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Ontario and Newfoundland incidents show gastrointestinal infections can have lasting consequences
Canadian outbreaks of two different gastrointestinal infections show the illnesses come with long-term health problems such as irritable bowel syndrome (IBS).
IBS puzzles doctors because medical tests usually don't show any abnormalities in the intestine, despite the presence of abdominal pain, diarrhea, constipation and bloating.
The two incidents -- the water-borne bacterial outbreak in Walkerton, Ont., in May 2000 and a food-borne viral outbreak at a scientific meeting in Newfoundland -- are providing researchers with an unprecedented look at what happens once the infections pass.
"It's a tragic opportunity, obviously we recognize that," says Dr. John Marshall, a gastroenterologist at McMaster University in Hamilton. "But it's an unusual opportunity to learn about the long-term outcomes of this sort of event."
The circumstances surrounding the Walkerton outbreak are well-known. Municipal water contaminated with E. coli bacteria killed seven local residents and made thousands of others sick. Some of them are still sick, according to Marshall's report.
He and his colleagues studied more than 2,000 Walkerton residents two to three years after the outbreak. One-third of those who got sick during the outbreak still had symptoms of IBS, including persistent diarrhea and abdominal pain. Just 10 per cent of people who did not get sick were found to have IBS.
The results lend a new note of credibility to the continuing health woes of Walkerton residents, Marshall says. "We need to bring legitimacy to this sort of complaint, because a lot of people -- certainly in Walkerton -- who've had irritable bowel syndrome find themselves a bit dismissed by the medical system because they don't have any identifiable abnormality."
As the researchers were collecting data on the Walkerton crisis, another outbreak occurred -- this time viral -- at the 2002 meeting of the Canadian Society of Gastroenterology Nurses and Associates.
Marshall and his team followed up on 100 people present during the meeting, 75 of whom fell ill at the time. Two years later, 20 per cent of those who got sick reported continuing symptoms of IBS and had higher rates of constipation and bloating, but not diarrhea.
In comparing the two outbreaks, Marshall notes the IBS seemed to clear up sooner after the viral infection than after the bacterial infection.
The new information will help guide doctors in counselling people who have suffered a bout of acute gastroenteritis, Marshall says. "We need to know how long this lasts and what proportion of people go back to normal over time. That's what every patient wants to know. When will this go away?"
http://www.macleans.ca/topstories/health/article.jsp?content=20050728_101720_5392
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Sickness and Satiety: Physiological Mechanisms Underlying Perceptions of Nausea and Stomach Fullness
Max E Levine PhD
Department of Internal Medicine Section of Gastroenterology, Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
Current Gastroenterology Reports 2005, 7:280-288
Published 1 August 2005
Abstract
The pathophysiology of nausea and the physiological mechanisms underlying perceptions of stomach emptiness and fullness are not clearly understood, but several potentially important factors have been identified. Gastric dysrhythmias are believed to contribute to the subjective experience of nausea and may also be involved with perceptions of stomach emptiness, hunger, and even dyspepsia symptoms like bloating and early satiety.
Normal gastric neuromuscular function is more evident in the absence of nausea and is also thought to be related to feelings of satiety or comfortable stomach fullness. Autonomic and endocrine influences may also play a critical role in the pathophysiology of nausea and abnormal perceptions of stomach emptiness or fullness. Achieving a better understanding of the gastric neuromuscular and neurohormonal influences on perceptions arising from the viscera may prove invaluable in the development of novel treatments for such conditions as unexplained nausea, functional dyspepsia, and obesity.
http://www.biomedcentral.com/1522-8037/7/280/abstract
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Role of Carbon Dioxide-Releasing Suppositories in the Treatment of Chronic Functional Constipation
A Double-Blind, Randomised, Placebo-Controlled Trial
Posted 08/10/2005
M. Lazzaroni; V. Casini; G. Bianchi Porro
Abstract and Introduction
Abstract
Objective: Treatment of chronic functional constipation is difficult. Both oral and topical laxatives may fail to adequately relieve symptoms, and there is risk of adverse effects such as functional or structural changes in the intestine, together with electrolyte disturbances. The aim of this study was to evaluate the efficacy and safety of a suppository that combines sodium bicarbonate and potassium bitartrate in a polyethylene glycol base to generate approximately 175mL of carbon dioxide (CO2). This release distends the rectal ampulla, thereby stimulating peristalsis and a subsequent bowel movement.
Patients and Methods:
This was a prospective, crossover, double-blind, randomised, placebo-controlled, sequential study of outpatients with chronic functional constipation. Each patient received two suppositories of identical appearance, containing active drug or placebo. The sequence of active drug-placebo (sequence 1) or placebo-active drug (sequence 2) was randomised in groups of eight. The second suppository was taken 7 days after the first. The following parameters were evaluated and scored: evacuation time, type of evacuation, feeling of emptying of the rectal ampulla, stool characteristics, anal complaints, abdominal pain and overall patient assessment.
Results:
A total of 29 patients entered the study. According to a restricted sequential plan, a statistical significance (p < 0.05) in favour of the active drug was reached after 26 patients. A positive response within 30 minutes of introduction of the suppository occurred in 51.7% and 6.9% of patients treated with the active drug and placebo, respectively (p = 0.0003). Normal evacuation occurred in 65.5% and 24.1% of patients treated with the active drug and placebo, respectively (p = 0.004). Normal stool consistency was found in 44.8% and 7.2% of patients treated with the active drug and placebo, respectively (p = 0.04). Patient assessment of treatment as satisfactory occurred in 51.7% and 20.7% of subjects treated with the active drug and placebo, respectively (p = 0.029). Only a trend in favour of the active drug was observed with regard to feeling of incomplete evacuation, and active drug was comparable to placebo with regard to anal and abdominal tolerability
Conclusion:
The CO2-releasing suppository may represent an alternative to rectal laxatives for the relief of chronic functional constipation. The data obtained in this study indicate that CO2-releasing suppositories may be usefully and safely employed in the treatment of patients at risk for electrolyte disorders such as the elderly or patients with renal or cardiovascular disorders.
M. Lazzaroni, V. Casini and G. Bianchi Porro, Gastrointestinal Unit, L. Sacco University Hospital, Milan, Italy
Disclosure: The authors have no potential conflicts of interest that are directly relevant to the contents of this article.
Clin Drug Invest. 2005;25(8):499-505. ©2005 Adis Data Information BV
http://www.medscape.com/viewarticle/509551?src=mp
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How Do Symptoms in Chronic Constipation and IBS With Constipation Differ?
Authors: Brooks Cash, MD, FACP; William D. Chey, MD, FACG, FACP
IBS is characterized by abdominal discomfort or pain, bloating, and disturbed defecation. This disturbed defecation can take the form of constipation (IBS-C), diarrhea (IBS-D), or mixed/alternating bowel habits (IBS-M) with roughly equivalent distribution of the 3 subtypes. The Rome criteria for IBS were developed by an international group of experts to provide a uniform means of identifying patients for clinical trials, though more recently, their use in clinical practice has been encouraged. The Rome II criteria for IBS include at least 12 weeks (which need not be consecutive), in the preceding 12 months, of abdominal discomfort or pain that is accompanied by at least 2 of the following symptoms: the abdominal discomfort or pain is (a) relieved with defecation, (b) associated with a change in the frequency of defecation, and/or (c) associated with a change in the form or appearance of the stool.
In contrast to IBS, the Rome Committee defined functional constipation as 2 or more of the following: straining during more than 25% of defecations; lumpy or hard stools at more than 25% of defecations; a sensation of incomplete evacuation during more than 25% of defecations; manual maneuvers to facilitate more than 25% of defecations; and/or fewer than 3 defecations per week for at least 12 weeks in the past 12 months.
There can be no doubt that there is substantial overlap between CC and IBS-C, but the cardinal feature for diagnosis and the most bothersome symptom in patients with IBS-C is abdominal discomfort or pain. However, it is important to note the absence of abdominal pain or discomfort from the Rome definition for CC. It can be argued that depending on the enthusiasm of the interviewer, many patients with severe constipation will have a history of at least mild abdominal pain or discomfort. However, in IBS, the abdominal discomfort or pain should be a critical symptom, while in patients with CC, abdominal discomfort or pain is typically only an aside to the stool-related complaints.
http://www.medscape.com/viewarticle/487948_4
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Clinical Gastroenterology and Hepatology
Volume 3, Issue 8 , August 2005, Pages 717-725
Irritable Bowel Syndrome: Toward an Understanding of Severity
Anthony Lembo, Vanessa Z. Ameen‡ and Douglas A. Drossman
Beth Israel Deaconess Medical Center, Boston, Massachusetts
‡GlaxoSmithKline, Research Triangle Park, North Carolina
UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
Irritable bowel syndrome (IBS) is a chronic disorder with symptoms that range in severity from mild and intermittent to severe and continuous. Although severity is a guiding factor in clinical decision making related to diagnosis and treatment, current guidelines related to IBS do not address the issue of severity. Recent data suggest that severity as a multidimensional concept, not fully explained by intensity of symptoms, has important clinical implications including health care utilization and health-related quality of life. Components of IBS severity include symptom intensity, time of assessment, whether the patient or physician makes the severity determination, the type of scale used to measure severity, and the degree of disability or impairment. Currently no consensus definition of IBS severity exists, although 2 validated scales of IBS severity have recently been published. Review of the literature suggests that the prevalence of severe or very severe IBS is higher than previously estimated with a range from 3%–69%. Individual IBS symptoms are important but are not sufficient to explain severity. Rather, severity has multiple components including health-related quality of life, psychosocial factors, health care utilization behaviors, and burden of illness. However, studies have not been adequately designed to determine the relative values of these factors in IBS severity.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GGW-4GV2755-9&_user=10&_handle=V-WA-A-W-WC-MsSAYVA-UUW-U-AAWDWECCVA-AAWVYDZBVA-WECDUEZWB-WC-U&_fmt=summary&_coverDate=08%2F31%2F2005&_rdoc=9&_orig=browse&_srch=%23toc%2320161%232005%23999969991%23603702!&_cdi=20161&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=669d2c4ee640b4aa481d7379c5afbf35
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PEDIATRICS Vol. 116 No. 3 September 2005, pp. e377-e380 (doi:10.1542/peds.2005-0490)
Increased Prevalence of Obesity in Children With Functional Constipation Evaluated in an Academic Medical Center
Objective. The rapidly increasing prevalence of obesity in children is the most important problem facing pediatricians today. A recent study suggested an association of obesity and constipation in children but lacked a control group for comparison. The objectives of this study were to evaluate the prevalence of obesity in a large cohort of children with functional constipation and to compare it with a control group representative of the general population.
Methods. Retrospective chart review was performed on 719 children, between the ages of 4 and <18 years, with chronic functional constipation seen in the general pediatric and pediatric gastroenterology clinics between July 2002 and June 2004. Data collected included age, gender, BMI, and signs and symptoms of constipation including fecal incontinence. Obesity was classified as a BMI of >95th percentile and severe obesity as a BMI of 5 kg/m2 above the 95th percentile for age and gender. The control group consisted of all 930 children (4 to <18 years of age) presenting to the pediatric clinic for a well-child visit between January and June 2004. The 2 and t tests were used for analysis.
Results. Overall prevalence of obesity was significantly higher in constipated children (22.4%) compared with control children (11.7%), and this higher prevalence was also seen for severe obesity. The prevalence rates of obesity were significantly higher in constipated males (25%) than in constipated females (19%) and were significantly higher compared with the control males (13.5%) and control females (9.8%). Constipated boys in all 3 age groups had significantly higher rates of obesity than the control boys; the constipated girls had significantly higher obesity rates for the age groups between 8 and <18 years. Fecal incontinence (encopresis) was present in 334 of 719 (46%) constipated children. The prevalence of obesity was similar in constipated children with and without fecal incontinence.
Conclusions. There is a significantly higher prevalence of obesity in children with constipation compared with age- and gender-matched controls. This higher prevalence is present in both boys (4 to <18 years of age) and girls (8 to <18 years of age) with constipation and is not related to the presence of fecal incontinence among constipated children. The higher prevalence of obesity may be a result of dietary factors, activity level, or hormonal influences and needs additional evaluation.
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Dinesh S. Pashankar, MD, MRCP* and Vera Loening-Baucke, MD
http://pediatrics.aappublications.org/cgi/content/abstract/116/3/e377
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Irritable Bowel Syndrome and Functional Dyspepsia: Different Diseases or a Single Disorder With Different Manifestations?
Posted 08/29/2005
Laura Noddin, MD; Michael Callahan, PhD; Brian E. Lacy, MD, PhD
Introduction
Functional gastrointestinal disorders (FGIDs) are common, chronic ailments that affect millions of adults on a daily basis. FGIDs are characterized by recurrent symptoms (ie, abdominal pain or discomfort, bloating, nausea, vomiting, early satiety, constipation, or diarrhea) that indicate a dysfunctional GI tract despite that an organic reason for the symptom generation is not identified on diagnostic studies.
It is estimated that 40% of all gastroenterology clinic visits are for FGIDs,[1] and a recent survey of generalists and gastroenterologists found that nearly one third of their patient population had symptoms of irritable bowel syndrome (IBS).[2] Many patients with IBS have dyspepsia; likewise, many patients with dyspepsia also have overlapping symptoms of IBS. These 2 groups of patients are similar in that symptoms are typically chronic in nature, may wax and wane, are aggravated by psychosocial stressors, and are often worsened by meals. In addition, both disorders are considered difficult to diagnose by many physicians and in the absence of warning signs or "red flags," extensive testing is unlikely to be helpful. These similarities raise the issue of whether IBS and dyspepsia are just different manifestations of the same disorder or whether they represent distinct clinical entities. Elucidating this clinical dilemma is important because it may improve our ability to diagnose and treat these common disorders.
At present, the ROME II committee classifies IBS as a distinctly separate functional bowel disorder from dyspepsia.[3] IBS is characterized by lower abdominal pain or discomfort in association with disordered defecation ( Table 1 ). Dyspepsia presents as recurrent upper abdominal pain or discomfort associated with symptoms of early satiety, fullness, bloating, and nausea ( Table 2 ). Because upper GI function regularly affects lower GI tract function (ie, the gastro-colic reflex), and lower GI function routinely affects upper GI function (ie, constipation slows gastric emptying), it should not be surprising that these 2 areas are intimately linked.[4]
This article reviews the prevalence, natural history, etiology, pathogenesis, and treatment of these 2 common FGIDs, and discusses whether these disorders are different manifestations of the same disorder or whether they are truly distinct clinical entities.
Laura Noddin, MD, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire
Michael Callahan, PhD, Regional Scientific Director, Novartis Pharmaceuticals, East Hanover, New Jersey
Brian E. Lacy, MD, PhD, Associate Professor of Medicine, Dartmouth Medical School, Hanover, New Hampshire; Director, GI Motility Laboratory, Division of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
Disclosure: Laura Noddin, MD, has disclosed no relevant financial relationships.
Disclosure: Michael Callahan, PhD, has disclosed that he is an employee of Novartis Pharmaceuticals, East Hanover, New Jersey, and holds stock options in the Company.
Disclosure: Brian E. Lacy, MD, PhD, has disclosed that he has received grants for clinical research from Novartis Pharmaceuticals, AstraZeneca, and GlaxoSmithKline.
Medscape General Medicine. 2005;7(3) ©2005 Medscape
To read this article in full, please click here:
http://www.medscape.com/viewarticle/506798?src=mp
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The American Journal of Gastroenterology
Volume 0 Issue 0 - October 2005
doi:10.1111/j.1572-0241.2005.00225.x
Guidelines for the Management of Dyspepsia
Nicholas J. Talley, M.D., Ph.D., F.A.C.G.1, Nimish Vakil, M.D., F.A.C.G.2, and the Practice Parameters Committee of the American College of Gastroenterology
Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD).
In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 48 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (10%); empirical PPI is an initial option in low prevalence situations.
If initial acid suppression fails after 24 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 48 wk; if symptoms recur, another course of the same treatment is justified.
The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.
(Am J Gastroenterol 2005;100:114)
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1572-0241.2005.00225.x
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Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
doi:10.1053/j.gastro.2005.06.062
Copyright © 2005 American Gastroenterological Association Published by Elsevier Inc.
Abdominal Bloating
Fernando Azpiroz, and Juan–R. Malagelada
Digestive System Research Unit, Hospital General Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
Received 5 August 2004; accepted 24 November 2004. Available online 6 September 2005.
Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect.
Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception.
All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception.
Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods.
Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.
Supported in part by the National Institutes of Health (grant DK57064), the Spanish Ministry of Education (grant BFI 2002-03413), and the Instituto Carlos III (grant C03/02).
Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFX-4H2162R-1G&_user=10&_handle=V-WA-A-W-DD-MsSWYWW-UUW-U-AAWEAYVAVY-AAWZDZVEVY-BBCBAECAD-DD-U&_fmt=summary&_coverDate=09%2F30%2F2005&_rdoc=42&_orig=browse&_srch=%23toc%236806%232005%23998709996%23605535!&_cdi=6806&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7663fa40aa8f7dc09ad26193f30710b2
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Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
doi:10.1053/j.gastro.2005.06.062
Copyright © 2005 American Gastroenterological Association Published by Elsevier Inc.
Abdominal Bloating
Fernando Azpiroz, and Juan–R. Malagelada
Digestive System Research Unit, Hospital General Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
Received 5 August 2004; accepted 24 November 2004. Available online 6 September 2005.
Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect.
Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception.
All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception.
Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods.
Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.
Supported in part by the National Institutes of Health (grant DK57064), the Spanish Ministry of Education (grant BFI 2002-03413), and the Instituto Carlos III (grant C03/02).
Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFX-4H2162R-1G&_user=10&_handle=V-WA-A-W-DD-MsSWYWW-UUW-U-AAWEAYVAVY-AAWZDZVEVY-BBCBAECAD-DD-U&_fmt=summary&_coverDate=09%2F30%2F2005&_rdoc=42&_orig=browse&_srch=%23toc%236806%232005%23998709996%23605535!&_cdi=6806&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7663fa40aa8f7dc09ad26193f30710b2
--------------------
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