Stool Color Research Articles

Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop.

Biliary atresia is the most common cause of end-stage liver disease in the infant and is the leading pediatric indication for liver transplantation in the United States. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver. However, establishing this diagnosis is problematic because of its rarity, the much more common indirect hyperbilirubinemia that occurs in the newborn period, and the schedule for routine infant health care visits in the United States. The pathogenesis of biliary atresia appears to involve immune-mediated fibro-obliteration of the extrahepatic and intrahepatic biliary tree in most patients and defective morphogenesis of the biliary system in the remainder. The determinants of the outcome of portoenterostomy include the age at surgery, the center's experience, the presence of associated congenital anomalies, and the postoperative occurrence of cholangitis. A number of screening strategies in infants have been studied. The most promising are early measurements of serum conjugated bilirubin and a stool color card given to new parents that alerts them and their primary care provider to alcholic stools. This report summarizes a National Institutes of Health workshop held on September 12 and 13, 2006, in Bethesda, MD, that addressed the issues of outcomes, screening, and pathogenesis of biliary atresia.

Ecstasy: An Important Cause of Acute Liver Failure

A twenty year old female was referred to hospital by her GP, after he received the results of blood tests taken earlier in the day. She had presented to him complaining of malaise, nausea and anorexia over a 3 day period. On the day of referral she had also become jaundiced with dark urine, but normal stool colour. There was no abdominal pain. She had no significant past medical history with no history of jaundice, liver disease or autoimmune conditions, and no apparent risk factors for blood-borne hepatitis infection. There was no relevant family history. She was taking no prescribed medication, had not taken any over the counter medication or herbal remedies. She denied excessive alcohol use or use of intravenous drugs in the past, although she was not specifically questioned on the use of other recreational drugs. She was a single mother and admitted to being under considerable stress recently. On examination she appeared well, apart from marked jaundice. There were no signs of hepatic encephalopathy or chronic liver disease. Abdominal examination revealed mild left upper quadrant tenderness, but no significant hepatomegaly. Liver function tests (LFTs) taken by her GP are shown in Table 1, revealing marked elevation of the Alanine Transaminase (ALT) (Table 1), with a relatively preserved albumin. Unfortunately her International Normalised Ratio (INR) had not been measured. An Ultrasound of the abdomen demonstrated a normal size liver with normal contour and texture with no other abnormality.

Screening for Biliary Atresia by Infant Stool Color Card in Taiwan

We aimed to detect biliary atresia (BA) in early infancy to prevent additional liver damage because of the delay of referral and surgical treatment and to investigate the incidence rate of BA in Taiwan. A pilot study to screen the stool color in infants for the early diagnosis of BA was undertaken from March 2002 to December 2003. We had designed an "infant stool color card" with 7 numbers of different color pictures and attached it to the child health booklet. Parents were then asked to observe their infant's stool color by using this card. The medical staff would check the number that the parents chose according to their infant's stool color at 1 month of age during the health checkup and then send the card back to the stool color card registry center. The average return rate was approximately 65.2% (78,184 infants). A total of 29 infants were diagnosed as having BA, and 26 were screened out by stool color card before 60 days of age. The sensitivity, specificity, and positive predictive value were 89.7%, 99.9%, and 28.6%, respectively. Seventeen (58.6%) infants with BA received a Kasai operation within 60-day age period. The estimated incidence of BA in screened newborns was 3.7 of 10,000. The stool color card was a simple, efficient, and applicable mass screening method for early diagnosis and management of BA. The program can also help in estimating the incidence and creating a registry of these patients.

Ostomy Care and the Consultant Pharmacist

Many long-term care residents have ostomies. Three types of ostomy are most common: ostomies of the small bowel (ileostomies/jejunostomies), ostomies of the large bowel (colostomy), and urostomies. Ostomates (people who have had an ostomy) must deal with their physical and psychological repercussions. Complications may include dermatological problems, short-bowel syndrome, and vitamin deficiencies. When the ostomy involves the bowel, medication absorption may be affected. Pharmacists should be aware of contraindicated medications, as well as those that change the color or odor of effluent or stool.

Neonatal Liver Disease

Establishing a rapid and accurate diagnosis of the cause of neonatal liver disease is an urgent matter. The initial detection of this condition relies on the sensitivity of the primary care provider or pediatrician to the signs and symptoms of jaundice and abnormal stool and urine color. It is critical to evaluate jaundice in any infant older than 2 weeks with measurement of fractionated bilirubin, and further assessment is necessary if the direct value is above 1.0 mg/dL in the setting of a total bilirubin of less than 5.0 mg/dL or a direct bilirubin of more than 20% of total if the total is more than 5.0 mg/dL. A diagnostic algorithm for the evaluation of infants who meet these criteria can guide physicians in selecting appropriate and timely diagnostic testing and referral to pediatric gastroenterology for these patients, whose outcome will rely on rapid diagnosis.

Pharmacist Interventions in Geriatric Nursing Facility NSAID Therapy: A One-Year Follow-up Study of Costs and Outcomes

To document costs and outcomes occurring with acceptance or rejection of ongoing pharmacists' interventions regarding therapy with a nonsteroidal anti-inflammatory drug (NSAID) versus acetaminophen (APAP) therapy in treating osteoarthritis in a long-term care facility in the sixth year of observation. A nonrandomized observational prospective cohort study with all patients resident for 30 or more days over the 12-month study period receiving NSAID or APAP therapy for osteoarthritis. A skilled nursing facility with more than 100 beds. All patients had a monthly drug regimen review, receiving full-dose NSAIDs (not low-dose aspirin alone) on a continuous basis, and were selected for intervention. A control group of patients receiving APAP on a continuous basis also was selected for comparison of outcomes. Patients receiving NSAIDs had (1) periodic hemoglobin and hematocrit determinations; (2) physical assessment of lower eyelid, nailbed, and stool color; (3) and a recommendation to replace NSAID with APAP or to add gastroprotective pharmacotherapy if the NSAID was continued. Patients not receiving an NSAID for osteoarthritis and continuously taking APAP served as a control group. Cost-analysis calculations were performed for existing regimens versus cost savings that would be experienced with recommended pharmacotherapeutic interventions. Fourteen intervention subjects and sixteen control patients were identified. In the three patients for whom the pharmacist's recommendations were accepted within three months (11 NSAID-use months), there were three substitutions of APAP therapy observed over an additional 26 patient-months. Five of 11 patients in the NSAID group for whom pharmacists' recommendations were rejected developed gastrointestional (GI) bleeding, necessitating six hospitalizations. Two of these patients died over the study period. No group for whom APAP was accepted nor control-group patients experienced suspected GI bleeding. Total costs of the control group analgesic therapy was $756.74, or $47.30 per patient. Cost savings for APAP substitution in the intervention rejection group would exceed $91,000, while cost savings with the addition of hemoglobin and hematocrit determinations would exceed $84,200. Cost savings from addition of gastroprotectives to the NSAID would have been misoprostol, $73,000; omeprazole, $71,400. Refusal to accept pharmacists' intervention recommendations regarding alternatives to NSAID pharmacotherapy in this nursing facility population is associated with sustained and considerable costs, morbidity, and mortality.

Optimum prednisolone usage in patients with biliary atresia postportoenterostomy

Purpose Prednisolone is used routinely after portoenterostomy (PE) in patients with biliary atresia (BA). The authors reviewed their patients with BA post-PE to assess prednisolone protocols. Method Severity of fibrosis at PE (moderate or severe), age at PE (30-70 days), size of bile ductules in the fibrotic biliary remnant at the porta hepatis (>100 μm), and type of BA (uncorrectable type) were used as criteria for selecting 63 subjects from our patients with BA post-PE. Subjects were divided into 5 groups according to prednisolone dosage: group 1, no prednisolone; groups 2 to 4, single courses of intravenous prednisolone commencing on day 7 post-PE administered in decreasing dose for 3 days each as follows: group 2, 6, 4, and 2 mg; group 3, 10, 5, and 2.5 mg; group 4, 20, 15, 10, 5, and 2.5 mg; group 5, same as group 4, but stool color was used to monitor bile excretion and a course was restarted from 20 mg whenever stools began to turn pale. If necessary, single courses were repeated until serum total bilirubin was less than 2.0 mg/dL. Protocol efficacy was assessed by comparing the number of patients who became jaundice free, the period taken to become jaundice free, and the incidence of side effects related to prednisolone. Results The number of patients who became jaundice free in the no prednisolone group (group 1, 7/12 or 58.3%) was not significantly different from the number in the single-course groups (group 2, 8/12 or 66.6%; group 3, 10/13 or 76.9%; and group 4, 11/15 or 73.3%). The number in the stool-monitored group (group 5, 10/11 or 90.9%) was significantly greater ( P < .05). The mean period taken to become jaundice free in group 1 (82.6 ± 29.1 days) was not significantly different from the single-course groups (group 2, 74.5 ± 29.3 days; group 3, 49.6 ± 19.8 days; and group 4, 48.3 ± 26.0 days). The mean period taken in the stool-monitored group (group 5, 33.3 ± 6.4 days) was significantly shorter ( P < .05). The number of subjects who developed cholangitis after becoming jaundice free was not significantly different (group 1, 2/7; group 2, 2/8; group 3, 2/10; group 4, 2/11; group 5, 2/10). There were no prednisolone-related complications identified in any subject. Conclusions These results provide strong evidence that large-dose prednisolone therapy with stool color monitoring of bile flow has a positive impact on the time taken for patients with BA post-PE to become jaundice free and the number of patients who remain jaundice free.

Explorative Studie: Sichtweisen zur Defäkation – Vergleich von Patienten und Pflegepersonen

The bowel movement pattern in hospitalised patients is an important aspect of nursing and therapeutic considerations. The aim of the study was to gather and compare the views patients and nursing personnel on the subject of bowel movement habits. The investigation was carried out by means of a questionnaire that should enable gathering data on demographic factors and bowel movement patterns (regularity, frequency, colour, form, problems, influence of external factors). Data obtained from the questionnaires completed by 122 nursing personnel and 168 patients were subject to statistical analysis. Data were analysed with the help of SPSS, and individually according to sample groups, using the Chi square test. Comparison (nursing personnel and patients) of the results showed significant differences between the two groups in their assessment of what was "normal" and what was "pathological" in bowel movement patterns. The two groups differed significantly in what they considered as normal bowel movement frequency namely, "several times daily", "every second day" and "twice a week". It is interesting to note that the nursing staff more often considered "irregular" bowel movements as "normal" in comparison to patients. Significant differences between the two groups were also observed in their assessment off "watery stools" and "formed stools". As far as the question of stool colour is concerned, patients more frequently than the nursing staff, looked upon "pathological" colour changes (yellow and reddish-brown to black) as being normal.

Effect of Xylooligosaccharide Intake on Severe Constipation in Pregnant Women

Xylooligosaccharides (XOS) are mainly composed of two or three xylose units with beta-1,4 linkages. They are obtained by hemicellulose hydrolysis, which is relatively abundant in the cell walls of grains. XOS increases the number of intestinal Bifidobacterium in humans, and maintains the fecal water content within the normal range. To examine the effect of XOS intake on severe constipation in pregnancy, which is predominant in the third trimester, thirty constipated pregnant women were treated with 4.2 g XOS daily for 4 wk. During the study, the clinical efficacy was assessed using a daily diary. The subjects indicated the number of stools and the clinical symptom scores. Twenty-nine subjects completed the study. The mean number of stools was 1.1 +/- 0.4 in the pre-treatment week, and increased in weeks 1-4 of XOS administration to 5.3 +/- 2.1, 5.9 +/- 2.5, 6.2 +/- 2.2 and 6.7 +/- 1.9, respectively. At the end of the study, 27 subjects could defecate spontaneously. The occurrence of very loose or very hard stools decreased and the stool consistency normalized. The stool color changed from dark to yellowish brown. No side effects were observed. XOS intake was highly effective for the reduction of severe constipation in pregnant women without adverse effects.

P0210 STOOL COLOR CARDS SCREENING FOR INFANTS AGED ONE MONTH

Introduction: Biliary atresia (BA) is the most common cause of obstructive jaundice in the first three months of life (1:10,000 live births). Prognosis depends on early diagnosis and treatment. Aim: To identify infants aged one month with pale stools matching stool color cards by Matsui and Dodoriki to exclude BA. Design: Observational prospective study. Methods: All children born in the Obstetric Center attending first month medical control were included. We used Matsui and Dodoriki’s stool color cards with photographs of 8 possible shades (1– 4: acholic or hypocholic stools; 5– 8: colored stools) Logistics: Mothers were instructed right after delivery to use matching cards to compare their infant’s stool color before attending first month physician visit. Patients identified with acholic or hypocholic stools (1– 4) were examined for jaundice, coluria and hepatomegaly and were further assessed by laboratory and echography tests and liver biopsy. Results: From August 1, 1999 to July 31, 2002 a total of 12,484 children were delivered at our hospital, 199 died during the first month. Out of 4,239 infants (39%) monitored in that period, 18 were seen at the Gastroenterology Section with 1– 4 stool color records obtained by their mothers and physicians. Colored stools 5– 8 were present in 14 patients who were excluded from the study, not requiring complementary tests. The remaining four were diagnosed with Luetic Hepatitis, Neonatal Hepatitis, Alagille’s Syndrome and Biliary Lithiasis. No cases of BA were found. Conclusion: High dropouts in the first month visit to the physician hamper early detection of low incidence pathologies. Further efforts should be made to adequately instruct mothers and professionals about the importance of stool color control in the newborn for early detection of underlying conditions to allow for the benefit of specific medical therapy.

Dysprosium Chloride as a Nonabsorbable Gastrointestinal Marker for Studies of Stable Isotope-Labeled Triglyceride Excretion in Man

Objective: The aim of this work was to determine if dysprosium chloride (DyCl3) is a suitable nonabsorbable marker for studies of labeled-triglyceride excretion in cystic fibrosis patients allowing excretion to be determined accurately after analysis of one or two stools.Methods: A series of 66 absorption studies were conducted in 36 young cystic fibrosis patients over a five year period. All tests consisted of ingesting a single test meal containing both 13C-labeled triglyceride (TG*) and DyCl3; in most studies the food colorant brilliant blue (FD&C blue #1) was administered along with the DyCl3. Ingestion of the test meal was followed by collection of individual stools for 72 to 96 hours. Stools were analyzed for 13C-Excess (13C*) and Dy.Results: Excretion of Dy in cystic fibrosis patients who exhibited a wide-range of steatorrhea was quantitative. Fractional excretion of Dy and 13C* in individual stools showed a high linear correlation (r2 = 0.969) with a slope and y-intercept close to unity and zero, respectively. As a result, estimates of TG* excretion based on analysis of only two stools (partial pool method, PPM) were not different from those based on the analysis of all stools or stool composites. This was true both when Dy content and when stool color due to ingested brilliant blue was used to determine which stools to analyze for the PPM.Conclusions: Combining the use of Dy and brilliant blue permits reasonably accurate estimates of fecal TG* excretion after analysis of samples from two easily identified stools. This practical method can be used to address many important clinical and experimental questions regarding triglyceride digestion and absorption that may otherwise go unanswered.

Cases from the osler medical service at johns hopkins university

Abstract Presenting features A 41-year-old man with a past history of alcohol abuse, drug abuse, and smoking (>40 pack-years) presented with chronic epigastric pain and weight loss. During the preceding year, the epigastric pain had worsened progressively and was exacerbated by eating. For the past 3 months, his nausea and vomiting had worsened so that he was no longer able to tolerate solid food. Consequently, he had lost 50 lbs in 1 year. During the 3 weeks before admission, he had daily subjective fevers but no night sweats. He denied any melena, hematemesis, jaundice, or changes in stool color or consistency. His past medical history was remarkable for an episode of massive hematemesis, for which he was admitted to another hospital 3 months ago and found to have a bleeding gastric ulcer. Despite treatment with a proton pump inhibitor, his abdominal pain, nausea, and vomiting worsened after dis-charge. He stopped drinking alcohol after that hospitalization, and he stopped using intravenous drugs 1 month before this admission. On physical examination, the patient appeared wasted. His vital signs were notable for a normal blood pressure with resting tachycardia and an orthostatic increase in pulse rate. His jugular veins were flat. Cardiac and respiratory examinations were normal. The abdominal examination revealed guarding in the epigastric region with hypoactive bowel sounds and no rebound tenderness. His stool was guaiac negative. Laboratory studies revealed a total white blood cell count of 4180/mm 3 , a hematocrit of 33.1%, a platelet count of 239,000/mm 3 , a total protein level of 8.3 g/dL, an albumin level of 3.7 g/dL, and antibodies to human immunodeficiency virus (HIV). A computed tomographic scan of the abdomen showed thickening of the antrum with large gastric folds. What is the diagnosis?

NEONATAL CHOLESTASIS RESULTING FROM VERTICAL TRANSMISSION OF HEPATITIS A INFECTION

NEONATAL CHOLESTASIS RESULTING FROM VERTICAL TRANSMISSION OF HEPATITIS A INFECTION

Cases from the Osler Medical Service at Johns Hopkins University

Presenting features A 41-year-old man with a past history of alcohol abuse, drug abuse, and smoking (>40 pack-years) presented with chronic epigastric pain and weight loss. During the preceding year, the epigastric pain had worsened progressively and was exacerbated by eating. For the past 3 months, his nausea and vomiting had worsened so that he was no longer able to tolerate solid food. Consequently, he had lost 50 lbs in 1 year. During the 3 weeks before admission, he had daily subjective fevers but no night sweats. He denied any melena, hematemesis, jaundice, or changes in stool color or consistency. His past medical history was remarkable for an episode of massive hematemesis, for which he was admitted to another hospital 3 months ago and found to have a bleeding gastric ulcer. Despite treatment with a proton pump inhibitor, his abdominal pain, nausea, and vomiting worsened after dis-charge. He stopped drinking alcohol after that hospitalization, and he stopped using intravenous drugs 1 month before this admission. On physical examination, the patient appeared wasted. His vital signs were notable for a normal blood pressure with resting tachycardia and an orthostatic increase in pulse rate. His jugular veins were flat. Cardiac and respiratory examinations were normal. The abdominal examination revealed guarding in the epigastric region with hypoactive bowel sounds and no rebound tenderness. His stool was guaiac negative. Laboratory studies revealed a total white blood cell count of 4180/mm 3, a hematocrit of 33.1%, a platelet count of 239,000/mm 3, a total protein level of 8.3 g/dL, an albumin level of 3.7 g/dL, and antibodies to human immunodeficiency virus (HIV). A computed tomographic scan of the abdomen showed thickening of the antrum with large gastric folds. What is the diagnosis?

3373 Acute middle gastrointestinal bleeding: diagnostic implications and cost analysis.

Separating traditional acute lower gastrointestinal bleeding into small bowel bleeding (middle gastrointestinal bleeding, MGIB) and colonic bleeding (CB) has helped delineate unique characteristics of bleeding from the two locations. In order to further characterize acute MGIB, clinical characteristics, in-patient work-up and hospital costs incurred were compared between consecutive patients diagnosed with upper gastrointestinal bleeding (UGIB), MGIB and CB. Patients with MGIB were identified by nuclear medicine scans and angiography records, and corroborated with endoscopy and inpatient records over a 4-year period. Matching numbers of consecutive patients with UGIB and LGIB formed the comparison groups, identified from interrogation of the endoscopy database. RESULTS: Twenty-nine patients with MGIB (15F/14M, mean age 68.6 ± 2.4 yr) were identified between 1995 and 1998. The comparison groups consisted of 29 patients with UGIB (13F/16M, mean age 58.3 ± 4.0 yr), and 29 patients with CB (13F/16M, mean age 70.3 ± 2.3 yr). Presentation of MGIB was indistinguishable from other bleeding sites, with stool color resembling bright- or dark-red blood in 41%, melena in 18%, and maroon stool in 41%. Patients with MGIB had a significantly higher in-hospital morbidity requiring longer hospital stays, and incurring significantly higher costs while in hospital, compared to CB or UGIB (p<0.001); there were no significant differences in these parameters between CB and UGIB. Patients with MGIB required 5.3 ± 0.5 investigative procedures (endoscopy, nuclear medicine scans, angiography, or combinations thereof) for localization of the bleeding source, as compared to 1.5 ± 0.1 procedures for UGIB and 2.1 ± 0.2 procedures for CB (p ≤ 0.02 across groups). Seventy-nine percent of patients with MGIB required >3 diagnostic procedures, compared to 0% of patients with UGIB and 14% of CB (p<0.0001). There was 10% mortality among patients with MGIB; there were no deaths among patients with CB or UGIB. CONCLUSIONS: These results suggest that: 1) MGIB has significantly higher morbidity and differing outcomes (longer hospital stay, higher hospital costs) compared to UGIB and CB, 2) Utilization of >3 diagnostic procedures in the localization of an acute bleeding source should increase the index of suspicion for a small bowel bleeding source, 3) Since presentation can be identical to CB or UGIB, early identification of a potential small bowel bleeding source may help improve the diagnostic outcome while decreasing the cost of hospitalization.

Assessment of stool colour in community management of prolonged jaundice in infancy

Jaundice persisting beyond the first 2 wk of life is often regarded as an indication for investigation to exclude cholestatic liver disease. Most babies with prolonged jaundice have breast milk‐related jaundice, which is a benign condition. Cholestatic liver disease is usually accompanied by pale stools and yellow or orange urine. A community programme was established to ascertain the incidence of prolonged jaundice and determine whether abnormal stool and urine colour could be used to assist primary care staff in referral decisions. Data were collected on normal stool and urine colour and used to devise a colour chart and information sheet for parents. Babies with prolonged jaundice were identified and referred for investigation. In all, 3661 babies were recruited into the study, of which 127 were jaundiced at 28 d of age. Of these, 125 were breastfed. The incidence of jaundice in breastfed babies at 28 d was 9.2% (95% CI 7.8%‐11.0%) Abnormal liver function tests (LFTs) were common, but no baby had abnormal stool or urine colour and none was found to have liver disease. Jaundiced breastfed babies who are well are unlikely to have serious disease. Elevated LFTs are compatible with a diagnosis of breast milk‐related jaundice. Prolonged jaundice in bottle‐fed babies, and persistent pallor of stools or yellow/orange urine, are rare and merit immediate referral. Parents and professionals can be advised to report pale stools without generating a large number of unnecessary referrals. Further work is needed to determine whether a colour chart reduces the mean age of referral and treatment of infants with cholestatic liver disease. □Breast milk jaundice, hyperbilirubinaemia, jaundice, liver function tests, stool colour

Assessment of stool colour in community management of prolonged jaundice in infancy.

Jaundice persisting beyond the first 2 wk of life is often regarded as an indication for investigation to exclude cholestatic liver disease. Most babies with prolonged jaundice have breast milk-related jaundice, which is a benign condition. Cholestatic liver disease is usually accompanied by pale stools and yellow or orange urine. A community programme was established to ascertain the incidence of prolonged jaundice and determine whether abnormal stool and urine colour could be used to assist primary care staff in referral decisions. Data were collected on normal stool and urine colour and used to devise a colour chart and information sheet for parents. Babies with prolonged jaundice were identified and referred for investigation. In all, 3661 babies were recruited into the study, of which 127 were jaundiced at 28 d of age. Of these, 125 were breastfed. The incidence of jaundice in breastfed babies at 28 d was 9.2% (95% CI 7.8%-11.0%) Abnormal liver function tests (LFTs) were common, but no baby had abnormal stool or urine colour and none was found to have liver disease. Jaundiced breastfed babies who are well are unlikely to have serious disease. Elevated LFTs are compatible with a diagnosis of breast milk-related jaundice. Prolonged jaundice in bottle-fed babies, and persistent pallor of stools or yellow/orange urine, are rare and merit immediate referral. Parents and professionals can be advised to report pale stools without generating a large number of unnecessary referrals. Further work is needed to determine whether a colour chart reduces the mean age of referral and treatment of infants with cholestatic liver disease.

副作用に関する情報提供方法の構築とその評価 リウマチ外来での試み

The pharmacist should provide the patient with suflcient information, including any expected adverse effects, to ensure that the patient can safely and appropriately use medication. However, informing patients of possible adverse effects might also induce the patients not to take the medication. Therefore, in an attempt to facilitate the counseling about adverse reactions of the dispensed medicine, the effect of illustrating adverse reactions on the rational use of the medication was studied. A total of 125 types of drugs prescribed for 107 out-patients with rheumatoid arthritis (RA) were classified into two groups. One was a group in which consultation by the pharmacist is extremely important for (64%), and the other is the one in which such consultation is only moderately required (36%). The former group has potentially severe adverse reactions, frequent mild adverse reactions, or the ability to change the color of urine, stool, or tears. The illustration cards were developed and provided for 30 out-patients with RA. These patients were also counseled by the pharmacist about the adverse reactions listed in the card. This information trial was found to help relieve the anxiety in 57% of the patients, and to help patients understand adverse reactions in 77%. From these.results, in order to improve the clinical effectiveness and avoid the adverse effects of the medication, it is thus important to develop proper drug information cards which provide patients with correct knowledge on the adverse reactions for the patients.

Mechanical obstruction of a Roux-Y limb

Two cases of mechanical obstruction of the defunctionalized limb of a Roux-en-Y loop of a bilioenteric conduit are reported. Both patients developed recurrent jaundice and acholic stools after apparently successful surgery for biliary atresia, and were initially diagnosed as having ascending cholangitis. However, the symptoms failed to respond to conservative treatment. At surgery, a mechanical obstruction of the Roux-Y limb due to adhesions was found. The jaundice disappeared and the stool color became normal after lysis of the adhesions.

An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding.

Subjective reporting of the color of blood passed per rectum has been used to predict the location of gastrointestinal bleeding, but the validity of this clinical approach has never been evaluated systematically. In this study we determined the spectrum of patient and physician descriptors used to characterize the color of blood passed per rectum and evaluated prospectively if an objective test of stool color would correlate with or improve upon subjective descriptions in predicting bleeding locations. The objective test employed was a card containing five numbered colors that typify the spectrum of stool blood colors. One hundred twenty patients used 23 different descriptors or terms to verbalize the color of blood they passed per rectum, and in 22% of cases there was a seeming discrepancy between their verbalized color and the color they pointed to on the test card. Patients pointing to card color 4 (the black color) resulted in closer matching to an upper bleeding source than physicians using terminology such as melena or tarry stools. Likewise, patients picking card colors 1 and 2 (the brightest red colors) resulted in closer matching to a coloanorectal bleeding source than physicians using the terms hematochezia or bright red blood per rectum (P < 0.02 for each comparison). The positive predictive value of card color 4 for an upper bleeding source was very high both when patients pointed to this color or when it was determined from the available stool (0.95 and 0.98, respectively). The positive predictive value of card color 1 for lower bleeding was greater for patients selecting this color than for a direct stool comparison (1.00 vs 0.83).(ABSTRACT TRUNCATED AT 250 WORDS)