PSYLLIUM & COLON
letteratura - references
1) Br J Nutr 1988 Nov;60(3):467-475
The
relation between bacterial degradation of viscous polysaccharides and
stool output in human beings
Tomlin J, Read NW
Sub-Department of Human Gastrointestinal
Physiology and Nutrition, Royal Hallamshire Hospital, Sheffield
The relation between bacterial
degradation of three viscous polysaccharides (guar gum, ispaghula and
xanthan gum) by colonic bacteria in vitro and their effects on colonic
function were investigated by comparing the results of anaerobic in
vitro incubations with fresh faeces from seven healthy volunteers (measuring
viscosity, pH and gas production) with the effects of feeding all three
polysaccharides to the same volunteers for 1 week each (14-15 g/d) on
faecal mass and whole-gut transit time. 2. Guar gum was rapidly
fermented in vitro by faecal bacteria from all volunteers with
concomitant loss of viscosity, reduction in pH and generation of gases.
Ispaghula maintained its viscosity during incubation, but the pH fell
significantly. The results of xanthan gum incubations showed
considerable individual variation. 3. Only ispaghula significantly
increased faecal mass, whilst none of the gums significantly affected
stool frequency or transit time. Statistical analysis of the pooled
results showed that although transit time and faecal output were
inversely related, feeding viscous polysaccharides could influence these
indices independently. Stool frequency was significantly correlated with
the transit time, but not the faecal output. 4. Transit time was reduced
by gum feeding to a significantly greater extent in those subjects whose
faecal bacteria reduced or removed the viscosity of that gum, than in
those subjects where the viscosity was maintained. In contrast, there
was a smaller increase in faecal mass when the viscosity of the
appropriate cultures was removed than when it was maintained or reduced.
Increases in stool frequency were significantly associated with hydrogen
production from in vitro cultures.
2) Aliment Pharmacol Ther 1997
Dec;11(6):1067-1072
Absence
of gaseous symptoms during ingestion of commercial fibre preparations
Zumarraga L, Levitt MD, Suarez F
The Minneapolis Veterans Affairs Medical
Center, MN 55417, USA.
BACKGROUND: While fibre is believed to
cause gaseous symptoms, a study in healthy volunteers showed no increase
in flatulence when the diet was supplemented with fermentable (psyllium)
or non-fermentable (methylcellulose) fibre. However, extrapolation of
this observation to subjects who use fibre is arguable since these
individuals may have a propensity to gaseousness. In the present study,
gaseous complaints during fibre ingestion were assessed in subjects who
believed that a previous exposure to fibre induced gas. METHODS: In a
double-blind protocol, subjects were randomized to one of four treatment
periods, during which the regular diet was supplemented for 1-week
periods with two daily doses of: placebo 10 g, psyllium 3.4 g,
methylcellulose 2 g or lactulose 5 g. A symptom diary was maintained for
1-week periods on or off treatment. RESULTS: During treatment, the
lactulose group passed gas significantly more often than did the
psyllium or the methylcellulose group (P = 0.01). No other symptom was
significantly different among the treatment groups. CONCLUSIONS: (1)
psyllium and methylcellulose did not cause greater gaseous
symptomatology than did placebo in subjects who believed that these
preparations caused gas; and (2) subjects commonly misidentify dietary
components that cause gaseous symptoms
3) Med Klin 1994 Dec 15;89(12):645-651
Effectiveness
of plantago seed husks in comparison with wheat bran on stool frequency
and manifestations of irritable colon syndrome with constipation
Hotz J, Plein K
Allgemeines Krankenhaus Celle, Innere
Medizin, Klinik fur Innere Medizin und Gastroenterologie, Freiburg.
BACKGROUND AND AIM: The importance of
dietary fibres in treatment of irritable bowel syndrome increased during
the last years. Yet the results of clinical studies on the different
dietary fibres are not consistent. Therefore we decided to perform a
controlled trial with a well defined group of patients to compare the
effectiveness of wheat bran to psyllium seeds. PATIENTS AND METHODS:
Thirty patients each with irritable bowel syndrome group II to III were
treated in an open, not controlled study design either with 3 times 3.25
g psyllium seeds or 3 times 7 g wheat bran daily. All patients entering
the study had not been treated for at least 3 weeks before. The study
comprised two treatment phases of two weeks each, separated by two weeks
without any treatment, thus leading to a study duration of 6 weeks
altogether. Parameters for evaluation were stool frequency and
consistency and the symptoms pain and abdominal distention, measured by
a score (1 to 4). RESULTS: In both treatments groups stool frequency and
consistency improved apparently compared to the starting point or the
two weeks treatment free time in between. The improvement of stool
frequency was statistically significant (p < 0.0001) for both
substances. Furthermore the effect of psyllium seeds exceeded that of
wheat bran statistically significant in week 1, 2, 3, 5 and 6 (p <
0.005). Other symptoms such as abdominal pain improved too by therapy,
psyllium seeds again tending to show better results. A significant
difference between both substances could be observed on the symptom
abdominal distension. Whereas abdominal distension decreased under
treatment with psyllium seeds it increased with wheat bran. This lead to
discontinuation of the study in 5 cases, 3 of which could be changed
successfully to psyllium seeds. The difference between psyllium seeds
and wheat bran concerning the occurrence of abdominal distension was
statistically significant (p < 0.01). CONCLUSION: The results of this
study demonstrate the effectiveness of psyllium seeds and wheat bran on
stool frequency and consistency of patients with irritable bowel
syndrome. Psyllium seeds showed to be superior to wheat bran with
respect to stool frequency and abdominal distension so that it should be
preferred in treatment of irritable bowel syndrome and constipation.
Publication Types: Clinical trial/Controlled clinical trial
4) Mov Disord 1997 Nov;12(6):946-951
Constipation
in Parkinson's disease: objective assessment and response to psyllium
Ashraf W, Pfeiffer RF, Park F, Lof J,
Quigley EM
We evaluated the reliability of patient
history and the effect of psyllium on symptoms and colorectal function
in 12 patients with Parkinson's disease (PD) and constipation. In all
but two, constipation anteceded the development of parkinsonian symptoms.
A comparison with prospectively obtained stool diaries confirmed the
patients' reported constipation in 7 of the 12 patients. Those patients
with confirmed constipation had lower stool weights and reported more
straining at stool. Measures of colonic and anorectal function were
similar in those who were truly constipated and those who were not.
Among those PD subjects with confirmed constipation, psyllium increased
stool frequency and weight but did not alter colonic transit or
anorectal function. We conclude that prospectively obtained stool
diaries should be employed to confirm constipation in PD and that
psyllium produces both subjective and objective improvements in
constipation related to PD
5) Aliment Pharmacol Ther 1995 Dec;9(6):639-647
Effects
of psyllium therapy on stool characteristics, colon transit and
anorectal function in chronic idiopathic constipation
Ashraf W, Park F, Lof J, Quigley EM
BACKGROUND: Psyllium is widely used in
the symptomatic therapy of constipation. Its effects on colonic function
and their correlation with symptomatic response have not been defined.
METHODS: After a 4-week baseline, placebo, run-in phase, 22 subjects
with idiopathic constipation confirmed by prospectively administered
stool diaries were randomly assigned to receive either psyllium (5 g
b.d., 11 patients) or placebo (11 patients) for 8 weeks, followed by
another 4-week wash-out, placebo phase. A colon transit study and
anorectal manometry were performed at the beginning and at the end of
each study phase. Subjects recorded, in diaries, their daily stool
frequency, difficulty with defecation and weekly stool weight. RESULTS:
Stool frequency increased significantly after 8 weeks of psyllium
treatment (3.8 +/- 0.4 vs. 2.9 +/- 0.1 stools/week, P < 0.05) as did
stool weight (665.3 +/- 95.8 g vs. 405.2 +/- 75.9 g, P < 0.05).
Subjects also reported an improvement in stool consistency (stool
consistency score: 3.2 +/- 0.2 vs. 3.8 +/- 0.2, P < 0.05) and pain on
defecation (pain score: 2.0 +/- 0.4 vs. 2.6 +/- 0.5, P < 0.05) on
psyllium. Colon transit and anorectal manometry parameters were
unchanged on psyllium. Subjects treated with placebo did not show any
change in either subjective or objective measures of constipation.
CONCLUSIONS: Psyllium increases stool frequency and weight and improves
stool consistency in idiopathic constipation. These effects are not
associated with significant changes in either colonic or rectal motor
function. We suggest that the beneficial effects of psyllium in
constipation are primarily related to a facilitation of the defecatory
process.Publication Types: Clinical trial
6) Rev Esp Enferm Dig 1992 Jul;82(1):17-22
The
efficacy of Plantago ovata as a regulator of intestinal transit. A
double-blind study compared to placebo
Tomas-Ridocci M, Anon R, Minguez M, Zaragoza A, Ballester J, Benages A
Unidad de Motilidad Digestiva, Hospital
Clinico Universitario, Valencia.
The effect of Plantago ovata on patients
with chronic constipation (CC) with or without irritable bowel syndrome
(IBS) has been assessed by a double blind study comprising 20 patients
with CC of which 10 had associated IBS. A clinical questionnaire, weight
of feces and intestinal transit time measured with radiopaque markers
were done. Patients were then randomly distributed, 10 receiving PO and
10 placebo. Similar tests were done after treatment one month later. All
patients receiving PO had good results against only one in the placebo
group. Frequency of stools increased from 2.5 +/- 1 vs 8 +/- 2.2 stools
per week, p less than 0.001 for paired data). A decrease in consistency
of stools was also observed in the treated group. Fecal weight and
colonic transit time were not significantly modified in placebo patients,
while weight increase was observed in the treated ones (124 +/- 71 vs
194 +/- 65, gr/d p less than 0.001 for paired data) as well as a
decrease in transit time (48 +/- 15 vs 34 +/- 18 hours p less than 0.05
for paired data). No adverse effects were observed and particularly no
flatulence as often seen in patients on bran. Publication
Types: Clinical trial; Randomized
controlled trial
7) Hepatogastroenterology 1996 Nov;43(12):1504-1507
Effect
of fiber supplements on internal bleeding hemorrhoids
Perez-Miranda M, Gomez-Cedenilla A,
Leon-Colombo T, Pajares J, Mate-Jimenez J
Gastroenterology Department, Hospital de
Ia Princesa, Universidad Autonoma de Madrid, Spain
BACKGROUND/AIMS: The aim of this study is
to assess prospectively the effect of fiber additions on internal
bleeding hemorrhoids. MATERIALS AND METHODS: Fifty patients with
bleeding internal hemorrhoids are studied and randomized in two groups.
Patients in the study group were treated with a commercially available
preparation of Plantago Ovata and those in the control group were
treated with a placebo. Endoscopy was performed on every patient before
and after treatment to establish: a) the degree of hemorrhoidal prolapse,
b) the number of congested hemorrhoidal cushions and c) contact bleeding
hemorrhoids. RESULTS: During the 15 days of treatment, the average
number of bleeding episodes was 4.8 +/- 3.8 for the study group versus
6.4 +/- 3 for the control group (n.s.). During the following 15 days, it
decreased to 3.1 +/- 2.7 in the study group versus 5.5 +/- 3.2 (p <
0.05) in the control group and in the last 10 days of treatment a
further reduction to 1.1 +/- 1.4 was found in the study group versus 5.5
+/- 2.9 (p < 0.001). The number of congested hemorrhoidal cushions
diminished from 2.6 +/- 1 to 1.6 +/- 2.2 after fiber treatment (p <
0.01) and no differences were found in the control group. In the fiber
group, hemorrhoids bled on contact in 5 out of 22 patients before
treatment and in none after treatment; no differences were found in the
control group. No modification of the degree of prolapse was observed
after treatment. CONCLUSION: Addition of dietary fiber may improve
internal bleeding hemorrhoids although with no immediate effect. Fiber
addition should be ensured in patients who refuse invasive treatment,
waiting for a more defined form of treatment, or with contraindications. Publication Types: Clinical trial Randomized
controlled trial
8) Gut 1994 Dec;35(12):1747-1752
Digestibility
and bulking effect of ispaghula husks in healthy humans
Marteau P, Flourie B, Cherbut C,
Correze JL, Pellier P, Seylaz J, Rambaud JC
INSERM U 290 Hopital Saint-Lazare, Paris, France.
The digestibility of ispaghula, a
mucilage from Plantago ovata composed mainly of arabinoxylans, and its
faecal bulking effect were studied in seven healthy volunteers who
ingested a low fibre controlled diet plus either placebo or 18 g/day of
ispaghula for two 15 day periods. Whole gut transit time and gas
excretion in breath and flatus were not different during the periods of
ispaghula and placebo ingestion. Faecal wet and dry weights rose
significantly, however, during ispaghula ingestion. Faecal short chain
fatty acid concentrations and the molar proportions of propionic and
acetic acids also increased. Most of the ispaghula had reached the
caecum four hours after ingestion in an intact highly polymerised form.
During ispaghula ingestion, the increase in the faecal output of neutral
sugars was accounted for by the faecal excretion of arabinose and xylose
in an intact highly polymerised form; the apparent digestibilities of
these sugars were 24 (11) and 53% (6) respectively (mean (SEM)). In
conclusion, ispaghula is more resistant to fermentation than previously
reported in humans, and its bulking effect largely results from intact
material. Publication Types: Clinical
trial, Randomized controlled trial
9) Nutrition 1998 May;14(5):470-471
Bran:
may irritate irritable bowel
Lewis MJ, Whorwell PJ
The irritable gut is known to be
hypersensitive, and it is reasonable to suspect that patients with the
disorder might be hyperreactive to agents that stimulate or irritate it.
This appears to be a possible explanation for the adverse effects of
bran on hospital patients with this disorder, but we do not yet know how
this product affects community IBS sufferers. We cannot ignore the fact
that fiber and bran have major beneficial effects in other areas, not
least in the reduction of colonic carcinoma. In conclusion, it is
probably best to recommend that patients with IBS be left to judge for
themselves whether bran helps or exacerbates their symptoms, but there
is enough evidence to suggest that the current dogma of routinely
treating all IBS sufferers with bran should be challenged. Proprietary
sources of fiber, such as ispaghula (psyllium), may be
more appropriate for those IBS subjects (for example, constipated) for
whom fiber supplementation is believed justified
10) Aliment Pharmacol Ther 1998 May;12(5):491-497
Psyllium
is superior to docusate sodium for treatment of chronic constipation.
McRorie JW, Daggy BP, Morel JG, Diersing
PS, Miner PB, Robinson M
BACKGROUND: Stool softening is a
physician's first step in the management of chronic constipation. AIM:
To compare stool softening (stool water content) and laxative efficacy
of psyllium hydrophilic mucilloid vs. docusate sodium. METHODS: The
multi-site, randomized, double-blind, parallel-design study of 170
subjects with chronic idiopathic constipation involved a 2-week baseline
(placebo) phase followed by 2 weeks of treatment. The treatment phase
compared psyllium (5.1 g b.d.) plus docusate placebo to docusate sodium
(100 mg b.d.) plus psyllium placebo. Stools were collected and assessed.
RESULTS: Compared to baseline, psyllium increased stool water content
vs. docusate (psyllium 2.33% vs. docusate 0.01%, P = 0.007). Psyllium
also increased stool water weight (psyllium 84.0 g/BM; docusate 71.4 g/BM;
P = 0.04), total stool output (psyllium 359.9 g/week: docusate 271.9 g/week;
P = 0.005), and O'Brien rank-type score combining objective measures of
constipation (psyllium 475.1; docusate 403.9; P = 0.002). Bowel movement
(BM) frequency was significantly greater for psyllium (3.5 BM/week) vs.
docusate (2.9 BM/week) in treatment week 2 (P = 0.02), with no
significant difference (P > 0.05) between treatment groups in
treatment week 1 (3.3 vs. 3.1 BM/week). CONCLUSION: Psyllium is superior
to docusate sodium for softening stools by increasing stool water
content, and has greater overall laxative efficacy in subjects with
chronic idiopathic constipation
11) J Clin Gastroenterol 1995 Dec;21(4):298-300
Traumatic
solitary rectal ulcer in Saudi Arabia. A distinct entity?
Contractor TQ, Contractor QQ
Solitary rectal ulcer syndrome is a
perplexing condition with a complex multifactorial pathophysiology.
Inappropriate contraction of the puborectalis muscle and rectal mucosal
prolapse have been commonly implicated, although self-induced trauma has
been suspected in some cases. Eight patients who presented with rectal
bleeding with excessive mucus were found to have an isolated rectal
ulcer on proctosigmoidoscopy. Constipation, straining at stools, and
pain in the anal region were present in seven of eight cases. All of
them confessed to rectal digitation. Most of them had consulted more
than two physicians and half of them had had barium enema and
colonoscopy in the past. An ulcer was present on the anterior wall at
6-8 cm from the anal verge in seven of eight patients and none of them
had either external or internal rectal prolapse. Rectal biopsy performed
in six of eight showed histological findings consistent with the
diagnosis of solitary rectal ulcer. Patients were convinced to stop
finger evacuation and were given psyllium supplements. There was
endoscopic healing with symptomatic improvement in the six patients who
followed up for an average period of 38 weeks. We conclude that
traumatic solitary rectal ulcer due to rectal digitation is a distinct
entity and response to avoidance of this habit is good
Thyroid 1998 Aug;8(8):667-671
12. Effects of pharmacological fiber supplements on levothyroxine absorption (49)Chiu AC, Sherman SI
Department of Medical Specialties, University of Texas, M.D. Anderson Cancer Center, Houston 77030, USA.
To determine the effect of pharmacological fiber supplements, we measured levothyroxine (LT4) absorption without and with simultaneous ingestion of either calcium polycarbophil or psyllium hydrophilic mucilloid. Serum thyroxine (T4) levels in 8 volunteers were measured following ingestion of 600 microg of LT4 on 3 separate occasions at 4-week intervals: (1) LT4 alone; (2) LT4 together with 1000 mg polycarbophil; and (3) LT4 together with 3.4 g psyllium. The amount of absorbed LT4 was calculated as the incremental rise in serum T4 level during the first 6 hours multiplied by the volume of distribution for the hormone, and expressed as a percentage of the dose administered. Absorption of LT4 alone averaged 89% (95% confidence interval [CI]: 75%-104%), occurring at a median of 180 minutes. After simultaneous ingestion of calcium polycarbophil, LT4 absorption was 86% (95% CI: 74%-97%), occurring at 180 minutes. With simultaneous ingestion of psyllium and LT4, the absorption was 80% (95% CI: 64%-95%), occurring at 240 minutes. In summary, neither calcium polycarbophil nor psyllium hydrophilic mucilloid are likely to cause malabsorption of LT4 that could be detected by these methods
Curr Med Res Opin 1998;14(4):227-33
13. A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in treatment of simple constipationDettmar PW, Sykes J
An open, multi-centre study in general practice compared with efficacy, speed of action and acceptability of ispaghula husk, lactulose and other laxatives in the treatment of patients with simple constipation. A total of 65 GPs recruited 394 patients, of whom 224 (56.9%) were assigned to treatment with ispaghula and 170 (43.1%) to other laxatives (mainly lactulose) for up to four weeks. Thirteen patients withdrew before treatment started, so that 381 entered the study. Patients were assessed by their GP before entry and after two and four weeks of treatment. Patients also kept daily records of their bowel movements. After four weeks' treatment, ispaghula husk was assessed by the GPs to be superior to the other treatments in improving bowel function and in overall effectiveness, palatability and acceptability. Patients' reports of time to first bowel movement showed little difference between the treatments. Over 60% of patients in each treatment group passed a first motion within 24 hours, and over 80% within 36 hours. Ispaghula husk produced a higher percentage of normal, well-formed stools and fewer hard stools than other laxatives. Incidences of soiling, diarrhoea and abdominal pain were lower in the group receiving ispaghula husk. Overall, ispaghula husk was an effective treatment for simple constipation, and was associated with better stool consistency and a lower incidence of adverse events compared with lactulose or with other laxatives
Dis Colon Rectum 1995 Jul;38(7):746-748
14. Fecal seepage and soiling: a problem of rectal sensationHoffmann BA, Timmcke AE, Gathright JB Jr, Hicks TC, Opelka FG, Beck DE
PURPOSE: To determine the physiologic alteration resulting in fecal seepage and soiling, results of anorectal manometric testing were evaluated in patients with varying degrees of fecal incontinence. METHODS: Anal manometric studies performed on 170 patients with fecal incontinence were reviewed. Results of their studies, including mean resting pressure, maximum resting pressure, maximum squeezing pressure, minimum rectal sensory volume, and minimum volume at which reflex relaxation first occurs, were compared with those of 35 control group subjects with normal fecal continence. Manometric studies were performed using a four-channel, water-perfused catheter. Incontinent patients were divided into three groups based on presenting complaints: complete incontinence (incontinence of gas and liquid and solid stool), partial incontinence (incontinence of gas and liquid), and seepage and soiling (incontinence of small amounts of liquid and solid stool without immediate awareness). RESULTS: Resting pressures were significantly lower in complete incontinence, partial incontinence, and seepage and soiling groups than in the controls (P < 0.001). Resting pressures of the complete incontinence group were also significantly lower than those of the partial incontinence and seepage and soiling groups (P = 0.03). Squeezing pressures were lower for both the complete incontinence and partial incontinence groups than for those in the control group (P < 0.001) and in the seepage and soiling group, which did not differ significantly from controls. The minimum rectal sensory volume was greater in all incontinent groups than in controls (P < 0.001). Sensory volume of the seepage and soiling group was significantly greater than that of the complete incontinence and partial incontinence groups (P < 0.01). The difference between sensory volume and the volume producing reflex relaxation was greatest in the seepage and soiling group and differed from that of the partial incontinence and control groups. CONCLUSIONS: These findings suggest that the mechanism of incontinence is different in seepage and soiling patients and involves a dyssynergy of rectal sensation and anal relaxation. Patients with the pattern of seepage and soiling may be successfully treated with stool bulking agents (e.g., psyllium or bran)
Am J Clin Nutr 1992 Mar;55(3):719-722
15. Guar, but not psyllium, increases breath methane and serum acetate concentrations in human subjectsWolever TM, ter Wal P, Spadafora P, Robb P
Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Ontario, Canada
Guar and psyllium are fermented by human fecal bacteria in vitro. To see if they were fermented in vivo, eight subjects were studied over 3 separate days, in random order, while eating a polysaccharide-free diet. Twenty grams guar or psyllium, taken at breakfast, had no effect on breath hydrogen levels over 14 h. Mean breath methane and serum acetate concentrations after guar, 37 +/- 1 ppm and 93 +/- 6 mumol/L, respectively, were significantly greater than after control, 20 +/- 2 ppm (P less than 0.05) and 62 +/- 4 mumol/L (P less than 0.01), and psyllium, 20 +/- 2 ppm (P less than 0.05) and 78 +/- 6 mumol/L (P less than 0.05). Serum acetate increased after guar (area under curve 193 +/- 56 mumol.h/L; P less than 0.02) but decreased after psyllium and control. We conclude that guar is fermented in the human colon, producing rises in breath methane and serum acetate but not hydrogen. Although psyllium had no effect on hydrogen, methane, or acetate, this does not prove that it is not fermented. Publication Types: Clinical trial, Controlled clinical trial
Gastroenterology 1993 Apr;104(4):1007-1012
16. Effect of psyllium, calcium polycarbophil, and wheat bran on secretory diarrhea induced by phenolphthaleinEherer AJ, Santa Ana CA, Porter J, Fordtran JS
Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas.
BACKGROUND: Fiber and water-holding agents are used for the treatment of constipation. In what may appear to be a paradox, they are sometimes also used for the treatment of diarrhea; it has been proposed that they sequester water from liquid stools and/or increase the ratio of fecal solids to fecal water and thereby improve stool consistency. The purpose of the present study was to test the validity of this hypothesis in normal subjects in whom secretory diarrhea was induced by phenolphthalein. METHODS: In random sequence, 9 subjects with phenolphthalein-induced diarrhea were treated with placebo, psyllium, calcium polycarbophil, or wheat bran. RESULTS: Calcium polycarbophil and wheat bran had no effect on fecal consistency or on fecal viscosity. By contrast, psyllium made stools firmer and increased fecal viscosity. In a dose-response study in 6 subjects, doses of 9, 18, and 30 g of psyllium per day caused a near linear increase in fecal viscosity. CONCLUSION: Psyllium, but not calcium polycarbophil or wheat bran, improves fecal consistency and viscosity in subjects with experimentally-induced secretory diarrhea. Publication Types: Clinical trial, Randomized controlled trial
Am J Clin Nutr 1998 Feb;67(2):317-321
17. Moderation of lactulose-induced diarrhea by psyllium: effects on motility and fermentationWashington N, Harris M, Mussellwhite A, Spiller RC
Division of Gastroenterology and
Department of Surgery, Queen's Medical Centre, Nottingham, United
Kingdom. neena.washington@nottingham.ac.uk
Psyllium has been reported to inhibit lactulose-induced colonic mass
movements and to benefit patients with irritable bowel syndrome,
improving both constipation and diarrhea. Our aim was to define how
psyllium modified the whole-gut transit of a radiolabeled
lactulose-containing test meal by using gamma scintigraphy. Eight
subjects participated in a randomized crossover study comparing gastric
emptying and small bowel and colonic transit after consumption of 20 mL
lactulose three times daily with or without 3.5 g psyllium three times
daily. Psyllium significantly delayed gastric emptying: the time to 50%
emptying increased from a control value of 69 +/- 9 to 87 +/- 11 min
(mean +/- SEM; P < 0.05, n = 8). Small bowel transit was unaltered.
However, progression through the colon was delayed with an increase in
the percentage of the dose at 24 h in the ascending (control group: 2
+/- 3%, psyllium group: 11 +/- 8%; P < 0.02) and transverse colon
(control group: 5 +/- 12%, psyllium group: 21 +/- 14%) with
correspondingly less in the descending colon. Although the time for 50%
of the isotope to reach the colon was not significantly different with
psyllium, psyllium significantly delayed the rise in breath-hydrogen
concentrations, which reached 50% of their peak at 217 +/- 34 min
compared with control values of 155 +/- 27 min (P < 0.05). Psyllium
delays gastric emptying, probably by increasing meal viscosity, and
reduces the acceleration of colon transit, possibly by delaying the
production of gaseous fermentation products
Scand J Gastroenterol 1996 Oct;31(10):1011-1020
18. Colonic production of butyrate in patients with previous colonic cancer during long-term treatment with dietary fibre (Plantago ovata seeds)Nordgaard I, Hove H, Clausen MR, Mortensen PB
Dept. of Medicine A, Rigshospitalet, University of Copenhagen, Denmark.
BACKGROUND: Butyrate has antineoplastic properties against colorectal cancer cells and is the preferred oxidative substrate for colonocytes. Like acetate and propionate (short-chain fatty acids; SCFAs), butyrate is produced by colonic fermentation of dietary fibre. METHODS: Twenty patients resected for colorectal cancer were treated with 20 g/day of the fibre Plantago ovata seeds for 3 months, which increased the intake of fibre by 17.9 +/- 0.8 g/day, from basal levels of 19.2 +/- 1.7 g/day; 17 patients completed the study. Faecal samples were obtained on eight occasions, twice before treatment, and monthly three times during and three time after treatment. RESULTS: One month of fibre therapy increased faecal concentrations of butyrate by 42 +/- 12% (from 13.2 +/- 1.2 to 19.3 +/- 3.0 mmol/l; P < 10(-4)), acetate by 25 +/- 6% (P < 10(-4)), propionate by 28 +/- 9% (P = 0.01), and total SCFAs by 25 +/- 6% (P < 10 (-4)). Concentrations were increased during the 3-month fibre treatment but reversed to pretreatment levels within 1 to 2 months after cessation of fibre supplementation. The relative concentration (ratio) of butyrate was not altered owing to a simultaneous increase in acetate and propionate. Faecal pH decreased initially but was normalized after 2 months of fibre supplements. Fibre therapy increased the 24-h productions of butyrate by 47 +/- 10% (P < 10(-4)) and acetate by 50 +/- 7% (P < 10(-4)) in 16.6% faecal homogenates with added P. ovata seeds (20mg/ml), but SCFA productions returned to pretreatment levels after discontinuation of additional fibre intakes. CONCLUSIONS: Oral intake of P. ovata seeds adapted the colonic flora to increase the production of butyrate (and acetate) from this fibre and increased faecal concentrations of butyrate by 42% in patients resected for colonic cancer. The effects depended on continuity of treatment
Dig Dis Sci 1998 Nov;43(11):2536-41
19. Psyllium improves fecal consistency and prevents enhanced secretory responses in jejunal tissues of piglets infected with ETECHayden UL, McGuirk SM, West SE, Carey HV
Department of Comparative Biosciences, University of Wisconsin School of Veterinary Medicine, Madison 53705, USA.
Infection with enterotoxigenic E. coli (ETEC) induces secretory diarrhea by stimulating net secretion of fluid and electrolytes. We tested the hypothesis that ETEC potentiates jejunal ion secretion induced by other agonists and also examined whether the soluble fiber psyllium ameliorates effects of ETEC-induced pathophysiology. Noninfected or ETEC-infected piglets were given oral electrolyte solution twice daily or electrolyte solution supplemented with psyllium for 48 hr. Jejunal tissues were mounted in flux chambers and basal and stimulated ion transport responses, as reflected by short-circuit current (I(SC)) were measured. The severity of ETEC-induced diarrhea was reduced by psyllium. I(SC) responses to carbachol and 5-hydroxytryptamine were greater in tissues from infected piglets compared with noninfected controls or infected piglets given psyllium. These results suggest that psyllium ameliorates ETEC-induced diarrhea and prevents the enhanced secretory responses to calcium-mediated agonists that occur in ETEC-infected piglet jejunum
Am J Gastroenterol 1999 Feb;94(2):427-33
20. Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Spanish Group for the Study of Crohn's Disease and Ulcerative ColitisFernandez-Banares F, Hinojosa J, Sanchez-Lombrana JL, Navarro E, Martinez-Salmeron JF, Garcia-Puges A, Gonzalez-Huix F, Riera J, Gonzalez-Lara V, Dominguez-Abascal F, Gine JJ, Moles J, Gomollon F, Gassull MA
OBJECTIVE: Butyrate enemas may be effective in the treatment of active distal ulcerative colitis. Because colonic fermentation of Plantago ovata seeds (dietary fiber) yields butyrate, the aim of this study was to assess the efficacy and safety of Plantago ovata seeds as compared with mesalamine in maintaining remission in ulcerative colitis. METHODS: An open label, parallel-group, multicenter, randomized clinical trial was conducted. A total of 105 patients with ulcerative colitis who were in remission were randomized into groups to receive oral treatment with Plantago ovata seeds (10 g b.i.d.), mesalamine (500 mg t.i.d.), and Plantago ovata seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months. RESULTS: Of the 105 patients, 102 were included in the final analysis. After 12 months, treatment failure rate was 40% (14 of 35 patients) in the Plantago ovata seed group, 35% (13 of 37) in the mesalamine group, and 30% (nine of 30) in the Plantago ovata plus mesalamine group. Probability of continued remission was similar (Mantel-Cox test, p = 0.67; intent-to-treat analysis). Therapy effects remained unchanged after adjusting for potential confounding variables with a Cox's proportional hazards survival analysis. Three patients were withdrawn because of the development of adverse events consisting of constipation and/or flatulence (Plantago ovata seed group = 1 and Plantago ovata seed plus mesalamine group = 2). A significant increase in fecal butyrate levels (p = 0.018) was observed after Plantago ovata seed administration. CONCLUSIONS: Plantago ovata seeds (dietary fiber) might be as effective as mesalamine to maintain remission in ulcerative colitis. Publication Types: Clinical trial, Multicenter study, Randomized controlled trial
J R Soc Health 1998 Oct;118(5):267-71
21. The influence of ispaghula husk on bowel habitDavies GJ, Dettmar PW, Hoare RC
Nutrition Research Centre,
South Bank University, London.
Frequency of defaecation, faecal form, straining at the start and end of defaecation, feelings of incomplete evacuation of faeces and urgency of defaecation were recorded in 69 healthy volunteers during three distinct 28-day study phases: pre-treatment, treatment with ispaghula husk and post-treatment. During treatment there was a significant increase (P < 0.001) in stool frequency and significant decreases in straining at the start (P < 0.001) and end (P < 0.001) of defaecation and in feelings of incomplete evacuation (P < 0.001). There was evidence of a beneficial residual effect after treatment had stopped. There are indications that ispaghula husk (Fybogel Orange) is of benefit in relieving constipation symptoms in apparently healthy people
Scand J Gastroenterol 1991 Jul;26(7):747-50
22. Ispaghula husk may relieve gastrointestinal symptoms in ulcerative colitis in remissionHallert C, Kaldma M, Petersson BG
Dept. of Internal
Medicine, Central Hospital, Norrkoping, Sweden
The efficiency of ispaghula husk in relieving gastrointestinal symptoms in patients with ulcerative colitis in remission was studied in a placebo-controlled trial running for 4 months. Twenty-nine patients (81%) completed the trial; four withdrew after colitis relapse (three while receiving placebo). Grading of symptoms judged ispaghula to be consistently superior to placebo (p less than 0.001) and associated with a significantly higher rate of improvement (69%) than placebo (24%) (p less than 0.001). The results show that ispaghula can be helpful in the management of gastrointestinal symptoms in quiescent ulcerative colitis.
23. Gut 1987 Nov;28(11):1510-3
Double blind study of
ispaghula in irritable bowel syndrome
Prior A, Whorwell PJ
Dept of Medicine, University Hospital of
South Manchester
A double blind placebo controlled trial
of ispaghula husk in 80 patients with irritable bowel syndrome is
reported. Global assessment judged treatment to be satisfactory in 82%
of patients receiving ispaghula and 53% of the placebo group (p less
than 0.02). Bowel habit was unchanged in the placebo group, while
constipation significantly improved in patients taking ispaghula (p =
0.026). Transit time decreased significantly in those taking ispaghula
compared with placebo (p = 0.001), especially in patients with initially
high transit times. Abdominal pain and bloating improved in both groups,
with no significant differences between ispaghula and placebo. Four of
the eight withdrawals on ispaghula and 10 of the 15 withdrawals on
placebo were because of treatment failure. Ispaghula significantly
improves overall well being in patients with irritable bowel syndrome,
and in those with constipation favourably affects bowel habit and
transit time.
24. Am J Clin Nutr 2000 Sep;72(3):784-789
An unfermented gel component of psyllium seed husk promotes laxation as a lubricant in humans.Marlett JA, Kajs TM, Fischer MH
Department of Nutritional Sciences, University of Wisconsin-Madison, and The Procter & Gamble Company, Mason, OH.
BACKGROUND: In addition to increasing stool weight, supplements of psyllium seed husk produce stools that are slick and gelatinous. OBJECTIVE: Our purpose was to test the hypothesis that a gel-forming fraction of psyllium escapes microbial fermentation and is responsible for the characteristics that enhance laxation. DESIGN: Fifteen healthy adults consumed controlled diets for two 7-d periods, one of which included 8.8 g dietary fiber provided by 15 g/d of a psyllium seed husk preparation. All stools were collected and evaluated and diet was monitored throughout. RESULTS: Psyllium significantly increased the apparent viscosity of an aqueous stool extract, stool moisture, and wet and dry stool weights. A very viscous fraction, not present in low-fiber stool and containing predominantly 2 sugars that are also found in abundance in psyllium husk, was isolated from psyllium stool. CONCLUSIONS: In contrast with other viscous fibers that are fermented completely in the colon, a component of psyllium is not fermented. This gel provided lubrication that facilitated propulsion of colon contents and produced a stool that was bulkier and more moist than were stools resulting with use of comparable amounts of other bowel-regulating fiber sources.
25. Nurs
Res 2001 Jul-Aug;50(4):203-13
Supplementation
with dietary fiber improves fecal incontinence.
Bliss
DZ, Jung HJ, Savik K, Lowry A, LeMoine M, Jensen L, Werner C, Schaffer K
School
of Nursing,
University of Minnesota, Minneapolis 55455, USA. bliss@tc.umn.edu
OBJECTIVE: To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. METHODS: Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. RESULTS: In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. CONCLUSIONS: Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.
26. Adv Nurse Pract 2001
Oct;9(10):57-8
Constipation during pregnancy. Fiber and fluid are keys to
self-management.
Morgan C
27.
Drugs Exp Clin Res 2001;27(5-6):165-75
Mucopolysaccharides
from psyllium involved in wound healing.
Westerhof W, Das PK, Middelkoop E, Verschoor J, Storey L, Regnier C
Department
of Dermatology, Academic Medical Center, University of Amsterdam,
Meibergdreef 9, 1005AZ Amsterdam, The Netherlands. w.westerhof@amc.uva.nl
Mucopolysaccharides derived from the husk of psyllium (Plantago ovata) have properties beneficial for wound cleansing and wound healing. Recent studies indicate that these mucopolysaccharides also limit scar formation. Our in vitro and in vivo studies aimed to investigate the mechanisms involved, e.g., fluid absorption, bacterial adherence and in vitro stimulatory effects on macrophages, which are pivotal in wound healing. The mucopolysaccharides contained in a sachet (Askina Cavity) or in a hydrocolloid mixture (Askina Hydro) were found to have a gradual and sustained absorbency over a period of 7 days, amounting to 4-6 times their weight in water. The swelling index was 9 mm after 312 h. Adherence of wound bacteria to the mucopolysaccharides started after 2 h and was more pronounced after 3 h. Semiquantitative measurements of bacterial adherence used centrifugation and subsequent optical density determinations of supernatant. These confirmed the strong adherence potential of psyllium particles. Lactic acid dehydrogenase staining of pretreated cultured human skin explants did not reveal toxicity of the mucopolysaccharides derived from psyllium husk. Langerhans' cell migration from the epidermis was negligible and interleukin-1 beta expression in the explants was not significant, supporting the very low allergenic potential of psyllium. The characteristics of mucopolysaccharide granulate derived from psyllium husk in Askina Cavity and Askina Hydro related to fluid absorption, bacterial adherence, biocompatibility, stimulation of macrophages, irritancy response and allergenicity showed an optimal profile, supporting the good clinical performance of wound healing products containing psyllium husk.
28.
J Agric Food Chem 2003 Jan 15;51(2):492-5
Effects of xylanase* treatments on gelling and water-uptaking properties
of psyllium.
Yu LL, Perret J
Department of Food Science and Human Nutrition, Colorado State University, 230 Gifford Building, Fort Collins, CO 80523-1571, USA. yu@cahs.colostate.edu
The effects of a commercial food-grade xylanase on the physicochemical properties of psyllium were evaluated. The enzymatic reactions were conducted in solid state at ambient temperature. The enzyme-treated psyllium preparations were analyzed and compared with the starting psyllium for their water-uptake properties, gelling capacities, soluble and insoluble fiber contents, and surface structures. The solid-state xylanase treatment significantly reduced both water-uptake and gelling capacities of psyllium (p < 0.01), with a slight decrease of soluble fiber content, whereas no effect on insoluble fiber content was observed. The xylanase treatment also resulted in a smoother surface structure of psyllium particles. In addition, no special equipment and operation were required to conduct the enzymatic reaction, which generated no waste. These data indicated a potential to improve the physicochemical properties of psyllium by use of the solid-state xylanase reactions to promote the utilization of psyllium fiber in functional foods for promoting human health.
*xylanasi = enzima di degradazione alcuni polisaccaridi costituenti le fibre vegetali (xilani). E’ ottenuto tramite processi di fermentazione di particolari ceppi fungini.
Sono stati valutati gli effetti di una xilanasi commerciale “food-grade” sulle proprietà fisico-chimiche dello psyllium. La reazione è stata condotta in stato solido e a temperatura ambiente.
La preparazione di psyllium trattata enzimaticamente è stata confrontata con lo psyllium di partenza in relazione alla capacità di trattenere acqua, capacità di formare gel, contenuto di fibra solubile ed insolubile, struttura della superficie.
Il trattamento con xilanasi ha comportato una significativa riduzione sia della capacità di trattenere acqua che capacità gelificanti dello psyllium, con una leggera diminuzione del contenuto in fibra solubile, mentre non si sono osservati effetti sul contenuto di fibra insolubile. Il trattamento effettuato è risultato conferire anche una struttura più liscia e levigata della superficie delle particelle di psyllium. In aggiunta, la reazione enzimatica è stata condotta senza l’utilizzo di operazioni e di equipaggiamenti particolari e non ha generato rifiuti.
Questi
dati indicano una possibilità di miglioramento delle proprietà
fisico-chimiche dello psyllium, tramite la reazione con xilanasi, così
da promuovere l’utilizzo di questa fibra in alimenti funzionali per la
salute.
COMMENTO INNOVARES
Si tratta dell’utilizzo della xilanasi per scindere la molecola dello xilano, uno dei principali polisaccaridi coinvolti nella gelificazione dello psy. Ad Innovares, contrariamente all’azione dell’enzima succitato, interessa particolarmente una elevata capacità gelificante nella materia prima impiegata (psyllium husk powder), la quale è espressione della capacità di espansione della massa fecale e di bilanciamento del contenuto idrico fecale, prerogative che indicano lo psyllium essere d’elezione nel trattamento sia della stipsi sia della diarrea (come sintomatico).
29.
Gastroenterol Hepatol 2003 Apr;26(4):248-50
Esophageal obstruction caused by Plantago ovata, accurate
information avoid this complication.
Salguero Molpeceres O, Seijas Ruiz-Coello MC, Hernandez Nunez J,
Caballos Villar D, Diaz Picazo L, Ayerbe Garcia-Monzon L
Especialistas
en Medicina Familiar y Comunitaria. Area 6.
[Medline record in process]
Introduction:
Plantago ovata (
Si riporta un caso di ostruzione esofagea dovuta all’ingestione di granuli di Plantago ovata.
Tuttavia: 1) un cucchiaio da tavola di granuli era stato tenuto in bocca
alcuni secondi senza bere acqua, 2) alla paziente in questione è
stata scoperta una lieve ernia iatale, 3) si specifica che la
maggioranza dei casi di ostruzione riportati sono dovuto
all’insufficiente apporto di liquidi, 4) è stata osservata in
seguito una ernia iatale di lieve entità 5) lo
psyllium in polvere presenta minori rischi di ostruzione esofagea.
COMMENTO INNOVARES
abbiamo sempre sostenuto che il
miglior modo di assumere psyllium sia di assumerlo già idratato,
proprio per prevenire complicanze come quelle esposte.
30. Int
J Colorectal Dis 2003 Mar 12;
Prickly pear fruit bezoar* presenting as rectal perforation in an
elderly patient.
Steinberg JM, Eitan A
Department of Surgery, Western Galilee Medical Center, Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
[Record supplied by publisher]
BACKGROUND
AND AIMS. Prickly pear fruit rectal seed bezoars are an extremely rare
entity. Only nine cases of rectal seed bezoar have been reported, only
one of which involved the prickly pear fruit seed. Furthermore, to our
knowledge, this is also the first reported case presenting as rectal
perforation. PATIENTS AND METHODS. We report a case of prickly pear
fruit bezoar occurring in the elderly whom presented with rectal
perforation. Consistent with physical signs, laboratory results, and
radiological findings the patient was diagnosed with acute perforation
of the rectum. A Hartman procedure was performed, and a colostomy was
placed. RESULTS. Currently there are very few data regarding seed
bezoars reaching the rectum. There are even fewer data concerning this
occurrence in the elderly, and the literature contains no report of this
phenomenon presenting or even progressing into perforation. We report
this rare entity to the existing literature. CONCLUSION. We report a
rare but important case. A prickly pear fruit phytobezoar presenting as
rectal perforation. This case may add to the increasing awareness of the
danger associated with ingestion of certain foodstuffs. The previously
benign sunflower and psyllium seeds are now known to cause
bezoar. We feel that the prickly pear fruit should join this small but
important list.
*Bezoar =
bezoario. Massa occludente che si ritrova nello stomaco di molti
mammiferi, rappresentata per lo più da peli; si rinviene anche nel lume
gastrico di bambini che ingeriscono i propri capelli.
COMMENTO INNOVARES: In
precedenza semi di girasole e di psyllium erano già noti come
potenziali cause di bezoari… un motivo per evitare l’assunzione si
psyllium semi interi, molto venduti nel canale erboristeria: si
consigliano infatti usualmente, data la capacità di rigonfiamento 10
volte inferiore del seme intero rispetto al solo pericarpo (psyllium
husk powder), diversi cucchiai da cucina al giorno di semi!!! In
presenza di alterata motilità esofagea, ciò può favorire la
formazione di bezoari.
31. Lancet 2003 May 3;361(9368):1491-5
Dietary
fibre and colorectal adenoma in a colorectal cancer early detection
programme.
Peters U, Sinha R, Chatterjee N, Subar AF, Ziegler RG, Kulldorff M,
Bresalier R, Weissfeld JL, Flood A, Schatzkin A, Hayes RB.
Division
of Cancer Epidemiology and Genetics, National Cancer Institute, US
National Institutes of Health, DHHS, MD,
USA
Background Although dietary fibre has
been reported to have no association with colorectal adenoma and cancer,
in some studies this topic remains controversial. Methods We used a
137-item food frequency questionnaire to assess the relation of fibre
intake and frequency of colorectal adenoma. The study was done within
the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening
Trial, a randomised controlled trial designed to investigate methods for
early detection of cancer. In our analysis, we compared fibre intake of
33971 participants who were sigmoidoscopy-negative for polyps, with 3591
cases with at least one histologically verified adenoma in the distal
large bowel (ie, descending colon, sigmoid colon, or rectum). Odds
ratios were estimated by logistic regression analysis. Findings High intakes of dietary fibre were associated with a lower risk of
colorectal adenoma, after adjustment for potential dietary and
non-dietary risk factors. Participants in the highest quintile of
dietary fibre intake had a 27% (95% CI 14-38, ptrend=0.002) lower risk
of adenoma than those in the lowest quintile. The inverse association
was strongest for fibre from grains and cereals and from fruits. Risks
were similar for advanced and non-advanced adenoma. Risk of rectal
adenoma was not significantly associated with fibre intake. Interpretation Dietary fibre, particularly from grains, cereals, and fruits, was
associated with decreased risk of distal colon adenoma.
All’interno
di un vasto “Cancer Screening Trial”, è stato affrontato un aspetto
ritenuto ancora per certi versi dibattuto: assunzione di fibra
alimentare e adenoma colorettale
Elevate somministrazioni di fibra alimentare sono correlate ad una
diminuzione del rischio di carcinoma colorettale. Ciò è stato ritenuto
ugualmente valido anche nella valutazione del rischio negli stati
avanzati o non avanzati di adenoma
In questo ampio studio infatti, comprendente anche oltre 3500 casi di
adenoma istologicamete verificati, il rischio di adenoma distale
diminuiva con l’incremento dell’introduzione di fibra alimentare sia
negli uomini che nelle donne. Il rischio di adenoma rettale non è stato
ritenuto significativamente associato con l’assunzione di fibra,
fatto, questo, che poteva riflettere locali differenze nell’ambiente
intestinale (contenuto in acqua, tempo di transito, flora microbica)
In conclusione, è stato rilevato che l’introduzione di fibra
alimentare è associata con la diminuzione di rischio di adenoma distale
del colon.
32. Lancet 2003 May 3;361(9368):1496-501
Dietary fibre in food and protection against colorectal cancer in
the European Prospective Investigation into Cancer and Nutrition (EPIC):
an observational study.
Bingham SA, Day NE, Luben R, Ferrari P, Slimani N, Norat T,
Clavel-Chapelon F, Kesse E, Nieters A, Boeing H, Tjonneland A, Overvad
K, Martinez C, Dorronsoro M, Gonzalez CA, Key TJ, Trichopoulou A, Naska
A, Vineis P, Tumino R, Krogh V, Bueno-de-Mesquita HB, Peeters PH,
Berglund G, Hallmans G, Lund E, Skeie G, Kaaks R, Riboli E; European
Prospective Investigation into Cancer and Nutrition.
MRC Dunn Human Nutrition Unit, Cambridge, UK.
BACKGROUND: Dietary fibre is thought to
protect against colorectal cancer but this view has been challenged by
recent prospective and intervention studies that showed no protective
effect. METHODS: We prospectively examined the association between
dietary fibre intake and incidence of colorectal cancer in 519978
individuals aged 25-70 years taking part in the EPIC study, recruited
from ten European countries. Participants completed a dietary
questionnaire in 1992-98 and were followed up for cancer incidence.
Relative risk estimates were obtained from fibre intake, categorised by
sex-specific, cohort-wide quintiles, and from linear models relating the
hazard ratio to fibre intake expressed as a continuous variable.
FINDINGS: Follow-up consisted of 1939011 person-years, and data for 1065
reported cases of colorectal cancer were included in the analysis.
Dietary fibre in foods was inversely related to incidence of large bowel
cancer (adjusted relative risk 0.75 [95% CI 0.59-0.95] for the highest
versus lowest quintile of intake), the protective effect being greatest
for the left side of the colon, and least for the rectum. After
calibration with more detailed dietary data, the adjusted relative risk
for the highest versus lowest quintile of fibre from food intake was
0.58 (0.41-0.85). No food source of fibre was significantly more
protective than others, and non-food supplement sources of fibre were
not investigated. INTERPRETATION: In populations with low average intake
of dietary fibre, an approximate doubling of total fibre intake from
foods could reduce the risk of colorectal cancer by 40%.
STUDIO
PROSPETTICO EUROPEO SU ALIMENTAZIONE E SALUTE
EPIC rappresenta il più vasto studio finora condotto sul legame tra
abitudini alimentari e cancro. Con lo scopo di reclutare individui
aventi abitudini alimentari differenti e provenienti da regioni con
diversa percentuale di incidenza di tumore, è stato realizzata questa
estesa indagine multicentrica, condotta tra il 1992 e il 1998, e che ha
visto coinvolti 22 centri di 10 nazioni europee. Il totale delle persone
monitorate è stato di 519978 di cui 1065 rappresentavano casi di cancro
colorettale.
Le fibre alimentari sono uno dei più importanti, sebbene a volte
controversi, fattori ritenuti svolgere un ruolo nella protezione
contro il tumore colorettale attraverso ben noti meccanismi biologici.
Una volta raggiunto il grosso intestino, la fibra aumenta il peso della
massa fecale, riduce il tempo di transito, diluisce i contenuti del
colon e stimola la fermentazione batterica anaerobia. Tutto ciò riduce
il contatto tra il contenuto intestinale e la mucosa ed induce la
produzione di acidi grassi a corta catena (acetato, propionato,
butirrato) che diminuiscono il valore di pH e permettono la conversione
degli acidi biliari da primari a secondari. Il butirrato in particolare
costituisce la maggior fonte di energia per il colon e su linee
cellulari ha mostrato riduzione della proliferazione cellulare ed
induzione dell’apoptosi, elementi questi che sono associati con
l’inibizione della trasformazione del epitelio del colon a carcinoma.
I risultati dello studio hanno evidenziato come il consumo totale di
fibre alimentari fossero inversamente associati al rischio di carcinoma
colorettale. Tale tipo di associazione è stata rilevata anche più
forte per il cancro al colon, specialmente il colon sinistro, rispetto
al cancro al retto. Quest’ultimo aspetto, in particolare, poteva
essere prevedibile considerando che il retto è vuoto per la maggior
parte del tempo e che quindi gli effetti descritti (nutritivi,
antiproliferativi e di diluizione del contenuto) attribuibili alle
fibre, sono ridotti.
Conclusione – In una popolazione con una bassa media di assunzione
di fibra alimentare, un aumento di circa il doppio della fibra totale
introitata con il cibo, può ridurre di cancro colorettale del 40%.
33. Proc Nutr Soc. 2003 Feb;62(1):207-9.
The active fraction of psyllium seed husk.
Marlett JA, Fischer MH.
Department of Nutrition
Sciences, University of Wisconsin-Madison, Wisconsin, 53706, USA. jmarlett@nutrisci.wisc.edu
Abstract:
A series of experiments and evaluations of fractions isolated from
psyllium seed husk (PSH) were used to test the overall hypothesis that a
gel-forming component of PSH is not fermented and that it is this
component that is responsible for the laxative and cholesterol-lowering
properties of PSH. A gel is isolated from human stools collected during
a controlled diet study when PSH is consumed but not when the control
diet only is consumed. Evaluations of three fractions isolated from PSH
suggest that gel-forming fraction B, which is about 55 % of PSH, is
poorly fermented and is the component that increases stool moisture and
faecal bile acid excretion, the latter leading to lower blood
cholesterol levels. Fraction C, representing < 15 % of PSH, is
viscous, but is rapidly fermented. Fraction A is alkali-insoluble
material that is not fermented. In concentrations comparable with their
presence in PSH, fractions A and C do not alter moisture and bile acid
output. The active fraction of PSH is a highly-branched arabinoxylan
consisting of a xylose backbone and arabinose- and xylose-containing
side chains. In contrast to arabinoxylans in cereal grains that are
extensively fermented, PSH possesses a structural feature, as yet
unidentified, that hinders its fermentation by typical colonic
microflora.
Sono stati condotti esperimenti sulle frazioni polisaccaridiche di
cuticola dei semi di Pyllium per verificare le ipotesi che la componente
formante gel fosse costituita dalla porzione non fermentata di tale
fibra e che questa componente fosse la responsabile diretta
dell’effetto lassativo nonché delle proprietà di riduzione del
colosterolo. Valutazioni condotte su tre frazioni isolate da PSH (Psyllium
seed husk) hanno indicato che la frazione B, presente per circa il 55%
è solo scarsamente fermentata e rappresenta il componente responsabile
dell’idratazione delle feci e dell’escrezione fecale degli acidi
biliari meccanismo, quest’ultimo, attraverso il quale si ottiene una
riduzione dei livelli di colesterolo. La frazione C costituisce meno del
15% di PSH, è viscosa ma rapidamente subisce fermentazione. Infine, la
frazione A è insolubile in ambiente alcalino e non è fermentata. In
concentrazioni paragonabili, sia A che C, non modificano né
l’idratazione delle feci né l’output di acidi biliari. La frazione
attiva di PSH (frazione B) è costituita da molecole altamente
ramificate di arabinoxilano formato da uno scheletro di xilosio e da
catene laterali di xilosio e arabinosio.
A differenza degli arabinoxilani di altri cereali, che sono altamente
fermentati, PSH possiede caratteristiche strutturali, non ancora
identificate, che impediscono la fermentazione da parte della tipica
microflora del colon.
34. Proc Nutr Soc. 2003 Feb;62(1):217-22.
Primary structure of arabinoxylans of ispaghula husk and wheat bran. Edwards S, Chaplin MF, Blackwood AD, Dettmar PW.
South Bank University, 103 Borough Road, London SE1 0AA, UK.
The primary structures of ispaghula husk and wheat bran were investigated in order to determine how and why these fibres are among the most beneficial dietary fibres. To this end, the polysaccharide preparations have been subjected to enzymic hydrolysis and methylation analysis.The results have shown ispaghula husk and wheat bran to be very-highly-branched arabinoxylans consisting of linear f-D-(1-4)-linked xylopyranose (Xylp) backbones to which a-L-arabinofuranose (AraJ3 units are attached as side residues via a-(l13) and a-(1-02) linkages.Other substituents identified as present in wheat bran include P-D-glucuronic acid attached via the C(O)-2 position, and arabinose oligomers, consisting of two or more arabinofuranosyl residues linked via 1-2, 1-3, and 1-4 linkages. Ispaghula-husk arabinoxylan is more complex having additional side residues which include a-D-glucuronopyranose (GalAp)-(1-42)-linked-a-L-rhamnopyranose-(1-04)-0-D-Xylp, a-D-GalAp-(l-o3)-linked-a-L-Araf-(l-4)-[3-D-Xylp, and a-L-Araf-(l-43)-linked-P-D-Xylp-(1l -4)--D-Xylp. The beneficial effects of increased faecal bulk and water-holding capacity are undoubtedly related to the structures of the arabinoxylans, with differences in their efficacy to treat various functional bowel disorders due to their specific structural features.
35. Scand J Gastroenterol. 1993 Mar;28(3):249-55.
Fermentation of dietary fibre by human colonic bacteria: disappearance
of, short-chain fatty acid production from, and potential water-holding
capacity of, various substrates.
Bourquin LD, Titgemeyer EC, Fahey GC Jr, Garleb KA.
Division of Nutritional Sciences, University of Illinois, Urbana.
Several dietary fibre-rich substrates were fermented in vitro with human colonic bacteria obtained from each of three adult male subjects to assess the extent of substrate fermentation short-chain fatty acid (SCFA) production, and the potential effect of fermented residues on faecal bulk. Substrates tested were two varieties of oat hull fibre, gum arabic, carboxymethylcellulose (CMC), soy fibre, psyllium, and six blends containing oat fibre, gum arabic, and CMC in various proportions. All substrates contained greater than 900 g/kg of total dietary fibre except for CMC (816 g) and soy fibre (778 g). In vitro organic matter disappearance during fermentation was greatest for gum arabic (69.5%), intermediate for soy fibre (56.4%), and less than 20% for the two oat fibres, CMC, and psyllium. Averaged across substrates, acetate, propionate, and butyrate were produced in the molar proportion of 64:24:12. Potential water-holding capacity (PWHC) of substrates, a measure of faecal bulking potential, was greatest for CMC (13.5 g H2O/g substrate) and lowest for gum arabic (1.92 g) and soy fibre (1.71 g). Organic matter disappearance and SCFA production of blends were directly proportional to their gum arabic content. Blend PWHC was proportional to CMC content. In vitro procedures are useful in predicting the actions of fibre blends formulated to produce desirable effects in vivo.
36. Scand J Gastroenterol. 1988 Dec;23(10):1237-40.
Treatment of chronic diarrhoea: loperamide versus ispaghula husk and
calcium.
Qvitzau S, Matzen P, Madsen P.
Surgical and Medical Dept. of Gastroenterology, Hvidovre Hospital,
University of Copenhagen.
Twenty-five
patients with chronic diarrhoea were included in an open, randomized
crossover trial comparing the effect of loperamide with ispaghula and
calcium. Nineteen patients completed both treatments. Before treatment
the median number of daily stools was 7 (range, 4-13), stool consistency
was loose in all, and urgency was present in 16 out of 19 patients. Both
treatments halved stool frequency, but with regard to urgency and stool
consistency ispaghula and calcium was significantly better. A
combination of ispaghula and calcium seems to be a cheap and effective
alternative to conventional treatment of chronic diarrhoea. Moreover,
side effects were minimized.
Publication
Types: Clinical Trial Randomized Controlled Trial
37.
Aliment Pharmacol Ther. 2004 Feb 1;19(3):245-51.
Systematic review: the role of different types of fibre in the treatment
of irritable bowel syndrome.
Bijkerk CJ, Muris JW, Knottnerus JA, Hoes AW, de Wit NJ.
Utrecht University Medical Center, Julius Center for Primary Care and
Health Sciences, Utrecht, The Netherlands.
BACKGROUND: Both high-fibre dietary advice and the prescription of fibre
as a bulking agent are very common in primary and secondary care
management of irritable bowel syndrome. Irritable bowel syndrome
patients with constipation may have delayed intestinal transit.
Therefore, fibres that accelerate intestinal transit may be beneficial
in these patients. The uncertain benefits reported in several clinical
studies, however, have led us to reappraise the value of fibre in
irritable bowel syndrome management. AIM: To quantify the effect of
different types of fibre on global and symptom relief from irritable
bowel syndrome. METHODS: Using a structured literature search in MEDLINE
(1966-2002), we selected randomized controlled trials involving
irritable bowel syndrome patients treated with fibre. Analyses were
performed for the total group and for trials using soluble and insoluble
fibre separately. RESULTS: Seventeen studies were included in the
analysis. None investigated primary care irritable bowel syndrome
patients. Fibre, in general, was effective in the relief of global
irritable bowel syndrome symptoms [relative risk, 1.33; 95% confidence
interval (CI), 1.19-1.50]. Irritable bowel syndrome patients with
constipation may receive benefit from fibre treatment (relative risk,
1.56; 95% CI, 1.21-2.02), but there was no evidence that fibre was
effective in the relief of abdominal pain in irritable bowel syndrome.
Soluble and insoluble fibre, separately, had different effects on global
irritable bowel syndrome symptoms. Soluble
fibre (psyllium, ispaghula, calcium polycarbophil) showed significant
improvement (relative risk, 1.55; 95% CI, 1.35-1.78), whereas
insoluble fibre (corn, wheat bran), in some cases, worsened the clinical
outcome, but there was no significant difference compared with placebo
(relative risk, 0.89; 95% CI, 0.72-1.11). CONCLUSIONS: The benefits of
fibre in the treatment of irritable bowel syndrome are marginal for
global irritable bowel syndrome symptom improvement and irritable bowel
syndrome-related constipation. Soluble and insoluble fibres have
different effects on global irritable bowel syndrome symptoms. Indeed,
in some cases, insoluble fibres may worsen the clinical outcome. Future
clinical studies evaluating the effect and tolerability of fibre therapy
are needed in primary care.
Publication Types: Review; Review, Academic
38.
Guidelines for the Treatment of Chronic Constipation: What Is the Evidence?
Posted 07/12/2005
Philip S. Schoenfeld, MD, MSEd, MSc
Introduction and Context
In July 2005, the American College of Gastroenterology Functional Gastrointestinal
Disorders Task Force produced an evidence-based
monograph on the management of chronic constipation in North America.[1] This
monograph follows the evidence-based format used in a previous review on the
treatment of irritable bowel syndrome (IBS),[2] and provides graded recommendations
regarding the appropriate diagnosis and treatment of chronic constipation. This
brief report outlines the recommendations of the Task Force and discusses the
evidence that supports these recommendations.
Epidemiology of Chronic Constipation in North America
The prevalence of chronic constipation in North America is approximately 15%, although only a minority of sufferers seek medical care.[3] On the basis of data from population-based studies, chronic constipation is more common in women, the elderly, nonwhites, and individuals from lower socioeconomic groups.[3] When these individuals complain about chronic constipation, they are referring to symptoms related to difficult stool passage: straining, hard/lumpy stools, prolonged time to stool, sense of incomplete evacuation, or need for manual maneuvers to pass stool. Only one third of chronic constipation sufferers complain of passing fewer than 3 bowel movements/week. Therefore, the Task Force defined chronic constipation as "unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both." Quality-of-life studies indicate that patients who self-report constipation suffer from a decreased quality of life.[3] Therefore, Task Force members recommended that physicians should institute treatment for chronic constipation after discussion with the patient and determination that the symptoms are diminishing the patient's quality of life.
Diagnostic Approach to Patients With Chronic Constipation Symptoms
If the pre-test probability of an organic disorder (eg, hypothyroidism) is increased in patients with chronic constipation symptoms compared with healthy control patients, then appropriate diagnostic tests (eg, thyroid function tests) should be ordered routinely in patients with (chronic constipation) symptoms. However, if the pre-test probability of an organic disorder (eg, hypercalcemia) is similar in patients with chronic constipations symptoms as compared with healthy control patients, then the routine use of diagnostic tests (eg, serum calcium) should not be performed. Unfortunately, there are no well-designed studies that assess the pre-test probability of different organic disorders (eg, hypercalcemia, hypothyroidism, colon cancer) among patients who present with chronic constipation symptoms. Therefore, Task Force members concluded that there were inadequate data to make a recommendation about the routine use of flexible sigmoidoscopy, colonoscopy, barium enema, thyroid function tests, serum calcium, and other diagnostic tests in patients who present with chronic constipation symptoms. However, if a patient presents with alarm symptoms or signs (eg, hematochezia, weight loss of 10 or more pounds, family history of colon cancer or inflammatory bowel disease, positive fecal occult blood tests, iron-deficiency anemia, or acute onset of chronic constipation symptoms in patients 50 years of age and older), then diagnostic studies are indicated because these alarm signs or symptoms may increase a patient's pretest probability of chronic constipation symptoms secondary to an organic disorder. Furthermore, if history or physical exam identifies signs/symptoms of an organic disorder (eg, symptoms or physical exam signs of hypothyroidism), then additional diagnostic testing should be performed for these specific disorders.
On the basis of the available evidence, colonoscopy does not identify organic disorders more frequently in patients with chronic constipation symptoms compared with healthy controls. Therefore, the Task Force recommends that colonoscopy should be used routinely as part of colon cancer screening in all patients 50 years of age and older. However, Task Force members suggest that the routine performance of colonoscopy in patients with symptoms of chronic constipation is not supported by available evidence. Task Force members suggest that the approach to patients with chronic constipation symptoms should involve empiric treatment without performance of diagnostic tests.
Therapy of Chronic Constipation
Bulking Agents
Findings from 3 placebo-controlled randomized controlled trials (RCTs) showed that psyllium improves stool frequency and stool consistency compared with placebo.[4-6] These trials were suboptimally designed, which led to a grade B recommendation (ie, recommendations based on evidence from RCTs with inadequate sample sizes, inappropriate methodology, or nonsignificant results). There are insufficient data to make a recommendation about the efficacy of calcium polycarbophil, methylcellulose, and wheat bran in patients with chronic constipation. Specifically, there are 3 RCTs of wheat bran in patients with chronic constipation,[7-9] but only 1 is placebo-controlled.[7] This trial did not demonstrate a significant improvement in stool frequency or consistency when compared with placebo -- neither did 2 trials[8,9] that compared wheat bran with corn biscuit or corn bran. There are no placebo-controlled RCTs of methylcellulose or calcium polycarbophil, although poorly designed RCTs involving fewer than 100 patients do not demonstrate differences between calcium polycarbophil or methylcellulose compared with psyllium.
Data on adverse events are quite limited, although taking 10-20 g/day of psyllium has been associated with bloating, which may be a bothersome event in these patients. Psyllium has also been associated with mechanical obstruction of the esophagus and colon and anaphylactic reactions in case reports.
Stool Softeners
On the basis of the available RCT evidence, there are insufficient data to make a recommendation regarding the efficacy of stool softeners in patients with chronic constipation (Grade B recommendation). Stool softeners may be inferior to psyllium for improvement of stool frequency (Grade B recommendation). Four RCTs[10-13] compared stool softeners with active comparators or placebo in patients with chronic constipation. Overall, these studies were poorly designed with small sample sizes and a diverse patient population. Docusate sodium was inferior to psyllium for increase in stool frequency. Placebo-controlled trials showed no difference in stool frequency or stool consistency between stool softeners and placebo. Overall, these data suggest that stool softeners are little more than a placebo for the treatment of chronic constipation. However, because the quality of the studies was so poor, Task Force members believed that there were insufficient data to state that stool softeners were similar to placebo. No data on adverse events with stool softeners were presented in these trials.
Osmotic Laxatives
Multiple well-designed RCTs,[14-17] demonstrate that polyethylene glycol appears superior to placebo for improving stool frequency and stool consistency in patients with chronic constipation (Grade A recommendation; Grade A recommendations are supported by 2 or more well-designed RCTs with adequate sample sizes and statistically significant results). Lactulose is also more effective than placebo in improving stool frequency and stool consistency in chronic constipation patients (Grade A recommendation).[18-20] However, only 1 RCT[21] assessed the efficacy of magnesium hydroxide in patients with chronic constipation, and this trial was not placebo-controlled. Therefore, Task Force members stated that there are insufficient data to make a recommendation about the effectiveness of magnesium hydroxide in patients with chronic constipation.
Data on adverse events were not adequately reported for most of these trials. However, lactulose-treated patients demonstrated a significant increase in bloating/abdominal discomfort compared with placebo-treated patients. Polyethylene glycol was associated with diarrhea. Review of available adverse event data indicates that the prevalence of diarrhea in polyethylene glycol-treated patients ranged from 2% to 40% in clinical trials.
Stimulant Laxatives
There are no placebo-controlled RCTs assessing stimulant laxatives in the management of chronic constipation symptoms. There are 4 RCTs[22-25] comparing stimulant laxatives with other therapies in the management of chronic constipation symptoms. Stimulant laxatives did not demonstrate superiority to other treatments in treating constipation. In fact, stimulant laxatives appeared to be less effective than lactulose in 1 RCT.[25] Conversely, stimulant laxatives appear to be similar to bulking agents in their efficacy for improving stool frequency and stool consistency. Most of these studies were poorly designed. Because of the lack of placebo-controlled studies and the suboptimal design of the available trials, Task Force members concluded that there are insufficient data to make a recommendation regarding the effectiveness of stimulant laxatives in patients with chronic constipation.
Senna-containing stimulant laxatives have been associated with melanosis coli. However, available evidence does not indicate that melanosis coli is associated with defects in colon physiology. Although cathartic colon (a syndrome characterized by colonic dilatation and loss of haustration) has been reported in patients using stimulant laxatives, this entity has not been reported in long-term users of currently available stimulant laxatives. Thus, it is unlikely that the long-term use of stimulant laxatives induces a permanent injury to colonic mucosa or to the enteric nervous system.
5HT4 Receptor Agonist Therapy
On the basis of data from 2 large, well-designed RCTs,[26,27] the 5-HT4 receptor agonist tegaserod is superior to placebo in improving stool frequency, stool consistency, and global chronic constipation symptoms (Grade A recommendation). Tegaserod is the only US FDA-approved treatment for chronic constipation. (ie, most laxatives are only approved for short-term use in the treatment of occasional constipation). For chronic constipation, tegaserod is approved for chronic use (longer than 12 weeks) with periodic reassessment by the physician to confirm the need for ongoing therapy. Unlike the IBS indication which is only for women, tegaserod is approved for the treatment of chronic constipation in men as well, because subgroup analysis in male patients demonstrated superiority of effect for tegaserod-treated patients vs placebo-treated patients. However, efficacy has not been demonstrated in patients 65 years of age and older, and therefore tegaserod is only FDA-approved for the management of chronic constipation in men and women younger than 65 years. RCT data also demonstrated improvements in total spontaneous bowel movements, complete spontaneous bowel movements, straining, and other individual symptoms of chronic constipation.
Adverse event data noted that diarrhea occurred more frequently in tegaserod-treated patients compared with placebo-treated patients (6.6% vs 3%), although it was usually mild and transient with fewer than 1% of patients discontinuing tegaserod due to diarrhea.
Herbal Supplements, Alternative Treatments, Lubricants, and Combination Laxatives
There are no published RCTs examining the efficacy of herbal supplements available in the United States. There are no published RCTs of combination laxatives (eg, psyllium plus senna) available in the United States. Therefore, Task Force members concluded that there are insufficient data to make a recommendation regarding the effectiveness of these agents in the treatment of chronic constipation. There are no placebo-controlled RCTs of biofeedback therapy in the management of patients with chronic constipation, although there are multiple nonrandomized trials demonstrating an increase in stool frequency from baseline, with biofeedback. Much of these data come from chronic constipation patients with pelvic floor disorders in whom biofeedback may be particularly helpful. Because it is difficult to do a "sham" biofeedback trial, it is unlikely that an appropriately designed RCT of biofeedback therapy in patients with chronic constipation will be performed. There are no RCTs examining the efficacy of mineral oil in adult patients with chronic constipation, although RCTs performed in pediatric patients[28,29] with chronic constipation demonstrate that mineral oil is more effective than stimulant laxatives but less effective than osmotic laxatives in improving stool frequency and stool consistency. (However, mineral oil may pass through the rectum and stain underwear in some patients, which may be disconcerting.)
Concluding Remarks
On the basis of available data, the following conclusions may be drawn:
- Among those patients who seek medical care for chronic constipation, the symptoms induce a clinically important decrement in their quality of life.
- Traditional approaches to treating chronic constipation, including dietary changes, increased water intake, or increased exercise, have not demonstrated improvement in symptoms in appropriately designed trials. Although as a physician I may discuss these interventions with patients, I do not emphasize these interventions.
- Pharmacologic intervention, including the use of psyllium, is appropriate for the initial management of patients with chronic constipation.
- The majority of patients with chronic constipation do not have an organic disorder causing their symptoms. Therefore, the routine performance of multiple diagnostic tests is not indicated in these individuals. If patients have alarm signs or symptoms or if patients fail to respond to appropriate therapy, then further diagnostic testing should be considered.
- On the basis of the available data, this physician recommends psyllium (10-20 g/day) as initial therapy for patients with chronic constipation symptoms. [Author Note: if patients have abdominal discomfort associated with their chronic constipation, then the appropriate diagnosis is IBS. In the management of IBS, psyllium is similar to placebo. In fact, the bloating associated with psyllium use will likely worsen symptoms in an IBS patient.]
- If a patient does not respond adequately to psyllium, then he/she should be treated with either an osmotic laxative (eg, polyethylene glycol 3350) or a promotility agent (eg, tegaserod). Both of these treatments have demonstrated efficacy in improving stool frequency and stool consistency in multiple well-designed RCTs.
- In cases of severe chronic constipation, multiple therapies may be combined. This physician's preference is to combine an osmotic laxative (eg, polyethylene glycol) with a promotility agent (eg, tegaserod). If necessary, a lubricant may be added (eg, mineral oil) to facilitate stool passage.
- Brandt L, Schoenfeld P, Prather C, Quigley E, Schiller L, Talley N. American College of Gastroenterology Functional Gastrointestinal Disorders Task Force. An Evidence Based Approach to the Management of Chronic Constipation in North America. Am J Gastroenterol. 2005;100:S1-S21.
- Brandt LJ, Locke GR, Olden K, et al. American College of Gastroenterology Functional Gastrointestinal Disorders Task Force. An evidence-based approach to the management of irritable bowel syndrome in North America. Am J Gastroenterol. 2002;97:S1-S26.
- Higgins PD, Johnson JF. Epidemiology of chronic constipation in North America: A systematic review. Am J Gastroenterol. 2004;99:750-759. Abstract
- Cheskin LJ, Kamal N, Crowell MD, et al. Mechanisms of constipation in older persons and effects of fiber compared with placebo. Am J Geriatr Soc. 1995;43:666-669.
- Fenn GC, Wilkinson PD, Lee CE, Akbar FA. A general practice study of the efficacy of Regulan in functional constipation. Br J Clin Pract. 1986;40:192-197. Abstract
- Ashraf W, Park F, Lof J, Quigley EM. Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation. Aliment Pharmacol Ther. 1995;9:639-647. Abstract
- Badiali D, Corazziari E, Habib FI, et al. Effect of wheat bran in treatment of chronic nonorganic constipation. A double-blind controlled trial. Dig Dis Sci. 1995;40:349-356. Abstract
- Anderson AS, Whichelow MJ. Constipation during pregnancy: dietary fibre intake and the effect of fibre supplementation.Hum Nutr Appl Nutr. 1985;39:202-207. Abstract
- Graham DY, Moser SE, Estes MK. The effect of bran on bowel function in constipation. Am J Gastroenterol. 1982;77:599-603. Abstract
- Castle SC, Cantrell M, Israel DS, Samuelson MJ. Constipation prevention: empiric use of stool softeners questioned. Geriatrics. 1991;46:84-86. Abstract
- Hyland CM, Foran JD. Dioctyl sodium sulphosuccinate as a laxative in the elderly. Practitioner. 1968;200:698-699. Abstract
- Fain AM, Susat R, Herring M, Dorton K. Treatment of constipation in geriatric and chronically ill patients: a comparison. South Med J. 1978;71:677-680. Abstract
- McRorie JW, Daggy BP, Morel JG, Diersing PS, Miner PB, Robinson M. Psyllium is superior to docusate sodium for treatment of chronic constipation. Aliment Pharmacol Ther. 1998;12:491-497. Abstract
- Corazziari E, Badiali D, Habib FI, et al. Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation. Dig Dis Sci. 1996;41:1636-1642. Abstract
- Corazziari E, Badiali D, Bassocchi G, et al. Long term efficacy, safety, and tolerabilitity of low daily doses of isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in the treatment of functional chronic constipation. Gut. 2000;46:522-526. Abstract
- DiPalma JA, DeRidder JH, Orlando RC, Kolts BE, Cleveland MB. A randomized, placebo-controlled, multicenter study of the safety and efficacy of a new polyethylene glycol laxative. Am J Gastroenterol. 2000;95:446-450. Abstract
- Attar A, Lemann M, Ferguson A, et al. Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut. 1999;44:226-230. Abstract
- Bass P, Dennis S. The laxative effects of lactulose in normal and constipated subjects. J Clin Gastroenterol. 1981;3(suppl 1):23-28. Abstract
- Sanders JF. Lactulose syrup assessed in a double-blind study of elderly constipated patients. J Am Geriatr Soc. 1978;26:236-239. Abstract
- Wesselius-De Casparis A, Braadbaart S, Bergh-Bohlken GE, Mimica M. Treatment of chronic constipation with lactulose syrup: results of a double-blind study. Gut. 1968;9:84-86. Abstract
- Kinnunen O, Salokannel J. Constipation in elderly long-stay patients: its treatment by magnesium hydroxide and bulk-laxative. Ann Clin Res. 1987;19:321-323. Abstract
- MacLennan WJ, Pooler AFWM. A comparison of sodium picosulphate ("Laxoberal") with standardised senna ("Senokot") in geriatric patients. Curr Med Res Opin. 1974-75;2:641-647.
- MacCallum G, Ballinger BR, Presly AS. A trial of bran and bran biscuits for constipation in mentally handicapped and psychogeriatric patients. J Hum Nutr. 1978;32:369-372. Abstract
- Rider JA. Treatment of acute and chronic constipation with bisoxatin acetate and bisacodyl. Double-blind crossover study. Curr Ther Res Clin Exp. 1971;13:386-392. Abstract
- Connolly P, Hughes IW, Ryan G. Comparison of "Duphalac" and "irritant" laxatives during and after treatment of chronic constipation: a preliminary study. Curr Med Res Opin. 1974-75;2:620-625.
- Johanson J, Wald A, Tougas G, et al. Effect of tegaserod in chronic constipation: a randomized, double-blind, controlled trial. Clin Gastroenterol Hepatol. 2004;2:796-805. Abstract
- Kamm M, Muller-Lissner S, Talley NJ, et al. Tegaserod for the treatment of chronic constipation: a randomized, double-blind, placebo-controlled multinational study. Am J Gastroenterol. 2005;100:362-372. Abstract
- Tolia V, Lin CH, Elitsur Y. A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children. Aliment Pharmacol Ther. 1993;7:523-529. Abstract
- Sondheimer JM, Gervaise EP. Lubricant versus laxative in the treatment of chronic functional constipation of children: a comparative study. J Pediatr Gastroenterol Nutr. 1982;1:223-226. Abstract
39) Bulk agent Plantago ovata after
Milligan-Morgan hemorrhoidectomy with LigasureTM
Dragutin M. Kecmanovic *, Maja J. Pavlov, Miljan S. Ceranic,
Mirko D. Kerkez, Vitomir I. Rankovic, Vesna P. Masirevic First Surgical
University Hospital, Institute for Digestive Diseases, Clinical Center of
Serbia, 6 Koste Todorovica St, Belgrade, Serbia
email: Dragutin M. Kecmanovic (mceranic@drenik.net)
*Correspondence to Dragutin M. Kecmanovic, Department for Colorectal
Surgery, First Surgical University Hospital, Clinical Center of Serbia, Koste
Todorovica 6, 11000 Belgrade, Serbia
Keywords
hemorrhoidectomy • Plantago ovata • pain • Milligan-Morgan
Abstract
The aim of this study was to determine usefulness of the bulk agent Plantago
ovata in reducing postoperative pain and tenesmus after open
hemorrhoidectomy (Milligan-Morgan with LigasureTM). Ninety-eight
patients were randomized into two groups of 49 patients each. In both groups
Milligan-Morgan open hemorrhoidectomy with LigasureTM was performed.
The first group received postoperatively two sachets daily of 3.26 g of the bulk
agent, Plantago ovata, for 20 days. The control group was treated
postoperatively with glycerin oil. There was no statistically significant
difference in age, gender distribution and hemorrhoid grading, between the two
groups. The pain score after first defecation (p < 0.001) and after 10
days (p < 0.01) and the global pain score (p < 0.001) was
statistically significantly lower in the group treated with Plantago ovata,
while there was no statistically significant difference in the pain level after
20 days (p > 0.05). The hospital stay was statistically significantly
shorter in the group receiving Plantago ovata (2.6 ± 0.6 vs 3.9 ± 0.7
days, p < 0.001). The incidence of tenesmus was higher in the control
group (40.8% vs 10.2%, p < 0.01). Treating patients with Plantago
ovata after open hemorrhoidectomy, reduces pain, tenesmus rate and shortens
postoperative hospital stay.
40) Gastroenterol Hepatol. 2008 Feb;31(2):59-74.
The latin-american consensus on chronic constipation.
Schmulson Wasserman M, Francisconi C, Olden K, Aguilar Paíz L, Bustos-Fernández L, Cohen H, Passos MC, González-Martínez MA, Iade B, Iantorno G, Ledesma Ginatta C, López-Colombo A, Pérez CL, Madrid-Silva AM, Quilici F, Quintero Samudio I, Rodríguez Varón A, Suazo J, Valenzuela J, Zolezzi A.
Laboratorio de Hígado, Páncreas y Motilidad (HIPAM). Departamento de Medicina Experimental. Facultad de Medicina. Universidad Nacional Autónoma de México (UNAM). Hospital General de México. México. maxjulio@avantel.net.
The Latin-American Consensus on Chronic Constipation aimed to establish guidelines to improve the identification, diagnosis and treatment of this disorder in the region. Two coordinators and an honorary coordinator established the process and the topics to be discussed, based on a systematic review of the literature published in the previous 10 years, since 1995. Seventeen members participated with the support of their local gastroenterology societies. The members reviewed the different subjects based on the levels of evidence and grades of recommendation; the topics were then discussed in a plenary session. A written report was drafted and the coordinators prepared the final declarations to be submitted to a vote by all the members in October 2006. The consensus concluded that chronic constipation has an estimated prevalence of 5-21% in the region, with a female-to-male ratio of 3:1. Among individuals with constipation, 75% use some type of medication, with more than 50% using home remedies. A diagnosis based on Rome Criteria was recommended and diagnostic testing only in persons older than 50 years or with alarm symptoms. The use of barium enema as an initial investigation was recommended only in countries with a high prevalence of idiopathic megacolon or Chagas' disease. Recommendations on treatment included an increase in dietary fiber of up to 25-30 g/day (grade C). No evidence was found to recommend measures such as exercise, increased water intake, or frequent visits to the toilet. Fiber supplements such as Psyllium received a grade B and pharmacological treatments such as tegaserod and polyethylene glycol, both grade A. There was insufficient evidence to recommend lactulose, but the consensus did not disadvise its use when necessary. Complementary investigations such as colonic transit followed by anorectal manometry and defecography were only recommended to rule out colonic inertia and/or obstructive defecation in patients not responding to treatment. Biofeedback was recommended (grade B) for those with pelvic dyssynergia.
^ Inizio