European society of neurogastroenterology and motility guidelines on functional constipation in adults.

INTRODUCTION: Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN: After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS: Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES: European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.

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.

[Relationship Pattern of Mothers with Functional Constipated Infants]. / Beziehungsmuster bei Müttern von Kleinkindern mit funktioneller Obstipation.

Relationship Pattern of Mothers with Functional Constipated Infants The present article investigates whether or not mothers of infants with functional constipation have a specific relationship pattern. This question is addressed by analyzing the data collected at the day care clinic for infant regulation disorders with appropriate methods like the questionnaire for the assessment of adjustment of mothers with children in infancy (EMKK, Engfer u. Codreanu, 1984) described here. The evaluation of data was performed in two ways: first with regard to the clinical study group of mothers with infants (age range from one to five years) suffering from functional constipation, and then compared to a clinical control group of mothers with infants who are coping with regulation disorders (by definition per Papousek, Schieche, Wurmser, 2010). With this comparison differences between the two groups are made visible and clinical interventions can be deduced accordingly. If the groups do not differ in their pattern described by the EMKK, the possible interventions can be adopted from the well-studied area of regulation disorders. The focus on analyzing the data of mothers with functional constipated infants serves as an important starting point for providing the best possible alignment of clinical intervention.

[Functional diarrhea - pathophysiology, investigation and treatment]. / Funktionelle Diarrhoe - Pathophysiologie, Abklärung und Therapie.

The most important reason for functional diarrhea in clinical practice is diarrhea-predominant irritable bowel syndrome (IBS) which is characterized by chronic intermittent diarrhea and abdominal pain. The pathophysiology underlying IBS is complex and includes visceral hypersensitivity, abnormal gut motility and autonomous nervous system dysfunction as well as genetic and psychosocial factors. Treatment should be tailored to the individual's symptoms and involves general measures, pharmacological treatments, dietary interventions, psychotherapy and complementary and alternative approaches. The following manuscript will give an overview over pathophysiology, reasonable investigations and treatment of IBS.

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.

Probiotics in the management of functional bowel disorders: promise fulfilled?

Irritable bowel syndrome (IBS) and chronic constipation (CC) are common problems worldwide and are associated with significant impact on activities of daily living and quality of life. Recent interest, in IBS in particular, has focused on the potential roles of the microbiota and its interaction with the host's immune system. Recently, high-quality clinical trials have been performed on prebiotics and probiotics in IBS or CC. Although strategies that seek to modify the microbiota, such as the use of probiotics, offer much promise in IBS and CC, more high-quality trials and, studies of longer duration are required.

Exploring the benefits of of anal irrigation.

This article discusses the prevalence, causes and impact of bowel dysfunction among adults, and suggests that anal irrigation may be considered as a viable alternative for selected patients who experience long-standing problems, where previous treatments have proved ineffective. Two case studies demonstrate the positive benefits of anal irrigation, and discuss some of the incidental findings such as fewer urinary tract.

Clinical trial assessing VSL#3 for the treatment of anterior resection syndrome.

BACKGROUND: Restoration of bowel continuity after a temporary loop ileostomy following rectal resection often produces impaired bowel function. The purpose of this clinical trial was to assess the efficacy of a probiotic, VSL#3 (VSL Pharmaceuticals Inc., Gaithersburg, MD, USA), in improving bowel function following ileostomy closure. METHODS: Between March 2005 and April 2008, a prospective, double-blind, placebo-controlled randomized trial of a probiotic preparation was conducted across four South Australian hospitals. Sixty-three patients who underwent a loop ileostomy reversal were randomized to receive 4-week treatment of either probiotic therapy (n= 31) or placebo (n= 32). Bowel symptomology was collected through a patient-completed bowel diary and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: Completion rates of the 4-week therapy regime were similar for both groups: 18 active versus 20 placebos. There was no statistically significant difference in the number of patients who withdrew or had adverse events in the two treatment groups. Reasons for patient withdrawal from the study were similar for both groups. Repeated measures analysis of variance showed no statistically significant difference between the GIQLI scores for the two treatment groups. CONCLUSIONS: The use of the probiotic preparation, VSL#3, did not alter the post-operative bowel function of patients undergoing loop ileostomy reversal.

Placebo responses and placebo effects in functional bowel disorders.

The nature and determinants of the placebo response are widely unknown, as are the underlying psychological and biological mechanisms. Placebo response rates in functional bowel disorders (functional dyspepsia, irritable bowel syndrome) trials are similar to those in nonintestinal pain conditions and are comparable with other organic gastrointestinal diseases (duodenal ulcer, inflammatory bowel diseases). In this narrative review, different methodologies (meta-analyses, reanalyses, and experimental setups) are discussed that have been applied to the study of the placebo response in functional dyspepsia and the irritable bowel syndrome.

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.

Synbiotic preparation in men suffering from functional constipation: a randomised controlled trial.

BACKGROUND: Evaluating the effects of a commercially available synbiotic preparation (contains both prebiotic and probiotic elements) on functional constipation in males. METHODS: In a randomised controlled trial, a total of 66 adult men with functional constipation were equally allocated to receive a synbiotic mixture or a placebo. The synbiotic mixture or placebo was given as capsules with the same shape and colour, and patients received the capsules twice a day for 4 weeks. RESULTS: A total of 60 patients (31 in the synbiotic group) completed the study. At baseline evaluation, there was no significant difference between the mean stool frequency per week in synbiotic and placebo groups [mean difference of 0.11 times (95% CI: -0.31-0.55), p = 0.58]. However, mean stool frequency increased significantly at weeks 2 [mean difference of 1.32 times (95% CI: 0.21-2.43)] and 4 [mean difference of 1.58 times (95% CI: 0.18-2.99)] in the synbiotic group compared with the placebo group (p = 0.02). A significant difference (p = 0.006) was found at weeks 2 [mean difference of 0.83 (95% CI: 0.20-1.45)] and 4 [mean difference of 0.91 (95% CI: 0.3-1.51)] between the synbiotic and placebo groups regarding the Bristol stool form score. No adverse effect was seen in the synbiotic group. CONCLUSION: The results of this study indicated that this specific commercial product seemed to be effective in increasing stool frequency and improving consistency in this sample of males with functional constipation. However, further studies with longer follow ups, and including females and elderly patients are required to confirm the efficacy of this product for treatment of functional constipation.