[Motility disorders of the colon]. / Motilitätsstörungen des Dickdarms.

The motility of the colon is modulated by the enteric nervous system. It is very complex, governing backward and forward movements of the feces. Primary megacolon and megarectum are clinically diverse. Megacolon refractory to laxative treatment may be subject to colectomy, while megarectum should be treated by consistent laxation. Acute colonic pseudo-obstruction may occur with severe systemic diseases and electrolyte disturbances or it may be postoperatively and/or medically induced. A small proportion of chronically constipated patients suffer from slow transit constipation, others from disordered defecation. In the remaining patients no objective cause of the complaints may be found. In slow transit constipation, propulsive colonic motility is disturbed, dietary fiber is ineffective, and the response to bisacodyl is blunted. Pelvic floor dyssynergia is characterized by a voluntary (although unconscious) contraction of the anal sphincter simultaneously with the abdominal muscles. It can be treated by avoiding straining and by sphincter training.

[Pharmacological treatment of constipation]. / Pharmakologische Behandlung der Obstipation.

Chronic constipation is a frequent condition often requiring pharmacological treatment. A number of laxatives that belong to very different pharmacological groups are available. Most relevant are the older representatives osmotic salts, sugars and sugar alcohols, macrogol, anthraquinones, diphenolic laxatives (bisacodyl and sodium picosulphate), and the newer compounds prucalopride and linaclotide. For all of these laxatives, efficacy has been shown in controlled trials. Electrolyte problems do not occur when laxatives are given in therapeutic doses (rare exceptions with salinic laxatives). The older laxatives are also safe regarding teratogenicity, abortion, and lactation; for the newer compounds no respective data are available as yet. It is questionable whether the newer laxatives offer advantages over the older ones. Unfortunately, comparative trials are lacking. Opiate-induced constipation may also be treated with laxatives or certain opiate antagonists.

Levels of satisfaction with current chronic constipation treatment options in Europe - an internet survey.

BACKGROUND: Data on treatment satisfaction in European men and women with chronic constipation are limited. AIM: To assess satisfaction with current treatment among European men and women with chronic constipation. METHODS: An internet-based survey was conducted in 2009 in 10 European countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands. Participants had self-reported chronic constipation (<3 bowel movements/week and ≥1 symptoms for ≥6 months of: pain during defecation; lumpy/hard faeces; and feeling of incomplete evacuation). Demographic data and disease history were collected. For participants using laxatives, drug name/class, satisfaction with treatment and interest in other treatments were collected. RESULTS: Of the 1941 participants screened, 1355 had chronic constipation and met the inclusion criteria (chronic constipation population). The majority of the chronic constipation population who disclosed their sex (n = 811) were women (82%). Sixty-eight per cent of respondents (n = 855/1255) reported using laxatives, with the proportion of laxative users differing between subsets. Twenty-eight per cent (n = 225/793) were (very) satisfied with their treatment, whereas 44% (n = 345/793) were neutral and 28% (n = 223/793) (very) dissatisfied. There was no relationship between type of laxative and degree of (dis)satisfaction. Interest in other treatments was high with 83% (n = 686/827) of respondents 'absolutely' or 'probably' interested. Respondents dissatisfied with their treatment were more likely to be interested in other treatments. CONCLUSIONS: Laxative-use is common for chronic constipation. In this large survey, 28% of participants were dissatisfied with their treatment, with the majority interested in other treatments.

[Laxative use and satisfaction of chronically constipated women - a survey of female patients and gastroenterologists in Germany]. / Laxanziengebrauch und Zufriedenheit chronisch obstipierter Frauen - eine Umfrage bei Patientinnen und Gastroenterologen in Deutschland.

OBJECTIVE: Data were collected concerning the patient satisfaction in the treatment of chronic constipation with laxatives. METHOD: An internet-based survey of female patients with chronic constipation and an online enquiry addressed to gastroenterologists in Germany were carried out. RESULTS: 492 female patients and 104 physicians participated in the survey. Only 20 % of the patients were currently consuming laxatives. Around one-third of those not using laxatives have had unsatisfactory experiences. Only 32 % of the participants currently taking laxatives were totally satisfied with their drugs. As a general rule several different preparations were tried. The laxatives most closely associated with satisfied patients were bisacodyl and sodium picosulfate, followed by macrogol. The main reasons for dissatisfaction were an insufficient relief of the constipation and a bloated feeling. The majority of the participants expressed an interest in new drugs for the treatment of constipation. The participating physicians stated that they saw several female patients per week who were not satisfied with their constipation treatment, but probably overestimate the proportion. CONCLUSION: The present survey shows that the majority of women suffering from constipation do not take laxatives and also that about half of them were not satisfied with the agents tried. Only about one-third of the chronic users were totally satisfied. Thus, there is a clear need for new laxatives.

Systematic review: cardiovascular safety profile of 5-HT(4) agonists developed for gastrointestinal disorders.

BACKGROUND: The nonselective 5-HT(4) receptor agonists, cisapride and tegaserod have been associated with cardiovascular adverse events (AEs). AIM: To perform a systematic review of the safety profile, particularly cardiovascular, of 5-HT(4) agonists developed for gastrointestinal disorders, and a nonsystematic summary of their pharmacology and clinical efficacy. METHODS: Articles reporting data on cisapride, clebopride, prucalopride, mosapride, renzapride, tegaserod, TD-5108 (velusetrag) and ATI-7505 (naronapride) were identified through a systematic search of the Cochrane Library, Medline, Embase and Toxfile. Abstracts from UEGW 2006-2008 and DDW 2008-2010 were searched for these drug names, and pharmaceutical companies approached to provide unpublished data. RESULTS: Retrieved articles on pharmacokinetics, human pharmacodynamics and clinical data with these 5-HT(4) agonists, are reviewed and summarised nonsystematically. Articles relating to cardiac safety and tolerability of these agents, including any relevant case reports, are reported systematically. Two nonselective 5-HT(4) agonists had reports of cardiovascular AEs: cisapride (QT prolongation) and tegaserod (ischaemia). Interactions with, respectively, the hERG cardiac potassium channel and 5-HT(1) receptor subtypes have been suggested to account for these effects. No cardiovascular safety concerns were reported for the newer, selective 5-HT(4) agonists prucalopride, velusetrag, naronapride, or for nonselective 5-HT(4) agonists with no hERG or 5-HT(1) affinity (renzapride, clebopride, mosapride). CONCLUSIONS: 5-HT(4) agonists for GI disorders differ in chemical structure and selectivity for 5-HT(4) receptors. Selectivity for 5-HT(4) over non-5-HT(4) receptors may influence the agent's safety and overall risk-benefit profile. Based on available evidence, highly selective 5-HT(4) agonists may offer improved safety to treat patients with impaired GI motility.

The Bowel Function Index for evaluating constipation in pain patients: definition of a reference range for a non-constipated population of pain patients.

Opioid-induced constipation (OIC) is a severe, persisting side-effect of opioid therapy. The Bowel Function Index (BFI(a), numerical analogue scale 0 - 100), calculated as the mean of three variables (ease of defaecation, feeling of incomplete bowel evacuation, and personal judgement of constipation) was developed to evaluate bowel function in opioid-treated patients with pain. This clinician-administered tool allows easy measurement of OIC from the patient's perspective. The purpose of this investigation was to define a reference range reflecting BFI values in non-constipated chronic pain patients who were recruited into a cross-sectional survey and asked for their perceptions of constipation. The BFI scores were assessed and compared with those of patients with confirmed OIC obtained from two previously published trials. Results were analysed and a reference range of BFI values of 0 - 28.8, into which 95% of non-constipated chronic pain patients fell, was defined. This permits discrimination between chronic pain patients with, or without, constipation.

Diagnosis and treatment of chronic constipation--a European perspective.

BACKGROUND: Although constipation can be a chronic and severe problem, it is largely treated empirically. Evidence for the efficacy of some of the older laxatives from well-designed trials is limited. Patients often report high levels of dissatisfaction with their treatment, which is attributed to a lack of efficacy or unpleasant side-effects. Management guidelines and recommendations are limited and are not sufficiently current to include treatments that became available more recently, such as prokinetic agents in Europe. PURPOSE: We present an overview of the pathophysiology, diagnosis, current management and available guidelines for the treatment of chronic constipation, and include recent data on the efficacy and potential clinical use of the more newly available therapeutic agents. Based on published algorithms and guidelines on the management of chronic constipation, secondary pathologies and causes are first excluded and then diet, lifestyle, and, if available, behavioral measures adopted. If these fail, bulk-forming, osmotic, and stimulant laxatives can be used. If symptoms are not satisfactorily resolved, a prokinetic agent such as prucalopride can be prescribed. Biofeedback is recommended as a treatment for chronic constipation in patients with disordered defecation. Surgery should only be considered once all other treatment options have been exhausted.

[Endoscopic procedures for patients on antithrombotic medication--risks and methods]. / Endoskopische Prozeduren bei Patienten unter antithrombotischer Medikation--Risiken und praktisches Vorgehen.

The decision how to handle an antithrombotic treatment when an intervention during GI endoscopy is planned is influenced both by the risk of bleeding and by the thromboembolic risk when treatment is suspended. The risk of bleeding is negligible even when on oral anticoagulants in diagnostic procedures with standard forceps biopsies. Oral anticoagulation has to be stopped, however, when planning invasive procedures such as polypectomy or EPT. In the case of patients with a high risk of thromboembolic complications such as artificial valves in mitral position or atrial fibrillation with risk factors, one has to temporarily switch to anticoagulants with shorter action ("bridging"). Treatment with inhibitors of platelet function does not preclude procedures with a low risk of bleeding including forceps biopsy. Urgent procedures with a high risk of bleeding should be performed after stopping clopidogrel one week previously but only after consultation with the treating cardiologist. In the case of colonoscopy, in particular as a screening procedure, there are two options: 1) stopping oral anticoagulation (with or without bridging) or clopidogrel, respectively, or 2) continuing antithrombotic treatment and performing a second elective endoscopy for polypectomy with tapered antithrombotic medication if polyps are found which are not amenable to resection by biopsy forceps. The choice between these two options has to be made individually.