William V. Harford

A Clinical Study of Patients With Fecal Incontinence and Diarrhea

Clinical and pathophysiologic studies were carried out in 29 patients with chronic diarrhea and incontinence. Most of these patients had been extensively investigated for diarrhea, whereas closer questioning revealed that the major (but previously unmentioned) problem was incontinence for liquid stools. Incontinent patients were, as a group, abnormal with regard to anal sphincter pressure, the ability to retain a solid sphere in the rectum as weights were applied, and the ability to retain saline that had been infused into the rectum. They were, however, no different from control subjects with regard to sphincter length and squeeze duration and with regard to the ability to detect the presence of fluid infused into the rectum. Estimation of sphincter tone by digital examination did not correlate with any objective measure of anal sphincter function or with continence to rectally infused saline. Analysis of the individual data from incontinent diarrhea patients showed that most of these patients had low stool volumes, low sphincter pressures, and an impaired ability to retain saline infused into the rectum. These results would be compatible with a defect in the function of the sphincter muscles. However, some patients had sphincter pressures well within the normal range, low stool volumes, and impaired saline continence. It seems likely that these patients have an abnormality in the continence mechanism other than a muscular weakness of the anal sphincter. Finally, 2 patients had sphincter pressures well within the normal range and good continence to saline, but passed very large amounts of -stool. Such patients probably represent a situation where large volume diarrhea overwhelms a fairly normal mechanism for preserving continence. Our results suggest that measurement of stool volume, sphincter pressure, and ability to retain rectally infused saline may aid in the diagnostic and therapeutic evaluation of patients with chronic diarrhea and fecal incontinence.

Pathogenesis of fecal incontinence in diabetes mellitus: evidence for internal-anal-sphincter dysfunction.

We studied 16 patients with diabetes and fecal incontinence. The onset of incontinence coincided with the onset of chronic diarrhea in most patients. Episodes of incontinence occurred when stools were frequent and loose; however, 24-hour stool weights were usually within normal limits. All patients had evidence of autonomic neuropathy, and one third had steatorrhea. Incontinent diabetics had a lower mean basal anal-sphincter pressure than 35 normal subjects (63 +/- 4 vs. 37 +/- 4 mm Hg; P less than 0.001), reflecting abnormal internal-anal-sphincter function. The increment in sphincter pressure with voluntary contraction (external-sphincter function) was not significantly different from normal. Incontinent diabetics also had impaired continence for a solid sphere and for rectally infused saline. In contrast, 14 diabetics without diarrhea or incontinence had normal sphincter pressures and normal results on tests of continence, even though 79 per cent had evidence of autonomic neuropathy and nearly half had steatorrhea. We conclude that incontinence in diabetic patients is related to abnormal internal-anal-sphincter function, and that as a group, diabetics without diarrhea do not have latent defects in continence.

Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel- preparation quality

BACKGROUND Recent studies suggest that colonoscopies done in the morning have better-quality bowel preparations than those done in the afternoon. OBJECTIVE We aimed to determine how the duration of the interval between the end of the preparation and the start of the colonoscopy affects preparation quality. DESIGN We prospectively studied consecutive outpatients who had colonoscopies performed at our hospital within a 3-month period. The time of day when the colonoscopy started and the time interval from the last dose of preparation agent to the start of the colonoscopy were recorded. The endoscopist graded the quality of the preparation in the right side of the colon by using a 5-point visual scale. PATIENTS We studied 378 patients (96% men, mean age 62.2 years) who received preparations of polyethylene glycol electrolyte-based (PEG) and sodium phosphate (SP) solution (71%), oral PEG and magnesium citrate (23%), or SP alone (6%). RESULTS Compared with patients whose preparations were graded as 2/3/4 (fair/poor/inadequate), those whose preparations were graded as 0/1 (excellent/good) had a significantly shorter interval between the time of the last preparation agent dose and the start of the colonoscopy (P = .013). LIMITATIONS We used a nonvalidated scale to assess the quality of bowel preparation. CONCLUSIONS Bowel-preparation quality varies inversely with the duration of the interval between the last dose of the bowel-preparation agent and the start of colonoscopy. This interval appears to be a better predictor of bowel-preparation quality than the time of day when colonoscopy is performed.

Acute gastritis with hypochlorhydria: report of 35 cases with long term follow up

BACKGROUND Between 1976 and 1987, 35 cases of acute gastritis with hypochlorhydria (AGH) were seen in our research laboratory. The aims of this study were to determine the natural history of AGH and the role ofHelicobacter pylori in its pathogenesis. METHODS Archived serum and gastric biopsy samples obtained from AGH subjects were examined for evidence of H pylori colonisation. Twenty eight of 33 (85%) surviving AGH subjects returned a mean of 12 years after AGH for follow up studies, including determination ofH pylori antibodies, basal and peak acid output, endoscopy, and gastric biopsies. A matched control group underwent the same studies. RESULTS Archived material provided strong evidence of new H pylori acquisition in a total of 14 subjects within two months, in 18 within four months, and in 22 within 12 months of recognition of AGH. Prevalence of H pylori colonisation at follow up was 82% (23 of 28) in AGH subjects, significantly (p<0.05) higher than in matched controls (29%). Basal and peak acid output returned to pre-AGH levels in all but two subjects. CONCLUSIONS One of several possible initial manifestations of H pylori acquisition in adults may be AGH. WhileH pylori colonisation usually persists, hypochlorhydria resolves in most subjects.

Remifentanil versus meperidine for monitored anesthesia care: A comparison study in older patients undergoing ambulatory colonoscopy

Colonoscopy is one of the most frequently performed outpatient procedures in the United States. This study was designed to test the hypothesis that a remifentanil infusion would be superior to boluses of meperidine in older patients undergoing ambulatory colonoscopy. One hundred ASA physical status I-IV patients undergoing colonoscopy were randomized in this double-blinded study to receive either remifentanil infusions (n = 49) or titrated boluses of meperidine (n = 51). Patient tolerance was assessed using physiologic variables and side effects associated with opioid analgesia. Verbal pain/anxiety and patient/operator satisfaction were also assessed. As a group, the physiologic characteristics demonstrated no significant differences in the response to the colonoscopy procedure. Although the patient and operator satisfaction surveys were similar between groups, the incidences of tachycardia, hypotension, and nausea were less and the adjusted verbal pain and anxiety scores were more in the Remifentanil group compared with the Meperidine group. This study demonstrates that remifentanil and meperidine were equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider. The differences in the pharmakinetics of remifentanil and meperidine most likely account for the differences noted between the two treatment groups. IMPLICATIONS Remifentanil infusions and meperidine boluses are equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider.

Double-blind, multicenter evaluation of lansoprazole and amoxicillin dual therapy for the cure of Helicobacter pylori infection

BackgroundTreatment with amoxicillin plus omeprazole results in disappointing cure rates of Helicobacter pylori infection. The minimal inhibitory concentration of lansoprazole for H. pylori in vitro is lower than that for omeprazole, prompting interest in treatment with amoxicillin plus lansoprazole.

Low Rate of Postpolypectomy Bleeding Among Patients Who Continue Thienopyridine Therapy During Colonoscopy

BACKGROUND & AIMS It is not clear whether the cardiovascular risk of discontinuing treatment with antiplatelet agents, specifically the thienopyridines, before elective colonoscopy outweighs the risks of postpolypectomy bleeding (PPB). We studied the rate of PPB in patients who continue thienopyridine therapy during colonoscopy. METHODS We performed a prospective study of 516 patients not taking warfarin who received polypectomies during elective colonoscopies; 219 were receiving thienopyridines, and 297 were not (controls). The occurrence of immediate PPB and delayed PPB was recorded. Delayed PPB was categorized as clinically important if it resulted in repeat colonoscopy, hospitalization, or blood transfusion. RESULTS Patients receiving thienopyridines were older and had significantly more comorbid diseases than controls; the mean number of polyps removed per patient was significantly higher (3.9 vs 2.9) in the thienopyridine group. Immediate PPB developed in 16 patients in the thienopyridine group (7.3%) and in 14 in the control group (4.7%, P = .25). Among patients who completed a 30-day follow-up analysis (96% of patients enrolled), clinically important, delayed bleeding occurred in 2.4% of patients receiving thienopyridines and in none of the controls (P = .01). All PPB events in both groups were resolved without surgery, angiography, or death. CONCLUSIONS Although a significantly higher percentage of patients who continue thienopyridine therapy during colonoscopy and polypectomy develop clinically important delayed PPB than patients who discontinue therapy, the rate of PPB events is low (2.4%), and all are resolved without sequelae. The risk for catastrophic cardiovascular risks among patients who discontinue thienopyridine therapy before elective colonoscopies could therefore exceed the risks of PPB. ClinicalTrials.gov, Number NCT01647568.

The Risk of Acute Myocardial Infarction With Etodolac Is Not Increased Compared to Naproxen : A Historical Cohort Analysis of a Generic COX-2 Selective Inhibitor

Background: This study compares the risk of acute myocardial infarction among patients exposed to etodolac, naproxen, celecoxib, and rofecoxib. Methods: A retrospective cohort study in 38 258 veteran patients (26 376 patient-years) measured the adjusted odds ratios of acute myocardial infarction during exposure to etodolac, naproxen, celecoxib, or rofecoxib. Results: Diagnosis of acute myocardial infarction was confirmed in 100 patients who were exposed to a study nonsteroidal anti-inflammatory drug. Compared to naproxen, the increased risk of acute myocardial infarction was not significant for etodolac (OR = 1.32, P = .27), whereas celecoxib (OR = 2.18, 95% CI 1.09-4.35, P = .03) and rofecoxib (OR = 2.16, 95 CI 1.04-4.46, P = .04) were significant. A post hoc analysis indicates that patients with a prior history of acute myocardial infarction had a significant, 4.26-fold risk for another acute myocardial infarction if taking celecoxib or rofecoxib. Conclusion: Etodolac is not associated with a statistically increased risk of acute myocardial infarction compared to naproxen.

Acalculous cholecystitis presenting as hemobilia and jaundice

The term hemobilia was first used by Sandblom to describe bleeding into the biliary system after a subcapsular liver injury.1 The term is now used to describe bleeding into the biliary system from any cause. The diagnosis and evaluation of hemobilia may be facilitated by the widespread availability of new imaging techniques.2 The most frequent causes are trauma, infections, tumors, inflammatory disorders, and gallstones.2-7 In a review of published reports Bismuth summarized 355 well-documented cases of hemobilia.8 Of these, 53% originated in the liver, 23% in the gallbladder, 22% in the bile ducts, and 2% in the pancreas. Of those cases in which hemobilia originated in the gallbladder, almost all were related to gallstones. Among the 30 reported cases of hemorrhagic cholecystitis, there is only one case of hemobilia due to acalculous cholecystitis.9 Cappell et al.6 reported a second case of hemobilia associated with acalculous cholecystitis, but the bleeding was thought to have been from a benign gallbladder polyp.6 We report two patients with hemobilia due to acalculous cholecystitis.

Southwestern Internal Medicine Conference: the syndrome of angina pectoris: role of visceral pain perception.

Angina pectoris is a pain syndrome caused by coronary arteriosclerosis but also by a number of other disorders, including micro-vascular angina, gastroesophageal reflux (GER), and esophageal dysmotility. The relationship between abnormal physiology and pain in these conditions is complex. Simultaneous ambulatory monitoring of esophageal pH and motility has demonstrated that patients may have identical episodes of chest pain with acid reflux, dysmotility, both types of events, or neither. Patients may have anginal chest pain with inflation of an esophageal balloon, and patients with microvascular angina may have pain with catheter manipulation in the right atrium. Recent evidence suggests that disorders of visceral pain perception may play a role in both chest pain of esophageal origin and microvascular angina. The physiology of visceral pain is reviewed, including concepts of convergence of somatic and visceral afferent input, descending modulation of pain perception, and sensitization of visceral pain afferents. An approach to evaluation and treatment of chest pain in patients with angio-graphically normal coronary arteries is outlined.