Normal Bowel Habits Research Articles

Risk Factors for Fecal Urgency Among Individuals With and Without Diarrhea, Based on Data From the National Health and Nutrition Examination Survey

Fecal urgency is a common symptom among patients with gastrointestinal disorders, but can also occur in healthy individuals with normal bowel habits. There have been few studies of fecal urgency in the general population. We performed a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) to analyze the prevalence of and risk factors for this symptom. We analyzed data from 4676 persons who completed the Bowel Health Questionnaire from the NHANES, from 2009 through 2010. The NHANES sampled a nationally representative group of adults in the United States and provides information on demographics, medical comorbidities, and dietary habits of survey participants. The Bowel Health Questionnaire provided additional information about bowel symptoms such as urgency, incontinence, constipation, and diarrhea. We identified individuals with fecal urgency and calculated differences in fecal urgency among subgroups using chi-squared analysis. We used logistic regression to identify factors associated with urgency. In our study population, the prevalence of fecal urgency was 3.3%; 29.5% of individuals with fecal urgency had diarrhea. The prevalence of fecal urgency was significantly higher in individuals who had diarrhea (14.8%) than in individuals without diarrhea (3.1%). Older age, female sex, poverty, urinary urge incontinence, diarrhea, and increased stool frequency were all associated with fecal urgency on multivariable analysis. Decreased fiber intake and increased carbohydrate intake were associated with urgency among individuals with diarrhea. In an analysis of data from 4676 individuals who completed a Bowel Health Questionnaire from the NHANES, we found a significantly higher proportion of individuals with diarrhea to have fecal urgency. However, most individuals with fecal urgency do not have diarrhea. Factors associated with fecal urgency vary among individuals with and without diarrhea.

Features of Upper Abdominal Pain that Predict Symptoms Relief after Cholecystectomy in Patients with Uncomplicated Gallstones Disease

Introduction: Gallbladder disease is common and results in high health care costs. Indeed, estimates of the lifetime risk of gallstone formation are as high as 10% to 20% of the general population. The natural history of symptomatic gallstone disease is such that approximately 70% of patients will continue to have episodic symptoms or experience a complication of gallstones within 2 years of initial diagnosis. Adding to this potential confusion is the occurrence of abdominal pain thought to resemble gallbladder pain but without gallstones present. Laparoscopic cholecystectomy remains the gold standard for treatment of symptomatic cholelithiasis. However, persistent symptoms after cholecystectomy occur in 10 to 33% of patients. Although a variety of clinical characteristics have been evaluated as preoperative factors associated with outcome after cholecystectomy, preoperative symptoms are generally used as a reference point for diagnosis and determination of need of cholecystectomy. Characterizing and identifying symptoms that predict relief from upper abdominal pain after cholecystectomy could better guide physicians to recommend cholecystectomy so as to reduce morbidity, mortality and cost and minimize unnecessary surgery. Aim: The objective of this study is to identify symptoms predicting complete relief of upper abdominal pain (UAP) after cholecystectomy to help better selection of patients who might benefit from surgery. Subjects and methods: This study is a prospective analysis involving 950 adult patients undergoing cholecystectomy for symptomatic cholelithiasis. The study included 721 females (75.89%) and 229 males (24.11%). The patients were asked to complete a previously-validated biliary symptoms questionnaire (BSQ) before operation and 3 months postoperatively as well. At the end of the last questionnaire, each patient was required to define whether (as overall) his symptoms were relieved or not. Our patients were divided into two groups according to pain relief after surgery; Group (I) included patients who had pain relief after surgery (713 patients-75.05%) and group (2) included patients who did not have pain relief after surgery (237 patients-24.95%). Results: Our study shows that the likelihood of having pain relief is greater in patients who have UAP onset one year or less preoperatively, UAP of short duration, UAP occurring most frequently in the evening or at night time and whose pain awakens them by night, patients who do not have lower abdominal pain, patients who have normal bowel habit pattern, patients who have infrequent nausea attacks, patients who do not often have excessive gas bloat or burps and patients who do not suffer concomitant GERD or IBS. Conclusion: Laparoscopic cholecystectomy is an effective management option for symptomatic cholelithiasis, with a cure rate of 75.05% in our study. Better rates of pain relief can be achieved by better selection of patients, as sub analysis of symptoms showed better cure rates in the subgroups. The followings were found as good predictors of outcome: older age, female patients, short onset of the disease (≤ 1 year), infrequent attacks of pain once or less per week, short duration of attacks less than 30 minutes, attacks occurring by night or awakening the patient by night, attacks of moderate to severe intensity, patient with normal bowel habits, absence of lower abdominal symptoms, absence of gas bloating, and absence of GERD or IBS. Our study shows that pain relief progressively increases with increasing the number of positive predictive symptoms, being the best at the level of 4 positive predictive symptoms. Further larger studies are still needed to further define reliable prognostic symptoms to assure better selection of patients.

Effect of Chicory-derived Inulin on Abdominal Sensations and Bowel Motor Function.

Goal:To determine the effect of a prebiotic chicory-derived inulin-type fructan on the tolerance of intestinal gas.Background:Subjects with gas-related complaints exhibit impaired handling of intestinal gas loads and we hypothesized that inulin would have a beneficial effect.Study:Placebo-controlled, parallel, randomized, double-blind trial. Subjects with abdominal symptoms and reduced tolerance of intestinal gas (selected by a pretest) received either inulin (8 g/d, n=18) or maltodextrin as a placebo (8 g/d, n=18) for 4 weeks. A gas challenge test (4 h jejunal gas infusion at 12 mL/min while measuring abdominal symptoms and gas retention for 3 h) was performed before and at the end of the intervention phase. Gastrointestinal symptoms and bowel habits (using daily questionnaires for 1 wk) and fecal bifidobacteria counts were measured before and at the end of the intervention.Results:Inulin decreased gas retention during the gas challenge test (by 22%; P=0.035 vs. baseline), while the placebo did not, but the intergroup difference was not statistically significant (P=0.343). Inulin and placebo reduced the perception of abdominal sensations in the gas challenge test to a similar extent (by 52% and 43%, respectively). Participants reported moderate gastrointestinal symptoms and normal bowel habits during baseline examination, and these findings remained unchanged in both groups during the intervention. Inulin led to a higher relative abundance of bifidobacteria counts (P=0.01 vs. placebo).Conclusions:A daily dose of inulin that promotes bifidobacteria growth and may improve gut function, is well tolerated by subjects with gastrointestinal complaints.

Covering the Cover

Covering the Cover

Comparative study of stapled haemorrhoidectomy under local anaesthesia versus spinal anaesthesia

Background The aim of this study is to compare and evaluate the results of stapled haemorrhoidectomy performed under local anaesthesia against those performed under spinal anaesthesia in terms of postoperative pain, bleeding per rectum, the time needed for return to normal bowel habits and resumption of normal physical activities (within one week of surgery), incidence of recurrence and stenosis (within three months of surgery).

Bowel Habit Pattern and Perception about Bowel Habit Pattern of Medical Students

Objectives: This study aimed at evaluating the bowel habit pattern of medical students along with their perception regarding their bowel habit. Materials and methods: In this observational study normal bowel habit was defined by both Western criteria (Rome III) and Asian diagnostic criteria. Results: Out of 249 (M = 155) students, 139 (55.8%) had predominantly Bristol type T4 stools, 51 (20.5%) had T3 stools, 18 (7.2%) had T5 stools, 23 (9.2%) had T 6/T7 stools and19 (7.6%) had T1/T2 stools. Weekly mean stool frequency was 9.09 ± 4.058(Male 9.6 vs. female 8.2, P = 0.016), with a range of 3- 28 motions/week. According to Western criteria 156 (62.65%, M = 101) had normal bowel habit, while by Asian criteria the figure was 109(43.8%). Predominant stool form in Western normal bowel habit group was T4 (n = 109, 69.9%); 34 (21.8%) had T3 stools. Mean stool frequency of normal bowel habit group (8.66/week) was different from constipation group (6.0/week, P = 0.004) but not from diarrhea group (9.38/week, P = 0.540). A total of 189 (75.9%) students perceived their bowel habit as normal, 17 as constipation, 2 as diarrhea and 12 as alternating diarrhea and constipation. Out of 156 students with normal bowel habit, 134 (85.9%) perceived their bowel habit as normal. A moderate agreement (K = 0.603, P < 0.0005) was found between western criteria and Asian criteria. Agreement between western normal bowel habit and students’ perception was poor (K = 0.61, P < 0.0005). Conclusion: Mean stool frequency of medical students was lower than some Asian countries but the predominant stool from was like most other countries. A wide mismatch was apparent between students’ perception of their bowel habit and Western criteria.

PP‐1 BOWEL HABITS IN SRI LANKAN INFANTS AND TODDLERS, A POPULATION BASED STUDY

Objective:To obtain knowledge about bowel habits in healthy population of infants and toddlers in Sri Lanka.Methods:We selected healthy children between 7 months and 5 years of age who visited vaccination and weighing clinics. To achieve data we used a self‐administered questionnaire about the child's bowel habits during the previous two months. All subjects were selected in Gampaha district, Sri Lanka. Only those without defecation disorders were used for analysis.Results:A total of 879 toddlers were eligible for analysis, (female n = 442 [50,3%], mean age 21,7 months, standard deviation [SD] 12,5 months). Of them, 595 (69,6%) defecated once a day, 20 (2,3%) had defecation &gt;3/week and 6 (0,7%) &lt;3/week. Stool consistency was hard or very hard in 30 (3,4%), 665 (78,9%) had smooth and soft stool and 107 (12,2%) had varying consistency. Straining and painful stool were reported in 560 (64,7%) respectively 194 (23%) of the sample, stool holding was present in 93 (10,8%) and 44 (4,9%) passed blood with the stool. No children reported fecal incontinence.Conclusions:This study provides data on normal bowel habits of Sri Lankan toddlers and infants. Bowel habits and disorders related to defecation in Sri Lankan toddlers and children differ from those living in the West probably due to dietary, genetic and environmental variations.

Semi-closed bilateral partial miotomy of the puborectalis for anismus: a pilot study: Partial miotomy of the puborectalis for anismus.

Anismus or non relaxing puborectalis muscle (PRM) may cause obstructed defecation (OD). Reported surgical treatment is partial miotomy, followed by sepsis, bleeding, and incontinence. The aim of the present study was to investigate on the feasibility and outcome of a modified mini-invasive operation. Consecutive patients with anismus and OD not responding to medical therapy, excluding multiparous females, patients with anal incontinence, recto-rectal intussusception, and disordered psychological pattern. Semi-closed bilateral partial division of PRM, pulled down through 1-cm perianal incisions, was performed. Concomitant significant rectal mucosal prolapse and rectocele, when present, were treated. OD was evaluated using a validated score and anal/vaginal ultrasound (US) was performed pre -and postoperatively. A control group of seven patients with normal bowel habit was also investigated. Eight patients (seven females), median age 48 years (range 29-71) were operated. Six also had significant mucosal prolapse and rectocele. All were followed up for a median of 12 months (range 2-40). None of them had postoperative sepsis or bleeding. One had just one occasional episode of mild anal incontinence. Symptoms improved in 6 or 75 % and, OD score decreased from 19.6 ± 1.0 to 9.2 ± 2.0 (mean ± s.e.m.), P = 0.007. No patient had anismus after surgery and PRM relaxation changed from 0 to 5.9 ± 0.8 mm being 6.6 ± 1.5 mm in controls. Semi-closed bilateral partial division of PRM achieves muscle's relaxation on straining in all patients without any significant postoperative complication. Further studies are needed prior to consider it a validated procedure.

Randomized controlled trial of probiotics after colonoscopy.

Up to 20% of patients have ongoing abdominal symptoms at day 2 and beyond following colonoscopy. It was hypothesized that some of these symptoms are related to alterations in gut microbiota secondary to bowel preparation and would improve with probiotics compared with placebo. Patients were given either a probiotic or placebo capsule in the days following colonoscopy. Colonoscopy was performed with air insufflation. The probiotic capsule contained the strains Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07. Patients recorded their symptoms at 1 h, 1, 2, 4, 7 and 14 days post colonoscopy and returned results once their symptoms had resolved. The primary outcomes used were the length of days to resolution of bloating, abdominal pain and altered bowel function post colonoscopy. A total of 320 patients were randomized. After loss to follow-up and withdrawal, 133 patients were analysed in the probiotic group and 126 in the placebo group. Patients having probiotic had a lower number of pain days following colonoscopy, 1.99 versus 2.78 days (P < 0.033). There was no significant difference in bloating or return to normal bowel habit days (P = 0.139 and 0.265 respectively). Subgroup analysis revealed that patients with pre-existing abdominal pain benefited from probiotics in number of pain days, 2.16 versus 4.08 (P = 0.0498). Our study has shown a significant reduction in the duration of pain days post colonoscopy in patients taking probiotic compared with placebo. No significant effect was seen in terms of return to normal bowel function or bloating post colonoscopy.

Laparoscopy in Neonates in Bangladesh: Technical Challenges and Experience in Chittagong

Introduction: Pediatric Minimally Invasive Surgery is a relatively newer concept in Bangladesh and started about 8 years ago. It took some time to gather sufficient expertise to start in the neonates. However, due to resource constraints we are to practice with conventional equipments and still performing soLaparoscopy in Neonates in Bangladeshme advanced procedures. We are one of the pioneers in neonatal laparoscopy in Bangladesh and this article will review the common procedures that we perform.Materials and methods: From 7, October 2005 to 30, June 2011, 1953 cases underwent laparoscopic/thoracoscopic procedures in our department of which 117 were neonates. We have used conventional 5 mm 30 cm instruments including 5 mm 30º telescope. First trocar was introduced by open method and CO2 was pressure was kept below 8 mmHg. Age, sex, indications, operative procedures, complications and outcomes are evaluated retrospectively.Results: Ages ranged from 3 days to 30days with males predominant (1: 0.56). Laparoscopy-assisted pullthrough for Hirschsprung’s disease was the commonest procedure (71) followed by Pyloromyotomy (21), Inguinal hernia repair (15), Ovarian cystectomy (06) and Diaphragmatic hernia repair (03). Six cases needed conversion, port-site infection occurred in 5 cases and incisional hernia in one. Six cases of Georgeson’s operation developed sepsis needing colostomy and three (2.56% of total neonates) of them died. Follow up was from 3 months to 5 years. Twenty three out of 60 successful Georgeson’s operations had peri-anal excoriation persisting for initial 2-3 weeks. Forty six cases are now having normal bowel habits, seven having constipation, five occasional soiling and two fecal incontinence. One (6.66%) inguinal hernia recurred. Overall 70% had uneventful outcomes and 9.4% had serious complications including death.Conclusions: Laparoscopy can be done in neonates using basic instruments with reasonable outcomes in a developing country settingJ. Paediatr. Surg. Bangladesh 4(1): 5-10, 2013 (January)

PTH-246 Can we trust reports of stool consistency? the validity and reliability of the bristol stool form scale

<h3>Introduction</h3> Stool form is frequently used as a proxy measure of stool consistency, which is a central component in the description of normal or altered bowel habit. The Bristol Stool Form Scale (BSFS) is in widespread use in clinical practice and research and yet has undergone incomplete assessment of validity and reliability. The aim of this study was to determine concurrent validity and intra-rater reliability of the BSFS. <h3>Method</h3> Healthy adults provided a single real stool that was independently categorised using the BSFS by both themselves and by an expert in gastroenterological research, following which stool water was measured using lyophilisation. Participants also used the BSFS to categorise 26 stool models, 7 representing the BSFS types (reference types) and 6 intermediate types, all covertly provided in duplicate. Concurrent validity (comparison with gold standard) was determined by measuring (i) agreement between participants and experts categorisation; (ii) comparison with stool water content; and (iii) the accuracy of categorisation of reference stool models. Intra-rater reliability was measured by the accuracy of categorisation of covert duplicate stool models. <h3>Results</h3> 86 healthy adults categorised the stool models, of which 59 provided a real stool. Stool water content was significantly different between stools categorised to different stool types (P &lt; 0.05) and water content correlated with BSFS type (rs = 0.320, p &lt; 0.05). Participants and experts agreed on 36% of real stool categorisations, representing only fair agreement (κ = 0.25). Stools categorised as Type 2 and 5 by participants (both at the border of normal consistency) were actually assigned a wide range of types by the experts. Participants correctly categorised reference stool models on 81% of occasions, representing substantial accuracy. However, the Type 2, 3 and 6 reference models were categorised correctly on less than 75% of occasions. Familiarity with the scale improved accuracy of model categorisation (p &lt; 0.05). Overall substantial intra-rater reliability was demonstrated (κ = 0.72), although low exact agreement was seen with the Type 2 and 3 models. <h3>Conclusion</h3> Overall, the BSFS has good concurrent validity and intra-rater reliability. However, categorisation of real stools proves difficult for some. In both categorisation of real stools and stool models issues arise around the borders of stool types representing normal and abnormal bowel habit (Types 2 and 3 and Types 5 and 6) and this should be taken into consideration when using the scale. Familiarity with the scale and education in its use may improve accuracy of stool categorisation. This study should be repeated in patients with abnormal bowel habit to determine its utility in clinical practice. <h3>Disclosure of interest</h3> None Declared.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction

PurposeTo evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group). Patients and methodsOne-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit. ResultsFFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections. ConclusionsFFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

Experience of the MACE Procedure at A Regional Pediatric Surgical Unit: A 15-Year Retrospective Review

The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit. Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States). A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3-19 years) and mean follow-up time was 6.5 years (range, 1-10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems. This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.

Promoting continence in women following childbirth

Continence in women during pregnancy and following childbirth is an important issue that needs to be managed appropriately. Urinary and bowel problems can have numerous negative physical and psychological consequences, and women may be too embarrassed to seek help. Healthcare professionals need to encourage and support women to identify any changes in their normal bowel and bladder habits. They also need to have knowledge of the anatomy and physiology of the urinary, reproductive and digestive systems to understand how continence may be affected during pregnancy and following childbirth.

Variation in Bowel Habits of Healthy Indian Children Aged up to Two Years

To study the normal bowel habits of healthy Indian children up to 2y of age. This cross sectional study was conducted in medical college associated teaching hospital in Delhi. Ethical clearance was obtained from Institutional Ethical Committee. A total of 500 infants and toddlers up to 2y of age were recruited for the study. Data were collected by interviewing parents of the eligible children who came for immunisation using pre designed Performa. There was steady decline in stool frequency with increasing age. Maximum decline in stool frequency was noted after 1mo of age. Variation in stool frequency between children was maximum in 0-3mo of age and decreased with increasing age. Stools at 4wk were usually semiliquid, watery and semisolid. By 6mo of age 55% infants were passing semisolid stools and 40% were passing formed stools. At 24mo of age, 89.2% children usually passed formed stools. This is the first study in India to date documenting the frequency and consistency of the stools of young children. These results make an important contribution to defining normal stool patterns in young Indian children.

Response to “A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practise”

To the Editor: It was with interest that we read the recent article by Cheng et al. published in Supportive Care in Cancer [1]. The study highlighted very well the importance of understanding patient’s subjective constipation experiences as little correlation was observed in this work between people’s reports, the frequency with which bowels were opened, and the stool form. Reporting stool form requires greater exploration as recording this information has been recommended as an aid to titrating laxatives. Observation charts such as the Bristol Stool Chart have been suggested to provide guidance to patients and health professionals [2]. This is based on previous observations that have identified stool form as a way to predict colon transit time [3]. However, this work was undertaken in a healthy population. Scant attention so far paid to understanding how such observations could be extrapolated to people with cancer who are likely to have several contributing factors for disturbed bowel habits occurring simultaneously. Recent work by Dinning et al. is relevant to consider [4]. The aim of this work was to objectively assess the effects of laxatives on people’s constipation symptoms. This included a review of people’s stool form charts (n094) all of whom had scintigraphically confirmed functional slow transit (>72 h). Eighty percent of this cohort were taking laxatives either daily (n028) or intermittently (n049). The results showed that despite proven slow transit constipation, people continued to pass soft to lose frequent stools whilst taking laxatives with 75 % of the people studied falling into the normal bowel habit category (i.e. passing a bowel action more than three times per week or more than every 3 days). However, subjects self-reported severe symptoms related to pain, bloating and a need to strain when attempting to pass a bowel motion. The main conclusion of this work was that whilst laxatives aid defecation in non-cancer populations with functional constipation, these medications have little effect to improve self-reported symptoms. More work is needed as it is likely that the underlying problems experienced by people with cancer are more complex than just functional slow transit constipation. Cancer patients are exposed to many other factors that could contribute to slow colonic transit including medications, reduced functional status, impaired appetite and electrolyte disturbances. They are also at high risk of developing problems that could hinder normal defecation such as muscle wasting of the pelvic floor [5]. There is a real need to try and classify cancer patients with constipation according to the underlying problems (pre-existing bowel dysfunction, slow transit and problems of defecation). This work requires well-tolerated and easy to perform physiological function tests of colon transit and defecation. Until such work is undertaken, it remains difficult to understand the optimal approaches to assessing and palliating bowel problems. K. Clark (*) Department of Palliative Care, Calvary Mater Newcastle, Edith St., Waratah, NSW 2298, Australia e-mail: Katherine.Clark@calvarymater.org.au

Bile Acid Malabsorption After Pelvic and Prostate Intensity Modulated Radiation Therapy: An Uncommon but Treatable Condition

Intensity modulated radiation therapy (IMRT) is a significant therapeutic advance in prostate cancer, allowing increased tumor dose delivery and increased sparing of normal tissues. IMRT planning uses strict dose constraints to nearby organs to limit toxicity. Bile acid malabsorption (BAM) is a treatable disorder of the terminal ileum (TI) that presents with symptoms similar to radiation therapy toxicity. It has not been described in patients receiving RT for prostate cancer in the contemporary era. We describe new-onset BAM in men after IMRT for prostate cancer. Diagnosis of new-onset BAM was established after typical symptoms developed, selenium-75 homocholic acid taurine (SeHCAT) scanning showed 7-day retention of <15%, and patients' symptoms unequivocally responded to a bile acid sequestrant. The TI was identified on the original radiation therapy plan, and the radiation dose delivered was calculated and compared with accepted dose-volume constraints. Five of 423 men treated in a prospective series of high-dose prostate and pelvic IMRT were identified with new onset BAM (median age, 65 years old). All reported having normal bowel habits before RT. The volume of TI ranged from 26-141 cc. The radiation dose received by the TI varied between 11.4 Gy and 62.1 Gy (uncorrected). Three of 5 patients had TI treated in excess of 45 Gy (equivalent dose calculated in 2-Gy fractions, using an α/β ratio of 3) with volumes ranging from 1.6 cc-49.0 cc. One patient had mild BAM (SeHCAT retention, 10%-15%), 2 had moderate BAM (SeHCAT retention, 5%-10%), and 2 had severe BAM (SeHCAT retention, <5%). The 3 patients whose TI received ≥45 Gy developed moderate to severe BAM, whereas those whose TI received <45 Gy had only mild to moderate BAM. Radiation delivered to the TI during IMRT may cause BAM. Identification of the TI from unenhanced RT planning computed tomography scans is difficult and may impede accurate dosimetric evaluation. Thorough toxicity assessment and close liaison between oncologist and gastroenterologist allow timely diagnosis and treatment.

Is bowel preparation necessary before kidney-ureter-bladder radiography and intravenous urography?

To assess whether bowel preparation prior to kidney-ureter-bladder (KUB) radiography and intravenous urography (IVU) are of value in improving visualization of the urinary system. A total of 186 patients participated in this study. Thirty-nine patients with chronic constipation based on Rome III criteria and 147 patients with normal bowel habits were included. All the patients were randomly divided into two groups. Patients in group 1 received castor oil before imaging and had to eat or drink nothing after midnight. Patients in group 2 were allowed to eat and drink before the examination and received no bowel preparation. Kidney-ureter-bladder radiographies were obtained in all the patients and IVUs were indicated in 77 patients. To assess the image quality, radiographic images were divided into 5 anatomical regions and each region was scored from 0 to 3 based on obscurity of the images by the bowel gas or fecal residue. Mean total score for visualization of the urinary system on plain and contrast images did not differ significantly between the two groups (P = .253). However, patients with chronic constipation who received bowel preparation revealed a significantly better visualization score on plain images (P = .001). Bowel preparation prior to KUB and IVU does not improve the quality of the images in patients with normal bowel habits. However, a significantly better visualization of KUB was noted among patients with chronic constipation who had received bowel preparation.

Plasma serotonin level in left-sided colonic diverticulosis: A pilot study

Abstract Neurotransmitters might participate in the development of diverticular disease. We measured fasting and postprandial serotonin levels in colonic diverticulosis patients and healthy volunteers. We demonstrated significantly lower maximal concentrations of serotonin in patients than the controls (respectively 109.8±61.4 and 251.3±44.1 ng/ml, p&lt;0.001) as well as lower serotonin minimal values (respectively 38.4±21.8 and 124.6±41.4 ng/ml, p&lt;0.001) and areas under time-course curves (respectively 288.8±139.8 and 739±167.4 ng/ml, p&lt;0.001); significant difference between alternating pattern and normal bowel habit concerning fasting serotonin level, the hormone response to test meal (p=0.041) as well as minimal serotonin level (p=0.044). Bowel habit was also related to peak serotonin values following a test meal with 38.5 ng/ml in constipation, 139.5 ng/ml in diarrhea, 122.4 ng/ml in alternating pattern and 249 ng/ml in subjects with normal bowel habit (p=0.040) as well as AUC with 120.8 ng/ml in constipation, 416 ng/ml in diarrhea, 298 ng/ml in alternating pattern and 684 ng/ml in subjects with normal bowel habit (p=0.043). We demonstrated substantial differences in fasting serum serotonin levels as well as the hormone response to a test meal between colonic diverticulosis patients and healthy individuals, which seemed to be associated with abnormal bowel habits rather than presence of diverticula.

Minimally Invasive Reconstruction of Colovesical Fistula

Introduction: Colovesical fistula may result from iatrogenic insults, benign pathologies like diverticulitis, or Crohn's disease and secondary to malignant etiologies. The commonest presentation is pneumaturia, fecaluria, or recurrent urinary infection. The established practices for management of colovesical fistula are resection/repair of the fistula with proximal bowel diversion and delayed restoration of bowel continuity or single-stage primary reconstruction. Traditionally, these have been performed via incisional approach.1 We present a video on minimally invasive approach of primary reconstruction of colovesical fistula. Methods: Patient was evaluated in detail with presenting complaints, clinical survey, and blood profile. Imaging included ultrasonography, magnetic resonance urogram, and colonoscopy. Cystoscopy was performed followed by definitive repair through minimally invasive approach. Operative and postoperative parameters were recorded. Patient was evaluated postprocedure at regular intervals. Results and Discussion: Preoperative evaluation revealed a colovesical fistula secondary to rupture of sigmoid diverticula. Patient underwent disconnection of fistula segment, partial cystectomy, and colo-colic anastomosis. Dense adhesions were encountered in view of diverticulitis. As the cystectomy margin was sufficiently distant from both ureteric orifices, no additional ureteric catheter or stents were employed. The proximal bowel was occluded by linear stapler. The pathological colonic segement was resected. Colonic continuity was re-established using circular stapler. The entire procedure was performed through laparoscopic approach. The operation duration was 165 min and blood loss was 100 mL. The patient recovered uneventfully in the postoperative period. He was ambulatory on the first postoperative day and tolerated orals by the third postoperative day. He was sent home on sixth postoperative day. At 11 months' follow-up, the patient was clinically stable with no symptom recurrence. He also revealed normal voiding and bowel habits. Single-stage definitive repair of enterovesical fistula secondary to benign pathologies requires removal of the pathological segment and satisfactory rehabilitation of the gastrointestinal and urinary systems. In the presence of diverticulitis, this exercise is demanding with a high risk of iatrogenic complications. With the advancements in the field of minimally invasive surgery, even such complex reconstructions may be attempted via this approach. Till date, these procedures have been performed in limited centers worldwide.2 Although this procedure has been reported with a high conversion rate,3 in this case it was completed. The key advantages are single-stage definitive management with excellent morbidity profile. As a result of minimally invasive approach, the risk of postoperative intestinal paresis is also reduced. The operator needs to be proficient in laparoscopic exercises and familiar with the laparoscopic pelvic anatomy. The outcome after such complex reconstruction is also satisfactory. No competing financial interests exist. Runtime of video: 6 mins 13 secs