Abdominal functional electrical stimulation for bowel management in multiple sclerosis.

Aim: Functional constipation is common in multiple sclerosis (MS) and first line treatments are frequently ineffective. The current study explored the use of abdominal functional electrical stimulation (ABFES) for treating constipation in MS. Patients/methods: 20 people with MS and constipation (ROME IV criteria). The patient assessment of constipation-related quality of life questionnaire was administered at baseline and after 6 weeks of ABFES treatment alongside semi-structured interviews. Results: All patient assessment of constipation-related quality of life subscales were significant: satisfaction (p = 0.003), psychosocial discomfort (p = 0.008), physical discomfort (p = 0.001) and worries and concerns (p = 0.003). A long-term therapeutic effect, reduction in laxative use and improved sexual functioning were also reported. Conclusion: ABFES provides a potential alternative treatment intervention for people with MS and constipation.

Nonpharmacological conservative treatments for chronic functional constipation: A systematic review and network meta-analysis.

BACKGROUND: Patients with functional chronic constipation (CFC) often select nonpharmacological treatments. We aimed to examine the comparative effectiveness of nonpharmacological conservative treatments in treating CFC. METHODS: We searched MEDLINE, EMBASE, Cochrane library, CINAHL, AMED, ISI web of knowledge, and conference proceedings from January 2000 to June 2016. Randomized controlled trials comparing nonpharmacological conservative treatments with placebo, sham interventions, or conventional treatments were included. Nonpharmacological conservative treatments were defined as interventions without involvement of medication or surgery. We extracted trial data in duplicate and assessed the risk of bias. We pooled continuous data using standard mean differences (SMDs) and binary data using risk ratios (RRs), and we provided their 95% confidence intervals. KEY RESULTS: We included 33 trials (4324 participants and 8 nonpharmacological treatments). Compared with placebo interventions, TENS (SMD 1.60, 95% CI 0.28-2.92), probiotic (SMD 1.40, 95% CI 0.94-1.86), and acupuncture (SMD 1.00, 95% CI 0.39-1.60) had significantly larger effect on stool frequency; acupuncture (RR 1.56, 95% CI 1.14-2.14) had significantly higher responder rate; and moxibustion (SMD 2.50, 95% CI 0.05-4.95) had significant larger effect on Bristol score. Compared with laxative, acupuncture had significantly larger effect on stool frequency (RR 2.01, 95% CI 1.16-3.49) and had lower rate of adverse events (RR 0.38, 95% CI 0.18-0.80). CONCLUSIONS: TENS and acupuncture relatively ranked the best in managing CFC, but the results should be interpreted with caution due to small study effects. Registration number: PROSPERO CRD42014006686.

[Hypnotherapeutic treatment of children and adolescents with functional abdominal pain disorder].

Many school children complain about recurrent abdominal pain. These children have diminished quality of life, increased school absence and functional disability. Despite the high prevalence and well-documented consequences for patients, their families and society, there is a remarkable lack of evidence-based treatments available. Hypnotherapeutic treatment (HT) has shown promising results. In this review, we discuss current research on HT of these patients. In conclusion, further studies are needed to confirm the effect of HT on functional abdominal pain disorder and to optimise the treatment format.

Sacral nerve stimulation can alleviate symptoms of bowel dysfunction after colorectal resections.

AIM: Poor functional results, such as faecal incontinence (FI), low anterior resection syndrome (LARS) or high stool frequency, can occur after colorectal resections, including proctocolectomy with ileal pouch-anal anastomosis (IPAA), rectal resection and left hemicolectomy. Management of such patients is problematic, and some case reports have demonstrated the effectiveness of sacral nerve stimulation (SNS) in these situations. Our aim was to analyse the effectiveness of SNS on poor functional results and on quality of life in patients after treatment with different types of colorectal resection. METHOD: At five university hospitals from 2006 to 2014, patients with poor functional results after rectal resection, IPAA or left hemicolectomy underwent a staged SNS implant procedure. Failure was defined by the absence or insufficient improvement (< 50%) of FI episodes. RESULTS: SNS for bowel dysfunction was performed in 16 patients after rectal resection with coloanal anastomosis, left hemicolectomy with colorectal anastomosis or IPAA. Two (13%) cases of primary failure were observed after the percutaneous stimulation test. Median frequency of stool, FI episodes and urgency were significantly improved in 14 patients. Wexner and LARS scores were also significantly improved for 14 patients. When we compared results according to the type of colorectal surgery (IPAA, rectal resection or left hemicolectomy), median frequencies of stool and urgency, Wexner and LARS scores were still significantly improved. Overall success rate was 75% (12/16 patients) in intention-to-treat analysis and 86% (12/14 patients with permanent electrode) in per-protocol analysis. CONCLUSION: SNS seems to improve bowel dysfunction following rectal resection, left hemicolectomy or IPAA.

Effects of Sulfate-Rich Mineral Water on Functional Constipation: A Double-Blind, Randomized, Placebo-Controlled Study.

BACKGROUND: Magnesium sulfate has a long tradition as a laxative. It osmotically prevents water absorption in the large bowel and thus leads to an acceleration of the intestinal transit and better stool consistency. We wanted to investigate the efficacy of a carbonated calcium/magnesium sulfate-rich natural mineral water in subjects with functional constipation (FC). PATIENTS AND METHODS: In this double-blind, randomized, placebo-controlled study, subjects with FC (Rome III criteria) received 1 l/day (4 × 250 ml) of mineral water (Ensinger Schiller Quelle) or carbonated tap water (placebo) for 6 weeks. The primary endpoint was the change in the frequency of bowel movements per week between baseline and visit 4 (after 6 weeks). The prespecified main secondary endpoint was the change in the frequency of bowel movements per week between baseline and visit 3 (after 3 weeks). RESULTS: Efficacy was analyzed in 100 subjects (intention-to-treat). After 6 weeks of treatment there was no statistical difference between the groups (p = 0.163). However, statistical significance was reached after 3 weeks, with an increase in the frequency of bowel movements per week of 2.02 ± 2.22 for the mineral water group compared to 0.88 ± 1.67 for the placebo group (p = 0.005). CONCLUSIONS: A 3-week treatment with 1 l/day of the sulfate-rich mineral water improved the frequency of bowel movements in subjects with FC compared with tap water; however, the difference was no longer significant after 6 weeks. Further evaluation in rigorously designed clinical studies will be necessary to validate the impact of sulfate-rich natural mineral water on FC.

Antegrade transverse or sigmoid colonic enema through a percutaneous endoscopic gastrostomy tube is an option in the treatment of colorectal dysfunction.

BACKGROUND: Antegrade colonic enemas are used in patients with colorectal dysfunction resistant to conservative therapy. A number of different operative techniques are applied, but their effectiveness is by and large unknown. We therefore evaluated the long-term usefulness of the left-sided percutaneous endoscopic gastrostomy (PEG) tube method in adult patients. METHODS: Twenty-one patients with colorectal dysfunction underwent insertion of a PEG tube colostomy by laparotomy between 1997 and 2006. In 2014, we evaluated how many of the patients had the tube still in place, how the patients coped with the tube, and what the reasons for the removal were. RESULTS: The main indications were severe constipation or fecal incontinence mainly related to neurological diseases. In 2014, 5 out of 21 patients had the tube still in use (median follow-up 14 years, range 11-17 years) and 4 out of 5 deceased patients had had the tube in use until their death, unrelated to this treatment (median follow-up 7 years, range 0-8 years). Four out of the 5 living patients considered the benefit of the tube to be good or excellent. Tubes were removed in 11 (52%) patients for various reasons, local skin irritation being the most common. CONCLUSIONS: A left-sided PEG tube colostomy was removed in over half of the patients, but despite that, it still seems to be a viable long-term option in the treatment of individual patients with colorectal dysfunction, when conservative methods are ineffective.

Comment on Zimmerman's use of the river metaphor in irritable bowel syndrome treatment.

The river approach has been used effectively in the treatment of irritable bowel syndrome within the U.K. National Health Service (Gonsalkorale, Houghton, & Whorwell, 2002; Whorwell, 2006) and in single case studies (Galovski & Blanchard, 2002; Zimmerman, 2003; Kraft & Kraft, 2007). Zimmerman (2003) pointed out that this metaphor was extremely powerful in that it linked the altered motility of the digestive system to an emotional disturbance: by encouraging his patient to imagine a smooth flowing river, he helped her to come to terms with her emotional conflict and, in turn, to experience normal gut activity. The author reviews this approach to treatment and offers an alternative which utilizes process suggestions, accessing questions and truisms while providing clients with the space to imagine their own tailor-made scene.

Novel diagnostics and therapy of colonic motor disorders.

Colonic motor abnormalities are implicated in several gastrointestinal disorders including constipation, irritable bowel syndrome and functional diarrhoea. Defining the colonic abnormalities is difficult and several novel techniques including, high-resolution fibre optic manometry, wireless motility capsules, ultrasound and magnetic resonance imaging have emerged to help in the diagnosis of these conditions. Coupled with the developing techniques are the novel treatments that look to restore normal colonic motility. These treatments include pharmacological agents (pharmabiotics, serotonin agonist, secretagogues) and medical devices (sacral nerve stimulation, transcutaneous electrical stimulation and biofeedback). This review summarizes the novel techniques used to record and define colonic motor abnormalities and the current status of the emerging treatments used to treat them.

A personalized systems medicine approach to refractory rumination.

RATIONALE, AIMS AND OBJECTIVES: As with many functional disorders, rumination syndrome poses a great dilemma when approached via standard of care. This case report illustrates how rumination syndrome may be effectively approached using the systems medicine. METHOD: The patient's treatment involved two distinctively different treatment cycles. Initially she was treated in an academic tertiary inpatient and outpatient multidisciplinary program with a primary symptom-based focus with little improvement. She subsequently sought care at a systems-based integrative medicine clinic within an academic family medicine centre, which identified the inciting events, diagnosed the current pathology and developed a stepwise treatment plan. RESULTS: The patient is now rumination free. CONCLUSION: Chronic or refractory diseases, especially when regarded as 'functional' may be approached by a systems medicine methodology, which allows physicians to fine-tune the vast amount of specific pieces of knowledge to achieve an integrated approach to managing the whole person.

Patient experience and satisfaction with sacral neuromodulation: results of a single-center sample survey.

PURPOSE: Sacral neuromodulation is a well researched and successful treatment for functional bowel disorders. Indications have expanded throughout the years and various studies have been published on clinical efficacy or on technique improvement. The main goal of this retrospective study was to systematically evaluate daily experiences with this treatment and measure the long-term satisfaction of sacral neuromodulation therapy for functional bowel disorders. METHODS: After institutional review board approval a new, self-designed postal questionnaire was sent to all patients in our center who were being treated with sacral neuromodulation. Only patients with a minimal follow-up of 1 year were included in the survey. Implantation years range from 2000 to 2007. RESULTS: A total of 174 patients received the questionnaire regarding patient satisfaction and experience with sacral neuromodulation therapy. The response rate after reminder letter was 71.8% (n = 125) including 114 (91.2%) females. Patient satisfaction was high: 81 patients (65.3%) reported their results as very satisfying, 30 patients (24.2%) were moderately satisfied, and 13 patients (10.4%) were not satisfied. Analysis showed that patient satisfaction can be explained by both patient perception of present bowel function and their evaluation of the quality of daily life. No significant relationship was found with patient demographics, self-ascribed (co)morbidity, behavioral habits, or therapy duration. A total of 47 patients (38.2%) reported having some concerns regarding the future with sacral neuromodulation treatment. Twenty-eight patients (23.1%) reported a temporary loss of effect at any time during sacral neuromodulation therapy. Pain at the implantation site was reported by 65 patients (52.4%). CONCLUSIONS: This study shows that patients treated with sacral neuromodulation, in general, are very satisfied. The main problems mentioned by patients are pain, loss of efficacy, and general concerns.

Sacral neuromodulations for female lower urinary tract, pelvic floor, and bowel disorders.

PURPOSE OF REVIEW: In recent years, sacral neuromodulation (SNM) has been investigated for the treatment of various types of lower urinary tract and bowel dysfunctions. This review discusses recently published data related to the therapeutic applications of SNM in female lower urinary tract, pelvic floor, and bowel disorders. RECENT FINDINGS: SNM has been employed initially in the treatment of refractory idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. Since then, several studies, including randomized and controlled trials, have confirmed the therapeutic effects of SNM in these disorders. The applications of SNM are now extended to the treatment of other female pelvic problems, such as fecal incontinence, chronic constipation, interstitial cystitis/painful bladder syndrome, sexual dysfunction, and neurogenic disorders, with similar promising results. SUMMARY: SNM is approved by the Food and Drug Administration for the treatment of idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. SNM is not yet an approved method for the treatment of other pelvic disorders, but data supporting its benefit are emerging. The major advantage of SNM lies in its potential to treat the bladder, urethral sphincter, anal sphincters, and pelvic floor muscles simultaneously, which might result in better therapeutic effects.

Recent insights on central processing and psychological processes in functional gastrointestinal disorders.

There is increasing evidence for a key role of psychological processes and their central nervous system substrates in functional gastrointestinal disorders, although the exact nature of the relationship remains only partially understood. However, progress in this key area of psychosomatic medicine is rapidly being made. In this review article, we will give an overview of recent advances in understanding the complex mechanisms by which psychological processes and functional gastrointestinal disorder symptoms reciprocally influence each other. Various lines of evidence from different branches of biomedical and psychological science will be discussed, particularly epidemiology, patho- and psychophysiology and functional brain imaging, focusing on the most recent and novel findings. We will conclude this paper with a paragraph on new insights into treatment.

A primary care approach to functional abdominal pain.

This article reviews the literature related to functional abdominal pain (FAP) in childhood, including the definition, etiology, contributing factors, clinical diagnosis, therapy and management, and associated long-term health effects. FAP is determined when no specific structural, infectious, inflammatory, or biochemical cause can be found in a child with chronic pain. The presence of abdominal pain as an isolated symptom is more suggestive of FAP, whereas multiple symptoms are more likely to be due to an organic or biochemical condition. While the exact cause of FAP is not completely understood, most researchers and clinicians agree that it is of multi-factorial etiology coupled with an altered brain-gut interaction. Children are highly susceptible to influences around them and can experience pain in response to normal childhood feelings and experiences. Psychological disorders such as anxiety and depression are common in both children with FAP and their parents. Children with FAP tend to have low levels of self-directedness, internalize their feelings and worries, and ruminate over issues they cannot control. The biopsychosocial model has proved to be a worthwhile framework for children with FAP, as it recognizes the interaction between social and environmental influences, psychological processes, and the state of the body. Interventions that focus on the child's cognitive processes associated with abdominal pain and the family's response to the pain have increased efficacy over standard education and reassurance. Providing children and families with techniques to use when experiencing pain decreases alterations in normal daily activities and improves long-term health outcomes.

Hypnotherapy for functional gastrointestinal disorders.

About 20% of people in the UK have functional gastrointestinal disorders such as irritable bowel syndrome and functional dyspepsia. These conditions account for about 4% of GP consultations and 50% of gastroenterologists' workload. Forsome, the symptoms affect quality of life and ability to work. Drug treatment aimed at relieving symptoms is often ineffective. Other options include psychological treatments such as cognitive behavioural therapy, brief psychotherapy and gut-directed hypnotherapy. Here we discuss whether hypnotherapy has a role in the treatment of patients with irritable bowel syndrome or functional dyspepsia.

[Levator ani syndrome, functional intestinal disorders and articular abnormalities of the pelvis, the place of osteopathic treatment]. / Syndrome des releveurs de l'anus, troubles fonctionnels intestinaux et anomalies articulaires du petit bassin, place du traitement ostéopathique.

OBJECTIVES: Various treatments of the Levator ani syndrome (LVAS) have been proposed. None of them alleviate symptoms in more than 20% of the cases. A new approach combining massages of the coccygeus muscle with physical treatment of frequently associated pelvic joint disorders was assessed. The outcome of the Irritable Bowel Syndrome (IBS) that is frequently associated was also studied. METHODS: One hundred and one patients (76 females and 25 males, mean age: 54 years) with a diagnosis of LVAS were studied prospectively over one year. Massages were given with a patient lying on the left side. Physical treatment of the pelvic joint disorders was given at the end of each massage session. RESULTS: Forty-seven patients (46.5%) suffered both from LVAS and IBS. A mean of less than 2 sessions of treatment was necessary. Sixty-nine per cent of the patients were LVAS-free at 6 months (p<0.0001) and 10% were improved. At 12 months, 62% were still free of symptoms and 10% improved (p=0.37). A comparable trend according to the Rome II criteria was found in the IBS-patient group (53% IBS free initially, 78% at 6 months [p=0.00001], 72% at 12 months [p=1]). There was a significant correlation between the favorable outcome of IBS and the LVAS at 6 and 12 months. All IBS-free patients were LVAS-free at 6 months. CONCLUSION: The LVAS may be cured or alleviated in 72% of the cases at 12 months with one to 2 sessions. This new comprehensive treatment suggests the role of a muscular and osteoligamentary etiology in the LVAS. Since most of IBS benefitted from such treament, it is logical to suspect a mutual pathogeny and to screen for LVAS in all such patients.

Use of acupressure to improve gastrointestinal motility in women after trans-abdominal hysterectomy.

The purpose of this study was to evaluate the effectiveness of acupressure on gastrointestinal (GI) motility in women after trans-abdominal hysterectomy (TAH). Patients were randomly assigned into two groups of 21 and 20 patients each. The experimental group received acupressure for 3 minutes at each of three meridian points: Neiguan (PC-6), Zusanli (ST-36) and Sanyinjiao (SP-6). The control group received 3 minutes of acupressure on sham points. Acupressure was performed twice a day. A questionnaire was used to determine patients' satisfaction prior to and after afternoon acupressure. GI contractions were measured with a multifunctional stethoscope before and after acupressure. Acupressure of these three meridian points significantly (p < 0.05) increased GI motility in the experimental group, but there was little change in the control group (p > 0.05). Our conclusions are that non-invasive acupressure of these meridian points can significantly improve GI motility and can be incorporated into the technical curriculum and clinical education program of nursing schools. Patients and their family members can be taught to continue this procedure at home to enhance GI motility in patients who have undergone TAH.

Irritable bowel syndrome: evaluation and treatment.

Irritable bowel syndrome is a common gastrointestinal disorder characterized by abdominal pain, bloating, and disturbed defecation in the absence of other medical conditions with similar presentations. Because physical findings and currently available diagnostic tests lack sufficient specificity for clinical use, the diagnosis of IBS is based on characteristic symptoms as outlined in several symptom-based criteria for IBS. When used in combination with a detailed history, physical examination, and limited diagnostic testing, these criteria are a valid method of diagnosing IBS. Once a confident diagnosis of IBS has been made, treatment of IBS should be based on the predominant symptom while taking into account the severity of symptoms and the degree of functional impairment both physically and psychologically. Most patients with IBS have mild symptoms and education, reassurance, dietary and lifestyle changes, and a therapeutic physician-patient relationship form the backbone of treatment. A smaller number of patients have moderate symptoms, which are typically intermittent, but may at times interrupt their normal activities. In addition to dietary and lifestyle modifications, pharmacologic intervention based on the predominant symptom (diarrhea, constipation, or pain) may be used to relieve symptoms. Finally, a small subset of patients has severe or intractable symptoms. These patients, often seen in tertiary referral centers, often have constant pain symptoms and psychosocial impairments. A multidisciplinary approach including pharmacologic treatments, psychologic treatments, and possibly a mental health or pain center involvement may be beneficial.

Traditional therapies for irritable bowel syndrome: an evidence-based appraisal.

Irritable bowel syndrome (IBS) is a common chronic disease that adversely effects quality of life and is associated with substantial direct and indirect health care costs. It is defined by a constellation of symptoms in conjunction with an alteration in bowel function and defecation, and its underlying pathophysiological basis remains unknown. Numerous therapies are available, but many relieve only one symptom of the syndrome, and their effectiveness has not been demonstrated with adequate evidence from high-quality studies. This article reviews the criteria for appropriate design of any treatment study as well as those criteria specific to studies of treatment for functional gastrointestinal diseases. Using these criteria, the author evaluates the published investigations of "traditional" IBS therapies (antidepressants, bulking agents/fiber, antispasmodics, antidiarrheals) and "alternative" IBS therapies (Chinese herbal supplements, peppermint oil, behavioral therapies). Based on this evaluation, the author concludes that the available evidence does not support the effectiveness of any of these treatments and, therefore, none of these treatments can be reliably recommended.

Cleaning up the river: a metaphor for functional digestive disorders.

The irritable bowel syndrome is characterized by abdominal pain, altered bowel habits and various other digestive symptoms. Emotional factors are important in some patients. I describe here a metaphor which links the altered motility of the digestive system to the emotional contents it may embody. A metaphor of a river is used to evoke both a smooth, coordinated flow through the normal digestive tract and a normal flow in the management of the patient's emotions. The possibility that some blockage has occurred in the river, resulting in perturbation of the normal flow is then suggested to the patient. This is followed by a suggestion for the patient to clear the blockage. This approach may lead patients to work on the emotional components of their symptoms, resulting in their subsequent resolution. I have used this approach with several patients and it proved very effective. This paper demonstrates the use of this metaphor in one of the patients.