How is constipation-predominant irritable bowel syndrome treated?

*For medical professionals to read for reference life>
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If the patient has the above symptoms, then it may not be chronic constipation, but irritable bowel syndrome with constipation (IBS-C)! Correct understanding: constipation-predominant irritable bowel syndrome irritable bowel syndrome (IBS) is characterized by abdominal pain, bloating or abdominal discomfort as the main symptoms, which are often accompanied by changes in defecation habits, such as changes in frequency and/or stool properties, through clinical routine On examination, no organic disease has been found to explain these symptoms
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For the diagnostic criteria of IBS, the 2016 Rome IV criteria were modified on the basis of the Rome III criteria, deleted the "abdominal discomfort" in the symptoms of IBS, and only emphasized the correlation between abdominal pain and defecation; and changed the frequency of attacks from 3 times/month.
Adjust to 4 times/month [1,2]
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Figure 1: IBS definition Rome IV standard vs Rome III standard Chinese clinical research data show that Rome IV standard does not fully conform to the actual clinical situation in China.
Therefore, many experts in China have formulated China's IBS diagnostic criteria based on China's national conditions [3] : Repeated episodes of abdominal pain, bloating, and abdominal discomfort, with any 2 or more of the following (1) associated with defecation; , the past 3 months meet the above diagnostic criteria
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And according to the Bristol stool characteristics of patients with abnormal defecation, IBS is divided into diarrhea-type IBS (IBS-D), constipation-type IBS (IBS-C), mixed IBS (IBS-M) and undetermined IBS (IBM-U) 4 subtypes
.

Constipation-predominant irritable bowel syndrome (IBS-C): >25% of bowel movements are Bristol fecal trait type 1 or 2, and <25% of Bristol fecal trait type 6 or 7
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Figure 2: How to treat Chinese IBS diagnostic criteria + Bristol stool trait scale IBS-C? The goal of treatment for IBS-C is to improve symptoms and improve quality of life.
Treatment includes life>
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1.
Life>
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1.
Develop a regular defecation time.
Generally, get up in the morning or after eating, and adopt a position that is conducive to the opening of the rectal angle.
It is recommended to defecate in a squatting position (the most suitable way for human defecation).
Small bench, keep squatting forward position, which is conducive to improving defecation
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2.
Dietary adjustment: It is recommended to consume 20-30g of cellulose and intake of sufficient water every day, which can promote intestinal peristalsis, effectively increase the frequency of defecation and improve stool properties [6]
.

In addition, some scholars believe that a low-FODMAP diet that reduces oligosaccharides (wheat, onions, beans, etc.
), monosaccharides (honey, mango, etc.
), disaccharides (dairy products, etc.
) and polyols (apples, mushrooms, etc.
) Improve abdominal symptoms in patients with IBS-C [7]
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3.
Regular aerobic exercise can improve the transit time of the whole colon and rectum, and improve the symptoms of constipation.
It is recommended to do moderate-intensity aerobic exercise 3-5 times a week for 150-300 minutes
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2.
Drug treatment 2.
1.
Traditional laxatives At present, laxatives mainly include volumetric laxatives, stimulatory laxatives and osmotic laxatives
.

Bulk laxatives: psyllium, polycarbophil calcium, and wheat bran are mainly used for some mild constipation.
However, bulk laxatives may aggravate the symptoms of abdominal distension in patients due to increasing the volume of stool and expanding the bowel, and have not been recommended in the past.
Treatment for IBS-C
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Stimulating laxatives: Anthraquinone drugs (such as rhubarb, senna, aloe and other botanical laxatives) act on the enteric nervous system, enhance intestinal motility and stimulate intestinal secretion.
Long-term use may lead to enteric nerve damage and colon lesions.
The latest guidelines have no relevant recommendations
.

Osmotic laxatives: mainly polyethylene glycol and lactulose, are currently the most widely used laxatives by forming a hypertonic environment in the intestinal lumen to promote intestinal secretion, thereby softening stool and accelerating intestinal transmission
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Studies have shown that polyethylene glycol can significantly increase the frequency of voluntary defecation in patients with IBS-C, reduce stool hardness, and effectively relieve constipation symptoms.
It is safe, but cannot improve abdominal discomfort
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2.
2.
Prokinetic agent serotonin receptor 4 can promote intestinal secretion, enhance intestinal peristalsis and transport
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Currently commonly used prokinetic agents in clinic include mosapride, prucalopride and itopride
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Mosapride: It can promote the release of acetylcholine, stimulate the gastrointestinal tract and exert a prokinetic effect, thereby improving the gastrointestinal symptoms of functional dyspepsia and improving constipation
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Prucalopride: It has intestinal motility activity and is suitable for the treatment of adult female patients with chronic constipation who cannot be adequately relieved by laxatives, and can improve abdominal pain, abdominal distension and other symptoms
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Itopride: It has the dual action of dopamine D2 receptor blocker and acetylcholinease inhibitor, stimulates the release of endogenous acetylcholine and inhibits its hydrolysis to enhance gastric and duodenal motility, promote gastric emptying, and increase intestinal motility
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2.
3, antispasmodic drugs: pinaverium bromide, otilonium bromide, alverine, trimebutine,
etc.

Mechanism: Taking pinaverium bromide as an example, its mechanism is to block voltage-dependent calcium channels on the outer surface of gastrointestinal smooth muscle cells with high selectivity and inhibit the inflow of Ca2+, thereby regulating visceral hypersensitivity and abnormal gastrointestinal motility.
Increase bowel motility
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Several international guidelines and consensus opinions recommend antispasmodics as a first-line drug for improving abdominal pain symptoms in IBS [8]
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2.
4.
Secretagogues Secretagogues (including guanylate cyclase C agonists and selective chloride channel agonists) mainly include linaclotide, lubiprostone and plecanatide
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In the 2018 American College of Gastroenterology's IBS treatment guidelines, linaclotide is the highest level of evidence and is strongly recommended for the treatment of IBS-C, while lubiprostone and plecanatide have moderate-quality evidence and are strongly recommended.
in the treatment of IBS-C [9]
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Linaclotide: The world's first guanylate cyclase C agonist, containing 14 amino acid residues, with dual action
.

Linaclotide can significantly increase the number of spontaneous bowel movements per week, improve defecation effort and stool quality, and effectively relieve abdominal discomfort such as bloating
.

Since the drug is metabolized in the gastrointestinal tract, it is rarely absorbed into the blood, so it is safe
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Lubiprostone: It can selectively activate chloride ion channels located in intestinal epithelial cells, and promote the secretion of chloride ions into the intestinal lumen.
The increased secretion of intestinal juice can loosen feces, speed up the frequency of defecation, reduce the feeling of laborious defecation and improve the symptoms of abdominal pain
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It is currently approved by the US FDA for female IBS-C patients over 18 years of age
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A phase III clinical study of lubiprostone in IBS-C is underway in China
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Plecanatide: regulates intestinal ion and fluid transport by activating guanylate cyclase
C.

The drug, which promotes intestinal transit and softens stool as it passes through the intestine, is currently FDA-approved for the treatment of IBS-C
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2.
5 Representative neurotransmitter drugs: fluoxetine, citalopram,
etc.

The pathogenesis of IBS-C may be related to the central nervous system, visceral hypersensitivity and mental and psychological factors
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Selective serotonin (5-HT) reuptake inhibitors (SSRIs) can not only regulate visceral hypersensitivity, but also enhance intestinal peristalsis, which can effectively improve abdominal distention, abdominal pain and feces in patients with IBS-C [10]
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2.
6.
Probiotics Many studies have shown that there is intestinal flora disorder in patients with IBS-C, which may be related to the occurrence and development of IBS-C
.

Probiotics (such as Bifidobacterium triple viable bacteria, Bacillus licheniformis viable bacteria granules, Lactobacillus acidophilus granules, etc.
) may be related to enhancing the ability of the intestine to resist pathogenic bacteria, strengthening the intestinal barrier function, and restoring intestinal movement
.

The 2018 ACG guidelines recommend probiotics as adjunctive therapy to improve abdominal discomfort in patients
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3.
Fecal microbiota transplantation (HMT or FMT) refers to the transplantation of functional flora in the intestines of healthy people into the intestines of patients, to rebuild the intestinal flora with normal functions, and to achieve the treatment of intestinal and extra-intestinal diseases
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In order to standardize the clinical application of bacterial flora transplantation technology and ensure the quality and safety of medical treatment, the Shanghai Health and Health Commission organized experts to study and formulate the "Shanghai flora transplantation technology management standard (2021 version)", which clearly pointed out that FMT is suitable for functional constipation and functional constipation.
Treatment of irritable bowel syndrome [11]
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Summary: IBS-C is a relatively common gastrointestinal functional disease with recurrent symptoms, which seriously affects the quality of life of patients
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In addition, IBS-C can overlap or transform with some symptoms of other functional diseases, and it is difficult to make a clear diagnosis.
Abdominal discomfort and changes in stool frequency and character are experienced for a long time or repeatedly.
It is recommended to seek medical attention as soon as possible to avoid aggravation of symptoms
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If diagnosed with IBS-C, good life>
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For those who are not well controlled, symptomatic treatment with drugs can be added
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References: [1] Drossman DA, et al.
Rome III: The Functional Gastrointestinal Disorders.
130 ed.
2006: 1377–1556.
.
[2] Douglas, A, Drossman, et al.
Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction[J].
Gastroenterology, 2016, 150(6): 1257-1261.
[3] Gastrointestinal Functional Diseases Collaborative Group of Gastroenterology Branch of Chinese Medical Association, Gastrointestinal Motility of Gastroenterology Branch of Chinese Medical Association Xue Group.
Expert consensus on irritable bowel syndrome in China in 2020 [J].
Chinese Journal of Digestive Medicine, 2020, 40(12): 16.
[4] Zhang Lu, Duan Liping, Liu Yixuan, et al.
Irritable Bowel Syndrome in Chinese Population Meta-analysis of prevalence and related risk factors.
Chinese Journal of Internal Medicine, 2014, 53(12): 969-975.
[5] Xin Haiwei.
Functional constipation and constipation-type irritable bowel syndrome-can we differentiate?[J ].
Journal of Gastroenterology and Hepatology, 2013, 22(2): 5.
[6] Fathallah N, et al.
[Diet and life>
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Member of the Digestive Endoscopy Committee of the Inflammatory Bowel Disease Group of the Gastroenterology Branch of the Chinese Medical Association, Deputy Director of the Youth Committee of the Behavioral Medicine Branch of the Chinese Medical Association, member of the Clinical Epidemiology Collaborative Group of the Gastroenterology Branch of the Chinese Medical Association, and Digestive Disease of the Chinese Medical Equipment Association Member of the Inflammatory Bowel Disease Group of the Academic Society Committee, member of the Inflammatory Bowel Disease Professional Committee of the Chinese Medical Doctor Association Anorectal Physician Branch, member of the Anorectal Intractable Disease Professional Committee, member of the Inflammatory Bowel Disease Expert Committee of the Digestive Endoscopy Professional Committee of the Chinese Society of Integrative Medicine, Beijing Member of the Inflammatory Bowel Disease Expert Committee of the Medical Award Foundation, member of the Standing Committee of the Inflammatory Bowel Disease Alliance of Wu Jieping Medical Foundation, member of the Standing Committee of the Intestinal Microecology Professional Committee, member of the Standing Committee of the Stem Cell Engineering Technology Branch of the Chinese Society of Biomedical Engineering, and Inflammation of the Gastroenterology Branch of the Tianjin Medical Association Deputy Director of the Sexual Bowel Disease Group Research direction: biological therapy and cell therapy for autoimmune diseases of inflammatory bowel disease and digestive tract immune disease, especially dedicated to the clinical application of mesenchymal stem cell transplantation
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His research results have won awards from international conferences such as the American Gastroenterology Annual Meeting and the European Union Gastroenterology Annual Meeting, and he has published dozens of papers in SCI journals and Chinese series journals
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Xie Dong is a clinical pharmacist in the General Hospital of Tianjin Medical University, a clinical pharmacist who specializes in gastroenterology in the National Clinical Pharmacist Training Base, and an MTM pharmacist certified by the American Pharmacists Association (APhA)
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Sun Bo Clinical Pharmacist, Lianyungang First People's Hospital