Madhulika G. Varma

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Fecal incontinence in females older than aged 40 years: who is at risk?

Purpose: This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years. Methods: The Reproductive Risks for Incontinence Study at Kaiser is a population‐based study of 2,109 randomly selected middle‐aged and older females (average age, 56 years). Fecal incontinence, determined by self‐report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self‐report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year. Results: Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form‐36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m2 (95 percent confidence interval)] with obesity [1.2 (1.1‐1.3)], chronic obstructive pulmonary disease [1.9 (1.3‐2.9)], irritable bowel syndrome [2.4 (1.7‐3.4)], urinary incontinence [2.1 (1.7‐2.6)], and colectomy [1.9 (1.1‐3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4‐0.9)]. Conclusions: Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

Colon, rectum, and anus

The colon is one structural unit with two embryological origins. The cecum and right and midtransverse colons are of midgut origin and as such are supplied by the superior mesenteric artery (SMA). The distal transverse, splenic flexure, and descending and sigmoid colon are of hindgut origin and receive blood from the inferior mesenteric artery (IMA). The entire colon starts as a midline structure that rotates during development and attaches laterally to the right and left posterior peritoneum. The right and left colonic mesenteries are obliterated, fusing to the posterior peritoneum in these regions, leaving these portions of the colon covered by peritoneum on the lateral, anterior, and medial surfaces. The transverse and sigmoid colons, in contrast, are completely covered with peritoneum and are attached by long mesenteries, allowing for great variation in the location of these structures (Fig. 51.1).

Gross versus microscopic pancolitis and the occurrence of neoplasia in ulcerative colitis.

ObjectiveThe gross extent of ulcerative colitis (UC) is a recognized risk factor for the development of colitis-related dysplasia and colorectal cancer (CRC). The risk of neoplasia associated with the microscopic extent of colitis is unknown. The aim of this study was to describe the gross and microscopic extent of colitis in patients with UC–related dysplasia/CRC. MethodsAll patients who underwent colectomy at our institution between 1992-2001 with colitis-related dysplasia/CRC were identified. Histological sections from each colectomy specimen were reviewed for the microscopic extent of colitis and the location of all lesions with dysplasia/CRC. ResultsThirty-six patients with colitis-related dysplasia/CRC were identified of whom 30 had slides available for review. Gross pancolitis was identified in 19 patients, though microscopic pancolitis was evident in all 30 patients. Among the 11 patients with only distal gross colitis, 4/15 neoplastic lesions were proximal to the area of gross involvement. ConclusionsUC-related neoplasia can occur in areas of the colon not grossly involved with colitis, though it did not occur in any patients without microscopic pancolitis. To devise rational cancer surveillance guidelines, further studies are needed to determine the risk of colitis-related neoplasia in patients with microscopic pancolitis but limited gross disease.

A Review of the Literature on Gender and Age Differences in the Prevalence and Characteristics of Constipation in North America

Constipation is a common problem and affects between 2% and 28% of the general population. It is thought to affect more women than men. The severity of constipation is variable and it can be an acute or chronic condition. Often, it requires frequent interventions that may produce mixed or even unsatisfactory results. Knowledge of potentially gender- and age-related differences in constipation would be useful to clinicians to help them identify high-risk patients. In addition, researchers might use this information to design both descriptive and intervention studies. This article reviews the evidence from the studies on gender and age differences in prevalence of constipation, gender differences in the prevalence and characteristics of constipation, and age differences in the prevalence and characteristics of constipation. The available literature suggests that the prevalence of constipation is consistently higher in women than in men. However, evidence of gender differences in the characteristics of constipation is inconsistent. Prevalence rates appear to increase gradually after the age of 50 years, with the largest increase after the age of 70 years. The literature is both sparse and inconsistent in its description of age differences in the characteristics of constipation. This lack of research is a significant issue given the magnitude of this problem in the older adult population. Research is needed on gender and age differences in the symptoms of constipation, and how covariates impact the prevalence and severity of constipation in the elderly.

An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery.

PURPOSE: The primary goal of the Surgical Care Improvement Project is to improve quality of care by implementing evidence-based health care practices that prevent surgical complications. This study was designed to test the hypothesis that an increase in compliance with quality process measures decreases the rate of surgical site infections in patients undergoing colorectal surgeries. METHODS: A multidisciplinary task force implemented and monitored compliance with individual quality measures in patients undergoing elective colorectal resections at a tertiary institution. Individual compliance rates and infections were collected prospectively and reviewed monthly. For data analysis, patients were assigned to 2 consecutive 14-month periods: period A (April 1, 2006 to May 31, 2007) and period B (June 1, 2007 to July 31, 2008). Comparisons between periods were performed to determine the association of compliance with process measures and outcomes in infections. RESULTS: A total of 491 consecutive patients were treated during the study periods (period A: n = 238; period B: n = 253). There were no statistically significant differences in patient characteristics, diagnoses, or surgical procedures between periods. Compliance with all process measures significantly increased within periods except for perioperative glucose control. Global compliance (compliance with all measures per patient) significantly improved from period A to B (40%–68%, respectively; P < .001). In total, 99 patients (19%) developed surgical site infections (period A, 18.9%; period B, 19.4%). CONCLUSION: An increase in compliance with the Surgical Care Improvement Project aimed to prevent surgical site infections does not translate into a significant reduction of surgical site infections in patients undergoing colorectal resections.

The Constipation Severity Instrument: A Validated Measure

PurposeThis study was designed to develop and test the validity and reliability of the Constipation Severity Instrument.MethodsScale development was conducted in two stages: 1) 74 items were generated through a literature review and focus groups of constipated patients and medical providers; and 2) a preliminary instrument was administered to 191 constipated patients and 103 healthy volunteers. Test-retest reliability of the constipated group was assessed (N = 90). Content, convergent, divergent, and discriminant validity were evaluated by using other validated measures by performing one-way analysis of variance and Pearson correlations.ResultsExploratory and confirmatory factor analysis revealed three subscales: obstructive defecation, colonic inertia, and pain. Internal consistency (α = 0.88–0.91) and test-retest reliability (intraclass correlation coefficients = 0.84–0.91) were high for all subscales. Constipated patients were grouped by Rome II criteria: functional constipation (22 percent), pelvic floor dyssynergia (15 percent), constipation predominant irritable bowel syndrome (23 percent), and no specific criteria (40 percent). Those with constipation predominant irritable bowel syndrome or pelvic floor dyssynergia scored higher on the Obstructive Defecation and Colonic Inertia subscales than those with functional constipation or no specific criteria (P = 0.001–0.058). Subjects with functional constipation had much lower scores on the pain subscale than constipation predominant irritable bowel syndrome, functional constipation, or no specific criteria (P < 0.009).The Constipation Severity Instrument subscale and total score correlated very highly with the subscales and total score of the Patient Assessment of Constipation Symptom measure. The Constipation Severity Instrument subscales discriminated well between constipated patients and healthy volunteers (P < 0.001) and demonstrated excellent divergent validity. Higher Constipation Severity Instrument scores inversely correlated with general quality of life.ConclusionsThe Constipation Severity Instrument is a reliable and valid instrument for assessing constipated patients. Administration of the Constipation Severity Instrument to other constipated patients will further validate its use.

The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence.

623 Diseases of the Colon & ReCtum Volume 58: 7 (2015) the american society of Colon and Rectal surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. this Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. this is accompanied by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive and not prescriptive. their purpose is to provide information based on which decisions can be made, rather than to dictate a specific form of treatment. these guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Practice parameters for the management of rectal prolapse.

T he American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Local therapy for rectal cancer

In selected patients with early rectal cancer, local therapy is an effective alternative to radical resection and offers minimal morbidity and the avoidance of a colostomy. Several techniques are described: transanal excision, dorsal approaches (York-Mason or Kraske procedures), transanal endoscopic microsurgery, endocavitary radiation, and transanal fulguration. Among these, transanal excision is favored for the low rate of complications, promising outcomes, and ability to secure tissue for pathology. Patients with T1 lesions with favorable histologic features may undergo local excision alone, while those with T2 lesions require adjuvant chemoradiation. The data currently available do not support the use of local therapy with curative intent for tumors that are advanced (T3 or T4), poorly differentiated, or have other negative pathologic characteristics. In carefully selected patients for local excision, local recurrence and survival rates are similar to traditional radical resection. Following local excision, patients require close observation for recurrence. Most patients with local recurrence can be salvaged by radical resection, though the long-term outcome is unknown.