Barostat or dynamic balloon distention test: which technique is best suited for esophageal sensory testing?

Esophageal sensation is commonly assessed by barostat-assisted balloon distension (BBD) or dynamic balloon distension (DBD) technique, but their relative merits are unknown. Our aim was to compare the usefulness and tolerability of both techniques. Sixteen healthy volunteers (male/female = 6/10) randomly underwent graded esophageal balloon distensions, using either BBD (n= 8) or DBD (n= 8). BBD was performed by placing a 5-cm long highly compliant balloon attached to a barostat, and DBD by placing a 5-cm long balloon attached to a leveling container. Intermittent phasic balloon distensions were performed in increments of 6 mm Hg. Sensory thresholds and biomechanical properties were assessed and compared. Sensory thresholds for first perception (mean ± standard deviation; 21 ± 6 vs. 21.2 ± 5, mm Hg, P= 0.9), discomfort (38 ± 8 vs. 35 ± 9, P= 0.5), and pain (44 ± 4 vs. 45 ± 3, P= 0.7) were similar with BBD and DBD techniques. However, more subjects tolerated DBD (7/8, 88%) when compared with BBD (4/8, 50%). Forceful expulsion of balloon into stomach (n= 4), pulling around the mouth (n= 4), chest discomfort (n= 2) and retching (n= 2) were overlapping reasons for intolerance with BBD. Esophageal wall distensibility was similar with both techniques. Both techniques provided comparable data on biomechanical properties. However, DBD was better tolerated than BBD for evaluation of esophageal sensation. Hence, we recommend DBD for performing esophageal balloon distension test.

Adenosine modulates oesophageal sensorimotor function in humans.

BACKGROUND AND AIMS: Adenosine mediates somatic and visceral pain, but its effects on gut visceral nociception are unknown. The aim of the present study was to test the hypothesis that adenosine alters oesophageal sensorimotor function. METHODS: In a double-blind, randomised, placebo-controlled study, 14 healthy volunteers (M/F = 4/10) received either intravenous adenosine 100 microg/kg/min or placebo infusion. Prior to and during infusion, all subjects underwent stepwise graded oesophageal balloon distensions using impedance planimetry. Sensory responses and biomechanical properties were assessed and compared. RESULTS: Adenosine significantly lowered thresholds for first perception (median (25th-75th), cm H(2)O; 10 (10-20) vs 30 (20-30), p = 0.007), discomfort (40 (30-40) vs 50 (50-60), p = 0.011) and pain (50 (40-60) vs 70 (60-70), p = 0.007) when compared with placebo. Also, the median threshold pressures required to induce first perception (p = 0.017), discomfort (p = 0.024) and pain (p = 0.026) were lower when compared with baseline. The cross-sectional area of the oesophagus increased (p = 0.032), and the circumferential wall tension/strain relationship shifted to the left (the wall became stiffer) (p = 0.043) after adenosine, when compared with baseline or placebo. CONCLUSIONS: Adenosine can induce visceral hyperalgesia and decrease oesophageal distensibility in humans. These evoked sensorimotor changes are similar to those described in patients with functional oesophageal (non-cardiac) chest pain. Thus, adenosine modulates oesophageal sensorimotor function and may play a role in the pathogenesis of functional chest pain.

Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient.

Management of the recent outbreak of the novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) remains challenging. The challenges are not only limited to its preventive strategies, but also extend to curative treatment, and are amplified during the management of critically ill patients with COVID-19. Older persons with comorbidities like diabetes mellitus, cardiac diseases, hepatic impairment, renal disorders and respiratory pathologies or immune impairing conditions are more vulnerable and have a higher mortality from COVID-19. Earlier, the Indian Resuscitation Council (IRC) had proposed the Comprehensive Cardiopulmonary Life Support (CCLS) for management of cardiac arrest victims in the hospital setting. However, in patients with COVID-19, the guidelines need to be modified,due to various concerns like differing etiology of cardiac arrest, virulence of the virus, risk of its transmission to rescuers, and the need to avoid or minimize aerosolization from the patient due to various interventions. There is limited evidence in these patients, as the SARS-CoV-2 is a novel infection and not much literature is available with high-level evidence related to CPR in patients of COVID-19. These suggested guidelines are a continuum of CCLS guidelines by IRC with an emphasis on the various challenges and concerns being faced during the resuscitative management of COVID-19 patients with cardiopulmonary arrest.

Oral rehydration for viral gastroenteritis in adults: a randomized, controlled trial of 3 solutions.

BACKGROUND: Pedialyte and Gatorade are advocated for the treatment of dehydration in viral gastroenteritis, but there is limited evidence to support their use. We examine the efficacy, safety, and palatability of Pedialyte, Gatorade, and a New Oral Rehydration Solution (N-ORS). This was a randomized double-blind trial conducted in an inpatient, community hospital. Seventy-five consecutive adult patients (male, 42; female, 33) admitted with viral gastroenteritis were randomized to receive Gatorade, Pedialyte, or N-ORS for 48 hours. A yogurt/rice diet was allowed ad libitum. Stool and urine output, electrolytes, fluid intake, body weight, hematocrit, and palatability of solutions were measured. RESULTS: Sixty completed the study. Stool frequency, consistency, and body weight improved (p < .001) in all 3 groups, but there was no difference between groups. Likewise, urine output, hematocrit, and correlations between fluid ingested, stool weight, or urine output were similar. At admission and 24 and 48 hours later, hypokalemia was observed in 7, 10, and 8 patients with Gatorade; 3, 2, and 1 with N-ORS; and 2, 2, and 1 with Pedialyte, respectively. Similarly, hyponatremia was observed in 6, 9, and 3 patients with Gatorade; 5, 3, and 4 with N-ORS; and 4, 5, and 4 with Pedialyte. Tastewise, Gatorade and N-ORS were rated higher (p < .05) than Pedialyte. Limitations were a smaller sample size and higher dropout (20%). CONCLUSIONS: Gatorade and N-ORS seem to be as effective as Pedialyte in correcting dehydration and in improving bowel symptoms. All 3 solutions were safe. Unlike other groups, hypokalemia persisted in the Gatorade group. Gatorade and N-ORS may be effective in the treatment of dehydration associated with mild viral gastroenteritis.

Endpoints for therapeutic interventions in faecal incontinence: small step or game changer.

Faecal incontinence (FI) is common and its pathophysiology and treatments continue to evolve. However, a standard measure(s) for assessing its clinical outcome has been elusive. Consequently, over 100 measures and scoring systems, each with intrinsic biases have been reported. These include adequate relief or global satisfaction, ≥50% reduction in episodes or days without FI, quality of life (QOL), FI severity scales and composite indices. Earlier scales relied on the frequency and type of solid, liquid or flatus incontinence and effects on life style whereas newer scales have incorporated urgency, use of pads, antidiarrhoeals and amount of leakage, using prospective daily stool diaries or retrospective weekly or single point assessments. Such a plethora of measures have negatively impacted the assessment and outcome of clinical trials, and have made comparisons difficult. So, how does one sort out the grain from the chaff? In a provocative, post-hoc analysis published in this issue, the minimal clinically important difference, i.e. the smallest change detected by an instrument that is associated with a clinically meaningful change was used to assess FI endpoint. Based on this a ≥50% reduction in FI episodes is recommended as a clinically meaningful outcome measure when assessed by prospective stool diary, and it correlates with symptoms and severity. However, this requires further validation in multi-centre, longer duration and therapeutically effective clinical trial(s). Simultaneous assessment of coping strategies, QOL and psychosocial domains can provide further insights regarding the overall impact of treatments. This mini-review discusses the advances and controversies in defining meaningful FI endpoints.

Randomised clinical trial: mixed soluble/insoluble fibre vs. psyllium for chronic constipation.

BACKGROUND: Fibre supplements are useful, but whether a plum-derived mixed fibre that contains both soluble and insoluble fibre improves constipation is unknown. AIM: To investigate the efficacy and tolerability of mixed soluble/insoluble fibre vs. psyllium in a randomized double-blind controlled trial. METHODS: Constipated patients (Rome III) received mixed fibre or psyllium, 5 g b.d., for 4 weeks. Daily symptoms and stool habit were assessed using stool diary. Subjects with ≥1 complete spontaneous bowel movement/week above baseline for ≥2/4 weeks were considered responders. Secondary outcome measures included stool consistency, bowel satisfaction, straining, gas, bloating, taste, dissolvability and quality of life (QoL). RESULTS: Seventy-two subjects (mixed fibre = 40; psyllium = 32) were enrolled and two from psyllium group withdrew. The mean complete spontaneous bowel movement/week increased with both mixed fibre (P < 0.0001) and psyllium (P = 0.0002) without group difference. There were 30 (75%) responders with mixed fibre and 24 (75%) with psyllium (P = 0.9). Stool consistency increased (P = 0.04), straining (P = 0.006) and bloating scores decreased (P = 0.02) without group differences. Significantly more patients reported improvement in flatulence (53% vs. 25%, P = 0.01) and felt that mixed fibre dissolved better (P = 0.02) compared to psyllium. QoL improved (P = 0.0125) with both treatments without group differences. CONCLUSIONS: Mixed fibre and psyllium were equally efficacious in improving constipation and QoL. Mixed fibre was more effective in relieving flatulence, bloating and dissolved better. Mixed fibre is effective and well tolerated.

Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome.

BACKGROUND: Dietary fibre supplements have been advocated for the management of chronic constipation (CC) and irritable bowel syndrome (IBS). Recently, a fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) restricted diet has been recommended for IBS. AIM: To systematically examine recent evidence for dietary interventions with fibre in CC and IBS and FODMAP-restricted diet in IBS, and provide recommendations. METHODS: We searched PUBMED, MEDLINE, OVID and COCHRANE databases from 2004 to 2014. Published studies in adults with CC and IBS and constipation-predominant IBS (IBS-C) that compared fibre with placebo/alternative and FODMAP-restricted diet with alternative were included. RESULTS: Of 550 potentially eligible clinical trials on fibre, 11 studies were found and of 23 potentially eligible studies on FODMAPs, six were found. A meta-analysis was not performed due to heterogeneity and methodological quality. Fibre was beneficial in 5/7 studies in CC and 3/3 studies in IBS-C. FODMAP-restricted diet improved overall IBS symptoms in 4/4 and IBS-C symptoms in 1/3 studies and three studies did not meet inclusion criteria. There were significant disparities in subject selection, interventions and outcome assessments in both fibre and FODMAPs studies. CONCLUSIONS: Fibre supplementation is beneficial in mild to moderate CC and IBS-C, although larger, more rigorous and long-term RCTs are needed (Fair evidence-Level II, Grade B). Although the FODMAP-restricted diet may be effective in short-term management of selected patients with IBS (Fair evidence-Level II, Grade C) and IBS-C (Poor evidence-Level III, Grade C), more rigorous trials are needed to establish long-term efficacy and safety, particularly on colonic health and microbiome.

Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test.

BACKGROUND: The diagnosis of small intestinal bacterial overgrowth (SIBO) remains challenging. Our aim was to examine the diagnostic yield of duodenal aspiration/culture and glucose breath test (GBT), and effects of gender, race and demographics on prevalence of SIBO. METHODS: Patients with unexplained gas, bloating and diarrhea and negative endoscopy, imaging and blood tests were prospectively enrolled in two centers in USA. Randomly, within 1 week each patient underwent both duodenal aspiration/culture and GBT. The diagnostic yield of each test and relationship of symptoms, and effects of ethnicity, age, and gender on prevalence of SIBO were assessed and compared. KEY RESULTS: Duodenal culture was positive in 62/139 (44.6%) subjects and GBT was positive in 38/139 (27.3%) subjects with an overall diagnostic agreement of 65.5%. The sensitivity, specificity, positive and negative predictive value of GBT was 42%, 84%, 68%, and 64%, respectively. Ethnicity or gender did not influence SIBO, but SIBO positive patients were older (p = 0.0018). Symptom patterns were similar except bloating was more prevalent in GBT positive and gas in culture positive subjects. CONCLUSIONS & INFERENCES: Duodenal aspiration/culture identifies 45% of patients with suspected SIBO. GBT has lower sensitivity but good specificity for detection of SIBO. There were no ethnic or gender differences in the prevalence of SIBO, but patients with SIBO were older. Because GBT is non-invasive, it should be considered first in patients with suspected SIBO.

ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders.

BACKGROUND: Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders. PURPOSE: The American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Motility convened a task force to examine the indications, study performance characteristics, methodologies used, and the efficacy of biofeedback therapy, and to provide evidence-based recommendations. Based on the strength of evidence, biofeedback therapy is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).

Review article: Recent trends in diagnosis and treatment of faecal incontinence.

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

Long-term outcome and objective changes of anorectal function after biofeedback therapy for faecal incontinence.

BACKGROUND: In the short-term, biofeedback therapy improves symptoms and anorectal function in patients with faecal incontinence but whether there is long-term improvement is incompletely understood. AIM: To prospectively evaluate bowel symptoms and anorectal function, both immediately and 12 months after biofeedback therapy. METHODS: A total of 105 consecutive patients (male/female = 12/93) with faecal incontinence, unresponsive to supervised medical treatment were enrolled in biofeedback training consisting of biweekly pelvic muscle strengthening exercises, anal squeeze and sensory-motor coordination training, and reinforcement sessions at 3, 6 and 12 months. Anorectal manometry, saline continence test, stool diaries and bowel satisfaction scores were used to assess improvement. RESULTS: 94/105 (male/female = 10/84) completed training and 11 dropped out. Sixty completed 1-year assessment. At 1-year, 63% reported no episodes of incontinence. Biofeedback decreased (P < 0.001) stool frequency and number of incontinence episodes and increased (P < 0.001) bowel satisfaction score, anal resting and squeeze pressures, squeeze duration and ability to retain saline infusion increased (P < 0.001), both immediately and at 1 year. Sensory thresholds decreased (P < 0.001). CONCLUSIONS: Biofeedback therapy produced sustained improvement in bowel symptoms and anorectal function. Because it is safe, inexpensive compared with other surgical interventions, and effective, biofeedback should be offered to incontinent patients unresponsive to medical therapy.

Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus).

Although 30-50% of constipated patients exhibit dyssynergia, an optimal method of diagnosis is unclear. Recently, consensus criteria have been proposed but their utility is unknown. To examine the diagnostic yield of colorectal tests, reproducibility of manometry and utility of Rome II criteria. A total of 100 patients with difficult defecation were prospectively evaluated with anorectal manometry, balloon expulsion, colonic transit and defecography. Fifty-three patients had repeat manometry. During attempted defecation, 30 showed normal and 70 one of three abnormal manometric patterns. Forty-six patients fulfilled Rome criteria and showed paradoxical anal contraction (type I) or impaired anal relaxation (type III) with adequate propulsion. However, 24 (34%) showed impaired propulsion (type II). Forty-five (64%) had slow transit, 42 (60%) impaired balloon expulsion and 26 (37%) abnormal defecography. Defecography provided no additional discriminant utility. Evidence of dyssynergia was reproducible in 51 of 53 patients. Symptoms alone could not differentiate dyssynergic subtypes or patients. Dyssynergic patients exhibited three patterns that were reproducible: paradoxical contraction, impaired propulsion and impaired relaxation. Although useful, Rome II criteria may be insufficient to identify or subclassify dyssynergic defecation. Symptoms together with abnormal manometry, abnormal balloon expulsion or colonic marker retention are necessary to optimally identify patients with difficult defecation.

Clinical utility of colonic manometry in slow transit constipation.

BACKGROUND: The clinical significance of colorectal sensorimotor evaluation in patients with slow transit constipation (STC) is unclear. We investigated whether colonic manometric evaluation is useful for characterizing colonic sensorimotor dysfunction and for guiding therapy in STC. METHODS: 24-h ambulatory colonic manometry was performed in 80 patients (70 females) with STC by placing a six sensor solid-state probe, along with assessment of colonic sensation with barostat. Anorectal manometry was also performed. Manometrically, patients were categorized as having colonic neuropathy or myopathy based on gastrocolonic response, waking response and high amplitude propagated contractions (HAPC); and based on colonic sensation, as colonic hyposensitivity or hypersensitivity. Clinical response to pharmacological, biofeedback, and surgical treatment was assessed at 1 year and correlated with manometric findings. KEY RESULTS: Forty seven (59%) patients who had abnormal colonic manometry, with features suggestive of neuropathy (26%), and myopathy (33%); 41% had normal colonic manometry. Patients who had abnormal colonic sensation were 74% and 61% had overlapping dyssynergic defecation. Patients with neuropathy were more likely to have colonic hyposensitivity. Sixty-four percent of patients with colonic myopathy or normal manometry improved with medical/biofeedback therapy when compared to 15% with colonic neuropathy (P < 0.01). Selected patients with colonic neuropathy had excellent response to surgery, but many developed bacterial overgrowth. CONCLUSIONS & INFERENCES: Colonic manometry demonstrates significant colonic sensorimotor dysfunction in STC patients and reveals considerable pathophysiological heterogeneity. It can be useful for characterizing the underlying pathophysiology and for guiding clinical management in STC, especially surgery.

Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth.

BACKGROUND: Whether intestinal dysmotility and the use of a proton pump inhibitor (PPI) either independently or together contributes to small intestinal bacterial overgrowth (SIBO), and/or small intestinal fungal overgrowth (SIFO) is not known. AIM: To investigate the role of dysmotility and PPI use in patients with persistent gastrointestinal complaints. METHODS: Patients with unexplained gastrointestinal symptoms and negative endoscopy/radiology tests completed a validated symptom questionnaire and underwent 24-h ambulatory antro-duodeno-jejunal manometry (ADJM). Simultaneously, duodenal aspirate was obtained for aerobic, anaerobic and fungal culture. Dysmotility was diagnosed by (>2): absent phase III MMC, absent/diminished postprandial response, diminished amplitude of antral/intestinal phasic activity, impaired antro-duodenal coordination. Bacterial growth ≥10³ CFU/mL or fungal growth was considered evidence for SIBO/SIFO. PPI use was documented. Correlation of symptoms with presence of SIBO or SIFO was assessed. RESULTS: One hundred and fifty subjects (M/F = 47/103) were evaluated; 94/150 (63%) had overgrowth: 38/94 (40%) had SIBO, 24/94 (26%) had SIFO and 32/94 (34%) had mixed SIBO/SIFO. SIBO was predominately due to Streptococcus, Enterococcus, Klebsiella and E. coli. SIFO was due to Candida. Eighty of 150 (53%) patients had dysmotility and 65/150 (43%) used PPI. PPI use (P = 0.0063) and dysmotility (P = 0.0003) were independent significant risk factors (P < 0.05) for overgrowth, but together did not pose additional risk. Symptom profiles were similar between those with or without SIBO/SIFO. CONCLUSIONS: Dysmotility and PPI use were independent risk factors for SIBO or SIFO and were present in over 50% of subjects with unexplained gastrointestinal symptoms. Diagnosis of overgrowth requires testing because symptoms were poor predictors of overgrowth.

Topographic and manometric characterization of the recto-anal inhibitory reflex.

BACKGROUND: Recto-anal inhibitory reflex (RAIR) is an integral part of normal defecation. The physiologic characteristics of RAIR along anal length and anterior-posterior axis are unknown. The aim of this study was to perform topographic and vector-graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components. METHODS: Anorectal topography was assessed in 10 healthy volunteers using HDM probe with 256 sensors. Recto-anal inhibitory reflex data were analyzed every mm along the length of anal canal for topographic, baseline, residual, and plateau pressures during five mean volumes of balloon inflation (15 cc, 40 cc, 71 cc, 101 cc, 177 cc), and in 3D by dividing anal canal into 4 × 2.1 mm grids. KEY RESULTS: Relaxation pressure progressively increases along anal canal with increasing balloon volume up to 71 cc and thereafter plateaus. In 3D, RAIR is maximally seen at the middle and upper portions of anal canal (levels 1.2-3.2 cm) and posteriorly. Peak residual pressure was seen at proximal anal canal. CONCLUSIONS & INFERENCES: Recto-anal inhibitory reflex is characterized by differential anal relaxation along anterior-posterior axis, longitudinally along the length of anal canal, and it depends on the rectal distention volume. It is maximally seen at internal anal sphincter pressure zone. Multidimensional analyses indicate that external anal sphincter provides bulk of anal residual pressure. Our findings emphasize importance of sensor location and orientation; as anterior and more distal location may miss RAIR.

Diagnostic utility of the oesophageal balloon distension test in the evaluation of oesophageal chest pain.

BACKGROUND: Oesophageal balloon distension test (EBDT) has been advocated for the evaluation of functional oesophageal noncardiac chest pain (NCCP), but its diagnostic utility remains unclear. AIM: To prospectively assess the diagnostic yield of EBDT in clinical practice and compare its yield with standard oesophageal tests. METHODS: Over a period of 6 years, patients with chest pain and negative cardiac work-up underwent sequential testing with endoscopy/biopsy, oesophageal manometry, 24 h pH study and EBDT to elucidate an oesophageal source for their symptoms. Patients with a definite abnormality, for example, erosive oesophagitis on oesophagogastroduodenoscopy (EGD) were designated as having positive test and excluded from further work up. RESULTS: Of 348 (m/f = 105/243) suspected NCCP patients, 16 (5%) were excluded; 332 (95%) underwent oesophageal testing. Among these, 48 (14%) had macro/microscopic oesophagitis on endoscopy, 7 (2%) had achalasia and 96 (28%) had excessive acid reflux (pH study). The remaining 181 (52%) patients underwent EBDT; 128 (37%) had oesophageal hypersensitivity. Chest pain was reproduced in 97/128 (75%) subjects. There were no adverse effects. CONCLUSIONS: Oesophageal testing can reveal an oesophageal source for chest pain in 86% of NCCP subjects. The majority (42%) of patients had gastro-oesophageal reflux disease (GERD). Oesophageal balloon distension test identified hypersensitivity in over one-third of subjects. The oesophageal balloon distension test provides useful diagnostic information and should be performed routinely in patients with NCCP after excluding GERD.

Evaluation of constipation in older adults: radioopaque markers (ROMs) versus wireless motility capsule (WMC).

There is scarce information regarding assessment of constipation in older subjects. We examined regional and whole-gut transit time (WGTT) with wireless motility capsule (WMC) and compared this with radioopaque markers (ROM) transit. 39 constipated and 11 healthy older subjects (≥ 65 years) ingested a ROM capsule and WMC, wore a data receiver and kept stool diaries for 5 days. WMC recordings were analyzed for colonic transit time (CTT), WGTT and gastric emptying time (GET). Radiographs obtained on day 5 assessed ROM transit. Results for each device were compared. The CTT (p = <0.0001), WGTT (p = <0.001) and GET (p = <0.04) as measured by WMC were all slower in constipated subjects compared to healthy subjects. ROM colonic transit was also slower (p = <0.007) in constipated compared to healthy subjects. The diagnostic utility for identifying subjects with constipation as assessed by receiver operating characteristics were similar; 0.85 (WMC) versus 0.73 (ROM). Device agreement for slow colonic transit was 88% with good correlation between WMC and ROM (CTT r=0.718, p=0.0001, WGTT r=0.693, p=0.0001). Slow transit constipation was identified in 28% with ROM and 32% with WMC. No adverse events were recorded. WMC is a safe and useful device that provides objective diagnosis of delayed colonic and whole gut transit in older constipated adults. It is a radiation-free, physiologic and ambulatory technique that provides additional diagnostic information than ROM.

Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation.

BACKGROUND: Treatment of chronic constipation remains challenging with 50% of patients dissatisfied with current therapy. There is an unmet need for natural and safe alternatives. Dried plums (prunes) have been used traditionally for constipation but their efficacy is not known. Aim To assess and compare the effects of dried plums and psyllium in patients with chronic constipation. METHODS: Subjects were enrolled in an 8-week, single-blind, randomised cross-over study. Subjects received either dried plums (50 g b.d., fibre=6 gm/day) or psyllium (11 g b.d., fibre=6 gm/day) for 3 weeks each, in a crossover trial with a 1-week washout period. Subjects maintained a daily symptom and stool diary. Assessments included number of complete spontaneous bowel movements per week, global relief of constipation, stool consistency, straining, tolerability and taste. RESULTS: Forty constipated subjects (m/f=3/37, mean age=38 years) participated. The number of complete spontaneous bowel movements per week (primary outcome measure) and stool consistency scores improved significantly (P<0.05) with dried plums when compared to psyllium. Straining and global constipation symptoms did not differ significantly between treatments (P=N.S.). Dried plums and psyllium were rated as equally palatable and both were safe and well tolerated. CONCLUSION: Dried plums are safe, palatable and more effective than psyllium for the treatment of mild to moderate constipation, and should be considered as a first line therapy.