Constipation

Constipation is a condition characterized by infrequent bowel movements and strained defecation. There are no conclusive definitions, but the Rome III criteria are commonly used to diagnose chronic constipation.1 This diagnostic tool defines constipation as a condition meeting two of the following criteria:

  • Fewer than 3 bowel movements a week
  • Forceful straining
  • Hard and/or lumpy stools
  • Sensation of incomplete evacuation
  • Sensation of anorectal obstruction
  • Manual manoeuvres to facilitate defecation

In children, these complaints are often accompanied by holding in bowel movements. In that case, and if the bowel is very full, it can happen that loose stools leak out past the hard stools. This is also known as overflow diarrhoea or faecal incontinence.2

About half of the population will be faced with constipation at some point in their lives, with most cases affecting children, pregnant women and elderly individuals. Although not life‑threatening, it can have a major adverse impact on a patient’s quality of life. In the vast majority of cases there is no obvious physical cause, and is indicated as functional constipation. Risk factors for constipation include depression, inactivity, extreme restriction of fat intake, low income and education and insufficient exercise.3 4 5

People are often advised to increase their fibre and fluid intake and to exercise more. However, there is no conclusive scientific evidence for the efficacy of these measures. In addition, laxatives and volume-enhancing and moisture-absorbing agents are prescribed. Despite this, about half of all constipation patients consulting their GP are not happy with their treatment and frequently experience unpleasant side effects, especially nausea, abdominal cramps and flatulence. Long-term use can lead to kidney stones, damage to the colonic mucosa and diarrhoea. 

Constipation and microbiota management

Although the precise cause of constipation is not known, an unbalanced microbiota does appear to play a role. Research has shown that both adults and children with constipation often have an unbalanced microbiota (i.e. dysbiosis), although not uniformly so. In one study focused on constipated children, higher Clostridium and Bifidobacterium numbers were found compared to non-constipated children,6 while in another study that was focused on adults, lower Lactobacillus and Bifidobacterium numbers were found.7 A recent study confirmed that total microbiota profiling does not provide a basis for a definitive assessment on constipation. However, conducting a so-called “ridge regression” analysis did allow a distinction to be made. This type of analyses zooms in on a subset of the microbiota. Using this method, patients with or without constipation could be distinguished based on their microbiota with 82% accuracy.8

Constipation and probiotics

Different studies have shown that probiotics contribute to relieving both constipation and IBS-C.9 10 11 The beneficial effects of probiotics are the result of several different mechanisms. First, probiotics, notably Bifidobacterium and Lactobacillus species, produce lactic acid and other acids, thereby lowering pH in the large intestine. Lower pH promotes peristalsis and shortens the transit time of faecal matter through the gut, resulting in more frequent bowel movements.12 13 In addition, probiotics have a beneficial effect on the composition of the microbiota.9 Also, probiotics soften faecal matter by increasing the water and electrolyte content.12

Although the aforementioned studies describe beneficial effects, large-scale reviews failed to provide unequivocal proof that these effects have a purpose in treating constipation – until recently. This is one of the reasons why the relevant guideline of the Netherlands Association for Paediatrics (NVK) still does not advocate prescribing probiotics for constipation in children (Richtlijn obstipatie (Constipation guideline), NVK 2009). This guideline is based on two studies looking into the effect of single bacterial strains.14 15 More recently it is recognized that the effects of probiotics are mostly achieved by multispecies probiotics.16 Indeed, a recent study has shown that a multispecies probiotic can lead to major improvement in cases of constipation as well.17

Ecologic® Relief formula to reduce constipation

In partnership with Emma Children’s Hospital in Amsterdam, Winclove developed and tested a multispecies probioticformulation, Ecologic® Relief (Bifidobacterium bifidum W23, Bifidobacterium lactis W52, Bifidobacterium longum W108, Lactobacillus casei W79, Lactobacillus plantarum W62, and Lactobacillus rhamnous W71), for the treatment of constipation in children or pregnant women. This process focused on the frequency of defecation and abdominal pain. In addition, faecal incontinence in children was monitored. Faecal incontinence is a problem frequently seen in children and involves liquid stool leaking out past the obstruction that is causing the constipation. Significant improvements were found in the pilot studies for both groups, with no notable side effects found. These pilot studies have confirmed that multispecies probiotics are a promising and safe therapy for the treatment of constipation, without significant side effects.10 18

The effect of the Ecologic® Relief formula was researched in two pilot studies in Amsterdam Medical Centre (AMC). In the first study, 20 children with constipation were given a daily dose of 4 grams (1x109 CFU/gram) of the formula for a period of 4 weeks. Using a standardized bowel movement diary, the defecation frequency and faecal incontinence was documented. The study also looked at the number of episodes of faecal incontinence a week, abdominal pain and other complaints. A clear link was shown to exist between the daily use of the bacterial composition of the formula and a notable, though not significant, increase in defecation frequency: with an increase from 2.0 to 4.2 toilet visits (p = 0.10) in week 2 and 3.8 toilet visits in week 4 (p = 0.13) (see figure 1). The number of children reported to experience abdominal pain was also reduced by half (from 45% to 20%). And a significant drop in faecal incontinence was seen from an average 4× to 0.3× a week. An important finding in this pilot study was that no side effects were reported.18

Figure 1: Relief study
Figure 1: The Ecologic® Relief formula showed a significant increase in defecation frequency (A), a significant decrease in faecal incontinence (B) and a significant decrease in abdominal pain. 

A second pilot study with the Ecologic® Relief formula was conducted with pregnant women. Twenty pregnant women suffering from constipation according to the Rome III criteria used a daily dose of 4 grams (1x109 CFU/gram) of the formula for 4 weeks. A standardized bowel movement diary was kept with questions about defecation frequency, stool consistency, straining, sensation of incomplete evacuation, abdominal pain and other complaints. In this study, daily use of the formula resulted in a significant increase in defecation frequency; from an average of 3× a week at the start of the study to 6× a week at the end (p < 0.01). In addition, 35% of women reported they did not need to strain during defecation and more than 50% of women reported that the sensation of incomplete evacuation had lessened. Finally, 50% of women reported a lessening of the sensation of anorectal obstruction and 66% of women experienced less abdominal pain and reflux episodes. As in the study with constipated children, no side effects were reported in this study either.10

The results of these two pilot studies with the Ecologic Relief® formula are promising and confirm that multispecies probiotics can be used safely in relieving constipation. In addition, no side effects were reported in either study. 

Winclove developed the indication-specific probiotic formulation Ecologic® Relief with the following strains:

  • Bifidobacterium bifidum W23,
  • Bifidobacterium lactis W52,
  • Bifidobacterium longum W108,
  • Lactobacillus casei W79,
  • Lactobacillus plantarum W62,
  • Lactobacillus rhamnous W71

The research formulation Ecologic® Relief is not sold as a consumer product. However our worldwide business partners offer the formulation Ecologic® Relief as their own branded product. Thus the specific bacterial composition can be found in different products around the world.

References

  • 1. Drossman, D.A. et al. Rome III: The Functional Gastrointestinal Disorders. (Degnon Associates, Virginia; 2006).
  • 2. Diemel, J.M. et al. in Huisarts Wet, Vol. 53. (ed. N.H. Genootschap) 484-498 (2010).
  • 3. Higgins, P.D. & Johanson, J.F. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 99, 750-759 (2004).
  • 4. Lindberg, G. et al. World Gastroenterology Organisation global guideline: Constipation--a global perspective. J Clin Gastroenterol 45, 483-487 (2011).
  • 5. Mathus-Vliegen, E.M.H. Feiten en misvattingen rondom obstipatie. Ned Tijdschr voor Voeding & Dietetiek 67 (2012).
  • 6. Zoppi, G. et al. The intestinal ecosystem in chronic functional constipation. Acta paediatrica (Oslo, Norway : 1992) 87, 836-841 (1998).
  • 7. Khalif, I.L., Quigley, E.M., Konovitch, E.A. & Maximova, I.D. Alterations in the colonic flora and intestinal permeability and evidence of immune activation in chronic constipation. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 37, 838-849 (2005).
  • 8. de Meij, T.G. et al. Characterization of Microbiota in Children with Chronic Functional Constipation. PLoS One 11, e0164731 (2016).
  • 9. a. b. Quigley, E.M. The enteric microbiota in the pathogenesis and management of constipation. Best Pract Res Clin Gastroenterol 25, 119-126 (2011).
  • 10. a. b. c. de Milliano, I., Tabbers, M.M., van der Post, J.A. & Benninga, M.A. Is a multispecies probiotic mixture effective in constipation during pregnancy? 'A pilot study'. Nutrition journal 11, 80 (2012).
  • 11. Chmielewska, A. & Szajewska, H. Systematic review of randomised controlled trials: probiotics for functional constipation. World J Gastroenterol 16, 69-75 (2010).
  • 12. a. b. Picard, C. et al. Review article: bifidobacteria as probiotic agents -- physiological effects and clinical benefits. Aliment Pharmacol Ther 22, 495-512 (2005).
  • 13. Miller, L.E. & Ouwehand, A.C. Probiotic supplementation decreases intestinal transit time: Meta-analysis of randomized controlled trials. World J Gastroenterol 19, 4718-4725 (2013).
  • 14. Banaszkiewicz, A. & Szajewska, H. Ineffectiveness of Lactobacillus GG as an adjunct to lactulose for the treatment of constipation in children: a double-blind, placebo-controlled randomized trial. The Journal of pediatrics 146, 364-369 (2005).
  • 15. Bu, L.N., Chang, M.H., Ni, Y.H., Chen, H.L. & Cheng, C.C. Lactobacillus casei rhamnosus Lcr35 in children with chronic constipation. Pediatrics international : official journal of the Japan Pediatric Society 49, 485-490 (2007).
  • 16. Timmerman, H.M., Koning, C.J., Mulder, L., Rombouts, F.M. & Beynen, A.C. Monostrain, multistrain and multispecies probiotics--A comparison of functionality and efficacy. Int J Food Microbiol 96, 219-233 (2004).
  • 17. Mezzasalma, V. et al. A Randomized, Double-Blind, Placebo-Controlled Trial: The Efficacy of Multispecies Probiotic Supplementation in Alleviating Symptoms of Irritable Bowel Syndrome Associated with Constipation. Biomed Res Int 2016, 4740907 (2016).
  • 18. a. b. Bekkali, N.L., Bongers, M.E., Van den Berg, M.M., Liem, O. & Benninga, M.A. The role of a probiotics mixture in the treatment of childhood constipation: a pilot study. Nutrition journal 6, 17 (2007).