi, la prévention de la constipation des patients en IRCT serait pertinente pour limiter les complications et leur assurer une meilleure qualité de vie.

Reducing Opioid-Induced Constipation Post-Cardiac Surgery: An Improvement Project in a Pediatric Cardiac Intensive Care Unit.

BACKGROUND: Pain management with opioids and underutilization of prophylaxis for constipation can prolong a patient's hospital length of stay and impede pain management efforts. PROBLEM: In pediatric postoperative cardiac patients, opioid therapy is a common approach to pain management but often places them at greater risk for constipation due to anatomy and age. METHODS: A retrospective review of 50 patients' medical records for baseline data was conducted, and a survey evaluated providers' current knowledge and practice. INTERVENTIONS: The intervention was an electronic order set that provided decision support. Additionally, prophylactic measures were supported by a validated assessment tool that created a common language to report constipation risk. RESULTS: Although not statistically significant, postintervention data demonstrated a 21.5% decrease in postoperative constipation and a 57% increase in ordered bowel regimens. CONCLUSION: More focus is needed toward prophylactic bowel regimens to reduce the risk in this already high-risk population.

Effects of flaxseed supplementation on functional constipation and quality of life in a Chinese population: A randomized trial.

BACKGROUND AND OBJECTIVES: This prospective, randomized, controlled study aimed to evaluate the effects of flaxseed supplementation on functional constipation and quality of life in adult men and women in China. METHODS AND STUDY DESIGN: 90 subjects with functional constipation diagnosed by the Rome IV criteria were enrolled. Subjects were randomly assigned to receive either 50 g/day flaxseed flour with meals (n=60) or 15 mL/day of a lactulose solution on an empty stomach (n=30) every morning for 4 weeks. Wexner constipation scores, stool consistency according to the Bristol Stool Form Scale, and bowel habits (frequency of bowel movements/week, the time spent on defecation) were the primary outcomes. The change in Patient Assessment of Constipation Quality of Life score was the secondary outcome. RESULTS: After 4 weeks, the bowel habits in both groups were significantly improved. The median Wexner constipation score decreased from 14 to 6.5 in the flaxseed group (p<0.001) and from 15 to 9 in the lactulose group (p<0.001). The median defecation frequency per week increased significantly (2 to 7 for flaxseed and 2 to 6 for lactulose, p<0.001 for both groups). The Patient Assessment of Constipation Quality of Life score decreased significantly (-1.34 and -0.66 for flaxseed and lactulose, respectively; p<0.001 for both groups). CONCLUSIONS: Flaxseed flour is somewhat more effective at increasing defecation frequency than lactulose, improving bowel movements and promoting life quality of subjects with chronic functional constipation in the Chinese population.

Randomised controlled trial of a comprehensive protocol for preventing constipation following total hip arthroplasty.

AIMS AND OBJECTIVES: To evaluate the efficacy and safety of a comprehensive protocol for constipation prevention. BACKGROUND: Constipation is a common problem for patients undergoing total hip arthroplasty (THA), yet sparse evidence is available to guide constipation prevention after THA. DESIGN: Randomised controlled superiority clinical trial. METHODS: This randomised controlled study was carried out according to the Consolidated Standards of Reporting Trials (CONSORT). A total of 80 THA patients were randomised to receive only preoperative education about lifestyle or the combination of education with postoperative abdominal massage and polyethylene glycol 4,000 (Forlax®). Efficacy outcomes included rates of postoperative constipation and enema rescue, as well as time to first postoperative defecation and readmission within 30 days. Safety outcomes were number and type of adverse events. RESULTS: Patients who received combination treatment showed a significantly lower rate of postoperative constipation during hospitalisation than patients who received only preoperative education (25% versus 55%), and they showed a significantly lower rate of enema rescue (12.5% versus 40%). Many more patients receiving combination treatment experienced their first defecation within two postoperative days than patients who received only preoperative education (62.5% versus 35.9%). In contrast, the two groups were similar in terms of constipation rate on postoperative days 15 and 30, rate of readmission within 30 days and rate of postoperative adverse events. CONCLUSIONS: These results suggest that our comprehensive protocol can relieve constipation after THA, reduce the need for enema rescue and shorten time to first defecation without sacrificing safety. More work is needed to optimise and develop this protocol further. RELEVANCE TO CLINICAL PRACTICE: Constipation is a distressing problem that frequently occurs after THA. This study confirmed that a comprehensive protocol including preoperative education, postoperative abdominal massage and polyethylene glycol 4,000 can effectively relieve constipation after THA without sacrificing safety.

Hemorrhoids: what are the options in 2018?

PURPOSE OF REVIEW: Efforts continue to improve the treatment of patients with symptomatic hemorrhoidal disease by interventions designed to improve efficiency and effectiveness, including by reducing intraoperative and postoperative pain, decreasing operating times, minimizing blood loss and controlling symptoms and recurrence rates. Simultaneously, there are also renewed efforts to minimize the number of patients who will require procedural intervention by focusing on conservative measures that encourage better bowel regulation and habits. The purpose of this brief report is to review the current status of the diagnosis and treatment of patients with hemorrhoidal disease. Overall, new procedures or procedural refinements to existing techniques continue to be introduced with promising short-term outcomes - at least in some instances. In most instances, long-term follow-up or equivalency data are still being accumulated such that a definitive, unequivocal answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial. One of the challenges is heterogeneity as regards diagnosis, intervention and, especially, outcomes measures such that comparing therapies is too difficult. A recent initiative to standardize metrics has promise. RECENT FINDINGS: Recent studies largely appear to suggest that conservative treatment approaches and managing patient expectations are critically important in which a primary objective should be to minimize the progression to symptomatic disease and complications in patients who are diagnosed with hemorrhoids. The pace of change as regards the development of new or improved surgical techniques appears may be accelerating. SUMMARY: Progress is being made and the knowledge base is being expanded as regards the treatment options for patients with hemorrhoids and expected outcomes. A key initiative to standardize the approaches to diagnosis and treatment about staging, procedural interventions and outcomes will facilitate comparative analytics, if successful.

Putative mechanisms of kiwifruit on maintenance of normal gastrointestinal function.

Kiwifruits are recognized as providing relief from constipation and symptoms of constipation-predominant irritable bowel syndrome (IBS-C). However, the underlying mechanisms, specifically in regards to gastrointestinal transit time and motility, are still not completely understood. This review provides an overview on the physiological and pathophysiological processes underlying constipation and IBS-C, the composition of kiwifruit, and recent advances in the research of kiwifruit and abdominal comfort. In addition, gaps in the research are highlighted and scientific studies of other foods with known effects on the gastrointestinal tract are consulted to find likely mechanisms of action. While the effects of kiwifruit fiber are well documented, observed increases in gastrointestinal motility caused by kiwifruit are not fully characterized. There are a number of identified mechanisms that may be activated by kiwifruit compounds, such as the induction of motility via protease-activated signaling, modulation of microflora, changes in colonic methane status, bile flux, or mediation of inflammatory processes.

Oral Prolonged-Release Oxycodone/Naloxone for Managing Pain and Opioid-Induced Constipation: A Review of the Evidence.

BACKGROUND: Opioids provide effective relief from moderate-to-severe pain and should be prescribed as part of a multifaceted approach to pain management when other treatments have failed. Fixed-dose oxycodone/naloxone prolonged-release tablets (OXN PR) were designed to address the opioid class effect of opioid-induced constipation (OIC) by combining the analgesic efficacy of oxycodone with the opioid receptor antagonist, naloxone, which has negligible systemic availability when administered orally. This formulation has abuse-deterrent properties, since systemic exposure to naloxone by parenteral administration would antagonize the euphoric effects of oxycodone. METHODS: A literature search was conducted to assess the evidence base for OXN PR to treat moderate-to-severe pain and its impact on bowel function, based on published clinical trials and observational studies. RESULTS: Extensive data demonstrate that OXN PR provides effective analgesia and clinically relevant improvements in bowel function in patients with OIC and moderate-to-severe cancer-related pain and noncancer pain types such as low back pain, neuropathic pain, and musculoskeletal pain. OXN PR has also been found to improve bowel function in patients with OIC refractory to multiple types of laxatives, and improve Parkinson's disease-related pain. No unanticipated safety concerns have been reported in elderly patients. CONCLUSIONS: Evidence from clinical trials and observational studies confirms that for selected patients OXN PR significantly improves moderate-to-severe chronic pain and provides relief from OIC. Treatment should be tailored to individual patients to establish the lowest effective dose. An absence of analgesic ceiling effect was seen across the clinically relevant dose range investigated (≤ 160/80 mg/day).

[A New Twist on the Administration of Naldemedine for Opioid-Induced Constipation in an Outpatient].

Opioid-induced constipation(OIC)occurs with high frequency in patients with cancer undergoing pain treatment using opioids. Osmotic or irritant laxatives are usually used to prevent OIC. Recently, naldemedine has become operational for OIC. Although naldemedine achieved the desired effect, diarrhea is a little feared from the results of clinical phase III study(V9236 clinical trial). We herein report the use of naldemedine to alleviate diarrhea and expect the improvement of the quality of the bowel habits in outpatients with cancer undergoing pain treatment using opioids.

[Proctological emergencies in pregnant women]. / Les urgences proctologiques chez la femme enceinte.

Hemorrhoids affect up to 85 % of pregnant women during the last two trimesters. The maximum incidence for anal fissure is 20 %. One of the common risk factors is constipation promoted during pregnancy. The history of anal pathology, the length of delivery and the baby's birth weight also promote these two entities. The treatment includes above all hygiene and dietary measures to prevent constipation and conservative measures (local anesthetics, sitz baths). Surgical procedures should be avoided and indicated only in case of failure of conservative treatment. Rectal prolapse is more rare and must be reduced manually before surgery. Measures to prevent constipation also apply.

Les hémorroïdes concernent jusqu'à 85 % des femmes enceintes durant les deux derniers trimestres. L'incidence maximale pour la fissure anale atteint 20 %. Un des facteurs de risque communs est la constipation favorisée durant la grossesse. Les antécédents de pathologies anales, la durée de l'accouchement et le poids de naissance du bébé favorisent aussi ces deux entités. Le traitement comprend avant tout des mesures hygiéno-diététiques pour prévenir la constipation et des mesures conservatives (anesthésiants locaux, bains de siège). Les interventions chirurgicales sont à éviter et indiquées uniquement en cas d'échec du traitement conservateur. Le prolapsus rectal est plus rare et doit être réduit manuellement avant une intervention chirurgicale à réaliser en postpartum. Les mesures de prévention de la constipation s'appliquent également.

Is There A Role for Pre-, Pro- and Synbiotics in the Treatment of Functional Constipation in Children? A Systematic Review.

PURPOSE OF REVIEW: To investigate the efficacy and safety of pre-, pro- and synbiotics in the treatment of pediatric functional constipation (FC). RECENT FINDINGS: A recent study reported that the gut microbiota in obese children with FC differs from that of obese children without FC. The gut microbiota may be involved in the pathophysiology of FC. Pre- and probiotics have been suggested as potential treatment modalities for FC in children. SUMMARY: PubMed and Cochrane databases were searched from inception to February 2016. We found 6 RCTs on prebiotics, 6 RCTs on probiotics and 1 RCT concerning synbiotics. Overall, most studies were at high risk of bias. The majority of studies were unable to demonstrate a significant effect of pre-, pro- or synbiotics on predefined outcome measures such as defecation frequency, fecal incontinence and painful or difficult defecation. Pre-, pro- and synbiotics were not associated with significant adverse effects. In conclusion, there is insufficient evidence to recommend pre-, pro- or synbiotics in the treatment of children with functional constipation. High-quality randomized controlled trials are warranted to further explore these treatment modalities.

Algorithms for Common Gastrointestinal Disorders.

Regurgitation, infantile colic and, or, constipationare frequent during the first 12 months of life, and although they aremost of the time functional disorders, these conditions can also be related to cow's milk. Practical algorithms for their management are presented. Management consists of exclusion of warning signs for organic disease, parental reassurance and nutritional strategies. The proposed algorithms will assist healthcare providers to manage frequent gastrointestinal and cows' milkrelated symptoms in infants.

Fermented Fiber Supplements Are No Better Than Placebo for a Laxative Effect.

BACKGROUND: Misconceptions about the effects of dietary fiber and 'functional' fiber on stool parameters and constipation persist in the literature. METHODS: A comprehensive literature review was conducted with the use of the Scopus and PubMed scientific databases to identify and objectively assess well-controlled clinical studies that evaluated the effects of fiber on stool parameters and constipation. RESULTS: The totality of well-controlled randomized clinical studies show that, to exert a laxative effect, fiber must: (1) resist fermentation to remain intact throughout the large bowel and present in stool, and (2) significantly increase stool water content and stool output, resulting in soft/bulky/easy-to-pass stools. Poorly fermented insoluble fiber (e.g., wheat bran) remains as discreet particles which can mechanically irritate the gut mucosa, stimulating water & mucous secretion if the particles are sufficiently large/coarse. For soluble fibers, some have no effect on viscosity (e.g., inulin, wheat dextrin) while others form high viscosity gels (e.g., ß-glucan, psyllium). If the soluble fiber is readily fermented, whether non-viscous or gel-forming, it has no effect on stool output or stool water content, and has no laxative effect. In contrast, a non-fermented, gel-forming soluble fiber (e.g., psyllium) retains its gelled nature and high water-holding capacity throughout the large bowel, resulting in soft/bulky/easy-to-pass stools. CONCLUSION: When considering a recommendation for a fiber supplement regimen to treat and/or prevent constipation, it is important to consider which fibers have the physical characteristics to exert a laxative effect, and which fiber supplements have rigorous clinical evidence of a significant benefit in patients with constipation.

Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol.

Gastrointestinal (GI) complications are among the most common complications following radical cystectomy and urinary diversion. The most common is postoperative ileus, although its precise pathophysiology is not completely understood. Enhanced recovery after surgery (ERAS) protocols include evidence-based steps to optimize postoperative recovery and shorten hospital stay, mainly through expedited GI function recovery. They include avoiding bowel preparation and postoperative nasogastric tube, early feeding, non-narcotic pain management, and the use of cholinergic and mu-receptor opioid antagonists. We reviewed the literature in regard to GI complications using enhanced recovery protocols and share our institutional experience with over 300 patients.

Aquaporins in the Colon as a New Therapeutic Target in Diarrhea and Constipation.

Aquaporins (AQPs) play important roles in the water transport system in the human body. There are currently 13 types of AQP, AQP0 through AQP12, which are expressed in various organs. Many members of the AQP family are expressed in the intestinal tract. AQP3 is predominantly expressed in the colon, ultimately controlling the water transport. Recently, it was clarified that several laxatives exhibit a laxative effect by changing the AQP3 expression level in the colon. In addition, it was revealed that morphine causes severe constipation by increasing the AQP3 expression level in the colon. These findings have shown that AQP3 is one of the most important functional molecules in water transport in the colon. This review will focus on the physiological and pathological roles of AQP3 in the colon, and discuss clinical applications of colon AQP3.

Management of opioid-induced constipation.

Up to 40% of patients taking opioids develop constipation. Opioid-induced constipation (OIC) may limit the adequate dosing of opioids for pain relief and reduce quality of life. Health professionals must therefore inquire about bowel function in patients receiving opioids. The management of OIC includes carefully re-evaluating the necessity, type and dose of opioids at each visit. Lifestyle modification and alteration of aggravating factors, the use of simple laxatives and, when essential, the addition of newer laxatives or opioid antagonists (naloxone, naloxegol or methylnaltrexone) can be used to treat OIC. This review discusses the recent literature regarding the management of OIC and provides a rational approach to assessing and managing constipation in individuals receiving opioids.

Gum chewing and gastrointestinal function following caesarean delivery: a systematic review and meta-analysis.

AIMS AND OBJECTIVES: The aims of this systematic review and meta-analysis were to summarise current knowledge regarding gum chewing intervention for activation of the gastrointestinal (GI) system following caesarean delivery. BACKGROUND: GI symptoms such as nausea, vomiting and defecatory difficulties are bothersome for women following a caesarean delivery. There is category A recommendation to not withhold oral intake postoperatively. However, current practice guidelines vary widely on time to initiate oral feeding post caesarean delivery, and additional research is needed. Gum chewing has been shown to stimulate the GI system in other postoperative patient populations. DESIGN: A systematic review and meta-analysis. METHODS: An electronic review was undertaken using the following resources: PubMed (Medline), CINAHL, EMBASE and ClinicalTrials.gov databases. Key words used in various combinations included cesarean section; cesarean delivery; postoperative chewing gum; bowel movement; bowel function and complications. RESULTS: A total of 171 articles were found of which 166 were excluded: 157 were duplicates and the remainder did not meet the inclusion criteria. Five randomised control trials were included in the meta-analysis, focusing on gum chewing as an intervention as compared with a nongum chewing intervention, with a total of 846 participants. Compared with the nongum chewing group, gum chewing showed a beneficial impact on the major outcomes of digestive system activation, including bowel sound, gas passage and defecation. CONCLUSIONS: This meta-analysis supports the effectiveness of gum chewing post caesarean delivery as a noninvasive/nonpharmacological intervention for reactivation of bowel movement. RELEVANCE TO CLINICAL PRACTICE: Gum chewing in the immediate postoperative period following caesarean delivery may provide a socially acceptable, low-cost and safe intervention to reduce postcaesarean delivery GI complications and restore GI function.

Effect of Connective Tissue Manipulation on Symptoms and Quality of Life in Patients With Chronic Constipation: A Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to examine the effects of connective tissue manipulation (CTM) on the severity of constipation and health-related quality of life in individuals diagnosed with chronic constipation. METHODS: Fifty patients with a diagnosis of chronic constipation according to Rome III criteria were recruited and randomized to an intervention (n = 25) or control group (n = 25). The intervention group received CTM in addition to the lifestyle advice, whereas the control group was given only lifestyle advice for constipation. All assessments were performed at baseline and at the end of 4 weeks. The primary outcome measure was the Constipation Severity Instrument. Secondary outcomes included Patient Assessment of Constipation Quality of Life Questionnaire, Bristol Stool Scale, and 7-day bowel diary. Differences between groups were analyzed with t tests, Mann-Whitney U test and χ(2) test. RESULTS: Compared with the control group, subjects in the intervention group reported significantly greater improvement in total and subscale scores of the Constipation Severity Instrument and Patient Assessment of Constipation Quality of Life Questionnaire (P < .05). Based on the results from bowel diaries, the improvements in the number of bowel movements, duration of defecation, stool consistency, and the feeling of incomplete evacuation in the intervention group were also significantly more than the control group (P < .05). CONCLUSION: This study showed that CTM and lifestyle advice were superior to reducing symptoms of constipation and quality of life compared with lifestyle advice alone for patients with chronic constipation.