Stephen Lewis

Stool Form Scale as a Useful Guide to Intestinal Transit Time

BACKGROUND Stool form scales are a simple method of assessing intestinal transit rate but are not widely used in clinical practice or research, possibly because of the lack of evidence that they are responsive to changes in transit time. We set out to assess the responsiveness of the Bristol stool form scale to change in transit time. METHODS Sixty-six volunteers had their whole-gut transit time (WGTT) measured with radiopaque marker pellets and their stools weighed, and they kept a diary of their stool form on a 7-point scale and of their defecatory frequency. WGTT was then altered with senna and loperamide, and the measurements were repeated. RESULTS The base-line WGTT measurements correlated with defecatory frequency (r = 0.35, P = 0.005) and with stool output (r = -0.41, P = 0.001) but best with stool form (r = -0.54, P < 0.001). When the volunteers took senna (n = 44), the WGTT decreased, whereas defecatory frequency, stool form score, and stool output increased (all, P < 0.001). With loperamide (n = 43) all measurements changed in the opposite direction. Change in WGTT from base line correlated with change in defecatory frequency (r = 0.41, P < 0.001) and with change in stool output (n = -0.54, P < 0.001) but best with change in stool form (r = -0.65, P < 0.001). CONCLUSIONS This study has shown that a stool form scale can be used to monitor change in intestinal function. Such scales have utility in both clinical practice and research.

Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials

Abstract Objective: To determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcomes. Design: Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases (PubMed, Embase, and the Cochrane controlled trials register) were searched, reference lists checked, and letters requesting details of unpublished trials and data sent to pharmaceutical companies and authors of previous trials. Main outcome measures: Anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay, and mortality. Results: Eleven studies with 837 patients met the inclusion criteria. In six studies patients in the intervention group were fed directly into the small bowel and in five studies patients were fed orally. Early feeding reduced the risk of any type of infection (relative risk 0.72, 95% confidence interval 0.54 to 0.98, P=0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33, P=0.001). Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to 1.08, P=0.080), wound infection, pneumonia, intra-abdominal abscess, and mortality, but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early (1.27, 1.01 to 1.61, P=0.046). Conclusions: There seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials. What is already known on this topic Enteral feeding within 24 hours after gastrointestinal surgery is tolerated Theoretically, early enteral feeding improves tissue healing and reduces septic complications after gastrointestinal surgery What this study adds There is no benefit in keeping patients “nil by mouth” after gastrointestinal surgery Septic complications and length of hospital stay were reduced in those patients who received early enteral feeding In patients who received early enteral feeding there were no significant reductions in incidence of anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess, and mortality

Effect of the Prebiotic Oligofructose on Relapse of Clostridium difficile-Associated Diarrhea: A Randomized, Controlled Study

BACKGROUND & AIMS Ten percent to 20% of patients relapse after successful treatment of their Clostridium difficile -associated diarrhea. We set out to determine if the prebiotic oligofructose could alter the fecal bacterial flora and, in addition to antibiotic treatment, reduce the rate of relapse from C difficile infection. METHODS Consecutive inpatients with C difficile -associated diarrhea were randomly allocated to receive oligofructose or placebo for 30 days in addition to specific antibiotic treatment. Patients were followed up for an additional 30 days. The main end point was the development of further diarrhea. Stools were collected for bacterial culture and C difficile toxin measurement. RESULTS One hundred forty-two patients were recruited. Stool culture confirmed the probiotic effect of oligofructose with an increase in fecal bifidobacteria from baseline 8.68 log(10) colony-forming units (cfu)/g to 9.37 log(10) cfu/g at discharge (P < .0001; 95% confidence interval [CI], 0.45-0.94), 9.64 log(10) cfu/g at 30 days (P < .0001; 95% CI, 0.74-1.18), and 9.42 log(10) cfu/g at 60 days (P < .0001; 95% CI, 0.56-0.93). Thirty patients experienced a relapse of diarrhea after a median of 18 days (range, 8-34 days). Relapse of diarrhea was more common in those taking placebo (8.3% oligofructose vs 34.3% placebo, P < .001, chi(2) = 14.35). Patients who relapsed stayed in the hospital longer than those who did not (53 vs 26 days, P = .021; 95% CI, 2-28), and there was a longer period of time from commencing metronidazole or vancomycin and their diarrhea settling (6 vs 3 days; P = .007; 95% CI, 1.0-5.0). CONCLUSIONS Fecal cultures confirmed the prebiotic effect of oligofructose. Patients taking oligofructose were less likely to develop further diarrhea than those taking the placebo.

Review article: the use of biotherapeutic agents in the prevention and treatment of gastrointestinal disease

There is presently a lack of well conducted clinical trials demonstrating any significant benefits of probiotics in humans. With the exception of diarrhoea due to rotavirus infection in children there is little evidence from randomized, double‐blind, placebo‐controlled studies that bacterial probiotics have a significant beneficial action in preventing diarrhoea of any cause. The yeast Saccharomyces boulardii has been shown to be of benefit in the prevention of antibiotic‐associated diarrhoea but not in preventing infection with Clostridium difficile. S. boulardii may also be of benefit in preventing relapse of C. difficile infection. Because of the simplicity of in vitro systems and some animal models, beneficial characteristics of probiotics such as the ability of bacteria to bind to epithelial surfaces are not always transferable to humans. Thus any postulated benefit from consumption of probiotic bacteria should only be accepted as fact after testing in clinical studies.

Gum chewing reduces postoperative ileus? A systematic review and meta-analysis

BACKGROUND An important cause of delayed recovery from intestinal surgery is postoperative ileus. Gum chewing is a form of sham feeding, which could encourage gastrointestinal motility through cephalic-vagal stimulation. METHODS We sought to identify all randomized controlled trials comparing gum chewing with standard care after elective intestinal surgery. We searched electronic databases (Cochrane, Embase, and PubMed), reference lists and contacted authors to obtain further data. We assessed the identified trials for quality and performed a meta-analysis and systematic review. The main outcome measures examined were time to flatus and stool postoperatively and length of hospital stay, which were analysed using random effect models. We also examined clinical complication rates. RESULTS We identified nine eligible trials that had enrolled a total of 437 patients. The intervention was well tolerated and complication rates were low. There was statistical evidence of heterogeneity for the three main outcomes. Pooled estimates showed a reduction in time to flatus by 14 h (95% CI: -20 to -8h, p=0.001), time to bowel movement by 23 h (95% CI: -32 to -15 h, p<0.001) and a reduction in length of hospital stay by 1.1 days (95% CI: -1.9 to -0.2 days, p=0.016). CONCLUSIONS Chewing sugarless gum following elective intestinal resection is associated with improved outcomes. Insufficient data were available to demonstrate a reduced rate of clinical complications or reduced cost. An adequately powered, methodologically rigorous trial of gum chewing is required to confirm if there are any benefits and if these result in differences in clinical outcomes such as infection.

Severity of imported falciparum malaria: effect of taking antimalarial prophylaxis.

OBJECTIVE--To investigate the effects of antimalarial chemoprophylaxis and other variables on the severity of falciparum malaria. DESIGN--Review of consecutive malaria cases between 1987 and 1991. SETTING--The Hospital for Tropical Diseases, London. SUBJECTS--250 consecutive cases of mild and 51 consecutive cases of severe falciparum malaria. RESULTS--Prophylaxis was taken in 52.4% (131/250) of the cases of mild malaria and 21.6% (11/51) of cases of severe malaria. Severe malaria was more common in white patients than in those of African origin and was also seen more commonly in people returning from central, southern, and east Africa than in those returning from west Africa. Patients with severe malaria presented sooner than patients with mild malaria. CONCLUSIONS--Prior chemoprophylaxis led to a reduction in the severity of falciparum malaria. Ethnic origin, time to presentation, and sex were also associated with the severity of malaria.

Failure of dietary oligofructose to prevent antibiotic‐associated diarrhoea

Background : Oligofructose is metabolized by bifidobacteria, increasing their numbers in the colon. High bifidobacteria concentrations are important in providing ‘colonization resistance’ against pathogenic bacteria.

Age-related faecal calprotectin, lactoferrin and tumour M2-PK concentrations in healthy volunteers

Objective Measurement of the faecal markers calprotectin, lactoferrin and tumour M2-PK has been reported to be useful in the diagnosis and management of a range of gastrointestinal disorders in both children and adults. The aim of this study was to investigate the requirement for age-related reference ranges. Methods Faecal samples were obtained from 132 healthy subjects and analysis of calprotectin, lactoferrin and tumour M2-PK performed using commercially available enzyme-linked immunosorbent assay. Results In the healthy subjects median concentrations were as follows: for calprotectin – 2–9 y, 34 μg/g, 10–59 y, 22 μg/g and ≥60 y, 27 μg/g; for lactoferrin – 2–9 y, 2.2 μg/g, ≥10 y, 0.5 μg/g; and for tumour M2-PK all subjects <1 U/mL. Significant differences between age groups for different markers resulted in the following age-related reference ranges: calprotectin – 2–9 y, <166 μg/g, 10–59 y, <51 μg/g, ≥60 y, <112 μg/g; lactoferrin – 2–9 y, <29 μg/g, ≥10 y <4.6 μg/g. Conclusion In healthy individuals, we found there to be variation in the faecal inflammatory markers calprotectin and lactoferrin with age. For both calprotectin and lactoferrin children aged 2–9 y had significantly higher concentrations than subjects aged ≥10 y. For calprotectin but not lactoferrin, adults ≥60 years had a higher concentration than those aged 10–59 y. There was no change with age in the metabolomic marker faecal tumour M2-PK in healthy subjects. The knowledge of age-related reference ranges in healthy subjects is important to fully interpret changes in gastrointestinal disease.

A systematic review of the role of immunonutrition in patients undergoing surgery for head and neck cancer

Patients with head and neck cancer are often malnourished and have a high incidence of postoperative complications. Studies of patients with head and neck cancer receiving immunonutrition in the perioperative period have suggested, but not conclusively demonstrated, benefit. This study reviews randomised trials comparing perioperative standard polymeric nutrition or no nutritional supplementation with immunonutrition in the treatment of head and neck cancer. Electronic databases were searched; reference lists checked and letters sent requesting details of further data. Data were combined to estimate the common relative risk of postoperative complications (wound infections, fistula formation, death and length of hospital stay), and associated 95% confidence intervals. Random effects models were used. 10 trials of polymeric nutritional supplementation with immunonutrition were identified; one compared two types of immunonutrition. There was little evidence of heterogeneity. Pooled estimates showed a reduction in length of hospital stay by 3.5 days (95% CI 0.7 to 6.3 day, P<0.01). No reductions in clinical complications were seen. Perioperative immunonutrition is associated with reduced length of hospital stay; the mechanism is unclear as other outcomes were not improved. Trials were small with incomplete reporting of outcomes. An adequately powered trial is required to substantiate benefit.

Guidelines for adults on self-medication for the treatment of acute diarrhoea

Acute uncomplicated diarrhoea is commonly treated by self‐medication. Guidelines for treatment exist, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice.