Cross cultural comparison of constipation profiles at tertiary care centers between India and USA.

BACKGROUND: Despite potential differences in patient perception of chronic constipation (CC) in geographically and culturally distinct regions, head-to-head studies comparing the clinical profile, constipation severity, impact on quality of life (QOL) and economic impact are lacking. METHODS: We conducted a cross-sectional cohort study of patients presenting with CC to tertiary care centers in the USA and India. Standardized instruments were used to assess constipation subtype, disease severity, disease-specific QOL, somatization, and psychiatric comorbidities. We used multivariable linear regression to determine the predictors of QOL and number of healthcare visits. KEY RESULTS: Sixty-six and 98 patients with CC were enrolled in the USA and India, respectively. Indian patients with CC had significantly more frequent bowel movements/week compared to their USA counterparts (Median 5 vs 3, P < .0001). The proportion of patients with Bristol stool form scale type 1 and 2 was significantly higher in the USA compared to India (65.5% vs 48%, P = .04). Higher depression score (P = .001), more severe constipation symptoms (P = .001) and site of the study being USA (P = .008) independently predicted worse QOL. Indian patients (P < .001) and worse QOL (P = .02) were independent predictors of number of healthcare visits in the last 12 months. CONCLUSIONS AND INFERENCES: Indian patients with CC have more frequent and softer bowel movements compared to those in the USA suggesting significant differences in perception of CC in different geographic and cultural settings. QOL and economic impact related to constipation varies with geographic/cultural setting irrespective of other clinical and psychosomatic features.

Number of retained radiopaque markers on a colonic transit study does not correlate with symptom severity or quality of life in chronic constipation.

BACKGROUND: Ingestion of radiopaque markers (ROM) is frequently used to determine colonic transit in chronic constipation. Although ≥20% of retained markers at 5 days defines slow-transit constipation, some clinicians use the number of retained markers to determine disease severity. METHODS: We assembled a cross-sectional cohort of patients presenting for evaluation of chronic constipation who underwent transit testing by ROM and completed validated symptom severity and quality-of-life (QOL) measures. We performed a correlation analysis to determine whether there was an association between number of retained markers and symptom severity and QOL. KEY RESULTS: Among 159 patients undergoing evaluation for chronic constipation, there was poor correlation between the number of retained markers and symptom severity (R = .09, P = .25) and QOL. Among the 55 patients with slow-transit constipation defined by ≥5 retained markers retained on day 5, there were similarly poor correlations between symptom severity (R = .17, P = .21) and QOL (R = .07, P = .60). Excluding patients with irritable bowel syndrome and outlet obstruction by balloon expulsion testing did not materially alter our results, nor did a multivariable analysis controlling for demographic and psychiatric confounders. CONCLUSIONS AND INFERENCES: Among patients with chronic constipation, number of retained markers on a ROM colonic transit study does not correlate with measures of symptom severity or QOL. Clinicians should be cautious about overinterpreting ROM transit testing.

Gender differences in chronic constipation on anorectal motility.

BACKGROUND: The epidemiology of chronic constipation (CC) skews toward female predominance, yet men make up an important component of those suffering from CC. We sought to determine whether there are sex-specific differences in symptoms and physiologic parameters on anorectal manometry (ARM). METHODS: We performed a case-control analysis of sequential men and age-matched women (2:1 ratio) presenting for ARM as part of the evaluation of CC. We collected physiologic parameters derived from 3D high-resolution ARM in addition to the ROME III constipation module and the Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaires. We analyzed univariate, sex-specific differences in ARM physiologic parameters and PFDI-20 parameters and adjusted for putative confounders using multivariate logistic regression. KEY RESULTS: Our study enrolled 80 men and 165 age-matched women. Men had a higher median sphincter resting pressure (81.2 vs 75.2 mm Hg, P=.01) and mean squeeze pressure (257.0 vs 170.5 mm Hg, P<.0001) than women. Although men reported significantly less severe straining and incomplete evacuation, they had greater mean rectoanal pressure differential (-106.7 vs -71.1 mm Hg, P<.0001), smaller mean defecation index (0.17 vs 0.27, P=.03) and higher volume threshold for urgency (115.2 v. 103.4 mL, P=.03). However, women were more likely to have abnormal balloon expulsion time (BET) than men (52.7% vs 35.0%, P=.01). After multivariate analysis, male gender was the only independent predictor of a normal BET (OR: 0.48, 95% CI: 0.27-0.86, P=.01). CONCLUSIONS & INFERENCES: Men and women with CC differ with regard to symptom severity and physiologic parameters derived from ARM suggesting differences in their pathophysiology.

Resting anal pressure, not outlet obstruction or transit, predicts healthcare utilization in chronic constipation: a retrospective cohort analysis.

BACKGROUND: Chronic constipation is common and exerts a considerable burden on health-related quality of life and healthcare resource utilization. Anorectal manometry (ARM) and colonic transit testing have allowed classification of subtypes of constipation, raising promise of targeted treatments. There has been limited study of the correlation between physiological parameters and healthcare utilization. METHODS: All patients undergoing ARM and colonic transit testing for chronic constipation at two tertiary care centers from 2000 to 2014 were included in this retrospective study. Our primary outcomes included number of constipation-related and gastroenterology visits per year. Multivariate linear regression adjusting for confounders defined independent effect of measures of colonic and anorectal function on healthcare utilization. KEY RESULTS: Our study included 612 patients with chronic constipation. More than 50% (n = 333) of patients had outlet obstruction by means of balloon expulsion testing and 43.5% (n = 266) had slow colonic transit. On unadjusted analysis, outlet obstruction (1.98 vs 1.68), slow transit (2.40 vs 2.07) and high resting anal pressure (2.16 vs 1.76) were all associated with greater constipation-related visits/year compared to patients without each of those parameters (p < 0.05 for all). Outlet obstruction and high resting anal pressure were also associated with greater number of gastroenterology visits/year. After multivariate adjustment, high resting anal pressure was the only independent predictor of increased constipation-related visits/year (p = 0.02) and gastroenterology visits/year (p = 0.04). CONCLUSIONS & INFERENCES: Among patients with chronic constipation, high resting anal pressure, rather than outlet obstruction or slow transit, predicts healthcare resource utilization.

Duodenal rather than antral motility contractile parameters correlate with symptom severity in gastroparesis patients.

BACKGROUND: Studies of symptomatic gastroparetics consistently find poor correlation with gastric emptying. We hypothesized that concomitant small bowel dysmotility may play a role in symptom causation in gastroparesis and sought to test this hypothesis by using wireless motility capsule (WMC) testing to simultaneously measure antral and duodenal area under pressure curve (AUC) in patients with delayed gastric emptying. METHODS: Using a cohort from a multicenter clinical trial and a separate tertiary clinical database, we identified gastroparetics that underwent concurrent WMC testing and completed the Gastroparesis Cardinal Symptom Index, a validated questionnaire. Our study included 35 gastroparetics defined by a gastric emptying time (GET) ≥ 5 h. Antral and duodenal AUC were assessed at 1-h windows pre-GET and post-GET, respectively. KEY RESULTS: We found moderate correlations between duodenal AUC and symptom severity in the combined cohort (n = 35; R = -0.42; p = 0.01; 95% CI -0.7, -0.1). Removing patients with colonic delay resulted in a stronger correlation of duodenal AUC to symptom severity (n = 21; R = -0.63; p < 0.01; 95% CI -0.81, -0.31). The multicenter trial (n = 20) and clinical practice cohorts (n = 15) had significantly different symptom severity and exclusion criteria. When analyzed separately, significant correlations between duodenal AUC and symptom severity were observed (R = -0.71; p < 0.01; 95% CI -0.9, -0.4 and R = -0.72; p < 0.01; 95% CI -0.9, -0.3, respectively). Symptom severity and antral motility showed no correlation. CONCLUSIONS & INFERENCES: We found significant correlations between duodenal AUC and symptom severity in two cohorts of gastroparetics. Small bowel motility may contribute to symptom generation in gastroparetic patients and this may inform therapeutic considerations.