Ashok K. Tuteja

Fecal Incontinence in US Adults: Epidemiology and Risk Factors

BACKGROUND & AIMS The study aims were to estimate the prevalence of different types and frequencies of fecal incontinence (FI), describe demographic factors, and identify risk factors. METHODS The National Health and Nutrition Examination Survey (NHANES) assesses health status in the civilian noninstitutionalized US population. The validated Fecal Incontinence Severity Index was added to NHANES in 2005-2006. Participants were 2229 women and 2079 men aged 20 years or older. FI was defined as accidental leakage of solid, liquid, or mucus at least once in the preceding month. Sampling weights were used to obtain prevalence estimates for the national population. Multivariate logistic regression identified independent risk factors. RESULTS The estimated prevalence of FI in noninstitutionalized US adults is 8.3% (95% confidence interval, 7.1-9.5) and consists of liquid stool in 6.2%, solid stool in 1.6%, and mucus in 3.1%. It occurs at least weekly in 2.7%. Prevalence is similar in women (8.9%) and men (7.7%) and increases with age from 2.6% in 20 to 29 year olds up to 15.3% in participants aged 70 years and older. FI is not significantly associated with race/ethnicity, education, income, or marital status after adjusting for age. Independent risk factors in women are advancing age, loose or watery stools, more than 21 stools per week, multiple chronic illnesses, and urinary incontinence. Independent risk factors in men are age, loose or watery stools, poor self-rated health, and urinary incontinence. CONCLUSIONS FI is a prevalent age-related disorder. Chronic diarrhea is a strong modifiable risk factor that may form the basis for prevention and treatment.

Is constipation associated with decreased physical activity in normally active subjects

BACKGROUND:The effectiveness of physical activity in the management of constipation remains controversial. We examined the associations among physical activity, constipation, and quality of life (QoL) in a population of employed adults to determine whether the risk of constipation is related to physical activity.METHODS:A total of 1,069 employees (age range 24–77) of the Veterans Affairs (VA) Black Hills Health Care System were mailed validated questionnaires (response rate 72%), inquiring about bowel habits, QoL (SF 36), and physical activity (modified Baecke questionnaire). Constipation was defined using the Rome I criteria.RESULTS:One hundred and forty (19.4%, 95% CI 16.2–22.4) employees reported constipation. The average total physical activity and all subscales of physical activity were not significantly different in subjects with and without constipation (all p≥ 0.2). Subjects with constipation had lower QoL scores than subjects without constipation, and physical activity was positively correlated with physical functioning and health perception.CONCLUSION:Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved QoL. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.

Abdominal Bloating in Employed Adults: Prevalence, Risk Factors, and Association With Other Bowel Disorders

BACKGROUND AND AIMS:Bloating is common, but its significance as a marker of underlying disease has not been defined. We report on risk factors for bloating, its relationship to physical activity and quality of life (QOL), and its predictive value for functional bowel disorders.METHODS:This is a cross-sectional population-based study of 1,069 employees of the Veterans Affairs Black Hills Health Care System. The validated Bowel Disease Questionnaire was used to identify subjects with abdominal bloating and other bowel disorders. The association of bloating with QOL was assessed using the SF36 (Short-Form 36) questionnaire. Physical activity was assessed using the modified Baecke questionnaire.RESULTS:The response rate was 72% (723 of 1,069). Bloating was reported by 21% of all subjects (95% confidence interval [CI] 17.7–23.7), 64% with irritable bowel syndrome (IBS), 35% with non-IBS constipation, 23% with non-IBS diarrhea, and 42% with dyspepsia. Functional bloating (i.e., bloating in the absence of other bowel disorders) was reported by 7% of subjects (95% CI 5.2–9.0). Of those with bloating, 28% had IBS, 25% non-IBS constipation, 8% non-IBS diarrhea, and 30% dyspepsia. The positive and negative predictive values of bloating in the diagnosis of functional bowel disorder were 66% and 87%, respectively. The only risk factors were smoking and high-dose aspirin. Bloating was not associated with physical activity. QOL on all subscales of SF36 was lower in subjects with bloating than those without bloating.CONCLUSIONS:Bloating is a common symptom in otherwise healthy adults, and is often associated with but not predictive of functional bowel disorders. Smoking and high-dose aspirin are associated with bloating while physical activity is not.

Double-blind placebo-controlled study of mesalamine in post-infective irritable bowel syndrome--a pilot study.

Abstract Objective. Post-infective irritable bowel syndrome (PI-IBS) is characterized by continuing symptoms of irritable bowel syndrome, typically diarrhea-predominant, following an episode of acute gastroenteritis. There is often an increase in sub-epithelial inflammatory and neuroendocrine cells on colonic mucosal biopsy. Mesalamine is an anti-inflammatory agent, effective in the treatment of inflammatory bowel disease. The goal of this study was to compare mesalamine to placebo on symptoms and quality-of-life (QOL) in PI-IBS. Material and methods. Twenty patients who developed diarrhea-predominant IBS after gastroenteritis were randomized to receive mesalamine (Asacol®) 1.6 gm b.i.d. or placebo for 12 weeks in a double-blind placebo-controlled study. QOL was assessed using the IBS-QOL questionnaire. Stool frequency, stool consistency, urgency, severity of abdominal pain, severity of bloating, and global-improvement scale were recorded in daily diaries for 7 days at baseline and every 4 weeks. Data were analyzed by comparing the change from baseline to last follow-up. Results. One patient withdrew after randomization; data were incomplete in two patients. Thus, data were analyzed from 17 patients (11 men and 6 women, median age: 27 years, range 22–45 years). Mesalamine was not associated with significant improvement in global symptoms, abdominal pain, bloating, stool urgency, frequency, or consistency (all p ≥ 0.11) or QOL (p ≥ 0.16). Conclusions. There was no significant improvement in global symptoms or overall QOL with mesalamine in patients with PI-IBS.

Minimum important differences for scales assessing symptom severity and quality of life in patients with fecal incontinence.

Objectives The objective of this study was to estimate the minimum important difference (MID) for the Fecal Incontinence Severity Index (FISI), the Colorectal-Anal Distress Inventory (CRADI) scale of the Pelvic Floor Distress Inventory, the Colorectal-Anal Impact Questionnaire (CRAIQ) scale of the Pelvic Floor Impact Questionnaire, and the Modified Manchester Health Questionnaire (MMHQ). Methods We calculated the MIDs using anchor-based and distribution-based approaches from a multicenter prospective cohort study investigating adaptive behaviors among women receiving nonsurgical and surgical management for fecal incontinence (FI). Patient responses were primarily anchored using a Global Impression of Change scale. The MID was defined as the difference in mean change from baseline between those who indicated they were “a little better” and those who reported “no change” on the Global Impression of Change scale 3 months after treatment. The effect size and SE of measurement were the distribution methods used. Results The mean changes (SD) in FISI, CRADI, CRAIQ, and MMHQ scores from baseline to 3 months after treatment were −8.8 (12.0), −52.7 (70.0), −60.6 (90.0), and −12.6 (19.2), respectively. The anchor-based MID estimates suggested by an improvement from no change to a little better were −3.6, −11.4 and −4.7, −18.1 and −8.0, and −3.2 for the FISI, CRADI (long and short version), CRAIQ (long and short version), and MMHQ, respectively. These data were supported by 2 distribution-based estimates. Conclusions The MID values for the FISI are −4, CRADI (full version, −11; short version, −5), CRAIQ (full version, −18; short version, −8), and MMHQ −3. Statistically significant improvements that meet these thresholds are likely to be clinically important.

Serotonin syndrome as a complication of fentanyl sedation during esophagogastroduodenoscopy.

To the Editor, Fentanyl is a medication commonly used to induce and maintain conscious sedation during endoscopic procedures. Fentanyl, a direct serotonin agonist, has many advantages, including its relatively short half-life and lack of histaminereleasing effect [1]. It can precipitate serotonin syndrome when prescribed with other serotogenic medications such as monoamine oxidase inhibitors, lithium, ondansetron, selective serotonin reuptake inhibitors, serotonin, norepinephrine reuptake inhibitors, tricyclic antidepressants, amphetamines, and others [2]. To our knowledge, serotonin syndrome has not been described as a complication of fentanyl use during esophagogastroduodenoscopy nor colonoscopy. Here we report the first case of serotonin syndrome secondary to fentanyl in a patient undergoing esophagogastroduodenoscopy.

Comparison of air-coupled balloon esophageal and anorectal manometry catheters with solid-state esophageal manometry and water-perfused anorectal manometry catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.

Overexpression of mutant amyloid-β protein precursor and presenilin 1 modulates enteric nervous system.

Alzheimers disease (AD) is a neurodegenerative disorder histologically characterized by amyloid-β (Aβ) protein accumulation and activation of associated microglia. Although these features are well described in the central nervous system, the process and consequences of Aβ accumulation in the enteric nervous system have not been extensively studied. We hypothesized that Aβ also may accumulate in the enteric nervous system and lead to immune cell activation and neuronal dysfunction in the digestive tract not unlike that observed in diseased brain. To test this hypothesis, ileums of the small intestine of thirteen month old AβPP/PS1 and C57BL/6 (wild type) mice were collected and analyzed using immunohistochemistry, western blot analysis, cytokine arrays, and ELISA. AβPP/PS1 mice demonstrated no differences in intestinal motility or water absorption but elevated luminal IgA levels compared to wild type mice. They also had increased protein levels of AβPP and the proteolytic enzyme, BACE, corresponding to an increase in Aβ1-40 in the intestinal lysate as well as an increase in both Aβ1-40 and Aβ1-42 in the stool. This correlated with increased protein markers of proinflammatory and immune cell activation. Histologic analysis localized AβPP within enteric neurons but also intestinal epithelial cells with elevated Aβ immunoreactivity in the AβPP/PS1 mice. The presence of AβPP, Aβ, and CD68 immunoreactivity in the intestines of some patients with neuropathologically-confirmed AD are consistent with the findings in this mouse model. These data support the hypothesis that in AD the intestine, much like the brain, may develop proinflammatory and immune changes related to AβPP and Aβ.

Lubiprostone for constipation and irritable bowel syndrome with constipation.

Chronic constipation and irritable bowel syndrome are heterogeneous disorders characterized by altered bowel habits, abdominal discomfort and/or difficult defecation. These conditions have a significant impact on patients’ quality of life, as well as on the US economy, both in terms of healthcare costs and lost productivity. Treatment typically begins with lifestyle changes, increased fiber intake and osmotic and stimulant laxative intake. However, treatments for constipation vary in terms of their efficacy and safety. Furthermore, surveys of physicians and patients have revealed a strong desire for improved therapeutic options. Lubiprostone is a synthetic bicyclic fatty acid that is gut selective and stimulates type 2 chloride channels, resulting in increased chloride, sodium and water secretion into the lumen. The increased fluid secretion causes luminal distension, secondary peristalsis and laxation. Randomized Phase III trials have shown that lubiprostone is efficacious in the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation. The US FDA has approved lubiprostone at a dose of 24 µg twice daily for the treatment of chronic idiopathic constipation in adults, and at a dose of 8 µg twice daily for irritable bowel syndrome with constipation in adult women. Nausea, diarrhea and headaches are the most commonly reported side effects. In long-term studies, lubiprostone appears to be safe.

High prevalence of vitamin D deficiency among patients with fecal incontinence.

To the Editor, Fecal incontinence is a common problem with a prevalence ranging from 0.7 to 24% depending on the population that is being studied [1]. The functional integrity of the internal and external anal sphincters requires normal functioning of the pelvic floor muscles to maintain continence [2]. Vitamin D deficiency is associated with muscle weakness and vitamin D plays an important role in muscle strength [3]. It is not known if vitamin D deficiency is associated with fecal incontinence. We evaluated serum vitamin D (25-hyroxy-cholecalciferol) levels of ten consecutive patients with fecal incontinence attending the gastroenterology clinic at a tertiary care center. Patients with infectious diarrhea and anorectal surgery were excluded. Patients with known cause of vitamin D deficiency including chronic kidney and liver diseases were also excluded from the study. Fecal incontinence was defined as recurrent uncontrolled passage of fecal material for at least 1 month. Normal vitamin D level was defined as 30 ng per milliliter or greater. Relative vitamin D insufficiency was defined as 20–29 ng per milliliter. Levels below 20 ng per liter were defined as vitamin D deficient [4, 5]. Ten patients were found to fulfill the inclusion criteria (eight males, two females). The median age was 56.7 years (range, 30–80). Mean body mass index was 31.9 (range, 19.8–38.3). All patients except one had loose stool. The average duration of fecal incontinence was 18.3 months (range, 1–240 months). The average frequency of fecal incontinence was 10.9 episodes per month (range, 2–30 episodes per month). All patients with fecal incontinence had hypovitaminosis D (60% had vitamin deficiency and 40% with relative vitamin D insufficiency). The mean vitamin D level in patients with fecal incontinence was 17 ng per milliliter (range 5.4–22.2 ng per milliliter). Historical data demonstrate that 36–57% of people have vitamin D deficiency or relative insufficiency [5]. In conclusion, in this small cohort study all patients with fecal incontinence had vitamin D deficiency or relative insufficiency. This is significantly higher than reported prevalence of vitamin deficiency or insufficiency in the general population. A prospective cross section study is warranted to determine if patients with fecal incontinence have a higher prevalence of vitamin D deficiency compared to a control group. Further research is required to determine whether hypovitaminosis D is a risk factor or a consequence of fecal incontinence.