Painful Defecation Research Articles

Evaluation and Management of Constipation in Children-Single Centre Study

Background: Constipation in Indian children is on raising mode and most of it is functional; if search the figure in multiple literature constipation is a worldwide common problem in children. Developed and developing countries have equally distributed identified risk factors for constipation in both. The quality of life has affected in constipated patients and increases the mental stress of kids and parents. It also constitutes a challenge for healthcare systems and society by incurring significant burden of expenditure. All the factors specify that childhood constipation is turn up as a significant public health problem.Materials and methodology: Two hundred pediatric patients within two year of study period who presenting with history suggestive of constipation were studied in terms of age, gender, presenting complaints and duration of symptoms. Constipation was assessed by proforma based history and examination including Bristol stool chart in all these patients up to 12 years of age of either sex with history suggestive of constipation included in study were patients with acute abdomen and who not following the criteria of inclusion are excluded from study. Illustrative data were measured in term of qualitative and quantitative variables. Qualitative measures like sex, presenting complaints and presenting symptoms of constipation and stool pattern, percentages and frequencies were calculated and quantitative variables like age, percentages/mean/Standard Deviation (SD) were calculated.Objectives: Early diagnosis and effective treatment of constipation in children, Implementation of guidelines to provide a consistent, coordinated approach and to improve outcome for children and Compare it with the other similar studies.Results: Constipation occurs comparatively frequent among children and functional type of constipation is the most common cause of constipation in pediatric patients. Stool consistency, bowel frequency, large caliber hard and painful defecation are more tactful parameters in diagnose of constipation. Age group 0 to 4 year children's are more commonly affected and male dominance is perceptible in both functional and in organic (pathologic) constipation. Functional constipation (84.5%) is the most common type of constipation presenting in children, though up to 15.5% of patients may have an organic cause in whom history of delayed passage of meconium, presence of distension of abdomen, and fecal mass in rectum are the detectable point to an organic pathology. Children who are constipated may be associated with urinary tract infection.Conclusion: Early diagnosis, adequate therapeutic intervention, toilet training and regular follow up are of key importance in the management of childhood constipation. Most of the patients are functional constipation so that diagnosis can be only by proper history and physical examination; rarely required investigation. Surgical options need to be considered only when medical therapy fails.

Lord's procedure prior to stapled haemorrhoidopexy, reduces post operative complications

Background: Acute pain, rectal bleeding and painful defaecation are the common complications of Stapled haemorrhoidopexy. Doing Lord’s procedure before stapled haemorrhoidopexy, reduces the risks of complications Material and Methods: A description of operation technique and demographics of patients are presented.Results: 245 patients of Grade III and Grade IV haemorrhoids were operated (January 2009 and December 2019) by stapled haemorrhoidopexy. Lord’s procedure of Manual Anal Dilatation was done in all patients before stapled haemorrhoidopexy. Our series showed complication rate less than 1% as compared to global rate of almost 4-5%.Conclusion: Stapled haemorrhoidopexy like any other surgical procedure is also associated with some post-operative complications. Pain, bleeding and discomfort at defaecation are most common. They occur in about 5% cases. Our study reveals that these complications can be reduced further if Lord’s procedure of Manual Anal Dilatation is done just prior to stapled haemorrhoidopexy.

Clinico-etiological spectrum of constipation in children

Background: Childhood constipation is a common problem that has been difficult to define because it may comprise of diverse symptoms, from delay or difficulty in defecation sufficient to cause significant distress, to symptoms of faecal incontinence, displaying of retentive posturing and withholding behaviour to painful defecation and passing of stools so large that they may obstruct the toilet. Knowledge of common etiology of constipation and characteristic presentation may help us in initial management of patient without subjecting them to armour of investigation.Methods: The prospective interventional analytical study conducted in the Department of Surgery and Department of Pediatrics Pt. J.N.M. Medical College and Dr. B.R.A.M Hospital, Raipur (Chhattisgarh), India. Consecutive 81 children with constipation presenting to OPD of pediatrics and pediatric surgery at Dr B.R.A.M Hospital, Raipur (Chhattisgarh), India between January 2010 to January 2011 were included in the study.Results: Mean age at presentation was found overall to be 54.49±10.85 months. Presentation of constipation in boys and girls (44% vs 56% in functional and 54% vs 46% in organic). Of the organic causes Hirschsprung’s disease was the commonest diagnosis made (63%). Other organic causes were Rectal stenosis with anteriorly placed anal canal (1.2%), rectal prolapsed (1.2%), anal fissure (1.2%) and associated with dysgerminoma in pelvic cavity in one case.Conclusions: Assessment and management of pediatric constipation poses many challenges for the practitioner including deciphering whether the problem is organic or non-organic in nature.

CSF TO ACE THE DIAGNOSIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a granulomatous disorder characterized by noncaseating granulomas affecting involved organs. Although the majority of sarcoidosis is diagnosed as pulmonary sarcoidosis incidentally on chest imaging, extrapulmonary sarcoidosis is the presenting symptom for approximately 30% of all cases, with 5-10% affecting the nervous system. Angiotensin Converting Enzyme can be produced by granulomas, with 55% of cases demonstrating positive ACE levels within cerebrospinal fluid. CASE PRESENTATION: A 28 year old man with no past medical history presented with bilateral lower extremity weakness and numbness, gradually worsening over four weeks, starting in the pelvic area causing urinary urgency and painful defecation with distal spread. Over the few days prior to admission his family had also noticed dysarthria. Physical exam was notable for anisocoria, dysarthria, ataxic gait, diminished lower extremity reflexes, and saddle anesthesia. Serum was unremarkable except a sed rate of 39 and a positive ANA. Lumbar puncture showed an elevated white count of 43 cells/uL, predominantly lymphocytes, and an elevated protein at 336mg/dL. CSF ACE level was elevated (7.0 units/L). An MRI of the brain and spine showed diffuse nodular leptomeningeal enhancement of the entire spinal cord and brain. A CT of chest abdomen and pelvis was obtained which demonstrated innumerable pulmonary nodules and masses in a perilymphatic distribution with upper lobe predominance and subcarinal, pelvic and abdominal lymphadenopathy. Endobronchial biopsies of right mainstem bronchus nodularity and EBUS guided transbronchial needle aspiration of the subcarinal lymph node revealed granulomatous inflammation. He was treated with IV pulsed Solumedrol for 3 days with improvement in his neurologic symptoms. He was discharged on prednisone 1 mg/kg and methotrexate 15 mg weekly. Repeat MRI 5 days post treatment showed improvement of leptomeningeal enhancement. DISCUSSION: In this case, we observed a young man who developed neurologic symptoms as his first sign of sarcoidosis. Neurosarcoidosis can effect any portion of the peripheral or central nervous system. Cranial mononeuropathy, cognitive deficits, radiculopathy, and aseptic meningitis are common manifestations, wherever a granuloma can obstruct a nerve. A helpful diagnostic cue is angiotensin I-converting enzyme within the CSF itself, as granulomas synthesize this enzyme which can diffuse into various fluid compartments. The mainstay of treatment for any neurologic symptom is to treat the underlying sarcoidosis with steroids, as was done on our patient. CONCLUSIONS: In a younger patient with a pulmonary nodules and masses with associated neurologic complaints, neurosarcoidosis is a unique diagnosis that physicians should consider on their differential, while excluding malignancy. Angiotensin Converting Enzyme in CSF can be a helpful diagnostic cue. Reference #1: "Neurosarcoidosis” by Burns, Arch Neurol. 2003 Aug;60(8):1166-8. Reference #2: "Clinical characteristics of patients in a case control study of sarcoidosis” by Baughman, Teirstein, Et Al. Am J Respir Crit Care Med. 2001 Nov 15;164(10 Pt 1):1885-9. Reference #3: "Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of central nervous system sarcoidosis.” By Khoury, Wellik, Et Al. Neurologist. 2009 Mar;15(2):108-11. https://doi.org/10.1097/NRL.0b013e31819bcf84. DISCLOSURES: No relevant relationships by Elena Burke, source=Web Response no disclosure on file for Christine Fleury; No relevant relationships by Kellen Mulhern, source=Web Response

Medical Therapy Optimization of Advanced Heart Failure in a Cancer Patient: When to Quit?

Introduction In CHF patients, medical therapy optimization (MTO) remains the mainstay of management. However, attaining MTO can be challenging in patients with advanced CHF due to their symptomatic and hemodynamic intolerance. We present a case of a patient with advanced CHF and rectal cancer in whom slowly cautious MTO succeeded in improving cardiac function and candidacy for cancer chemotherapy and surgery. Case A 57-year-old male with a medical history of advanced nonischemic CHF (EF 10-15%), a-fib, and rectal well-differentiated adenocarcinoma stage IIA (diagnosed 1 month ago) with GI bleeding and defecation pain presented with dyspnea on minimal exertion and orthopnea. He also had dizziness with standing due to symptomatic hypotension. SBP was between 100-115 mmHg. MRI pelvis showed T3 rectal mass with no enlargement of lymph nodes. Further imaging showed no distant metastases. Due to his advanced CHF, the patient was considered at high risk for surgery or chemotherapy. Rectal palliative radiation therapy was performed. He agreed on hospice palliative care for symptomatic relief. From Cardiology stand of point, the decision was made to continue MTO aiming for myocardial recovery. Radical adjustment of regimen and initiation of medications at miniscule doses eventually led to myocardial recovery with EF of 51% (figure 1). Patient's SOB and dizziness improved. Cancer progressed to stage IIIb. Due to his improvement, the patient became at lower cardiac risk for other cancer therapy options. As a result, Oncology plan changed to proceed with FOLFOX (5-FU/ Leucovorin/ Oxaliplatin) chemotherapy and surgery. Discussion In our patient, advanced therapy with left ventricular assist device was not possible given his risk of worsening GI bleeding on anticoagulation. Heart transplantation was not an option given the risk of cancer progression on immunosuppressive therapy. In the context of the patient's condition and comorbidities, the best option left was to proceed with cautious MTO with clinical and hemodynamic monitoring. MTO resulted in clinical and cardiac function improvement. This gave the patient the window to become a candidate for other cancer therapy options that were not available for him before. Conclusion Medical therapy optimization in all patients with CHF should always be sought. Despite being challenging under certain circumstances, as seen in our patient, slow and cautious MTO can eventually result in significant improvement in clinical status, cardiac function, and candidacy for other therapy options for other comorbidities.

Comparison of Polyethylene Glycol Powder and Polyethylene Glycol 40% Syrup in Treatment of Chronic Idiopathic Constipation in Pediatrics

Introduction: Constipation is one of the most common gastrointestinal complaints in children that can lead to many complications. The aim of this study was to compare the efficacy of polyethylene glycol powder and polyethylene glycol 40% syrup to treat constipation.
 Materials and Methods: This study was a nonrandomized semi-experimental clinical trial. The current study was conducted on 80 patients with constipation, referring to Imam Ali (PBUH) Clinic, Shahrekord randomly assigned to two groups of 40 each. Subjects were children under 15 years old with functional constipation selected by simple sampling since 2015. Group 1 was treated with polyethylene glycol powder and Group 2 was treated with polyethylene glycol 40% syrup for two months. During the treatment, the patients were examined five times with 2-week intervals and their symptoms consisting of defecation frequency, stool consistency, painful defecation, bloody defecation, and stool incontinence were registered in a checklist. Data were analyzed using SPSS24.
 Results: The comparison of patients’ total status before and after intervention shows that two groups were assessed in the weak level in the polyethylene glycol powder group 28(0.70%) cases and syrup group 36(0.90%), while after intervention, polyethylene glycol powder group was assessed in the high level 35(87.5%) cases and syrup group 37(92%) cases and most of patients after intervention promoted from weak and intermediate level before intervention to High level.
 Conclusion: The findings indicated similar efficacy and treatment response of the PEG powder and syrup. However, the PEG syrup can be used instead of its powder because of pleasant taste and ease of use.

An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy

Objective: To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. Results: There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. Conclusion: For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.

Polyethylene Glycol vs. Lactulose in Infants and Children with Functional Constipation

In this randomized, multicentric trial, patients with functional constipation received either polyethylene glycol (PEG) or lactulose for 12 weeks and were subsequently followed for 4 weeks. The primary outcome variables were the number of defecations per week after 12 weeks of treatment, and improvement in stool consistency of at least 2 points in the Bristol scale. Bowel movements ≥3 per week and stool consistency ≥2 (Bristol scale) were considered as successful treatment. Investigators enrolled 102 patients with mean (SD) age of 3.62 (1.42) years, out of which 88 completed the study. The mean (SD) number of defecations per week was more in PEG group as compared to the lactulose group (7.9 (0.6) vs 5.7 (0.5), P=0.008). Both groups had similar frequency of painful defecation, stool retention, large volume of stools, and hard stools. There were more patients with side effects of bloating and abdominal pain in the lactulose group (23 vs 15, P=0.02). The authors concluded that PEG 3350 is more effective and causes fewer side effects compared to lactulose in the treatment of constipation in infants and children.

Bacillus coagulans Unique IS2 in Constipation: A Double-Blind, Placebo-Controlled Study

Functional constipation has a high prevalence in both adults and children affecting quality of life. Evidence suggests that probiotics can reduce the symptoms of constipation. As the effects of probiotics are strain specific, the efficacy of Bacillus coagulans Unique IS2 in the treatment of functional constipation in adults was evaluated. Subjects (n = 100) diagnosed with functional constipation were supplemented with either B. coagulans Unique IS2 (2billion CFU) or placebo capsules once daily for 4weeks. Subjects were evaluated for treatment success (defined as three or more spontaneous stools per week), stool consistency, difficulty of defecation, defecation and abdominal pain. By the end of the fourth week, there was a statistically significant (p < 0.001) increase in number of bowel movements in the probiotic treated group as compared to placebo. Ninety eight percent of subjects in the probiotic group achieved normal stool consistency as compared to placebo (74%). Moreover, there was relief from symptoms of incomplete evacuation, painful defecation and abdominal pain associated with constipation in probiotic treated group as compared to placebo. In conclusion, B. coagulans Unique IS2 significantly decreased the symptoms of constipation indicating effectiveness of the strain in the treatment of constipation.Trial registration: CTRI/2017/11/010539.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study

ObjectivesEvaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation. MethodsThis was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses. ResultsOn consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported. ConclusionGreen banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Chronic Functional Constipation in Infants and Children.

Functional constipation is a common problem among children. The prevalence worldwide is about 3% and it is accounting for about 3-5% of all visits to pediatricians implicating a significant impact on health care cost. In most children presenting with the symptom constipation no underlying medical disease responsible for the symptom can be found; this is the so-called functional constipation. Functional constipation is characterized by infrequent bowel movements, hard and/or large stools, painful defecation, sometimes in combination with fecal incontinence, and is often accompanied by abdominal pain, without evidence of a structural or biochemical explanation.The recommendation for the management of FC includes a normal intake of fibers and fluids, normal physical activity, and an additional pharmacologic treatment for fecal disimpaction followed by a pharmacologic maintenance therapy.In infants constipation is treated somewhat differently as compared with children. When constipation presents early in life, the risk of an underlying organic disease is increased compared to older children.

Segmental resection combined with anoplasty for the treatment of circumferential mixed hemorrhoids.

Circumferential mixed hemorrhoids are very difficult to treat non-surgically. Therefore, it is important to explore the surgical methods for its complete resolution as well as maintenance of normal anal anatomy and function. The present study was designed to evaluate the effect of segmented and plastic hemorrhoidectomy (SPH) on patients with circumferential mixed hemorrhoids. A total of 300 patients with circumferential mixed hemorrhoids were divided into experimental group (n=150) undergoing SPH and control group (n=150) undergoing Milligan-Morgan hemorrhoidectomy. There were no differences in cure and effectiveness rates between two groups. Compared with the control group, patients in the experimental group had shorter healing time (15.7±1.3 vs 12.5±0.7 days) and recovery to normal activity (18.5±2.7 vs 14.7±1.2 days). In addition, anal function of all patients in the experimental group was normal during short- and long-term follow-up. However, more cases in the control group showed anal dampness and itching, and poor control of intestinal liquid. Compared with the control group, patients in the experimental group had better outcomes in overall anal function and smoothness at 6, 12, and 18 months after operation as well as patient satisfaction. Furthermore, the rating in the visual analogue scale for defecation pain and edema in the experimental group was less than that in the control group. SPH was more effective, had fewer complications, better protection of anal function, and a better cosmetic result.

Surgery for deep endometriosis without involvement of digestive or urinary tracts: do not worry the patients!

To report postoperative outcomes after surgery for deep endometriosis without involvement of the digestive or urinary tracts. Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. University tertiary referral center. One hundred thirty consecutive patients whose follow-up ranged from 1 to 6years. Laparoscopic excision of deep endometriosis nodules. Postoperative complications were recorded in the CIRENDO database and medical charts. Postoperative digestive function was assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott Symptom Questionnaire. Deep endometriosis nodules involved uterosacral ligaments, rectovaginal space, and vagina and spared the bowel, the bladder, and the ureters. Nodule size was <1cm, 1-3cm, and >3cm in diameter in 20.8%, 64.6%, and 14.6% of cases, respectively. Clavien-Dindo 1, 2, and 3b complications occurred in 0.8%, 4.6%, and 5.4% of cases, respectively. Among Clavien-Dindo 3b complications, most involved pelvic hematoma. Gastrointestinal scores revealed significant improvement in digestive function or defecation pain at 1 and 3years after surgery. The pregnancy rate was, respectively, 43.3% and 56.7% at 1 and 3years postoperatively, among which 66.7% and 64.7% were spontaneous conceptions. Our data suggest that surgery for deep endometriosis without involvement of the digestive or urinary tracts provides a low rate of postoperative complications and satisfactory fertility outcomes.

Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery

Introduction: Bowel endometriosis can cause debilitating symptoms. Surgical colorectal resection is often required for symptomatic relief. Aim of our study was to evaluate quality of life over a one-year follow-up period in patients submitted to a colorectal resection for the treatment of deep endometriosis. Change in intestinal and extra-intestinal symptoms, and reproductive outcome were also evaluated.Methods: A prospective observational study was conducted on a cohort of 20 women affected by intestinal endometriosis and submitted to a laparoscopic colorectal resection. The subjects completed a questionnaire about quality of life (SF-36), and they scored in a 100-point rank questionnaire gynecological, urinary and gastrointestinal symptoms, pre-operatively and one- year postoperatively.Results: Significant improvements were observed in all domains of the SF-36 throughout the study period. Dysmenorrhea, dyspareunia and not menstrual pelvic pain showed a significant decrease 1 year after surgery. There was also a decrease in abdominal pain, rectal bleeding and constipation but not of nausea, abdominal pain, defecation pain, tenesmus, diarrhea, mucorrhea. Also some urinary symptoms did not improve.Conclusions: The radical surgical approach has a positive impact on quality of life, although it does not improve all the symptoms complained before surgery. Clear pre-surgical counseling and careful patient selection is suggested.

Laxative action of sennoside A, which causes decreased colonic aquaporin‐3 expression, is controlled by the anti‐inflammatory effect of glycyrrhizin

ABSTRACTAimThe laxative action of daiokanzoto (a compound containing rhubarb and glycyrrhiza) is thought to be due to sennoside A, an ingredient in rhubarb. Glycyrrhizin, which has anti‐inflammatory effects, is the main ingredient in glycyrrhiza, and it alleviates adverse reactions, such as abdominal pain and painful defecation, due to rhubarb. No consensus has been reached, however, on why daiokanzoto contains glycyrrhiza. We found that sennoside A exerts a laxative action by decreasing aquaporin‐3 (AQP3) expression through the activation of macrophages in the colon. This study analyzed the effect of glycyrrhizin on the laxative action of sennoside A focusing on AQP3 expression.MethodsSennoside A, glycyrrhizin, or a combination of both were given orally to rats, and diarrhea severity was assessed. The expression of AQP3, inflammatory cytokines, and cyclo‐oxygenase (COX) was analyzed.ResultsAlthough diarrhea occurred when sennoside A and glycyrrhizin were given together orally, it was less severe than when sennoside A was used alone, and, correspondingly, only sennoside A inhibited AQP3 expression to a greater extent than the combination of both drugs. When glycyrrhizin was given concomitantly, the sennoside A‐induced increased expression of pro‐inflammatory cytokines and COX‐2 was suppressed.ConclusionsThe laxative action of sennoside A and the decreased expression of AQP3 were suppressed when sennoside A and glycyrrhizin were given concomitantly, likely due to the anti‐inflammatory effects of glycyrrhizin. This indicates that glycyrrhizin both attenuates the adverse reactions caused by sennoside A and plays a role in its laxative action.

A rare cause of obstructive defecation in a 29-year-old woman: Ileo-colo-colonic intussusception treated by subtotal colectomy with posterior rectopexy.

Adult intussusception is a rare clinical condition. In majority of adult cases, there is an underlying cause such as polyps or colon cancers. In the present study, a 29-year-old woman with intermittent and colicky abdominal pain, constipation, and painful defecation, accompanied with distention and sense of rectal fullness, was evaluated with computed tomography. Ileo-colo-colic intussusception was determined. Subtotal colectomy with posterior rectopexy was performed. After the surgery, she was doing well at 13-month follow-up.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study

ObjectivesEvaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation. MethodsThis was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses. ResultsOn consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported. ConclusionGreen banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Efficacy of actinidin-containing kiwifruit extract Zyactinase on constipation: a randomised double-blinded placebo-controlled clinical trial.

Zyactinase® is an extract of green kiwifruit, formulated into the consumer healthcare products marketed as Phloe® and Kivia, used to assist in the relief of the symptoms associated with a range of digestive system dysfunction, including constipation and Irritable Bowel Syndrome (IBS). A randomised, double-blind, placebo-controlled clinical trial was undertaken to determine the ef-fects of the kiwifruit extract on bowel movement, stool formation and IBS associated symptoms amongst a sub-ject group of generally healthy individuals experiencing a period of moderate constipation. Fifty-eight partici-pants were randomized to the kiwifruit extract (28) or placebo (30). Selection criterion was decreased number of bowel movements (<3/week), with increased faecal hardness and IBS associated symptoms. The study ran for three weeks, with participants first undergoing a seven-day wash out period, followed by a seven-day dosing pe-riod, and then a seven-day follow up period. There was a significant increase in the defecation frequency (p<0.001), with a significant improvement in faecal score (p<0.01). There was a significant difference in pain-ful defecation and abdominal pain between the two groups (p<0.01). No side effects, including diarrhoea, urgen-cy or abdominal pain, were observed during the trial. The green kiwifruit extract significantly in-duced normal bowel movements with no adverse effects. The kiwifruit extract relieved constipation and the symptoms of IBS such as bloating, flatulence and abdominal pain.

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial.

STUDY QUESTIONIs there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?SUMMARY ANSWERNo evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel.WHAT IS KNOWN ALREADYAdopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection.STUDY DESIGN SIZE, DURATIONFrom March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up.PARTICIPANTS/MATERIALS, SETTING, METHODSPatients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles–Eccersley–Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36).MAIN RESULTS AND THE ROLE OF CHANCEA total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22–2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis.LIMITATIONS REASONS FOR CAUTIONThe inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint.WIDER IMPLICATIONS OF THE FINDINGSConservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study.TRIAL REGISTRATION NUMBERThis study is registered with ClinicalTrials.gov, number NCT 01291576.TRIAL REGISTRATION DATE31 January 2011.DATE OF FIRST PATIENT’S ENROLMENT7 March 2011.

Clinical effect of Arshohar Vati in the management of Arsha (1st and 2nd grade haemorrhoids) - Short communication

Management of Arsha (hemorrhoids) has been a challenge for physicians of all the system of medicines. Sushruta has mentioned four types of treatment of Arsha and has given more emphasis on Bhaisajya Chikitsa. In this clinical study the Arshohar vati two tablets thrice a day were advised to be taken for 2 weeks continuously with plain water. Along with this adjuvant drugs like sitz bath with panchavalkal and yarandbhrishta haritaki, triphala guggulu was used in 10 patients. The observation and assessment was done with gradation to symptoms. In result 88.33% relief was noted in bleeding per rectum, 91.33% relief noted in painful defecation, 100% relief noted in discharge per rectum and 68.75% relief noted in prolapse of piles were noted. The study was concluded that Arshohar Vati was effective in the 1st and 2nd grade piles