Infrequent Stools Research Articles

767 Functional GI Disorders are Less Common in College Athletes

0.005). The frequency of hard and normal stools did not differ between groups. While loose stools were more common in the laxative users (0.5 ± 0.8 v 1.8 ± 2.0 loose stools/wk; P = 0.01). The majority (86%) of patients were classified with slow transit constipation. The frequency of hard and loose stools were equally prevalent between delayed and normal transit and there was no difference in overall stool frequency between the two groups; indicating no correlation between stool form/frequency and delayed transit. Controlling for frequency of laxative use did not change either the magnitude or statistical significance of the difference between normal and delayed transit groups with respect to any of the stooling characteristics. Conclusion: These data indicate that in a population referred to a tertiary centre for treatment of constipation neither stool form or frequency correlates with delayed transit when laxative use is taken into account. While infrequent and hard stools are commonly associated with constipation, in reality frequent, loose stools are equally prevalent in patients with demonstrable slow transit constipation. Laxative use must be taken into account when assessing such patients. Supported by NHMRC Australia.

M1345 Assessing Treatment Response in Chronic Constipation Clinical Trials: Concepts Elicited Through Qualitative Interviews With Patients

INTRODUCTION The assessment of treatment response in CC trials has historically focused on bowel symptoms; however, the FDA guidance on patient reported outcome (PRO) measures recommends that selection of appropriate endpoints for clinical trials be based upon direct patient input obtained through open-ended patient interviews or focus groups. AIMS and METHODS The study aimed to identify a comprehensive set of CC symptoms important to patients and optimal terminology to measure those symptoms. Twenty-eight in-depth qualitative interviews were conducted in two geographic locations in patients meeting modified Rome II criteria for CC. A semi-structured interview guide was used, beginning with a series of open-ended questions to ascertain all relevant symptoms. Participants were subsequently probed to identify their most bothersome CC symptoms as well as other symptoms not mentioned spontaneously. RESULTS Patients spontaneously reported bowel symptoms including infrequent stools (28/28), hard stools (22/28) straining (20/28), unsuccessful attempts to have a BM (18/28), stools too small or too large (18/28), and incomplete BMs (13/28). In addition, patients frequently reported abdominal symptoms including bloating (22/28), abdominal pain (22/28), abdominal discomfort (15/28), stomach pains/aches (14/28), abdominal cramping (13/28), and feeling of fullness/feeling stuffed (13/ 28). Other symptoms elicited were predominantly the consequence of severe bowel or abdominal symptoms. For example, patients reported rectal pain, hemorrhoids, and rectal bleeding secondary to straining and hard stools. The symptoms reported most frequently by patients as their most bothersome included bloating, rectal pain, infrequent BMs, and abdominal pain. CONCLUSIONS This study is the first published report of symptoms spontaneously identified by CC patients through open-ended interviews using the methods outlined in FDA's guidance on PROs. Although patients identified a wide variety of symptoms, symptom assessment in a clinical trial should be focused on the most relevant symptoms reported by patients. These interview results suggest that in addition to bowel symptoms, abdominal symptoms are important and bothersome to CC patients and should be considered for inclusion in the assessment of treatment response in CC clinical trials.

M1346 High Prevalence of Lower Gastrointestinal (GI) Symptoms in Functional Dyspepsia: A Factor and Cluster Analysis in the General Population

INTRODUCTION The assessment of treatment response in CC trials has historically focused on bowel symptoms; however, the FDA guidance on patient reported outcome (PRO) measures recommends that selection of appropriate endpoints for clinical trials be based upon direct patient input obtained through open-ended patient interviews or focus groups. AIMS and METHODS The study aimed to identify a comprehensive set of CC symptoms important to patients and optimal terminology to measure those symptoms. Twenty-eight in-depth qualitative interviews were conducted in two geographic locations in patients meeting modified Rome II criteria for CC. A semi-structured interview guide was used, beginning with a series of open-ended questions to ascertain all relevant symptoms. Participants were subsequently probed to identify their most bothersome CC symptoms as well as other symptoms not mentioned spontaneously. RESULTS Patients spontaneously reported bowel symptoms including infrequent stools (28/28), hard stools (22/28) straining (20/28), unsuccessful attempts to have a BM (18/28), stools too small or too large (18/28), and incomplete BMs (13/28). In addition, patients frequently reported abdominal symptoms including bloating (22/28), abdominal pain (22/28), abdominal discomfort (15/28), stomach pains/aches (14/28), abdominal cramping (13/28), and feeling of fullness/feeling stuffed (13/ 28). Other symptoms elicited were predominantly the consequence of severe bowel or abdominal symptoms. For example, patients reported rectal pain, hemorrhoids, and rectal bleeding secondary to straining and hard stools. The symptoms reported most frequently by patients as their most bothersome included bloating, rectal pain, infrequent BMs, and abdominal pain. CONCLUSIONS This study is the first published report of symptoms spontaneously identified by CC patients through open-ended interviews using the methods outlined in FDA's guidance on PROs. Although patients identified a wide variety of symptoms, symptom assessment in a clinical trial should be focused on the most relevant symptoms reported by patients. These interview results suggest that in addition to bowel symptoms, abdominal symptoms are important and bothersome to CC patients and should be considered for inclusion in the assessment of treatment response in CC clinical trials.

Multiple Rectal Polyps in a Young Woman with Constipation

A 27-year-old Asian-American woman presented for evaluation of long-standing constipation. Her first severe episode of constipation occurred at age 7 and resolved with colonic lavage. Colonoscopy at that time was normal. She then experienced complete resolution of her symptoms from ages 7 to 17, when she started again experiencing defecatory difficulties with infrequent and hard stools, difficulties with evacuation, and a sensation of incomplete rectal emptying. On presentation in July 2009, she was dependent on two Senna pills per day; without them, she would not have a bowel movement for up to 1 week. She also reported episodes of rectal bleeding or blood in toilet paper, and abdominal bloating and pain that were relieved with bowel evacuation, as well as continuous and severe straining at evacuation with a feeling of incomplete evacuation. She did not, however, use finger manipulations to facilitate defecation. Her past medical and surgical history was negative and she was using no other medications except for oral contraceptives and multivitamins. She was single, worked as a program manager, lived with her boyfriend, and exercised 3–4 times/week. She did not smoke cigarettes, and drank wine socially. She was vaccinated against human papillomavirus (HPV). Family history was significant for her mother having lung cancer and her father with diabetes mellitus; she had one healthy sister. Upon further review of systems, she reported 8 lbs of weight gain, general fatigue, headaches, and mild anxiety. Her physical examination was normal except for small external hemorrhoids. Complete blood count, comprehensive chemistry panel, and thyroid function tests were all normal. On initial assessment of her constipation, a lactulose breath test was negative. A colon transit study using Sitzmarks was normal. An anorectal motility and compliance study showed a normal anal sphincter length of 5 cm, a normal internal anal sphincter pressure of 72 mmHg, and a slightly decreased external anal sphincter pressure of 91 mmHg. Rectal sensation was impaired since she barely sensed a rectal balloon filled with 50 cc of water. The anorectal inhibitory reflex was present and elicited with 30 cc of balloon distention, thereby excluding Hirschsprung’s disease. Rectal compliance was normal, but she was unable to expel an empty rectal balloon, which was suggestive of pelvic floor dysfunction. Colonoscopy revealed multiple inflammatory polyps in the rectal vault extending circumferentially to the anorectal junction. Biopsies of the polyps were performed and were associated with significant oozing that required control with application of hemostatic clips (Fig. 1). Pathologic examination of the polyp biopsies revealed six separate fragments of rectal mucosa. Five of these fragments showed polypoid hyperplastic mucosa with areas of ulceration, consistent with rectal prolapse. One of these fragments showed an area of moderate squamous epithelial dysplasia (AIN 2). No evidence of an invasive lesion was identified (Fig. 2). Despite her previous vaccination history, HPV immunohistochemistry was positive. She was then treated with polyethylene glycol twice daily for the next 3 months with some improvement of her G. Triadafilopoulos (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: vagt@stanford.edu

An approach to constipation associated with pelvic floor dysfunction

Constipation is usually characterized by infrequent defecation, straining, hard stools and feelings of incomplete evacuation. It is essential to distinguish between acute and chronic constipation. Primary constipation maybe classified as normal transit constipation, slow transit constipation or anorectal dysfunction, which can be either due to ansimus or abnormal perineal descent. A detailed history and physical examination is necessary. Tests of colonic and pelvic floor function help distinguish constipation due to transit problems from that due to anorectal dysfunction. Patients can be divided into 4 main groups : Slow-transit constipation, pelvic floor dysfunction, combined (slow-transit and pelvic floor dysfunction) and normal transit constipation. A small group of patients, refractory to medical therapy should be considered for surgery. Should test results show pelvic floor dysfunction, then behavioural modifications such as biofeedback is successful in up to 76% of patients. An algorithmic approach to treatment is associated with an excellent long term outcome.

A Case of a Vesical Diverticula Causing Constipation

Constipation is generally defined as infrequent stools and or difficult defecation. Most cases of constipation reflect a disorder of bowel function rather than structure. Systemic and structural gastrointestinal causes require exclusion. Lesions that obstruct fecal flow to the point of producing constipation must be advanced and distally located. These can include both benign and malignant processes. Of the benign lesions, a vesical diverticula is an extremely rare cause of constipation. Case Report: 82 year old man with a history of Parkinsons disease, benign prostatic hyperplasia and urinary incontinence presented to the outpatient radiology department for cat scan (CT) for complaints of constipation and vague lower abdominal discomfort. He reported decrease in his frequency of stool as well as a change in the caliber of the stool over the last several months. Symptoms had previously been attributed to his Parkinsons as well as pain medication for his arthritis. Colonoscopy performed two years prior was reportedly normal. CT revealed significant colonic dilation of the sigmoid and descending colon with rectal narrowing as a result of a bladder diverticulum. Flexible sigmoidoscopy was subsequently performed under fluoroscopy which excluded an intraluminal obstructing lesion and documented that the rectal narrowing was caused by the bladder and diverticulum. A foley catheter was inserted with resultant decompression of the bladder and significant improvement in extrinsic compression. Discussion: Bladder diverticula with gastrointestinal manifestations are rare. These diverticula often occur at the entrance of the upper urinary system into the bladder junction. Acquired diverticula are usually related to bladder obstruction, more commonly as a result of bening prostatic hyperplasia (BPH). Patients with bladder diverticulum are usually asymptomatic and require no further intervention. A diverticula only becomes significant if it becomes very large. In these cases, the diverticulum may cause incomplete bladder excretion (leading to stagnation of urine) predisposing to urinary tract infections, harbor an undetected neoplasm, or cause colonic obstruction. The definitive treatment of a symptomatic bladder diverticulum is therefore surgical excision. Summary: Constipation is a relatively common complaint which may be the result on an uncommon process.

Nutritional care of the patient with constipation

Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3 months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. On the other hand, the presence of clinically important abdominal discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating chronic constipation in patients without slow colonic transit or disordered constipation. On the other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and the population being studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic constipation.

Constipation: A common problem in childhood

Constipation in children is defined as the infrequent and difficult passage of hard stool, not necessarily associated with in-frequent stools. All healthy newborns have their first stool within the first 24 to 48 hours after birth. Intestinal transit time increases with age, therapy decreasing the frequency of stooling. ANATOMY AND PHYSIOLOGY OF ANUS AND RECTUM: Acquisition of fecal continence requires: normal internal and external anal sphincters, puborectal muscle as well as intact sensory input from both the rectal vault and anal canal. ETIOLOGY AND DIFFERENTIAL DIAGNOSIS: During the first year of life, failure to have bowel movement every other day warrants evaluation. During infancy, constipation is usually due to dietary manipulations, malnutrition or some other functional abnormalities. Anatomic causes are found only in 5% of patients. Diagnosis relies on history and physical examination. Digital rectal examination usually reveals a shorter anal canal with decreased sphincter tone. The rectal ampulla is dilated and filled with stool. Anorectal manometry is helpful in differentiating functional constipation from aganglionosis or other neurologic problems. Treatment varies depending on the underlying cause. Bowel retraining, aimed at establishing regular daily bowel movement, is of utmost importance in children. The response to treatment is usually dramatic. Constipation in children causes anxiety in the family and successful treatment requires persistent reassurance and repeted reevaluation.

EARLY GASTROINTESTINAL SYMPTOMS and SUBSEQUENT RECURRENT ABDOMINAL PAIN OF CHILDHOOD

Introduction Little is known of the precursors and natural history of childhood recurrent abdominal pain (RAP) and its relationship to early gastrointestinal (GI) function. This study determines the prevalence of common GI problems in childhood and assesses the relationship of RAP at age eight to prior GI function and symptoms. Methods The Raine Study enrolled 2979 women by the eighteenth week of pregnancy in a prospective cohort that has been followed to age eight with extensive data collection every 1 to 2 years. The prevalence of GI symptoms and problems in this population was determined and the relationship of these to the reporting of RAP at age eight was analysed. Results Two thousand eight hundred and sixty infants were assessed at birth, and 2162 of 2620 potentially still available were followed to year 8. One hundred and forty-two children (6.6%) experienced RAP at age eight (9.3% of girls, 5.3% of boys, P = 0.009). Only 16% of these children experienced pain more frequently than several times per week. The occurrence of GI symptoms and function at various ages up to eight have been defined. Seventy five percent of children at all ages defaecated between twice a day and once every second day. The proportion with infrequent defaecation increased with age. Ten per cent of 5-year old had been treated for constipation and 12% had difficulties with faecal soiling. The risk of RAP for early GI symptoms is shown in the table. Symptom/feature Prevalence (%) Odds ratio 95% CI * P < 0.05, ** P < 0.001. Infantile colic 28.7 4.23 3.6–5.0* GOReflux 0–4 months 29 1.23 0.84–1.80 GOReflux 5–12 months 12.8 1.16 0.70–1.91 Frequent stools year 1 17.2 0.70 0.42–1.17 Frequent stools year 2 5.9 1.0 0.43–2.34 Infrequent stools year 2 1.6 4.19 1.57–11.16* Infrequent stools year 8 2.9 4.12 2.17–7.8** Soiling year 5 11.8 1.38 0.28–6.79 Conclusions 1 RAP at age 8 is associated with infrequent defaecation at ages 2 and 8. 2 RAP at age 8 is associated with infantile colic This may reflect underlying sensitivity to gastrointestinal distension and contraction. or reflect parental anxiety. 3 RAP is not associated with frequent stools, GOReflux or with disorders of defaecation.

Symptoms and physiology in severe chronic constipation.

Symptoms of constipation have been attributed to slow colon transit, irritable bowel syndrome (IBS), or pelvic floor dysfunction (PFD). Our aim was to determine the existence of symptom-based constipation subgroups and whether these correspond to differences in colonic transit and anorectal sensorimotor function. Constipated patients (n = 108) completed questionnaires, and underwent colon transit studies, anorectal manometry, and rectal sensory testing. Factor analysis of symptoms was performed. Factor-based symptom scores were correlated with physiological findings. Three symptom factors were identified as compatible with slow colonic transit, IBS, and PFD. There was a significant correlation between the symptoms of slow transit and total and rectosigmoid colon transit. There were also significant correlations between both the IBS symptom score and the number of Manning criteria with measures of rectal hypersensitivity typical of IBS. Neither PFD symptom scores nor symptoms of straining correlated with any electromyographic or manometric measure of anal defecatory function or with rectosigmoid colon transit. Based on physiological testing patients were classified as slow transit, visceral hypersensitivity (typical of IBS), PFD, or no abnormalities found. As expected, slow-transit patients had symptoms of infrequent stools and patients with visceral hypersensitivity had an increased number of Manning criteria for IBS. Patients with PFD physiology and those with no detectable abnormalities had no specific symptoms. Three symptom-based subgroups for constipation were confirmed: slow transit, IBS, and PFD. Slow transit and IBS symptoms correlated with expected physiology. Conversely, PFD symptoms and physiology did not correlate.

Symptoms and physiology in severe chronic constipation

Objective: Symptoms of constipation have been attributed to slow colon transit, irritable bowel syndrome (IBS), or pelvic floor dysfunction (PFD). Our aim was to determine the existence of symptom-based constipation subgroups and whether these correspond to differences in colonic transit and anorectal sensorimotor function. Methods: Constipated patients (n = 108) completed questionnaires, and underwent colon transit studies, anorectal manometry, and rectal sensory testing. Factor analysis of symptoms was performed. Factor-based symptom scores were correlated with physiological findings. Results: Three symptom factors were identified as compatible with slow colonic transit, IBS, and PFD. There was a significant correlation between the symptoms of slow transit and total and rectosigmoid colon transit. There were also significant correlations between both the IBS symptom score and the number of Manning criteria with measures of rectal hypersensitivity typical of IBS. Neither PFD symptom scores nor symptoms of straining correlated with any electromyographic or manometric measure of anal defecatory function or with rectosigmoid colon transit. Based on physiological testing patients were classified as slow transit, visceral hypersensitivity (typical of IBS), PFD, or no abnormalities found. As expected, slow-transit patients had symptoms of infrequent stools and patients with visceral hypersensitivity had an increased number of Manning criteria for IBS. Patients with PFD physiology and those with no detectable abnormalities had no specific symptoms. Conclusions: Three symptom-based subgroups for constipation were confirmed: slow transit, IBS, and PFD. Slow transit and IBS symptoms correlated with expected physiology. Conversely, PFD symptoms and physiology did not correlate.

Acute diarrhea in children.

Acute diarrhea is a common problem in children. Understanding the different pathologic processes that cause diarrhea, and the agents that are associated with those processes, can aid the clinician in predicting the etiology of the diarrhea in an individual patient. Small bowel involvement, most commonly caused by Rotavirus, produces a high incidence of vomiting, often before the onset of diarrhea, and large, watery, and relatively infrequent stools. Large bowel involvement, usually due to Campylobacter, Salmonella, or Shigella produces frequent, often bloody stools containing leukocytes. Treatment of diarrhea should be focused on correcting dehydration, principally with oral rehydration solutions containing appropriate concentrations of electrolytes and carbohydrates. Early refeeding, avoiding foods containing lactose, should be considered for most pediatric patients with acute diarrhea. Antimicrobial therapy should be reserved primarily for parasitic infectious, pseudomembranous enterocolitis, and the early stages of a Campylobacter dysentery. The etiology of acute pediatric diarrhea can be predicted in most patients and early, appropriate treatment can be instituted.

A case of typhoid fever with multiple repeated perforations of the small intestine

T., 21 years old, navigator of the oil fleet, was admitted to the clinic for infectious diseases on the 9th day of illness with complaints of headache, chills, fever, lack of appetite, small diffuse pain and rumbling in the abdomen, loose stools without pathological impurities 1-2 times From the first day of illness, the temperature was constantly in the range of 39.2-40 , there was a headache, loss of appetite. By the end of the first week, there were abdominal pains and infrequent loose stools. He first consulted a doctor on the 9th day of illness and was sent to a hospital with a diagnosis of typhoid fever.