Allison Malcolm

Gastrointestinal Symptoms in Spinal Cord Injury: Relationships With Level of Injury and Psychologic Factors

INTRODUCTIONPrevious surveys of gastrointestinal symptoms after spinal cord injury have not used validated questionnaires and have not focused on the full spectrum of such symptoms and their relationship to factors, such as level of spinal cord injury and psychologic dysfunction. This study was designed to detail the spectrum and prevalence of gastrointestinal symptoms in spinal cord injury and to determine clinical and psychologic factors associated with such symptoms.METHODSEstablished spinal cord injury patients (>12 months) randomly selected from a spinal cord injury database completed the following three questionnaires: 1) Rome II Integrative Questionnaire, 2) Hospital Anxiety and Depression Scale, and 3) Burwood Bowel Dysfunction after spinal cord injury.RESULTSA total of 110 patients participated. The prevalence of abdominal bloating and constipation were 22 and 46 percent, respectively. Bloating was associated with cervical (odds ratio = 9.5) and lumbar (odds ratio = 12.1) level but not with thoracic level of injury. Constipation was associated with a higher level of injury (cervical odds ratio = 5.6 vs. lumbar) but not with psychologic factors. In contrast, abdominal pain (33 percent) and fecal incontinence (41 percent) were associated with higher levels of anxiety (odds ratio = 6.8, and odds ratio = 2.4) but not with the level of injury. CONCLUSIONSThere is a high prevalence and wide spectrum of gastrointestinal symptoms in spinal cord injury. Abdominal bloating and constipation are primarily related to specific spinal cord levels of injury, whereas abdominal pain and fecal incontinence are primarily associated with higher levels of anxiety. Based on our findings, further physiologic and psychologic research studies in spinal cord injury patients should lead to more rational management strategies for the common gastrointestinal symptoms in spinal cord injury.

Evidence for Pelvic Floor Dyssynergia in Patients With Irritable Bowel Syndrome

PURPOSE: Although functional constipation is known to often manifest concomitant features of pelvic floor dyssynergia, the nature of pelvic floor symptoms and anorectal dysfunction in non-diarrhea predominant irritable bowel syndrome is less clear. This study aims to compare anorectal sensorimotor function and symptoms of patients who have non-diarrhea predominant irritable bowel syndrome with those who have functional constipation. METHODS: We studied 50 consecutive female patients referred with constipation and 2 or more symptoms of pelvic floor dyssynergia, who also satisfied Rome II criteria for either non-diarrhea predominant irritable bowel syndrome (n = 25; mean age, 47 ± 3 y) or functional constipation (n = 25; 49 ± 3 y). Assessments included the Rome II Integrative Questionnaire, a validated constipation questionnaire, Hospital Anxiety and Depression scale, visual analog scores for satisfaction with bowel habit and for impact on quality of life, and a comprehensive anorectal physiology study. RESULTS: Both groups displayed physiological evidence of pelvic floor dyssynergia; but patients with non-diarrhea predominant irritable bowel syndrome exhibited a higher prevalence of abnormal balloon expulsion (P < .01) and less paradoxical anal contraction with strain (P = .045) than patients with functional constipation. These patients with irritable bowel syndrome also reported more straining to defecate (P = .04), a higher total constipation score (P = .02), lower stool frequency (P = .02), a trend toward harder stools (P = .06), and less satisfaction with bowel habit (P = .03) than patients with functional constipation. CONCLUSION: Patients with non-diarrhea predominant irritable bowel syndrome with symptoms of pelvic floor dyssynergia exhibit overall pelvic floor dyssynergia physiology similar to that of patients with functional constipation. Certain features, however, such as abnormal balloon expulsion, may be more prominent in the patients with irritable bowel syndrome. Therapeutic modalities, such as biofeedback, that are effective in patients with functional constipation with pelvic floor dyssynergia should therefore be considered in selected patients with irritable bowel syndrome with pelvic floor dyssynergia.

Predictors of outcome of anorectal biofeedback therapy in patients with constipation.

Aliment Pharmacol Ther 2011; 33: 1245–1251

Prolonged Balloon Expulsion Is Predictive of Abdominal Distension in Bloating

OBJECTIVES:Abdominal bloating and distension are common in patients with constipation. The precise mechanism of abdominal distension remains uncertain. We hypothesized that constipated patients with bloating plus distension exhibit a greater degree of anorectal dysfunction, potentially affecting gas evacuation, than those without distension. Therefore, our aim was to evaluate anorectal function and other clinical features in patients with constipation who exhibit bloating with and without distension.METHODS:In all, 88 female patients with abdominal bloating and either non-diarrhea irritable bowel syndrome (IBS) or functional constipation were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire, and all patients underwent comprehensive clinical assessment and anorectal function studies.RESULTS:Patients were divided into two groups: abdominal bloating with distension (D; n=53) and abdominal bloating without distension (ND; n=35). D featured a prolonged balloon expulsion time (P=0.005), a higher resting anal sphincter pressure (P=0.002), and a higher maximum anal sphincter squeeze pressure (P=0.015) than ND. They also experienced more bloating (P<0.001), more abdominal pain (P=0.004), harder stools (P=0.01), and more incomplete emptying (P=0.005). In logistic regression modeling, prolonged balloon expulsion time was a significant predictor of abdominal distension (P=0.018).CONCLUSIONS:This is the first study to show that prolonged balloon expulsion time predicts abdominal distension in patients with bloating and constipation. Hence, ineffective evacuation of gas and stool associated with prolonged balloon expulsion may be an important mechanism underlying abdominal distension.

Direct clinical evidence for spinal hyperalgesia in a patient with irritable bowel syndrome

OBJECTIVE:Our objective was to evaluate GI motor and sensory function and spinal cord testing in a patient with severe irritable bowel syndrome.METHODS:A patient is described who underwent an extensive assessment of GI motor and sensory function including transit studies, colonic and rectal barostat studies, sensory and manometric studies of the small bowel, and colon and anorectal physiology testing. The patient also underwent testing with spinal cord stimulation and spinal drug delivery as part of a pain management assessment.RESULTS:The viscerosomatic referral pain pattern resulting from rectal distention was consistent with spinal hyperalgesia. The patient underwent testing for spinal cord stimulation and spinal drug delivery.CONCLUSION:This novel finding provides direct clinical evidence for the presence of spinal hyperalgesia in a patient with irritable bowel syndrome, consistent with the existing indirect clinical evidence and animal data.

Feeding and colonic distension provoke altered autonomic responses in irritable bowel syndrome

Objective. Alterations in autonomic balance, detectable by heart rate variability (HRV) analysis, have been shown to occur after a meal in patients with irritable bowel syndrome (IBS). There are few data on changes in sympathovagal responses in IBS to other forms of enteric stimulation such as colonic distension. The aim of this study was to determine the effects of colonic balloon distension on HRV in the fasting and the postprandial state in healthy subjects and in IBS patients. Material and methods. Eight IBS patients and 8 age- and gender-matched healthy subjects underwent unsedated descending colonic distension before and after a 1000 kcal liquid meal. Low- (LF) and high-frequency (HF) HRV band values obtained from 2-min ECG segments recorded before and during distension were compared between groups, and between fasting and postprandial states. A visual analogue scale was used to determine sensation during colonic distension. Results. HF values decreased significantly with feeding in IBS patients (p=0.01), but not in healthy subjects. The low-to-high frequency (LF/HF) ratio was significantly higher postprandially in IBS patients (p=0.02) and, additionally, was decreased (p<0.01) with colonic distension in the fed state, independently of colonic sensitivity or distending volume. Moreover, changes in the LF/HF ratio with distension in the fed versus the fasting state were negatively correlated in IBS patients but positively correlated in healthy subjects (both p<0.05). Conclusions. IBS patients demonstrated altered autonomic responses to feeding and colonic distension. Further studies should determine whether these alterations could explain the postprandial exacerbation of symptoms in IBS.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

Background Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non‐diarrhea predominant IBS (non‐D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

Efficacy of a Chinese Herbal Medicine in Providing Adequate Relief of Constipation-predominant Irritable Bowel Syndrome: A Randomized Controlled Trial

BACKGROUND & AIMS Irritable bowel syndrome (IBS) is the most common chronic functional bowel disorder, with few treatment options. IBS affects 10%-20% of the population; as many as 58% of patients have constipation-predominant IBS (IBS-C). We evaluated efficacy and safety of a standardized, specifically formulated Chinese herbal medicine (CHM) preparation in treatment of patients with IBS-C. METHODS We performed a double-blind trial of 125 patients with IBS-C (according to Rome III criteria), who were recruited from 13 medical centers or clinics in Australia from July 2009 through February 2012. Patients were randomly assigned to groups given a standardized extract of 7 selected CHM ingredients (n = 61) or placebo (controls, n = 64) for 8 weeks (5 capsules, twice daily). Subjects were then followed for 16 weeks. Chemical definition, standardization, and stability testing of the formulation were completed. Subjects completed a self-administered, validated binary questionnaire of global symptom improvement at weeks 2, 4, 8, and 16 (primary outcome). Secondary outcomes included results from the self-administered IBS Symptom Severity Scale and the Bristol Stool Form Scale (BSFS), which were completed at weeks 4, 8, and 16. RESULTS There was statistically and clinically significant (per protocol analyses) improvement among subjects who received CHM (n = 50) vs controls (n = 58) for 8 weeks. A greater proportion of subjects receiving CHM reported adequate relief (P = .010). Compared with controls, the CHM group had improved bowel habits vs controls at week 8, including lower IBS Symptom Severity Scale scores (P < .001), reduced straining during defecation (P = .002), and a significant decrease in hard lumpy stools (P = .031). The CHM group also had increased stool consistency, which was based on the Bristol Stool Form Scale (week 8, P < .001). There was no statistically significant difference between groups in abdominal pain at week 8 (P = .692). The CHM was well-tolerated. CONCLUSIONS In a prospective, controlled study, CHM reduced symptoms of IBS-C, increased bowel satisfaction and stool consistency, and reduced straining and hard lumpy stools, compared with placebo. Clinical trial registration no: ACTRN12609000558224.

Distension technique influences the relationship between colonic and rectal hypersensitivity in irritable bowel syndrome

Abstract  In irritable bowel syndrome (IBS), it remains unclear whether rectal hypersensitivity is a ‘marker’ of colonic hypersensitivity. Our aim was to examine the relation between colonic and rectal sensitivity in IBS patients, comprising phasic and ramp distension techniques. Twenty IBS patients and 12 healthy subjects (N) underwent stepwise ramp and random phasic barostat distensions in the colon and rectum in random order. The sensory threshold pressure (ramp distension) and the visual analogue scale score (VAS, phasic distension), for pain and non‐pain, were recorded. Colonic thresholds were lower, and VAS scores were generally higher, for pain and non‐pain sensitivities in IBS compared to N. Rectal thresholds were lower, and VAS scores were higher, for pain but not for non‐pain, in IBS compared to N. In IBS, for phasic distension, there was good correlation between the colon and rectum for non‐pain (e.g. at 16 mmHg, r = 0.59, P = 0.006) and pain (r = 0.60, P = 0.006) sensitivities. In contrast, there was no significant correlation between the colon and rectum for ramp distension. In conclusion, colonic and rectal sensitivity in IBS are correlated in response to phasic but not ramp barostat distensions. The rectum serves as a legitimate ‘window’ for evaluating colonic hypersensitivity in IBS, provided that phasic distensions are employed.

Intestinal perforation associated with octreotide therapy in scleroderma

TO THE EDITOR: We thank Drs. Di Stefano, Veneto, and Corazza for their interest in our article. Perhaps we did not make it clear that we were trying to assess the utility of measuring endomysial antibody (EMA) as a screening test for celiac disease (CD) in asymptomatic patients referred to an osteoporosis clinic because of low bone density. Earlier articles have clearly documented low bone density in patients with CD (1–3). We wished to consider whether the converse might also be true: that subclinical CD might be found with increased frequency in a group of patients with low bone density, as had been suggested in another small European study (4). The purpose of performing the EMA test would be as a screening tool to identify individuals at high risk for CD among patients with no abnormalities of calcium metabolism beyond the problem of a low bone density. Any patient with a low bone density who also had a low serum calcium or high parathyroid hormone would have been identified as an individual who obviously merits a workup for underlying causes like CD, and would therefore have been excluded from our analysis. We only performed intestinal biopsies on the patients with positive EMA screening tests, so cannot comment on the possible presence of flattened mucosa in the other patients. Only 10 subjects were under the age of 40 yr, but although many of the others might be classed as “perimenopausal,” we are unable to provide an accurate assessment of this. We accept the writers’ suggestion that the EMA positive patients may later develop more typical biopsy findings of CD. However, it should be noted that, in other studies of patient populations thought to be at higher risk of CD, typical biopsy evidence of CD was seen at the time when a clearly positive EMA was identified (5, 6). Our index patients all had positive EMA studies at a low titer, and we identified a potential problem in interpreting the test when used at the manufacturer’s specifications. The fact that we did not find any cases of CD in nearly 100 consecutive patients referred for evaluation of low bone density suggests that the EMA measurement should not be used as a screening tool in these patients, in the absence of other clinical clues to the diagnosis of CD. Rather, for patients with osteoporosis, diagnostic tests such as EMA should only be used after the physician’ s assessment of the patient identifies other symptoms or biochemical abnormalities that raise the index of suspicion for the presence of CD.