Normal Bowel Habits Research Articles

Nutritional intakes in irritable bowel syndrome

Background: Irritable bowel syndrome (IBS) is a chronic and relapsing bowel disorder that affects 12% of the UK population. Two‐thirds of patients perceive their symptoms to be diet related (Simren, 2001) and restrict their food intake hoping to improve symptoms. This may put them at risk of low nutrient intakes. This study aimed to assess the dietary intake of IBS patients and compare nutrient intake to control subjects.Methods: Patients with IBS and controls were recruited from gastroenterology clinics from local hospitals. Controls were patients who were attending for colonoscopy surveillance for colon cancer or polyps and had a normal bowel habit with no history of IBS symptoms. Each consenting subject completed a validated food frequency questionnaire (FFQ; Bingham, 1997). Energy and nutrient intakes (excluding supplements) were calculated and comparisons were made between groups and with the UK DRVs. Data were compared between the IBS and control groups using unpaired t‐tests or Mann–Whitney U‐tests and a P < 0.05 was considered statistically significant. For nutrients with a significant difference, one‐sample t‐tests were used to determine the significance of any differences between the IBS group and DRVs.Results: Food frequency questionnaires were completed on 34 patients with IBS (35.3 ± 10.3 years; six male) and 17 controls (46.5 ± 9.8 years; 12 male). Energy and macronutrient intakes were similar between groups (Table 1). Intakes of calcium and iron were significantly lower in the IBS group than in controls. Nine women had a calcium intake and nine women had an iron intake below the reference nutrient intake. Twenty‐five (74%) patients with IBS and eight (47%) controls (chi‐squared test, P = 0.1) were taking supplements compared with 35% of respondents in the 2003 National Diet & Nutrition Survey. Nine (26%) patients with IBS and six (35%) controls (chi‐squared test, P = 0.7) were taking either multivitamins or multivitamins & minerals. Energy and nutrient intakes of controls and IBS patients Energy and nutrient intakes IBS Control P‐value Mean (SD) Energy (kcal) day−1 2000 (753) 2258 (621) 0.2 Protein (g) day−1 71.0 (24.8) 71.3 (19.1) 0.9 Fat (g day−1) 83.4 (42.2) 89.7 (35.9) 0.6 Carbohydrate (g day−1) 243.4 (103.5) 270.0 (103.5) 0.3 Fibre (NSP) (g day−1) 20.6 (10.9) 20.4 (7.8) 0.9 Lactose (mg day−1) 3.4 (3.7) 2.3 (2.1) 0.5 Calcium (mg day−1) 580 (303) 673 (192) 0.03 Iron (mg day−1) 9.6 (2.9) 13.2 (4.1) 0.001 Discussion: Patients with IBS may be at risk of low micronutrient intakes. Consideration of calcium and iron intakes and multivitamin and mineral supplementation is important when giving dietary advice for the management of IBS.Conclusions: Patients with IBS should be assessed for inadequate intakes of key nutrients and supplements recommended where appropriate.References Bingham, S.A., Gill, C., Welch, A., Cassidy, A., Runswick, S.A., Oakes, S. et al. (1997) Validation of dietary assessment methods in the UK arm of EPIC using weighed records, and 24‐hour urinary nitrogen and potassium and serum vitamin C and carotenoids as biomarkers. Int. J. Epidemiol. 26, S137–S151.Simren, M., Mansson, A., Langkilde, A.M., Svedlund, J., Abrahamsson, H., Bengtsson, U. & Bjornsson, E.S. (2001) Food‐related gastrointestinal symptoms in the irritable bowel syndrome. Digestion63, 108–115.

Cochrane review: Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

AbstractBackgroundFaecal incontinence is a common and potentially distressing disorder of childhood.ObjectivesTo assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.Search strategyWe searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).Selection criteriaRandomised and quasi‐randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.Data collection and analysisReviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta‐analysis when appropriate.Main resultsEighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow‐up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).Authors' conclusionsThere is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.Plain language summaryBehavioural interventions for the treatment of faecal incontinence in childrenChildren with "faecal incontinence" cannot control their bowel movements and so they soil their underwear. Sometimes people use the word "soiling" or "encopresis" to mean the same thing. Faecal incontinence can be caused by either physical or psychological problems. The term "organic faecal incontinence" is used when faecal incontinence is due to a physical damage or abnormality whilst "functional faecal incontinence" is used when faecal incontinence is caused by non‐organic/psychological factors. Behavioural interventions (toilet training, rewards) are used to reduce children's anxiety and to restore normal bowel habits. Biofeedback is a technique that can be used to teach children how to control the muscles around their back passage.This review identified 18 studies with a total of 1168 children. Behavioural interventions when used together with laxative therapy may improve continence in children with non‐organic faecal incontinence and constipation whilst biofeedback does not add any long‐term benefit. Children who received biofeedback treatment had not always evaluated beforehand for the suitability of the treatment.There was not enough evidence to assess the effects of biofeedback in children with organic faecal incontinence.

Increased prevalence of constipation in pre‐school children is attributable to under‐consumption of plant foods: A community‐based study

To evaluate consumption of foods rich in dietary fibre and its relation to the prevalence of constipation in pre-school children. In total, 368 children aged 3-5 years were randomly selected from kindergartens in Hong Kong. Constipation was confirmed by Rome-criteria. Children with normal bowel habits served as non-constipated controls. Consumption of vegetables, fruits, whole-grain cereals and fluid were determined using a 3-day food record. A total of 28.8% children were reported to have constipation. Median dietary fibre intake of constipated children was significantly lower than non-constipated children (3.4 g/d (inter-quartile range (IQR): 2.3-4.6 g/d) vs. 3.8 g/d (IQR: 2.7-4.9 g/d); P = 0.044) corresponding to 40% reference dietary fibre intake. Constipated children also had significantly lower intakes of vitamin C (P = 0.041), folate (P = 0.043) and magnesium (P = 0.002). Fruit intake and total plant foods intake were significantly lower in the constipated than non-constipated children: (61 g/d (IQR: 23.8-115 g/d) vs. 78 g/d (IQR: 41.7-144.6 g/d); P = 0.047) and (142.5 g/d (IQR: 73.7-214.7 g/d) vs. 161.1 g/d (IQR: 98.3-233.3 g/d); P = 0.034), respectively. Total fluid intake did not differ between groups but milk intake among the constipated children was marginally higher than the non-constipated children (P = 0.055) Insufficient dietary fibre intake is common in Hong Kong pre-school children. Constipated children had significantly lower intakes of dietary fibre and micronutrients including vitamin C, folate and magnesium than non-constipated counterparts which was attributable to under-consumption of plant foods. However, milk intake was marginally higher in the constipated children. More public education is necessary for parents to help develop healthy dietary habit and bowel habit in early life in order to prevent childhood constipation.

Anti-peristaltic ileocolonproctoplasty: a salvage procedure in extensive resective colorectal surgery

In a few patients undergoing extensive colorectal resections, a short intermediate colon segment could be saved and interposed between the ileum and the anorectum, although technical problems usually lead to its loss. Two cases of anti-peristaltic ileocolonproctoplasty after demolitive surgery of both proximal and distal colon (necrosis of the colonic stump after debulking of ovarian cancer and Crohn's disease) are reported. Because the length of the colonic stump was insufficient to allow for a regular clockwise rotation of the colon and an orthotopic, iso-peristaltic colorectal anastomosis, the remnant colon was rotated in an anti-clockwise fashion and an anti-peristaltic anastomosis was performed, similar to a technique we have recently proposed (anti-peristaltic cecorectal anastomosis) for slow-transit constipation. Owing to the different pathological and surgical findings, two technical variants were adopted, involving the preservation of the middle colic artery and the left colic artery, respectively. Post-operative course was uneventful, and the patients shortly recovered normal bowel habits (a mean of 4 and 3 motions over 24 h, respectively). In selected patients, the anti-peristaltic interposition of a saved intermediate colon segment between the ileum and the rectal remnant is an advisable technical solution to preserve some re-absorption and reservoir function and to reduce the risk of diarrhoea, incontinence and urgency.

Can Pain be an Optional Inclusion Criterion for Irritable Bowel Syndrome?

Dear Editor, The diagnosis of irritable bowel syndrome (IBS) is based on Manning or Rome criteria. These criteria have been formulated for the deviations in normal bowel habits for the western population. The normal bowel habits in India differ from those in the West with a median frequency of 2/day [1]. The application of Rome criteria for the Indian subpopulation is not well understood. A retrospective symptom analysis of 320 IBS labeled individuals was done with an aim to derive symptoms which could prospectively predict a diagnosis of IBS. A diagnosis of IBS was made when individuals presented with altered bowel habits with or without abdominal pain for a period exceeding 3 months, absence of alarm symptoms like bleeding per rectum, nocturnal symptoms, weight loss and anorexia. The haemogram, stool microscopy, blood sugar and thyroid hormone profile, small bowel and colon were normal. Data retrieved included age, sex, duration of illness, details of location and duration of abdominal pain, relation of pain to defecation, presence of abdominal bloat, stool frequency, presence or absence of mucus in stool, urgency, and history of incomplete evacuation. The male/female ratio was 2:1. Almost two-thirds of the individuals were between the third and fourth decades (189 patients; 59%). The duration of illness ranged from 3 months to 22 years with a mean of 1.7 ! 1 years. Among the symptoms, diarrhea was the commonest (82%) followed by abdominal pain/abdominal discomfort (33%). Constipation was the least common symptom (15.6%). The abdominal pain was associated with diarrhea and uncommonly with constipation (10%). In conclusion, IBS was more common in males, diarrhea was the predominant presentation and abdominal pain was present only in one third of patients in contrast to the West where IBS prevalence is common in the female gender and constipation predominant IBS is frequent.

Female Bowel Function: The Real Story

There has been minimal research done on normal female bowel habits. Because we do not know what is normal, this affects counseling of patients and research. The aim of this study was to conduct a survey of females with no bowel pathology to obtain a baseline of normal bowel function and examine any normal changes that occur during a woman's lifetime. Females accompanying patients to our hospital and clinic were invited to fill out an IRB-approved questionnaire after excluding those with current bowel pathology, depression, a stoma, or were wheelchair bound. Four hundred twenty-five of 528 questionnaires of females who reported they had normal bowel habits were evaluated. The age range was from 18 to 80 years and comparison was according to age, race, and parity. Fifty-one percent had one bowel movement daily while 30 percent reported fewer. Overall, 15 percent reported constipation, which was higher in African-American females (26 percent) vs. Caucasian females (14 percent), P = 0.08. The average time for a bowel movement was 5-6 minutes, which was longer in African-American females (7.7 min) vs. Caucasian (5.0 min), P = 0.002. Younger females had changes in their bowel pattern reported as soft stool usually associated with their menstrual cycle; this was seen mostly in single females. Menopause did not affect bowels. Thirty-six percent of parous females reported occasional stool incontinence. Flatal incontinence was seen occasionally in over 50 percent of females, more frequently in those over 35 years old. Seventy-four percent of parous females reported incontinence to gas. One-third of females read on the toilet, with a majority doing so to relax or to be distracted and with African-American females reading more (54 percent) vs. Caucasian (32 percent), P = 0.004. Interestingly, Caucasian females read to conserve time (26 percent) vs. African-Americans (4 percent), P = 0.02. Fiber as a supplement was taken by only 8 percent. Foods affected bowel function in all age groups, while travel and exercise did not. Stress affected a change in 35 percent in the 18 to 50-year group. There is a vast diversity in what is considered normal female bowel habits. One daily bowel movement is not the norm. Normal older females and those who have had children report more flatal incontinence. One-third experience some element of fecal incontinence. Foods most commonly caused a change in bowel pattern, followed by menstruation, stress, and childbirth. A vast majority do not take fiber as a supplement.

Is there a hidden mortality after one-stage transanal endorectal pull-through for patients with Hirschsprung’s disease?

One-stage transanal pull-through (TAP) has become a standard definitive procedure for the treatment of Hirschsprung's disease (HD). Short-term results of this operation seem to be excellent, but long-term outcome is still obscure. We evaluated the morbidity and mortality of our patients with one-stage TAP, and we reviewed the literature. We performed a TAP without a colostomy in 21 patients with HD. The primary outcome measures are age, sex, complications during surgery, enterocolitis (EC) attacks after surgery, postoperative stooling problems and mortality. All patients were called over telephone, and their clinical and functional outcomes were obtained. Case series of TAP in the literature were also reviewed in terms of postoperative problems. Twenty-one patients with full thickness rectal biopsy-proven HD underwent one-stage TAP. Average follow-up was 28 months. One early postoperative EC and three more late attacks of EC were observed. All survived patients had normal bowel habits. Three patients had perianal excoriations, three patients soiling, seven cases required anal dilatations and four patients experienced a diarrhea after surgery. We have been informed that four patients died after discharge from hospital. Two of them were a sudden death (one patient had metabolic problems, the other might have had an EC attack). The cause of death of one patient with an associated Down syndrome was a severe pneumonia, and one other case died of a septic shock of unknown etiology. None of these patients had a diarrhea or abdominal distention, which could have been an evidence of an EC attack prior to their deaths. We observed similar fatal cases, when reviewed the published series in the literature. There might be a hidden mortality within the long-term period after TAP for HD. Therefore, we recommend a close follow-up for all patients with any associated health problem and those from low socioeconomic regions after one-stage pull-through.

Disturbed bowel habits in patients with non‐ulcer dyspepsia

BACKGROUND; Emerging medications for non-ulcer-dyspepsia, such as the serotonin-receptor modulators, also affect bowel habits by altering colonic transit. If drugs that alter colonic function were to prove useful in non-ulcer dyspepsia, knowledge of baseline bowel habit disturbances would be potentially critical. To estimate the rate of non-ulcer dyspepsia patients with clinically relevant constipation or diarrhoea potentially precluding use of motility agents. Consecutive patients with non-ulcer dyspepsia (n = 79), gastro-oesophageal reflux disease (n = 135) and organic upper gastrointestinal disease (upper gastrointestinal disease; n = 36) completed a validated symptom questionnaire evaluating predominant bowel habits in the last year. Prevalence of constipation was higher in non-ulcer dyspepsia (34%) than in gastro-oesophageal reflux disease (P = 0.01) and organic upper gastrointestinal disease (P = 0.01), prevalence of alternating diarrhoea/constipation (24%) and diarrhoea (22%) was similar, while prevalence of normal bowel habits was significantly less in non-ulcer dyspepsia (20%; P = 0.01 vs. gastro-oesophageal reflux disease and P < 0.01 vs. organic upper gastrointestinal disease). Constipation was particularly frequent in ulcer-like and dysmotility-like non-ulcer dyspepsia, while prevalence of diarrhoea was lowest in dysmotility-like non-ulcer dyspepsia. A normal bowel habit was equally uncommon in male (21%) and female non-ulcer dyspepsia patients (20%). Only one of five non-ulcer dyspepsia patients had normal bowel habits based on clinical symptoms; constipation is particularly prevalent. Patients with functional dyspepsia who are prescribed motility altering drugs should be evaluated by taking a thorough bowel habit history.

Normal or increased bile acid uptake in isolated mucosa from patients with bile acid malabsorption

Bile acid malabsorption as reflected by an abnormal Se-labelled homocholic acid-taurine (SeHCAT) test is associated with diarrhoea, but the mechanisms and cause-and-effect relations are unclear. Primarily, to determine whether there is a reduced active bile acid uptake in the terminal ileum in patients with bile acid malabsorption. Secondarily, to study the linkage between bile acid malabsorption and hepatic bile acid synthesis. Ileal biopsies were taken from patients with diarrhoea and from controls with normal bowel habits. Maximal active bile acid uptake was assessed in ileal biopsies using a previously validated technique based on uptake of C-labelled taurocholate. To monitor the hepatic synthesis, 7alpha-hydroxy-4-cholesten-3-one, a bile acid precursor, was assayed in blood. The SeHCAT-retention test was used to diagnose bile acid malabsorption. The taurocholate uptake in specimens from diarrhoea patients was higher compared with the controls [median, 7.7 (n=53) vs 6.1 micromol/g per min (n=17)] (P<0.01) but no difference was seen between those with bile acid malabsorption (n=18) versus diarrhoea with a normal SeHCAT test (n=23). The SeHCAT values and 7alpha-hydroxy-4-cholesten-3-one were inversely correlated. The data do not support bile acid malabsorption being due to a reduced active bile acid uptake capacity in the terminal ileum.

A Dose Determination Study of Polyethylene Glycol 4000 in Constipated Children: Factors Influencing the Maintenance Dose

To determine the doses of polyethylene glycol (PEG) 4000 without additional salts allowing normal bowel habits in childhood functional constipation. This multicenter noncomparative study allocated children to 4 groups: 6-12 months, 13 months-3 years, 4-7 years, and 8-15 years. Constipation was defined as <1 stool/d for more than 1 month in children aged 6-12 months and <3 stools/w for more than 3 months in older children. Children randomly received either a nominal or a double starting dose. Treatment scheduled for 3 months could be adapted. Data were collected daily by the parents and rated at each visit by the investigator. In the 96 children included, the median (interquartile) effective daily doses were by groups; 3.75 (2.50-5.00) g, 6.00 (4.00-7.43) g, 11.71 (7.00-16.00) g, and 16.00 (16.00-24.00) g, respectively, i.e., around 0.50 g/day/kg with a potential increment of the maintenance dose with higher initial dosages. More children had a final dosage identical to the initial one when started on the nominal dose (73%) than with the double one (42%, P < 0.003). More than 90% of children recovered normal bowel habits. Fecal soiling ceased in >60% of children with this symptom at enrolment. Fecal mass in the rectum and abdominal pain were markedly reduced and appetite improved. A daily dose of PEG 4000 around 0.50 g/day/kg in children aged 6 months to 15 years is effective in more than 90% of constipated children and 60% of those with fecal soiling.

Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex® rectopexy for rectal prolapse

Two treatment policies for rectal prolapse were prospectively assessed between April 1986 and January 1989. Sixteen patients had a Marlex mesh posterior rectopexy alone and 13 underwent a sigmoidectomy combined with a sutured posterior rectopexy. Preoperative and post-operative assessment included manometry, a saline infusion test and video-proctography. Hospital stay, control of prolapse and complications were comparable in both groups. Restoration of continence occurred in nine of the 12 incontinent patients after Marlex rectopexy, compared with six of nine after sutured rectopexy and sigmoidectomy. Constipation persisted in three patients who were constipated before operation and in four of 13 who had previously normal bowel habits became constipated after Marlex rectopexy; constipation persisted in one of five previously constipated patients while none with previously normal bowel habits became constipated after sutured rectopexy and sigmoidectomy. Sigmoidectomy combined with sutured rectopexy was safe and as efficient as Marlex rectopexy in prolapse control and improvement of continence; significantly fewer patients were constipated (one of 13) after sigmoidectomy than following rectopexy alone (seven of 16). A randomized trial now seems justified.

Self-perceived normality in defecation habits

Background Available information on normal bowel habits was mainly gathered by means of telephone interviews or mailed questionnaires. Aims We undertook a prospective study to evaluate the defecatory habits in subjects perceiving themselves as normal concerning this function. Subjects and Methods A questionnaire (4-week diary with “yes–no” daily answers to six questions concerning bowel habits) was distributed to 204 subjects perceiving their defecation behaviour as normal. Results The completed questionnaire was returned by 140 subjects. No significant differences were found between sexes or age groups for any variable, even though straining at stool and feeling of incomplete and/or difficult evacuation showed a trend to increase with age. No subject had less than three bowel movements per week or more than three per day. The percentage of symptoms linked to an abnormal defecatory behaviour was well below 10%. Fifty-five percent of subjects reported at least one parameter of abnormal functioning; the most frequent was straining at stool and the rarer was the manual manoeuvres to help defecation. Conclusions In normal subjects the prevalence of symptoms considered in Rome II criteria as part of an abnormal defecatory behaviour (in more than 25% of defecations) is well below 10%, manual manoeuvres are almost never used to help defecation, and the frequency of defecations is at least three per week.

Adrenal Incidentaloma: The Influence of a Decision-Making Algorithm on the Short-Term Outcome of Laparoscopy

At the present time, the precise indications for laparoscopic surgery of adrenal incidentaloma (AI) have yet to be completely clarified. The most controversial issue is the role of laparoscopy in the treatment of potentially malignant and large adrenal masses. Trying to address these questions, we retrospectively examined a group of patients with AIs. Forty-two patients with AIs who were laparoscopically treated since 1995 were enrolled in this study. The patients were divided into two groups: the 27 patients of the immediate surgery (IS) group were operated on immediately, whereas the 15 subjects in the delayed surgery (DS) group needed further evaluations and/or a follow-up period before surgery. Surgical timing for both groups was decided according to a widely accepted decision-making algorithm. Many outcome parameters of laparoscopy (operative time, blood loss, conversion rate, time to liquid and solid food nutrition, drainage removal, resumption of normal bowel habits, and average hospital stay) were analyzed in the two groups. The subjects had AIs of various sizes and different histotypes. Patients in the DS group had a higher risk for malignancy. The definitive pathology revealed a malignant biology in 26.6% of DS vs. 0% of IS cases. No difference in the outcome parameters of laparoscopy was observed between the two groups or among pathologically different AIs. A significant correlation was found between the operative time and the size of the AI (r=0.836, P<0.001, linear regression test). Our study shows that laparoscopy is feasible and safe for AIs, regardless of the preoperative probability of malignancy. The size of the AI was the only determinant for choosing a laparotomy. Further long-term studies are necessary to confirm the laparoscopic efficacy in terms of oncologic safety.

Descending Perineum Syndrome: Are Abdominal Hysterectomy and Bowel Habits Linked?

This retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome. Eighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography. Dyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05). Clinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.

Celiac Disease Presenting as Resistant Hypothyroidism

The high prevalence of celiac disease in patients with autoimmune hypothyroidism, compared to the general population, has been well documented but screening for celiac disease is not recommended as yet in otherwise asymptomatic hypothyroid patients. In recent years the high prevalence of undiagnosed celiac disease in the general population, largely as a result of the many atypical manifestations of the disease, has become apparent. We report the case of a 58-year-old woman with autoimmune hypothyroidism who was initially suspected of having celiac disease on the basis of apparent resistance to levothyroxine therapy, and who had no other clinical or laboratory clues to suggest the diagnosis. Cases of undiagnosed celiac disease causing levothyroxine malabsorbtion have previously been described, but all previous cases had other obvious manifestations of the disease. We believe that this atypical presentation of celiac disease warrants further attention, and that the diagnosis of celiac disease should always be considered in patients requiring higher than expected doses of thyroid hormone replacement, even in patients with normal bowel habit, and no other apparent manifestations of the disease.

A prospective assessment of bowel habit in irritable bowel syndrome in women: Defining an alternator

Irritable bowel syndrome (IBS) is subtyped as IBS with diarrhea (IBS-D) or IBS with constipation (IBS-C) based on Rome II guidelines. The remaining group is considered as having mixed IBS (IBS-M). There is no standard definition of an alternator (IBS-A), in which bowel habit changes over time. Our aim was to use Rome II criteria to prospectively assess change in bowel habit for more than 1 year to understand IBS-A. Female patients (n=317) with IBS entering a National Institutes of Health treatment trial were studied at baseline with questionnaires and 2-week daily diary cards of pain and stool frequency and consistency. Studies were repeated at the end of treatment (3 months) and at four 3-month intervals for one more year. Algorithms to classify subjects into IBS-D, IBS-C, and IBS-M groups used diary card information and modified Rome II definitions. Changes in bowel habit at 3-month intervals were then assessed using these surrogate diary card measures. At baseline, 36% had IBS-D, 31% IBS-M, and 34% IBS-C. Except for stool frequency, there were no differences between groups. While the proportion of subjects in each subgroup remained the same over the year, most individuals (more than 75%) changed to either of the other 2 subtypes at least once. IBS-M was the least stable (50% changed out by 12 weeks). Patients were more likely to transition between IBS-M and IBS-C than between IBS-D and IBS-M. Notably, only 29% switched between the IBS-D and IBS-C subtypes over the year. While the proportion of subjects in each of the IBS subtypes stays the same, individuals commonly transition between subtypes, particularly between IBS-M and IBS-C. We recommend that IBS-A be defined as at least one change between IBS-D and IBS-C by Rome II criteria over a 1-year period.

PASSCLAIM--gut health and immunity.

The gut and immune system form a complex integrated structure that has evolved to provide effective digestion and defence against ingested toxins and pathogenic bacteria. However, great variation exists in what is considered normal healthy gut and immune function. Thus, whilst it is possible to measure many aspects of digestion and immunity, it is more difficult to interpret the benefits to individuals of variation within what is considered to be a normal range. Nevertheless, it is important to set standards for optimal function for use both by the consumer, industry and those concerned with the public health. The digestive tract is most frequently the object of functional and health claims and a large market already exists for gut-functional foods worldwide. To define normal function of the gut and immune system and describe available methods of measuring it. We have defined normal bowel habit and transit time, identified their role as risk factors for disease and how they may be measured. Similarly, we have tried to define what is a healthy gut flora in terms of the dominant genera and their metabolism and listed the many, varied and novel methods for determining these parameters. It has proved less easy to provide boundaries for what constitutes optimal or improved gastric emptying, gut motility, nutrient and water absorption and the function of organs such as the liver, gallbladder and pancreas. The many tests of these functions are described. We have discussed gastrointestinal well being. Sensations arising from the gut can be both pleasant and unpleasant. However, the characteristics of well being are ill defined and merge imperceptibly from acceptable to unacceptable, a state that is subjective. Nevertheless, we feel this is an important area for future work and method development. The immune system is even more difficult to make quantitative judgements about. When it is defective, then clinical problems ensure, but this is an uncommon state. The innate and adaptive immune systems work synergistically together and comprise many cellular and humoral factors. The adaptive system is extremely sophisticated and between the two arms of immunity there is great redundancy, which provides robust defences. New aspects of immune function are discovered regularly. It is not clear whether immune function can be "improved". Measuring aspects of immune function is possible but there is no one test that will define either the status or functional capacity of the immune system. Human studies are often limited by the ability to sample only blood or secretions such as saliva but it should be remembered that only 2% of lymphocytes circulate at any given time, which limits interpretation of data. We recommend assessing the functional capacity of the immune system by: measuring specific cell functions ex vivo. measuring in vivo responses to challenge, e. g. change in antibody in blood or response to antigens. determining the incidence and severity of infection in target populations during naturally occurring episodes or in response to attenuated pathogens.

Digestive health in the elderly: faecal incontinence in adults.

Digestive health in the elderly: faecal incontinence in adults.

Irritable bowel syndrome subtypes according to bowel habit: revisiting the alternating subtype.

Disturbed bowel habit, diarrhoea or constipation is a key manifestation of irritable bowel syndrome (IBS). In some patients, diarrhoea and constipation alternate, giving rise to the so-called alternating subtype. To assess IBS subtype breakdown (constipation (C-IBS), diarrhoea (D-IBS) or alternating (A-IBS)) according to the Rome II criteria and patients' self-assessment, the predominance in the alternating subtype (i.e. constipation, diarrhoea or neither), and the medical and personal impact, including health-related quality of life (HRQoL), of the different IBS subtypes. Two thousand individuals selected randomly to represent the general population were classified as potential IBS subjects (n = 281) or as non-potential IBS subjects (n = 1719) according to a validated questionnaire. Bowel habit classification was determined using the Rome II IBS supportive symptoms. Among 201 subjects meeting the Rome I criteria, 15% presented with D-IBS, 44% presented with C-IBS, 19% presented with A-IBS, and 22% presented with normal bowel habit. Among the 63 subjects meeting the Rome II criteria, 23% presented with A-IBS. According to the subjects' self-assessment, of those meeting the Rome I criteria, 16% considered themselves to have D-IBS, 66% to have C-IBS and 18% to have A-IBS. In subjects meeting the Rome II criteria, 24% considered themselves to have A-IBS. Among those classified with A-IBS by the Rome II criteria, most considered themselves to be constipated. Regardless of the subtype self-classification, most subjects reported a normal frequency of bowel movements. Clinical manifestations in A-IBS were very similar to those of C-IBS but with the added presence of defecatory urgency. Abdominal discomfort/pain and frequency of visits to physicians were greater in the A-IBS subtype than in the other two IBS subtypes. HRQoL was affected similarly in all IBS subtypes. Approximately one-quarter of subjects with IBS belong to the A-IBS subtype by the Rome II criteria, although the majority consider themselves to be constipated; indeed, clinical manifestations are more akin to the C-IBS subtype than to the D-IBS subtype. Abdominal discomfort/pain and frequency of visits to physicians are greater in the A-IBS subtype than in the other two IBS subtypes, while HRQoL is impaired similarly.

Delayed gastrointestinal transit in patients with hepatocellular carcinoma.

Disturbed gastrointestinal (GI) motility exists in cirrhotic patients; however, less is known about the character of GI transit in hepatocellular carcinoma (HCC) patients. It is interesting to study the GI transit in HCC patients and to explore the patient factors modulating GI transit. A non-invasive hydrogen breath test, which measured the orocecal transit time (OCTT), was used to study GI transit in 40 HCC patients, 20 cirrhotics and 40 age- and sex-matched healthy volunteers with normal bowel habits. Meanwhile, their clinical manifestations and various blood parameters, such as platelet count, prothrombin time, erythrocyte sedimentation rate etc. were collected. The plasma endothelin-1 and nitrate/nitrite levels were also measured. The OCTT were delayed in HCC and cirrhotic patients compared with controls (116.3 +/- 7.8 and 104.5 +/- 10.6 vs 75.3 +/- 5.1 min, P < 0.05). Neither the severity of liver damage, presence of ascites, tumor size, portal hypertension, nor various blood parameters, such as nitrate/nitrite, endothelin-1, platelet count etc., had any influence on GI transit. Only serum alpha-fetoprotein levels exhibited a trend toward positive correlation with the OCTT (r = 0.271, P = 0.091). Hepatocellular carcinoma patients have delayed GI transit. The confounding factor responsible for the disturbance of GI transit in HCC patients needs further exploration.