Abnormal Stool Research Articles

467 Human Milk Oligosaccharides Improve All the Central Symptoms of Irritable Bowel Syndrome: A Multi-Center, Open Label Trial

INTRODUCTION: Altered gut microbiota is increasingly seen as a potential factor in irritable bowel syndrome (IBS) pathophysiology. Human milk oligosaccharides (HMOs) have been shown in healthy adults to increase the abundance of bifidobacteria, which are reported to be depleted in IBS. HMOs may also have beneficial impact on gut motility and visceral pain. We conducted a multi-center, open label trial in patients with IBS (Rome IV criteria plus physician diagnosis) to assess the potential for HMOs to support normal bowel habits and improve other bowel symptoms of IBS. METHODS: Subjects were recruited from 17 sites across the United States. The subjects took 5 grams of the HMOs 2'fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) in a 4:1 mix daily by mouth for 12 weeks. Bowel habits, IBS symptoms and quality of life were assessed at baseline and every 4 weeks during the intervention. Results were analyzed with Intention-to-Treat (ITT) methodology (last observation carried forward for non-completers), using repeated measures Analysis of Variance. RESULTS: A total of 317 subjects (70.7% females; mean age 44.0 years, range 18-93 years) received the study product; 136 with constipation predominant, 85 with diarrhea predominant, 95 with mixed, and 1 with unspecified IBS. The full 12-week intervention was completed by 245 subjects. In the ITT analyses, the subjects showed a significant reduction from baseline to 12 weeks in total percentage of abnormal bowel movements (Bristol Stool Form Scale types 1, 2, 6, or 7), overall IBS Symptom Severity Score, abdominal pain severity and bloating severity, as well as improvement in health-related quality of life (see Table 1 and Figures 1 and 2). Most of the symptom improvement occurred in the first 4 weeks of intervention. Younger age was predictive of greater improvement in stool consistency and abdominal pain severity. The study product was well tolerated by most patients. The only common side effects were mild GI symptoms such as abdominal discomfort, distension and flatulence. CONCLUSION: Our findings suggest that oral supplementation with 2'FL and LNnT can provide nutritional support that significantly reduces abnormal stool consistency, abdominal pain and bloating and improves health-related quality of life in IBS sufferers of all subtypes. However, the results from this open label trial need to be followed up by a randomized controlled trial.

Transabdominal Functional Magnetic Stimulation for the Treatment of Constipation in Brain-Injured Patients: A Randomized Controlled Trial.

ObjectiveTo investigate the effects of the transabdominal functional magnetic stimulation (A-FMS) for constipation in stroke or brain-injured patients.MethodsTwenty-four brain-injured patients (11 males and 13 females; median age, 65 years; 22 cases of stroke and 2 cases of traumatic brain injury) with constipation, who were admitted to the rehabilitation department, were enrolled and randomly divided into magnetic stimulation (MS) group and sham stimulation (Sham) group. Several parameters related with constipation such as total and segmental colon transit time (CTT), defecation frequency, and Bristol Stool Scale (BSS) before and after 2 weeks of A-FMS (5 times per week, total 10 times of A-FMS) were evaluated. The Korean version of the Modified Barthel Index (K-MBI) was also evaluated.ResultsA significant decrease in segmental CTT in the left colon (-8.2±3.9 vs. 4.1±2.5 hours; p<0.05 by paired sample t-test) and a significant increase in the frequency of defecation (1.5±0.2 vs 0.7±0.3; p<0.05 by paired sample t-test) were observed in the MS group compared with the Sham group. Stool hardness became significantly softer in the MS group compared with the Sham group (2.3–3.5 in the MS and 2.6–3.1 in the Sham; p<0.05 by chi-square test) as evaluated by BSS. No difference in the K-MBI was observed between the two groups.ConclusionThe present study suggests that A-FMS can be an additional therapeutic tool for managing constipation in brain-injured patients with abnormal bowel movement, defecation frequency, and stool hardness.

Fructus Gardeniae-induced gastrointestinal injury was associated with the inflammatory response mediated by the disturbance of vitamin B6, phenylalanine, arachidonic acid, taurine and hypotaurine metabolism

Ethnopharmacological relevanceFructus Gardenia (FG) is a widely used bitter and cold herb for clearing heat and detoxicating. Currently, toxicity of FG and its relative formula has been reported in many clinical and animal studies. However, no systematic research has been carried out on FG-related gastrointestinal (GI) injury which has been emphasized in China since the Ming Dynasty. Aim of the studyThe purpose of this article is to investigate whether FG could damage GI and explore the mechanisms involved. Material and methodsFG was given to male mice by 7-day intragastric administration at average doses of 0.90 g (L group), 1.50 g (M group), and 3.00 g (H group) crude drug/kg FG. Comprehensive understanding of changes in weight, diarrhea degree, stool routine, histomorphology and inflammatory factors of stomach, small intestine, and colon for evaluating the effect of different doses of FG on GI injury. Moreover, metabolomics-based mechanisms exploration of FG on GI injury was carried out via HPLC-Q-TOF/MS analysis on mice urine. ResultsHigh dose FG caused GI injury with serious diarrhea, decreased weight, abnormal stool routine, sever alteration in histomorphology of small intestine and colon (mild change in stomach), and significant change in inflammatory factors. The results of metabolomics suggested that 55 endogenous metabolites dispersed in 21 significantly altered metabolic pathways in 3.00 g/kg crude FG treated mice. The hub metabolites of GI injury were mainly related with vitamin B6 metabolism, phenylalanine metabolism, arachidonic acid metabolism, and taurine and hypotaurine metabolism via correlated network analysis. ConclusionFG affected the normal functions of GI via the regulating a variety of metabolic pathways to an abnormal state, and our results provided a research paradigm for the GI-injury of the relative bitter and cold traditional Chinese medicines.

Atopic Dermatitis in Adults and Irritable Bowel Syndrome: A Cross-sectional Study.

Background:Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder affecting a large number of people in the world. Atopic dermatitis (AD) is a common inflammatory skin condition characterized by relapsing eczematous lesions in a typical distribution. It was first described in 1933 but exists since antiquity.Aim and Objectives:To determine the relationship between AD and IBS.Materials and Methods:A total of 109 patients with AD and 100 healthy controls were included in the study. They were defined for diagnosis of IBS according to ROME-III diagnostic criteria. Supporting findings, Bristol stool scale, frequency of defecation and history of AD and IBS were also evaluated. AD severity was assessed using Severity Scoring of Atopic Dermatitis index.Results:A total of 62 patients (56.9%) in the AD group and 28 patients (28%) in the control group were diagnosed with IBS (P<0.001). Supportive findings excluding abnormal stool frequency and passage of mucus were more frequent in AD patients. There was no significant relationship between disease severity according to SCORAD index and variables in AD patients.Conclusions:This is a rather uncultivated area in the field of AD. We observed that IBS was more common in AD group. Also, supporting findings like abnormal stool form, abdominal distension, feeling of incomplete evacuation, and straining were found more frequently in AD patients. These results may indicate the association between AD and IBS. In our opinion, patients with atopic dermatitis should be questioned in terms of IBS.

Surgical management of functional constipation: An intermediate report of a new approach using a laparoscopic sigmoid resection combined with malone appendicostomy

IntroductionWe previously reported our surgical technique for functional constipation for patients who have failed medical management using a novel collaborative approach with gastroenterology input, pre-operative contrast enema, colonic manometry, and laxative protocol combined with a laparoscopic colonic resection with Malone appendicostomy. Now we report our intermediate outcomes. MethodsPatients who failed bowel management program for functional constipation were reviewed from 3/2014–2/2017. Patients with Hirschsprung disease, anorectal malformation, tethered cord, spina bifida, Trisomy 21, cerebral palsy, mitochondrial disease, or prior colon resection were excluded. ResultsOf 31 patients (14 females; median age 12years, follow-up 10.3months) with functional constipation and failed medical management, 26 (84%) had preoperative colonic manometry which, in addition to the contrast enema, guided laparoscopic colon resection. Ten patients (32.3%) are clean with no flushes (1 takes no laxatives, 8 are on low dose laxatives only, and 1 patient was clean on laxatives but chose to switch back to flushes). Of the 21 patients that remain on antegrade flushes, 20 (95.2%) are clean, and one patient (4.8%) continues to soil. We define clean as no soiling and no abnormal stool burden on x-ray. Laxative trials are planned for all patients on an antegrade flush regimen. ConclusionOur intermediate results show that laparoscopic colon resection with Malone appendicostomy allows the majority of patients to be clean on antegrade flushes, and some to be on no or minimal laxatives. Type of studyRetrospective review. Level of Evidence3

Functional Dyspepsia Symptoms Are Strongly Associated With Coeliac Disease: Results From a Population-Based Study

Introduction: Coeliac disease (CD) is estimated to affect up to 1 in 100 Australians. Although CD has a wide range of clinical manifestations, patients frequently present with gastrointestinal (GI) symptoms which overlap with functional GI disorders such as irritable bowel syndrome (IBS) or functional dyspepsia (FD).Patients with CD have been shown to experience persistent GI symptoms despite long term treatment with a gluten free diet. Methods: The aim of this study was to define GI symptoms reported in an Australian cohort with a doctor diagnosis of CD and compare with those not reporting CD. A total of 3825 people (mean age 58.4 years, age range 18-100 years and 47.5% males) randomly selected from the Australian population returned a mail survey (Digestive Health & Wellbeing Survey, response rate=45%) which contained questions on whether the participant had ever been told by a physician that they had CD, and GI symptom questions to establish whether they had co-existent functional GI disorders. Adherence to a gluten free diet was not assessed. Prevalence of CD, FD and IBS are reported with 95% exact confidence intervals. The difference between symptoms in CD compared with the unaffected population was tested for significance using a Pearson chi-square test. Results: The prevalence of doctor diagnosed CD was 1.17% in this cohort. Subjects with CD reported significantly higher levels of GI symptoms than unaffected individuals, including abdominal pain associated with abnormal bowel habit, diarrhoea, bloating, distention, epigastric burning and early satiety (see Table 1). There was no significant difference observed in symptoms of post-prandial fullness, nausea, constipation, abnormal stool consistency, or straining with defecation. The prevalence of FD as defined by Rome III criteria in the CD cohort was 37.5% (95% CI 22.7-54.2) compared to 13.9% (95% CI 12.8- 15.1) in the non-affected population (OR 3.7, 95% CI 1.9-7.1, p < 0.001). There was no significant difference in the prevalence of IBS in the affected compared with the non- affected cohort (30.8% versus 22.2%, p=0.2).Table: Table. Gastrointestinal symptoms reported in patients with and without coeliac disease (CD). Items reported as greater than one day per week (*) or greater than or equal to “often” (**)Conclusion: The prevalence of gastrointestinal symptoms and a diagnosis of functional dyspepsia are significantly higher in patients with a doctor diagnosis of CD than in the unaffected population.

Reduced interstitial cells of Cajal and increased intraepithelial lymphocytes are associated with development of small intestinal bacterial overgrowth in post-infectious IBS mouse model

Objective: Intestinal dysmotility and immune activation are likely involved in the pathogenesis of small intestinal bacteria overgrowth (SIBO) in irritable bowel syndrome (IBS). We aimed at investigating the role of interstitial cells of Cajal (ICC) and intestinal inflammation in the development of SIBO using a post-infectious IBS (PI-IBS) mouse model.Materials and methods: NIH mice were randomly infected with Trichinella spiralis. Visceral sensitivity and stool pattern were assessed at 8-weeks post-infection (PI). Intestinal bacteria counts from jejunum and ileum were measured by quantitative real-time PCR to evaluate the presence of SIBO. ICC density, intraepithelial lymphocytes (IELs) counts, and intestinal cytokine levels (IL1-β, IL-6, toll-like receptor-4 (TLR-4), IL-10) in the ileum were examined.Results: PI-IBS mice demonstrated increased visceral sensitivity compared with the control group. One-third of the PI-IBS mice developed SIBO (SIBO+/PI-IBS) and was more likely to have abnormal stool form compared with SIBO negative PI-IBS (SIBO−/PI-IBS) mice but without difference in visceral sensitivity. SIBO+/PI-IBS mice had decreased ICC density and increased IELs counts in the ileum compared with SIBO−/PI-IBS mice. No difference in inflammatory cytokine expression levels were detected among the groups except for increased TLR-4 in PI-IBS mice compared with the control group.Conclusions: Development of SIBO in PI-IBS mice was associated with reduced ICC density and increased IELs counts in the ileum. Our findings support the role of intestinal dysmotility and inflammation in the pathogenesis of SIBO in IBS and may provide potential therapeutic targets.

A Double-Blind Randomized Placebo-Controlled Pilot Study of Azithromycin in Youth with Acute-Onset Obsessive-Compulsive Disorder.

Sudden and severe onset of obsessive-compulsive disorder (OCD) may present secondary to infectious and/or immune-mediated triggers. We assessed the preliminary efficacy, tolerability, and safety of azithromycin compared with placebo in the treatment of OCD and associated symptoms in children with pediatric acute-onset neuropsychiatric syndrome (PANS). Thirty-one youth aged 4-14 years (M = 8.26 ± 2.78 years, 62.5% male) were randomized to receive either placebo or azithromycin for 4 weeks (10 mg/kg up to 500 mg per day). Both groups were administered twice daily probiotics. The primary outcome, obsessive-compulsive symptom severity, was assessed using the OCD Clinical Global Impressions Severity (CGI-S OCD) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Participants in the azithromycin group (n = 17) showed significantly greater reductions in OCD severity on the CGI-S OCD than the placebo group (n = 14) posttreatment (p = 0.003), although there were no significant differences on the CY-BOCS. Significantly more participants in the azithromycin condition met treatment responder criteria on the CGI-I OCD at the end of week 4 (41.2%, n = 7) in comparison to the placebo group (7.1%, n = 1; p = 0.045). Tic severity moderated treatment response, with greater tic severity being associated with enhanced treatment response on the CGI-S OCD. Azithromycin was well tolerated with minimal adverse effects and no study dropouts due to side effects. However, the azithromycin group showed a trend toward significantly greater electrocardiography QTc (p = 0.060) at the end of week 4, and significantly more reports of loose or abnormal stools (p = 0.009). This double blind pilot study suggests that azithromycin may be helpful in treating youth meeting the PANS diagnosis, especially those with elevated levels of both OCD and tic symptoms. Azithromycin was well tolerated, but the potential for cardiac risks suggests that additional monitoring may be needed to ensure safety.

Efficacy and safety of 5-hydroxytryptamine 3 receptor antagonists in irritable bowel syndrome: A systematic review and meta-analysis of randomized controlled trials.

AimWe assessed the efficacy and safety of 5-hydroxytryptamine (5-HT3) receptor antagonists in adults with non-constipated irritable bowel syndrome (IBS) or diarrhea-predominant IBS (IBS-D).MethodsWe searched PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trials Register for randomized controlled trials (RCTs) involving adults with non-constipated IBS or IBS-D that compared 5-HT3 receptor antagonists with placebo or other conventional treatment. Dichotomous symptom data were pooled to obtain the relative risk (RR) and 95% confidence intervals (CIs) for improving global IBS symptoms, abdominal pain and abnormal bowel habits, or stool consistency symptoms after therapy, and adverse events, including constipation. Meta- analysis was performed with Mantel Haenszel method using Revman 5.3 software.ResultsWe included 21 RCTs; 16 were high quality (Jadad score ≥ 4). The pooled RR of global IBS symptoms improved by 5-HT3 receptor antagonists versus placebo or mebeverine was 1.56 (95% CI: 1.43–1.71); alosetron, ramosetron, and cilansetron had similar treatment effects. The pooled RR of abdominal pain relieved by 5-HT3 receptor antagonists versus placebo was 1.33 (95% CI: 1.26–1.39). The pooled RR showed that 5-HT3 receptor antagonists improved abnormal bowel habits or stool consistency symptoms (RR = 1.63, 95% CI: 1.33, 1.99). The pooled RR of adverse events following 5-HT3 receptor antagonist treatment was 1.15 (95% CI: 1.08, 1.22). Subgroup analysis indicated that alosetron had a high rate of adverse effects (RR = 1.16, 95% CI: 1.08, 1.25); adverse events following ramosetron treatment were not statistically significantly different. 5-HT3 receptor antagonists were likelier to cause constipation: the pooled RR of constipation developing with 5-HT3 receptor antagonist versus placebo was 3.71 (95% CI: 2.98–4.61). However, constipation was likelier in patients with non-constipated IBS after taking 5-HT3 receptor antagonists than in patients with IBS-D only (non-constipated IBS and IBS-D: RR = 5.28 [95% CI: 3.93, 7.08] vs. IBS-D only 3.24 [2.54, 4.12]).ConclusionsRamosetron, cilansetron, ondansetron, and alosetron are effective for treating non-constipated IBS and IBS-D. Our systematic review found rare serious adverse events.

Prevalence of fecal incontinence in a cohort of systemic sclerosis patients within a regional referral network.

The prevalence of gastrointestinal involvement in systemic sclerosis is higher than 75%. The estimated prevalence of fecal incontinence varies from 22% to 77%, but suffers from recruitment bias and patient reluctance. Our goal was to evaluate the prevalence of fecal incontinence in systemic sclerosis, and to identify associated risk factors. Patients were recruited in the referral systemic sclerosis network of the Lyon University Hospitals, using self-administered questionnaires including constipation, fecal incontinence and Bristol Stool scales, quality of life, anxiety and depression. The cohort was compared with the historical ORALIA cohort that established the prevalence of fecal incontinence in the general population of the Rhône-Alpes region (France). Seventy-seven patients were included (mean age: 60 years, range: 32-84), and 86% were female. These were compared to 153 ORALIA individuals matched for age and sex. Fecal incontinence was present in 38% of patients and 6% of the general population. A longer duration of systemic sclerosis was the only characteristic associated with fecal incontinence. Abnormal stool consistency was more frequent in patients with fecal incontinence. Fecal incontinence and abnormal stool consistency are common in systemic sclerosis and should be systematically addressed.

Development of the Diary for Irritable Bowel Syndrome Symptoms to Assess Treatment Benefit in Clinical Trials: Foundational Qualitative Research.

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by abdominal pain and alterations in bowel habits. Three subtypes are defined on the basis of stool patterns: diarrhea-predominant IBS, constipation-predominant IBS, and alternating or mixed IBS. To develop patient-reported outcome measures for qualification by the Food and Drug Administration to support product approvals and labeling in IBS; the article focuses on the qualitative research that provided the foundation for the new measures. Forty-nine concept elicitation and 42 cognitive debriefing interviews were conducted with subjects meeting Rome III criteria; additional criteria were imposed to yield a sample representative of the target patient population. Although incomplete bowel movements, abnormal stool frequency and consistency, and abdominal pain, discomfort, and bloating were reported most frequently across concept elicitation interviews, the relative importance of specific symptoms varied by subtype. Among their five symptoms most important to treat, diarrhea-predominant and alternating or mixed IBS subjects frequently identified urgency, loose/watery stools, abdominal pain, and cramping, whereas constipation-predominant IBS subjects commonly included infrequent and incomplete bowel movements, bloating, and abdominal pain. The cognitive debriefing interviews facilitated refinement of each item set, supported minor modifications following translatability assessment, and suggested improvements to the electronic interface. Furthermore, subjects reported that every item was relevant and no concepts of importance were missing. Results support the content validity of the IBS patient-reported outcome measures. A pilot study was recently initiated to inform item reduction, develop scoring algorithms, and provide preliminary psychometric information. Comprehensive psychometric evaluation and responder definition development will follow.

Long-term outcome of neonates with suspected Hirschsprung's disease, but normal rectal biopsy.

Hirschsprung's disease (HD) must always be considered in very early-onset constipation. Although HD has a well-described clinical course, little is known about those neonates in whom HD was excluded. We aimed to describe the long-term clinical outcomes of neonates with a clinical suspicion of HD that was excluded by rectal suction biopsy. This is a single-center double-cohort comparative study. Neonates who underwent rectal mucosa biopsy for suspected HD were age and sex matched with healthy controls. A survey on clinical outcomes, stooling patterns, and other gastrointestinal (GI)-related conditions was sent to parents. Pathology slides were re-reported by an experienced histopathologist blinded to the clinical data. A total of 51 neonates were included [25 cases, 26 controls; 41% males, median time of follow-up 4.25 years (interquartile range 2.7-6.9)]. Nine (36%) of patients in the case group required prolonged laxative use for constipation during the first year of life compared with 0 (0%) controls (P<0.001). This difference was maintained at the end of follow-up, with 5 (20%) versus 0 (0%), respectively (P=0.02). Case neonates were significantly more likely to be hospitalized or to be diagnosed with a chronic GI-related condition than the controls (33 vs. 12%, P=0.01; and 19 vs. 8%, P=0.04, respectively). Neonatal constipation is associated with long-term GI-related disorders and should be considered clinically significant even when the diagnosis of HD is excluded. Neonates with early-onset abnormal stooling patterns should be monitored with adequate pediatrician or pediatric gastroenterologist follow-up.

Screening for Coeliac Disease: Are We Good at It?

Department of Paediatrics, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland Coeliac disease (CD) is an immune reaction to gluten in genetically predisposed subjects. CD is likely to affect approximately 1% of the population of England [1]. The age of presentation is influenced by the age of introduction of gluten into the diet. CD may present as a large variety of non-specific signs and symptoms. Children with CD may experience unexplained poor growth following the introduction of gluten, delay puberty, abnormal stools and constipation. General irritability, chronic abdominal pain, abnormal liver biochemistry, abdominal distension and buttock wasting have been reported. CD should be considered in children presented with iron deficiency anaemia, growth failure with or without gastrointestinal symptoms. Patients with CD may experience low bone mineral density [2], but similar health-related quality of life as their peers without CD [3]. However individuals with CD may exhibit no symptoms. Certain individuals are at an increased risk; such as patients with type 1 diabetes mellitus, Down’s syndrome and Turner’s syndrome, for example, and presymptomatic screening is advised [4]. Diagnosis can be confirmed by flat mucosa on jejunal biopsy followed by the resolution of symptoms and catch up growth upon gluten withdrawal. Diagnostic serological tests have been developed. These’s include IgA anti-tissue transglutaminase (IgA-tTG) and antiendomysium antibody (EMA) values. It is important to measure serum IgA level and IgG-tTG values should be considered in those with low IgA levels. In previous study, biopsyproven CD and positive EMA were reported in 60% of those with elevated IgA-tTG levels above the reference range, whereas biopsy-proven CD was reported in all patients with positive EMA [5]. European Society for Paediatric Gastroenterology, Hepatology and Nutrition working group suggested that typing for HLA-DQ2 and HLA-DQ8 can be helpful where there is uncertain diagnosis of CD; such as cases with negative CD antibodies and mild changes on biopsy or with strong clinical suspicion, highly specific CD antibodies and biopsies are not going to be performed, for example [4]. Monitoring for CD is required in children with unexplained poor growth, delayed puberty or unexplained gastrointestinal symptoms and screening in asymptomatic individuals who are at an increased risk is advised.

Moxibustion for Diarrhea-Predominant Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background. The complementary and alternative medicines in treatment of diarrhea-predominant irritable bowel syndrome (IBS-D) are controversial. Methods. We searched PubMed, Ovid Embase, Web of Science, Cochrane Library databases, CNKI, Wanfang Database, CBM, VIP, and AMED for randomized controlled trials (RCTs) of moxibustion compared with pharmacological medications in patients with IBS-D. A meta-analysis was performed using both fixed and random-effects models based on heterogeneity across studies. Results. In total, 568 patients in 7 randomized controlled trials were randomly treated with moxibustion and pharmacological medications. The improvement of global IBS-D symptoms and overall scores was significant (P = 0.0001 and P < 0.0001, resp.) in patients treated by moxibustion only compared to pharmacological medications. The specific IBS-D symptoms of abdominal pain, abdominal distension, abnormal stool, and defecation frequency were alleviated in patients treated by moxibustion compared to pharmacological medications, but no significance was found except for abdominal distension and defecation frequency (P = 0.03 and P = 0.02, resp.). There were no serious adverse events related to moxibustion. Conclusions. Moxibustion appears to be effective in treating IBS-D compared with pharmacological medications. However, further large, rigorously designed trials are warranted due to insufficient methodological rigor in the included trials.

Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations.

Rater reproducibility of the Bristol Stool Form Scale (BSFS), which categorizes stools into one of seven types, is unknown. We sought to determine reliability and agreement by individual stool type and when responses are categorized by Rome III clinical designation as normal or abnormal (constipation or diarrhea). Thirty-four gastroenterology providers from three institutions rated 35 stool photographs using the BSFS. Twenty rerated the photographs. 1190 individual stool type ratings were completed. Though only four photographs had absolute agreement (all Type 1 or Type 7), general agreement was high with 1132 (95.1%) of ratings being within one category type of the modal rating. Inter-rater and intra-rater reliability of the BSFS by individual stool type was excellent with intraclass correlations of 0.88 (95% CI: 0.86-0.90, p < 0.001) and 0.89 (95% CI: 0.86-0.91, p < 0.001), respectively. However, agreement decreased when using Rome III designations with 13 (37%) photographs having significantly diverging classifications (semi-interquartile range = 0.5). These 13 photographs were rated by the majority of raters as either type 2 vs type 3 or type 5 vs type 6 stools, representing the boundaries of normal vs abnormal stools. Inter-rater and intra-rater reliability of the BSFS by Rome III clinical categorization decreased with intraclass correlations of 0.75 (95% CI: 0.69-0.81, p < 0.001) and 0.65 (95% CI: 0.49-0.81, p < 0.001), respectively. The Bristol Stool Form Scale has excellent reliability and agreement when used to rate individual stool type by raters. However, BSFS reliability and agreement decreases when determining Rome III stool form categories.

Early Impact of Fontan Operation on Enteric Protein Loss

Protein-losing enteropathy (PLE) is a challenging complication after a Fontan operation. Subclinical enteric protein loss may precede development of overt PLE. We evaluated the acute effects of Fontan circulation on enteric protein loss and mesenteric vascular resistance. A prospective cohort study was performed evaluating enteric protein loss in children undergoing Fontan operations. Stool alpha-1 antitrypsin (A1AT) concentration was measured in the preoperative, early postoperative, and intermediate postoperative (3-9 months) periods. The intestinal circulation was characterized by Doppler-derived resistance indices of the superior mesenteric artery (SMA), and serum albumin and protein levels were obtained. We enrolled 33 participants at a median age at operation of 3.0 years (interquartile range [IQR], 2.5-3.3 years). No clinical PLE was observed. Six of the 93 stool samples obtained had elevated A1AT levels (>54 mg/dL), with 2 abnormal samples at each of the 3 time points. Two of the 5 participants with elevated stool A1AT values had significant hemodynamic disturbances requiring intervention (junctional bradycardia or tricuspid stenosis). There was no difference in SMA resistance in the preoperative versus early postoperative periods (p = 0.9). Serum albumin levels were lower in the early postoperative period compared with the preoperative period (3.2 mg/dL [{IQR}, 2.9-3.5] versus 4.1 mg/dL; IQR, 3.4-4.5; p = 0.01) but did not correlate with abnormal stool A1AT concentration or SMA resistance indices. The Fontan operation does not commonly result in acute development of increased enteric protein loss. However, increased enteric protein loss may occur in children before or after a Fontan operation, particularly when hemodynamic disturbances are present.

Recent Trends in the Diagnosis and Management of Biliary Atresia in Developing Countries.

Biliary atresia is a progressive obstructive cholangiopathy and is fatal if left untreated within 2 years of life. Delay in referral is because of difficulties in differentiating it from physiologic jaundice and identifying an abnormal stool color. This paper presents an overview on the diagnosis and discusses the current strategies in the management of this disease in developing countries. Articles were retrieved from the PubMed database using the terms biliary atresia, Kasai portoenterostomy and pediatric liver transplantation. Contents of the article are also based on personal experience of the authors. A national screening program using stool color cards as part of standard care in the neonatal period will greatly improve early detection of biliary atresia. Outcomes will improve if it is diagnosed at the earliest after birth, the child is referred to an experienced pediatric hepatobiliary unit for evaluation, and undergoes an early Kasai procedure. If an early Kasai portoenterostomy is performed, nearly half of all children survive into adolescence, and about one-third are likely to have a long-term, symptom-free life with normal liver biochemistry. Sequential treatment combining Kasai as first line and liver transplantation as second line results in 90% survival for children with biliary atresia.

The Severity of Bowel Dysfunction in Patients with Neurogenic Bladder

Patients with neurological conditions often experience severe debilitating lower urinary and bowel dysfunction in addition to the physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized. This is a cross-sectional analysis of a prospective institutional neurogenic bladder database from 2010 to 2013. Of the 175 patients 60.6% had traumatic spinal cord injury and 18.3% had multiple sclerosis. Median ± SD FISI (Fecal Incontinence Severity Index) scores were 18.0 ± 1.39 (moderate). The median neurogenic bowel dysfunction score was 11.0 ± 0.63 (moderate). Those scores were worse in those patients with spinal cord injury and spina bifida compared to those with other diseases and in younger patients (each p = 0.020), and those in the spinal cord injury group with higher levels of injury (p = 0.0046). Based on the Bristol stool scale 65% of patients had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or neurogenic bowel dysfunction scores correlated significantly with SF-12® quality of life measures. However, bladder symptom scores on M-ISI (Michigan Incontinence Symptom Index) (p = 0.05) and AUA-SI (American Urological Association symptom index) (p = 0.03) correlated with FISI severity while the neurogenic bowel dysfunction score correlated with M-ISI (ρ = 0.29, p= 0.02). Patients with abnormal stool consistency on the Bristol scale reported more urgency and stress incontinence on M-ISI. Bowel dysfunction is common among patients with neurogenic bladder. Those with worse bladder symptoms also experience worse bowel dysfunction. This highlights the importance of addressing both bowel and bladder dysfunction in this often poorly understood population.

MULTIDISCIPLINARY APPROACH TO CHRONIC CONSTIPATION ASSOCIATED WITH FECAL INCONTINENCE IN CHILDREN

Constipation is a common symptom in clinical practice. Definition include abnormal transit difficulty during defecation and abnormal stool consistency. Limited diagnostic methods and the many diseases that lead to symptoms, leading to more cases of drug resistance. Treatment includes dietary and behavioral approaches, pharmacological therapy and surgery in carefully selected cases. Surgery is recommended in patients with severe constipation resistant to conservative treatment. Confirmation of indication for surgical treatment requires colonic transit studies, defecation function and conducting anorectal manometry. Therefore, a close collaboration between pediatric gastroenterologists and surgeon pediatricians is essential for the careful preoperative evaluation and gastrointestinal function. Postoperative complications include intestinal obstruction, abdominal pain, flatulence and diarrhea. The effectiveness of surgery and prevalence of postoperative complications are determined by a careful preoperative evaluation of the gastrointestinal function.

PD10-08 THE NATURAL HISTORY OF NEUROGENIC BLADDER IN ADULTS WITH SEVERE CEREBRAL PALSY

INTRODUCTION AND OBJECTIVES: Patients with neurological conditions often suffer from severe debilitating lower urinary and bowel dysfunction in addition to their physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized. The primary aim in this study was to determine the level of severity and impact on quality of life of bowel dysfunction in a population with neurogenic bladder using validated surveys and to determine those patient variables that correlate with worse bowel symptoms. Our second aim was to determine if the severity of bowel dysfunction correlates with the severity of bladder dysfunction. METHODS: This is a cross-sectional analysis of a prospective institutional Neurogenic Bladder Database from 2010e2013. RESULTS: Among the 175 patients 60.6% had traumatic SCI and 18.3% MS. Fecal Incontinence Severity Index (FISI) scores were a median of 18.0 1.39 (moderate). Neurogenic Bowel Dysfunction (NBD) score, which is specific to patients with neurological disease, were a median of 11.0 0.63 (moderate). NBD Scores were worse in those patients with SCI and myelomeningocele compared to other diseases (P1⁄40.020), in younger patients (p1⁄40.020) and in the SCI group those with higher levels of injury (p1⁄40.0046). Based on the Bristol stool scale 65% of patient had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or NBD scores correlated significantly with SF12 quality of life measures. None of the urodynamic findings correlated with any of the bowel symptom scores. However, both of the bladder symptom scores Michigan Incontinence Symptom Index (MISI)(p1⁄40.05) and the AUA-SI (p1⁄40.03) correlated with FISI severity and the NBD score correlated with the M-ISI (~ n1⁄40.29, p1⁄40.02). Those patients with abnormal stool consistency on the Bristol reported more urgency and stress incontinence on M-ISI. CONCLUSIONS: Bowel dysfunction is very common among patients with neurogenic bladder. Those patients with worse bladder symptoms also suffered from worse bowel dysfunction although the severity of bowel dysfunction did not correlate with overall quality of life or urodynamic measures.