Natural Ways to Treat GERD
Gastroesophageal reflux (chalasia, cardiochalasia) is the return of gastric contents into the esophagus and possibly the pharynx. It is caused by dysfunction of the cardiac sphincter at the esophagus-stomach juncture. Reasons for this incompetence include an increase of pressure on the lower esophageal sphincter following esophageal surgery or immature lower esophageal neuromuscular function. The result of the persistent reflux is inflammation, esophagitis, and bleeding causing possible anemia and damage to the structure of the esophagus as scarring occurs. It also may predispose to aspiration of stomach contents causing aspiration pneumonia and chronic pulmonary conditions. Most commonly affected are infants and young children. As the condition becomes more severe or does not respond to medical treatment and the child experiences failure to thrive, surgical fundoplication to create a valve mechanism or other procedures may be done to correct the condition.
Gastroesophageal reflux (GER) has been suggested as another important factor contributing to rhinosinusitis in some children.45-47 This concept is based on the theory that there is reflux into the nasopharynx, and that when low pH gastric contents contact upper respiratory mucosa, edema and irritation result, potentially leading first to obstruction of the eustachian tubes or sinus ostia, and eventually to rhinosinusitis. Most children do not exhibit typical GER symptoms such as heartburn or regurgitation, however in these cases, the history is often not suggestive of the condition.
Ambulatory pH monitoring, using glass or antimony electrodes with either combined or external reference electrodes. For a 24-hour monitoring period, the exposure of oesophageal mucosa to a pH less than 4 for more than 5 of the duration of the test indicates pathological acid reflux.
Gastroesophageal reflux disease (GERD) is a syndrome that is caused by esophageal reflux, or the backward flow of gastroesophageal contents into the esophagus. Approximately 7 of the U.S. population has symptoms of heartburn each day. GERD occurs because of inappropriate relaxation of the lower esophageal sphincter (LES) in response to an unknown stimulus. Reflux occurs in most adults, but if it occurs regularly, the esophagus cannot resist the irritating effects of gastric acid and pepsin because the mucosal barrier of the esophagus breaks down. Without this protection, tissue injury, inflammation, hyperemia, and even erosion occur. Barrett esophagus is a condition thought to be caused by the chronic reflux of gastric acid into the esophagus. It occurs when squamous epithelium of the esophagus is replaced by intestinal columnar epithelium, a situation that may lead to adenocarcinoma. Barrett esophagus is present in approximately 10 to 15 of patients with GERD.
Spasticity of muscles, or brain injury Dyspepsia Impairment of gastric function upset stomach Dysphagia Difficulty in swallowing Dysphonia Altered voice production Dyspnea Shortness of breath, difficulty in breathing Ecchymosis Purplish patch extending more than 3 mm across the skin
Achalasia hypertensive lower esophageal sphincter (LES), ingbr'nplete relaxation of LES, and loss or derangement of peristalsis. Achalasia is usually idi opathic but may be secondary to Chagas' disease (South America). Patients have intermittent dysphagia for solids and liquids with no heartburn. Barium swallow reveals dilated esophagus with distal bird-beak narrowing. Diagnosis can be made with esophageal manometry. Treat with calcium channel blockers, pneumatic balloon dilatation, and, as a last resort, surgery (myotomy). 3. Scleroderma may cause aperistalsis due to fibrosis and atrophy of smooth .muscle. Lower LES becomes incompetent, and patients may develop GERD. Look for positive antinuclear antibody and mask-like fades, other autoimmune symptoms (CREST calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias). 4. Barrett's esophagus columnar metaplasia due to acid reflux must be followed with periodic endoscopy and biopsies to rule out...
Ammi is cultivated in Mediterranean countries, Southwest Asia, the Indian subcontinent, and Northeast Africa. In Ethiopia, its aromatic fruits are sold in most markets. Local lore suggests that ammi reduces the pungency of chili peppers (also much used in Ethiopian cooking). In India, the fruit is a characteristic spice in curries and in pickles and beverages. Indians also use ammi as a household remedy for indigestion, often recommend it against cholera, and include it in many cough mixtures. The oil in the fruits, extracted by steam distillation, contains about fifty percent thymol, which is a powerful antiseptic and is used against fungal infections of the skin and in
Dill is native to the Mediterranean and west Asia, where both leaves and fruit have long been used. Dill was present in Late Neolithic lake settlements in Switzerland, 7th century bc Samos, and the tomb of Amenophis II in Egypt. It figures in Theophrastus' Inquiry into Plants and Apicius' recipes. In the Middle Ages, burned dill seeds placed on wounds reputedly speeded healing. Dill was also used for indigestion and insomnia. It has been cultivated in England since 1570, but grown commercially in the United States only from the early 19th century. It is an ingredient of curry powder.
Dried rhizomes and roots of a legume, Glycyrrhiza glabra, distributed from Europe to western Asia and North Africa, are the source of licorice, used to flavor tobacco and confectionery. In India, licorice is chewed with betel nut. Medicinally, it has been valued against indigestion. Derivatives of licorice have been used to treat stomach ulcers. Spanish (including Italian and Greek) licorice is considered the best quality. Lower quality Oriental licorice is cultivated in the Middle East, the Caucasus, and north China. In the United States, roots from different regions are blended to make various brands of licorice extract.
Heartburn is another symptom of esophageal disorders. This burning pain rises in the chest and can be felt in the neck, throat, or face. Heartburn usually occurs after meals, after taking certain medications, or while lying down. Some people also may feel a burning pain or tightness when swallowing solids or liquids. Heartburn can indicate a problem with a medication or with the lower esophageal sphincter, the muscular valve that prevents stomach acid from rising up into the esophagus. (Heartburn also may be a symptom of coronary artery disease see page 204.) Gastroesophageal Reflux Disease The most common disorder of the esophagus is gastroesophageal reflux disease (GERD). In GERD, the muscle at the bottom of the esophagus, the lower esophageal sphincter, does not close completely, allowing stomach acids and other irritants to flow backward (reflux) into the esophagus. Certain medications can interfere with the action of this muscle, including nitrates, calcium channel blockers,...
Omeprazole (p. 167) can cause maximal inhibition of HCl secretion. Given orally in gastric juice-resistant capsules, it reaches parietal cells via the blood. In the acidic milieu of the mucosa, an active metabolite is formed and binds co-valently to the ATP-driven proton pump (H+ K+ ATPase) that transports H+ in exchange for K+ into the gastric juice. Lansoprazole and pantoprazole produce analogous effects. The proton pump inhibitors are first-line drugs for the treatment of gastroesophageal reflux disease.
Special Concerns Use with care during lactation. Safety and efficacy have not been determined in children less than 12 years of age. Side Effects CNS Drowsiness, fatigue. GI Nausea, dyspepsia. Miscellaneous Viral infection (flu, colds), dysmenorrhea, sinusitis, throat irritation.
Additional Side Effects CV Vasodilation, pallor. Oral Dry mouth, stomatitis. GI GI pain, peptic ulcers, nausea, dyspepsia, flatulence, GI fullness, excessive thirst, GI bleeding (higher risk in geriatric clients), perforation. CNS Headache, nervousness, abnormal thinking, depression, euphoria. Hypersensitivity Bronchospasm, anaphylaxis. Miscellaneous Purpura, asthma, abnormal vision, abnormal liver function.
Constipation is commonly defined as the paucity of bowel movements. However, patients may have constipation regardless of the number of bowel movements in a unit of time. The inability to satisfactorily evacuate one's colon and rectum can be manifested by different degrees of abdominal discomfort associated with normal bowel habits, infrequent stools, or even overflow diarrhea. In addition, many other abdominal complaints are related to constipation, including pain syndromes, bloating, fullness, and even heartburn and dyspepsia.
Dosages of up to 30 mg rhDNase I per day were well tolerated in healthy volunteers and CF patients 69,87 . Severe bronchospasms or anaphylactic reactions, as seen after inhalation of bovine DNase I, have never been observed with rhDNase I. The most common adverse effects reported after daily inhalation of 2.5 mg rhDNase I were voice alterations (hoarseness), pharyngitis, rash, laryngitis, and conjunctivitis 74,76,78 . All these events are generally mild and transient. In patients with severe pulmonary disease (FVC 40 ), rhinitis, fever, dyspepsia, dyspnea, and an FVC decrease of 10 have also been reported 76,88 . Facial edema has been reported to an exceptional degree in patients receiving 2.5 or 10 mg rhDNase I twice daily 70 . It has also been shown that rhDNase I may increase airway inflammation by releasing elastase and proinflammatory cytokines that are bound to DNA in the airway secretions 89-91 . However, other studies did not confirm this observation 92-94 . Antibodies against...
Cyclosporiasis is a 'flu-like illness, and diarrhoea with weight loss, low-grade fever, fatigue, anorexia, nausea, vomiting, dyspepsia, abdominal pain and bloating have been described as symptoms (Ortega et al., 1993 Huang et al., 1995 Fleming et al., 1998). The incubation period is between 2 and 11 days (Soave, 1996) with moderate numbers of unsporulated oocysts being excreted for up to 60 days or more. In immunocompetent individuals the symptoms are self-limiting and oocyst excretion is associated with clinical illness, whereas in immunocompromised individuals diarrhoea may be prolonged. The self-limiting watery diarrhoea can be explosive, but leukocytes and erythrocytes are usually absent. Often, diarrhoea can last longer than 6 weeks in immunocompetent individuals. The diarrhoeal syndrome may be characterised by remittent periods of constipation or normal bowel movements (Ortega et al., 1993). Malabsorption with abnormal D-xylose levels has also been reported (Connor et al., 1993).
All meta-analyses should be conducted in the context of a systematic review and should analyse all appropriate data in order to reduce bias. Although many papers published in the medical literature are described as meta-analyses, such projects are not all of a similar design, quality or validity. Although, there is a continuum in the effort that can be invested in ensuring that a meta-analysis is systematic and comprehensive, there are three broad types of data that can be obtained. Information can be extracted from published reports, summary data canbecollectedfromtrialists, or individual patient data (IPD) can be obtained from trialists. These IPD projects involve the central collection, validation and re-analysis of, usually updated, 'raw' data, from all clinical trials, worldwide, that have addressed a common research question obtained from those responsible for the original trials 13 . Although they are less common than other types of review, they are becoming increasingly used...
The major unmet medical need in the field of prokinetic agents has resulted from the withdrawal of cisapride due to issues with QT prolongation. Cisapride had gained widespread use, primarily for the treatment of GERD, but also in the treatment of a wide range of GI disorders including ileus, functional dyspepsia, constipation, and IBS, thus leaving a gap in the pharmacopoeia. The need for a prokinetic agent continues, with a corresponding increased use of metoclopramide, although the adverse events associated with this agent, primarily dyskinesias, are considered unacceptable for most patients. Cholinergic modulators are not sufficiently tolerated for chronic use in outpatients and the efficacy of both motilin and DA receptor agonists have so far failed to convince the clinical community of their usefulness. The opportunity for a safe and effective prokinetic agents remains in the treatment of GERD, postoperative ileus, constipation, and potentially dyspepsia and IBS.
In the prokinetic arena, the void left by the withdrawal from the market of cisapride has yet to be filled. There is still some confusion over whether the beneficial prokinetic effects of cisapride resulted wholly from activity at the 5HT4 receptor and only the successful development of a selective 5HT4 receptor agonist will allow that question to be fully answered. Since the withdrawal of cisapride, the treatment of GERD has been refined, with proton pump inhibitors becoming the standard of care. These drugs offer high levels of symptom relief in many patients and thus the clinical usefulness of the next generation of prokinetic drugs will need to be established within this context. The projected rise in the number of patients with diabetes suggests that diabetic gastroparesis could also substantially increase, offering another opportunity for prokinetic agents to bring benefit to patients (see 6.19 Diabetes Syndrome X). Jeremy D Gale is a drug developer with 17 years experience in...
Adults 150 mg b.i.d. for active ulcer. Maintenance 150 mg at bedtime Gastroesophageal reflux disease. Adults 150 mg b.i.d. Treatment and maintenance for duodenal ulcer, hypersecretory conditions, gastroesophageal reflux. Adults, IM 50 mg q 6-8 hr. Intermittent IV injection or infusion 50 mg q 6-8 hr, not to exceed 400 mg day. Continuous IV infusion 6.25 mg hr.
Uses Prevention of disseminated Mycobacterium avium complex (MAC) disease in clients with advanced HIV infection. Contraindications Hypersensitiv-ity to rifabutin or other rifamycins (e.g., rifampin). Use in clients with active tuberculosis. Lactation. Special Concerns Safety and efficacy have not been determined in children, although the drug has been used in HIV-positive children. Side Effects Oral Taste perversion, discolored saliva (brownish-orange). GI Anorexia, abdominal pain, diarrhea, dyspepsia, eructation, flatulence, N&V. Respiratory Chest pain, chest pressure or pain with dyspnea. CNS Insomnia, seizures, paresthesia, aphasia, confusion. Musculoskeletal Asthenia, myalgia, arthralgia, myo-sitis. Body as a whole Fever, headache, generalized pain, flu-like syndrome. Dermatologic Rash, skin discoloration. Hematologic Neutro-penia, leukopenia, anemia, eosino-philia, thrombocytopenia. Miscella
Most cases are mild, no treatment is necessary, and the stridor gradually fades, resolving completely by about age 2. However, 10 of cases are severe with failure to thrive (and often associated gastroesophageal reflux). In these patients an endoscopic aryepiglottoplasty may be required to release the epiglottis and reduce the aryepiglottic folds. Most cases are mild, no treatment is necessary, and the stridor gradually fades, resolving completely by about age 2. However, 10 of cases are severe with failure to thrive (and often associated gastroesophageal reflux). In these patients an endoscopic aryepiglottoplasty may be required to release the epiglottis and reduce the aryepiglottic folds.
Stepwise Summary of Assessment Management and Management of Uncomplicated Chronic Pediatric Rhinosinusitis
Step 2 Evaluation for predisposing factors and concomitant diseases, with treatment of positive findings Allergy atopy Immune deficiency Cystic fibrosis Ciliary dyskinesia Enviromnent (smoking, day care) Gastroesophageal reflux 45. Hamilos D. Gastroesophageal reflux and sinusitis in asthma. Chin Chest Med 1995 16 683-697 47. Barbero G. Gastroesophageal reflux and upper airway disease a commentary. Otolaryngol Clin North Am 1996 29 27-38
Antisecretory compounds are used for the long-term treatment of GERD, a chronic disorder of the esophagus that results a decrease of the low esophageal sphincter (LES) barrier tone, leading to acid reflux, epithelial erosion, ulceration, and, sometimes, hyperplasia accompanied by inflammation. The introduction of endoscopes and ambulatory devices for the monitoring of esophageal pH has led to an improved diagnosis of GERD and its complications. Prokinetics and antacids are also used currently, but these therapies, although effective, do not influence the underlying causes of the disease. GERD is not sensitive to the eradication of H. pylori, and is highly prevalent in the population (8-10 in USA).10 New approaches to GERD include endoscopic suturing devices to tighten the LES, endoscopic submucosal implantation of gelatinous microspheres in the lower esophagus, and radiofrequency energy delivery to the LES, but larger controlled trials with long-term follow-up are needed to establish...
Toxicological animal studies have been published on ALN, clodronate, etidronate, incadronate, pamidronate, and tiludronate. When bisphosphonates are administered subcutaneously, local toxicity can occur, with local inflammation and necrosis. This is especially the case for the N-BPs. Clinical evidence of upper gastrointestinal irritation is observed in some patients.115,116 The risk of this problem is reduced through dosing instructions designed to avoid both esophageal tablet retention and reflux of acidic stomach contents in patients with gastroesophageal reflux disease (GERD). Moreover, all oral bisphosphonate products are soluble salts rather than less soluble free acids. erosions. These effects were not attributable to changes in gastric acid secretion, or prostaglandin synthesis, but are thought to be due to a topical irritant effect. No esophageal or gastrointestinal effects are observed with intravenously administered bisphosphonates. From analyses in dogs, the pH of the BP...
Diabetic ketoacidosis, with or without coma. Type 1 diabetes. Special Concerns Use with caution in impaired hepatic function. Safety and efficacy have not been determined in children. Side Effects CV Chest pain, angina, ischemia. GI Nausea, diarrhea, constipation, vomiting, dyspepsia. Respiratory URI, sinusitis, rhinitis, bronchitis. Musculoskeletal Arthralgia, back pain. Miscellaneous Hypoglyce-mia, headache, paresthesia, chest pain, urinary tract infection, tooth disorder, allergy.
Almost everyone has experienced indigestion (also known as an upset stomach or dyspepsia). This painful, burning sensation in the upper abdomen is often accompanied by nausea, bloating, belching, and sometimes vomiting. Indigestion is usually a symptom of a digestive disorder, such as an ulcer. However, some people have persistent indigestion that has no identifiable cause this is called functional indigestion or nonulcer indigestion. Smoking, drinking too much alcohol, taking certain medications, or being exhausted or stressed can cause or worsen indigestion. If you frequently experience indigestion, see your doctor so that he or she can examine you, determine the cause of your symptoms, and provide treatment. Contact your doctor promptly if your indigestion is accompanied by vomiting, weight loss, lack of appetite, blood in vomit or stool, pain when you eat, or severe pain in the upper abdomen. Symptoms of indigestion accompanied by shortness of breath, sweating, or pain radiating...
5HT4 receptors are located on the enteric nervous system within the GI tract of humans and a number of animal species. Activation of these receptors with agonists evokes the release of excitatory and inhibitory neurotransmitters, with the net result of increasing motility and orthograde peristalsis in the GI tract. The first 5HT4 receptor agonist prokinetic, metoclopramide (5), was adopted for clinical use before the target receptor had been characterized and the molecular mechanism of action of metoclopramide was disputed. Metoclopramide has moderate affinity and potency at the 5HT4 receptor in vitro and has prokinetic activity in models of gastric emptying. For example, in a rat model metoclopramide increased gastric emptying dose-dependently following oral dosing.6 The mechanism of action of metoclopramide to increase gastric emptying was proposed as the enhancement of acetylcholine release, but this was the subject of controversy. Furthermore, the precise molecular target for...
Pain related to esophageal reflux and esophageal inflammation 370 Gastroesophageal Reflux Disease (GERD) Although diet therapy alone can manage symptoms in some patients, most patients can have their GERD managed pharmacologically. Dietary modifications that may decrease symptoms include reducing intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, and peppermint. Reducing the intake of spicy and acidic foods lets esophageal healing occur during times of acute inflammation. Encourage the patient to eat five to six small meals during the day rather than large meals. Ingestion of large amounts of food increases gastric pressure and thereby increases esophageal reflux. Both weight loss and smoking cessation programs are also important for any patients who have problems with obesity and tobacco use.
The term 'acute abdomen' defines a clinical syndrome characterized by a history of hitherto undiagnosed abdominal pain lasting less than one week. A large number of disorders, ranging from benign, self-limited diseases to conditions that require immediate surgery, can cause acute abdominal pain. Eight conditions account for over 90 of patients who are referred to hospital and are seen on surgical wards with acute abdominal pain acute appendicitis, acute cholecystitis, small bowel obstruction, urinary colic, perforated peptic ulcer, acute pancreatitis, acute diverticular disease, and non-specific, non-surgical abdominal pain ('dyspepsia', 'constipation').
The only effective therapy for sphincter dysfunctions, except those secondary to a curable underlying disease, is myotomy of the sphincter. Here, cineradiographic examination serves not only to diagnose the dysfunction, but also to establish indications for and contraindications against myotomy. A good result after surgery can only be expected if pharyngeal propulsion of the bolus is not severly impaired. In severe gastroesophageal reflux, myotomy is contraindicated as the pharyngoe-sophageal sphincter is the last barrier against reflux into the pharynx and aspiration of gastric contents. Zenker's diverticula invariably have their origin within Killian's triangle, between the pharyngoesophageal sphincter and the pharyngeal constrictor muscles. They are very frequently associated with dysfunctions of the sphincter, mostly with premature closure. Although the transition from a mere dysfunction of the sphincter into the formation of a diverticulum has not yet been demonstrated in a...
GI Abdominal pain, nausea, dyspepsia, constipation, diarrhea, flatulence, acid regurgitation, esoph-ageal ulcer, vomiting, dysphagia, abdominal distention, gastritis. Miscellaneous Musculoskeletal pain, headache, rash and erythema (rare). Drug Interactions Antacids l Absorption of alendro-nate
Muscles tighten as stress starts, often causing intense headaches, backaches, and gastrointestinal problems. Stress also can cause testosterone levels to decrease and blood vessels in the penis to constrict, often resulting in erection problems. The rush of hormones caused by a stressful situation can bring on an asthma attack in a person with a history of asthma. Stress also draws the blood supply away from the abdominal area and encourages overproduction of acids in the digestive system, often leading to indigestion and other gastrointestinal problems. Other problems related to stress include insomnia and irritability.
Esophageal carcinoma typically occurs in the sixth or seventh decades of life with a history of excessive use of tobacco and alcohol is common. Symptoms from esophageal carcinoma may be of insidious onset, beginning as nonspecific retrosternal discomfort or indigestion. As the tumor enlarges, symptoms progress with weight loss, odynophagia, chest pain, and occasionally hematemesis. Dysphagia is the presenting complaint in 80 to 90 of patients with esophageal carcinoma. Any adult who complains of progressive dysphagia warrants both a barium esophagogram and esophagoscopy to rule out carcinoma.
Gastroesophageal reflux has been identified as an important factor in many inflammatory and neoplastic disorders of the aerodigestive tract. Although no definitive studies have shown a correlation between reflux and fistulization, Seikaly and Park6 showed a decreased rate of fistulae formation in patients treated with a postoperative antireflux regimen. We routinely maintain intravenous H2 blocking agents until gastric feeding can be started via tube feeds.
Special Concerns Use with caution, if at all, during lactation. Give a lower initial dose in liver impairment. Safety and efficacy have not been determined in children less than 2 years of age. Side Effects Most commonly, headache, somnolence, fatigue, and dry mouth. GI Altered salivation, gastritis, dyspepsia, stomatitis, tooth ache, thirst, altered taste, flatulence. CNS Hypoesthesia, hyperkinesia, migraine, anxiety, depression, agitation, paroniria, amnesia, impaired concentration. Ophthalmologic Altered lacrimation, conjunctivitis, blurred vision, eye pain, blepharo-spasm. Respiratory Upper respiratory infection, epistaxis, pharyngitis, dyspnea, coughing, rhinitis, sinusitis, sneezing, bronchitis, bronchospasm, hemoptysis, laryngitis. Body as a whole Asthenia, increased sweating, flushing, malaise, rigors, fever, dry skin, aggravated allergy, pruritus, purpura. Musculoskeletal Back chest pain, leg cramps, arthralgia, myalgia. GU Breast pain, menorrha-gia, dysmenorrhea, vaginitis....
Gastroesophageal reflux disease (GERD) can be associated with chronic sinusitis.21 The incidence of GERD in children is unknown, but Barbero21 is convinced that it is present in most patients. There is a paucity of information on the subject in the literature. Over the past 4 years, only 14 articles in the literature have associated gastroesophageal reflux and sinusitis in their titles or abstracts. Most of these articles have concentrated on airway disease as the primary manifestation of reflux. Clearly, there are cases of patients with sinusitis and GERD, and treatment of the GERD is associated with improvement in their sinus symptoms. In our experience to date, it is not frequent and usually associated with additional symptoms such as cough or airway disease. Because both sinusitis and GERD can be associated with chronic cough, it is very difficult to differentiate between the two. The disease should diagnosed with a 24-hour pH probe study. If present, therapy should consist of a...
Not only sleeping and waking but also many other bodily functions, including cardiovascular and respiratory function, hormone secretion, mitosis rate, intracranial pressure, and atten-tiveness, follow a circadian pattern (chronobi- ology). Circadian variation in performance is im- portant in the workplace and elsewhere. Some diseases are associated with certain times of the day (chronopathology)-certain types of epileptic seizures, asthma, cluster headache, gastro-esophageal reflux disease, myocardial infarction, vertricular tachycardia.
Be undertaken in order to optimize management. In addition to performing continuous pulse oximetry and serial polysomnography (as necessary),4 a full endoscopic evaluation of the upper aerodigestive system should be considered, to rule out other possible treatable causes of obstruction.1 An evaluation for gastroesophageal reflux disease (GERD) may be appropriate, as GERD may worsen known airway compromise. Children with retrognathia are at risk of GERD because of the increased negative intrathoracic pressure often found in this population of children. Both a pH probe and a gastric emptying scan should be obtained to quantify any potential problems.4
In a study comparing symptoms with physiologic findings, Glia et al34 evaluated 134 patients with symptom registration, anorectal manome-try, electromyography, colonic transit time measurement, and defecography. In this study, three symptoms had an independent value for the diagnosis of slow-transit constipation infrequent evacuation (
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