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      Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

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          Summary

          Background

          Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders.

          Aim

          To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic‐based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation.

          Methods

          Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices.

          Results

          Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects.

          Conclusions

          Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence‐based treatments by a gastroenterology provider.

          Abstract

          Gastroenterology providers should be familiar with the constipation subtypes and their underlying pathophysiology, as well as key signalling pathways that may contribute to constipation. Familiarisation with the varied mechanisms of action, expected efficacy and side effects of available therapies helps to select the appropriate treatment and meet patient expectations.

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          Most cited references184

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          Bowel Disorders.

          Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, gender, race, creed, color or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical as they impose a negative economic impact to the global health care system in addition to reducing quality of life. Research in the basic and clinical sciences during the past decade has produced new information on the epidemiology, etiology, pathophysiology, diagnosis and treatment of FBDs. These important findings created a need to revise the Rome III criteria for FBDs, last published in 2006. This manuscript classifies the FBDs into five distinct categories: irritable bowel syndrome (IBS); functional constipation (FC); functional diarrhea (FDr); functional abdominal bloating/distention (FAB/D); and unspecified FBD (U-FBD). Also included in this article is a new sixth category, opioid induced constipation (OIC) which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features and treatment. It is the hope of this committee that this new information will assist both clinicians and researchers in the decade to come.
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            Chronic constipation: a survey of the patient perspective.

            Constipation is a common, often chronic, gastrointestinal motility disorder characterized by such symptoms as straining, hard stool, and infrequent defecation. Published literature is limited regarding symptom prevalence, healthcare-seeking behaviour, and patient satisfaction with traditional therapies for chronic constipation. To assess the prevalence of chronic constipation among a random sample of Americans, to identify the frequency, severity and bothersomeness of their symptoms, and to assess satisfaction levels with traditional treatments. All members (N = 37,004) of the Knowledge Networks Panel, representative of the US population, participated in a web-based survey. Eligibility was established using a six-question screener. Of the 24,090 panellists consenting to participate, 557 met eligibility requirements and took the 45-question survey. The most prevalent symptom was straining (79%). Hard stool and straining were the top two severe symptoms, and bloating, straining and hard stool were the top three bothersome symptoms. Symptoms affected quality of life of more than half (52%) the respondents. Among those who worked or went to school, 12% experienced reduced productivity and a mean of 2.4 days of absence in the month before the survey. Most respondents had used (96%) or were using (72%) constipation relief therapy; however, nearly half (47%) were not completely satisfied, mainly because of efficacy (82%) and safety (16%) concerns. Chronic constipation is common. Individual symptoms are often severe and bothersome, and many patients are dissatisfied with traditional treatment options, primarily because of lack of efficacy.
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              A placebo-controlled trial of prucalopride for severe chronic constipation.

              In this 12-week trial, we aimed to determine the efficacy of prucalopride, a selective, high-affinity 5-hydroxytryptamine4 receptor agonist, in patients with severe chronic constipation. In our multicenter, randomized, placebo-controlled, parallel-group, phase 3 trial, patients with severe chronic constipation (< or =2 spontaneous, complete bowel movements per week) received placebo or 2 or 4 mg of prucalopride, once daily, for 12 weeks. The primary efficacy end point was the proportion of patients having three or more spontaneous, complete bowel movements per week, averaged over 12 weeks. Secondary efficacy end points were derived from daily diaries and validated questionnaires completed by patients. Adverse events, clinical laboratory values, and cardiovascular effects were monitored. Efficacy was analyzed in 620 patients. The proportion of patients with three or more spontaneous, complete bowel movements per week was 30.9% of those receiving 2 mg of prucalopride and 28.4% of those receiving 4 mg of prucalopride, as compared with 12.0% in the placebo group (P<0.001 for both comparisons). Over 12 weeks, 47.3% of patients receiving 2 mg of prucalopride and 46.6% of those receiving 4 mg of prucalopride had an increase in the number of spontaneous, complete bowel movements of one or more per week, on average, as compared with 25.8% in the placebo group (P<0.001 for both comparisons). All other secondary efficacy end points, including patients' satisfaction with their bowel function and treatment and their perception of the severity of their constipation symptoms, were significantly improved with the use of 2 or 4 mg of prucalopride as compared with placebo, at week 12. The most frequent treatment-related adverse events were headache and abdominal pain. There were no significant cardiovascular effects of treatment. Over 12 weeks, prucalopride significantly improved bowel function and reduced the severity of symptoms in patients with severe chronic constipation. Larger and longer trials are required to further assess the risks and benefits of the use of prucalopride for chronic constipation. (ClinicalTrials.gov number, NCT00483886 [ClinicalTrials.gov].). Copyright 2008 Massachusetts Medical Society.
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                Author and article information

                Contributors
                amosharma@augusta.edu
                Journal
                Aliment Pharmacol Ther
                Aliment Pharmacol Ther
                10.1111/(ISSN)1365-2036
                APT
                Alimentary Pharmacology & Therapeutics
                John Wiley and Sons Inc. (Hoboken )
                0269-2813
                1365-2036
                28 April 2021
                June 2021
                : 53
                : 12 ( doiID: 10.1111/apt.v53.12 )
                : 1250-1267
                Affiliations
                [ 1 ] Division of Gastroenterology/Hepatology Medical College of Georgia Augusta University Augusta GA USA
                [ 2 ] DuPage Medical Group Hoffman Estates IL USA
                [ 3 ] Atlanta Gastroenterology Atlanta GA USA
                [ 4 ] Department of Pharmacology and Experimental Therapeutics Thomas Jefferson University Philadelphia PA USA
                Author notes
                [*] [* ] Correspondence

                Amol Sharma, Augusta University, 1120 15th Street, Augusta University Medical Center, AD 2226, Augusta, GA 30912, USA.

                Email: amosharma@ 123456augusta.edu

                Author information
                https://orcid.org/0000-0002-5843-1220
                Article
                APT16369
                10.1111/apt.16369
                8252518
                33909919
                4585e0c9-6466-4184-96bd-b1ff9e4abcdf
                © 2021 The Authors. Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 24 December 2020
                : 08 December 2020
                : 31 March 2021
                Page count
                Figures: 5, Tables: 3, Pages: 18, Words: 13628
                Funding
                Funded by: Salix Pharmaceuticals, Inc (Bridgewater, NJ, USA)
                Funded by: Targeted Diagnostic & Therapeutics, Inc.
                Funded by: National Institute of Health , open-funder-registry 10.13039/100000002;
                Award ID: 1R01 CA204881
                Award ID: 1R01 CA206026
                Award ID: P30 CA56036
                Funded by: Department of Defense Congressionally Directed Medical Research Program
                Award ID: W81XWH‐17‐PRCRP‐TTSA
                Funded by: The Courtney Ann Diacont Memorial Foundation , open-funder-registry 10.13039/100016424;
                Categories
                Review Article
                Review Articles
                Custom metadata
                2.0
                June 2021
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.4 mode:remove_FC converted:02.07.2021

                Pharmacology & Pharmaceutical medicine
                Pharmacology & Pharmaceutical medicine

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