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.
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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
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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)