Geoffrey K. Turnbull

Recommendations on Chronic Constipation (Including Constipation Associated with Irritable Bowel Syndrome) Treatment

While chronic constipation (CC) has a high prevalence in primary care, there are no existing treatment recommendations to guide health care professionals. To address this, a consensus group of 10 gastroenterologists was formed to develop treatment recommendations. Although constipation may occur as a result of organic disease, the present paper addresses only the management of primary CC or constipation associated with irritable bowel syndrome. The final consensus group was assembled and the recommendations were created following the exact process outlined by the Canadian Association of Gastroenterology for the following areas: epidemiology, quality of life and threshold for treatment; definitions and diagnostic criteria; lifestyle changes; bulking agents and stool softeners; osmotic agents; prokinetics; stimulant laxatives; suppositories; enemas; other drugs; biofeedback and behavioural approaches; surgery; and probiotics. A treatment algorithm was developed by the group for CC and constipation associated with irritable bowel syndrome. Where possible, an evidence-based approach and expert opinions were used to develop the statements in areas with insufficient evidence. The nature of the underlying pathophysiology for constipation is often unclear, and it can be tricky for physicians to decide on an appropriate treatment strategy for the individual patient. The myriad of treatment options available to Canadian physicians can be confusing; thus, the main aim of the recommendations and treatment algorithm is to optimize the approach in clinical care based on available evidence.

Overlapping compared with end-to-end repair of third- and fourth-degree obstetric anal sphincter tears: a randomized controlled trial.

OBJECTIVE: To compare overlapping repair with end-to-end repair of obstetric tears and to investigate which procedure results in a higher rate of flatal incontinence. METHODS: One-hundred forty-nine primiparous women sustaining a complete third- or a fourth-degree tear of the perineum were assigned randomly to a primary sphincter repair using either an end-to-end (n=75) or an overlapping surgical technique (n=74) using 3–0 polyglyconate. Outcome measures at 6 months included rates of flatal and fecal incontinence, quality-of-life scores, integrity of the internal and external anal sphincters by anal ultrasonography, and anal sphincter function as reflected by anal manometry. RESULTS: Women who underwent overlapping repair compared with end-to-end repair had higher rates of flatal incontinence, 61% compared with 39% (odds ratio [OR] 2.44, confidence interval [CI] 1.2–5.0). The rate of fecal incontinence was also higher, 15% compared with 8% (OR 1.97, CI 0.62–6.3) but did not attain statistical significance. Rates of internal and external anal sphincter defects did not differ significantly between groups and did not correlate with anal incontinence symptoms. Fecal incontinence was higher when there was a defect in both sphincter muscles. Anal sphincter function as assessed by manometry did not differ significantly between groups. CONCLUSION: End-to-end repair of third- or fourth-degree obstetric anal sphincter tears is associated with lower rates of anal incontinence when compared with overlapping repair. Clinical Trial Registration: ISRCTN Register, isrctn.org, ISRCTN04149919. LEVEL OF EVIDENCE: I

Postpartum Flatal and Fecal Incontinence Quality-of-Life Scale: A Disease- and Population-Specific Measure

Using various recruiting methods, the authors identified 10 women who suffer from flatal and/or fecal incontinence subsequent to one or more previous vaginal deliveries. Each of these women participated in an individual in-depth 1-hour interview assessing symptom frequency, severity, and impact on quality of life. Participants also completed the Fecal Incontinence Quality-of-Life Scale and evaluated how well this scale captured their experiences. The authors used qualitative analyses to generate themes from the interviews and modified the existing scale, adding new items and themes to capture this populations particular symptom experience. This scale is being evaluated in the context of a surgical clinical trial comparing two techniques for repairing anal sphincter lacerations from delivery.

Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial.

OBJECTIVE: To report on a 3-year follow-up of women who underwent overlapping repair of a complete third-degree or fourth-degree obstetric tear. METHODS: Primiparous women sustaining a complete third-degree or a fourth-degree tear of the perineum were randomized to a primary sphincter repair using either an end-to-end or an overlapping surgical technique. At 1, 2, and 3 years, questionnaires on rates of flatal and fecal incontinence were mailed to participants. RESULTS: At 1 year, women who underwent an end-to-end repair reported lower rates of flatal and fecal incontinence than women who had an overlapping repair. For flatal incontinence the rates were 31% compared with 56% (95% confidence interval for the rate difference 6–43%, P=.012). For fecal incontinence, the rates were 7% compared with 16% (95% confidence interval for the rate difference −4% to 21%, P=.17). The difference between the two methods of surgical repair had largely disappeared by the end of year 2. CONCLUSION: At 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is associated with significantly lower rates of anal incontinence when compared with overlapping repair. There is no long-term benefit associated with either technique over the other. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://isrctn.org, ISRCTNO 4149919. LEVEL OF EVIDENCE: I

Investigating and treating fecal incontinence: When and how

Fecal incontinence is a common disorder in our aging population and can have profound effects on patients well-being. The present review examines the current understanding of fecal incontinence and provides a practical approach to the investigation and management of this condition. A special emphasis is placed on specialized testing, focusing on indications and impact on guiding management.

Impact of Disease Activity on the Quality of Life of Crohn’s Disease Patients

Crohn’s disease (CD) patients often suffer severe symptoms that impair their quality of life. A sample of 39 CD patients who were assessed using well validated measures of disease activity and disease-specific quality of life is reported. Twenty-six of these patients were reassessed an average of four months after the initial assessment to determine the impact of changes in disease activity on quality of life. For the total sample (n=39) disease activity did not predict quality of life for any of the scales of the Inflammatory Bowel Disease Questionnaire (IBDQ) (r<0.13 for each). Thus, examining fluctuations in disease activity between patients did not demonstrate a disease activity-quality of life relationship. In contrast, changes in disease activity within the same individuals over time (the repeat assessment sample, n=26) were correlated with changes in quality of life; increases in disease activity predicted decreases in quality of life on the IBDQ bowel symptoms subscale (r=-0.463, P<0.01) and the IBDQ systemic symptoms subscale (r=0.44, P<0.05). The 10 patients with the largest decrease in disease activity over time (mean decrease of 43.54 points using the Dutch Activity Index) had significant improvement in quality of life on the bowel and systemic subscales. In contrast, the nine patients with the largest increase in disease activity over time (mean increase of 20.57 points using the Dutch Activity Index) had significant reduction in quality of life on the bowel and systemic symptoms subscales. These differences between extreme groups were significant for both the bowel symptoms (P<0.05) and systemic symptoms (P<0.05) subscales. The authors conclude that changes in disease activity affect some important aspects of quality of life: aspects related to disease-specific (bowel symptoms) and nondisease-specific (systemic symptoms) physical symptoms. Importantly, disease activity was not able to predict the emotional and social aspects of IBD-related quality of life. This suggests that nondisease factors need to be considered when working with CD patients. Future research should evaluate the role of psychological intervention in improving quality of life for patients with reduced well-being, particularly in areas of emotional and social functioning.

Treatment of Bile Duct Stones Endoscopically and by Extracorporeal Shock Waves

Endoscopic sphi ncterotomy was performed in a 68-year-old female patient with multiple stones in the common bile duct and cholangitis. Because the extraction of all the stones was not achieved extracorporeal lithotripsy was performed. Following fragmentation all the residual stones passed spontaneously and no complication occurred.

Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-Degree Obstetric Tears: Three-Year Follow-up of a Randomized Controlled Trial

Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial - Obstetrics and Gynecology - Vol. 120, 4 - ISBN: 1873-233X - p.803-808

Overlapping Compared With End-to-End Repair of Third- and Fourth-Degree Obstetric Anal Sphincter Tears: A Randomized Controlled Trial

The traditional procedure in obstetric practice used to repair external anal sphincter defects has been an end-to-end technique. Clinicians have been concerned, however, by reports of high rates of external anal sphincter defects and associated symptoms of anal incontinence with this technique. In a small retrospective study, another procedure, overlapping repair, lowered the rate of postoperative defects and improved anal function leading to suggestions that the traditional end-to-end surgical repair technique does not restore normal anatomy or function. As a result, some investigators believe that overlapping repair should replace the end-to-end technique as the standard of care. A Cochrane review of 3 randomized trials comparing the overlapping and end-to-end repair techniques reported no difference in flatal or fecal incontinence rates but a lower rate of fecal urgency and a lower anal incontinence scores in the overlapping group. Although these data suggest some advantage of the overlapping repair technique, the 3 trials were limited by deficiencies in design. Limitations included lack of reporting surgeon experience, inclusion of multiparous women and women with partial tears of the external anal sphincter, and lack of clarity in regard to interpreting outcome measures. This randomized controlled trial compared the use of overlapping repair and end-to-end repair of obstetric tears and investigated which of these procedures is associated with a higher rate of flatal incontinence. The study subjects—149 primiparous women who had sustained a complete third- or a fourth-degree tear of the perineum—were randomly assigned to overlapping (n = 74) or end-to-end (n = 75) external anal sphincter repair. The study was conducted at a tertiary care academic center between 2001 and 2007. All participants and follow-up assessment personnel were blinded as to the surgical procedure performed. At the 6-month follow-up, outcome measures examined included rates of flatal and fecal incontinence, rates of internal and external anal sphincter defects using ultrasonography, anal function using anal manometry, and quality-of-life scores. Compared with end-to-end repair, overlapping repair was associated with higher rates of flatal incontinence (61 % vs. 39%); the odds ratio was 2.44, with a 95% confidence interval of 1.2-5.0 (P = 0.015). The rate of fecal incontinence was also higher with overlapping repair (15% vs. 8%) but not statistically significant (P = 0.243). The difference between groups in rates of internal and external anal sphincter defects was not significant. The presence of a defect in both sphincter muscles was associated with a higher rate of fecal incontinence. There was no significant difference in anal sphincter function between the surgical groups. These findings indicate that overlapping repair of third- or fourth-degree obstetric anal sphincter tears is more likely to result in anal incontinence compared with the traditional end-to-end repair procedure. The investigators recommend use of the traditional end-to-end procedure for repair of these tears.

Clinical Management of Inflammatory Bowel Disease: Beyond Disease Activity. I. Assessing Psychosocial Factors

Inflammatory bowel disease (IBD) is a chronic, relapsing disorder that can be very disabling to the patient and often leads to significant lifestyle problems (eg, emotional distress, social isolation, work impairment and disability). Available evidence strongly indicates that health status is influenced by psychosocial factors as well as disease activity. This is the first of a two-part series, the purpose of which is to provide a framework to guide the gastroenterologist in the assessment and management of psychosocial factors that impact on the health status of the IBD patient. Part I contains a review of existing approaches to assessment of psychosocial factors, which include focusing on psychosomatic or psychiatric factors. The growing body of evidence in support of a “biopsychosocial” approach to understanding and treating health status is reviewed. In this approach, distress and disability are not seen as due to psychopathology, but stemming directly from the experience of illness itself. Part II will focus on specific strategies to maximize psychosocial adjustment to this disabling illness.