Irritable Bowel Syndrome-Constipation, Rectal Hypersensitivity
Conditions
Brief summary
Constipation is a common digestive disorder. After excluding dietary factors, drugs and other secondary causes, at least three broad pathophysiologic subtypes are recognized- dyssynergic defecation, constipation-predominant irritable bowel syndrome (IBS-C) and slow transit constipation (STC), all predominantly affect women and elderly. Many patients also demonstrate abnormal rectal perception with both rectal hyposensitivity and hypersensitivity being common. Recent surveys show that most constipated patients are dissatisfied with current therapy. Also, constipated patients showed significant psychological dysfunction and impaired quality of life. OBJECTIVE: To investigate a novel biofeedback technique of improving rectal hypersensitivity. METHODS: A large compliant balloon attached to a barostat was placed in the rectum in 8 patients with rectal hypersensitivity (urgency/pain threshold \<30 mm Hg). Sensory deconditioning was performed by incremental balloon distensions (1-2 mmHg) until normal thresholds were reached.
Detailed description
To investigate a novel biofeedback technique of improving rectal hypersensitivity using rectal barostat and to compare this with clinical standard of care comprising of low dose antidepressant therapy with escitalopram. Patients will be randomized to sensory adaptation training or escitalopram in a 1:1 ratio
Interventions
PROCEDURESensory Adaptation Training
This study will last for approximately 3 months and will include 4-6 clinic visits with each visit lasting 2 hours every week or every 2 weeks. At the beginning of each visit we will ask you about your health status and level of satisfaction of your bowel habits. We will then place the pencil-thick probe and balloon inside your rectum and attach it to the barostat device and a computer. We will increase and decrease the volumes of the balloon until the most pressure you can tolerate or a certain level of pressure as measured by the machine is reached, whichever occurs first. You will continue to keep stool diaries and pain diaries for 7 days before and after each visit.
DRUGEscitalopram Therapy
Escitalopram; 10 mg every day, orally.
Sponsors
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Augusta University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
All patients must fulfill the diagnostic criteria for IBS-C (Rome III) as defined below and have rectal hypersensitivity (see below). * Patients must report recurrent abdominal pain or discomfort for at least 3 days per month in the last 3 months with two or more of the following symptoms: * Improvement with defecation; and/or * Onset associated with a change in frequency of stool; and/or * Onset associated with a change in form (appearance) of stool * No structural diseases * On a diary: * Pain/discomfort for at least 2 days/week; * No loose or watery stool \<25% of bowel movements.
Exclusion criteria
* Patients with mixed-IBS. * Patients currently on SSRI or MAO inhibitors. Patients on stable doses of other antidepressants will be included provided the dose is unchanged during study. * Patients taking drugs that are constipating, (e.g.; calcium channel antagonists will either be excluded or drug discontinued) * Patients with co-morbid illnesses; severe cardiac disease, chronic renal failure or previous gastrointestinal surgery except cholecystectomy and appendectomy. * Neurologic diseases e.g.; head injury, epilepsy, multiple sclerosis, strokes, spinal cord injuries. * Impaired cognizance (mini mental score of \< 15) and/or legally blind. * Pregnant or likely to conceive during the course of the study. Women with potential for pregnancy must be willing to use contraceptive measures during the study. Urinary pregnancy tests will be performed on such women prior to any radiologic procedures. * Hirschsprung's disease. * Alternating constipation and diarrhea (22). * Ulcerative/Crohns colitis. * Previous pelvic surgery, rectocele/bladder repair, radical hysterectomy, anal surgery. * Rectal prolapse or anal fissure.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Rectal Sensory Thresholds | Trial entry and at the end of 3 months | The primary physiologic outcome measure is increase in rectal sensory thresholds after treatment. A rectal hypersensitivity responder is defined as an individual who show at least 20% increase in two or more sensory thresholds (first, desire and urge defecate/pain) after treatment when compared to baseline, and will be compared between the SAT and escitalopram groups. An overall responder is defined as both a hypersensitivity responder and abdominal pain responder. |
| Abdominal Pain | Trial entry and at the end of 3 months | The symptomatic outcome measure is decrease in pain score as assessed by daily pain logs where pain is scored on a scale of 0 to 4, after treatment when compared to the baseline period. A pain responder is defined as a subject with 30% decrease in pain compared to baseline. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Rectal compliance | Trial entry and at the end of 3 months | We will assess the changes in intrarectal pressures and intrarectal volumes during Barostat rectal balloon distention between the two groups. |
| Global Bowel Satisfaction Score (GSA) | Trial entry and at the end of 3 months | The global bowel satisfaction will be analysed using a visual analog scale 0-10 cm (0 - very dissatisfied, 10 - completely satisfied). |
| Psychological profiles | Trial entry and at the end of 3 months | The psychological profiles will be assessed using the SCL-90R questionnaire and compared between the two groups. |
| IBS quality of life | Trial entry and at the end of 3 months | The IBS quality of life will be assessed using the 8 domains of IBS-QOL and compared between the two groups. |
| Bowel symptoms | Trial entry and at the end of 3 months | We will assess the number of complete spontaneous bowel movements, mean straining scores, mean stool consistency (Bristol Stool Scale) (numerical mean scores for individual questions) between the two groups. |
Countries
United States
Outcome results
None listed