Kyle Staller

Patients with irritable bowel syndrome-diarrhea have lower disease-specific quality of life than irritable bowel syndrome-constipation

AIM To determine effect of irritable bowel syndrome (IBS) subtype on IBS-specific quality of life (QOL) questionnaire and its subscales. METHODS We studied IBS patients visiting our functional gastroenterology disorder clinic at a tertiary care center of Unites States. IBS and IBS subtype were diagnosed using Rome-III questionnaire. QOL was assessed using IBS-QOL questionnaire. IBS-QOL assesses quality of life along eight subscales: dysphoria, interference with activities, body image, health worry, food avoidance, social reactions, sexual health, and effect on relationships. IBS-QOL and its subscales were both scored on a range of 0-100 with higher scores suggestive of better QOL. Results of overall IBS-QOL scores and subscale scores are expressed as means with 95%CI. We compared mean IBS-QOL score and its subscales among various IBS-subtypes. Analysis of variance (ANOVA) was used to compare the mean difference between more than two groups after controlling for age and gender. A post-hoc analysis using Bonferroni correction was used only when P value for ANOVA was less than 0.05. RESULTS Of 542 patients screened, 243 had IBS as per Rome-III criteria. IBS-mixed (IBS-M) was the most common IBS subtype (121 patients, 49.8%) followed by IBS- diarrhea (IBS-D) (56 patients, 23.1%), IBS-constipation (IBS-C) (54 patients, 22.2%) and IBS-unspecified (IBS-U) (12 patients, 4.9%). Overall IBS-QOL scores were significantly different among various IBS-subtypes (P = 0.01). IBS-QOL of patients with IBS-D (61.6, 95%CI: 54.0-69.1) and IBS-M (63.0, 95%CI: 58.1-68.0) was significantly lower than patients with IBS-C (74.5, 95%CI: 66.9-82.1) (P = 0.03 and 0.02 respectively). IBS-D patients scored significantly lower than IBS-C on food avoidance (45.0, 95%CI: 34.8-55.2 vs 61.1, 95%CI: 50.8-71.3, P = 0.04) and interference with activity (59.6, 95%CI: 51.4-67.7 vs 82.3, 95%CI: 74.1-90.6, P < 0.001). IBS-M patients had more interference in their activities (61.6, 95%CI: 56.3-66.9 vs 82.3, 95%CI: 74.1-90.6, P = 0.001) and greater impact on their relationships (73.3, 95%CI: 68.4-78.2 vs 84.7, 95%CI: 77.2-92.2, P = 0.02) than IBS-C patients. Patients with IBS-M also scored significantly lower than IBS-C on food avoidance (47.2, 95%CI: 40.7-53.7 vs 61.1, 95%CI: 50.8-71.3, P = 0.04) and social reaction (66.1, 95%CI: 61.1-71.1 vs 80.0, 95%CI: 72.1-87.7, P = 0.005). CONCLUSION IBS-D and IBS-M patients have lower IBS-QOL than IBS-C patients. Clinicians should recognize food avoidance, effects on daily activities and relationship problems in these patients.

Duodenal rather than antral motility contractile parameters correlate with symptom severity in gastroparesis patients

Studies of symptomatic gastroparetics consistently find poor correlation with gastric emptying. We hypothesized that concomitant small bowel dysmotility may play a role in symptom causation in gastroparesis and sought to test this hypothesis by using wireless motility capsule (WMC) testing to simultaneously measure antral and duodenal area under pressure curve (AUC) in patients with delayed gastric emptying.

Constipation prophylaxis reduces length of stay in elderly hospitalized heart failure patients with home laxative use

Elderly, hospitalized patients suffer disproportionately from constipation; however, little data suggest that constipation prophylaxis reduces length of stay (LOS). We performed a retrospective analysis of elderly patients admitted to our hospital with congestive heart failure (CHF) to determine the effects of constipation prophylaxis on LOS.

New Pathways, New Targets: Visceral Hypersensitivity Pathogenesis in Irritable Bowel Syndrome

New Pathways, New Targets: Visceral Hypersensitivity Pathogenesis in Irritable Bowel Syndrome

Rectosigmoid Localization of Radiopaque Markers Does Not Correlate with Prolonged Balloon Expulsion in Chronic Constipation: Results from a Multicenter Cohort

OBJECTIVES:Ingestion of radiopaque markers (ROMs) is a common means of assessing colonic transit time in chronic constipation. Because anorectal manometry (ARM) testing for pelvic floor dysfunction is mostly limited to academic centers, clinicians frequently use rectosigmoid accumulation of markers as a surrogate for pelvic floor dysfunction. We sought to determine whether rectosigmoid localization of markers on a ROM study correlated with measures of pelvic floor dysfunction by ARM and balloon expulsion testing.METHODS:We assembled a multicenter, retrospective cohort of patients diagnosed with chronic constipation who underwent both transit testing by ROM transit testing and ARM with balloon expulsion testing. We compared the proportion of patients with outlet obstruction by rectoanal pressure gradient or prolonged balloon expulsion stratified by marker location.RESULTS:There were 610 patients with both ROM testing and ARM with balloon expulsion testing. The mean age was 44 years and 526 were women (86%). Eighty-one (13%) patients had markers confined to the rectosigmoid area alone and were compared with 529 patients with markers elsewhere (51%) or no retained markers (49%). Of those with markers confined to the rectosigmoid colon, 48 (59%) had a prolonged balloon expulsion compared with 276 (52%) who did not have rectosigmoid markers (P=0.28). The mean rectoanal gradient for patients with markers in the rectosigmoid colon was −29±46 mm Hg compared with −34±59 mm Hg for all others (P=0.59).CONCLUSIONS:Among patients with chronic constipation undergoing ROM transit testing, there is no association between rectosigmoid location of markers and rectoanal gradient or prolonged balloon expulsion.

Need for Rectal Biopsy for Childhood Constipation Predicts Severity of Illness and Need for Laxatives.

Objectives: This study aimed to examine the long-term clinical outcomes of children with severe constipation, as defined by need for rectal biopsy (RB), and to determine which baseline characteristics were predictors of successful outcome. Methods: Children with severe constipation who underwent RB for evaluation of Hirschsprung disease at a tertiary medical center were eligible. A cohort of children with constipation without a history of RB served as controls (matched 2:1 by sex and age). Retrospective chart review of clinic visits was performed at baseline, 3, 6, 12, 18, and 24 months. Successful clinical outcomes were defined as ≥3 bowel movements weekly for ≥4 weeks, with ⩽2 fecal incontinence episodes monthly, irrespective of laxative use. Results: A total of 175 RB children (90 boys, mean age: 6.7 years) were matched to 350 controls. Mean duration of constipation symptoms before intake in the RB group was significantly longer compared with controls (3.7 vs 0.4 years, P < 0.001). By 24 months, the cumulative percentage of children achieving at least 1 period of successful outcome was significantly higher in the control group compared with RB population (73% vs 24%, P < 0.001). Multivariate analysis revealed that younger age (P = 0.001, odds ratio 0.87) and shorter duration of constipation before RB (P = 0.03, odds ratio 0.45) were significant predictors of successful outcome. Conclusions: Only one-quarter of patients with severe constipation achieved successful outcome during 2-year follow-up. Younger age and shorter duration of constipation at time of biopsy were predictors of successful outcomes, emphasizing the importance of early diagnosis and initiation of treatment in this population.

Resting anal pressure, not outlet obstruction or transit, predicts healthcare utilization in chronic constipation: a retrospective cohort analysis.

Chronic constipation is common and exerts a considerable burden on health‐related quality of life and healthcare resource utilization. Anorectal manometry (ARM) and colonic transit testing have allowed classification of subtypes of constipation, raising promise of targeted treatments. There has been limited study of the correlation between physiological parameters and healthcare utilization.

Role of Anorectal Manometry in Clinical Practice

Opinion statementPhysiologic assessment of the anorectum and pelvic floor by anorectal manometry and balloon expulsion testing provides important insights into the pathologic processes underlying defecatory disorders and guides treatment, specifically the use of biofeedback for the treatment of dyssynergic defecation and the identification of possible structural abnormalities of the pelvic floor. While symptoms and digital rectal examination may suggest pelvic floor dysfunction to the clinician, only pelvic floor testing provides definitive diagnoses of these often treatable abnormalities. The use of anorectal manometry in clinical practice is currently limited by substantial variation in performance of the test and interpretation of the results, but anorectal manometry with the addition of balloon expulsion test to improve specificity provides the best current modality for the diagnosis of dyssynergic defecation. With the introduction of high-resolution and three-dimensional, high-definition probes, our ability to characterize the structure and function of the anorectum has never been better, though further research is still needed to improve our ability to diagnose pelvic floor dysfunction and refer appropriate patients to treatment. In areas where the availability of anorectal manometry (ARM) is limited, a thorough digital rectal exam performed by an experienced clinician plus the balloon expulsion test alone may identify appropriate patients to refer for additional testing. This review describes the appropriate indications for and appropriate performance of anorectal manometry in clinical practice with an eye toward the diagnosis of dyssynergic defecation in patients with chronic constipation, fecal incontinence, and chronic proctalgia.

Development, Anatomy, and Physiology of the Esophagus

Esophageal embryonic development and anatomic features play an important role in both normal function and common pathology of the esophagus. The embryonic endoderm provides the scaffolding for the future esophagus, which will ultimately connect the pharynx to the stomach. The developed esophagus has close anatomic relationships with the cervical spine, thoracic aorta, left atrium, and diagphragmatic haitus—relationships associated with esophageal pathology. Esophageal musculature is composed of an external layer of longitudinal fibers and an internal layer of circular fibers which provide peristaltic force; the backflow of food and acidic gastric contents is prevented at the level of two high-pressure regions: the upper and the lower esophageal sphincters. Microscopically, the esophageal wall is composed of four layers: internal mucosa, submucosa, muscularis propria, and adventitia. The esophagus has a segmental arterial supply without dedicated vasculature. Venous drainage is notable for being a portal-caval connection susceptible to portal hypertension. Esophageal innervation occurs via the sympathetic and parasympathetic nervous systems, as well as the intrinsic enteric nervous system.

Gender differences in chronic constipation on anorectal motility

The epidemiology of chronic constipation (CC) skews toward female predominance, yet men make up an important component of those suffering from CC. We sought to determine whether there are sex‐specific differences in symptoms and physiologic parameters on anorectal manometry (ARM).