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PubMed1997

[Proctocolectomy with ileal W pouch anal anastomosis for ulcerative colitis].

Restorative proctocolectomy with ileal pouch anal anastomosis, which is a relatively new procedure, has become a standard procedure for ulcerative colitis (UC) requiring surgical management. The main impact of this procedure is to cure patients of disease and to avoid permanent ileostomy, preserving better defecatory function and acceptable QOL. Some key aspects of our surgical procedure are as follows: 1) two or three separate staged operation, 2) W-shaped reservoir, 3) distal rectal mucosectomy and handsewn ileo-anal anastomosis, 4) short muscular cuff, and 5) temporary diverting ileostomy. Staged operation and diverting ileostomy are helpful to decrease risk of pelvic infection. Total removal of the rectal mucosa is necessary to cure the disease, and shorter muscular cuff decreases operating time and bleeding and thus the risk of pelvic sepsis. The W-shaped reservoir described by Nicholls brings both spontaneous defecation and improved function. We have adopted ileal W-pouch among several types of reservoir to 58 patients with UC since 1984, and found that a large and wide reservoir might allow better defecatory function. There were no cases of serious complications and no needs to remove the reservoir. Mean daily stool frequency was gradually decreased with time, and 4.9 stools per 24 hours at present day, and clinical score of neorectal function also gradually improved according to reduction of stool frequency. Seventy three percent of patients felt their defecatory function satisfactory and 89% of the patients recovered acceptable QOL no less than that obtained during the medically treated period.

Adolescent↗
PubMed1997

[The classification and choice of the method of treatment in fecal incontinence in children].

Complex examinations of 682 children with fecal incontinence including the colonodynamic investigation, computed tomography of the pelvis and endorectal sonography have shown that disturbance of the reservoir function and defecation urge mainly take place in cases of functional disorders. Anal incontinence of an organic type can also arise without an injury of the sphincter apparatus as a result of prolapse of the mucose membrane or stenosis of the distal portion of the rectum. In such cases the operative treatment is indicated. In patients with the incompetent internal and partially injured external sphincter treatment should be started by conservative measures. When the function of the pubo-rectal muscle or of all the elements of the closing apparatus is disturbed the operative treatment is indicated. The operative correction is possible for neurogenic incontinence in order to create the ano-rectal angle. A classification of anal incontinence in children is proposed which takes into account the etiology, pathogenesis and allows the optimum treatments to be chosen.

Anal Canal↗
PubMed1997

The pelvic floor in health and disease.

Normal pelvic floor function involves a set of learned and reflex responses that are essential for the normal control and evacuation of stool. A variety of functional disturbances of the pelvic floor, including incontinence and constipation, are not life threatening, but can cause significant distress to affected patients. Understanding the normal anatomy and physiology of the pelvic floor is essential to understanding and treating these disorders of defecation. This article describes the normal function of the pelvic floor, the diagnostic tools available to investigate pelvic floor dysfunction, and the etiology, diagnosis, and management of the functional pelvic floor disorders that lead to incontinence and constipation.

Constipation↗
PubMed1997

[The surgical correction of anterior rectocele. Our experience].

Rectocele, or namely the protrusion of the anterior wall of the rectum into the vaginal lumen following the collapse of the rectovaginal septum, is the most common anatomic alteration observed in patients suffering from defecation disorders. The surgical treatment of this pathology is still controversial, particularly in the choice of the surgical approach. From 1992 to 1994 10 patients suffering from low type, symptomatic anterior rectocele associated with intrarectal intussusception underwent muscular plastic surgery of the rectocele and anterior mucosectomy. The aim of this study was to evaluate whether surgical muscular plastic of the rectocele using a transanal approach associated with anterior mucosectomy represents in selected symptomatic patients, a rational and elective therapeutic option. In spite of the small number of patients and the short postoperative follow-up, the authors state that, on the basis of the results obtained, the surgical technique used in this clinical series significantly improves symptoms with a lower incidence of complications compared to the transvaginal approach.

Adult↗
PubMed1997

[Colorectal cancer. Location dependent symptoms?].

It is claimed that the symptoms of cancer in different parts of the colorectum are varied. The aim of the study was to decide how well the "classical" symptoms are divided between left and right colonic and rectal adenocarcinomas. This was a retrospective study of 102 patients with colorectal cancer at Ullevål hospital in 1992. Red blood in the faeces (p = 0.001), and changes in stool pattern (p = 0.001), were left colonic and rectal cancer specific. Moreover tenesmus, mucous stools, and pain at defecation were specific of rectal cancer. All these findings agree with the textbooks. Melaena, diarrhoea (p = 0.23), weight-loss (p = 0.09), a feeling of general physical weakness (p = 0.13), and ileus/subileus were not found as localisation specific symptoms, contrary to the claims of several textbooks. Pain was always correlated to the affected side in left and right colonic cancer, while in rectal cancer the localisation of pain was non-specific, and it appeared rather often; (37%) in Dukes' A and Dukes' B. Only a few patients had anorexia, but the number was still significant for those with right colonic cancer (p = 0.04). With few exceptions, our results generally support the textbooks. The referring symptoms may help to decide the necessity for further examinations, when total colonoscopy is not obtained.

Adenocarcinoma↗
PubMed1997

Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis.

AIM: Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis. PATIENTS AND METHODS: Prospective study in 24 patients with an ileoanal "J" pouch (n = 8: mucosectomy and hand-sewn anastomosis; n = 16: stapled anastomosis without mucosectomy). A clinical survey was carried out during two evolutive follow-ups of the functional pouch (medians: 14.5 and 39.0 months) as well as an anorectal manometry study during the preoperative period and in two follow-ups after the creation of the pouch (medians: 6.0 and 35.5 months). RESULTS: The mean frequency of defecation per 24 hours and per night was significantly reduced in the first follow-up (5.5 [24 h]; p < 0.003 and 1.0 [per night]; p < 0.009) compared with the postoperative period (7.9 [24 h] and 1.4 [per night]), with no significant changes in the second follow-up (5.5 [24 h] and 0.9 [per night]). At the same time, it has been significantly lower in patients with stapled anastomosis in the different evolutive follow-ups. One patient (4.2%) had major fecal incontinence in the two evolutive follow-ups and 7 (29.2%) and 6 (25%) patients had minor incontinence in the first and second follow-up respectively. The mean maximum resting anal pressure in the first follow-up was significantly lower (p = 0.002) in patients with mucosectomy than the values observed in patients with stapled anastomosis (35.4 vs 68.0 mmHg). In the second follow-up increased significantly (p = 0.046) only in patients with mucosectomy (55.1 mmHg). Recto-anal inhibitory reflex was present in 2 (10%) and 9 (45%) patients in the first and second follow-up respectively. CONCLUSIONS: The functional results improve significantly with the follow-up time, fundamentally during the first year of the functional pouch.

Adult↗
PubMed1978

[Postoperative feeding of patients after maxillofacial surgery with Sokoham--a new parenteral nutritive solution].

20 patients--15 to 71 years old--, who underwent maxillofacial operations received Sokoham for 10 days via a nasogastric tube. In 0.8% of all applications vomiting occurred. Wound healing and time of hospitalisation were the same as in a control group. Mean frequency of defecation was 0.5/24 hours. Body weight, serum electrolytes, fat content of the blood, blood gases, pH, base deficit, serum transaminases, urea-nitrogen and creatinine in the serum did not change significantly.

Adolescent↗
PubMed1988

Perianal cellulitis. Cutaneous group A streptococcal disease.

Five case reports of perianal cellulitis caused by group A beta-hemolytic streptococci are presented. These reports illustrate delays in diagnosis and therapy of this condition that may present as chronic diaper dermatitis, perirectal fissures, painful defecation, fecal hoarding behavior, or proctocolitis. One patient had associated guttate psoriasis. In children especially, guttate psoriasis should alert physicians to culture perirectal as well as pharyngeal sites for group A streptococci.

Adult↗
PubMed2000

Predictive factors for short-term symptom persistence in children after emergency department evaluation for constipation.

BACKGROUND: Children with symptoms and signs of constipation are commonly assessed in pediatric emergency departments (EDs). Little is known about their outcome following the ED visit. OBJECTIVES: To describe the clinical characteristics of children presenting to the ED with constipation and the ED interventions; to measure short-term symptom resolution at 48 hours and 7 days after the ED visit; and to identify predictive factors associated with poor symptom resolution at 48 hours and 7 days after the ED visit. DESIGN/METHODS: Cohort study conducted between July 10, 1997, and September 10, 1997, in a tertiary care pediatric hospital ED. All children (aged 1-18 years) with idiopathic constipation were included. Constipation was diagnosed if there were at least 2 of the following: abdominal pain, infrequent bowel movements, hard feces, fecal soiling, pain on defecation, and/or clinical evidence of excessively retained feces. Data on the presenting symptoms, signs, and ED treatment plan were collected on study enrollment and then in 2 standardized 10-minute telephone interviews at 48 hours and 7 days after the ED visit. At each follow-up, patient disposition was measured and dichotomized based on symptom resolution to "improved" vs "not improved." The presenting features and ED management were compared between groups using chi(2) analyses and t tests. RESULTS: Consent and full questionnaire completion was obtained in 102 children. The mean + SD age was 6.5 + 3.8 years; 47 (46%) were male. The predominant presenting symptom was abdominal pain (83 [81%]); the most frequent sign was palpable abdominal stool (67 [66%]). A high-fiber diet (75 [74%]) and mineral oil (48 [47%]) were prescribed most frequently. Enemas were given to 64 (63%) of the children. Improvement was found in 32 (31%) of the children at 48 hours and in the majority at 7 days (77 [75%]). Risk factors for poor symptom resolution at both 48 hours and 1 week included: female sex (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.0 6.6); history of recurrent abdominal pain (OR = 2.8; 95% CI = 1.2-6.5); duration of primary presenting symptom longer than 2 days (OR = 2.4; 95% CI = 1.0-6.4); and history of medical visits for the same symptom (OR = 2.3; 95% CI = 1.0-5.3). There was no difference in outcome based upon ED treatment (enema vs oral or no therapy) (OR = 1.0; 95% CI = 0.4-2.3). CONCLUSIONS: Most children with constipation evaluated in the ED have acute symptoms and rapid improvement, regardless of presentation characteristics or ED management. In this study, 4 risk factors for poor outcome were found consistently at 48 hours and 7 days. This subgroup of children deserve closer clinical attention. Emergency department therapy did not influence short-term symptom resolution. Further studies are warranted to examine the effects of therapy for constipation in the ED setting. Arch Pediatr Adolesc Med. 2000;154:1204-1208.

Adolescent↗
PubMed1991

Lichen sclerosus et atrophicus in children.

The symptoms, findings, associated conditions, and treatment of lichen sclerosus et atrophicus were studied in 10 girls and one boy. Lichen sclerosus et atrophicus is a benign but chronic condition of the anogenital area of girls and, less frequently, of boys. The characteristic lesions are hypo-pigmented plaques in a figure-of-8 pattern surrounding the vulva and anus and often involving the natal cleft. The affected hypopigmented skin is sharply demarcated from the normal skin. Hemorrhagic, bullous lesions are uncommon. Fissures and ulcers are seen on the labia, between the labia, and on the perineum, anus, and natal cleft in many children and on the glans penis in boys. Lichen sclerosus et atrophicus causes painful defecation and anal and vulval bleeding. In two patients, one girl and one boy, anal stenosis due to lichen sclerosus et atrophicus and laxative treatment developed. Lichen sclerosus et atrophicus mimics sexual abuse and has led to false accusation and investigations. The anogenital lesions cleared in three patients at the ages of 9, 11, and 12 years, but lesions can persist into adulthood.

Anus Diseases↗
PubMed2002

Stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial.

HYPOTHESIS: Stapled hemorrhoidectomy offers several advantages over excision hemorrhoidectomy, including reduced postoperative pain, a reduced hospital stay, and an earlier recovery time. Furthermore, stapled hemorrhoidectomy is associated with lower hemorrhoidal recurrence on long-term follow-up. DESIGN: A randomized prospective trial. Patients were blinded to the operation technique used. Follow-up occurred at 1 and 3 weeks and 12 months postoperatively. SETTING: A university hospital providing primary, secondary, and tertiary care. PATIENTS: Forty patients with second- and third-degree hemorrhoid disease were randomized to undergo either stapled or excision hemorrhoidectomy. Two patients were excluded. All patients were subject to a follow-up examination. INTERVENTIONS: Stapled hemorrhoidectomy (Longo technique) vs excision hemorrhoidectomy (Ferguson technique). MAIN OUTCOME MEASURES: Operating time, postoperative pain (measured by the visual analog scale), hospital stay, histologic features, morbidity, defecation habit, continence, recovery time (return to work), and hemorrhoid recurrence at 1 year. RESULTS: Stapled vs excision hemorrhoidectomy was associated with a significantly reduced operating time (30 vs 43.25 minutes; P<.001), reduced postoperative pain scores (visual analog score) on the first 4 postoperative days (day 1: 2.7 vs 6.3; day 2: 1.7 vs 6.3; day 3: 0.8 vs 5.4; and day 4: 0.5 vs 4.8, where 0 indicates no pain, and 10, maximum pain; P < or = .001), and an earlier return to work (6.7 vs 20.7 days;P =.001). There were no differences for stapled vs excision hemorrhoidectomy in length of hospital stay (2.4 vs 2.1 days), complications (3 [15%] of 20 patients vs 5 [25%] of 20 patients), and recurrence rate (1 [5%] of 20 patients vs 1 [5%] of 20 patients). CONCLUSIONS: Stapled hemorrhoidectomy is associated with reduced postoperative pain, earlier recovery time and return to work, and a similar recurrence rate compared with the excision technique. Provided further clinical trials confirm these findings, stapled hemorrhoidectomy may become a future gold standard.

Adult↗
PubMed2007

Quality of life and morbidity after permanent sacral nerve stimulation for fecal incontinence.

HYPOTHESIS: Permanent sacral nerve stimulation (SNS) is a promising emerging treatment for fecal incontinence. However, there is little data on morbidity and quality of life (QOL) during long-term stimulation. DESIGN: Prospective trial to assess morbidity and QOL in patients treated with SNS. Median follow-up was 13 months (range, 1-42 months). SETTING: University hospital providing primary, secondary, and tertiary care. PATIENTS: Between December 2001 and July 2005, SNS was tested in 44 patients (30 women), with a median age of 65 years (range, 15-88 years). INTERVENTIONS: Percutaneous nerve evaluation and permanent insertion of an implantable pulse generator. MAIN OUTCOME MEASURES: Morbidity, stool diary, and Wexner Score for fecal incontinence; Hanley Score for urinary incontinence; and Gastrointestinal Quality of Life Index, the 36-item short form health survey, and the Royal London Hospital questionnaire for QOL. RESULTS: A permanent stimulator was implanted in 37 patients (84%). Eight patients (22%) experienced complications that required surgical intervention. (A successful restimulation was possible for 5 of those patients.) Adverse effects of SNS were remedied in 5 patients by reprogramming the stimulator. Wexner Scores decreased from a median of 16 points preoperatively (range, 6-20), to a median of 5 points postoperatively (range, 0-13; P<.001). The median number of involuntary stool losses and for urge defecations also decreased significantly. Significant improvement in QOL was found in both generic and incontinence-specific questionnaires (P<.05). The success rate of SNS was 77% (34 of 44 patients) and 92% (34 of 37) in patients with permanent implantation. CONCLUSIONS: The minimally invasive technique of SNS is safe and effective. Most adverse effects can be easily remedied. Our data demonstrate that SNS significantly improves patients' QOL, including their physical and psychological well-being.

Adolescent↗
PubMed2004

Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial.

CONTEXT: Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies lacked sufficient power to assess the impact of household handwashing on diarrhea in infants. OBJECTIVE: To evaluate the effect of promoting household handwashing with soap among children at the highest risk of death from diarrhea. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized controlled trial of 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Field workers visited participating households at least weekly from April 15, 2002, to April 5, 2003. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years. INTERVENTIONS: Weekly visits in 25 neighborhoods to promote handwashing with soap after defecation and before preparing food, eating, and feeding a child. Within intervention neighborhoods, 300 households (1523 children) received a regular supply of antibacterial soap and 300 households (1640 children) received plain soap. Eleven neighborhoods (306 households and 1528 children) comprised the control group. MAIN OUTCOME MEASURE: Incidence density of diarrhea among children, defined as the number of diarrheal episodes per 100 person-weeks of observation. RESULTS: Children younger than 15 years living in households that received handwashing promotion and plain soap had a 53% lower incidence of diarrhea (95% confidence interval [CI], -65% to -41%) compared with children living in control neighborhoods. Infants living in households that received handwashing promotion and plain soap had 39% fewer days with diarrhea (95% CI, -61% to -16%) vs infants living in control neighborhoods. Severely malnourished children (weight for age z score, <-3.0) younger than 5 years living in households that received handwashing promotion and plain soap had 42% fewer days with diarrhea (95% CI, -69% to -16%) vs severely malnourished children in the control group. Similar reductions in diarrhea were observed among children living in households receiving antibacterial soap. CONCLUSION: In a setting in which diarrhea is a leading cause of child death, improvement in handwashing in the household reduced the incidence of diarrhea among children at high risk of death from diarrhea.

Adolescent↗
PubMedDate not supplied

Effect of galanin on isolated strips of smooth muscle from the gastrointestinal tract of chickens.

The contractile effects of galanin on isolated longitudinal smooth muscle strips of pre-crop esophagus, proventriculus, duodenum, colon, and cecum of chickens were investigated. Application of galanin (5.0-100.0 nM) evoked strong contractions from the colon and cecum (hindgut), but evoked minimal responses from the pre-crop esophagus, proventriculus, and duodenum (foregut). Previous studies have demonstrated that the central administration of galanin stimulates food consumption in rats. Since galanin-like immunoreactivity is present in the chicken brain, we speculate that the central release of galanin may increase food intake and possibly be involved in a hypothalamic-colonic reflex modulating hindgut motility and generating a defecation. Thus, the results of this study demonstrate the presence of galanin receptors in the chicken gut and suggest a possible link with their functional presence in the hindgut to the chicken central nervous system.

Animals↗
PubMed1998

Seed handling by three prosimian primates in southeastern Madagascar: implications for seed dispersal.

In this paper, we studied three species of prosimian primate (Propithecus diadema edwardsi, Eulemur fulvus rufus, and Eulemur rubriventer) from June-July 1995 at the Ranomafana National Park to answer three questions: 1) how they handle and process seeds, 2) how the physical properties of seeds influence seed handling and seed fate, and 3) whether handling and processing patterns influence seed dispersal. Seeds from five plant species were collected from feces and examined for external damage (punctures and scrapes), weighed, measured, and checked daily for germination. P. d. edwardsi masticated seeds into two or more pieces while feeding. Seed fragments were either dropped under the parent tree or chewed and swallowed; seeds never emerged as recognizable units in feces. In contrast, both Eulemur species either dropped or swallowed seeds whole while feeding. E. rubriventer passed seeds that were longer, wider, and heavier than seeds passed by E.f. rufus. Although seeds emerged as separate units when passed by both Eulemur species, 65 Protorhus sp. seeds were scraped and/or punctured prior to being swallowed. Based on physical property tests, Protorhus seeds were more susceptible to mastication than undamaged seeds from Eugenia sp., Cissus sp., and Chrysophyllum madagascariensis. H. madagascariensis seeds also were undamaged but had physical properties comparable to Protorhus and may avoid being masticated due to their small size (2-3 mm). All damaged seeds were moldy or rotten within 6 days, and only 15% of the undamaged seeds passed by E. rubriventer germinated. None of the seeds passed by E.f. rufus germinated. Eulemur species also rested in the same tree after feeding and defecated prior to a new feeding bout or before moving, so seeds were most likely to be dispersed under the parent tree. Consequently, we concluded that these primate species do not appear to serve as effective seed dispersers for these plant species at this time of year.

Animals↗
PubMed1996

Tyrosine enhances behavioral and mesocorticolimbic dopaminergic responses to aversive conditioning.

Tyrosine is a precursor in the biosynthesis of catecholamines and, when administered systemically, has been shown to enhance the in vivo rate of tyrosine hydroxylation in the medial prefrontal cortex. Additionally, exogenous tyrosine has been demonstrated to enhance the pharmacologically-induced increase in dopamine metabolism seen following administration of haloperidol or the anxiogenic B-carboline, FG-7142. In this report, we examine the effect of a physiologically relevant dose of tyrosine (25 mg/kg) on biochemical and behavioral consequences of aversive conditioning. Rats were conditioned to fear a tone by pairing it with footshock, so that when challenged with the tone alone, rats responded with immobility, defecation, and elevated dopamine metabolism in the medial prefrontal cortex and nucleus accumbens. When tyrosine was administered on the test day (tones alone), the rats displayed an even greater elevation of dopamine metabolism in the nucleus accumbens and prolonged immobility to the tone, compared to the saline/conditioned controls. Tyrosine did not alter mobility or dopamine utilization in the nucleus accumbens in nonconditioned controls. However, dopamine metabolism in the medial prefrontal cortex of nonconditioned rats treated with tyrosine was increased to levels similar to those in the conditioned groups. This may be accounted for by handling and by exposure to an unfamiliar environment necessary for nonconditioned controls. We conclude that exogenous tyrosine is able to 1) elevate stress-induced dopamine metabolism in the nucleus accumbens, 2) alter dopamine utilization in the medial prefrontal cortex of handled, nonconditioned controls, and 3) enhance fear-induced immobilization. These data suggest a role for dietary tyrosine in biochemical and behavioral responses to aversive stimuli.

3,4-Dihydroxyphenylacetic Acid↗
PubMed1998

Determination of the population pharmacokinetic parameters of sustained-release and enteric-coated oral formulations, and the suppository formulation of diclofenac sodium by simultaneous data fitting using NONMEM.

Data from sustained-release and enteric-coated oral formulations, and the suppository formulation of diclofenac sodium are fitted simultaneously using NONMEM and the general linear model, ADVAN 5. Absorption and disposition parameters, serum levels, and absorption profiles were determined. The in vivo absorption profiles were determined using the program TOPFIT. The in vivo absorption for the sustained-release formulation is slow first order and follows a flip-flop model since disposition rate constants are greater than absorption rate constants. Absorption from the enteric-coated form is essentially complete (> or = 95%) at about 7.5 h, while it is 95% complete at 24 h from the sustained-release formulation. This suggests likely absorption from the colon in the case of the sustained-release formulation since absorption is only 75% complete during the first 10 h. The sustained-release relative bioavailability is 90-99%. Absorption from the suppository is essentially complete at about 4.5 h. However, the relative bioavailability of the suppository formulation is low (55%), since defecation may remove the drug from the absorption site before complete absorption.

Administration, Oral↗
PubMed1999

Prevalence of anal incontinence in 409 patients investigated for stress urinary incontinence.

A clinical questionnaire concerning anorectal symptoms and urodynamic tests was used to investigate 409 women consulting for stress urinary incontinence. To compare urodynamic data, patients were divided into three groups of women who had either stress urinary incontinence associated with incontinence for formed and/or liquid stools or with gas incontinence, or isolated stress urinary incontinence. To take in account the patients'age for data interpretation, a Mantel-Haenszel test or covariate analysis was performed. Anal incontinence was reported in 114 (28%) of the 409 women investigated. The prevalence of incontinence for gas only, for liquid, or for solid stools was 18.3, 9.3, and 1%, respectively. The duration of gas incontinence was longer than that of fecal incontinence or stress urinary incontinence. Difficult defecation was more frequently observed in patients with double incontinence than in patients with only stress urinary incontinence, and the difference was significant between patients with gas incontinence and patients with stress urinary incontinence (53% versus 37%, P = 0. 03). There was no difference in the number of bowel movements per week among the three groups of patients. The number of vaginal deliveries was surprisingly lower in patients with fecal incontinence associated with urinary incontinence than in others. There was no urodynamic feature that could distinguish patients with urinary incontinence and patients with double incontinence. This study confirmed the close relationship between anal and stress urinary incontinence. Neurourol. Urodynam. 18:579-590, 1999.

Adolescent↗