Changes In Bowel Movements Research Articles

The prevalence and clinical characteristics of atopic manifestations in patients with irritable bowel syndrome in a Brazilian urban community

Irritable bowel syndrome (IBS) is a common chronic disorder characterized by recurrent abdominal pain, bowel movement changes, diarrhea, constipation, or both and affect approximately 10-20% of the general population. Today, IBS is considered a disorder of dysregulation of the so called brain-gut axis and evidence also suggests that gastrointestinal inflammation may be of great importance in the majority of cases of IBS. In addition to gastrointestinal symptoms, many patients have atopic symptoms. The aim of this study was to study the prevalence of atopic manifestations in volunteers with IBS in a Brazilian urban community. Volunteers over 18 years of age were enrolled and evaluated. The participants were evaluated by a gastroenterologist of the Group of Study of Intestinal Diseases at Hospital Universitario Antonio Pedro. All volunteers were evaluated to determine if patients had symptoms compatible with the diagnosis of IBS based on Rome III criteria. The identification of the atopic manifestations was based in a structured questionnaire for atopy. Three hundred and fifty volunteers were enrolled. Of them, 330 volunteers were evaluated: 78 (23.6%) of the volunteers had symptoms compatible with IBS (Group I) and 252 (76.3%) without symptoms compatible with IBS (Group II). Atopic manifestations were present in 46 (65.3%) in Group I and 105 (41. 0%) in Group II (P=0.0107, OR-2.01 95%CI -1. 20-3. 37). The association between atopic manifestations and the presence of IBS was relevant in patients in this Brazilian urban community. This fact may have implications for diagnosis and treatment of patients with IBS.

Solitary Fibrous Tumor Originating in the Pelvis: A Case Report

A 52 year old male presented with changes in bowel movements, and a mass was detected on digital rectal exam. Both CT and MRI revealed a large pelvic and gluteal mass filling the pelvic cavity displacing the adjacent pelvic structures. After surgical removal, pathology revealed solitary fibrous tumor; a rare neoplasm uncommonly discovered in the thorax, and even less commonly in extrapleural locations. We discuss in this article imaging findings and histological features of extrapleural solitary fibrous tumor.

A Retrospective Chart Review Investigating the Use of Colonoscopy in the Elderly

Purpose: Currently, there are no guidelines regarding colonoscopy in the elderly population, excluding cancer screening. There is conflicting data regarding the use of colonoscopy in patients over the age of 80. There exists a significant population in the elderly undergoing colonoscopy for screening, fecal occult blood positive results, hematochezia, and change in bowel habits. Methods: A retrospective chart review from 11/01/04 to 10/13/06 was performed on all patients who underwent a colonoscopy at a community hospital. Patient age, sex, indication for colonoscopy, adverse events during the procedure, findings during colonoscopy, and results of biopsy or polypectomy, if completed, were all documented. A colonoscopy performed for a screening exam, fecal occult blood positive, hematochezia, and change in bowel habits were included. Results: A total of 173 colonoscopic examinations took place that met the strict inclusion/exclusion criteria of the study. Four adverse events occurred in our study population. Two colonic perforations and two events of aspiration occurred. Additionally, seven patients had incomplete exams due to a poor colon preparation. Of the 173 examinations, only 1 examination revealed a malignant process. This malignancy was found in a patient with change in bowel movements. No malignant lesions were found in the hematochezia and screening population of the study. Conclusion: Colonoscopy in patients over the age of 80 demonstrated minimal diagnostic yield. Colonoscopy itself does carry risk of adverse events that must be considered, especially when diagnostic yield is extremely minimal. Further research is necessary to establish guidelinesTable: Colonoscopy in the Elderly.

Electronic Clinical Challenges and Images in GI

Question: A 45-year-old woman presented with acute right upper abdominal pain, diaphoresis, and nausea. Physical examination revealed abdominal guarding and a palpable mass below the right costal arch. No fever or change in bowel movements was present. Her only medication was oral contraception. The patient had had similar attacks of abdominal pain several times before, which resolved spontaneously. Laboratory exam revealed slightly elevated liver enzymes (aspartate aminotransferase, 67 U/L [normal range, 35]; alanine aminotransferase, 95 U/L [normal ange, 34]), and normal complete blood count, bilirubin, and lipase; no anemia was present. Abdominal contrast-enhanced computer omography (CT) showed an encapsulated, hypodense, hypoperfused mass (10 15 cm) below the liver (Figure A, B, white arrows) with the allbladder situated posteriorly from the tumor (Figure A , C, long black arrow). At the liver/tumor interface in segment V close to the liver hilum, helical formation of arteries (“swirl sign”) was seen, fed by the cystic artery and branches arising from the segment V of the liver (Figure C, white mall arrow). Nearby, another well-perfused, small tumor was present (Figure C, small black arrow). After receiving pain medication, her symptoms esolved, and abdominal magnetic resonance imaging (MRI) of the upper abdomen was performed on the same day with hepatocyte-specific ontrast material (gadoxetic acid; Primovist or Eovist; Bayer Schering Pharma) to further characterize the hepatic masses. In contrast to CT, there as a multinodular hyperperfusion without a “swirl” of arteries. During the hepatobiliary phase, both masses did not demonstrate specific epatocellular contrast accumulation (Figure D–F; white arrows and small black arrow). This time, the gallbladder was located anteriorly and showed ontrast filling in the hepatobiliary phase proving the patency of the cystic duct (Figure F, long black arrow). What is the most likely diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Pneumoperitoneum Complicating Peritoneal Dialysis Catheter

A 55-year-old male presented with progressively worsening nausea over a one-year period. It began when he started peritoneal dialysis for end-stage renal disease. His nausea progressed to the point that he could not tolerate oral intake. He also had difficulty with exchanges, but the exchange fluid was clear. He denied any fever, chills, abdominal pain, change in bowel movements, hematochezia, or hematemesis. The physical exam was unremarkable except for mild discomfort in the right lower quadrant. The peritoneal dialysis catheter was intact and appeared to be clean. The laboratory exam showed a normal white cell count and a negative peritoneal fluid culture. A KUB showed a large amount of free intra-peritoneal air. Further questioning of the patient revealed improper use of the peritoneal dialysis system as a cause of the pneumoperitoneum. The prevalence and clinical significance of pneumoperitoneum in peritoneal dialysis (PD) patients is not defined fully in the current literature. Some reports suggested that, unlike in nonPD patients, it rarely is caused by gastrointestinal perforation. 1 Intestinal perforation can be ruled out by rapid clinical improvement with standard therapy, growth of Staphylococcus epidermidis in the peritoneal effluent culture, reduction of pneumoperitoneum after correction of the technical fault, and in contrast to the Gram-negatives and/or anaerobes usually found during bowel perforation. 2-3

A Preliminary Evaluation of the Safety and Tolerance of Medicinally Ingested Vinegar in Individuals with Type 2 Diabetes

Vinegar (VIN) ingestion at mealtime reduces postprandial glycemia and may benefit individuals with diabetes; hence, the medicinal use of VIN has increased in recent years. This study examined the safety and tolerance of medicinally ingested VIN in type 2 diabetics. Participants (n = 27) were stratified by gender, age, and body mass and randomized into three groups: commercial VIN pills (the reference treatment [REF] (30 mg of acetic acid daily), pickles (PCK) (approximately 1,400 mg of acetic acid daily), or VIN (2,800 mg of acetic acid daily). Participants continued their normal eating habits during the 12-week trial. At baseline and weeks 6 and 12, fasting blood and urine samples were collected, and adverse changes in bowel movements, frequency of burping or flatulence, and episodes of acid reflux were recorded. Reporting frequency for adverse events did not vary significantly by group during the trial; however, 50-56% of PCK and VIN participants reported at least one treatment-emergent adverse event at week 6 as compared to 11% of REF participants (P = .110). Urinary pH was significantly reduced in VIN participants at week 12 as compared to the other groups (-9% vs. +3% and +2% for the PCK and REF groups, respectively, P = .023). At week 6 there was a tendency for aspartate aminotransferase concentrations to increase in the VIN group as compared to the other groups (+17% vs. +8% and -8% for VIN, PCK, and REF, respectively; P = .090). These data indicate that chronic VIN ingestion may influence hepatic function and metabolic pathways aside from glucose metabolism.

Complicated Periappendiceal Abscess Diagnosed on Colonoscopy

Purpose: Appendicitis with its complications like periappendiceal abscess is diagnosed with 93% to 98% accuracy using CT. In several reported cases, appendicitis with atypical symptoms and/or nondiagnostic imaging was diagnosed during colonoscopy. We present a case of complicated periappendiceal abscess diagnosed on colonoscopy. Case Report: A 37 yr old female presented to our clinic being referred for an abnormal CT scan showing mass extending into the cecum. She had intermittent right lower quadrant pain for past 2–3 months, increasing in intensity with menstruation. She had no change in bowel movements, no urinary symptoms, no nausea or vomiting. CT abdomen showed right pelvic cystic mass attached to the uterus, adnexa, cecum and sigmoid colon with no visualization of appendix (Fig. 1). Colonoscopy showed edematous cecum with clear pus extruding from the appendiceal orifice confirming appendicitis (Fig. 2). Laparotomy showed large mass in the pelvis covered with omentum and small bowel. Pus was expressing from necrotic base of the appendix and from the right ovarian cyst. Appendectomy and hysterectomy with bilateral salphingo-oophorectomy were performed. Pathology confirmed appendicitis with abscess formation along with the ovarian abscesses on both sides. The culture from the pus was positive for Bacteroides fragilis indicating bowel as the source of infection. Our patient had appendicitis with abscess that disseminated causing infection of the ovarian cysts. The infection was walled off by omentum causing atypical symptoms, thus misleading physicians till colonoscopy. Conclusion: This unusual case illustrates a key role played by colonoscopy in diagnosing a complicated periappendiceal abscess presenting with atypical symptoms and non diagnostic radiologic workup.[figure1][figure2]FigureFigure

From the Roots of Parasitology: Hippocrates' First Scientific Observations in Helminthology

Although knowledge of intestinal parasites predates Hippocrates, the Hippocratic Corpus provides the first scientific observations about the clinical perception and treatment of helminthic diseases. These observations follow the scientific principles of Hippocrates, the father of modern medicine, who relied on knowledge and observation. This article is based on a systematic study of the Hippocratic texts, and presents observations on diseases caused by intestinal parasites with respect to regularity of appearance, patient age, symptoms, and treatment. Three types of helminths are described: "helmins strongyle" (roundworm), "helmins plateia" (flatworm), and "ascaris" (which corresponds to Enterobius vermicularis). Helminthic diseases primarily appear during childhood, well after teething. The described systemic symptoms include weakness, sickness, discomfort, tiredness, anorexia, and emotional instability; gastrointestinal symptoms include change in bowel movements, vomiting, and colic pain in the epigastrium. We identified several accounts of cases of helminthic diseases in the Hippocratic texts. Of particular interest are the descriptions of a helminth emerging from a fistula in the navel region and the surgical treatment of helminthic diseases, reinforced by being described on a dedicatory inscription at the Asclepion in Epidaurus. We finally encountered the use of powerful purgatives as antihelminthics, which have been widely used, even into the 21st century.

Pheochromocytoma: An Unexpected Finding

This article reports a patient who had a pheochromocytoma identified on 123I MIBG scintigraphy following incidental detection of an adrenal mass on abdominal CT. The CT study was performed to evaluate ongoing severe lower abdominal pain and changes in bowel movements.

Are we giving too much iron? Low-dose iron therapy is effective in octogenarians

Purpose Elderly patients are vulnerable to the dose-dependent adverse effects of iron replacement therapy. Our study examines whether low-dose iron therapy can efficiently resolve iron-deficiency anemia in patients over the age of 80 years and reduce adverse effects. Subjects and methods Ninety hospitalized patients with iron-deficiency anemia were randomized to receive elemental iron in daily doses of 15 mg or 50 mg as liquid ferrous gluconate or 150 mg of ferrous calcium citrate tablets for 60 days. Thirty control patients without anemia were given 15 mg of iron for 60 days. A 2-hour iron absorption test was performed after the initial dose. Hemoglobin and ferritin levels were measured on day 1, 30, and 60 after initiating therapy. Each patient completed a weekly questionnaire regarding drug-induced adverse effects. Results Serum iron rose significantly in the anemic patients beginning 15 minutes after the first dose but not in nonanemic patients. Two months of iron treatment significantly increased hemoglobin and ferritin concentrations similarly in all 3 groups of iron-deficiency anemia patients (for example, hemoglobin levels rose from 10.0 g/dL to 11.3 g/dL with 15 mg/d of iron therapy and from 10.2 g/dL to 11.6 g/dL with 150 mg/d). Abdominal discomfort, nausea, vomiting, changes in bowel movements, and black stools were significantly more common at higher iron doses. Conclusions Low-dose iron treatment is effective in elderly patients with iron-deficiency anemia. It can replace the commonly used higher doses and can significantly reduce adverse effects.

Review of tegaserod in the treatment of irritable bowel syndrome

Tegaserod is a drug in a new class of compounds called aminoguanidine indoles and is structurally similar to serotonin (5-HT) with modifications that make the drug selective for the 5-HT4 receptor. Tegaserod has a stimulatory effect on gastrointestinal (GI) motility that has been demonstrated in animal studies and in healthy adults. Tegaserod also increases GI secretion and reduces rectal sensitivity. Tegaserod is currently approved by the FDA for the treatment of women with constipation-predominant irritable bowel syndrome (C-IBS). Eight large Phase III clinical trials involving > 5000 IBS patients support the clinical efficacy of tegaserod in this group of patients. Patients who were treated with tegaserod had an overall improvement in IBS symptoms (Subject’s Assessment of Global Relief) as well as in secondary end points, such as abdominal pain and discomfort, stool consistency, change in bowel movements and relief of bloating. Tegaserod was well-tolerated. The most common adverse reaction in clinical trials was diarrhoea, which was usually temporary and mild, although severe diarrhoea requiring hospitalisation has been rarely (< 1%) reported.

CAROLIʼS DISEASE IN A PATIENT WITH IDIOPATHIC FOCAL GLOMERULOSCLEROSIS

Caroli's disease is a rare congenital disease of intrahepatic ductal dilatation. It is usually associated with polycystic kidney diseases. We present a patient with recently diagnosed idiopathic focal glomerulosclerosis and Caroli's disease. A 32 year-old Pakistani male presented with epigastric and right upper quadrant abdominal pain. He had similar pain approximately 1 week prior to admission. There was no nausea, vomiting, fevers, chills, or change in bowel movements. The patient was recently diagnosed with focal glomerulosclerosis confirmed by renal biopsy and was started on oral steroid treatment. The only other past medical history was of hypertension and a small bowel perforation of unknown etiology. The patient's brother died of liver cirrhosis of unknown etiology at age 42. The patient denied drug use, smoking, drinking, or history of HIV Medications included famotidine, prednisone, and ramipril. On admission, he had a temperature of 38.2C, heart rate of 77, BP of 125/71. Physical exam revealed right upper quadrant and epigastric abdominal tenderness without guarding or rebound and a 5 inch midline scar. There was no hepatomegaly or evidence of portal hypertension. Bowel sounds were normal. Rectal examination was normal. Laboratory examination revealed a white blood cell count of 17,900, 80% neutrophils, total bilirubin of 2.5 and direct bilirubin of 1.6. Aminotransferases and alkaline phophatase were normal. BUN was 44 and creatinine was 1.9. US, CT scan, MRCP, and MRI all showed massive cystic dilatations of the intrahepatic ducts with stones and debris. The common bile duct was mildly dilated with a stone and sludge. The patient was started on broad spectrum antibiotics and IV fluids. ERCP with sphincterotomy was performed. Stones were swept from the common bile duct and a stent was placed for drainage. The patient was discharged home on ursodeoxycholic acid. This is the first case of Caroli's disease associated with idiopathic focal glomerosclerosis.

A population-based study on defecatory conditions in Japanese subjects: methods for self-evaluation.

We examined the defecatory conditions in a population of Japanese subjects and analyzed the measured parameters as a means for self-evaluation of defecation. Subjects (n=1195) were residents of northern Japan and were all aged over 40 years. The state of defecation and fecal characteristics were assessed with regard to nine parameters including "self-reported bowel habit" and "bowel movement frequency." Logistic regression analysis was carried out to analyze the association between the complaint of constipation and other eight parameters. A higher tendency for constipation was noted in women than in men. The highest value of the odds ratio was "bowel movement frequency"; especially the value "once per three days or more" was noted in both genders (odds ratio: 13.38 and 42.46 in men and women, respectively). In addition, "stool appearance", "length of time for bowel movement", "straining after bowel movement", "alternating diarrhea/constipation/disorder" and "travel-related changes in bowel movements" were significantly related with the complaint of constipation ("self-reported bowel habits") in both genders. In conclusion, the study elucidated that personal and subjective evaluation of bowel habits in normal subjects consisted of various factors under the heading of "bowel movement frequency".

Colourachal Fistula in an Adult Presenting with Feculent Umbilical Drainage

A 26-year-old female presented with a 2-week history of fever, left lower abdominal pain and feculent drainage from the umbilicus. During the previous month the patient had also noticed increased urinary frequency but denied any hematuria, dysuria or pneumaturia. She had no significant changes in bowel movements. She denied any previous medical conditions or surgeries. Aside from abdominal tenderness and umbilical drainage, the examination was unremarkable. Urine culture and microscopic analysis were negative, while cultures taken of the umbilical fluid grew Escherichia coli. Abdominal computerized tomography (CT) revealed a urachal remnant containing gas and an adjacent inflammatory mass from sigmoid diverticulitis (see figure). Cystoscopy demonstrated edematous changes at the bladder dome with no obvious fistula. The patient was placed on a 6-week course of levofloxacin and metronidazole with resolution of the abdominal pain, although the umbilical drainage persisted. The patient underwent elective excision of the urachal remnant with bladder cuff and en bloc sigmoid colectomy with primary end-to-end colonic anastomosis. Intraoperatively, the patient had an abscess from perforated sigmoid diverticulitis and fistulization to the urachus. Pathological examination showed a patent urachal remnant measuring 3 cm in diameter, cystitis glandularis of the bladder dome, sigmoid diverticulitis and a colourachal fistula. Postoperative course was uneventful with removal of the urinary catheter on day 11 and complete resolution of symptoms.

Obstructive lesions of the descending colon and rectum.

Since all lesions of the descending colon and rectum may become obstructive, they are of interest not only to the proctologist but to the general surgeon, to the internist and sometimes to the urologist and gynecologist. The term rectosigmoid has been discarded, because of variations of interpretations of its boundaries. The movable portion above the pelvic peritoneal reflection is designated as sigmoid, and the fixed portion below as the rectum, which in this discussion will also include the anus. The signs and symptoms of obstructive lesions usually have a mild onset and a gradual increase in severity. As the lesion becomes more and more constricted, the vague abdominal uneasiness progresses to definite discomfort and, later, pain. In some instances the pain may be more intense in the right lower quadrant of the abdomen. Definite changes in bowel movements become more pronounced, until there are real colicky pains and palpable or