Probiotics

Probiotics

PEP Topic 
Constipation
Description 

Probiotics are live microorganisms capable of colonizing the intestinal tract, altering the microflora, and exerting a positive effect on the host. The mechanism by which probiotics exert positive effects remains to be elucidated. However, purported mechanisms include antagonizing pathogens through the production of antimicrobial or antibacterial compounds, decreasing gut pH by stimulating lactic-acid producing bacteria, preventing colonization of pathogenic microorganisms by competing for binding sites, improving immune function, competing with pathogens for nutrients and growth factors, producing lactase to aid lactose digestion, and signaling cells to stop production of virulence factors. Probiotics have been used for the treatment of diarrhea and constipation. Preoperative probiotics were examined for prevention of infection in patients undergoing colorectal surgery.

Effectiveness Not Established

Guideline/Expert Opinion

Bharucha, A.E., Pemberton, J.H., & Locke, G.R., 3rd. (2013). American Gastroenterological Association technical review on constipation. Gastroenterology, 144, 218–238.

doi: 10.1053/j.gastro.2012.10.028
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Purpose & Patient Population:

To identify rational, effective, and cost-effective treatment approaches for patients with constipation.

Type of Resource/Evidence-Based Process:

In this evidence-based guideline, material was selected from reviews and focused literature searches of peer-reviewed published studies.

Databases searched, search keywords, and inclusion criteria were not stated.

Studies were excluded if they reported on children or patients with constipation as a secondary symptom caused by problems such as spinal cord injury.
 

Phase of Care and Clinical Applications:

The study has clinical applicability to older adult and palliative care.

Results Provided in the Reference:

Evidence was categorized according to the U.S. Preventive Services Task Force grading system. Rome II criteria were used to define constipation. The resource identified causes of constipation, approaches for assessment, and recommendations for management based on evidence review. In addition to opiates, other causative agents associated with constipation in patients with cancer were antidepressants, anticholinergic agents, vinca alkaloids, vincristine, and cyclophosphamide.

Guidelines & Recommendations:

  • No evidence suggests increasing fluid intake improves constipation.
  • Increased physical activity is associated with less constipation.
  • Data are limited regarding the impact of probiotics on constipation.
  • Dietary fiber has potential therapeutic benefits, and fiber supplementation should be considered as a first step in patients with chronic constipation. However, the quality of evidence in this area is low.
  • If needed, osmotic agents should be used regularly and supplemented with stimulant laxatives as rescue medication, although the quality of evidence is moderate at best.

Limitations:

Limited high-quality evidence exists for effective interventions in managing constipation.

Research Evidence Summaries

Higashikawa, F., Noda, M., Awaya, T., Nomura, K., Oku, H., & Sugiyama, M. (2010). Improvement of constipation and liver function by plant-derived lactic acid bacteria: A double-blind, randomized trial. Nutrition, 26, 367–374.

doi: 10.1016/j.nut.2009.05.008
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Study Purpose:

To evaluate the effects of yogurts made with different types of lactic acid bacteria (LAB) on the gastrointestinal system.

Intervention Characteristics/Basic Study Process:

Participants were recruited via advertisement. Consenting patients were assigned using stratified randomization by defecation frequencies to receive one of three types of yogurt.

  • Type A: plant-derived LAB—Lactobacillus plantarumSN35N (95%) with SN13T (5%)
  • Type B: plant-derived LAB—Lb. plantarumSN13T (98%) with SN35N (2%)
  • Type C: animal-derived LAB—Lb. lactis A6 (86.1%), Streptococcus thermophilus 510 (13.8%), and Lb. bulgaricus C6 (0.1%)

Participants consumed 100 g of yogurt daily for a six-week period. Data were collected from clinic visits at two-week intervals.

Sample Characteristics:

  • The study reported on a sample of 68 patients aged 21 to 65 years.
  • The sample comprised 49 women and 19 men.
  • Patients were healthy adults with some complaints of intestinal health, such as constipation, diarrhea, abdominal pain, and bloating.

Setting:

Hiroshima, Japan

Study Design:

This was a randomized, double-blind study.

Measurement Instruments/Methods:

Bristol Stool Form Scale

Results:

  • No statistical difference existed between the study types (groups A and B) and the control (group C).
  • Total cholesterol decreased significantly in all individuals from 214.3 mg/dl at baseline to 203.2 mg/dl at six weeks (p = 0.012) in group B, but not in groups A and C.
  • No participants reported any significant adverse events resulting from yogurt intake during the trial.
  • No abnormal changes in urine analysis or serum biochemical parameters were observed during the study.

Conclusions:

In healthy adults, Lb. plantarum SN13T may improve serum lipid levels and liver function. Actual effects in relieving constipation are unclear.

Limitations:

  • The sample size was small (fewer than 100).
  • The study did not include patients with cancer.

Nursing Implications:

Effects in relieving constipation are unclear in healthy adults. Additional studies are warranted that include a larger sample and patients with cancer.

Ohigashi, S., Hoshino, Y., Ohde, S., & Onodera, H. (2011). Functional outcome, quality of life, and efficacy of probiotics in postoperative patients with colorectal cancer. Surgery Today, 41, 1200–1206.

doi: 10.1007/s00595-010-4450-6
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Study Purpose:

To compare functional outcome and quality of life (QOL) in patients who received surgical resection for rectal versus colon cancer, and to review the efficacy of the use of probiotics in bowel function afterwards.

Intervention Characteristics/Basic Study Process:

A questionnaire was sent to 193 patients with non–stage IV colon cancer. Some patients with stage III disease received adjuvant chemotherapy over the six-month postoperative period, but no patients were undergoing chemotherapy when the questionnaire was administered. Seventy-seven respondents agreed to take probiotics. Patients received a probiotic that contained Bacillus natto and Lactobacillus acidophilus as the principal ingredients.

Patients took three tablets after meals TID for a total of nine tablets. The questionnaire was readministered three months after probiotic initiation.

Sample Characteristics:

  • The study reported on a sample of 77 patients with colorectal cancer, divided into right-side, left-side, and rectal groups.
  • Patient age ranged from 52 to 77 years across all study groups.
  • The final sample comprised 35 men (right side: n = 11; left side: n = 12; rectal: n = 12) and 26 women (right side: n = 7; left side: n = 9; rectal: n = 10).

Setting:

  • Single site
  • Multiple settings
  • Japan

Phase of Care and Clinical Applications:

  • Patients were in the late-effect and survivorship phases of care.
  • The study has clinical applicability to older adult care.

Study Design:

 This was a questionnaire-based study with a cross-sectional design.

Measurement Instruments/Methods:

  • Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36) in Japanese
  • European Organization for Research and Treatment of Cancer (EORTC) Cancer Core Quality of Life Questionnaire (QLQ-C30) in Japanese
  • Functional outcome was scored using the Wexner Fecal Incontinence Score and questions specific to bowel function.

Results:

  • Functional outcomes (related to defecation frequency and anal pain), Wexner score, and social function on the QLQ-C30 were worse in the rectal group.
  • The right-side group had a tendency toward softer stools and more frequent nighttime defecation than the left-side group.
  • Global QOL, constipation, and diarrhea on the QLQ-C30 was improved in the rectal group.
  • Frequency of defecation, role of emotion on the SF-36, and constipation on the QLQ-C30 were improved in the left-side group.
  • Defecation, frequency, feeling of incomplete evacuation, and global QOL on the SF-36 were significantly improved in the right-side group.
  • Patients who were receiving probiotics had a statistically significant reduction in frequency of stools per day (0.4 change; p < 0.05), and 50% fewer patients with right-side colon disease experienced the feeling of incomplete defecation after probiotic use (p < 0.05).
  • Specific aspects of QOL scores showed mixed results, with some improving and some subscale scores worsening.

Conclusions:

Some improvements were observed in all groups after the administration of probiotics. Changes in defecation and related symptoms differed according to disease location over time. The role of probiotic use cannot be determined from this study report.

Limitations:

  • The sample size was small (fewer than 100 patients).
  • Risk of bias existed because the study lacked a control group, blinding, and random assignment.
  • Unintended interventions or applicable interventions that may have influenced the results were not described.
  • Changes over time were not compared between patients who received probiotics and those who did not. As bowel habits and problems can be expected to change over time after surgery and according to tumor location, the impact of probiotic use cannot be determined based on this study.

Nursing Implications:

The study did not provide sufficient evidence to demonstrate the efficacy of probiotic use for managing bowel symptoms in patients after colorectal surgery. However, the study showed differences in bowel symptoms based on initial tumor location and surgical area.


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