Incomplete Evacuation Research Articles

A poly-herbal blend (Herbagut\xae) on adults presenting with gastrointestinal complaints: a randomised, double-blind, placebo-controlled study

BackgroundTo evaluate the efficacy and tolerability of a poly-herbal formulation, Herbagut, for the treatment of gastrointestinal symptoms and its effect on quality of life parameters in patients presenting with self-reported, unsatisfactory bowel habits.MethodsThis was a randomised, double-blind, placebo-controlled trial. Fifty adults with self-reported unsatisfactory bowel habits, primarily characterised by chronic constipation were randomly allocated to take Herbagut or a matching placebo for 28 days. Efficacy of gastrointestinal changes was measured by the completion of a patient daily diary evaluating changes in stool type (Bristol Stool Form Scale), ease of bowel movements, and feeling of complete evacuation; and the Gastrointestinal Symptom Rating Scale (GSRS). Changes in quality of life were also examined using the World Health Organization Quality of Life – abbreviated version (WHOQOL-BREF), and the Patient Assessment of Constipation-Quality of Life (PAC-QOL).ResultsAll participants completed the 28-day trial with no adverse events reported. Compared to the placebo, weekly bowel movements increased over time (p < .001), as did self-reported, normal bowel motions (76% vs 4%; p < .001). Self-reported incomplete evacuation was also lower in the Herbagut group compared to placebo (24% vs 76%; p = <.001). GSRS domain ratings for abdominal pain, constipation, diarrhoea, indigestion, and reflux also decreased significantly in people taking Herbagut compared to placebo (p < .001, for all domains). Moreover, quality of life significantly improved in the Herbagut group compared to placebo as indicated by significantly greater improvement in WHOQOL-BREF domain ratings for overall quality of life, social relations, environmental health, psychological health, and physical health (p < .001, for all domains); and PAC-QOL domain ratings for physical discomfort, psychosocial discomfort, worries and concerns, and life satisfaction (p < .001, for all domains). The changes were considered clinically meaningful as evidenced by their large effect sizes.ConclusionHerbagut ingestion over a 28-day period resulted in improvements in several gastrointestinal symptoms and overall quality of life. Further investigation utilising larger sample sizes and diverse clinical and cultural populations are needed.Trial registrationClinical Trials Registry- India /2016/11/007479. Registered 24 April 2015 (retrospectively registered).

Biofeedback efficacy to improve clinical symptoms and endoscopic signs of solitary rectal ulcer syndrome.

Solitary rectal ulcer syndrome (SRUS) is often resistant to medical and surgical treatment. This study assessed the effect of biofeedback in decreasing the symptoms and the healing of endoscopic signs in SRUS patients. Before starting the treatment, endoscopy and colorectal manometry was performed to evaluate dyssynergic defecation. Patients were followed every four weeks, and during each visit their response to treatment was evaluated regarding to manometry pattern. After at least 50% improvement in manometry parameters, recipients underwent rectosigmoidoscopy. Endoscopic response to biofeedback treatment and clinical symptoms were investigated. Duration of symptoms was 43.11±36.42 months in responder and 63.9 ± 45.74 months in non-responder group (P=0.22). There were more ulcers in non-responder group than responder group (1.50 ±0.71 versus 1.33±- 0.71 before and 1.30 ± 0.95 versus 0.67 ±0.50 after biofeedback), although the difference was not significant (P=0.604, 0.10 respectively). The most prevalent symptoms were constipation (79%), rectal bleeding (68%) and anorectal pain (53%). The most notable improvement in symptoms after biofeedback occured in abdominal pain and incomplete evacuation, and the least was seen in mucosal discharge and toilet waiting as shown in the bar chart. Endoscopic cure was observed in 4 of 10 patients of the non-responder group while 8 patients in responder group experienced endoscopic improvement. It seems that biofeedback has significant effect for pathophysiologic symptoms such as incomplete evacuation and obstructive defecation. Improvement of clinical symptoms does not mean endoscopic cure; so to demonstrate remission the patients have to go under rectosigmoidoscopy.

Role of MR Defecography in the Assessment of Obstructed Defecation Syndrome

AbstractBackground: Obstructed Defecation Syndrome (ODS) is characterized by the urge to defecate but an impaired ability to expel the fecal bolus. Symptoms include unsuccessful fecal evacuation attempts, excessive straining, pain, bleeding after defecation, and a sense of incomplete fecal evacuation. ODS has been linked to anatomic abnormalities of rectocele, rec-toanal or recto-rectal intussusception, paradoxical puborectalis contraction, pelvic organ prolapse, descending perineum syndrome, solitary rectal ulcer syndrome, sigmoidocele, and enterocele. A functional abnormality such as pelvic floor dyssynergia, decreased rectal compliance and decreased rectal sensation has also been shown to contribute to symptoms of ODS.Objective: To assess the role of MR defecography in finding functional abnormalities in patients with obstructed defecation syndrome.Patients and Methods: A prospective study was carried out on 30 patients (20 females and 10 males) with clinical symptoms of obstructed defecation syndrome for a period longer than 6 months. Patients were assessed statically using T2 weighted images and dynamically by MR defecography using fast imaging via steady-state acquisition sequences. All patients had symptoms of obstructed defecation syndrome as unsuccessful fecal evacuation attempts, excessive straining, pain during defecation, a sense of incomplete fecal evacuation and digital rectal evacuation.Results: A total of 30 patients with a mean age of 40.2 with 20 (66.7%) females and 10 (33.3%) males. MR defecog-raphy revealed rectocele in 19 (63.3%) of all patients and cystocele in 17 (56.7%) patients. Four patients (13.3%) had rectal intussusception. Spastic pelvic floor syndrome was found in 2 patients (6.75%). Multicompartmental dysfunction was observed in 18 (60%) of the female patients.Conclusion: MR defecography was proven to be highly valuable in assessing patients with obstructed defecation syndrome, particularly females as it depicts multicompart-mental dysfunction in females with a seemingly single com-partment symptom ultimately changing the treatment approach.

Evaluation of bowel habits in benign anorectal diseases

Background: Evaluation of bowel habit is useful indicator of functional gastrointestinal disorders. Assessment of bowel habit is retrospective in nature and it is best done by questionnaire technique. Aims and objectives of the study was to look for the bowel habit in common benign anorectal disorder.Methods: One-hundred patients with benign anorectal diseases who presented in the Surgery out patient’s department (SOPD) at AIIMS Rishikesh, India from January 2014 to December 2016 were included in the study. Inclusion criteria were all the cases of benign anorectal disorder attended in the Surgery OPD and exclusion criteria were cases with malignant anorectal disease. Patients were assessed on 7 questionnaires as bowel movements (number/day), consistency, feeling of incomplete defecation and/or difficult evacuation, straining at defecation, bleeding per rectum, pain during defecation, use of laxatives. These questionnaires were given to all these patients and asked to prepare a four-week daily diary.Results: One hundred patients with benign anorectal diseases enrolled in the study. All the patients came in the follow up with four-week daily diary. Author have encountered mainly haemorrhoid, Fissure in Ano and fistula in Ano at the General Surgery OPD. Most common disease was haemorrhoid (51%) and least common was fistula in Ano (3%). Most common bowel habits in haemorrhoid was passage of hard stool (51%) whereas in fissure in Ano it was straining at stool and in fistula in Ano it was passage of hard stool (100%), straining at defecation (100%) followed by bleeding and pain during defecation (67% each). Frequency of bowel movement was one per day and consistency was hard in majority of male and female patients. Laxative was used by 29% patients mainly for hard stool, incomplete evacuation and straining at stool.Conclusions: Bowel habit can be best investigated by questionnaire technique. Stool consistency is better guide of colonic transit time. Hard stool is the major cause of majority of the benign anorectal disorder.

Sacral neuromodulation versus personalized conservative treatment in patients with idiopathic slow-transit constipation: study protocol of the No.2-trial, a multicenter open-label randomized controlled trial and cost-effectiveness analysis

PurposeThe evidence regarding the (cost-)effectiveness of sacral neuromodulation (SNM) in patients with therapy-resistant idiopathic slow-transit constipation is of suboptimal quality. The Dutch Ministry of Health, Welfare and Sports has granted conditional reimbursement for SNM treatment. The objective is to assess the effectiveness, cost-effectiveness, and budget impact of SNM compared to personalized conservative treatment (PCT) in patients with idiopathic slow-transit constipation refractory to conservative treatment.MethodsThis study is an open-label, multicenter randomized controlled trial. Patients aged 14 to 80 with slow-transit constipation, a defecation frequency (DF) < 3 per week and meeting at least one other Rome-IV criterion, are eligible. Patients with obstructed outlet, irritable bowel syndrome, bowel pathology, or rectal prolapse are excluded. Patients are randomized to SNM or PCT. The primary outcome is success at 6 months (DF ≥ 3 a week), requiring a sample size of 64 (α = 0.05, β = 0.80, 30% difference in success). Secondary outcomes are straining, sense of incomplete evacuation, constipation severity, fatigue, constipation specific and generic quality of life, and costs at 6 months. Long-term costs and effectiveness will be estimated by a decision analytic model. The time frame is 57 months, starting October 2016. SNM treatment costs are funded by the Dutch conditional reimbursement program, research costs by Medtronic.ConclusionsThe results of this trial will be used to make a final decision regarding reimbursement of SNM from the Dutch Health Care Package in this patient group.Trial registrationThis trial is registered at clinicaltrials.gov, identifier NCT02961582, on 12 October 2016.

The impact of naloxegol on anal sphincter function - Using a human experimental model of opioid-induced bowel dysfunction

Background and aimsOpioid treatment interferes with anal sphincter function and its regulation during defecation. This may result in straining, incomplete evacuation, and contribute to opioid-induced bowel dysfunction (OIBD). Employing an experimental model of oxycodone-induced OIBD, we hypothesized that co-administration of the peripherally acting μ-opioid antagonist naloxegol would improve anal sphincter function in comparison to placebo. MethodsIn a double-blind randomized crossover trial, 24 healthy males were assigned to a six-day treatment of oral oxycodone 15 mg twice daily in combination with either oral naloxegol 25 mg once daily or placebo. At baseline and at day 6, anal resting pressure and the recto-anal inhibitory reflex (RAIR) were evaluated using manometry and rectal balloon distension. Furthermore, the functional lumen imaging probe was used to measure distensibility of the anal canal. Gastrointestinal symptoms were assessed with the Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire and the Bristol Stool Form Scale. ResultsDuring oxycodone treatment, naloxegol improved RAIR-induced sphincter relaxation by 15% (−45.9 vs −38.8 mm Hg; P < 0.01). No differences in anal resting pressure and anal canal distensibility were found between treatments (all P > 0.5). Naloxegol improved PAC-SYM symptoms (mean score over days; 2.6 vs 4.5, P < 0.001) and improved stool consistency scores (mean score over days; 3.3 vs 2.9, P < 0.01). ConclusionsIn this experimental model of OIBD, naloxegol improved the RAIR and reduced gastrointestinal symptoms. Hence, in contrast to conventional laxatives, naloxegol may regulate opioid-induced anal sphincter dysfunction and facilitate the defecation process.

53: Long-term subjective outcomes of porcine-derived small intestine submucosa graft-augmented versus native tissue rectocele repair

To evaluate long-term subjective outcomes of porcine small intestine submucosa (SIS) graft-augmented compared to native tissue rectocele repair. This is a follow up study of a previously published multi-center, randomized trial in which 159 women with stage 2 or greater posterior wall prolapse were randomized to SIS graft-augmented versus native tissue repair, completed in 2009. Exclusion criteria were concurrent sacral-colpopexy, porcine allergy, or past pelvic radiation. We mailed surveys to all participants at one institution (147) and conducted follow-up phone calls. Surveys assessed the Pelvic Floor Distress Inventory (PFDI) and interval care-seeking, treatment and surgery for bowel or prolapse symptoms. Failure was defined as presence of mild, moderate or severe bother (“bother”) associated with: 1) vaginal bulge 2) “bowel symptoms” defined as straining, splinting, sensation of incomplete evacuation on the PFDI; and/or 3) stool trapping. Post hoc power calculation estimated the detectable difference in failure by response rate to be 33-37% (response rate 40%, two-sided alpha 0.05, power 80%, graft:native tissue - 1:1). We used Students’ t-test and Wilcoxon rank sum test to compare groups. Of the 147 subjects, we mailed surveys to 122 (25 - not located). We received 57 completed surveys (25/81 graft, 32/78 native tissue); the overall response rate was 36%, with no difference between groups (p=0.2). The duration between surgery and follow-up was 8-13 years. Among responding subjects, there was one demographic difference between groups: a higher proportion of the graft group reported preoperative incomplete evacuation with bowel movement compared to native tissue (96% vs. 70%, respectively; p=0.03). At 8-13 years, 12% of responders reported bother with vaginal bulge, 63% with bowel symptoms, and 35% with stool trapping; these did not differ between groups. Twenty percent reported interval care-seeking for bowel or bulge symptoms, 5% reported non-surgical treatment and 5% reported surgical repair for any prolapse symptoms, with no differences between groups. Of the women who did not report bothersome symptoms at 12 months, by 8-13 years, 12% (6) developed new bothersome vaginal bulge, 54% (15) developed bowel symptoms, and 31% (14) developed stool trapping symptoms; there were no differences between groups. Of the women who reported bothersome symptoms at 12 months, at 8-13 years, no women reported worsening vaginal bulge symptoms, 50% (14) reported worsening bowel symptoms and 27% (3) reported worsening stool trapping. However, without any interval treatment, 75% (3) reported improvement/resolution of vaginal bulge, 25% (7) had improvement of bowel symptoms, and 45% (5) had improvement of stool trapping. There were no differences between groups. Among women randomized to graft-augmented versus native tissue rectocele repair, 30-50% of patients with no rectocele symptom bother at 12 months postoperative developed bothersome symptoms at long-term follow up. However, 25-75% of symptomatic women had spontaneous symptom improvement by 8-13 years postoperative.

Cost-effectiveness of curettage vs. expectant management in women with an incomplete evacuation after misoprostol treatment for first-trimester miscarriage: a randomized controlled trial and cohort study.

Curettage is more effective than expectant management in women with suspected incomplete evacuation after misoprostol treatment for first-trimester miscarriage. The cost-effectiveness of curettage vs. expectant management in this group is unknown. From June 2012 until July 2014 we conducted a randomized controlled trial and parallel cohort study in the Netherlands, comparing curettage with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. Successful treatment was defined as a sonographic finding of an empty uterus 6 weeks after study entry, or an uneventful course. Cost-effectiveness and cost-utility analyses were performed. We included costs of healthcare utilization, informal care and lost productivity. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated using bootstrapping. We included 256 women from 27 hospitals; 95 curettage and 161 expectant management. Treatment was successful in 96% of the women treated with curettage vs. 83% of the women after expectant management (mean difference 13%, 95% confidence interval 5-20). Mean costs were significantly higher in the curettage group (mean difference €1157; 95% C confidence interval €955-1388). The incremental cost-effectiveness ratio for curettage vs. expectant management was €8586 per successfully treated woman. The cost-effectiveness acceptability curve showed that at a willingness-to-pay of €18 200/extra successfully treated women, the probability that curettage is cost-effective is 95%. Curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment. This indicates that curettage in this group should be restrained.

Ocean destratification and fish evacuation caused by a Mid-Atlantic tropical storm

AbstractTropical and extratropical storms commonly occur in the Northwest Atlantic Ocean, sometimes causing catastrophic losses to coastal fisheries. Still, their influence on fish movements and range shifts is poorly known. We coupled biotelemetry observations of black sea bass in the U.S. Mid-Atlantic Bight with numerical modelling of the coastal ocean to evaluate the influence of Hermine (3–8 September 2016) on cold pool thermal destratification and fish evacuation. Spring through fall, black sea bass is a sedentary species, with movements focused on structure where they support important commercial and recreational fisheries. During summer 2016, we characterized the movements of 45 acoustically tagged black sea bass at three sites deploying acoustic receivers moored in shelf waters 18–31 km east of Ocean City, Maryland, and at depths 20–32 m in the southern Mid-Atlantic Bight. On 3 September 2016, cyclonic winds of Hermine caused rapid destratification of the water column. At experimental sites, bottom temperatures rose from 13 to 23°C in 10 h. An oceanographic model and observing data showed that the effects of this destratification dominated large portions of the Mid-Atlantic Bight and had long term effects on seasonal evolution of the shelf temperature. Nearly half of remaining black sea bass on 3 September (40%) permanently evacuated the experimental sites. Those that remained showed long-term depressed activity levels. Although the cause of this incomplete evacuation is unknown, it exemplifies partial migration, which may buffer black sea bass to regional impacts of changed timing or increased incidence of tropical storms.

P180 ENDOSCOPIC CORRECTION OF TWISTED POUCH RELATED STENOSIS

Total proctocolectomy with creation of a pouch using a loop of small bowel followed by Ileal pouch-anal anastomosis (IPAA) is a commonly performed surgical treatment for ulcerative colitis (UC). The surgery is usually performed in 3 stages, and the ‘J-type’ of pouch is the most commonly created pouch reservoir after proctocolectomy. If the pouch is anastomosed with a twist along its longitudinal axis it may lead to stenosis at the IPAA. A 30 year old female with history of medically refractory UC underwent 3-staged total proctocolectomy and IPAA within a year since diagnosis. Two months after ileostomy closure, she developed partial small bowel obstruction as evidenced by abdominal CT scan which showed dilated loops of small bowel (>3 cm) with interloop pockets of ascites. Multiple pouchoscopies were performed which showed anastomotic obstruction, but no endoscopic therapy was given. A repeat pouchoscopy examination demonstrated partial stenosis at anastomosis which was in fact caused by twisted distal pouch along its longitudinal axis (Figure 1). There was no evidence of pouchitis but it appeared that the pouch had a twist creating a stenosis at the IPAA. An endoscopic needle knife (NK) with electroincision/cauterization was used and the apex of twisted pouch was incised in circumferential fashion (Figure 2). No significant bleeding was noted during and after the outpatient endoscopy procedure Within 1 day she had complete resolution of her GI symptoms and repeat pouchoscopy 2 weeks later showed resolution of the obstruction. Surgical proctocolectomy with IPAA is a technically challenging surgery and can sometimes lead to a twist in the pouch at time of anastomosis with anus. This can lead to stenosis at IPAA leading to incomplete pouch evacuation and small bowel obstruction. A therapeutic NK can be used for cutting the mucosal tissue at the apex of the twisted pouch near the IPAA, thereby releasing the stenosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

White Matter Microstructural Similarity and Diversity of Functional Constipation and Constipation-predominant Irritable Bowel Syndrome.

Background/AimsThe Rome III criteria separated chronic constipation into functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C), but some researchers questioned the partitioning and treated both as distinct parts of a continuum. The study aims to explore the similarity and diversity of brain white matter between FC and IBS-C.MethodsThe voxel-wise analysis of the diffusion parameters was used to quantify the white matter changes of female brains in 18 FC patients and 20 IBS-C patients compared with a comparison group with 19 healthy controls by tract-based spatial statistics. The correlations between diffusive parameters and clinical symptoms were evaluated using a Pearson’s correlation.ResultsIn comparison to healthy controls, FC patients showed a decrease of fractional anisotropy (FA) and an increase of radial diffusivity (RD) in multiple major fibers encompassing the corpus callosum (CC, P = 0.001 at peak), external capsule (P = 0.002 at peak), corona radiata (CR, P = 0.001 at peak), and superior longitudinal fasciculus (SLF, P = 0.002 at peak). In contrast, IBS-C patients showed FA and RD aberrations in the CC (P = 0.048 at peak). Moreover, the direct comparison between FC and IBS-C showed only RD differences in the CR and SLF. In addition, FA and RD in the CC were significantly associated with abdominal pain for all patients, whereas FA in CR (P = 0.016) and SLF (P = 0.040) were significantly associated with the length of time per attempt and incomplete evacuation separately for FC patients.ConclusionThese results may improve our understanding of the pathophysiological mechanisms underlying different types of constipation.

Surgical correction of functional disorders in performing sphincterosafing operations for rectal cancer (literature review)

For many decades the main goal of oncologists was to increase life expectancy of patients with malignant tumors, without paying due attention to quality of life. Currently, the goals of patients’ treatment with rectal cancer are to cure, to minimize the risk of local recurrence, preserve the normal course of intestine, to optimize it's function and to ensure quality of life. For a long time, the standard surgical treatment of patients with low rectal cancer was abdominoperineal extirpation, but recently sphincterosafing operations have seen a widespread introduction in surgical practice. However, functional results after these types of operations don't always meet the expectations of surgeons and patients. In the postoperative period, patients often develop a syndrome of low anterior resection, characterized by frequent bowel movements, repeated, prolonged and incomplete evacuation of bowel and the imperative urge to defecate. The manifestation of this syndrome can significantly impair the quality of patient's life and reduce to nothing the efforts of the surgeon to preserve the sphincter of the rectum. For surgical correction of low anterior resection syndrome, various types of colonic reservoir anastomoses have been proposed. The purpose of formation of colonic reservoirs is to increase the cumulative function of intestine. However, the existing methods have several disadvantages related to technical complications and the risk of developing evacuation dysfunction, which is the reason for search the new ways of optimization of anastomoses when performing sphincterotomy operations for cancer of the rectum.

Immediate results from biofeedback and anorectal electrostimulation in the treatment of paradoxical puborectal muscle contraction in women with obstructed defecation

ObjectiveThis study was conducted to evaluate the effects of “biofeedback” (BF), electrostimulation (ES), and of the high-fiber diet associated with behavioral therapy in women with obstructed evacuation and paradoxical puborectalis contraction and to compare the results among these three modalities. MethodThirty-one women were evaluated who fulfilled the Rome III Criteria, and with an electromanometric test positive for the presence of contraction in the evacuation maneuver. These patients were randomized into three groups: group I – conventional treatment of constipation, group II – conventional treatment of constipation associated with biofeedback and group III – conventional treatment of constipation associated with electrostimulation. At the beginning of this study and after six weeks, subjective and objective parameters of the anorectal function were evaluated using the Wexner constipation scoring system, the Bristol scale, an visual analogical scale, and anorectal electromanometry. ResultsAll patients demonstrated improvement in bowel satisfaction, stool frequency, effort and feeling of incomplete evacuation, stool-type modifications, and improvement in the quality of life. On examination, there was increased mean pressure of voluntary contraction in group III (p=0.043), decreased sensitivity threshold in group II (p=0.025) and III (p=0.012) and decreased maximum rectal capacity in group II (p=0.005). Only 19.4% (n=6) had their dynamic defecation normalized, and 80.6% (n=25) expressed clinical, non-instrumental, improvement. ConclusionThe conventional treatment of constipation, biofeedback and electrostimulation show a significant subjective improvement in symptoms of obstructed evacuation and in quality of life, regardless of the reversal of the paradoxical puborectalis contraction.

Predictors of healthcare-seeking behavior among Chinese patients with irritable bowel syndrome.

AIMTo analyze predictors of healthcare-seeking behavior among Chinese patients with irritable bowel syndrome (IBS) and their satisfaction with medical care.METHODSParticipating patients met IBS Rome III criteria (excluding those with organic diseases) and were enrolled in an IBS database in a tertiary university hospital. Participants completed IBS questionnaires in face-to-face interviews. The questionnaires covered intestinal and extra-intestinal symptoms, medical consultations, colonoscopy, medications, and self-reported response to medications during the whole disease course and in the past year. Univariate associations and multivariate logistic regression were used to identify predictors for frequent healthcare-seeking behavior (≥ 3 times/year), frequent colonoscopies (≥ 2 times/year), long-term medications, and poor satisfaction with medical care.RESULTSIn total, 516 patients (293 males, 223 females) were included. Participants’ average age was 43.2 ± 11.8 years. Before study enrollment, 55.2% had received medical consultations for IBS symptoms. Ordinary abdominal pain/discomfort (non-defecation) was an independent predictor for healthcare-seeking behavior (OR = 2.07, 95%CI: 1.31-3.27). Frequent colonoscopies were reported by 14.7% of patients (3.1 ± 1.4 times per year). Sensation of incomplete evacuation was an independent predictor for frequent colonoscopies (OR = 2.76, 95%CI: 1.35-5.67). During the whole disease course, 89% of patients took medications for IBS symptoms, and 14.7% reported they were satisfied with medical care. Patients with anxiety were more likely to report dissatisfaction with medical care (OR = 2.08, 95%CI: 1.20-3.59). In the past year, patients with severe (OR = 1.74, 95%CI: 1.06-2.82) and persistent (OR = 1.66, 95%CI: 1.01-2.72) IBS symptoms sought medical care more frequently.CONCLUSIONChinese patients with IBS present high rates of frequent healthcare-seeking behavior, colonoscopies, and medications, and low satisfaction with medical care. Intestinal symptoms are major predictors for healthcare-seeking behavior.

Frequency patterns of core constipation symptoms among the Asian adults: a systematic review

BackgroundIn clinical practice, assessment of constipation depends on reliability, consistency and frequency of several commonly reported or core symptoms. It is not known if frequency patterns of constipation symptoms in adults are different between the West and the East. This review aimed to describe core constipation symptoms and their frequency patterns among the Asian adults.MethodsArticles published in PubMed, MEDLINE, CINAHL and Science Direct from 2005 to 2015 were searched systematically. Studies were included if constipation satisfied the Rome II and or III criteria. Study populations consisted of Asian adults above 18 years old and with sample size above 50.ResultsOf 2812 articles screened, 11 met the eligibility criteria. Constipation among Asian adults was characterized by three core symptoms of ‘straining’ at 82.8%, ‘lumpy and hard stool’ at 74.2% and ‘sensation of incomplete evacuation’ at 68.1% and the least frequent symptom was ‘manual maneuver to facilitate defecation’ at 23.3%. There was heterogeneity in frequency patterns of core symptoms between different Asian studies but also differences in core symptoms between constipation subtypes of functional constipation and irritable bowel syndrome with constipation.ConclusionsIn general, Asian adults perceive constipation symptoms in a similar but not equivalent manner to the West. Recognition of core symptoms will increase the diagnostic confidence of constipation and its subtypes but more studies of the various specific Asian populations are needed to address their differences.

Efficacy of Biofeedback Therapy in the Treatment of Dyssynergic Defecation in Community-Dwelling Elderly Women.

The aim of this study was to evaluate the efficacy of biofeedback therapy in the treatment of dyssynergic defecation in chronically constipated community-dwelling elderly women. After an initial assessment phase carried out during 1 month, 20 chronically constipated women with dyssynergic defecation were randomly assigned to either electromyographic biofeedback (EMG-BF) group (n=10) or control group (n=10). Outcome measures used to evaluate the efficacy of treatment were weekly stool frequency, sensation of incomplete evacuation, difficulty evacuation level, mean EMG-activity (μV) of the external anal sphincter during straining to defecate and Anismus index. The results obtained in this randomized controlled trial showed significant differences between the groups in all the dependent variables after 1 month of treatment. Moreover, there was no difference between the groups neither in age nor in the duration of chronic constipation symptoms. At the follow-up, 3 months later, clinical gains were maintained. This study demonstrates that the EMG-BF is an effective behavioral therapy for the treatment of dyssynergic defecation in community-dwelling elderly women.

Management of vaginal wall perforation during a second trimester dilation and evacuation

Background: We report an unusual case involving vaginal perforation associated with second trimester dilation and evacuation. Review of the literature fails to identify additional reports. Case: A 22 year G3P1011 female at 16 weeks gestation referred for evaluation following incomplete dilation and evacuation was found to have vaginal perforation, and communication with the peritoneal cavity on pelvic examination. Examination under anesthesia and laparoscopy confirmed multiple vaginal perforations with intraperitoneal defects and hematomas but no viscus involvement. Cervical dilation was accomplished with osmotic dilators placed under ultrasound guidance during exam under anesthesia, with evacuation completed approximately 16 hours later without further complication. Conclusion: This is the first case of vaginal perforation at time of dilation and evacuation reported in the literature. Laparoscopy should be performed to evaluate for intraabdominal injury to bowel, bladder and/or blood vessels. Use of osmotic dilators during the second trimester could potentially decrease the risk of vaginal perforation during the dilation portion of the procedure.

How Do We Evacuate Stool? Insights From Combined High-Resolution Anorectal Manometry With Defecography

Introduction: The sense of incomplete evacuation is a feature of a defecatory disorder- however the mechanism of evacuation is not well understood. The aim of this study was to use simultaneous barium defecography and high resolution anorectal manometry (HRAM) to elucidate the mechanism of defecation in patients and controls Methods: Simultaneous seated HRAM and defecography (using180ml barium paste) were performed in 26 constipated women and 22 asymptomatic controls. Anal diameter and rectal pressures during evacuation and percentage of barium emptied, and the rectoanal pressure gradient during evacuation were calculated. Values less than 25th percentile for controls was considered abnormal. Results: Healthy women evacuated 80% of barium paste (median, IQ range-18-90%) while patients evacuated 21% (0-70%). Five controls and 12 patients evacuated < 18% of barium (25th percentile for controls). They were classified as “poor-evacuators” or PE); of these 9 had an abnormal balloon expulsion test (>60 seconds). The rest were classified as “adequate evacuators” (AE). Rectal and anal pressures increased initially during evacuation in all women. Thereafter, anal pressures declined, but the rectoanal pressure gradient exceeded 0 mm Hg only in AEs, enabling evacuation in this group. Rectal pressure at the onset of evacuation (median 87 vs 47mmHg, p=0.1) and anal diameter during evacuation (13 vs 0mm, p=0.002) was greater in AEs than PEs. Among AEs, a moving average of recto-anal pressure gradients (median = 4.2 mmHg) was positive (>0 mm Hg) for a median duration of 5s, which is 60% of the median duration of evacuation (8.5s). Among constipated PEs, disturbances were inadequate rectal pressure (4 patients) or impaired anal relaxation (8 patients). In a multivariate linear regression model, the rectoanal gradient, average anal canal diameter, and duration of anal relaxation during evacuation explained 40% of the variation in percent of barium emptied (p=0.0001). Conclusion: Adequate evacuation of barium (≥18%) is characterized by an initial simultaneous increase in rectal and anal pressure followed by anal relaxation. Conversely, either an inadequate increase in rectal pressure or in anal diameter during evacuation leads to incomplete evacuation. Not all women who have poor evacuation are symptomatic. The simultaneous increase in rectal and anal pressures during evacuation may be mediated by a reflex induced by increased abdominal pressure. Simultaneous defecography with HRAM may be useful in the clinical evaluation of chronic constipation.

Incidental Discovery of Early Strongyloides stercoralis Colitis in an Active Duty Service Member

Strongyloides stercoralis is a potentially lethal parasitic infection with a broad range of clinical and endoscopic manifestations. While hyperinfection can result in dramatic colonoscopic findings that mimic ulcerative colitis, asymptomatic patients may exhibit more subtle findings such as erythema or nonspecific white lesions. A 43-year-old Nigerian born woman was referred to the gastroenterology clinic for workup of longstanding constipation. She reported onset related to her uncomplicated spontaneous vaginal deliveries. Varied laxative use yielded no improvement. The patient denied weight loss, fatigue, tenesmus, urgency, or incomplete evacuation. Travel history was remarkable for recent travel to Nigeria and annual vacations in Belize. Abdominal exam was unremarkable. A rectal exam revealed a palpable mass in the left lateral rectal wall. Laboratory evaluation was notable for a mild normocytic anemia and peripheral eosinophilia. Computed tomography of the pelvis with contrast revealed retroversion of the uterus with suggestion of mass effect on the rectum and sigmoid colon. Defacography confirmed mild uterine prolapse and a small rectocele. A subsequent optical colonoscopy revealed grossly normal colonic mucosa, with exception of external hemorrhoids and punctate white papules in the proximal right colon. Biopsy and histologic examination of the lesions revealed colonic mucosa with eosinophilic infiltrate and filariform S. stercoralis larva. The patient was subsequently treated with ivermectin, and referred to urogynecology for pelvic floor physical therapy. This case illustrates subtle colonoscopic findings of S. stercoralis colitis. Endoscopy in foreign born patients with a history of exotic travel requires a high index of suspicion for diagnosis of parasitic infections. In this case, the burden of parasitic disease was unlikely a prime contributor to her presenting symptom profile; however, the biopsy of suspicious lesions led to an early diagnosis of a potentially life threatening infection. Recognition of the more subtle colonoscopic findings is key to early diagnosis and treatment to prevent significant morbidity and mortality.Figure

Effect of Naldemedine on Frequency of Spontaneous Bowel Movements and Associated Symptoms

Introduction: Opioid-induced constipation (OIC) is a well-known side effect of opioid therapy. Naldemedine (NAL) is a peripherally-acting μ-opioid receptor antagonist approved for the treatment of OIC in patients with chronic non-cancer pain. Methods: Two randomized, double-blind placebo (PBO) controlled 12-week studies (NCT01965158 and NCT01993940), assessed the effect over time of NAL 0.2 mg once daily vs PBO in the frequency of spontaneous bowel movements (SBMs), complete SBMs (CSBMs, defined as SBMs with a perception of complete evacuation), SBMs without straining, and SBMs with a Bristol Stool Scale (BSS) Score of 3 or 4 in adult (age 18-80 years) subjects with chronic non-cancer pain and OIC. Subjects were required to not be on laxatives at screening or to agree to discontinue laxatives upon signing informed consent. The mean changes in the frequency per week from baseline to each week was compared between NAL and PBO, with a mixed-effects model repeated measures which opioid dose strata and study as a covariate and treatment group, time, time-by-treatment group interaction as fixed effects. Safety was assessed based on the incidence of adverse events (AEs). Results: In the two studies pooled, 1095 subjects were randomized 1:1 to NAL (N=549) or PBO (N=546) for 12 weeks. In all four endpoints, NAL was associated with a significantly (P≤0.0001) greater improvement from baseline at each week relative to PBO, starting at Week 1 and up to Week 12 (Figure). The overall incidence of AEs was generally similar between groups. Treatment with NAL was associated with a greater incidence of gastrointestinal AEs (abdominal pain, diarrhea, nausea) compared with PBO (Table).Figure: Change from Baseline* to Each Week (LS Mean ± SE) in Assessed Endpoints.Table: Table. Overall Summary of Treatment Emergent Adverse Events (Safety Population)Conclusion: Treatment with NAL over 12 weeks compared with placebo improved the frequency of bowel movements as well as the signs and symptoms of OIC frequently reported with bowel movements including perception of incomplete evacuation, need for straining, and hard stools,. NAL was generally well tolerated.