To manage chronic constipation, dietary and lifestyle modifications should be tried before pharmacological intervention. Although there is no standardized treatment guideline for medical practice, the key considerations in the choice of laxative include the treatment duration, dosing schedule, type of agent, effects and side effects of the agent, and cost. The first-line treatment is a bulking or osmotic laxative. If the patient is still symptomatic, the physician can add or switch to other laxatives. Next, prucalopride, a highly selective 5-hydroxytryptamine 4 (5-HT4) receptor agonist, could be considered. If the constipation is refractory to combination therapy with conventional laxatives and prucalopride, patients should be referred for further evaluation, including physiological testing.
Appointments and Schedules ; Constipation ; Humans ; Laxatives* ; Life Style ; Serotonin

The treatment for constipation should be individualized and dependent on the cause, coexisting morbidities, and patient's cognitive status. Although most cases of constipation respond to conservative treatment, including dietary and life-style changes, or mild laxatives, some patients still complain of consistent symptoms and need an assessment of defecatory dysfunction. There is insufficient evidence to support the use of enemas in chronic constipation, although many clinicians and patients find them useful and effective for the treatment of fecal impaction when used with other modalities. In addition, suppositories can be considered as an initial trial for the treatment of defecatory dysfunction, since they help to initiate or facilitate rectal evacuation. The routine use of enemas is typically discouraged, especially sodium phosphate enemas, although tap-water enemas seem safe for more regular use. Soapsuds enemas are not recommended due to possible rectal mucosal damage.
Constipation* ; Enema* ; Fecal Impaction ; Humans ; Laxatives ; Sodium ; Suppositories*

A significant proportion of chronic constipation patients are dissatisfied with their treatment. Recently, a number of new medications have been introduced for patients refractory to conventional laxatives, such as prucalopride, lubiprostone, linaclotide, and elobixibat. Prucalopride is a novel gastrointestinal prokinetic agent that acts as a 5-hydroxytryptamine type 4 (5-HT4) agonist. Compared with older nonselective 5-HT4 agonists, the higher selectivity of prucalopride for 5-HT4 receptors can reduce the risk of significant adverse cardiovascular events. Prucalopride improves stool frequency and consistency, and reduces the need for rescue medications. Lubiprostone, a chloride channel activator, increases the secretion of intestinal fluid, improves the stool frequency and consistency, and reduces straining. Linaclotide, a guanylate cyclase-C agonist, is effective in treating patients with chronic constipation and its effect on visceral sensitivity, as shown mainly in animal studies, provides an attractive pharmaceutical option for patients with irritable bowel syndrome with constipation. Elobixibat is an ileal sodium-dependent bile acid transporter inhibitor that blocks the enterohepatic circulation of bile acids, increasing the bile acid concentration in the intestine, which accelerates colonic transit and softens the stool. A phase III trial of the treatment of chronic constipation and irritable bowel syndrome with constipation is underway. The clinical application of new-generation laxatives will contribute to the management of chronic constipation refractory to conventional laxatives.
Animals ; Bile ; Bile Acids and Salts ; Chloride Channels ; Colon ; Constipation ; Enterohepatic Circulation ; Humans ; Intestines ; Irritable Bowel Syndrome ; Laxatives* ; Receptors, Serotonin, 5-HT4 ; Serotonin ; Serotonin 5-HT4 Receptor Agonists ; Lubiprostone

Based on published guidelines on the management of chronic constipation, secondary causes should be excluded and then patients should be told to increase their dietary fiber intake to 20-25 g per day. If these measures do not improve the symptoms, conventional laxatives are generally the next choice. Although there is limited evidence for the efficacy of these older laxatives due to a lack of well-designed clinical trials, most clinicians agree that they are effective at relieving the symptoms of constipation. Conventional laxatives include bulk-forming, osmotic, and stimulant laxatives. Bulking laxatives consist of fiber such as psyllium, cellulose, and bran. Osmotic laxatives are classified into sugar-based laxatives and polyethylene glycol. Bisacodyl and sodium picosulfate are stimulant laxatives. Understanding their mechanisms of action, efficacy, and side effects might improve the quality of life of patients suffering from chronic constipation.
Bisacodyl ; Cellulose ; Constipation ; Dietary Fiber ; Humans ; Laxatives* ; Polyethylene Glycols ; Psyllium ; Quality of Life ; Sodium

Protective effect of human cerebrospinal fluid antioxidants against enzyme inactivation caused by metal-catalyzed oxidation systems were investigated. When purified glutamine synthetase(GS) was incubated with human cerebrospinal fluid(CSF), the enzyme was progressively inactivated. Catalase and EDTA could inhibit the enzyme inactivation by 50-80%. Small-molecular(Mr<-10,000) fraction of CSF inactivated the exogenous GS, but large-molecular(Mr>-10,000) fraction did not. The GS inactivation by the small-molecular fraction was also markedly inhibited by catalase and EDTA. These results suggested that metal-catalyzed oxidation is involved in the GS inactivation by the small-molecular fraction of CSF. Dithiothreitol(DTT)was shown to inhibit almost completely the oxidative inactivation of GS by CSF. However, DTT inhibited only partially the oxidative inactivation of GS caused by small-molecular fraction of CSF. When large-molecular fraction of CSF was separated by anion-exchange HPLC chromatography, there was a peak of antioxidant activity inhibiting the small-molecular fraction-induced GS inactivation in the presence of DTT. The antioxidant activity was neutralized by monoclonal antibodies to transthyretin. Purified transthyretin was found to efficiently inhibit ascorbate/Cu2+-induced GS inactivation in the presence of DTT. Uric acid and glucose did not shoe any protective effect on the GS inactivation in the same condition. The above results suggest that metal-catalyzed oxidation occurs normally in human CSF, and the transthyretin may play an important role as a CSF antioxidant in protecting proteins from metal-catalyzed oxidation.
Antibodies, Monoclonal ; Antioxidants ; Catalase ; Cerebrospinal Fluid* ; Chromatography ; Chromatography, High Pressure Liquid ; Edetic Acid ; Glucose ; Glutamine ; Humans* ; Prealbumin* ; Shoes ; Uric Acid

Post-polypectomy surveillance has become a major indication for colonoscopy as a result of increased use of screening colonoscopy in Korea. However, because the medical resource is limited, and the first screening colonoscopy produces the greatest effect on reducing the incidence and mortality of colorectal cancer, there is a need to increase the efficiency of postpolypectomy surveillance. In the present report, a careful analytic approach was used to address all available evidences to delineate the predictors for advanced neoplasia at surveillance colonoscopy. Based on the results of review of the evidences, we elucidated the high risk findings of the index colonoscopy as follows: 1) 3 or more adenomas, 2) any adenoma larger than 10 mm, 3) any tubulovillous or villous adenoma, 4) any adenoma with high-grade dysplasia, and 5) any serrated polyps larger than 10 mm. In patients without any high-risk findings at the index colonoscopy, surveillance colonoscopy should be performed five years after index colonoscopy. In patients with one or more high risk findings, surveillance colonoscopy should be performed three years after polypectomy. However, the surveillance interval can be shortened considering the quality of the index colonoscopy, the completeness of polyp removal, the patient's general condition, and family and medical history. This practical guideline cannot totally take the place of clinical judgments made by practitioners and should be revised and supplemented in the future as new evidence becomes available.
Adenoma/*diagnosis/surgery ; Adenoma, Villous/diagnosis/surgery ; Colonic Polyps/pathology/*surgery ; *Colonoscopy ; Colorectal Neoplasms/*diagnosis/surgery ; Databases, Factual ; Humans ; Republic of Korea ; Risk Factors ; Time Factors

There are indirect evidences to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary, secondary and tertiary and medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, Pubmed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.
Adenoma/diagnosis/*surgery ; Anti-Inflammatory Agents, Non-Steroidal/therapeutic use ; Aspirin/therapeutic use ; Colonic Polyps/pathology/*surgery ; Colonoscopy ; Colorectal Neoplasms/diagnosis/*surgery ; Databases, Factual ; Epinephrine/therapeutic use ; Gastrointestinal Hemorrhage/prevention & control ; Humans ; Lymphatic Metastasis ; Republic of Korea ; Surgical Instruments ; Thrombosis/drug therapy ; Vasoconstrictor Agents/therapeutic use

Colorectal cancer is the second most common cancer in males and the fourth most common in females in Korea. Since the most of colorectal cancer occur through the prolonged transformation of adenomas into carcinomas, early detection and removal of colorectal adenomas are one of the most effective methods to prevent colorectal cancer. Considering the increasing incidence of colorectal cancer and polyps in Korea, it is very important to establish Korean guideline for colorectal cancer screening and polyp detection. Korean Multi-Society Take Force developed the guidelines with evidence-based methods. Parts of the statements drawn by systematic reviews and meta-analyses. Herein we discussed the epidemiology of colorectal cancers and adenomas in Korea, optimal screening methods for colorectal cancer, and detection for adenomas including fecal occult blood tests, radiologic tests, and endoscopic examinations.
Adenoma/*diagnosis/epidemiology/radiography ; Age Factors ; Colonic Polyps/pathology ; Colonoscopy ; Colorectal Neoplasms/*diagnosis/epidemiology/radiography ; Databases, Factual ; Early Detection of Cancer ; Female ; Humans ; Immunohistochemistry ; Male ; Occult Blood ; Republic of Korea ; Tomography, X-Ray Computed

BACKGROUND/AIMS: There are no evidence-based, procedural guidelines to appropriately perform a colon polypectomy. Thus, we investigated the treatment modality for colon polypectomy in Korea, using a web-based e-mail survey. METHODS: A questionnaire of preferred treatment modality for colon polypectomy was sent via e-mail to members of the Korean Association for the Study of Intestinal Diseases and primary care physicians who performed colonoscopies as a screening or surveillance program nationwide. Among 425 colonoscopists who were sent the e-mail, 263 replied. We analysed data from 252 colonoscopists who had performed colon polypectomies. RESULTS: The stopping time for antiplatelet and anticoagulation therapy before a colon polypectomy had a tendency to increase and the restarting time for these drugs was delayed as polyp size increased. Colonoscopists preferred cold biopsy removal for polyps <5 mm in size and a hot snare polypectomy after injecting normal saline and epinephrine mixture for polyps > or =5 mm in size. More than half of colonoscopists preferred observation rather than additional procedures for adenomas with incomplete resection. In contrast, most colonoscopists recommended additional procedures, such as endoscopic mucosal resection, endoscopic submucosal dissection or surgery for an advanced adenoma with incomplete resection. The most preferred prophylactic treatment for immediate postpolypectomy bleeding was hemoclipping. CONCLUSIONS: Various treatment modalities were used for a colon polypectomy because there are few guidelines for performing a colon polypectomy based on a critical review of the available data. Further well-designed, prospective studies are needed to develop evidence-based guidelines for colon polypectomy.
Adenoma ; Biopsy ; Cold Temperature ; Colon ; Colonoscopy ; Electronic Mail ; Epinephrine ; Hemorrhage ; Humans ; Intestinal Diseases ; Korea ; Mass Screening ; Physicians, Primary Care ; Polyps ; SNARE Proteins ; Surveys and Questionnaires

There are indirect evidences to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary outpatient clinics and secondary and tertiary medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, PubMed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.
Adenomatous Polyps ; Ambulatory Care Facilities ; Cohort Studies ; Colonoscopy ; Colorectal Neoplasms ; Consensus ; Humans ; Incidence ; Korea ; Polyps ; Prospective Studies ; Standard of Care