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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Managing Chronic Constipation: Advances in the Science of Gastrointestinal Motility


GOAL
To provide gastroenterologists with up-to-date information on the diagnosis and treatment of patients with chronic constipation and irritable bowel syndrome.

TARGET AUDIENCE
This activity is designed for gastroenterologists.
No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Identify key elements of gastrointestinal physiology and anatomy that normally aid the defecation process and/or influence constipation.
  • Differentiate, identify, and diagnose constipation caused by various etiologies, and provide examples of each.
  • Categorize treatments into pharmacologic groups based on mechanism of action, and explain basic features of these mechanisms.
  • Discuss clinical relevance for newer treatments and cite appropriate precautions, warnings, and contraindications to their use.
  • Choose appropriate treatments based on specific criteria of patient age, health, and other factors, such as safety.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 3 hours.

Release date: February 15, 2006. Expiration date: February 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Sucampo Pharmaceuticals and Takeda Pharmaceuticals North America, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Linda Lee, MD
Assistant Professor of Medicine
Division of Gastroenterology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Lee reports having no financial or advisory relationships with corporate organizations related to this activity

PARTICIPATING FACULTY

Adil E. Bharucha, MD
Associate Professor of Medicine
Division of Gastroenterology and Hepatology
Mayo Clinic
Rochester, Minnesota
Dr Bharucha reports having no financial or advisory relationships with corporate organizations related to this activity.

Lin Chang, MD
Associate Professor of Medicine
Division of Digestive Diseases
Director, Women's Digestive Health Center
Center for Neurovisceral Sciences and   Women's Health
Director, UCLA Motility Clinic
University of California at Los Angeles
Los Angeles, California
Dr Chang reports receiving grants/research support from GlaxoSmithKline and Novartis; and serving as a consultant for GlaxoSmithKline, Novartis, and Solvay.

William L. Hasler, MD
Associate Professor of Internal Medicine
Division of Gastroenterology
University of Michigan Medical Center
Ann Arbor, Michigan
Dr Hasler reports serving on the speaker's bureau for GlaxoSmithKline, Novartis, and Solvay.

Anthony J. Lembo, MD
Assistant Professor of Medicine
Division of Gastroenterology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts
Dr Lembo reports serving as a consultant for Novartis, Schwarz, and Takeda.

Felix W. Leung, MD
Chief, Gastroenterology and Endoscopy
Veterans Affairs Sepulveda Ambulatory Care Center
Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
Dr Leung reports having no financial or advisory relationships with corporate organizations related to this activity.

Satish S. C. Rao, MD, PhD, FRCP (Lond)
Professor of Medicine and Director
Neurogastroenterology and Gastrointestinal Motility
Carver College of Medicine
University of Iowa
Iowa City, Iowa
Dr Rao reports having no financial or advisory relationships with corporate organizations related to this activity.

John F. Schnelle, PhD
Research Health Scientist
Med-Geri/Borun Center for Gerontological Research
University of California at Los Angeles
Los Angeles, California
Dr Schnelle reports having no financial or advisory relationships with corporate organizations related to this activity.

 

Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Chang—lubiprostone and opioid antagonists.
Dr Lembo—lubiprostone.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Managing Chronic Constipation: Advances in the Science of Gastrointestinal Motility
Linda Lee, MD*

This issue of Advanced Studies in Medicine highlights the proceedings of a roundtable held in Santa Monica, California, on September 22, 2005. The roundtable, titled "Managing Chronic Constipation: Advances in the Science of Gastrointestinal Motility," featured a distinguished faculty of gastroenterologists with expertise in gastrointestinal (GI) motility disorders, pharmacology, biofeedback therapy, women's health, and geriatrics. Individually and as a group, the faculty focused on the scientific aspects of chronic constipation (CC) and irritable bowel syndrome (IBS) without losing sight of the clinical issues involved in managing these common and troublesome conditions.

Although the prevalence of CC and IBS varies widely because of differences in definition, survey methods, and the populations surveyed, it is clear that these conditions are more common than supposed, largely because they are often unreported or underreported and because of the considerable degree of symptom overlap with other GI syndromes. These 2 circumstances alone warrant increased vigilance on the part of the physician when taking the patient's history and during the physical examination.

The faculty addressed these and other issues during the roundtable in their presentations, case studies, and discussions, which are summarized in this monograph to help practicing physicians effectively integrate scientific evidence with clinical management.

Lin Chang, MD, begins this issue of Advanced Studies in Medicine with an overview of the clinical, economic, and personal impact of CC and IBS. She reviews the epidemiology and etiology of both conditions, in addition to their diagnostic criteria, symptoms, impact on quality of life, resource utilization, and economic burden. She also notes that the symptoms are not inconsequential, but frequent and bothersome in many patients with either condition.

Adil E. Bharucha, MD, follows with a detailed look at the pathophysiology of CC and IBS. Beginning with a review of normal colonic motor patterns, he then explores the mechanisms that alter these patterns and lead to constipation or IBS, the enteric neuropathologic changes that are present in some patients with slow-transit constipation, and the serotoninergic disturbances seen in patients with IBS.

Felix W. Leung, MD, presents the results of his literature search for scientific evidence to support or refute the role of dietary fiber, fluid intake, physical activity, medication side effects, hypothyroidism, hormonal imbalances, and malignant colorectal obstructions in the etiology of constipation. He also explains why the inconclusive results of the search, in which some studies found associations between these factors and constipation whereas others did not, are at odds with the typical approach to the management of constipation, which assumes that these factors play a causative role.

In addressing the challenges in diagnosing CC and constipation-predominant IBS, Satish S. C. Rao, MD, PhD, FRCP (Lond), reviews the importance of a comprehensive patient history and physical examination. He also reviews the strengths and shortcomings of the diagnostic criteria for constipation and IBS, the symptoms of both, the need to differentiate slow-transit constipation from dyssynergia, the diagnostic tests used for further evaluation, and the clinical utility of these tests in establishing the diagnosis. His article includes a case study that is presented in segments to illustrate the main elements of the diagnostic evaluation. A second case study is also included at the end of the article to serve as a diagnostic review.

In his article on nonpharmacologic and over-the-counter (OTC) therapies for CC, William L. Hasler, MD, first addresses studies evaluating the use of lifestyle measures, such as increased fluid and fiber intake. He then reviews studies assessing OTC laxatives and stool softeners and the metabolic complications of laxative therapy. He closes with a review of studies assessing the efficacy of biofeedback therapy, which isgenerally considered the therapy of last resort and is often associated with significant postoperative morbidity. His article also includes a case study to illustrate the clinical outcomes of lifestyle measures, OTC laxatives, and biofeedback.

Anthony J. Lembo, MD, closes this issue of Advanced Studies in Medicine with a review of clinical and experimental studies of prescription laxatives and several new and novel pharmacologic therapies for CC. These therapies include tegaserod, which has been available since 2002; lubiprostone, which was approved by the US Food and Drug Administration in February 2006 for the treatment of chronic idiopathic constipation; renzapride; µ-opioid antagonists, such as naloxone, methylnaltrexone, and alvimopan; NT-3; and MD-1100.

All of the articles include discussion highlights, and some are accompanied by case studies. We hope that the information presented in this monograph will eventually lead to improved treatment of patients with CC and IBS.

*Assistant Professor of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Linda Lee, MD, Division of Gastroenterology, Johns Hopkins University School of Medicine, 918 RossÐGastroenterology, 600 North Wolfe Street, Baltimore, MD 21287. E-mail:
llee12@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.