|Year : 2021 | Volume
| Issue : 2 | Page : 183-189
Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study
Ahmad Raed Tarakji1, Hussam Zaid Alorabi2, Yazeed Abdullah Alhusainy3, Nasser Yousef Alhowaish4, Abdullah Abdulaziz Alsebti4, Hamad Sulaiman Aljutaili5
1 Department of Medicine, Nephrology Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
3 Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
4 Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
5 Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
|Date of Submission||23-Sep-2020|
|Date of Decision||10-Dec-2020|
|Date of Acceptance||13-Dec-2020|
|Date of Web Publication||13-Apr-2021|
Ahmad Raed Tarakji
Department of Medicine, Nephrology Unit, College of Medicine, King Saud University, P.O. Box 300158, Riyadh 11372
Source of Support: None, Conflict of Interest: None
Objectives: Constipation among peritoneal dialysis (PD) patients can lead to serious complications and impair the quality of life. The aim of this study was to determine the prevalence of constipation and its associated factors among PD patients in our center. Methods: A quantitative, cross-sectional study was conducted on PD patients at King Khaled University Hospital in Riyadh, Saudi Arabia, from November 2016 to January 2017. Results: A total of 36 PD patients were included; the male to female ratio was 1. Based on a self-reporting questionnaire, 15 PD patients (41.7%) reported suffering from constipation. However, the prevalence was the same using at least one of Rome III criteria (41.7%) and much lower using Bristol stool form Scale (11%). No significant difference was detected between PD patients with and without constipation in terms of dietary fiber intake, use of calcium and iron supplements, water intake, presence of diabetes and hypertension, or demographic profiles. Conclusion: The high prevalence of constipation among PD patients seen in our population is comparable to those seen in other studies.
Keywords: Constipation, peritoneal dialysis, prevalence, Saudi Arabia
|How to cite this article:|
Tarakji AR, Alorabi HZ, Alhusainy YA, Alhowaish NY, Alsebti AA, Aljutaili HS. Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study. J Nat Sci Med 2021;4:183-9
|How to cite this URL:|
Tarakji AR, Alorabi HZ, Alhusainy YA, Alhowaish NY, Alsebti AA, Aljutaili HS. Prevalence of constipation among peritoneal dialysis patients in Saudi Arabia: A single-center study. J Nat Sci Med [serial online] 2021 [cited 2021 Jun 13];4:183-9. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/183/313639
| Introduction|| |
Chronic constipation has an impact on patient quality of life, since straining during defecation to pass hard stool or having infrequent/incomplete evacuation can impair a person's general health, social life, and mental health. The medications used to treat chronic constipation are also more expensive than the cost of managing irritable bowel syndrome., Several methods are available to assess and diagnose constipation. One is the Bristol stool form scale (BSFS), which is a validated, reliable, and convenient tool for assessing chronic constipation.,,, The Rome III criteria is another well-known tool, although some concerns regarding its limitations have been raised in the literature., Nevertheless, the Rome III is still considered a suitable reference tool in most recent studies for defining functional gastroenterological disorders, such as functional constipation.,
The pooled prevalence of chronic idiopathic constipation in the general population determined in different studies ranges between 7% and 14%., For Saudi Arabia, we were able to find only one study that reported a perceived bowel irregularity in 18.1% of the respondents but without specifying the percentage of constipation. Therefore, we conducted an internet-based pilot study and found a prevalence of 42%, 60%, and 25% by self-reporting, Bristol, and Rome II criteria, respectively, in the general population in Saudi Arabia. A subsequent study conducted in the central region of Saudi Arabia found a presence of constipation in only about 4% of the population.
Constipation is not normally considered life-threatening in healthy persons, but it is a risk factor of peritonitis in patients undergoing peritoneal dialysis (PD), one of the effective treatments for patients with end stage renal disease. PD involves filling and draining the peritoneal cavity with special fluid through a transcutaneous PD catheter, and one of the challenges of PD is to have a good functioning catheter, which requires regular bowel movements. In contrast to hemodialysis patients, PD patients with constipation have impaired health-related quality of life; therefore; more attention should be paid to PD patients. PD patients have higher scores for constipation than the general population using the gastrointestinal symptom rating scale, although some studies have refuted that claim. PD patients also suffer more reflux symptoms and eating dysfunctions (such as early satiety, difficulties in eating normal portion and post prandial pain), and yet constipation is still one of the main gastrointestinal symptoms.,, Studies have shown that the prevalence of constipation in PD patients ranges from 6.2% to 28.9%, depending on the assessment tools used in the study.,,,, For example, an Australian study showed a prevalence of constipation among PD patients of 12.3% using the Rome III criteria, 25.7% using the BSFS, and 46.3% by the patient's perception.
Multiple studies have revealed diabetes as one established factor for constipation.,, However, in PD patients, the results were contradictory.,,, The diet of PD patients might have a role in the development of constipation due to low fiber and fluid intakes. In general, high fiber diets or fiber supplements are used to manage constipation, though many fiber-rich foods are also rich in potassium and should be limited in PD patient diets. Another study also found that PD patients have difficulty committing to high fiber diets and that fiber is better administered as supplements. The use of medications such as calcium-based phosphate binders, oral iron supplements, and calcium channel blockers can also contribute to constipation., An increased number of daily pill intakes are associated with higher GI symptoms, including constipation, in PD patients.
At the end of 2011, 13,356 patients were on dialysis in Saudi Arabia and more than 1200 patients (9.28%) were on PD. These numbers, as well as the lack of previous study regarding constipation among PD patients in Saudi Arabia, prompted us to conduct the present study to identify the prevalence of constipation and its associated factors among our PD patients.
| Methods|| |
A quantitative, cross-sectional study was conducted in the PD unit between November 2016 and January 2017 at King Khalid University Hospital in Riyadh, Saudi Arabia. All adult (>18 years of age) patients who had been on PD for more than 3 months were included in the study. Patients were excluded if they had a history of dementia, colitis, diabetic gastroparesis, liver or gallbladder disease, or peritonitis in the last 3 months prior to recruitment for the study.
Convenience sampling was used to recruit 36 out of total 53 patients in our PD center based on the inclusion and exclusion criteria. Information about demographics (gender, nationality, residency, age, daily activity, educational level, medical conditions, medications, liquid intake and diet) were collected from all patients.
Data about constipation were collected using a self-administered bilingual Arabic-English questionnaire to assess constipation using three tools: self-perception of constipation, Rome III criteria, and BSFS scores. The questions on the Rome III criteria for functional constipation include straining during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, sensation of incomplete evacuation for at least 25% of defecations, sensation of anorectal obstruction/blockage for at least 25% of defecations, manual maneuvers to facilitate at least 25% of defecations, and fewer than three defecations per week. Patients were asked to compare the character of their stools with the Bristol Stool Chart., This validated questionnaire was adopted with permission from a previous similar study. Then we added Rome III criteria and BSFS from standardized published questionnaires. The Arabic translation was done by the authors who are fluent in both languages and further confirmed by two other consultants. An initial pilot study was conducted among 20 normal subjects using the questionnaire to ensure language clarity.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 22.0 (SPSS Inc., Armonk, New York, USA). Results are expressed as numbers and percentages for categorical data. A P < 0.05 was considered statistically significant.
Ethical approval was granted by the Institutional Review Board (IRB) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia (16/0552/IRB, Research Project Number E-10-2118). All participants signed a consent form. No incentives or rewards were given to participants, and their anonymity and confidentiality were guaranteed.
| Results|| |
A total of 36 PD patients were included in the study: 18 (50.0%) males and 18 (50.0%) females. [Table 1] shows the detailed demographic profiles of the 36 PD patients. Thirty-one (86.1%) patients were Saudis. Sixteen patients (44.4%) had a sedentary lifestyle, and 29 patients (80.6%) were educated to at least the high school level. Among the 36 patients, 31 (86.1%) had hypertension and 12 (33.3%) had diabetes. Twenty-seven patients (75.0%) took calcium supplements, and 26 patients (72.2%) took laxatives. Fifteen patients (41.7%) claimed to have suffered from constipation. Most patients consumed rice and pasta as their main dish (n = 31, 86.1%), and a similar number consumed fruits and vegetables (n = 30, 83.3%).
|Table 1: Demographic profiles of 36 peritoneal dialysis patients at King Khaled University Hospital, Riyadh, Saudi Arabia|
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Based on a self-reporting questionnaire, 15 PD patients (41.7%) reported suffering from constipation. However, the prevalence was the same using at least one of Rome III criteria (41.7%) and much lower using BSFS (11%). The reported symptoms of our PD patients based on the Rome III diagnostic criteria for functional constipation is summarized in [Figure 1]. The type of stool reported by our patients based on the BSFS is shown in [Figure 2].
|Figure 1: Frequencies of responses according to the Rome III diagnostic criteria for functional constipation|
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|Figure 2: Patient responses according to the Bristol stool form scale|
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Statistical analysis had shown that no significant differences were noted in the character of the stool using the Bristol chart between males and females (P = 0.359), between Saudis and nonSaudis (P = 0.470), across different age groups (P = 0.580), across different daily activities (P = 0.583), and across different educational levels (P = 0.411) [Table 2]. No significant differences in character of stool were noted according to the amount of water intake (P = 0.559), the lumpiness and hardness of stool (P = 0.181), the use of calcium-based phosphorus binders (P = 0.392), the use of laxatives (P = 0.642), the use of thyroid replacement (P = 0.960), or the sensation of having difficulty in defecation (P = 0.142), the sensation of incomplete defecation (P = 0.707), the sensation of anorectal obstruction (P = 0.557), or defecation fewer than 3 times per week (P = 0.612). However, significantly more patients with constipation had to manually facilitate defecation compared with patients who had normal stool character or those having diarrhea (P = 0.010) [Table 3].
|Table 2: Demographic variables of patients according to the Bristol stool form scale|
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|Table 3: Patient responses to questions using the Rome III criteria and perceptions according to the Bristol stool character chart|
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Of the 12 patients who had diabetes, six (50.0%) suffered from constipation; however, the difference in the prevalence of constipation among diabetic and nondiabetic PD patients was not statistically significant (P = 0.499). Of the 15 patients with hypertension, 11 patients (73.3%) suffered from constipation; however, no significant difference was detected in the prevalence of constipation among hypertensive and nonhypertensive PD patients (P = 0.134). Ten of 15 patients (66%) who had constipation used laxatives, but again the difference in the use of laxatives among PD patients who were constipated and not constipated was not statistically significant (P = 0.709). No significant differences were also noted in the amount of water and liquid intake per day between patients who were constipated and not constipated (P = 0.441). The prevalence of constipation was also not significantly different among patients who consumed or did not consume dairy products (P = 0.236), pepper and spices (P = 0.192), meat and chicken (P = 0.630), fruits and vegetables (P = 0.677), wheat and bran grains (P = 0.499), and rice and pasta (P = 0.630).
| Discussion|| |
This study showed that four patients (11.1%) experienced mild to severe constipation based on the BSFS, similar to the findings from previous prevalence studies.,,,, Conversely, based on the Rome III diagnostic criteria, one third to almost one half of the PD patients had one of the following symptoms: straining, lumpy or hard stool, or incomplete evacuation; this level was higher than the 12.3% reported by Lee et al. in 2016. The high prevalence of constipation among PD patients is believed to be an effect of their dietary restrictions, which limit the consumption of high-fiber foods as these are high in potassium and phosphate., Some studies have found that age might be associated with constipation in PD patients; however, our patients were all in the young to middle-aged groups. Old age might not pay a direct role in developing constipation among PD patients, whereas decreased appetite from depression might be a contributor.
Our finding in this study of no significant association between the prevalence of constipation among diabetic and nondiabetic PD patients is worth mentioning. This result is in contrast to previous studies that established diabetes as one factor for constipation among PD patients.,,
For PD patients who have no concern regarding potassium and phosphorus intake, several studies have shown that the consumption of a high dietary fiber diet and the use of laxatives reduce the occurrence of constipation in PD patients.,, However, in the present study, no relationship was evident between the types of food and constipation among our PD patients. Our previous study done on the general population showed that low dietary intake of fruits and vegetables was significantly associated with constipation, based on Bristol's criteria and self-perception. The prevalence of constipation was not significantly higher among our PD patients who used calcium and iron supplements, in contrast to other studies that reported a significant association between the use of these medications and the increased risk of constipation among PD patients., Various gastrointestinal problems occur among PD patients with a greater intake of pills per day. However, we did not collect data regarding the duration of use and the number of pills of these medications in our study population.
One main limitation of our study is that the data were collected by self-administered questionnaires, which may have affected the accuracy of the responses through subjective bias in answering the questions. Another limitation is the relatively small number of subjects, which may have influenced the power of the statistical tests and the significance of the results. Further study with larger samples is therefore warranted. Dietary studies have limitations. We used a general question to ask about the different types of food without specific details. Knowing that patients on PD have special diet requirements, further study with detailed dietary records is warranted.
| Conclusion|| |
The prevalence of constipation among PD patients seen in this population is comparable to those reported in other studies. However, the findings of the present study did not indicate any significant relationship between the prevalence of constipation among PD patients and their dietary fiber intake, use of calcium and iron supplements, water intake, presence of diabetes and hypertension, or demographic profiles, including age and gender.
We would like to thank Scribendi (https://www.scribendi.com/) for English language editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]