Normal Bowel Habits Research Articles

Constipation is associated with an increased risk of major adverse cardiac events in a UK population.

Traditional cardiovascular risk factors, including hypertension, only explain part of major adverse cardiac events (MACEs). Understanding what other risk factors contribute to MACE is essential for prevention. Constipation shares common risk factors with hypertension and is associated with an increased risk of several cardiovascular diseases. We hypothesized that constipation is an underappreciated risk factor for MACE. We used the population healthcare and genomic data in the UK Biobank (n = 408,354) to study the contribution of constipation (ICD10 K59.0) to the risk of MACE, defined by any episode of acute coronary syndrome (ACS), ischemic stroke, and heart failure (HF). Analyses were controlled for traditional cardiovascular risk factors. We also assessed genetic correlations (rg) between constipation and MACE. Constipation cases (n = 23,814) exhibited a significantly higher risk of MACE compared with those with normal bowel habits [odds ratio (OR) = 2.15, P < 1.00 × 10-300]. Constipation was also significantly associated with individual MACE subgroups, in order: HF (OR = 2.72, P < 1.00 × 10-300), ischemic stroke (OR = 2.36, P = 2.02 × 10-230), and ACS (OR = 1.62, P = 5.82 × 10-113). In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE (OR = 1.68, P = 1.05 × 10-136) and a 34% increased risk of MACE occurrence (P = 2.3 × 10-50) after adjustment for medications that affect gut motility and other traditional cardiovascular risk factors. Finally, we detected positive genetic correlations between constipation and MACE subgroups ACS (rg = 0.27, P = 2.12 × 10-6), ischemic stroke (rg = 0.23, P = 0.011), and HF (rg = 0.21, P = 0.0062). We identified constipation as a potential risk factor independently associated with higher MACE prevalence. These findings warrant further studies on their causal relationship and identification of pathophysiological mechanisms.NEW & NOTEWORTHY Analyzing 408,354 participants of the UK Biobank, we show that constipation cases exhibited a significantly higher risk of major adverse cardiac events (MACEs) than those with regular bowel habits. In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE and a 34% increased risk of subsequent MACE occurrence. Finally, we detected positive genetic correlations between constipation and MACE. This association holds potential for therapeutic exploitation and prevention based on individuals' risk assessment.

Motilin fluctuations in healthy volunteers determined by liquid chromatography mass spectrometry.

Motilin is a hormone secreted by specialised enteroendocrine cells in the small intestine, and is known to modulate gastrointestinal motility in humans, regulating the migratory motor complex. It is understudied at least in part due to the lack of commercially available immunoassays. A multiplexed liquid chromatography mass spectrometry (LC-MS/MS) method was optimised to measure motilin, insulin, C-peptide, GIP (1-42) and GIP (3-42). Corresponding active ghrelin concentrations were determined by immunoassay. Ten healthy volunteers with no prior history of gastroenterological or endocrine condition attended after overnight fast and had blood samples taken every 15 minutes for 4 hours whilst continuing to fast, and then further sampling for 2 hours following a liquid mixed meal. Hunger scores were taken at each time point using a visual analogue scale. Normal bowel habit was confirmed by 1 week stool diary. Motilin levels fluctuated in the fasting state with an average period between peaks of 109.5 mins (SD:30.0), but with no evidence of a relationship with either ghrelin levels or hunger scores. The mixed meal interrupted cyclical motilin fluctuations, increased concentrations of motilin, insulin, C-peptide, GIP(1-42) and GIP(3-42), and suppressed ghrelin levels. This study highlights the utility of LC-MS/MS for parallel measurement of motilin alongside other peptide hormones, and supports previous reports of the cyclical nature of motilin levels in the fasting state and interruption with feeding. This analytical method has utility for further clinical studies into motilin and gut hormone physiology in human volunteers.

Evaluation of Solitary Rectal Ulcer Syndrome from Twenty-Four Iraqi Patients

Background: Solitary rectal ulcer syndrome (SRUS) is a rare benign rectal disorder that can present with bleeding, mucus passage, straining during defecation, constipation, rectal prolapse, and a feeling of incomplete evacuation. It is characterized by a combination of clinical findings, histological abnormalities, and symptoms. Since patients frequently come with lesions that are neither solitary nor ulcerated, the nomenclature of the syndrome is deceptive. Multiple factors may be implicated in the etiology and pathogenesis of the illness, which is usually linked to pelvic floor abnormalities. Objectives: To study the distribution of age and sex for this syndrome among a sample of Iraqi patients and to further characterize this syndrome in our population. Materials and Methods: A retro-prospective, descriptive single-center study with this research design was carried out at the Baghdad Gastroenterology and Hepatology Teaching Hospital involved reading reports from (1784) lower gastrointestinal endoscopies (sigmoidoscopy and colonoscopy) performed at the Baghdad Gastroenterology and Hepatology hospital over the course of fourteen months. Of those, twenty-four patients who met the requirements for the clinical, endoscopic, and histological diagnosis of SRUS were examined and monitored. Results: Sixteen patients were female and eight patients were male, mean age was (26.5±9.69), mean duration of symptoms until diagnosis was 12.083 months ±11.5. The most frequent symptom was bleeding per rectum (95.8%).All patients(100%) were subjected to several treatment options, they were advised on normal defecatory behavior and bowel habits, Sulfasalazine enema1-2gm/day for(3-6 months),sucralfate enema(2gm/day for 3months), only four patients(16.6%)ended with endoscopic treatment and two patients(8.3%)ended with surgery. Conclusion: SRUS is a chronic, benign disorder in young adults, often related to straining or abnormal defecation. SRUS remains a well-defined but nonspecific entity with varied presentation, characterized by a rectal lesion caused by straining during defecation. Clinicians, surgeons, and pathologists should be aware of the features of SRUS so that it is not confused with other conditions.

De Novo Diagnosis of Lymphocytic Colitis After SARS-CoV-2 Vaccination

ABSTRACTSARS-CoV-2 mRNA vaccines are safe and effective for most patients. Gastrointestinal complications reported after vaccination have included gastroparesis and inflammatory bowel disease flares. In this study, we present a unique case of lymphocytic colitis that occurred in a healthy middle-aged man after Moderna SARS-CoV-2 mRNA vaccination. This reveals an unexpected complication of a mRNA vaccine that presented as worsening diarrhea after vaccination in a dose-dependent pattern. Caregivers should be aware of lymphocytic colitis as a possible complication of the Moderna vaccine and monitor those patients closely for symptom resolution.

Fluid intake and urinary osmolality in pediatric patients with functional constipation.

This study aimed to evaluate fluid intake and urinary osmolality in pediatric patients with functional constipation. This was a cross-sectional, case-control study that prospectively included two groups: 36 pediatric patients older than 4years with functional constipation (Rome III criteria) who were consecutively admitted in a public tertiary pediatric gastroenterology outpatient clinic and 93 controls with normal bowel habits. The control group was recruited from a public school and did not have any of the characteristics of the Rome III criteria. Fluid and food intakes were assessed using a daily diet inquiry and 24h recording method. Hypohydration was defined as osmolality greater than 800mOsm/kg H2O in a spot urine sample. The age of the functional constipation group (median, 8.9years; range 7.3-10.0years) and the control group (8.8years) was similar (p = 0.51). The proportion of boys in the functional constipation group (76.6%; 25/36) was higher (p = 0.01) than that in the control group (45.2%; 41/93). The total water intake of the functional constipation group (median 1566mL) was lower (p < 0.001) than that of the control group (median 2177mL). Urinary osmolality was higher (p = 0.039) in the functional constipation group (median 859mOsm/kg H2O) than in the control group (median 775mOsm/kg H2O). The association between hypohydration and functional constipation did not reach statistical significance (Odds ratio 2.06; 95% confidence interval 0.93-4.55; p = 0.073). Compared to the control group, patients with functional constipation have lower fluid intake and higher urinary osmolality.

Bowel monitoring in psychiatry of old age: a quality improvement project

AimsThis project aims to ensure all patients in the dementia ward 1 in Kingsway Care Centre, Dundee have daily bowel monitoring and achieve a normal bowel habit. The hypothesis is that patients are inadequately screened and substantial undiagnosed constipation exists.BackgroundConstipation has a prevalence of 16-50% among individuals over 65 years old in the community. Psychiatric illnesses are known risk factors with older psychiatric patients 3-6 times more likely to be constipated. Untreated constipation may progress to serious complications such as bowel obstruction and bowel perforation. Delirium, often mislabelled as worsening psychiatric symptoms, also may occur leading to additional psychotropic medications being prescribed, further worsening the constipation.MethodAll patients in Ward 1, Kingsway Care Centre Dundee over 4 months were included, amounting to 25 patients. Data were gathered from stool charts weekly. Quality improvement framework was followed with two plan-do-study-act (PDSA) cycles completed. Normal bowel function was assessed against ROME IV constipation criteria and less than 75% of Bristol stool type 6 or 7 due to the risk of overflow diarrhoea and laxative overuse. In the first PDSA cycle, stool charts were modified to account for patients independently mobilising to the bathroom and daily documentation even if bowel movements were uncertain. The second PDSA cycle introduced a sticker on charts folder to “ask the patient” along with a staff education leaflet on the complications of constipation. Data were anonymised and analysed with run charts using Microsoft Excel.ResultAt baselines, 50% of patients had a stool chart. This increased to 90% in cycle 1, 100% in cycle 2. 28% of patients had any stools documented at baselines. This increased to 31% in cycle 1, 59% in cycle 2. At baselines, 0% of patients had a normal bowel habit. This maintained at 0% in cycle 1 but increased to 13% in cycle 2. No serious complications were found in patients assisted with toileting. However, 34% of independently mobile patients developed serious complications.ConclusionPoor documentation existed in all patients, particularly those independently mobile. Independently mobile patients were particularly at risk of serious complications of constipation compared to assisted patients. Introduction of new stool charts in the first PDSA cycle resulted in increased documentation but limited benefit for identification of constipation. The second PDSA cycle, targeting staff education and compliance, showed an increase in identification of constipation indicating limited staff knowledge as a key barrier to improvement in patients’ bowel habit.

Conservative management of anterior located anus: A medium-long term follow up

Background/PurposeThe anterior anus (AA) is a condition, almost exclusively present in females, in which the anus is located abnormally anterior along the perineal body, well separated from the vulva. Definition and treatment are still controversial. This study aimed to evaluate the medium-long term follow up of patients with AA conservatively managed, considering the gynaecologic aspects in post-menarchal girls. Matherials/MethodsThis cross-sectional study includes AA patients older than 3 years at time of the study, followed in two referral centres for ARM between January 2000 and May 2017. The API (Anal Position Index) was applied to define AA. A questionnaire regarding the ano-rectal function, occurrence of urinary infection (UTI), familiarity for ARM/AA was administered to parents and patients. Gynecological examination was performed in post-menarchal patients. ResultsFifty-three patients (all females) were retrieved. Three were excluded (2 underwent surgery at another center, 1 was lost at follow-up), 7/50 had major malformations (2 oesophageal atresia, 4 cardiovascular malformations and 1 with Fallot, uretheral duplicity and vertebral anomalies), 5/50 had familiarity for ARM/AA. Only 10% were constipated. Fifteen patients underwent gynecological examination. Their mean API was 0.278 +/- 0.013 DS, they had good buttock tropism, normal resident bacteria, and no UTI. ConclusionAA patients in our centers do not undergo any kind of surgery. At least three quarters of them have a perfectly normal bowel habits and adolescents do not present symptoms related to their condition. These results support the conservative management of this condition.

Laparoscopic posterior mesh rectopexy for rectal prolapse: Our experience

Background: Complete rectal prolapse is not only a physical ailment but also has a huge impact on patient’s mental and social health. A number of surgical methods have been adopted but all have fair outcomes of recurrences and complications in form of constipation.Method: Between July 2018 to December 2019 a total of 20 patients presenting with complete rectal prolapse underwent laparoscopic posterior mesh rectopexy in our hospital. In this prospective study we have tried to analyse the outcomes of this novel approach in terms of recurrence, fecal incontinence and constipation.Result: In the follow up period of 6 months no recurrence was found. Post operative complication was seen in 4 patients as pelvic sepsis and retrograde ejaculation. Fecal incontinence was significantly improved from preoperative baseline. Most of the patients developed a normal bowel habit with acceptable level of constipation.Conclusion: It can be safely concluded that laparoscopic mesh rectopexy not only has an advantage of it being minimally invasive, it also provides acceptable levels of postoperative results in terms of recurrence, fecal incontinence and constipation as compared to open rectopexy found in other studies.

A comparative study on bowel habits among the rural and urban school going adolescents of Puducherry

Background: Adolescence stage the most challenging periods and critical period in one’s life. Bowel habit an important process in day to day life which also shows changes in its pattern from daily life. These changes need to be evaluated for the cause and to prevent certain diseases involving colon and rectum. Objectives was to determine and compare the bowel habits among school going adolescents in rural and urban areas of Puducherry.Methods: A cross sectional study was conducted from Jun 2019 to Aug 2019. School students from 6th to 12th standard were selected by multistage random sampling method. A semi structured self-administered questionnaire was used to collect the data. Data were analyzed by SPSS version 20.Results: A cross sectional school-based study was conducted among 1350 school going adolescence, among them 618 students from rural area and 732 students from urban area participated in the study. Prevalence of constipation was higher among school going adolescents of urban area (21.9%) compared to that of rural area (19.2%). Prevalence of diarrhoea was higher among the school going adolescents of rural area (6.2%) compared to that of urban area (4.1%). Open field defaecation practice was high among the rural adolescents (26.9%) compared to that of urban adolescents (7.4%). Type 3 stool form was the predominant type in both rural (50.03%) and urban (51.8%) school which is the normal stool form in bristol stool chart.Conclusions: Total 87.2% of rural and 87% of urban school going adolescents have a normal bowel habit. Open field defaecation practice was high among the rural adolescents compared to that of urban adolescents.

Incidence of benign anal diseases after bariatric surgery

AimDue to the altered bowel habits after bariatric surgery (BS), we hypothesize that there is a high frequency of benign anal diseases (BAD) in these patients. We aimed to assess the incidence of BAD in patients that underwent BS and the factors associated with its development. MethodA retrospective review of the patient's records with morbid obesity that underwent BS at a single institution from 2010 to 2016 was conducted. ResultsTwo-hundred thirty-five patients who underwent BS were included. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) was performed in 210 (89.4%) and 25 (10.6%) patients, respectively. The total follow-up was 804.3 person-years. The mean postoperative follow-up was 41 months (95% CI: 38–44.1). At follow-up, normal bowel habits were found in 186 (79.2%) patients, constipation in 36 (15.3%), and diarrhea in 13 (5.5%). BAD occurred in 9 (3.8%) patients; hemorrhoids were diagnosed in 6 (2.5%) and abscess/fistulae in 3 (1.3%). There was no predominance of BAD regarding sex (2.9% females Vs. 6.2% males, p = 0.237) or BS performed (3.8% RYGB Vs. 4% SG, p = 0.963). Postoperative weight change was not associated with BAD. Patients who developed BAD after BS were older (median 52 Vs. 45 years, p = 0.011) and had fewer bowel movements per day (median 1 Vs. 2, p < 0.001). All patients with BAD had constipation after BS in comparison to 11.9% of patients without BAD (p < 0.001). In the logistic regression analysis only the age was associated to the development of BAD (p = 0.033). ConclusionThe frequency of BAD after BS was 3.8% over a mean follow-up time of 41 months. The estimated incidence density of BAD after BS was 11.1 events per 1000 person-years. Older age was associated with its occurrence.

Bile pigment in small-bowel water content may reflect bowel habits: a retrospective analysis of a capsule endoscopy imaging series

BackgroundPigmented bile salts darken the small-bowel lumen and are present with bile acid, which is involved in the development of bowel habits. The small-bowel water content (SBWC) in the ileum could represent the colonic environment, but no studies have focused on this feature. However, measurement of crude SBWC can be challenging because of the technical difficulty of the endoscopic approach without preparation. Our aim was to evaluate optically active bile pigments in the SBWC of patients with abnormal bowel habits using capsule endoscopy (CE) to investigate the impact of bile acid on bowel habits.MethodsThe study population included 37 constipated patients, 20 patients with diarrhea, and 77 patients with normal bowel habits who underwent CE between January 2015 and May 2018. Patients with secondary abnormal bowel habits were excluded. In addition to conventional imaging, we used flexible spectral imaging color enhancement (FICE) setting 1 imaging, in which the effects of bile pigments on color are suppressed. Intergroup color differences of SBWC in the ileum (ΔE) were evaluated from conventional and FICE setting 1 images. Color values were assessed using the CIE L*a*b* color space. Differences in SBWC lightness (black to white, range 0–100) were also evaluated.ResultsThe ΔE values from the comparison of conventional images between patients with constipation and with normal bowel habits and between patients with diarrhea and with normal bowel habits were 12.4 and 11.2, respectively. These values decreased to 4.4 and 3.3, respectively, when FICE setting 1 images were evaluated. Patients with constipation and diarrhea had significantly brighter (34.4 versus 27.6, P < .0001) and darker (19.6 versus 27.6, P < .0001) SBWC lightness, respectively, than patients with normal bowel habits. The FICE setting 1 images did not reveal significant differences in SBWC lightness between those with constipation and with normal bowel habits (44.1 versus 43.5, P = .83) or between those with diarrhea and with normal bowel habits (39.1 versus 43.5, P = .20).ConclusionsDifferences in SBWC color and darkness in the ileum appear to be attributable to bile pigments. Therefore, bile pigments in SBWC may reflect bowel habits.

EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children.

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea.

Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear. We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3months. A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea. In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.

Gastrointestinal Tolerance and Microbiome Response to Snacks Fortified with Pea Hull Fiber: A Randomized Trial in Older Adults.

ABSTRACTBackgroundConsuming foods with added fiber may help older adults achieve fiber recommendations; however, many high-fiber ingredients have little effect on laxation and may contribute to unpleasant gastrointestinal side effects.ObjectivesThe aim of the study was to determine the effects of consuming snacks fortified with pea hull fiber (PHF) on stool frequency and form, gastrointestinal symptoms, and appetite in older adults. An exploratory aim was to determine if PHF altered the microbiota profile.MethodsA 10-wk, randomized, blinded, crossover study was carried out. Following a 2-wk baseline period, participants [aged (mean ± SD) 69.7 ± 6.5 y; n = 31; 14 men, 17 women] consumed snacks providing 10 g/d of PHF or a control, each for 2-wk periods followed by 2-wk washouts. Participants used the Bristol Stool Form Scale (BSFS) to record daily stool frequency and gastrointestinal symptoms, and completed the Gastrointestinal Symptom Rating Scale (GSRS) and Simplified Nutritional Appetite Questionnaire (SNAQ) biweekly. One stool was collected per period for 16S ribosomal RNA high-throughput amplicon sequencing of the fecal microbiota profile.ResultsParticipants reported 1.63 ± 0.05 stools/d and 76.6% normal transit stool form at baseline and no change with PHF. GSRS syndrome scores were similarly unchanged. Daily abdominal noises and bloating were higher for PHF versus control, and flatulence was higher for PHF versus baseline, suggesting fermentation in some individuals. There was no evidence to suggest a common PHF-induced microbiome response for the group as a whole; however, a subgroup of participants (n = 7) who responded with increased flatulence (fermenters), harbored many different taxa than nonfermenters, and demonstrated lower abundance of Clostridiales with PHF. Appetite was unchanged with PHF.ConclusionsPHF did not modulate stool form or frequency in older adults with normal bowel habits. Because snacks fortified with PHF did not suppress appetite, PHF may be an appropriate fiber source for older adults at nutritional risk. Microbiome profile may be predictive of gastrointestinal symptom response to PHF. This trial was registered at www.clinicaltrials.gov as NCT02778230.

Twisted Adnexa in a Premenarchal Girl

An 11-year-old premenarchal girl was admitted with a complaint of 1 day of acute right lower quadrant pain radiating toward her right leg, accompanied by nausea, vomiting, and fever. Tachycardia was observed upon admission, with normal bowel and bladder habits. There was tenderness on palpation in the right lower quadrant. Ultrasonography showed a cystic space-occupying lesion in the right ovary, which measured 7.0 × 5.3 cm2. Color Doppler did not show diminished blood flow. Laparoscopy was proposed for confirmation of the diagnosis and treatment.

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.

Chronic Diarrhea and Constipation Are More Common in Depressed Individuals

Depression is a major health issue in the United States and is highly comorbid with gastrointestinal conditions. We collected data from the National Health and Nutrition Examination Survey (NHANES), a representative sample of the US population, to study the relationship between depression and bowel habits. Using data from the NHANES (2009-2010), we identified 495 depressed and 4709 non-depressed adults who filled out the Bowel Health Questionnaire. Depression was defined according to a validated questionnaire. We used multivariable analysis, controlling for clinical and demographic variables, to evaluate the relationship between mood and bowel habits. In our weighed sample, 24.6% of depressed individuals and 12.6% of non-depressed individuals reported disordered bowel habits. Chronic diarrhea was significantly more prevalent in depressed individuals (15.53%; 95% CI, 11.34%-20.90%) than non-depressed individuals (6.05%; 95% CI, 5.24%-6.98%; P = .0001). Chronic constipation was also more common in depressed individuals (9.10%; 95% CI, 7.02%-11.69%) than non-depressed individuals (6.55%; 95% CI, 5.55%-7.70% CI; P = .003). Mean depression scores in patients with chronic diarrhea (4.9 ± 5.8) and with chronic constipation (4.4 ± 4.93) were significantly higher than mean depression scores for individuals with normal bowel habits (3.2 ± 4.6) (P < .001). Moderate and severe depression were significantly associated with chronic diarrhea but not chronic constipation. Only mild depression was significantly associated with chronic constipation. In an analysis of the NHANES database, we found a higher proportion of depressed individuals to have chronic diarrhea and constipation than non-depressed individuals; chronic diarrhea was more strongly associated with depression. Our findings provide support for the relationship between mood and specific bowel habits, accounting for multiple co-variables in a large sample of the general US population.

Comparative study of outcome following primary posterior sagittal ano-rectoplasty and primary anterior sagittal ano-rectoplasty for vestibular fistula

Background: To compare the postoperative complications and bowel function following primary PSARP and primary ASARP.Methods: This prospective study was carried out over a period of 4 years. Patients above 4 months, who needed surgical repair for vestibular fistula were included in study. They were randomly allocated into PSARP group and ASARP group. After surgical intervention, patients of both groups were compared with respect to post-operative complications, voluntary bowel control, constipation, need for laxatives.Results: 44 patients were enrolled in the study. Of these, 22 patients were allocated to primary PSARP group while remaining patients underwent ASARP. One patient from each group was lost to follow‑up and hence, excluded from the final analysis. The two groups were comparable with respect to age, maturity at birth, weight at the time of surgery, blood investigations. Total 16 patients had associated congenital anomalies. During the postoperative period, four patients from PSARP group and two patients from ASARP group had superficial wound infection of perineal incision which was managed conservatively. One patient in PSARP group had a major breakdown of perineal wound with retraction of pulled rectum which required colostomy. There was no recurrence of fistula in any patient. No patient had stenosis of neo-anus or anterior displacement of rectum. Functional assessment of bowel function was done in 25 patients who completed 3 years of age. Voluntary bowel movements were observed in 75% of cases in the ASARP group compared to 38 % in PSARP group. 15% patients of PSARP group and 7.5% patients with ASARP had soiling. Though the difference was not statistically significant, nearly 38% of the patients after PSARP, needed laxative for normal bowel habit compared to 8% patients in ASARP group.Conclusions: ASARP promises many advantages in the treatment of vestibular fistula in comparison to PSARP. Comparable post-operative complications, good cosmetic results, excellent continence with less need for laxatives are the advantages of ASARP.

Chronic Diarrhea After Infectious Enteritis: Not the Diagnosis You Are Thinking of

Microscopic colitis is described as an inflammatory bowel disease characterized by chronic, non-bloody diarrhea with normal or close to normal endoscopic findings. Histopathological examination reveals two subtypes: collagenous colitis and lymphocytic colitis, which are indistinguishable clinically. Microscopic colitis has a female preponderance, with a mean age at diagnosis of 65 years. The pathogenesis of microscopic colitis is unclear, but it is likely to be multifactorial, involving mucosal immune responses to luminal factors in a genetically predisposed individual. We present two cases of young patients presenting with chronic diarrhea, which began after episodes of infection enteritis, both ultimately diagnosed with lymphocytic colitis. A 30-year-old male presented to the office with diarrhea for 5 months. The change in bowel habits occurred after an episode of apparent food poisoning due to eating oysters. While acute vomiting subsided, he continued to have painless, watery, non-bloody bowel movements 5-6 times per day particularly after meals with nocturnal symptoms. Physical examination, labs and chemistry were unremarkable. Colonoscopy was macroscopically normal. Random colon biopsies revealed increase in lymphoid cells in the lamina propria and intraepithelial regions. A 23-year-old female presented with diarrhea and 10lb weight loss over the preceding six months. Diarrhea was painless, non-bloody, watery, multiple times a day, particularly after meals and waking her from sleep. Medical interview identified a trip to Mexico which preceded her diarrheal illness and during which she suffered from a seemingly self-limited episode of infectious enteritis. Physical exam, CBC, chemistry, serology for celiac disease and stool studies were unremarkable. Colonoscopy was remarkable for mild patchy erythema throughout the colon, biopsies revealed changes consistent with lymphocytic colitis. Loperamide did not improve diarrhea in either case. Both patients were started on budesonide 9mg and tapered over several weeks, which led to full remission of diarrhea and return to normal bowel habits. Simple infectious enteritis can be a predisposing factor for microscopic colitis and should be considered along with post-infectious irritable bowel syndrome when patients do not improve with time and supportive care alone. This diagnosis should be considered in very young patients even though they are not the typical demographic for the disease.2090 Figure 1. Colon Biopsy

Limited uptake of ulcerative colitis "treat-to-target" recommendations in real-world practice.

A "treat-to-target" approach has been proposed for ulcerative colitis (UC), with a target of combined clinical and endoscopic remission. The aim of the study was to evaluate the extent to which proposed targets are achieved in real-world care, along with clinician perceptions and potential challenges. A multicentre, retrospective, cross-sectional review of patients with UC attending outpatient services in South Australia was conducted. Clinical and objective assessment of disease activity (endoscopy, histology, and/or biomarkers) was recorded. A survey evaluated gastroenterologists' perceptions of treat to target in UC. Statistical analysis included logistic regression and Fisher's exact tests. Of 246 patients with UC, 61% were in clinical remission (normal bowel habit and no rectal bleeding), 35% in clinical and endoscopic remission (Mayo endoscopic sub-score≤1), and 16% in concordant clinical, endoscopic, and histological (Truelove and Richards' Index) remission. Rather than disease-related factors (extent/activity), clinician-related factors dominated outcome. Hospital location and the choice of therapy predicted combined clinical and endoscopic remission (OR 3.6, 95% CI 1.6-8.7, P<0.001; OR 3.3, 95% CI 1.1-12.5, P=0.04, respectively). Clinicians used C-reactive protein more often than endoscopy as a biomarker for disease activity (75% vs 47%, P<0.001). In the survey, 45/61 gastroenterologists responded, with significant disparity between clinician estimates of targets achieved in practice and real-world data (P<0.001 for clinical and endoscopic remission). Most patients with UC do not achieve composite clinical and endoscopic remission in "real-world" practice. Clinician uptake of proposed treat-to-target guidelines is a challenge to their implementation.