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BACKGROUND: The bowel purgative Visicol contains microcrystalline cellulose (MCC) residue, which may impair full visibility during a colonoscopy. An MCC residue-free sodium phosphate (RF-NaP; OsmoPrep) tablet was developed. OBJECTIVE: To investigate appropriate RF-NaP dosing. DESIGN: Phase 2, randomized, investigator-blinded study. SETTING: Six research centers in the United States. PATIENTS AND INTERVENTIONS: Patients undergoing a colonoscopy received Visicol (n = 34) or 1 of 6 RF-NaP regimens administered as either split (S) dosing (the evening before and the day of colonoscopy) or evening-only (E) dosing. Dosing regimens for RF-NaP were 40 tablets S, 3 every 15 minutes (n = 33); 40 tablets S, 4 every 15 minutes (n = 34); 32 tablets E, 4 every 15 minutes (n = 34); 32 tablets S, 4 every 15 minutes (n = 36); 28 tablets E, 4 every 15 minutes (n = 34); 28 tablets S, 4 every 15 minutes (n = 34). Visicol was administered as 40 tablets S, 3 every 15 minutes. MAIN OUTCOME MEASURE: Overall colon cleansing (OCC) was assessed by a physician questionnaire (4-point scale, based on colonic contents). An OCC rating of "excellent" or "good" was considered a response. Safety measures were also monitored. RESULTS: Split dosing with RF-NaP was associated with high OCC and achieved response rates of 90%, 97%, and 100% for 28, 32, and 40 tablets, respectively, compared with 86% for Visicol. In addition, RF-NaP evening-only regimen response rates were 90% (32 tablets) and 72% (28 tablets). Transient shifts in electrolyte levels were reduced, and GI adverse events were less common with lower RF-NaP dose regimens. CONCLUSIONS: Administration of RF-NaP retains the benefits of a tablet purgative but eliminates MCC issues. Split dosing and 32-tablet evening-only dosing of RF-NaP tablets were efficacious and well tolerated, and split dosing of RF-NaP tablets is recommended.
Our ability to function successfully as efficient physicians depends substantially on our employees who surround us in our practices. It is our office associates who initially come into contact with our patients, generally spend more time with them than we do, and clearly play the major role in the scheduling of, and preparation for, endoscopic examinations. In this article we discuss ways in which we can improve scheduling and preparation for endoscopic procedures.
Virtual colonoscopy (CT colonography) is a technique whereby CT images of the cleansed and distended colon are acquired, ostensibly for detecting colonic neoplasia, although also providing additional diagnostic information from extracolonic organs. This article examines the current status of virtual colonoscopy, reviewing the technical parameters, performance characteristics, and issues surrounding implementation in routine clinical practice. Future directions for virtual colonoscopy are explored, including advances toward prepless examinations and automated interpretation.
Based on current evidence, bulking agents are not more effective than placebo at improving global irritable bowel syndrome (IBS)symptoms, although they may increase stool frequency in large doses. Tricyclic antidepressants are more effective than placebo for patients with diarrhea-predominant IBS. Imodium is more effective than placebo at improving stool consistency and decreasing stool frequency in patients with IBS, and it may be an important component for treating diarrhea-predominant IBS. Antispasmodics agents available in the United States are not more effective than placebo for treating IBS, although the studies are small and poorly designed. There are no randomized controlled trials examining the efficacy of laxatives for managing IBS. Tegaserod is more effective than placebo at improving global IBS symptoms in women with nondiarrhea-predominant IBS. Alosetron is more effective than placebo in women with diarrhea-predominant IBS, although its use should be limited to patients who have failed conventional therapy because of its adverse event profile.
Nephrocalcinosis is a chronic tubulointerstitial nephropathy characterized by tubular calcium phosphate deposition and slowly progressive renal insufficiency. We report a novel association of acute nephrocalcinosis and acute renal failure (ARF) with colonoscopy preceded by a bowel-cleansing regimen consisting of oral sodium phosphate solution (OSPS). A cohort of 5 patients (mean age, 69.2 years) had normal renal function (mean serum creatininem 0.9 mg/dL) before colonoscopy and presented with ARF (mean serum creatinine, 4.9 mg/dL) from 3 days to 2 months postcolonoscopy. Past medical history included hypertension in all 5 patients. Medications included an angiotensin-converting enzyme (ACE) inhibitor (ACE-I) or angiotensin receptor blocker (ARB) in 4 patients and diuretics in 2 patients. In all patients, colonoscopy was preceded by bowel cleansing with OSPS; OSPS was contraindicated in a single patient with hyperparathyroidism and was used at excessive doses in another. Renal biopsy specimens obtained from all 5 patients revealed diffuse tubular injury and abundant tubular deposition of calcium phosphate. Although the tubular injury involved all tubular segments, lectin and immunohistochemical staining disclosed calcium phosphate deposition confined to distal tubules and collecting ducts. At a mean of 5.8 weeks of postbiopsy follow-up, renal function was unchanged in 4 patients and mildly improved in 1 patient. We conclude that acute nephrocalcinosis is a seemingly rare complication of bowel cleansing with OSPS. The pathophysiology of acute nephrocalcinosis after treatment with OSPS likely involves transient hyperphosphatemia; volume depletion exacerbated by intercurrent ACE-I, ARB, and diuretic use; and elevated distal tubular phosphate and calcium concentrations. Greater awareness of this entity is needed to identify potential risk factors.
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The area of bowel care in the intensive care unit (ICU) is often overlooked in the holistic care of the critically ill individual. With the primary concern of optimising patients to preserve life the problem of bowel care has been given less priority. The guidelines included within this service improvement paper offer a simple approach to bowel care management with the use of an algorithm and visual display score to be used in conjunction with the algorithm. This was developed in the intensive care unit of the Royal Free Hospital, London and is presently in use.
PURPOSE: To estimate the prevalence of past year laxative use or vomiting weight control behaviors among adolescent females in the general population and to examine the relationship between these behaviors and substance use among adolescent females, with a specific focus on past year 3-4 methylenedioxymethamphetamine (MDMA) ("Ecstasy") use. METHODS: Secondary analyses were conducted using a nationally representative sample of females aged 12 to 17 years (n = 4292) from the 2001 National Household Survey on Drug Abuse (NHSDA). Logistic regression was used to examine bivariate relationships between past year laxative use or vomiting weight control behaviors and substance use and the multivariate relationship between unhealthy weight control behaviors and Ecstasy use. RESULTS: Approximately 10% of adolescent females had used laxatives or vomited to lose weight in the past year. Adolescent females who had used laxatives or vomited to lose weight in the past year were more likely than those who had not to have used substances during the past year, including Ecstasy, inhalants, nonmedical psychotherapeutics, marijuana, cigarettes, and alcohol. After controlling for demographics and other substance use, past year laxative use or vomiting weight control behaviors were positively associated with past year Ecstasy use (OR = 1.81; 95% CI = 1.05, 3.14; p = 0.04). CONCLUSION: Laxative use or vomiting weight control behaviors are a significant problem among the general population of adolescent females and are related to an increased risk of Ecstasy use.
OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.
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We evaluated the pharmacological properties and spasmogenic activities of Yumijangquebotrade mark, a Korean herbal laxative formulation. Doses in the range 12-50 microg/ml induced a large spasmogenic effect in isolated guinea pig ileum, similar to that induced by acetylcholine. Pre-treating the tissue with atropine (0.2 microM) completely abolished the contractile effect of Yumijangquebo. The spasmogenic effect of Yumijangquebo and the inhibition of this effect by atropine suggest that a cholinergic mechanism is responsible for its effects. Yumijangquebo increased the gastrointestinal motility in ICR mice at doses between 10 and 37 mg/kg. Yumijangquebo exhibited higher activity than three other laxatives tested, which had activities about 85% of that of Yumijangquebo. In an acute toxicity study using Sprague-Dawley rats, the median lethal dose (LD50) of Yumijangquebo was greater than 2000 mg/kg, and we found no pathological changes in macroscopic examination by necropsy of rats treated with Yumijangquebo. We conclude that Yumijangquebo may be safely used as a herbal spasmogenic laxative agent.
In traditional Chinese medicine (TCM), there are three Cheng-Chi-Tang decoctions (CCTDs) including: Ta-Cheng-Chi-Tang (TCCT), Xiao-Chen-Chi-Tang (XCCT) and Tiao-Wei-Chen-Chi-Tang (TWCCT), which are the frequently used purgative remedies to treat "internal heat"-induced symptoms like a bloated and painful abdomen, hard stools and fever, etc. Constituents in each formulation are Rheum palmatum L. (Polygonaceae), Magnolia officinalis Rehd. et Wils. (Magnoliaceae), Citrus aurantium L. (Rutaceae), Mirabilitum (mirabilite, crystals of sodium sulfate, Na2SO4) for TCCT; Rheum palmatum, Magnolia officinalis, Citrus aurantium for XCCT; and Rheum palmatum, Mirabilitum, Glycyrrhiza uralensis Fisch. (Leguminosae) for TWCCT. However, the underlying mechanisms for purging internal pathological heat are far from fully clarified, and few scientific investigations have been carried out to delineate the relationships between the anti-inflammatory effects and laxative potencies of these formulations. In this study, the anti-inflammatory effects of the three CCTDs on lipopolysaccharide (LPS)-induced nitric oxide (NO) and prostaglandin E (PGE2) production in RAW 264.7 cells, carrageenan-induced paw edema in mice and the laxative effect in mice were explored. The results showed that TCCT inhibited LPS-induced NO and PGE2 production and inducible nitric oxide synthase (iNOS) expression in RAW 264.7 cells more effectively than did XCCT or TWCCT. Moreover, paw edema of carrageenan-treated mice was significantly attenuated in mice pretreated with 1 g/kg TCCT. TCCT also showed the strongest purgative activity among the three formulations. These findings indicate that TCCT has anti-inflammatory effects in addition to its traditionally known purgative activities. It may have potential to treat inflammatory disease conditions.
The three purgative Cheng-Chi-Tang decoctions (CCTDs) including Ta-Cheng-Chi-Tang (TCCT), Xiao-Chen-Chi-Tang (XCCT), and Tiao-Wei-Chen-Chi-Tang (TWCCT) are used for treating gastrointestinal disorders, including liver diseases in traditional Chinese medicine. However, the underlying mechanisms as liver disease remedies are far from fully clarified. The objective of the study is to investigate and compare the antioxidant activity of the three purgative CCTDs in order to delineate their hepatic protective potential and mechanism. Antioxidant activity measured with the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging test indicated XCCT as the most potent preparation (IC(50) 8.94 microg/ml). In tert-butylhydroperoxide (TBH, 50mM)-induced lipid peroxidation in ICR mice liver homogenates, XCCT also showed stronger and dose-dependent inhibitory activity against TBH-induced malondialdehyde (MDA, a marker of lipid peroxidation) production (IC(50) 53.66 microg/ml). In addition, XCCT showed dose-dependent protective effect against TBH-induced cytotoxicity in normal human Chung liver cells Furthermore, in carbon tetrachloride (CCl(4))-induced acute liver injury model, mice pretreated with 0.2g/kg and 0.4 g/kg of XCCT extracts showed a decrease of 59.8 and 43.1% in serum glutamic oxaloactetic transaminase (GOT) level, 51.4 and 52% in glutamic pyruvate transaminase (GPT) level, along with a reduction of 31 and 15% in MDA level, respectively, similar to the effects exerted by silymarin. XCCT pretreated mice also showed milder necrotic changes in the microscopic picture of the liver. The results suggest that XCCT has significant antioxidant activity and hepatic protection potential.
BACKGROUND/AIMS: Hepatic encephalopathy is a frequent event after transjugular-intrahepatic-portosystemic-shunt (TIPS), especially during the first months. Aim of this study was to compare two different treatments (lactitol 60 g/day, rifaximin 1200 mg/day) with no-treatment in the prevention of post-TIPS hepatic encephalopathy. METHODS: Seventy-five consecutive cirrhotics submitted to TIPS were randomized to receive either one of the above treatments or no-treatment. The main end-point was the occurrence of an episode of overt hepatic encephalopathy during the first month post-TIPS. Before the procedure and weekly thereafter the patients were evaluated by examining their mental status, asterixis, ammonia and trail-making-test Part-A (TMT-A). RESULTS: The three groups were comparable for age, sex, etiology, Child-Pugh-score, post-TIPS porto-systemic gradient, previous hepatic encephalopathy, basal values of ammonia and psychometric performance. Twenty-five patients developed hepatic encephalopathy (33%, CI 95%=22-45%). One-month incidence was similar in the three groups (P=0.97). Previous hepatic encephalopathy (Relative Hazard=3.79;1.27-11.31) and basal-TMT-A Z-score>1.5 (RH=3.55;1.24-10.2) were predictors of post-TIPS encephalopathy at multivariate analysis. A <5 mmHg porto-systemic gradient was also significantly related to the occurrence of encephalopathy. CONCLUSIONS: Our data show that treatment with lactitol or rifaximin is not effective in the prophylaxis of hepatic encephalopathy during the first month after a TIPS.
Alvimopan has been shown to reverse the inhibitory effect of opioids on gastrointestinal transit without affecting analgesia. We evaluated oral alvimopan, 0.5 or 1 mg, versus placebo, once daily for 21 days, in 168 patients with opioid-induced bowel dysfunction (OBD) who were receiving chronic opioid therapy (minimum, 1 month) for nonmalignant pain (n = 148) or opioid dependence (n = 20). The primary outcome was the proportion of patients having at least one bowel movement (BM) within 8 hours of study drug on each day during the 21-day treatment period. Averaged over the 21-day treatment period, 54%, 43%, and 29% of patients had a BM within 8 hours after alvimopan 1 mg, 0.5 mg, or placebo, respectively (P < .001). Secondary outcomes of median times to first BM were 3, 7, and 21 hours after initial doses of 1 mg, 0.5 mg, and placebo, respectively (P < .001; 1 mg vs placebo). Weekly BMs and overall patient satisfaction were increased after the 1-mg dose (P < .001 at weeks 1 and 2 vs placebo, and P = .046, respectively). Treatment-emergent adverse events were primarily bowel-related, occurred during the first week of treatment, and were of mild to moderate severity. Alvimopan was generally well tolerated and did not antagonize opioid analgesia. Patients treated with chronic opioid therapy often experience opioid-induced bowel dysfunction as a result of undesirable effects on peripheral opioid receptors located in the gastrointestinal tract. Alvimopan, a novel peripheral opioid mu-receptor antagonist, has demonstrated significant efficacy for the management of opioid-induced bowel dysfunction without compromise of centrally mediated opioid-induced analgesia.
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OBJECTIVE: To assess safety, efficacy, and acceptance of polyethylene glycol 3350 without electrolytes (PEG) for bowel preparation for colonoscopy in children. Study design In a prospective study, 46 children (mean age, 11.2 years; range, 2.8-17.8) were given PEG at a dose of 1.5 g/kg/day for 4 days before colonoscopy. Patients were allowed to mix PEG in the beverage of their choice. Stool frequency and adverse effects were monitored during PEG therapy. Compliance, tolerance, and quality of colonic preparation were assessed. Serum electrolytes were measured before and after PEG therapy in 29 children. RESULTS: Daily stool frequency increased with PEG therapy from baseline of 2.6+/-0.3 to 3.0+/-0.5 on day 1, 4.6+/-0.4 on day 2, 5.5+/-0.7 on day 3, and 6.0+/-0.6 on day 4 (days 2, 3, and 4, P<.001 for difference vs baseline). The colonic preparations were rated as excellent or good in 91% and 95% in the right and left colon, respectively, at endoscopy. Adverse effects were mild nausea (13%), abdominal pain (11 %), and vomiting (11%). Electrolyte profile revealed small, clinically insignificant changes with PEG therapy. Compliance and tolerance were rated as excellent by 89% and 85% of patients, respectively. CONCLUSIONS: Electrolyte-free PEG 3350 can be used as an effective and safe bowel preparation that is well accepted by children for colonoscopy.