Trans-anal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis

BMC Gastroenterology, Oct 2015

Background Trans-anal irrigation (TAI) is used widely to treat bowel dysfunction, although evidence for its use in adult chronic functional constipation remains unclear. Long-term outcome data are lacking, and the effectiveness of therapy in this patient group is not definitively known. Methods Evidence for effectiveness and safety was reviewed and the quality of studies was assessed. Primary research articles of patients with chronic functional constipation, treated with TAI as outpatients and published in English in indexed journals were eligible. Searching included major bibliographical databases and search terms: bowel dysfunction, defecation, constipation and irrigation. Fixed- and random-effect meta-analyses were performed. Results Seven eligible uncontrolled studies, including 254 patients, of retrospective or prospective design were identified. The definition of treatment response varied and was investigator-determined. The fixed-effect pooled response rate (the proportion of patients with a positive outcome based on investigator-reported response for each study) was 50.4 % (95 % CI: 44.3–56.5 %) but featured substantial heterogeneity (I 2  = 67.1 %). A random-effects estimate was similar: 50.9 % (95 % CI: 39.4–62.3 %). Adverse events were inconsistently reported but were commonplace and minor. Conclusions The reported success rate of irrigation for functional constipation is about 50 %, comparable to or better than the response seen in trials of pharmacological therapies. TAI is a safe treatment benefitting some patients with functional constipation, which is a chronic refractory condition. However findings for TAI vary, possibly due to varying methodology and context. Well-designed prospective trials are required to improve the current weak evidence base.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://www.biomedcentral.com/content/pdf/s12876-015-0354-7.pdf

Trans-anal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis

Emmett et al. BMC Gastroenterology Trans-anal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis Christopher D. Emmett 0 Helen J. Close 2 Yan Yiannakou 1 James M. Mason 2 0 Old Trust Headquarters, University Hospital of North Durham , North Road, Durham DH1 5TW , UK 1 County Durham and Darlington NHS Foundation Trust , North Road, Durham DH1 5TW , UK 2 School of Medicine, Pharmacy & Health, Durham University Queen's Campus, University Boulevard , Thornaby, Stockton-on-Tees TS17 6BH , UK Background: Trans-anal irrigation (TAI) is used widely to treat bowel dysfunction, although evidence for its use in adult chronic functional constipation remains unclear. Long-term outcome data are lacking, and the effectiveness of therapy in this patient group is not definitively known. Methods: Evidence for effectiveness and safety was reviewed and the quality of studies was assessed. Primary research articles of patients with chronic functional constipation, treated with TAI as outpatients and published in English in indexed journals were eligible. Searching included major bibliographical databases and search terms: bowel dysfunction, defecation, constipation and irrigation. Fixed- and random-effect meta-analyses were performed. Results: Seven eligible uncontrolled studies, including 254 patients, of retrospective or prospective design were identified. The definition of treatment response varied and was investigator-determined. The fixed-effect pooled response rate (the proportion of patients with a positive outcome based on investigator-reported response for each study) was 50.4 % (95 % CI: 44.3-56.5 %) but featured substantial heterogeneity (I2 = 67.1 %). A random-effects estimate was similar: 50.9 % (95 % CI: 39.4-62.3 %). Adverse events were inconsistently reported but were commonplace and minor. Conclusions: The reported success rate of irrigation for functional constipation is about 50 %, comparable to or better than the response seen in trials of pharmacological therapies. TAI is a safe treatment benefitting some patients with functional constipation, which is a chronic refractory condition. However findings for TAI vary, possibly due to varying methodology and context. Well-designed prospective trials are required to improve the current weak evidence base. - Background Overview of the condition Chronic constipation may be defined as ‘a symptom-based disorder defined as unsatisfactory defecation characterised by infrequent stools, difficult stool passage, or both, for at least three months’ [1]. For the purposes of this review, ‘chronic functional constipation’ refers to any condition fitting broadly within this definition, with no clear underlying cause. This includes obstructed defecation syndrome (ODS), functional defecation disorder (FDD), chronic idiopathic constipation (CIC), and constipation-predominant irritable bowel syndrome (IBS-C). This reflects the considerable overlap in symptoms between each of these conditions [2], and also the fact that observational studies indicate many patients reporting constipation do not fulfil the Rome III criteria for chronic functional constipation [1]. This definition does not include constipation secondary to a neurological cause (for example, spinal cord injury, stroke, Parkinson’s disease, Multiple Sclerosis), opioid-induced constipation or constipation secondary to any other medical diagnosis. Chronic constipation is a common condition in the community: a recent systematic review [3] gave a pooled prevalence of 14 %, although it becomes more common in older people and women. There is a considerable burden of symptoms and decreased quality of life [1]: one recent study reporting ‘extremely/very bothersome’ symptoms in 72 % of IBS-C patients, 62 % of CIC patients with abdominal symptoms and 40 % of CIC patients without abdominal symptoms [2]. The costs of treating constipation are significant and appear to be increasing; one American study reported aggregate national (U.S.) costs of Emergency © 2015 Emmett et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Department attendances due to constipation of $1.6 billion in 2011 [4]. Trans-anal irrigation Trans-anal irrigation therapy (TAI) is in widespread use throughout the UK as a treatment for bowel dysfunction. Irrigation involves instilling tap water into the rectum via the anus, using either a balloon catheter or cone delivery s (...truncated)


This is a preview of a remote PDF: http://www.biomedcentral.com/content/pdf/s12876-015-0354-7.pdf

Christopher Emmett, Helen Close, Yan Yiannakou, James Mason. Trans-anal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis, BMC Gastroenterology, 2015, pp. 139, 15, DOI: 10.1186/s12876-015-0354-7