J Neurogastroenterol Motil 2024; 30(1): 97-105  https://doi.org/10.5056/jnm21091
Relationship Between Colonic Transit Response to Eating With Self-reported Constipation Severity in Constipated Patients According to the Phenotype
David Deutsch,1 Michel Bouchoucha,1,2* Julien Uzan,1 Gheorghe Airinei,1 Jean-Marc Sabate,1 and Robert Benamouzig1
1Department of Gastroenterology, Hôpital Avicenne, Bobigny, France; and 2Department of Physiology, Université de Paris, Paris, France
Correspondence to: *Michel Bouchoucha, MD
CEFRED (centre d’exploration fonctionnelle et de rééducation digestive), Service de gastro-entérologie, Hôpital Avicenne, 93009 BOBIGNY Cedex, France
Tel: +33-0148957432, E-mail: michel.bouchoucha@avc.aphp.fr
Received: May 10, 2021; Revised: April 29, 2023; Accepted: May 11, 2023; Published online: January 30, 2024
© The Korean Society of Neurogastroenterology and Motility. All rights reserved.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background/Aims
Eating is the major synchronizer of gastrointestinal motility and secretions. The present study aims to evaluate the interplay between self-perceived constipation severity (CS) and colonic response to eating in constipated patients according to the phenotype.
Methods
We included 387 consecutive outpatients complaining of Rome IV chronic idiopathic constipation. Likert scales for CS, abdominal pain severity, bloating severity, depression and anxiety assessment, total and segmental colonic transit time (CTT), and colonic transit response to eating (CTRE) were performed in all patients.
Results
Of the 387 patients included (49.7 ± 16.4 years), 320 (83%) were female, 203 had irritable bowel syndrome with constipation (IBS-C), 184 as functional constipation (FC), and 283 had defecation disorders (DD). The female gender was characterized by increased bloating severity (P = 0.011) and decreased Bristol stool form (P = 0.002). In IBS-C and FC patients, CS was related with bloating severity (P < 0.001 in both groups) and total CTT (P = 0.007 in IBS-constipation, P = 0.040 in FC). In IBS-C patients, CS was also associated with abdominal pain severity (P = 0.003) and Bristol stool form (P = 0.004). In contrast, in FC, CS was only related to left CTRE (P = 0.006), and in patients with DD, CS was associated with total CTT (P < 0.001) and left CTRE (P = 0.002).
Conclusion
Colonic transit response to eating was not associated to CS in IBS-C patients, but left CTRE was associated with constipation severity in FC and DD patients.
Keywords: Anxiety; Constipation; Defecation; Depression; Irritable bowel syndrome
Introduction

Food intake, the principal synchronizer of secretory and motor digestive functions, is classically divided into cephalic, gastric, intestinal, and colonic phases. These phases’ control is multifactorial, implying mechanical, neurological, and hormonal mediators.1 The cephalic stimuli generated by the idea, view, odor, taste, and mastication of food contribute to the cephalic phase of the overall gastrointestinal (GI) secretory and motor response to a meal. The digestive tract’s response to the stomach’s stretch resulting from food ingestion defines the gastric phase.2 However, in humans, the importance of the cephalic and gastric phase on the colonic response to eating is discussed.3

In contrast, the intestinal phase is well shown, characterized by increased intestinal and colonic motor activity, resulting from chyme action entering into the intestine, as seen when food is placed directly into the duodenum in experimental studies or taken after total gastrectomy.3 This increased intestinal motility associates both the cessation of the intestine’s migrating motor complexes and a high colonic motor index.4 This increased colonic motor activity results in increased migrating and nonmigrating long spike bursts.5

In recent years, high-resolution colonic manometry has provided greater insight into stationary and propagating colonic motor patterns.6-8 In particular, the colonic response to feeding has shown that the sigmoid colon is the most impacted digestive segment during the phasic motor response of digestion, which consists of peristaltic waves that propel feces distally toward the rectum. Although high-resolution anorectal manometry identified new colonic motor patterns, the clinical significance of these motor changes remains undetermined.7 In particular, these techniques could not be used as routine tests in managing patients with functional bowel disorders.

To evaluate food’s action on colonic propulsion, we have previously proposed using colonic transit response to eating (CTRE) as a simple method to estimate the colonic response to eating in functional bowel disorders patients by using radiopaque markers.9-12 In healthy subjects, CTRE is characterized by changes in the colon’s 2 distal parts: emptying of the proximal part, the ascending colon, and filling of the distal part, the rectosigmoid area.9 In contrast, constipated subjects reported a weaker response to food with different designs according to the type of constipation.11 We have also shown that self-perceived constipation severity (CS) was linearly associated with bloating severity and Bristol stool form independently of the constipation phenotype.13

We hypothesize that self-perceived constipation severity could also be associated with colonic transit time (CTT) and CTRE in constipated patients. According to the Rome phenotype, the present study is designed to characterize the psychological and transit correlates of CS.

Materials and Methods

Study Design and Legal Registration

Following the French legislation, this retrospective observational study in consecutive outpatients presenting to a tertiary center was reported and registered on the decision number 2020-A02995-34 in the Agence Nationale de Sécurité du Médicament et des Produits de santé.

Ethical Consideration

All procedures contributing to this work comply with the relevant national and institutional committees’ ethical standards on human experimentation and the Helsinki Declaration of 1975, revised in 2008. All participants provided informed written consent.

Subjects

Between September 1, 2016, and September 30, 2020, 387 consecutive outpatients referred to our tertiary center for constipation management were included in the present study. The mean duration of their disease was 16 ± 8 years (range 0.9 to 39 years).

Clinical and Psychological Evaluation

As previously described, a comprehensive clinical and biological evaluation, including colonic endoscopy, failed to find an organic cause to explain their complaint.13 As stated by the Rome IV criteria, the patients were classified as having irritable bowel syndrome with constipation (IBS-C) or functional constipation.14 In these constipated patients, defecation disorder was diagnosed when patients showed at least 2 of the following: (1) evidence of impaired evacuation, based on balloon expulsion test or imaging; (2) less than 20% relaxation of basal resting sphincter pressure by manometry or inappropriate contraction of the pelvic floor muscles (ie, anal sphincter or puborectalis); and (3) inadequate propulsive forces assessed by manometry or imaging during repeated attempts to defecate.15

The patients filled out also 4 clinical scales: the Bristol stool form, and three 10-point (0-9) Likert scale to report self-perceived constipation severity, bloating severity, and abdominal pain severity during the last week as previously described.13,16 The reproducibility of these Likert scales was previously described.16,17 At the first visit, patients also filled the Beck depression inventory and the state and trait anxiety inventory as a part of the psychometric evaluation.13

Colonic Transit Time and Colonic Transit Response to Eating

Total and segmental CTT was calculated as previously described.18,19 After the daily ingestion of 10 radiopaque markers (MARQUAT Génie biologique et Médical, Boissy-Saint-Léger, France) for 6 days at 9 AM, a plain film of the abdomen was taken on the 7th day at 9 AM. During the week of markers ingestion, patients were asked to stop all laxatives or colokinetic drugs. Markers were counted and localized in the different segments of the colon according to bony landmarks.18,19

CTRE was measured the same day as the measure of CTT. It was quantified by determining the change in the number of markers in each of the 7 zones of interest (cecum and ascending colon, hepatic flexure, right transverse colon, left transverse colon, splenic flexure, descending colon, and sigmoid colon and rectum) between the films taken after eating and that before eating a standard-1000 calories meal furnished by our dietary unit (lipids 38.7 g, proteins 38.7 g, and carbohydrates 122.7 g).9,11 In a given site, the response was negative when a decrease in the number of markers was found (ie, emptying the zone) and positive when an increase was found (ie, filling the area). This result was interpreted in terms of the increase (or the decrease) of CTT in one site.

Statistical Methods

For the statistical analysis, we used Statistical Package for the Social Sciences (Released 2011. SPSS statistics versopm 20.0 for Windows;IBM Corp, Armonk, NY, USA). The results were expressed as mean ± standard deviation for quantitative variables and percentages for qualitative variables. Chi-square tests and one-way ANOVA were used to compare patients with IBS-C and functional constipation (FC) and patients with or without defecation disorders (DD). Correlations between CS and Bristol stool form and CTT were calculated using Pearson correlation coefficients. Multivariable logistic regression was calculated for the phenotypes using the other parameters as explanatory variables.

Stepwise adjusted linear regression analysis was performed to model the relationship between CS with physiological and psychological variables for the total population and each phenotype independently. Explanatory variables were age, gender, body mass index (BMI), depression, state, and trait anxiety, bloating severity, abdominal pain severity, total and segmental CTT, and total and segmental colonic transit response to eating; a variance inflation factor < 2 assessed an absence of colinearity.

Results

On the 387 patients included, 203 (52%) were classified as IBS-C, 184 (48%) as FC, and 283 had DD (73%). The patients’ mean age was 49.7 ± 16.4 years; the mean BMI was 24.4 ± 5.0 kg/m2 and 320 (83%) were female patients.

Characteristics of the Population

Table 1 reports patients’ characteristics according to the phenotype. The prevalence of DD was higher in IBS-C than in FC (80% vs 66%, P = 0.002). CS was significantly correlated with right CTT (r = 0.161, P = 0.001), left CTT (r = 0.103, P = 0.042), total CTT (r = 0.186, P < 0.001), and Bristol stool form (r = –0.241, P < 0.001).

Table 1 . Demographic, Psychological, Clinical, and Physiologic Parameters of the Population According to the Phenotypes

All patientsIBS-ConstipationFunctional constipationP-valueDefecation disordersNo defecation disordersP-value
Demographics
n387203184283104
Age (yr)49.7 ± 16.449.1 ± 15.950.4 ± 16.90.42749.3 ± 16.150.8 ± 17.00.415
Female gender (%)320 (83)178 (88)142 (77)0.007235 (83)85 (82)0.764
Body mass index (kg/m2)24.4 ± 5.024.3 ± 5.324.6 ± 4.70.66524.6 ± 5.123.9 ± 4.80.198
Psychological
Depression14.8 ± 10.115.4 ± 10.714.1 ± 9.40.20214.6 ± 10.015.2 ± 10.60.599
State anxiety43.1 ± 11.644.6 ± 12.141.4 ± 10.70.00643.5 ± 12.442.1 ± 9.10.288
Trait anxiety45.0 ± 9.245.8 ± 9.344.1 ± 9.10.07345.3 ± 9.744.2 ± 8.00.318
Clinical
Defecation disorders283 (73)162 (80)121 (66)0.002
Colonic transit time (hr)
Right colon23.4 ± 21.222.5 ± 20.124.3 ± 22.30.40123.6 ± 19.122.8 ± 25.90.728
Left colon27.8 ± 21.628.4 ± 23.727.0 ± 19.00.52927.6 ± 21.628.3 ± 21.60.757
Rectosigmoid area16.9 ± 17.616.5 ± 17.417.3 ± 17.80.65116.5 ± 17.317.9 ± 18.40.510
Total colonic transit time68.0 ± 38.667.5 ± 39.668.7 ± 37.60.75367.7 ± 37.769.0 ± 41.00.777
Colonic transit response to eating (hr)
Right colon−3.0 ± 7.6−3.2 ± 7.9−2.9 ± 7.30.707−3.2 ± 7.7−2.6 ± 7.60.519
Ascending colon−1.9 ± 5.1−2.1 ± 5.1−1.7 ± 5.10.412−1.9 ± 5.0−1.9 ± 5.50.936
Hepatic flexure−0.3 ± 6.4−0.1 ± 7.2−0.4 ± 5.40.674−0.2 ± 6.6−0.3 ± 6.10.910
Right transverse colon−0.9 ± 5.8−0.9 ± 6.1−0.8 ± 5.50.812−1.1 ± 5.9−0.4 ± 5.70.296
Left colon−3.2 ± 10.7−2.8 ± 10.3−3.7 ± 11.10.445−2.4 ± 9.9−5.6 ± 12.20.008
Left transverse colon−1.2 ± 6.0−1.2 ± 6.2−1.2 ± 5.80.996−0.9 ± 5.9−1.9 ± 6.10.144
Splenic flexure−1.5 ± 7.4−1.9 ± 7.8−1.0 ± 6.90.202−1.4 ± 7.4−1.6 ± 7.50.882
Descending colon−0.6 ± 8.9−0.3 ± 9.2−1.5 ± 8.50.048−0.0 ± 9.2−2.1 ± 8.00.038
Rectosigmoïd area2.6 ± 11.22.1 ± 11.13.0 ± 11.30.4232.2 ± 10.73.6 ± 12.50.264
Entire colon−3.7 ± 13.5−3.9 ± 14.4−3.5 ± 12.50.785−3.4 ± 12.9−4.6 ± 15.00.426
Defecation after eating (%)52 (13)30 (15)22 (12)0.45837 (13)15 (14)0.738
Scales
Constipation severity6.3 ± 2.56.6 ± 2.36.0 ± 2.70.0366.0 ± 2.74.0 ± 3.0< 0.001
Bloating severity5.7 ± 2.96.5 ± 2.54.8 ± 3.1< 0.0015.7 ± 2.94.9 ± 3.10.024
Abdominal pain severity4.6 ± 3.05.8 ± 2.63.4 ± 3.0< 0.0014.9 ± 3.03.8 ± 2.90.001
Bristol stool form2.1 ± 1.42.0 ± 1.42.3 ± 1.40.1102.4 ± 1.73.1 ± 1.70.001

IBS, irritable bowel syndrome.

Data are expressed as mean ± SD or n (%) for qualitative variables.

P < 0.05 is considered statistically significant.



Patients with IBS-C reported higher state anxiety (44.6 ± 12.1 vs 41.4 ± 10.7, P = 0.006), higher bloating severity (6.5 ± 2.5 vs 4.8 ± 3.1, P < 0.001), and higher abdominal pain severity (5.8 ± 2.6 vs 3.4 ± 3.0, P < 0.001) than patients with FC. In contrast, CTT, CTRE, CS, and Bristol stool form were not different between the 2 constipation phenotypes. The multivariable logistic regression showed that patients with IBS-C are characterized by increased prevalence of female gender (P = 0.027; OR, 1.98; 95% CI, 1.08-3.64), and increased abdominal pain severity (P < 0.001; OR, 1.30; 95% CI, 1.20-1.41).

Patients with DD are characterized by higher constipation severity (6.0 ± 2.7 vs 4.0 ± 3.0, P < 0.001), higher bloating severity (5.7 ± 2.9 vs 4.9 ± 3.1, P = 0.024), abdominal pain severity (4.9 ± 3.0 vs 3.8 ± 2.9, P = 0.001), and harder stool (2.4 ± 1.7 vs 3.1 ± 1.7, P = 0.001). These patients had also a decreased emptying of the left part of the colon (–2.4 ± 9.9 vs –5.6 ± 12.2, P = 0.008). In contrast, depression, state and trait anxiety, total and segmental CTT were not different in these 2 groups. The multivariable logistic regression showed that patients with DD are characterized by increased prevalence of patients with IBS-C (P = 0.023; OR, 1.76; 95% CI, 1.08-2.87), harder stools (P = 0.019; OR, 0.82; 95% CI, 0.69-0.97), higher constipation severity (P = 0.001; OR, 1.17; 95% CI, 1.07-1.29), and decreased emptying of the descending colon after eating (P = 0.041; OR, 1.03; 95% CI, 1.00-1.06).

The Supplementary Table 1 reports patient characteristics according to gender. By comparison with male patients, female patients were younger (47.5 ± 16.0 years vs 52.1 ± 17.2 years, P = 0.035), have more frequently IBS-C (56% vs 37%, P = 0.007), and longer CTT (70.0 ± 38.6 hours vs 58.8 ± 37.2 hours, P = 0.030) by delayed right transverse CTT (24.4 ± 22.0 hours vs 18.8 ± 15.8 hours, P = 0.050). They also reported higher bloating severity (6.0 ± 2.8 vs 4.4 ± 3.2, P < 0.001), higher abdominal pain severity (4.8 ± 3.0 vs 3.8 ± 3.3, P = 0.015), and harder stools (2.0 ± 1.3 vs 2.7 ± 1.7, P < 0.001). In contrast, colonic transit response to eating and patients’ prevalence with defecation after eating was not different between male and female patients.

Relationship of the Self-perceived Constipation Severity With Colonic Transit Time and Colonic Transit Response to Eating (See Figure)

Figure 1. Significant unstandardized linear coefficient between constipation severity and clinical and physiological parameters according to the phenotype. Self-perceived constipation severity is associated with total colonic transit time in the 3 groups of constipated patients. It was associated with left colonic transit response to eating in functional constipation and defecation disorders patients, whereas in irritable bowel syndrome (IBS), it was associated with bloating severity, abdominal pain severity, and Bristol stool form.

In the total population of patients complaining of constipation, self-reported constipation severity was significantly related to bloating severity (P < 0.001), Bristol stool form (P < 0.001), depression (P = 0.029), total CTT (P = 0.002), and the left colonic CTRE (P = 0.029) (Table 2).

Table 2 . Significant Predictors of Perceived Constipation Severity in the Different Groups of Constipated Patients

GroupParameterBetatP-value
All patientsBloating severity0.3377.262< 0.001
Bristol stool form–0.167–3.663< 0.001
Total CTT0.1453.1380.002
Depression0.1022.1930.029
CTRE left colon0.1002.1890.029
IBS-constipationBloating severity0.3295.106< 0.001
Abdominal pain severity0.1983.0070.003
Bristol stool form–0.179–2.9390.004
Total CTT0.1632.7040.007
Functional constipationBloating severity0.3074.444< 0.001
CTRE left colon0.1932.7940.006
Total CTT0.1412.0660.040
Defecation disordersTotal CTT0.2143.695< 0.001
CTRE left colon0.1843.1840.002

CTT, colonic transit time; CTRE, colonic transit response to eating; IBS, irritable bowel syndrome.

The standardized coefficient Beta was calculated by stepwise linear regression. The model explains 23.7%, 31.2%, 17.1%, and 7.2% of the total variance for all patients, IBS-constipation, functional constipation, and defecation disorders respectively.

P < 0.05 is considered statistically significant.



In the 2 constipation phenotypes (IBS-C and FC), CS was significantly associated with bloating severity (P < 0.001 in both groups) and total CTT (P = 0.007 in IBS-C, P = 0.040 in FC). However, the other predictors of CS varied according to the phenotype. In patients with IBS-C, CS was associated with abdominal pain severity (P = 0.003) and Bristol stool form (P = 0.004). In contrast, CS was only related to the left colonic CTRE (P = 0.006) in patients with FC. In patients with DD, CS was associated with total CTT (P < 0.001), and left colonic CTRE (P = 0.002).

As shown in the Supplementary Table 2, the parameters associated with CS also varied with gender. Despite CS was associated with bloating severity in both genders (P = 0.006 in males, P < 0.001 in females), it was associated with Bristol stool form (P < 0.001), total CTT (P = 0.003), and depression (P = 0.014) in females, and with CTRE in the descending colon (P = 0.002) in males. The significant associations of constipation severity according to gender and phenotype are shown in the Supplementary Table 2, whereas the non-significant predictors are shown in the Supplementary Table 3.

Discussion

This study describes the parameters related to self-perceived constipation severity in a large sample of constipated patients referred to a single tertiary center. We show that CS, a subjective parameter, is related to physiological, psychological, and clinical characteristics. This study also shows that CS is always associated with total CTT but varies according to the phenotypes. In IBS-C, CS was also associated with bloating severity, abdominal pain severity, and Bristol stool form; in FC, it was also associated with bloating severity and CTRE in the left colon, and in patients with DD, it was also associated with CTRE in the left colon.

Among the significant relationships of CS, total CTT was associated with CS in all groups of patients, independently of the phenotype (IBS-C, FC, and DD), in agreement with a previous study of our group,20 but in possible contradiction with a Danish study showing no correlations between the GI symptoms and transit times or colonic volumes.21 The difference of parameters used in these 2 studies, CTT and constipation severity for the present study, GI symptoms, and magnetic capsule to evaluate the total and segmental CTT in the Danish study, could explain these discordant results.

Also, it is interesting to remark that CS is associated with total CTT in the 3 groups of constipated patients, but with Bristol stool form only in patients with IBS-C, regardless of the well-known relationship between the Bristol stool form and the CTT.22

This study also shows the relationship between CS with bloating severity in both phenotypes (IBS-C and FC), but not in the DD group. Previous studies reported the association of constipation with bloating and abdominal pain, mainly in patients with IBS-C.23,24 Lubiprostone,25 linaclotide,26 and tegaserod27,28 improve constipation, abdominal pain severity, and bloating severity in chronic idiopathic constipation patients. Besides, bloating is associated with altered quality of life and treatment responsiveness amid constipated patients independently of the phenotype.24

In contrast, in the present study, abdominal pain severity was associated with constipation severity only in the IBS-C group, in agreement with previous studies29-33 and a recent review.34 The improvement of abdominal pain associated with constipation improvement agrees with a relationship between these 2 disorders. However, some drugs that decrease constipation could increase abdominal bloating as lactulose35 or increase abdominal pain as bisacodyl.36

One of the most significant results of this study is the relationship between CS and the left colonic CTRE in FC and DD groups. The positive linear relationship between these 2 variables indicated that increased CS was associated with an increased filling or decreased emptying of the left colon.

In healthy subjects, food ingestion is associated with a significant increase in pressure waves and a post-meal increase in propagating pressure waves.37 A recent study found that spontaneous colonic motility remained unchanged in non-phenotyped patients with chronic constipation compared to control subjects despite the increased sensitivity to cholinergic nerve stimulation found in constipated patients.38 In contrast, using heart rate as a biological marker, a decreased vagal activity was associated with greater postprandial colonic motility in patients with IBS.39

The relationship between colonic motility and colonic transit remains discussed because high-resolution manometric studies have found that in healthy subjects, as in constipated subjects, retrograde propagating sequences are more prevalent than anterograde propagating sequences.40 This result contradicts some previous low-resolution colonic motility studies showing that propagating contractions were associated with the rapid progress of luminal contents.41,42 These studies showed that colonic motility and transit are quiescent during the fasting state and that the transverse colon acts as a mixing and storage area. The present study shows that an increase of perceived constipation severity is associated with a rise in filling the left colon in patients with FC in favor of an abnormal synchronization between colonic motility and colonic propulsion in these patients. However, it was found in constipated patients with normal CTT, normal colonic motility,43 but this study was performed on a limited number of patients.

CTRE is a simple method to assess, not the change of colonic motility induced by feeding, but the propulsion of colonic content after feeding.11,12 In controls, CTRE is characterized by emptying the right part of the colon and a filling of the recto-sigmoid area. In contrast, in constipated patients, CTRE could be associated with decreased intensity of this normal pattern, such as in colonic inertia patients, decreased emptying of the right colon such as hindgut dysfunction phenotype, or failed to empty the rectosigmoid area such as in the outlet obstruction phenotype.11 As in the present study, these previous studies were performed using absolute changes in the number of markers in the different colonic segments when studying constipated patients11 or the relative change of the colonic content when studying patients with different CTT.12 In the present study, total and segmental CTT were not different in the different phenotypes of constipated patients (Table 1). We have then chosen to assess the CTRE as the absolute variation in the number of markers in the different colonic segments.

The present study shows that in IBS patients with constipation, self-reported CS was not associated with CTRE. It was only positively related to total CTT, bloating severity, and abdominal pain severity and negatively with Bristol stool form. In a previous study, we found that, by comparison with healthy controls, CTRE was characterized by emptying the right colon in patients with IBS-C.12 In contrast, in patients with FC, CTRE was characterized by emptying the left colon.12 This study shows similar results, but we also show that the CS is only related to the left CTRE.

Perceived constipation severity indicates the severity of the symptom constipation related to many psychological and demographics factors. We found no relationship between constipation severity, gender, age, or BMI among the demographics factors. The importance of psychological factors in the perceived constipation severity was not found in the different constipation phenotypes but only related to depression in the entire group of constipated patients (Table 2). This result shows the relatively limited weight of psychological factors in the perception of constipation severity, although anxiety was higher in patients with IBS-C than in patients with FC44-47 (Table 1).

Although this retrospective study included a large number of fully explored constipated patients, this study has several limits. The first concerns sampling. We drawed our population from the practice of a single French center. While our results concur with others, there is undoubtedly a bias toward that we included patients who were referred to a tertiary care center. We can speculate that the severity of our patients with functional gastrointestinal disorder was higher than the severity of patients seen by physicians of a primary or secondary care center. Secondly, there is a higher frequency of female patients in the IBS-C group than in the FC group (56% vs 44%, P = 0.007), and as shown in the Supplementary Table 2, the factors associated with CS varied with gender, although bloating severity was associated with CS in constipated patients of both genders. The high prevalence of female patients (320 [83%] vs 67 [17%]) in the population limits the interpretation of results in male patients. Finally, this observational study was limited to constipated subjects. The extrapolation of these results to healthy subjects needs further studies.

To conclude, this study on a large sample of constipated patients in a tertiary center shows that, in all phenotypes, increased perceived constipation severity is associated with an increase of perceived bloating severity and an increase of total CTT. In patients with FC and not in IBS-C, increased constipation severity is associated with increased left colon filling after eating.

Supplementary Materials

Note: To access the supplementary tables mentioned in this article, visit the online version of Journal of Neurogastroenterology and Motility at http://www.jnmjournal.org/, and at https://doi.org/10.5056/jnm21091.

Acknowledgements

We thank Marouane BOUBAYA that supervised the statistical analysis of the study.

Financial support

None.

Conflicts of interest

None.

Author contributions

Michel Bouchouch, David Deutsch, Gheorghe Airinei, Julien Uzan, Jean-Marc Sabate, and Robert Benamouzig: substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; drafting the article or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References
  1. Christensen J. Colonic motility. In: JD W, ed. Handbook of physiology: the gastrointestinal system. 2nd ed. Bethesda: American Physiological Society 1989:939-973.
    CrossRef
  2. Feldman M, Richardson CT. Role of thought, sight, smell, and taste of food in the cephalic phase of gastric acid secretion in humans. Gastroenterology 1986;90:428-433.
    Pubmed CrossRef
  3. Christensen J. The response of the colon to eating. Am J Clin Nutr 1985;42(5 suppl):1025-1032.
    Pubmed CrossRef
  4. Deloose E, Janssen P, Depoortere I, Tack J. The migrating motor complex: control mechanisms and its role in health and disease. Nat Rev Gastroenterol Hepatol 2012;9:271-285.
    Pubmed CrossRef
  5. Medeiros JA, Pontes FA, Mesquita OA. Is colonic electrical activity a similar phenomena to small-bowel electrical activity?. Dis Colon Rectum 1997;40:93-99.
    Pubmed CrossRef
  6. Rosli RM, Heitmann PT, Kumar R, et al. Distinct patterns of myogenic motor activity identified in isolated human distal colon with high-resolution manometry. Neurogastroenterol Motil 2020;32:e13871.
    Pubmed KoreaMed CrossRef
  7. Dinning PG. A new understanding of the physiology and pathophysiology of colonic motility?. Neurogastroenterol Motil 2018;30:e13395.
    Pubmed CrossRef
  8. Lindberg G. High-resolution manometry changes our views of gastrointestinal motility. Neurogastroenterol Motil 2013;25:780-782.
    Pubmed CrossRef
  9. Bouchoucha M, Odinot JM, Devroede G, Landi B, Cugnenc PH, Barbier JP. Simple clinical assessment of colonic response to food. Int J Colorectal Dis 1998;13:217-222.
    Pubmed CrossRef
  10. Bouchoucha M, Thomas SR. Error analysis of classic colonic transit time estimates. Am J Physiol Gastrointest Liver Physiol 2000;279:G520-G527.
    Pubmed CrossRef
  11. Bouchoucha M, Devroede G, Faye A, Le Toumelin P, Arhan P, Arsac M. Colonic response to food in constipation. Int J Colorectal Dis 2006;21:826-833.
    Pubmed CrossRef
  12. Bouchoucha M, Devroede G, Raynaud JJ, Bon C, Bejou B, Benamouzig R. Is the colonic response to food different in IBS in contrast to simple constipation or diarrhea without abdominal pain?. Dig Dis Sci 2011;56:2947-2956.
    Pubmed CrossRef
  13. Bouchoucha M, Fysekidis M, Deutsch D, Bejou B, Sabate JM, Benamouzig R. Biopsychosocial model and perceived constipation severity according to the constipation phenotype. Dig Dis Sci 2021;66:3588-3596.
    Pubmed CrossRef
  14. Lacy BE, Mearin F, Chang L, et al. Bowel Disorders. Gastroenterology 2016;150:1393-1407, e5.
    Pubmed CrossRef
  15. Rao SS, Bharucha AE, Chiarioni G, et al. Functional anorectal disorders. Gastroenterology 2016;150:1430-1442, e4.
    Pubmed KoreaMed CrossRef
  16. Bouchoucha M, Devroede G, Fysekidis M, Rompteaux P, Sabate JM, Benamouzig R. Data mining approach for the characterization of functional bowel disorders according to symptom intensity provides a small number of homogenous groups. Dig Dis 2020;38:310-319.
    Pubmed CrossRef
  17. Deutsch D, Bouchoucha M, Uzan J, Raynaud JJ, Sabate JM, Benamouzig R. Abdominal pain severity is mainly associated with bloating severity in patients with functional bowel disorders and functional abdominal pain. Dig Dis Sci 2022;67:3026-3035.
    Pubmed CrossRef
  18. Bouchoucha M, Devroede G, Bon C, Raynaud JJ, Bejou B, Benamouzig R. How many segments are necessary to characterize delayed colonic transit time?. Int J Colorectal Dis 2015;30:1381-1389.
    Pubmed CrossRef
  19. Bouchoucha M, Fysekidis M, Rompteaux P, Airinei G, Sabate JM, Benamouzig R. Influence of age and body mass index on total and segmental colonic transit times in constipated subjects. J Neurogastroenterol Motil 2019;25:258-266.
    Pubmed KoreaMed CrossRef
  20. Bouchoucha M, Devroede G, Fysekidis M, Rompteaux P, Sabate JM, Benamouzig R. Data mining approach for the characterization of functional bowel disorders according to symptom intensity provides a small number of homogenous groups. Dig Dis 2020;38:310-319.
    Pubmed CrossRef
  21. Grønlund D, Vase L, Knudsen SA, Christensen M, Drewes AM, Olesen AE. Comparison of subjective and objective measures of constipation - employing a new method for categorizing gastrointestinal symptoms. J Pharmacol Toxicol Methods 2018;94(pt 2):23-28.
    Pubmed CrossRef
  22. Saad RJ, Rao SS, Koch KL, et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol 2010;105:403-411.
    Pubmed CrossRef
  23. Kanazawa M, Miwa H, Nakagawa A, Kosako M, Akiho H, Fukudo S. Abdominal bloating is the most bothersome symptom in irritable bowel syndrome with constipation (IBS-C): a large population-based Internet survey in Japan. Biopsychosoc Med 2016;10:19.
    Pubmed KoreaMed CrossRef
  24. Neri L, Iovino P; Laxative Inadequate Relief Survey Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil 2016;28:581-591.
    Pubmed CrossRef
  25. Chang L, Chey WD, Drossman D, et al. Effects of baseline abdominal pain and bloating on response to lubiprostone in patients with irritable bowel syndrome with constipation. Aliment Pharmacol Ther 2016;44:1114-1122.
    Pubmed KoreaMed CrossRef
  26. Lacy BE, Schey R, Shiff SJ, et al. Linaclotide in chronic idiopathic constipation patients with moderate to severe abdominal bloating: a randomized, controlled trial. PLoS One 2015;10:e0134349.
    Pubmed KoreaMed CrossRef
  27. Müller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther 2001;15:1655-1666.
    Pubmed CrossRef
  28. Chey WD, Paré P, Viegas A, Ligozio G, Shetzline MA. Tegaserod for female patients suffering from IBS with mixed bowel habits or constipation: a randomized controlled trial. Am J Gastroenterol 2008;103:1217-1225.
    Pubmed CrossRef
  29. Bharucha AE, Locke GR, Zinsmeister AR, et al. Differences between painless and painful constipation among community women. Am J Gastroenterol 2006;101:604-612.
    Pubmed CrossRef
  30. Bouchoucha M, Devroede G, Mary F, Bon C, Bejou B, Benamouzig R. Painful or mild-pain constipation? A clinically useful alternative to classification as irritable bowel syndrome with constipation versus functional constipation. Dig Dis Sci 2018;63:1763-1773.
    Pubmed CrossRef
  31. Rey E, Balboa A, Mearin F. Chronic constipation, irritable bowel syndrome with constipation and constipation with pain/discomfort: similarities and differences. Am J Gastroenterol 2014;109:876-884.
    Pubmed CrossRef
  32. Cremonini F, Lembo A. IBS with constipation, functional constipation, painful and non-painful constipation: e Pluribus...Plures?. Am J Gastroenterol 2014;109:885-886.
    Pubmed CrossRef
  33. Pannemans J, Van den Houte K, Fischler B, Piessevaux H, Carbone F, Tack J. Prevalence and impact of self-reported painful and non-painful constipation in the general population. Neurogastroenterol Motil 2020;32:e13783.
    Pubmed CrossRef
  34. Wong MYW, Hebbard G, Gibson PR, Burgell RE. Chronic constipation and abdominal pain: independent or closely interrelated symptoms?. J Gastroenterol Hepatol 2020;35:1294-1301.
    Pubmed CrossRef
  35. Bass P, Dennis S. The laxative effects of lactulose in normal and constipated subjects. J Clin Gastroenterol 1981;3(suppl 1):23-28.
    Pubmed CrossRef
  36. Kamm MA, Mueller-Lissner S, Wald A, Richter E, Swallow R, Gessner U. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011;9:577-583.
    Pubmed CrossRef
  37. Rao SS, Singh S, Mudipalli R. Day-to-day reproducibility of prolonged ambulatory colonic manometry in healthy subjects. Neurogastroenterol Motil 2010;22:640-e178.
    Pubmed KoreaMed CrossRef
  38. Yarullina DR, Shafigullin MU, Sakulin KA, et al. Characterization of gut contractility and microbiota in patients with severe chronic constipation. PLoS One 2020;15:e0235985.
    Pubmed KoreaMed CrossRef
  39. Tanaka Y, Kanazawa M, Palsson OS, et al. Increased postprandial colonic motility and autonomic nervous system activity in patients with irritable bowel syndrome: a prospective study. J Neurogastroenterol Motil 2018;24:87-95.
    Pubmed KoreaMed CrossRef
  40. Dinning PG, Wiklendt L, Gibbins I, et al. Low-resolution colonic manometry leads to a gross misinterpretation of the frequency and polarity of propagating sequences: initial results from fiber-optic high-resolution manometry studies. Neurogastroenterol Motil 2013;25:e640-e649.
    Pubmed CrossRef
  41. Bazzocchi G, Ellis J, Villanueva-Meyer J, et al. Postprandial colonic transit and motor activity in chronic constipation. Gastroenterology 1990;98:686-693.
    Pubmed CrossRef
  42. Moreno-Osset E, Bazzocchi G, Lo S, et al. Association between postprandial changes in colonic intraluminal pressure and transit. Gastroenterology 1989;96(5 pt 1):1265-1273.
    Pubmed CrossRef
  43. Vork L, van Avesaat MHP, van Hoboken EA, et al. Normal colonic transit time predicts the outcome of colonic manometry in patients with chronic constipation-an exploratory study. Int J Colorectal Dis 2019;34:1819-1822.
    Pubmed CrossRef
  44. Bouchoucha M, Hejnar M, Devroede G, Babba T, Bon C, Benamouzig R. Anxiety and depression as markers of multiplicity of sites of functional gastrointestinal disorders: a gender issue?. Clin Res Hepatol Gastroenterol 2013;37:422-430.
    Pubmed CrossRef
  45. Devroede G, Girard G, Bouchoucha M, et al. Idiopathic constipation by colonic dysfunction. Relationship with personality and anxiety. Dig Dis Sci 1989;34:1428-1433.
    Pubmed CrossRef
  46. Han B. Correlation between gastrointestinal hormones and anxiety-depressive states in irritable bowel syndrome. Exp Ther Med 2013;6:715-720.
    Pubmed KoreaMed CrossRef
  47. Midenfjord I, Polster A, Sjövall H, Törnblom H, Simrén M. Anxiety and depression in irritable bowel syndrome: exploring the interaction with other symptoms and pathophysiology using multivariate analyses. Neurogastroenterol Motil 2019;31:e13619.
    Pubmed CrossRef


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