Functional constipation and outlet delay: A population-based study

doi:10.1016/0016-5085(93)90896-K

Gastroenterology

Volume 105, Issue 3, September 1993, Pages 781-790

https://doi.org/10.1016/0016-5085(93)90896-K Get rights and content

Abstract

Background: Chronic constipation may result from many mechanisms including colonic inertia or rectosigmoid outlet delay, but risk factors for constipation in the community are poorly defined. The prevalence of and predictors for symptoms consistent with functional constipation and outlet delay were estimated. Methods: An age- and gender-stratified random sample of 1,021 residents of Olmsted County, MN, aged 30–64 years, was mailed a valid self-report questionnaire; 835 responded (82%). These respondents were mailed a second questionnaire 12–20 months later that gathered data on symptoms compatible with functional constipation and outlet delay; 690 responded (83%). Results: Self-reported constipation did not reliably identify functional constipation or outlet delay. The overall age- and gender-adjusted prevalences (per 100) of functional constipation and outlet delay were 19.2 (95% confidence interval [CI], 16.1–22.3) and 11.0 (95% CI, 8.7–13.3), respectively. Outlet delay but not functional constipation was more frequent in women. After adjusting for age, gender, and other symptoms, an increased usage of aspirin was associated with functional constipation but not outlet delay. Conclusions: In apparently healthy middle-aged persons, approximately 1 in 5 have symptoms compatible with functional constipation, and 1 in 10 may experience outlet delay, but these groups correspond poorly with self-reported constipation.

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The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases.
However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.
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The composition of intestinal microbiota is influenced by a number of factors, including medications, which may have a substantial impact on host physiology. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics are among those widely used medications that have been shown to alter microbiota composition in both animals and humans. Although much effort has been devoted to identify microbiota signatures associated with these medications, much less is known about the underlying mechanisms. Mucosal inflammation, changes in intestinal motility, luminal pH and bile acid metabolism, or direct drug-induced inhibitory effect on bacterial growth are all potential contributors to NSAID- and opioid-induced dysbiosis, however, only a few studies have addressed directly these issues. In addition, there is a notable overlap between the microbiota signatures of these drugs and certain diseases in which they are used, such as spondyloarthritis (SpA), rheumatoid arthritis (RA) and neuropathic pain associated with type 2 diabetes (T2D). The aims of the present review are threefold. First, we aim to provide a comprehensive up-to-date summary on the bacterial alterations caused by NSAIDs and opioids. Second, we critically review the available data on the possible underlying mechanisms of dysbiosis. Third, we review the current knowledge on gut dysbiosis associated with SpA, RA and neuropathic pain in T2D, and highlight the similarities between them and those caused by NSAIDs and opioids. We posit that drug-induced dysbiosis may contribute to the persistence of these diseases, and may potentially limit the therapeutic effect of these medications by long-term use. In this context, we will review the available literature data on the effect of probiotic supplementation and fecal microbiota transplantation on the therapeutic efficacy of NSAIDs and opioids in these diseases.
Constipation in Patients With Symptoms of Gastroparesis: Analysis of Symptoms and Gastrointestinal Transit
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Constipation can be an important symptom in some patients with gastroparesis. The aims were to: 1) Determine prevalence of constipation and delayed colonic transit in patients with symptoms of gastroparesis; 2) Correlate severity of constipation to severity of symptoms of gastroparesis; and 3) Relate severity of constipation to GI transit delays assessed by gastric emptying scintigraphy (GES) and wireless motility capsule (WMC).
Patients with symptoms of gastroparesis underwent gastric emptying scintigraphy (GES), wireless motility capsule (WMC) assessing gastric emptying, small bowel transit, and colonic transit, and questionnaires assessing symptoms using a modified Patient Assessment of Upper GI Symptoms [PAGI-SYM] and Rome III functional GI disorder questionnaire.
Of 338 patients with symptoms of gastroparesis, 242 (71.5%) had delayed gastric emptying by scintigraphy; 298 (88.2%) also met criteria for functional dyspepsia. Severity of constipation was severe/very severe in 34% patients, moderate in 24%, and none/very mild/mild in 42%. Increasing severity of constipation was associated with increasing symptoms of gastroparesis and presence of irritable bowel syndrome (IBS). Severity of constipation was not associated with gastric retention on GES or WMC. Delayed colonic transit was present in 108 patients (32% of patients). Increasing severity of constipation was associated with increasing small bowel transit time, colonic transit time, and whole gut transit time.
Severe/very severe constipation and delayed colon transit occurs in a third of patients with symptoms of gastroparesis. The severity of constipation is associated with severity of gastroparesis symptoms, presence of IBS, small bowel and colon transit delay, but not delay in gastric emptying. ClinicalTrials.gov Identifier: NCT01696747
Global prevalence of functional constipation according to the Rome criteria: a systematic review and meta-analysis
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Functional constipation is a common functional bowel disorder in the community, which has a varying prevalence across cross-sectional surveys. We did a contemporaneous systematic review and meta-analysis of studies using comparable methodology and all iterations of the Rome criteria to estimate the global prevalence of functional constipation.
In this systematic review and meta-analysis, we searched MEDLINE, Embase, and Embase Classic from Jan 1, 1990, to Dec 31, 2020, to identify population-based cross-sectional studies comprising at least 50 participants that reported the prevalence of functional constipation in adults (age 18 years and older) according to Rome I, II, III, or IV criteria. We excluded studies that reported the prevalence of functional constipation in convenience samples. We extracted prevalence estimates of functional constipation from eligible studies, according to the study criteria used to define it. For each study, we extracted data for country; method of data collection; criteria used to define functional constipation; whether the study used the Rome I, II, III, or IV diagnostic questionnaires or approximated these definitions of the condition using another questionnaire; the total number of participants providing complete data; age; the number of participants with the condition; the number of male and female participants; and the number of male and female participants with the condition. We calculated pooled prevalence, odds ratios (OR), and 95% CIs.
Of 8174 citations evaluated, 45 studies fulfilled the eligibility criteria, representing 80 separate populations and comprising 275 260 participants. The pooled prevalence of functional constipation was 15·3% (95% CI 8·1–24·4, I²=99·4%) in studies using the Rome I criteria, 11·2% (7·9–14·9; I²=99·6%) in studies that used Rome II criteria, 10·4% (6·5–14·9; I²=99·8%) in those that used Rome III criteria, and 10·1% (8·7–11·6; I²=98·2%) when Rome IV criteria were used. Prevalence of functional constipation was higher in women, irrespective of the Rome criteria used (OR 2·40 [95% CI 2·02–2·86] for Rome I, 1·94 [1·46–2·57] for Rome II, and 2·32 [1·85–2·92] for Rome III; no studies using Rome IV criteria reported prevalence by sex). There was significant heterogeneity between studies in all of our analyses, which persisted even when the same criteria were applied and similar methodologies used.
Even when uniform symptom-based criteria are used to define the presence of functional constipation, prevalence varies between countries. Thus, environmental, cultural, ethnic, dietary, or genetic factors can influence reporting of symptoms. Future studies should aim to elucidate reasons for this geographical variability.
None.
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The overall prevalence of major symptom groupings including gastroesophageal reflux disease was consistent among residents in a community on 3 survey time points (1990-1992, 2003-2004, and 2008-2009). The transitions of GI symptoms were common in 228 patients who responded to all 3 surveys; only 29% had the same symptom category in 3 surveys; otherwise, symptoms changed over time, resolving, recurring, or transitioning to another disorder. Observed proportions of symptom transitions were significantly different from expected during 20 years (P<.001). Higher non-GI somatic symptom scores were significantly associated with both symptom transitions (odds ratio, 3.9; 95% CI, 1.38 to 10.77) and having sustained symptoms (odds ratio, 12.7; 95% CI, 4.62 to 34.90).
The overall population prevalence of chronic unexplained GI symptoms is stable, but in individuals, transitions seem to be the rule. As these various GI syndromes appear to be so intimately interconnected, the common underlying pathogenesis may account for a major subgroup of chronic unexplained GI disorders.
Pretest and Post-test Probabilities of Diagnoses of Rectal Evacuation Disorders Based on Symptoms, Rectal Exam, and Basic Tests: a Systematic Review
2020, Clinical Gastroenterology and Hepatology
There is controversy over the utility of symptoms, examination, and tests for diagnosis of rectal evacuation disorders (REDs) or slow-transit constipation (STC). We aimed to ascertain the pooled prevalence, sensitivity, specificity, and likelihood ratios for clinical parameters to determine pretest and post-test probabilities of diagnoses of RED and STC without RED.
We searched the MEDLINE and PUBMED databases since 1999 for studies that used binary data to calculate sensitivity, specificity, and likelihood ratios to determine the diagnostic utility of history, symptoms, and tests for RED and STC. RED and STC were defined based on confirmation by at least 1 objective anorectal test or colonic transit test. Controls had normal test results based on the specific protocol in each study.
We reviewed 100 articles; 63 studies of RED and 61 studies of STC met the inclusion criteria. Among 3364 patients with chronic constipation, objective tests demonstrated RED alone, 27.2%; normal transit constipation alone, 37.2%; STC alone, 19.0%; and RED with STC, 16.6%. To diagnose RED, discriminant features were urinary symptoms (specificity, 100%; likelihood ratio, above 10; 58 patients), less than 2 findings of dyssynergia in a digital rectal exam (sensitivity, 83.2%; negative likelihood ratio, 0.2; 462 patients) and rectoanal pressure gradient below –40 mm Hg with high anal pressure during straining (specificity, 100%; likelihood ratio, above 10; 101 patients). The features most strongly associated with STC alone were call to stool (specificity, 91.5%; likelihood ratio, 10.5; 75 patients) and absence of abdominal distension, fullness, or bloating (sensitivity, 92.9%; negative likelihood ratio, 0.1; 93 patients).
In a systematic review, we found specific symptoms, lack of dyssynergia in a digital rectal exam, and findings on anorectal manometry to be highly informative and critical in evaluation of RED and STC.

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: Supported In part by research grants AG09440 and AR30582 from the National Institutes of Health and by a research grant from Glaxo Inc.

: This work was presented in part at the American Gastroenterological Association meeting in May 1992 in San Francisco (Gastroenterology 1992;102:A524).

View full text

Functional constipation and outlet delay: A population-based study,

Abstract

Gastroenterology

Gastroenterology

Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women

Am J Public Health

Symptom prevalence in the elderly: an evaluation of age, sex, disease and medication use

J Am Geriatr Soc

Bowel habits in young adults not seeking health care

Dig Dis Sci

Constipation in the elderly living at home: definition, prevalence, and relationship to lifestyle and health status

J Am Geriatr Soc

A longitudinal survey of self-reported bowel habits in the United States

Dig Dis Sci

Epidemiology of constipation in the United States

Dis Colon Rectum

Demographic and dietary determinants of constipation in the U.S population

Am J Public Health

Functional gastrointestinal symptoms in a Wellington community sample

N Z Med J

Identification of sub-groups of functional gastrointestinal disorders

Gastroenterol Int