Constipation medical therapy: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
No edit summary |
||
| Line 4: | Line 4: | ||
==Overview== | ==Overview== | ||
Chronic constipation treatment includes both [[behavioral]] and [[pharmacological]] interventions. [[Behavioral]] management mostly consists of life style and [[Dietary Management|dietary modification]], while [[pharmacological]] interventions are mostly based on [[laxatives]]. Increasing [[physical activity]] is postulated to improve constipation and colonic transit time in patients with constipation. The most important [[behavioral]] treatment for constipation is [[biofeedback]], consisting of teaching the patients how to use their [[Abdominal muscle|abdominal]] and [[Pelvic floor muscles|pelvic muscles]] during [[defecation]]. [[Probiotics]] are live [[microorganisms]] that are eaten to improve the [[gastrointestinal tract]] function. Recently, | Chronic constipation treatment includes both [[behavioral]] and [[pharmacological]] interventions. [[Behavioral]] management mostly consists of life style and [[Dietary Management|dietary modification]], while [[pharmacological]] interventions are mostly based on [[laxatives]]. Increasing [[physical activity]] is postulated to improve constipation and colonic transit time in patients with constipation. The most important [[behavioral]] treatment for constipation is [[biofeedback]], consisting of teaching the patients how to use their [[Abdominal muscle|abdominal]] and [[Pelvic floor muscles|pelvic muscles]] during [[defecation]]. [[Probiotics]] are live [[microorganisms]] that are eaten to improve the [[gastrointestinal tract]] function. Recently, use of [[probiotics]] in food industry is growing. ''[[Bifidobacterium]]'' and [[Lactobacillus]] are most studied [[organisms]] as [[probiotics]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
| Line 38: | Line 38: | ||
==== Lifestyle modification ==== | ==== Lifestyle modification ==== | ||
* Increasing [[physical activity]] is postulated to improve constipation and colonic transit time in patients with constipation.<ref name="pmid2604760">{{cite journal |vauthors=Meshkinpour H, Kemp C, Fairshter R |title=Effect of aerobic exercise on mouth-to-cecum transit time |journal=Gastroenterology |volume=96 |issue=3 |pages=938–41 |year=1989 |pmid=2604760 |doi= |url=}}</ref> | * Increasing [[physical activity]] is postulated to improve constipation and colonic transit time in patients with constipation.<ref name="pmid2604760">{{cite journal |vauthors=Meshkinpour H, Kemp C, Fairshter R |title=Effect of aerobic exercise on mouth-to-cecum transit time |journal=Gastroenterology |volume=96 |issue=3 |pages=938–41 |year=1989 |pmid=2604760 |doi= |url=}}</ref> | ||
* Moderate [[physical exercise]] as much as 32 min per day | * Moderate [[physical exercise]] as much as 32 min per day have shown significant improvement of quality of life but no significant decrease in [[laxative]] need for treatment.<ref name="pmid16875507">{{cite journal |vauthors=Chin A Paw MJ, van Poppel MN, van Mechelen W |title=Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial |journal=BMC Geriatr |volume=6 |issue= |pages=9 |year=2006 |pmid=16875507 |pmc=1562427 |doi=10.1186/1471-2318-6-9 |url=}}</ref> | ||
* Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with [[Irritable bowel syndrome|irritable bowel syndrome (IBS)]].<ref name="pmid21206488">{{cite journal |vauthors=Johannesson E, Simrén M, Strid H, Bajor A, Sadik R |title=Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial |journal=Am. J. Gastroenterol. |volume=106 |issue=5 |pages=915–22 |year=2011 |pmid=21206488 |doi=10.1038/ajg.2010.480 |url=}}</ref> | * Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with [[Irritable bowel syndrome|irritable bowel syndrome (IBS)]].<ref name="pmid21206488">{{cite journal |vauthors=Johannesson E, Simrén M, Strid H, Bajor A, Sadik R |title=Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial |journal=Am. J. Gastroenterol. |volume=106 |issue=5 |pages=915–22 |year=2011 |pmid=21206488 |doi=10.1038/ajg.2010.480 |url=}}</ref> | ||
==== Dietary interventions ==== | ==== Dietary interventions ==== | ||
* [[Dietary fiber|Fiber supplementation]] is the main primary [[therapeutic]] intervention for every patients with constipation. | * [[Dietary fiber|Fiber supplementation]] is the main primary [[therapeutic]] intervention for every patients with constipation. | ||
* The [[polysaccharide]] fibers are the agents that increase the weight of [[stool]] and and improve the [[stool]] consistency | * The [[polysaccharide]] fibers are the agents that increase the weight of [[stool]] and and improve the [[stool]] consistency by absorbing and retaining water.<ref name="pmid19824937">{{cite journal |vauthors=Emmanuel AV, Tack J, Quigley EM, Talley NJ |title=Pharmacological management of constipation |journal=Neurogastroenterol. Motil. |volume=21 Suppl 2 |issue= |pages=41–54 |year=2009 |pmid=19824937 |doi=10.1111/j.1365-2982.2009.01403.x |url=}}</ref> | ||
* The most common used bulking organic [[polysaccharide]] in Canada is [[Psyllium]]. [[Psyllium]] is found to significantly decrease colonic transit and improve [[stool]] consistency | * The most common used bulking organic [[polysaccharide]] in Canada is [[Psyllium]]. | ||
* [[Psyllium]] and [[lactulose]] is found to significantly decrease colonic transit and improve [[stool]] consistency.<ref name="pmid8824651">{{cite journal |vauthors=Ashraf W, Park F, Lof J, Quigley EM |title=Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation |journal=Aliment. Pharmacol. Ther. |volume=9 |issue=6 |pages=639–47 |year=1995 |pmid=8824651 |doi= |url=}}</ref><ref name="pmid9891195">{{cite journal |vauthors=Dettmar PW, Sykes J |title=A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation |journal=Curr Med Res Opin |volume=14 |issue=4 |pages=227–33 |year=1998 |pmid=9891195 |doi=10.1185/03007999809113363 |url=}}</ref> | |||
==== Biofeedback treatment ==== | ==== Biofeedback treatment ==== | ||
* The most important [[behavioral]] treatment for constipation is [[biofeedback]], consisting of teaching the patients how to use their [[Abdominal muscle|abdominal]] and [[Pelvic floor muscles|pelvic muscles]] during [[defecation]]. | * The most important [[behavioral]] treatment for constipation is [[biofeedback]], consisting of teaching the patients how to use their [[Abdominal muscle|abdominal]] and [[Pelvic floor muscles|pelvic muscles]] during [[defecation]]. | ||
* During the [[biofeedback]] patients receive [[feedback]] | * During the [[biofeedback]], patients receive [[feedback]] on their [[Abdominal muscle|abdominal]] and [[Pelvic floor muscles|pelvic floor muscle]] [[contractions]] recording by means of surface [[Electromyography|electromyography (EMG)]]. | ||
* Based on the [[biofeedback]], patients are | * Based on the [[biofeedback]], patients are taught how to increase intra-abdominal pressure and also relax their [[pelvic floor muscles]] to have a coordinated evacuation.<ref name="pmid20801775" /> | ||
* Regarding the outcomes, the [[biofeedback]] behavioral therapy is the choice treatment for functional [[defecation]] disorder.<ref name="pmid16012938">{{cite journal |vauthors=Chiarioni G, Salandini L, Whitehead WE |title=Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation |journal=Gastroenterology |volume=129 |issue=1 |pages=86–97 |year=2005 |pmid=16012938 |doi= |url=}}</ref> | * Regarding the outcomes, the [[biofeedback]] behavioral therapy is the choice treatment for functional [[defecation]] disorder.<ref name="pmid16012938">{{cite journal |vauthors=Chiarioni G, Salandini L, Whitehead WE |title=Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation |journal=Gastroenterology |volume=129 |issue=1 |pages=86–97 |year=2005 |pmid=16012938 |doi= |url=}}</ref> | ||
==== Pharmacological intervention ==== | ==== Pharmacological intervention ==== | ||
Pharmacological intervention for constipation include:<ref name="urlTreatment for Constipation | NIDDK">{{cite web |url=https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/treatment |title=Treatment for Constipation | NIDDK |format= |work= |accessdate=}}</ref> | |||
===Constipation | ===Constipation=== | ||
* '''1 Adult''' | * '''1 Adult''' | ||
** '''1.1 Over the counter medicines''' | ** '''1.1 Over the counter medicines''' | ||
| Line 70: | Line 72: | ||
***1.1.3 '''''Stool softeners''''' | ***1.1.3 '''''Stool softeners''''' | ||
****Preferred regimen (1): [[Colace Glycerin Suppositories|Colace]] 100-300 mg [[Rectal|intra-rectal]] daily | ****Preferred regimen (1): [[Colace Glycerin Suppositories|Colace]] 100-300 mg [[Rectal|intra-rectal]] daily | ||
****Preferred regimen (2): | ****Preferred regimen (2): [[Docusate sodium]]: 50-300 mg [[Per os|PO]] daily | ||
****Preferred regimen (3): [[Docusate]] calcium: 240 mg [[Per os|PO]] daily | |||
**** | |||
****Alternative regimen (1): [[Surfak]] 240 mg [[Per os|PO]] daily | ****Alternative regimen (1): [[Surfak]] 240 mg [[Per os|PO]] daily | ||
***1.1.4 '''''Lubricants''''' | ***1.1.4 '''''Lubricants''''' | ||
| Line 127: | Line 128: | ||
=== Probiotics === | === Probiotics === | ||
* [[Probiotics]] are live [[ | * [[Probiotics]] are live [[microorganism]] [[spores]] that are given orally to improve the [[gastrointestinal tract]] function. Recently, use of [[probiotics]] in food industry is growing.<ref name="pmid22114754">{{cite journal| author=Liu LW| title=Chronic constipation: current treatment options. | journal=Can J Gastroenterol | year= 2011 | volume= 25 Suppl B | issue= | pages= 22B-28B | pmid=22114754 | doi= | pmc=3206558 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22114754 }}</ref> | ||
* ''[[Bifidobacterium]]'' and [[Lactobacillus]] are most | * ''[[Bifidobacterium]]'' and [[Lactobacillus]] are most studied [[organisms]] as [[probiotics]].<ref name="pmid20039451">{{cite journal |vauthors=Chmielewska A, Szajewska H |title=Systematic review of randomised controlled trials: probiotics for functional constipation |journal=World J. Gastroenterol. |volume=16 |issue=1 |pages=69–75 |year=2010 |pmid=20039451 |pmc=2799919 |doi= |url=}}</ref> | ||
* It is found that [[probiotics]] significantly improve the chronic constipation [[symptoms]] in patients.<ref name="pmid20697291">{{cite journal |vauthors=Del Piano M, Carmagnola S, Anderloni A, Andorno S, Ballarè M, Balzarini M, Montino F, Orsello M, Pagliarulo M, Sartori M, Tari R, Sforza F, Capurso L |title=The use of probiotics in healthy volunteers with evacuation disorders and hard stools: a double-blind, randomized, placebo-controlled study |journal=J. Clin. Gastroenterol. |volume=44 Suppl 1 |issue= |pages=S30–4 |year=2010 |pmid=20697291 |doi=10.1097/MCG.0b013e3181ee31c3 |url=}}</ref> | * It is found that [[probiotics]] significantly improve the chronic constipation [[symptoms]] in patients.<ref name="pmid20697291">{{cite journal |vauthors=Del Piano M, Carmagnola S, Anderloni A, Andorno S, Ballarè M, Balzarini M, Montino F, Orsello M, Pagliarulo M, Sartori M, Tari R, Sforza F, Capurso L |title=The use of probiotics in healthy volunteers with evacuation disorders and hard stools: a double-blind, randomized, placebo-controlled study |journal=J. Clin. Gastroenterol. |volume=44 Suppl 1 |issue= |pages=S30–4 |year=2010 |pmid=20697291 |doi=10.1097/MCG.0b013e3181ee31c3 |url=}}</ref> | ||
=== General treatment priorities in patients with constipation<ref name="pmid22114754" /> | === General treatment priorities in patients with constipation === | ||
{{family tree/start}} | Flow chart showing general treatment priorities in patient with constipation include:<ref name="pmid22114754" />{{family tree/start}} | ||
{{family tree| | A01 | | | | | | | | | | | | | | | |A01='''Education'''<br> Aknowledgement and attention to patietns' concerns<br>Guiding and encouraging the patients to participate in the treatment and have realistic goals}} | {{family tree| | A01 | | | | | | | | | | | | | | | |A01='''Education'''<br> Aknowledgement and attention to patietns' concerns<br>Guiding and encouraging the patients to participate in the treatment and have realistic goals}} | ||
{{family tree| | |!| | | | | | | | | | | | | | | | }} | {{family tree| | |!| | | | | | | | | | | | | | | | }} | ||
Revision as of 18:18, 10 January 2018
|
Constipation Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Constipation On the Web |
|
American Roentgen Ray Society Images of Constipation |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]
Overview
Chronic constipation treatment includes both behavioral and pharmacological interventions. Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives. Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation. The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation. Probiotics are live microorganisms that are eaten to improve the gastrointestinal tract function. Recently, use of probiotics in food industry is growing. Bifidobacterium and Lactobacillus are most studied organisms as probiotics.
Medical Therapy
- General principles of medical therapy in patients with chronic constipation are as following:[1]
| Chronic Constipation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| EXCLUDE: • Inadeqate fiber intake • Medication • Cancer • Stricture • Systemic or neurologic disease | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No clinical response | Fiber supplement, Simple laxatives | Clinical response | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | • Anorectal manometry • Balloon expulsion test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Colonic transit time | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Unclear diagnosis | Evacuation disorder | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Delayed | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| • Barium enema • MR proctography | • Pelvic floor retraining • Psychology • Diet | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| • Fiber supplement • Osmotic laxatives • Secretagogues • Prokinetics | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Clinically significant structural disorder | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Clinical response | No clinical response | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Rectal surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Colonic manometry | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Colonic inertia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consider colectomy plus ileorectostomy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Chronic constipation management
- Chronic constipation treatment includes both behavioral and pharmacological interventions.
- Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives.
Lifestyle modification
- Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation.[2]
- Moderate physical exercise as much as 32 min per day have shown significant improvement of quality of life but no significant decrease in laxative need for treatment.[3]
- Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with irritable bowel syndrome (IBS).[4]
Dietary interventions
- Fiber supplementation is the main primary therapeutic intervention for every patients with constipation.
- The polysaccharide fibers are the agents that increase the weight of stool and and improve the stool consistency by absorbing and retaining water.[5]
- The most common used bulking organic polysaccharide in Canada is Psyllium.
- Psyllium and lactulose is found to significantly decrease colonic transit and improve stool consistency.[6][7]
Biofeedback treatment
- The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation.
- During the biofeedback, patients receive feedback on their abdominal and pelvic floor muscle contractions recording by means of surface electromyography (EMG).
- Based on the biofeedback, patients are taught how to increase intra-abdominal pressure and also relax their pelvic floor muscles to have a coordinated evacuation.[1]
- Regarding the outcomes, the biofeedback behavioral therapy is the choice treatment for functional defecation disorder.[8]
Pharmacological intervention
Pharmacological intervention for constipation include:[9]
Constipation
- 1 Adult
- 1.1 Over the counter medicines
- 1.1.1 Bulk forming agents
- 1.1.2 Osmotic agents
- Preferred regimen (1): Cephulac 5 g (1 tablespoon) dissolved in 250 mL water PO q6-8h
- Preferred regimen (2): Fleet Phospho-Soda 15 mL dissolved in 250 mL water PO q6-8h
- Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
- Alternative regimen (1): Miralax 34 g dissolved in 250 mL water PO daily
- Alternative regimen (1): Sorbitol 30-150 mL (70% solution) once
- 1.1.3 Stool softeners
- Preferred regimen (1): Colace 100-300 mg intra-rectal daily
- Preferred regimen (2): Docusate sodium: 50-300 mg PO daily
- Preferred regimen (3): Docusate calcium: 240 mg PO daily
- Alternative regimen (1): Surfak 240 mg PO daily
- 1.1.4 Lubricants
- 1.1.5 Stimulants
- 1.2 Prescription medicines
- 1.2.1 Chloride channel activators
- Preferred regimen (1): Lubiprostone (Amitiza) 24 mcg PO q12h with food and water
- 1.2.2 Guanylate cyclase-C agonists
- Preferred regimen (1): Linaclotide (Linzess) 145 mcg PO daily
- 1.2.1 Chloride channel activators
- 1.1 Over the counter medicines
- 2 Pediatrics
- 2.1 Over the counter medicines
- 2.1.1 Bulk forming agents
- 1.1.2 Osmotic agents
- Preferred regimen (1): Cephulac 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q6-8h
- Preferred regimen (2): Fleet Phospho-Soda 5-10 mL dissolved in 250 mL water PO q6-8h (not for < 5 years of age)
- Preferred regimen (3): Milk of Magnesia 5-15 mL PO daily
- Alternative regimen (1): Miralax 17 g dissolved in 250 mL water PO daily
- Alternative regimen (2): Sorbitol 2 mL/kg (as 70% solution) once
- 1.1.3 Stool softeners
- Preferred regimen (1): Colace 100 mg intra-rectal daily
- Preferred regimen (2): Docusate
- Docusate sodium
- Docusate calcium
- < 12 years: Not recommended
- >12 years: 240 mg PO daily
- Alternative regimen (1): Surfak 50 mg PO q12h
- 1.1.4 Lubricants
- 1.1.5 Stimulants
- 2.2 Prescription medicines
- 2.2.1 Chloride channel activators
- Preferred regimen (1): Lubiprostone (Amitiza) not approve for pediatrics
- 2.2.2 Guanylate cyclase-C agonists
- Preferred regimen (1): Linaclotide (Linzess) not approve for pediatrics
- 2.2.1 Chloride channel activators
- 2.1 Over the counter medicines
Probiotics
- Probiotics are live microorganism spores that are given orally to improve the gastrointestinal tract function. Recently, use of probiotics in food industry is growing.[10]
- Bifidobacterium and Lactobacillus are most studied organisms as probiotics.[11]
- It is found that probiotics significantly improve the chronic constipation symptoms in patients.[12]
General treatment priorities in patients with constipation
Flow chart showing general treatment priorities in patient with constipation include:[10]
| Education Aknowledgement and attention to patietns' concerns Guiding and encouraging the patients to participate in the treatment and have realistic goals | |||||||||||||||||||||||||||||||||||||||
| Diet and physical activity Improving the previous habits | |||||||||||||||||||||||||||||||||||||||
| Fiber supplementation | |||||||||||||||||||||||||||||||||||||||
| Osmotic laxatives MoM, Lactulose, PEG | |||||||||||||||||||||||||||||||||||||||
| Prokinetics Prucalopride | |||||||||||||||||||||||||||||||||||||||
| Surgery | |||||||||||||||||||||||||||||||||||||||
References
- ↑ 1.0 1.1 Camilleri M, Bharucha AE (2010). "Behavioural and new pharmacological treatments for constipation: getting the balance right". Gut. 59 (9): 1288–96. doi:10.1136/gut.2009.199653. PMC 3189401. PMID 20801775.
- ↑ Meshkinpour H, Kemp C, Fairshter R (1989). "Effect of aerobic exercise on mouth-to-cecum transit time". Gastroenterology. 96 (3): 938–41. PMID 2604760.
- ↑ Chin A Paw MJ, van Poppel MN, van Mechelen W (2006). "Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial". BMC Geriatr. 6: 9. doi:10.1186/1471-2318-6-9. PMC 1562427. PMID 16875507. Vancouver style error: missing comma (help)
- ↑ Johannesson E, Simrén M, Strid H, Bajor A, Sadik R (2011). "Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial". Am. J. Gastroenterol. 106 (5): 915–22. doi:10.1038/ajg.2010.480. PMID 21206488.
- ↑ Emmanuel AV, Tack J, Quigley EM, Talley NJ (2009). "Pharmacological management of constipation". Neurogastroenterol. Motil. 21 Suppl 2: 41–54. doi:10.1111/j.1365-2982.2009.01403.x. PMID 19824937.
- ↑ Ashraf W, Park F, Lof J, Quigley EM (1995). "Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation". Aliment. Pharmacol. Ther. 9 (6): 639–47. PMID 8824651.
- ↑ Dettmar PW, Sykes J (1998). "A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation". Curr Med Res Opin. 14 (4): 227–33. doi:10.1185/03007999809113363. PMID 9891195.
- ↑ Chiarioni G, Salandini L, Whitehead WE (2005). "Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation". Gastroenterology. 129 (1): 86–97. PMID 16012938.
- ↑ "Treatment for Constipation | NIDDK".
- ↑ 10.0 10.1 Liu LW (2011). "Chronic constipation: current treatment options". Can J Gastroenterol. 25 Suppl B: 22B–28B. PMC 3206558. PMID 22114754.
- ↑ Chmielewska A, Szajewska H (2010). "Systematic review of randomised controlled trials: probiotics for functional constipation". World J. Gastroenterol. 16 (1): 69–75. PMC 2799919. PMID 20039451.
- ↑ Del Piano M, Carmagnola S, Anderloni A, Andorno S, Ballarè M, Balzarini M, Montino F, Orsello M, Pagliarulo M, Sartori M, Tari R, Sforza F, Capurso L (2010). "The use of probiotics in healthy volunteers with evacuation disorders and hard stools: a double-blind, randomized, placebo-controlled study". J. Clin. Gastroenterol. 44 Suppl 1: S30–4. doi:10.1097/MCG.0b013e3181ee31c3. PMID 20697291.