EFFECT OF VISCERAL MANIPULATION ON CHILDREN WITH REFRACTORY CHRONIC FUNCTIONAL CONSTIPATION: A RANDOMIZED CONTROLLED TRIAL.

BACKGROUND: Functional constipation (FC) is a common global high prevalence issue in children. OBJECTIVE: The purpose of the present study is to evaluate the effect of visceral manipulation (VM) on children with chronic interacble FC unresponsive to the standard treatment. METHODS: This study was conducted as a randomized, single-blind controlled trial. Fifty-two children with refractory chronic functional constipation unresponsive to the standard medical treatment were randomly allocated to two groups of 26 control (standard medical care (SMC)) and 26 intervention (SMC with VM) for 4 weeks. Abdominal pain, painful defecation, stool consistency, defecation frequency, and the dose of oral laxative were evaluated before and after the treatment period using the Pain Rating Scale, Bristol stool form scale, and patient/parents report. RESULTS: At the end of treatment, except for the dose of oral laxative in the control group, all of the results showed a significant difference in both groups (P<0.05). The dose of oral laxative in the intervention group decreased significantly (P<0.05), however, no significant change was observed in the control group (P>0.05). In the intervention group comparison, statistically significant differences were found in all va-riables except the Bristol stool form scale (P<0.05). The Bristol stool form scale after treatments was not different when the groups were compared (P=0.32), but the number of subjects who had normal stool consistency was significantly increased in the intervention group than in the control group (P<0.05). CONCLUSION: VM can be considered as a possible treatment without side effects besides SMC for the management of chronic FC. Further studies are needed to investigate the long-term effect of VM.

Picosulfato de sodio para alivio del estreñimiento / Sodium Picosulfate for Constipation Relief

INTRODUCCIÓN: La evidencia de cuidados paliativos es un planteamiento para mejorar la calidad de vida de los pacientes (adultos y niños) y sus familias, que afrontan problemas inherentes a una enfermedad potencialmente mortal. El de cuidados paliativos es un planteamiento para mejorar la calidad de vida de los pacientes (adultos y niños) y sus familias, que afrontan problemas inherentes a una enfermedad potencialmente mortal. Los cuidados paliativos permiten prevenir y aliviar el sufrimiento mediante la detección temprana, la evaluación correcta y el tratamiento del dolor y otros problemas. La atención paliativa previene y alivia el sufrimiento de todo orden, físico, psicológico, social o espiritual, que experimentan los adultos y niños que viven con problemas de salud que limitan la vida. Promueve la dignidad, la calidad de vida y la adaptación a las enfermedades progresivas, y utiliza para ello los mejores datos probatorios disponibles. Se calcula que en el mundo se requieren cuidados paliativos en el 40% al 60% de las defunciones 2. Los cuidados paliativos son necesarios para una amplia gama de enfermedades que limitan la vida. La mayoría de los adultos que los precisan tienen enfermedades crónicas, como enfermedades cardiovasculares (38,5%), cáncer (34%), enfermedades respiratorias crónicas (10,3%), sida (5,7%) y diabetes (4,6%). Muchas otras afecciones pueden requerir cuidados paliativos, incluidas la insuficiencia renal, la hepatopatía crónica, la artritis reumatoide, las enfermedades neurológicas, la demencia, las anomalías congénitas y la tuberculosis farmacorresistente. El dolor es uno de los síntomas más frecuentes y graves que sufren los pacientes que necesitan cuidados paliativos. Los analgésicos opioides son esenciales para tratar el dolor y otros síntomas físicos penosos comunes que se asocian con numerosas enfermedades progresivas en estado avanzado. Por ejemplo, el 80% de los pacientes con sida o cáncer y el 67% de los que padecen enfermedades cardiovasculares o enfermedad pulmonar obstructiva crónica experimentará dolor de moderado a intenso al final de la vida 3 En el 2011, el 83% de la población mundial vivía en países en los que el acceso a los analgésicos opioides era escaso o nulo. METODOLOGÍA: 1. Descripción del medicamento solicitado según FDA/AEMPS. 2. Informe Técnico: Revisión de la evidencia científica, recomendaciones de uso de las Agencias Reguladoras y Guías de Práctica Clínica de los medicamentos. 3. Costos del medicamento y disponibilidad. 4. Conclusiones. 5. Recomendaciones. RESULTADOS: Se han cotejado las fichas farmacológicas de Agencias Reguladoras como AEMPS/FDA, Con aprobación de la Food and Drug Administration (FDA) desde 1996 y de la European Medicines Agency (EMA) desde 1997. Además de verificar Expediente Electrónico de la DNM, para: PICOSULFATO DE SODIO. Además, se han encontrado publicaciones científicas que avalan el uso de este medicamento para enfermedad de Alzheimer de moderada a grave. CONCLUSIONES: De acuerdo a la investigación de información técnica y científica sobre el tema, se concluye lo siguiente: El ISSS cuenta con un Centro Especializado Integral de Atención Ambulatoria La Ceiba, la cual suministra Atención domiciliar y Cuidados paliativos. El dolor es uno de los síntomas más frecuentes y graves que sufren los pacientes que necesitan cuidados paliativos. Los analgésicos opioides son esenciales para tratar el dolor y otros síntomas físicos penosos comunes que se asocian con numerosas enfermedades progresivas en estado avanzado. Por ejemplo, el 80% de los pacientes con sida o cáncer y el 67% de los que padecen enfermedades cardiovasculares o enfermedad pulmonar obstructiva crónica experimentará dolor de moderado a intenso al final de la vida 18 En el 2011, el 83% de la población mundial vivía en países en los que el acceso a los analgésicos opioides era escaso o nulo. Según la OPS/OMS. el estreñimiento es altamente prevalente (50-95 %) en cuidados paliativos (CP). Alrededor del 90 % de los pacientes que reciben opioides fuertes y del 65% de los que no los reciben, requieren laxantes. A pesar de ser una importante causa de morbilidad, su importancia suele ser subestimada en el contexto de otros síntomas. Debido a las limitaciones que se encuentran en la definición de etiologías que encierra el término "estreñimiento", entre ellos: estreñimiento crónico idiopático, estreñimiento secundario por el uso de opioides, síndrome de intestino irritable con estreñimiento, entre otras, y cada una de estas etiologías representa una población diferente y por ende, un tratamiento específico. Además, entre las mismas etiologías de la enfermedad, existen diferencias de tratamiento entre pacientes según la edad y patologías subyacentes, por dar un ejemplo, el manejo del estreñimiento crónico idiopático es diferente en pacientes adultos que en población considerada de primera infancia. Varios medicamentos utilizados para el tratamiento del dolor y otros síntomas comunes en los cuidados paliativos, están incluidos en la Lista Modelo de la OMS de Medicamentos Esenciales para adultos y niños. Con estos medicamentos esenciales se puede aliviar adecuadamente la gran mayoría de los síntomas penosos para los pacientes. Los analgésicos opioides son esenciales para controlar eficazmente el dolor de moderado a intenso. Las directrices de la OMS del 2012 sobre manejo del dolor en niños recomiendan la analgesia fuerte con opioides, como esencial para el alivio del dolor de moderado a intenso en los niños. Desde la perspectiva del sistema de salud colombiano indican que tanto el picosulfato de sodio como la lactulosa, nominadas por el Ministerio de Salud y Protección Social no son estrategias costo efectivas frente al psyllium ya que este último tiene una mayor efectividad, pero, además, los costos estimados de utilizarlo son muchos menores. Al comparar la lactulosa (Código LOM 8020706), con las demás alternativas, se aprecia que es la menos efectiva, sin embargo, no es una diferencia sustancial, de hecho, es posible argumentar que ésta, junto con polietilenglicol, picosulfato de sodio, bisacodilo, prucaloprida y lubiprostone conforman un grupo con efectividades muy similares. Las diferencias que se aprecian están en el costo de las dos últimas, prucaloprida y lubiprostone tienen un costo que dobla al de las otras cuatro alternativas, bajo las condiciones actuales del mercado local (de Colombia). Con respecto a la información sobre efectividad y seguridad encontrada en las diferentes evaluaciones técnicas consultadas, sugieren que los medicamentos utilizados en estos casos, (mencionados arriba), son más efectivos frente al placebo, y que comparándolo uno a uno, estos no presentan diferencias de efectividad estadísticamente significativas.

Efficacy, safety, and acceptability of polyethylene glycol 3350 without electrolytes vs magnesium hydroxide in functional constipation in children from six months to eighteen years of age: A controlled clinical trial.

INTRODUCTION AND AIMS: There are few studies that compare polyethylene glycol (PEG) 3350 and magnesium hydroxide (MH), as long-term treatment of functional constipation (FC) in children, and they do not include infants as young as 6 months of age. Our aim was to determine the efficacy, safety, and acceptability of PEG vs MH in FC, in the long term, in pediatric patients. METHODS: An open-label, parallel, controlled clinical trial was conducted on patients from 6 months to 18 years of age, diagnosed with FC, that were randomly assigned to receive PEG 3350 or MH for 12 months. Success was defined as: ≥ 3 bowel movements/week, with no fecal incontinence, fecal impaction, abdominal pain, or the need for another laxative. We compared adverse events and acceptability, measured as rejected doses of the laxative during the study, in each group and subgroup. RESULTS: Eighty-three patients with FC were included. There were no differences in success between groups (40/41 PEG vs 40/42 MH, p = 0.616). There were no differences in acceptability between groups, but a statistically significant higher number of patients rejected MH in the subgroups > 4 to 12 years and > 12 to 18 years of age (P = .037 and P = .020, respectively). There were no differences regarding adverse events between the two groups and no severe clinical or biochemical adverse events were registered. CONCLUSIONS: The two laxatives were equally effective and safe for treating FC in children from 0.5 to 18 years of age. Acceptance was better for PEG 3350 than for MH in patients above 4 years of age. MH can be considered first-line treatment for FC in children under 4 years of age.

The use of two Comfort Young Child Formulas in the dietary management of toddlers with functional constipation: a randomized controlled trial.

BACKGROUND: Pharmacological intervention with laxatives is the conventional treatment for functional constipation (FC). Data to support the dietary management of FC is lacking. This study compared the efficacy of two Comfort young child formulas (YCFs) with regards to the maintenance of healthy stooling parameters in toddlers with a history of constipation. It was registered in the Netherlands Trial Registry [identifier: NL7420 (NTR7653)], registration date 20/09/2018. METHODS: Ninety-five healthy toddlers, aged 12 to 32 months, diagnosed with FC (Rome III criteria) were randomized to receive one of two study formulas after pharmacological treatment. For the first month of the intervention, subjects received a laxative in a decreasing maintenance dose alongside a test or control formula (maintenance phase). Subsequently, subjects only consumed formula for another month (post-maintenance phase). Stooling parameters were obtained weekly using the Bristol Stool Scale and the modified Rome III Questionnaire on Paediatric Gastrointestinal Symptoms for infants and toddlers. Differences in percentages of hard stools (primary outcome) and other stooling parameters were analysed using analysis of covariance and Chi-Square methods. RESULTS: Both formulas resulted in similar overall percentage of hard stools during the intervention period, respectively 5.02% in the test and 2.99% in the control group (n.s.). In the test group, percentages dropped from 7.11% at the end of the maintenance phase, to 3.92% at the end of the post-maintenance phase. In contrast, the percentage of hard stools in the control group was similar at the end of the maintenance (3.18%) and post-maintenance phase (2.83%; n.s.). No difference was found in the overall stool frequency between groups. At the end of the maintenance phase, only 22% and 19% of toddlers consuming the test and control formulae, respectively, met 2 or more of the criteria for FC. At the end of the study, this percentage of subjects decreased further to 9% in the test group, which tended to be lower compared to the 21% found in the control (p = 0.107). No laxative use was reported in either study group during the post-maintenance phase. CONCLUSION: Both Comfort YCF support the maintenance of improved stooling over time in toddlers with a history of constipation. The percentage of subjects suffering from functional constipation tended to be lower after the intervention period when receiving the formula with intact protein.

Does prophylactic use of postcesarean section laxatives favor bowel movements?

Introduction: Chronic constipation (CC) is a highly prevalent disease in Western society. Chronic constipation can have a different etiology in patients who underwent a cesarean section and result from postoperative stress and metabolic response to trauma, analgesic agents, immobilization, and dietary restrictions. Chronic constipation may also occur due to puerperium-related psychological changes and to the stretching and weakening of the perineal and abdominal muscles after childbirth. Objectives: The present study analyzes intestinal transit restoration after a cesarean section and the influence of osmotic laxative agents. Methods: The present prospective, nonrandomized sample study used the ROME III questionnaire and the Bristol stool scale in adult women who underwent a cesarean section. We divided the subjects into 2 groups, each with 30 patients, to compare the effect of the prophylactic administration of an osmotic laxative. Results: We evaluated 60 randomly-chosen pregnant women from the Obstetrics ward of Hospital Santa Marcelina, São Paulo, SP, Brazil, from October 2019 to March 2020. Their mean age was 26.8 years old, and the mean gestation time was 37.95 weeks. Ten patients (16.7%) presented with constipation before the cesarean section, and 38 (63.3%) had a bowel movement after the procedure. However, in 84.2% of these patients, the usual stool consistency worsened. After the cesarean section, 46.7% of the women who did not receive laxative agents had a bowel movement, compared with 80% of those who did (p = 0.0074). Conclusion: Some factors, including those related to the procedure, may hamper intestinal transit restoration after a cesarean section. Osmotic laxative agents can facilitate transit restoration with no negative effects in this group of patients. (AU)

Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation. STUDY DESIGN: Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation. RESULTS: We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture. CONCLUSIONS: More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.

Estreñimiento funcional en pediatría, diagnóstico y tratamiento / Functional constipation in pediatrics, diagnosis and treatment

El estreñimiento funcional es un motivo de consulta frecuente en pediatría, con una prevalencia del 3 %. El Grupo de Trabajo de Constipación del Comité de Gastroenterología de la Sociedad Argentina de Pediatría se reunió con el objetivo de actualizar el diagnóstico y tratamiento de la constipación funcional en pediatría.Se realizó una búsqueda de literatura para evaluar la calidad de la evidencia. Ante un paciente constipado, es fundamental una historia y examen clínico completos. Los Criterios de Roma IV establecen pautas que, habitualmente, permiten diagnosticar la constipación funcional y evitar estudios innecesarios. La realización de estudios diagnósticos solo se pondrá en consideración ante la presencia de respuesta refractaria al tratamiento médico o en los casos de signos de alarma (banderas rojas). El primer paso del tratamiento es la desimpactación (por vía oral o enemas), seguida del tratamiento dietético, de hábitos y laxantes (es de primera elección el polietilenglicol).

Functional constipation is a common disease and one of the most frequent reasons of visit in pediatric clinics with a 3 % of prevalence. The Constipation Working Group of the Gastroenterology Committee of the Sociedad Argentina de Pediatría met with the objective of updating the diagnosis and treatment of functional constipation in pediatrics.A literature search was performed to assess the quality of the evidence. In a constipated patient, a complete history and clinical examination is essential. The Rome IV Criteria establish guidelines that usually allow us to diagnose functional constipation, avoiding unnecessary studies. The performance of diagnostic studies will only be considered in the absence of response to medical treatment or in cases of alarm signs (red flags). The first step of treatment is disimpaction (orally or enemas), followed by dietary treatment, habits and laxatives, with polyethylene glycol being the first choice.

[Functional constipation in pediatrics, diagnosis and treatment]. / Estreñimiento funcional en pediatría, diagnóstico y tratamiento.

Functional constipation is a common disease and one of the most frequent reasons of visit in pediatric clinics with a 3 % of prevalence. The Constipation Working Group of the Gastroenterology Committee of the Sociedad Argentina de Pediatría met with the objective of updating the diagnosis and treatment of functional constipation in pediatrics. A literature search was performed to assess the quality of the evidence. In a constipated patient, a complete history and clinical examination is essential. The Rome IV Criteria establish guidelines that usually allow us to diagnose functional constipation, avoiding unnecessary studies. The performance of diagnostic studies will only be considered in the absence of response to medical treatment or in cases of alarm disimpaction (orally or enemas), followed by dietary treatment, habits and laxatives, with polyethylene glycol being the first choice.

de consulta frecuente en pediatría, con una prevalencia del 3 %. El Grupo de Trabajo de Constipación del Comité de Gastroenterología de la Sociedad Argentina de Pediatría se reunió con el objetivo de actualizar el diagnóstico y tratamiento de la constipación funcional en pediatría. Se realizó una búsqueda de literatura para evaluar la calidad de la evidencia. Ante un paciente constipado, es fundamental una historia y examen clínico completos. Los Criterios de Roma IV establecen pautas que, habitualmente, permiten diagnosticar la constipación funcional y evitar estudios innecesarios. La realización de estudios diagnósticos solo se pondrá en consideración ante la presencia de respuesta refractaria al tratamiento médico o en los casos de signos de alarma (banderas rojas). El primer paso del tratamiento es la desimpactación (por vía oral o enemas), seguida del tratamiento dietético, de hábitos y laxantes (es de primera elección el polietilenglicol).

Constipation in Hospitalized Patients: A Study of Prevalence and Associated Factors.

PURPOSE: The purpose of this study was to identify the prevalence of constipation in hospitalized patients, along with sociodemographic and clinical variables associated with its occurrence. DESIGN: Observational, cross-sectional study. SUBJECTS AND SETTINGS: The study sample comprised 343 adult patients hospitalized at a University Hospital in Sao Paulo, Brazil. METHODS: Point-prevalence data were collected on the same day each month over a 4-month period. Data were collected via interviews, physical examination, medical record review, and completion of a data collection form that queried sociodemographic data and incorporated the Bowel Function in the Community instrument. Patients were classified as constipated if they met 2 or more of the Rome III criteria. Logistic regression analyses were used to identify clinical or sociodemographic factors associated with constipation. RESULTS: Fifty-one patients had constipation, reflecting a point-prevalence of 14.8% (95% CI, 11.49-19.02). The prevalence of constipation was 15% in females (n = 29) and 14.7% in males (n = 22). Multivariable logistic regression showed that use of laxatives (OR = 9.98; 95% CI, 3.539-29.666) was associated with a higher likelihood of constipation. CONCLUSION: The prevalence of constipation in hospitalized adult patients was lower than that in previous studies. Patients using laxatives were more likely to experience constipation.

Potentially Inappropriate Prescriptions for Anticholinergic Medications for Patients with Constipation.

INTRODUCTION: Constipation is a very common functional gastrointestinal disorder in the general population and can be primary or secondary. OBJECTIVE: The aim of this study was to estimate the anticholinergic burden of prescribed drugs in a population diagnosed with constipation in Colombia. METHODS: This was a cross-sectional study that used a population database of 6.5 million people to identify the prescription of cholinergic antagonists and drugs for the management of constipation in outpatient services. The anticholinergic burden was evaluated using the Anticholinergic Drug Scale. Potentially inappropriate prescriptions that increased the risk of constipation were identified. RESULTS: A total of 3,887 patients with constipation were identified; the identified patients had a mean age of 54.4 ± 21.9 years, and 69.4% were women. Eighty percent received at least one laxative, and the most prescribed laxative was bisacodyl (50.5%). Forty-one percent (n = 1,586) of all patients received drugs with cholinergic antagonist activity, in particular codeine (6.5%) and valproic acid (6.5%). Being over 30 years of age (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.24-2.57), being treated in the cities of Manizales (OR: 2.20; 95% CI: 1.50-3.21) and Pereira (OR: 1.49; 95% CI: 1.07-2.09), and having hypothyroidism as a comorbidity (OR: 1.37; 95% CI: 1.08-1.73) were associated with a greater probability of receiving medications with an anticholinergic burden of 3 or more points. CONCLUSIONS: The majority of patients with constipation were women and were using laxatives to manage constipation. A large proportion of patients were prescribed at least one cholinergic antagonist drug, with an increased probability of use after 30 years of age.

Physiotherapy for Children with Functional Constipation: A Pragmatic Randomized Controlled Trial in Primary Care.

OBJECTIVE: To determine the effectiveness of physiotherapy plus conventional treatment compared with conventional treatment alone for the treatment of functional constipation in children age 4-17 years in primary care. STUDY DESIGN: Pragmatic randomized controlled trial with 8 months follow-up. Primary care physicians recruited children diagnosed with functional constipation (n = 234), and pediatricians recruited newly referred children with a diagnosis of functional constipation (n = 11). Conventional treatment comprised toilet training, nutritional advice, and laxative prescribing, whereas physiotherapy focused on resolving dyssynergic defecation. The primary outcome was treatment success over 8 months, defined as the absence of functional constipation (Rome III criteria) without laxative use. Secondary outcomes included the absence of functional constipation irrespective of continuation of laxative use and global perceived treatment effect. RESULTS: Children were allocated to conventional treatment plus physiotherapy or conventional treatment alone (67 per group), mean (SD) age was 7.6 (3.5) years. Results of longitudinal analyses in the intention-to-treat population showed that the treatment success percentage was not statistically improved by adding physiotherapy to conventional treatment (adjusted relative risk [aRR] 0.80, 95% CI 0.44-1.30). At 4 months, fewer children receiving physiotherapy had treatment success (17%) than children receiving conventional treatment alone (28%), but this had equalized by 8 months (42% and 41%, respectively). The percentage of children without functional constipation, irrespective of continuation of laxative use, was not statistically different between groups over 8 months (aRR 1.12, 95% CI 0.82-1.34). Notably, parents reported significantly more global symptom improvement after physiotherapy than after conventional treatment (aRR 1.40; 95% CI 1.00-1.73). CONCLUSIONS: We find no evidence to recommend physiotherapy for all children with functional constipation in primary care. TRIAL REGISTRATION: Netherlands Trial Registry: NTR4797.

Effect of polyethylene glycol versus lactulose on abdominal pain in children occult constipation: a randomized controlled study: un estudio controlado aleatorio / Efecto del polietilenglicol versus lactulosa sobre el dolor abdominal en el estreñimiento oculto en niños

Introduction and aim: Functional abdominal pain (FAP) is one of the major gastrointestinal complaints in childhood. Studies have reported occult constipation (OC) as one of the leading causes of abdominal pain. Recent researches have proposed laxatives as potent therapeutic targets for abdominal pain in patients with OC. However, no study has compared effect of poly ethylene glycol (PEG) and lactulose on occult constipation. Materials and methods: 51 patients aged 4 to 18 years with abdominal pain who had OC (defined as fecal impaction in abdominal X ray) were studied. Demographic and clinical data including age, sex, body weight, height, abdominal pain duration, abdominal pain rate and fecal odor were registered. They were randomly assigned to receive PEG (1gr/kg) or Lactulose (1cc/kg) for at least two weeks. All patients were reevaluated by pain measurement scale after at least two weeks of treatment. Results: It is indicated that the efficacy of PEG for reducing abdominal pain in OC was 48% while it was 37% for Lactulose. This study indicated that this efficacy is not affected significantly by sex and fecal odor, however this efficacy is influenced by age, body weight, abdominal pain duration and abdominal pain rate for both PEG and Lactulose. Conclusion: It could be concluded that PEG is a more efficient drug for treating abdominal pain in occult constipation than Lactulose and its optimum effect can be achieved in elder patients with more severe abdominal pain.

Introducción y objetivo: El dolor abdominal funcional (FAP) es una de las principales molestias gastrointestinales en la infancia. Los estudios han informado que el estreñimiento oculto (OC) es una de las principales causas de dolor abdominal. Investigaciones recientes han propuesto laxantes como objetivos terapéuticos potentes para el dolor abdominal en pacientes con OC. Sin embargo, ningún estudio ha comparado el efecto del polietilenglicol (PEG) y la lactulosa sobre el estreñimiento oculto. Materiales y métodos: Se estudiaron 51 pacientes de 4 a 18 años con dolor abdominal que tenían OC (definida como impactación fecal en rayos X abdominales). Se registraron datos demográficos y clínicos que incluyen edad, sexo, peso corporal, altura, duración del dolor abdominal, tasa de dolor abdominal y olor fecal. Fueron asignados aleatoriamente para recibir PEG (1 gr/kg) o lactulosa (1 cc/kg) durante al menos dos semanas. Todos los pacientes fueron reevaluados por la escala de medición del dolor después de al menos dos semanas de tratamiento. Resultados: Se indica que la eficacia de PEG para reducir el dolor abdominal en OC fue del 48% mientras que fue del 37% para la lactulosa. Este estudio indicó que esta eficacia no se ve afectada significativamente por el sexo y el olor fecal, sin embargo, esta eficacia está influenciada por la edad, el peso corporal, la duración del dolor abdominal y la tasa de dolor abdominal tanto para PEG como para lactulosa. Conclusión: Se podría concluir que el PEG es un fármaco más eficaz para tratar el dolor abdominal en el estreñimiento oculto que la lactulosa y que su efecto óptimo se puede lograr en pacientes mayores con dolor abdominal más severo.Palabras clave: dolor abdominal, estreñimiento oculto, polietilenglicol, lactulosa.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study / Combinações de laxantes e biomassa de banana verde no tratamento de constipação funcional em crianças e adolescentes: estudo randomizado

Abstract Objectives: Evaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation. Methods: This was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses. Results: On consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported. Conclusion: Green banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Resumo Objetivos: Avaliar o efeito das combinações da biomassa de banana verde e laxantes em crianças e adolescentes com constipação crônica. Métodos: Estudo randomizado de 80 crianças e adolescentes com constipação funcional de acordo com os Critérios de Roma IV divididos em cinco grupos: 1) Somente biomassa de banana verde; 2) Biomassa de banana verde mais PEG 3350 com eletrólitos; 3) Biomassa de banana verde mais picossulfato de sódio; 4) PEG 3350 somente com eletrólitos e 5) somente picossulfato de sódio. O desfecho primário foi a redução da proporção de pacientes com as classificações 1 ou 2 da Escala de Bristol para Consistência de Fezes. Os desfechos secundários foram: aumento da produção de > 3 evacuações/semana e redução da proporção de incontinência fecal, esforço na defecação, defecação dolorosa, sangue nas fezes, dor abdominal e redução nas dose de laxantes. Resultados: No consumo somente de biomassa de banana verde há uma redução estatisticamente significativa na proporção de crianças com classificação 1 ou 2 da Escala de Bristol para Consistência de Fezes, esforço na defecação, defecação dolorosa e dor abdominal. Por outro lado, não houve redução nos episódios fecais/semana de incontinência, sangue nas fezes e nenhum aumento na proporção de crianças com > 3 evacuações/semana. O percentual de crianças que tiveram sua dose de laxante reduzida foi alto quando a biomassa de banana verde foi associada a picossulfato de sódio (87%) e PEG 3350 com eletrólitos (63%). A biomassa de banana verde sozinha e associada a laxantes foi bem tolerada e não houve efeitos adversos relatados. Conclusão: A biomassa de banana verde é vantajosa como uma terapia adjuvante na constipação funcional, principalmente na redução das doses de laxantes.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study.

OBJECTIVES: Evaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation. METHODS: This was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses. RESULTS: On consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported. CONCLUSION: Green banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Effect of polyethylene glycol versus lactulose on abdominal pain in children occult constipation: a randomized controlled study.

INTRODUCTION AND AIM: Functional abdominal pain (FAP) is one of the major gastrointestinal complaints in childhood. Studies have reported occult constipation (OC) as one of the leading causes of abdominal pain. Recent researches have proposed laxatives as potent therapeutic targets for abdominal pain in patients with OC. However, no study has compared effect of poly ethylene glycol (PEG) and lactulose on occult constipation. MATERIALS AND METHODS: 51 patients aged 4 to 18 years with abdominal pain who had OC (defined as fecal impaction in abdominal X ray) were studied. Demographic and clinical data including age, sex, body weight, height, abdominal pain duration, abdominal pain rate and fecal odor were registered. They were randomly assigned to receive PEG (1gr/kg) or Lactulose (1cc/kg) for at least two weeks. All patients were reevaluated by pain measurement scale after at least two weeks of treatment. RESULTS: It is indicated that the efficacy of PEG for reducing abdominal pain in OC was 48% while it was 37% for Lactulose. This study indicated that this efficacy is not affected significantly by sex and fecal odor, however this efficacy is influenced by age, body weight, abdominal pain duration and abdominal pain rate for both PEG and Lactulose. CONCLUSION: It could be concluded that PEG is a more efficient drug for treating abdominal pain in occult constipation than Lactulose and its optimum effect can be achieved in elder patients with more severe abdominal pain.

Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria / Diagnóstico e tratamento da constipação crônica: atualização baseado nos critérios Roma IV

ABSTRACT The aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors' experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient.

RESUMO O objetivo deste trabalho foi avaliar os consensos de sociedade de especialistas e guidelines publicados sobre o diagnóstico e tratamento da constipação intestinal crônica em adultos, e confrontar com a experiência dos autores, a fim de padronizar condutas que auxiliem o raciocínio e a tomada de conduta do médico. Foi realizada busca na literatura científica, mais precisamente nas bases de dados eletrônicos Medline/Pubmed, Scielo, EMBASE and Cochrane, tendo sido utilizado os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Pode-se concluir que constipação crônica é condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. Identificar com precisão a fisiopatologia presente na constipação crônica funcional é complexo, requerendo a realização de testes funcionais nos casos refratários. O entendimento da motilidade intestinal e do mecanismo defecatório é importante para o manejo da constipação intestinal crônica funcional, sendo o tratamento cirúrgico indicado para casos selecionados, onde à abordagem medicamentosa não surtiu efeito. As informações contidas neste artigo de revisão devem ser submetidas à avaliação e à crítica do médico especialista responsável pela conduta a ser tomada, frente à sua realidade e ao estado clínico de cada paciente.

Adherence to Polyethylene Glycol Treatment in Children with Functional Constipation Is Associated with Parental Illness Perceptions, Satisfaction with Treatment, and Perceived Treatment Convenience.

OBJECTIVES: To assess treatment adherence in children with functional constipation and to evaluate the association with parental beliefs about medication, illness perceptions, treatment satisfaction, and satisfaction with information about medication. STUDY DESIGN: A cross-sectional survey was administered among parents of children with functional constipation treated with polyethylene glycol. Adherence was measured via the Medication Adherence Report Scale (MARS-5, score 5-25), with greater scores indicating better adherence (scores ≥23 were defined as adherent). Beliefs about medication, illness perceptions, satisfaction with treatment, and satisfaction with information about treatment were measured with the Beliefs about Medication Questionnaire, the Brief Illness Perception Questionnaire, the Treatment Satisfaction Questionnaire for Medication (TSQM), and the Satisfaction with Information about Medication Questionnaire. Associations between the questionnaire scores and adherence (MARS-5 score as a continuous variable) were analyzed with regression analyses. RESULTS: In total, 43 of 115 included children (37%) were adherent (MARS-5 ≥23). Spearman rank correlation test revealed a statistically significant correlation between TSQM-convenience, TSQM-satisfaction, Brief Illness Perception Questionnaire question 8 (emotions), and the MARS-5 score (rs 0.342, P = .000; rs 0.258, P = .006; rs -0.192, P = .044), which suggests that parental perceived treatment convenience, satisfaction with treatment, and illness perceptions may affect adherence in children with functional constipation. In the hierarchical multivariate regression model, 22% of the variability of the MARS-5 score could be explained by the selected predictors. The TSQM-convenience score contributed the most to the model (ß: 0.384, P = .000). CONCLUSIONS: Parents reported low adherence rates in their children with functional constipation. Treatment inconvenience, dissatisfaction with treatment, and the emotional impact of functional constipation may negatively influence treatment adherence.

PEG 3350 Administration Is Not Associated with Sustained Elevation of Glycol Levels.

OBJECTIVE: To determine whether trace amounts of ethylene glycol (EG), diethylene glycol (DEG), or triethylene glycol (TEG) in PEG 3350 are associated with increased blood levels of EG, DEG, or TEG in children receiving daily PEG 3350 therapy. STUDY DESIGN: Blood samples were drawn from 9 children who were being treated for constipation with PEG 3350 (6-12 years old) before and every 30 minutes for 3 hours after receiving 17 g of PEG 3350. PEG 3350, tap water, and blood samples from 18 age- and sex-matched controls also were analyzed. RESULTS: Baseline blood levels of EG and TEG did not differ between control and treated groups. DEG levels (median [IQR]) were lower in the PEG 3350 group (40.13 ng/mL [36.69, 63.94] vs 92.83 ng/mL [51.06, 128.93], P = .008). After PEG 3350 dose, levels of EG (390.51 ng/mL [326.06, 624.55]) and TEG (2.21 ng/mL [0, 4.5]) peaked at 90 minutes at 1032.81 ng/mL (826.84, 1486.13) (P = .009) and 35.17 ng/mL (15.81, 45.13) (P = .0005), respectively. DEG levels did not significantly change. Standard 17-g doses of PEG 3350 in 8 oz (237 mL) of water resulted in concentrations (mean ± SD) of EG, DEG, and TEG of 1.32 ± 0.23 µg/mL, 0.18 ± 0.03 µg/mL, and 0.12 ± 0.01 µg/mL, respectively. EG, DEG, and TEG levels in public water supply were 0.07 µg/mL, 0.21 µg/mL, and 0.02 µg/mL, respectively. CONCLUSIONS: Daily PEG 3350 therapy in children was not associated with sustained elevation of EG, DEG, or TEG blood levels over levels in matched controls. Although EG and TEG levels increased after a standard dose of PEG 3350, their peak values remained well below toxic levels.

Long-term follow-up of patients with intestinal neuronal dysplasia type B: Protocol for an observational, ambispective, and comparative study.

Intestinal neuronal dysplasia type B (IND-B) is a pathological entity of the group of gastrointestinal neuromuscular diseases characterized by complex alterations in the enteric nervous system. Patients typically present with intestinal constipation, sometimes complicated by episodes of intestinal obstruction. The 2 therapeutic modalities include conservative clinical treatment and surgical treatment. Nevertheless, the results of the different therapeutic modalities are conflicting, and follow-up studies are scarce and include only a limited number of patients.This is a single-center, ambispective, observational, longitudinal, and comparative follow-up study to compare the results of conservative clinical and surgical treatments in patients with IND-B. Sixty-three patients (<15 years) who received this diagnosis will be included. These patients will be divided into 2 groups according to the type of treatment that they previously received: 29 patients in the surgical treatment group and 34 patients in the conservative treatment group. Previous data will be recovered from the medical records of the study patients, including signs and symptoms present at the time of diagnosis, particularly those related to bowel habits, and treatments undergone. Later, these patients will be invited to participate in a semistructured interview during which aspects related to the long-term functional results of the bowel habit and quality of life will be investigated after a minimum interval of 5 years posttreatment.This project aims to assess the long-term clinical evolution of patients diagnosed with IND-B and compare the results obtained following conservative clinical and surgical treatments.This protocol will provide sufficient data to analyze the long-term clinical outcome obtained through the 2 treatment modalities proposed for patients with IND-B.