Devinder Kumar

Primary repair of obstetric anal sphincter rupture using the overlap technique

Objective To evaluate the feasibility of a new technique of primary overlap anal sphincter repair instead Setting A teaching hospital and a district general hospital.

Antibiotics increase functional abdominal symptoms

OBJECTIVE:Data suggest that subjects with irritable bowel syndrome are more likely to report a recent course of antibiotics. This study tests the hypothesis that a course of antibiotics is a risk factor for an increase in the number of functional bowel complaints over a 4-month period in a general population sample.METHODS:We initiated a prospective case-control study in three general practices in South London. Consecutive patients aged 16–49 attending their general practitioner with non-GI complaints and given a prescription for antibiotics were invited to participate. Comparison subjects who had not had antibiotics for 1 yr were identified from the practice records by age group, gender, and previous general practitioner visits. Fifty-eight antibiotic and 65 control patients agreed to participate. Questionnaires covering demographic, GI, and psychological data were sent at recruitment and at 4 months. Seventy-four percent of subjects completed the study. The number of symptoms at follow-up compared to that at recruitment.RESULTS:Twenty of 42 antibiotic subjects (48%) versus 11/49 control subjects (22%) demonstrated one or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 3.14 [1.27–7.75]) (χ2= 6.4, p = 0.01). Ten of 42 antibiotic subjects (24%) versus 3/49 control subjects (6%) demonstrated two or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 4.79 [1.22–18.80]) (χ2= 5.8, p = 0.02).CONCLUSIONS:Functional bowel symptoms come and go, but subjects who are given a course of antibiotics are more than three times as likely to report more bowel symptoms 4 months later than controls.

Systematic review: adipose tissue, obesity and gastrointestinal diseases

Obesity is increasingly being recognized as a risk factor for a number of benign and malignant gastrointestinal conditions. However, literature on the underlying pathophysiological mechanisms is sparse and ambiguous. Insulin resistance is the most widely accepted link between obesity and disease, particularly colorectal cancer. The recognition that intra‐abdominal fat is immunologically active sheds new light not only on the pathogenesis of obesity‐related gastrointestinal conditions, but also on inflammatory conditions such as Crohns disease.

Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome

Objective Dietary modification improves symptoms in irritable bowel syndrome (IBS). Identification of offending foods by dietary elimination/re-challenge is cumbersome. IgG4 antibodies to common food antigens are elevated in IBS. The aim of this article was to evaluate the effect of exclusion diet based on IgG4 titres on IBS symptoms and rectal sensitivity and compliance. Material and methods The study comprised 25 patients with IBS (3 M, 22 F, mean age 43 years, Rome II criteria). IgG4 titres to 16 foods (milk, eggs, cheese, wheat, rice, potatoes, chicken, beef, pork, lamb, soya bean, fish, shrimps, yeast, tomatoes and peanuts) were measured. Foods with titres >250 µg/l were excluded for 6 months. Symptom severity was assessed with a previously validated questionnaire at baseline, at 3 months and at 6 months. Rectal compliance and sensitivity were measured in 12 patients at baseline and at 6 months. Results IgG4 antibodies to milk, eggs, wheat, beef, pork and lamb were commonly elevated. Significant improvement was reported in pain severity (p<0.001), pain frequency (p=0.034), bloating severity (p=0.001), satisfaction with bowel habits (p=0.004) and effect of IBS on life in general (p=0.008) at 3 months. Symptom improvement was maintained at 6 months. Rectal compliance was significantly increased (p=0.011) at 6 months but the thresholds for urge to defecate/discomfort were unchanged. Conclusions Food-specific IgG4 antibody-guided exclusion diet improves symptoms in IBS and is associated with an improvement in rectal compliance.

Irritable bowel syndrome

Epidemiology Although IBS is the cause of 20–50% of referrals to gastroenterology clinics, most patients with IBS do not seek medical care. In 1980, Thompson and Heaton, using a precoded questionnaire, found that 14% of patients had a spastic colon with abdominal pain that was relieved by defaecation. This was not a representative population sample drawn from medical technicians, a hospital screening clinic, or wardencontrolled flats; nor did the study use the Rome criteria to define IBS. Nevertheless, 14% remains the most commonly quoted figure for UK prevalence of IBS. A 1992 questionnaire study, which used the Manning criteria to define IBS in community patients obtained from general-practitioners lists, recorded a 22% prevalence of IBS. The male to female ratio was 1·38, and 33% of those with IBS had sought medical advice for it during the preceding 2 years. The study also showed that abdominal pain in childhood was reported significantly more commonly by patients with current IBS (12% vs 11%). Other investigators have also suggested that exaggeration of the importance of minor illnesses in early childhood increases the likelihood of adult IBS. The Rome criteria were used to identify IBS in 13% of women and 5% of men in a stratified randompopulation sample in Bristol. A reasonable assumption is that different definitions and population groups might well produce different prevalence rates for IBS, but there is remarkable consistency across the major surveys carried out in Europe, New Zealand, and the USA. In all groups women seem to be affected more frequently than men, except on the Indian subcontinent where the reverse is true; the reason for this difference is unclear, but it might be explained by a combination of reduced availability of medical care and different cultural approaches to illness. IBS is a chronic relapsing condition, and some suggest it occurs in most adults at some point in their lives. Symptoms begin before age 35 in 50% of patients, and 40% of patients are aged 35–50. IBS is recognised in Irritable bowel syndrome (IBS) has confounded clinicians for over a century. “Mucous colitis” was first described by Osler in 1892. He wrote of a disorder characterised by the passage of tubular casts of the colon, consisting of mucus (mucorrhoea), cell debris, and “intestinal sand”. Osler stated that the colonic epithelium was normal and that many of the patients were hysterical, hypochondriac, or depressed, and suffered from colicky abdominal pains. This condition was also recognised by Hurst, but the disease they described seemed to have disappeared from both clinical practice and medical texts by the late 1920s. The term “mucous colitis” persisted with a new definition, such that by 1928 it described only colonic spasm. The term “irritable colon” first appeared in published research in 1929 when Jordan and Kiefer used it to describe a colonic musculoneural disturbance present in 30% of gastroenterology outpatients. Irrritable colon described abdominal pain and disordered defaecation; it thus had a meaning similar to its present one.

Preliminary evaluation of an injectable anal sphincter bulking agent (Durasphere) in the management of faecal incontinence

Background : It has been previously shown that ‘bulking’ of internal anal sphincter defects may provide an effective method to treat patients with faecal incontinence, but the benefit wears off with time.

Food hypersensitivity and irritable bowel syndrome

Irritable bowel syndrome is a common condition but its pathophysiology remains poorly understood. Many irritable bowel syndrome patients give a history of food intolerance, but data from dietary elimination and re‐challenge studies are inconclusive. Multiple aetio‐pathological mechanisms have been postulated.

Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators

This systematic review examined the use of immunomodulators and the risk of postoperative complications after abdominal surgery in patients with inflammatory bowel disease.

Review article: immune suppression and colorectal cancer

Advances in immunology and molecular biology have shown that colorectal cancer is potentially immunogenic and that host immune responses influence survival. However, immune surveillance and activation is frequently ineffective in preventing and/or controlling tumour growth.

A deficiency of interstitial cells of Cajal in Chagasic megacolon.

Disordered gut motor activity is a feature of patients with Chagas’ disease: colonic involvement leads to the development of megacolon and symptoms of constipation. Interstitial cells of Cajal are thought to modulate gut motility. The aim of this study was to test the hypothesis that there is an abnormality of the density of distribution of interstitial cells of Cajal in Chagasic megacolon. Interstitial cells of Cajal were identified by immunohistochemistry using an anti-c-kit antibody. Six patients with Chagasic megacolon were compared with normal controls. The density of distribution of interstitial cells of Cajal was assessed in the longitudinal and circular muscle layers, and in the intermuscular plane of the Chagasic and normal colon. Statistical analysis was performed using Fisher’s exact test. The interstitial cells of Cajal density in Chagasic megacolon was much reduced in comparison to normal colonic tissue in the longitudinal muscle layer (P50.0084), intermuscular plane (P,0.0001), and circular muscle layer (P50.0051). The lack of interstitial cells of Cajal may play a role in the pathophysiology of the disease, leading to the development of megacolon and symptoms of constipation.