日本消化管学会（編）：便通異常症診療ガイドライン2023 慢性便秘症、南江堂、2023.
Ruszkowski J, Heleniak Z, Król E, Tarasewicz A, Gałgowska J, Witkowski JM, Dębska-Ślizień A.
Constipation and the Quality of Life in Conservatively Treated Chronic Kidney Disease Patients: A Cross-sectional Study.
Int J Med Sci. 2020;17(18):2954-2963. doi: 10.7150/ijms.49648. Epub 2020 Oct 18.
Abstract/Text
Background: Constipation is a common gastrointestinal disorder that in general population is associated with worse health-related quality of life (HRQoL). The epidemiology of constipation has not been reliably determined in conservatively-treated CKD patients. We aimed to determine the prevalence of constipation and constipation-related symptoms in conservatively-treated CKD patients, to find factors associated with their altered prevalence ratio (PR), and to verify the associations between constipation and HRQoL. Methods: In this cross-sectional study, 111 conservatively-treated CKD outpatients fulfilled questionnaires that included questions addressing HRQoL (SF-36v2®), constipation-related symptoms (The Patient Assessment of Constipation-Symptoms questionnaire), the Bristol stool form scale (BSFS), Rome III criteria of functional constipation (FC), and frequency of bowel movement (BM). Results: Depending on the used definition, the prevalence of constipation was 6.6-28.9%. Diuretics and paracetamol were independently associated with increased PR of BSFS-diagnosed constipation (PR 2.86, 95% CI 1.28-6.37, P = 0.01) and FC (PR 2.67, 95% CI 1.07-6.64, P = 0.035), respectively. The most commonly reported symptoms were bloating (50.9%) and straining to pass a BM (42.7%). Abdominal discomfort (37.3%) was independently associated with worse scores in all analyzed HRQoL domains. In multiple regressions, FC and having <7 BM/week, but not BSFS-diagnosed constipation, were associated with lower scores in several HRQoL domains. Conclusions: Constipation and related symptoms are prevalent in CKD patients. FC and decreased frequency of defecation, but not BSFS-diagnosed constipation, are associated with worse assessment of HRQoL in conservatively-treated CKD patients.
© The author(s).
Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Yamagata K, Kalantar-Zadeh K, Kovesdy CP.
Constipation and risk of death and cardiovascular events.
Atherosclerosis. 2019 Feb;281:114-120. doi: 10.1016/j.atherosclerosis.2018.12.021. Epub 2018 Dec 23.
Abstract/Text
BACKGROUND AND AIMS: Constipation is one of the most frequent symptoms encountered in daily clinical practice and is implicated in the development of atherosclerosis, potentially through altered gut microbiota. However, little is known about its association with incident cardiovascular events.
METHODS: In a nationally representative cohort of 3,359,653 US veterans with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 between October 1, 2004 and September 30, 2006 (baseline period), with follow-up through 2013, we examined the association of constipation status (absence or presence; defined using diagnostic codes and laxative use) and laxative use (none, one, or ≥2 types of laxatives) with all-cause mortality, incident coronary heart disease (CHD), and incident ischemic stroke.
RESULTS: Among 3,359,653 patients, 237,855 (7.1%) were identified as having constipation. After multivariable adjustments for demographics, prevalent comorbidities, medications, and socioeconomic status, patients with (versus without) constipation had 12% higher all-cause mortality (hazard ratio [HR], 1.12; 95% CI, 1.11-1.13), 11% higher incidence of CHD (HR, 1.11; 95% CI, 1.08-1.14), and 19% higher incidence of ischemic stroke (HR, 1.19; 95% CI, 1.15-1.22). Patients with one and ≥2 (versus none) types of laxatives experienced a similarly higher risk of all-cause mortality (HRs [95% CI], 1.15 [1.13-1.16] and 1.14 [1.12-1.15], respectively), incident CHD (HRs [95% CI], 1.11 [1.07-1.15] and 1.10 [1.05-1.15], respectively) and incident ischemic stroke (HRs [95% CI], 1.19 [1.14-1.23] and 1.21 [1.16-1.26], respectively).
CONCLUSIONS: Constipation status and laxative use are independently associated with higher risk of all-cause mortality and incident CHD and ischemic stroke.
Published by Elsevier B.V.
Yang Z, Wei C, Li X, Yuan J, Gao X, Li B, Zhao Z, Toh S, Yu X, Brayne C, Yang Z, Sha F, Tang J.
Association Between Regular Laxative Use and Incident Dementia in UK Biobank Participants.
Neurology. 2023 Apr 18;100(16):e1702-e1711. doi: 10.1212/WNL.0000000000207081. Epub 2023 Feb 22.
Abstract/Text
BACKGROUND AND OBJECTIVES: The use of over-the-counter laxatives is common in the general population. The microbiome-gut-brain axis hypothesis suggests that the use of laxatives could be associated with dementia. We aimed to examine the association between the regular use of laxatives and the incidence of dementia in UK Biobank participants.
METHODS: This prospective cohort study was based on UK Biobank participants aged 40-69 years without a history of dementia. Regular use of laxatives was defined as self-reported use in most days of the week for the last 4 weeks at baseline (2006-2010). The outcomes were all-cause dementia, Alzheimer disease (AD), and vascular dementia (VD), identified from linked hospital admissions or death registers (up to 2019). Sociodemographic characteristics, lifestyle factors, medical conditions, family history, and regular medication use were adjusted for in the multivariable Cox regression analyses.
RESULTS: Among the 502,229 participants with a mean age of 56.5 (SD 8.1) years at baseline, 273,251 (54.4%) were female, and 18,235 (3.6%) reported regular use of laxatives. Over a mean follow-up of 9.8 years, 218 (1.3%) participants with regular use of laxatives and 1,969 (0.4%) with no regular use developed all-cause dementia. Multivariable analyses showed that regular use of laxatives was associated with increased risk of all-cause dementia (hazard ratio [HR] 1.51; 95% CI 1.30-1.75) and VD (HR 1.65; 95% CI 1.21-2.27), with no significant association observed for AD (HR 1.05; 95% CI 0.79-1.40). The risk of both all-cause dementia and VD increased with the number of regularly used laxative types (p trend 0.001 and 0.04, respectively). Among the participants who clearly reported that they were using just 1 type of laxative (n = 5,800), only those using osmotic laxatives showed a statistically significantly higher risk of all-cause dementia (HR 1.64; 95% CI 1.20-2.24) and VD (HR 1.97; 95% CI 1.04-3.75). These results remained robust in various subgroup and sensitivity analyses.
DISCUSSION: Regular use of laxatives was associated with a higher risk of all-cause dementia, particularly in those who used multiple laxative types or osmotic laxative.
© 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
Adams-Carr KL, Bestwick JP, Shribman S, Lees A, Schrag A, Noyce AJ.
Constipation preceding Parkinson's disease: a systematic review and meta-analysis.
J Neurol Neurosurg Psychiatry. 2016 Jul;87(7):710-6. doi: 10.1136/jnnp-2015-311680. Epub 2015 Sep 7.
Abstract/Text
OBJECTIVE: To systematically review published literature to estimate the magnitude of association between premorbid constipation and later diagnosis of Parkinson's disease.
BACKGROUND: Constipation is a recognised non-motor feature of Parkinson's and has been reported to predate diagnosis in a number of observational studies.
METHODS: A systematic review and meta-analysis was carried out following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) criteria. A literature search was undertaken in December 2014 using PubMed and the search terms 'Parkinson's disease' and 'constipation'. Articles were screened for suitability and reviewed against inclusion and exclusion criteria. Studies were included if they assessed constipation by means of a structured questionnaire or if constipation/drugs used to treat constipation were coded in patient medical records. Data were extracted using a standardised template and effect size estimates combined using a fixed-effects model. Heterogeneity was explored with the I(2) statistic.
RESULTS: 9 studies were included in the meta-analysis, with a combined sample size of 741 593 participants. Those with constipation had a pooled OR of 2.27 (95% CI 2.09 to 2.46) for developing subsequent Parkinson's disease compared with those without constipation. Weak evidence for heterogeneity was found (I(2)=18.9%, p=0.282). Restricting analysis to studies assessing constipation more than 10 years prior to Parkinson's disease gave a pooled OR of 2.13 (95% CI 1.78 to 2.56; I(2)=0.0%).
CONCLUSIONS: This systematic review and meta-analysis demonstrates that people with constipation are at a higher risk of developing Parkinson's disease compared with those without and that constipation can predate Parkinson's diagnosis by over a decade.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Matsumoto M, Misawa N, Tsuda M, Manabe N, Kessoku T, Tamai N, Kawamoto A, Sugama J, Tanaka H, Kato M, Haruma K, Sanada H, Nakajima A.
Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography.
Diagnostics (Basel). 2022 Jan 25;12(2). doi: 10.3390/diagnostics12020300. Epub 2022 Jan 25.
Abstract/Text
Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient's colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.
日本看護科学学会 看護ケア開発・標準化委員会（編）：看護ケアのための便秘時の大腸便貯留アセスメントに関する診療ガイドライン、南江堂、2023.
Metcalf AM, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG.
Simplified assessment of segmental colonic transit.
Gastroenterology. 1987 Jan;92(1):40-7. doi: 10.1016/0016-5085(87)90837-7.
Abstract/Text
Transit times of radiopaque markers through the human gut were measured by published techniques and compared with a simplified method. Three sets of distinctive markers were ingested by 24 healthy persons on 3 successive days. In the first part of the study, daily abdominal x-rays were taken and individual stools were collected for radiography. Mouth-to-anus transits were assessed from the fecal output of markers and mean colonic and segmental colonic transits were calculated from the daily radiographs. These established methods were then compared with estimates of total colonic and segmental transits based on a single abdominal film, taken on the fourth day. The single-film technique correlated well with values obtained from the previous, but more inconvenient, methods. Using the simpler approach, colonic transit was assessed in 49 additional healthy subjects, for a total group of 73. Total colonic transit was 35.0 +/- 2.1 h (mean +/- SE); segmental transits was 11.3 +/- 1.1 h for the right colon, 11.4 +/- 1.4 h for the left colon, and 12.4 +/- 1.1 h for the rectosigmoid. Men had significantly shorter transits for the whole colon than did women (p less than 0.05), and this difference was apparent to some extent in the right (p = 0.06) and left colon (p = 0.07) but not in the rectosigmoid. Age did not influence transit significantly nor did a small dose of supplemental fiber. The technique is simple, convenient for clinical usage, and reduces the exposure to radiation to acceptable levels. There should be a role for this approach in the evaluation of colonic transit in selected patients.
Haaga JR, Boll D. CT and MRI of the Whole Body, 6th Ed in 2 Vols., Elsevier, 2016.
Tagart RE.
The anal canal and rectum: their varying relationship and its effect on anal continence.
Dis Colon Rectum. 1966 Nov-Dec;9(6):449-52. doi: 10.1007/BF02617443.
Abstract/Text
Tian H, Ge X, Nie Y, Yang L, Ding C, McFarland LV, Zhang X, Chen Q, Gong J, Li N.
Fecal microbiota transplantation in patients with slow-transit constipation: A randomized, clinical trial.
PLoS One. 2017;12(2):e0171308. doi: 10.1371/journal.pone.0171308. Epub 2017 Feb 3.
Abstract/Text
Fecal microbiota transplantation has been proposed as a therapeutic approach for chronic constipation. This randomized, controlled trial aimed to compare the effects of conventional treatment alone (control) with additional treatment with FMT (intervention) in patients with slow-transit constipation (STC). Adults with STC were randomized to receive intervention or control treatment. The control group received education, behavioral strategies, and oral laxatives. The intervention group was additionally provided 6 days of FMT. The primary endpoint was the clinical cure rate (proportion of patients achieving a mean of ≥ three complete spontaneous bowel movements [CSBMs] per week]. Secondary outcomes and safety parameters were assessed throughout the study. Sixty patients were randomized to either conventional treatment alone (n = 30) or FMT (n = 30) through a nasointestinal tube. There were significant differences between the intervention group and control group in the clinical improvement rate (intention-to-treat [ITT]: 53.3% vs. 20.0%, P = 0.009), clinical cure rate (ITT: 36.7% vs. 13.3%, P = 0.04), mean number of CSBMs per week (ITT: 3.2 ± 1.4 vs. 2.1 ± 1.2, P = 0.001), and the Wexner constipation score (ITT: 8.6 ± 1.5 vs. 12.7 ± 2.5, P < 0.00001). Compared with the control group, the intervention group showed better results in the stool consistency score (ITT: 3.9 vs. 2.4, P < 0.00001) and colonic transit time (ITT: 58.5 vs. 73.6 h, P < 0.00001). The intervention group had more treatment-related adverse events than did the control group (50 vs. 4 cases). FMT was significantly more effective (30% higher cure rate) for treatment of STC than conventional treatment. No serious adverse events were observed.
Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S.
American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation.
Gastroenterology. 2023 Jun;164(7):1086-1106. doi: 10.1053/j.gastro.2023.03.214.
Abstract/Text
INTRODUCTION: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults.
METHODS: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations.
RESULTS: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone.
DISCUSSION: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
Copyright © 2023. Published by Elsevier Inc.
Chmielewska A, Szajewska H.
Systematic review of randomised controlled trials: probiotics for functional constipation.
World J Gastroenterol. 2010 Jan 7;16(1):69-75. doi: 10.3748/wjg.v16.i1.69.
Abstract/Text
AIM: To systematically evaluate and update evidence on the efficacy and safety of probiotic supplementation for the treatment of constipation.
METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched in May 2009 for randomised controlled trials (RCTs) performed in paediatric or adult populations related to the study aim.
RESULTS: We included five RCTs with a total of 377 subjects (194 in the experimental group and 183 in the control group). The participants were adults (three RCTs, n = 266) and children (two RCTs, n = 111) with constipation. In adults, data suggests a favourable effect of treatment with Bifidobacterium lactis DN-173 010, Lactobacillus casei Shirota, and Escherichia coli Nissle 1917 on defecation frequency and stool consistency. In children, L. casei rhamnosus Lcr35, but not L. rhamnosus GG, showed a beneficial effect.
CONCLUSION: Until more data are available, we believe the use of probiotics for the treatment of constipation condition should be considered investigational.
Passos MDCF, Takemoto MLS, Corradino GC, Guedes LS.
Systematic review with meta-analysis: lubiprostone efficacy on the treatment of patients with constipation.
Arq Gastroenterol. 2020 Oct-Dec;57(4):498-506. doi: 10.1590/S0004-2803.202000000-83.
Abstract/Text
BACKGROUND: Lubiprostone is a type 2 chloride channel activator that has been shown to be efficacious and safe in the treatment for chronic constipation.
OBJECTIVE: To systematically review randomized clinical trials (RCTs) assessing efficacy of lubiprostone for patients with chronic idiopathic constipation (CIC), irritable bowel syndrome with predominant constipation (IBS-C) and opioid-induced constipation (OIC).
METHODS: Searches were conducted in PubMed, LILACS, Cochrane Collaboration Database, and Centre for Reviews and Dissemination. Lubiprostone RCTs reporting outcomes of spontaneous bowel movements (SBM) and abdominal pain or discomfort were deemed eligible. Meta-analysis was performed calculating risk ratios and 95% confidence intervals, using the Mantel-Haenszel method and random effects model.
RESULTS: Searches yielded 109 records representing 93 non-duplicate publications, and 11 RCTs (978 CIC, 1,366 IBS-C, 1,300 OIC, total = 3,644) met inclusion criteria. Qualitative synthesis showed that for CIC patients, lubiprostone is superior to placebo in terms of SBM outcomes. Meta-analysis for CIC was feasible for full responder and SBM within 24h rates, indicating superiority of lubiprostone over placebo. For IBS-C, lubiprostone was significantly superior for all SBM outcomes in follow-ups ranging from 1 week-3 months. In terms of abdominal pain, lubiprostone provided significantly better symptoms relief, particularly after 1 month of treatment. For OIC, lubiprostone was more effective than placebo for both SBM and discomfort measures.
CONCLUSION: Our findings demonstrated that lubiprostone is superior to placebo in terms of SBM frequency for CIC, IBS-C and OIC. In terms of abdominal symptoms, the most pronounced effect was seen for abdominal pain in IBS-C patients.
Rembert FC, Giesecke AH Jr, Jenkins MT.
Anesthetic morbidity in the traumatized patient.
Anesth Analg. 1970 Nov-Dec;49(6):890-8.
Abstract/Text
Nakajima A, Shoji A, Kokubo K, Igarashi A.
A Systematic Review and Network Meta-Analysis on the Efficacy of Medications in the Treatment of Chronic Idiopathic Constipation in Japan.
Gastroenterol Res Pract. 2021;2021:5534687. doi: 10.1155/2021/5534687. Epub 2021 Nov 30.
Abstract/Text
BACKGROUND: In the 2010s, medications with new mechanisms were introduced in Japan for the treatment of chronic idiopathic constipation (CIC). A few systematic reviews have compared medications' relative efficacy, but the reviews included studies on patients from various races, even though the mechanism of CIC is considered to differ between races. The aim of this study was to use a systematic review and network meta-analysis to compare the relative efficacy of these medications in Japanese patients.
METHODS: We conducted a meta-analysis and report it here according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We identified studies by searching MEDLINE (via the PubMed interface) and the Cochrane Library and ICHUSHI databases and included randomized clinical trials that compared medications for CIC with placebo in Japanese adults. Two reviewers independently screened and assessed articles, abstracted data, and assessed the risk of bias. We pooled data by random-effects meta-analyses and also performed a Bayesian network meta-analysis to indirectly compare data.
RESULTS: The present systematic review and meta-analyses included 1460 patients in 6 randomized clinical trials: 2 on linaclotide, 3 on elobixibat, 2 on lubiprostone, and 1 on lactulose. The results of direct comparisons showed that linaclotide, elobixibat, and lubiprostone were superior to placebo in the change of spontaneous bowel movements (SBMs) within 1 week: linaclotide, 1.95 (95% CI, 1.51-2.39); elobixibat, 5.69 (95% CI, 3.31-8.07); and lubiprostone, 2.41 (95% CI, 0.82-4.01). The Bayesian network meta-analysis showed consistent results. Elobixibat 10 mg was ranked first for the increase in SBMs and complete SBMs within 1 week and the time to first SBM. Lubiprostone 48 μg was ranked first for the proportion of patients with SBM within 24 hours.
CONCLUSION: Our direct and indirect meta-analyses revealed that the new CIC medications available in Japan have equal efficacy but that elobixibat and lubiprostone are highly likely to be more efficacious.
Copyright © 2021 Atsushi Nakajima et al.
日本消化器病学会（編）：機能性消化管疾患診療ガイドライン2020-過敏性腸症候群（IBS）改訂第2版、南江堂、2020.
