Effect of Pancrelipase Therapy on Exocrine Pancreatic Insufficiency Symptoms and Coefficient of Fat Absorption Associated With Chronic Pancreatitis

OBJECTIVE

The aim of this study was to evaluate whether improvement in coefficient of fat absorption (CFA) with pancreatic enzyme replacement therapy correlates with clinical symptoms in patients with chronic pancreatitis with moderate to severe exocrine pancreatic insufficiency.

METHODS

Data were pooled from 2 randomized double-blind trials of the effects of 1 week of pancrelipase (n = 59) versus placebo (n = 57) on CFA and stool frequency, stool consistency, abdominal pain, and flatulence; 1 trial included a 51-week open-label pancrelipase treatment period (n = 34).

RESULTS

Compared with placebo, significantly more patients receiving pancrelipase reported decreased stool frequency at week 1 (72% vs 38%; P < 0.001). Although 30% of patients receiving pancrelipase and 20% receiving placebo reported improved stool consistency, changes in stool consistency, abdominal pain, and flatulence were not different between groups. Mean CFA absolute change from baseline was significantly greater with pancrelipase versus placebo (24.7% vs 6.4%; P < 0.001). Improvements in stool consistency and frequency correlated with CFA improvement. Symptom improvements persisted or further improved through 52 weeks of treatment.

CONCLUSIONS

Pancrelipase significantly improved exocrine pancreatic insufficiency maldigestive symptoms. Improvements in objective stool symptoms with pancreatic enzyme replacement therapy correlated with CFA improvement at 1 week.

Milk Containing A2 β-Casein ONLY, as a Single Meal, Causes Fewer Symptoms of Lactose Intolerance than Milk Containing A1 and A2 β-Caseins in Subjects with Lactose Maldigestion and Intolerance: A Randomized, Double-Blind, Crossover Trial

Acute-feeding and multiple-day studies have demonstrated that milk containing A2 β-casein only causes fewer symptoms of lactose intolerance (LI) than milk containing both A1 and A2 β-caseins. We conducted a single-meal study to evaluate the gastrointestinal (GI) tolerance of milk containing different concentrations of A1 and A2 β-casein proteins. This was a randomized, double-blind, crossover trial in 25 LI subjects with maldigestion and an additional eight lactose maldigesters who did not meet the QLCSS criteria. Subjects received each of four types of milk (milk containing A2 β-casein protein only, Jersey milk, conventional milk, and lactose-free milk) after overnight fasting. Symptoms of GI intolerance and breath hydrogen concentrations were analyzed for 6 h after ingestion of each type of milk. In an analysis of the 25 LI subjects, total symptom score for abdominal pain was lower following consumption of milk containing A2 β-casein only, compared with conventional milk (p = 0.004). Post hoc analysis with lactose maldigesters revealed statistically significantly improved symptom scores (p = 0.04) and lower hydrogen production (p = 0.04) following consumption of milk containing A2 β-casein only compared with conventional milk. Consumption of milk containing A2 β-casein only is associated with fewer GI symptoms than consumption of conventional milk in lactose maldigesters.

A Dose-Escalation Study Demonstrates the Safety and Tolerability of Cellobiose in Healthy Subjects

The disaccharide and innovative ingredient cellobiose, consisting of two β-glucose molecules linked by a β(1→4) bond is the main component of cellulose. Cellobiose can be used within a wide variety of foodstuffs and functional foods as a low-caloric bulking agent or as a substitute for lactose. For purposes of industrial large-scale production, cellobiose is produced by an enzymatic reaction in which sucrose and glucose are converted to cellobiose and fructose. The goal of this single-arm, dose-escalation study was to evaluate the safety and tolerability of cellobiose and to determine the maximum tolerated dose of cellobiose in healthy subjects. Following a baseline period, consecutive cohorts of six subjects each consumed either single doses of 10, 15, 20 and 25 g, while 12 subjects each received multiple doses of 15 g or 20 g cellobiose (twice daily, 14 days). The main recorded parameters were stool consistency, gastrointestinal well-being (Gastrointestinal Symptom Rating Scale) and adverse events. In each highest single/multiple dosage group, some sensitive subjects experienced flatulence, borborygmus and/or transient diarrhoea. A 100% global tolerability rating makes 20 g cellobiose a tolerable dose for single use. For repeated consumption, we propose up to 15 g cellobiose twice daily (92.6% global tolerability rating). Cellobiose is a promising new ingredient with excellent tolerability.

Enhanced Recovery Pathway for Right and Left Colectomy: Comparison of Functional Recovery

BACKGROUND

Enhanced recovery (ERAS) guidelines do not differentiate between left- and right-sided colectomies, but differences in recovery have been reported for the two procedure types. We aimed to compare compliance with the ERAS protocol and outcomes after right versus left colectomy.

METHODS

Between June 2011 and September 2014, all patients undergoing elective colonic resection were treated according to a standardized ERAS protocol and entered a prospective database. This retrospective analysis compared right and left colectomy regarding application of the ERAS pathway, bowel recovery, complications, and hospital stay.

RESULTS

Eighty-five patients with right colectomy matched well with 138 left-sided resections for baseline demographics. Overall compliance with the ERAS protocol was 76 % for right versus 77 % for left colectomy patients (p = 0.492). First flatus occurred at postoperative day 2 in both groups (p = 0.057); first stool was observed after a median of 3 (right) and 2 days (left), respectively (p = 0.189). Twenty patients (24 %) needed postoperative nasogastric tube after right colectomy compared to 11 patients (8 %) after left colectomy (p = 0.002). Overall complication rates were 49 and 37 % for right and left colectomy, respectively (p = 0.071). Median postoperative length of stay was 6 days (IQR 4-9) after right and 5 days (IQR 4-7.5) after left colectomy (p = 0.020).

CONCLUSION

Overall compliance with the protocol was equally high in both groups showing that ERAS protocol was applicable for right and left colectomy. Functional recovery however, tended to be slower after right colectomy, and postoperative ileus rate was significantly higher. More cautious early feeding after right colectomy should be considered.

Bloating and Abdominal Distension: Old Misconceptions and Current Knowledge

Bloating, as a symptom and abdominal distension, as a sign, are both common functional-type complaints and challenging to manage effectively. Individual patients may weight differently the impact of bloating and distension on their well-being. Complaints may range from chronic highly distressing pain to simply annoying and unfashionable protrusion of the abdomen. To avoid mishaps, organic bloating, and distension should always be considered first and appropriated assessed. Functional bloating and distension often present in association with other manifestations of irritable bowel syndrome or functional dyspepsia and in that context patients tend to regard them as most troublesome. A mechanism-based management bloating and distension should be ideal but elucidating key operational mechanisms in individual patients is not always feasible. Some clues may be gathered through a detailed dietary history, by assessing bowel movement frequency and stool consistency and special imaging technique to measure abdominal shape during episodes of distension. In severe, protracted cases it may be appropriate to refer the patient to a specialized center where motility, visceral sensitivity, and abdominal muscle activity in response to intraluminal stimuli may be measured. Therapeutic resources focussed upon presumed or demonstrated pathogenetic mechanism include dietary modification, microbiome modulation, promoting gas evacuation, attenuating visceral perception, and controlling abdominal wall muscle activity via biofeedback.

Effect of Chicory-derived Inulin on Abdominal Sensations and Bowel Motor Function

GOAL

To determine the effect of a prebiotic chicory-derived inulin-type fructan on the tolerance of intestinal gas.

BACKGROUND

Subjects with gas-related complaints exhibit impaired handling of intestinal gas loads and we hypothesized that inulin would have a beneficial effect.

STUDY

Placebo-controlled, parallel, randomized, double-blind trial. Subjects with abdominal symptoms and reduced tolerance of intestinal gas (selected by a pretest) received either inulin (8 g/d, n=18) or maltodextrin as a placebo (8 g/d, n=18) for 4 weeks. A gas challenge test (4 h jejunal gas infusion at 12 mL/min while measuring abdominal symptoms and gas retention for 3 h) was performed before and at the end of the intervention phase. Gastrointestinal symptoms and bowel habits (using daily questionnaires for 1 wk) and fecal bifidobacteria counts were measured before and at the end of the intervention.

RESULTS

Inulin decreased gas retention during the gas challenge test (by 22%; P=0.035 vs. baseline), while the placebo did not, but the intergroup difference was not statistically significant (P=0.343). Inulin and placebo reduced the perception of abdominal sensations in the gas challenge test to a similar extent (by 52% and 43%, respectively). Participants reported moderate gastrointestinal symptoms and normal bowel habits during baseline examination, and these findings remained unchanged in both groups during the intervention. Inulin led to a higher relative abundance of bifidobacteria counts (P=0.01 vs. placebo).

CONCLUSIONS

A daily dose of inulin that promotes bifidobacteria growth and may improve gut function, is well tolerated by subjects with gastrointestinal complaints.

[State of homeostasis links in the children with intestinal colic]

The state of homeostasis links in the children with intestinal colic is represented by the following parameters and clinical characteristics. The data of investigated children's contingent with intestinal colic prevailed by following comorbidities: SARS--12 (18.18% ± 4.78%), protein-energy malnutrition--9 (12.85% ± 3.82%), pneumonia--6 (8.57% ± 3.57%), atopic dermatitis--7 (10.00% ±.3.57%). All children have a next complaints: flatulence (100%), in the 62 children (88.57% ± 3.82%) were identificated frequent regurgitation, in the 48 (80.33%)--hyperbilirubinemia. ALT levels were elevated in 25 children (41%) and 31 (51.66%) children had increased levels of AST. IL8 level were elevated in the 40 children (71.42%). The level of antibodies to elastase was greatly increased in all 56 (100%) children.

Resolution of acute gastroenteritis symptoms in children and adults treated with a novel polyphenol-based prebiotic

AIM: To test efficacy and durability of a polyphenol-based prebiotic treatment for acute gastroenteritis in a 300 patient double-blinded clinical study.

METHODS: A two-arm randomized, double-blinded, placebo-controlled clinical study was conducted at two public health centers in Managua, Nicaragua. Potential subjects who qualified based on inclusion and exclusion criteria were randomly assigned to one of two treatment arms. Two thirds of the subjects (n = 200) received a single titrated 0.5-2 ounce liquid dose of a novel polyphenol-based prebiotic (Aliva^TM) diluted with 2 to eight ounces of oral rehydration solution (ORS). One third of the subjects (n = 100) were randomized to receive two liquid ounces of a taste and color-matched placebo diluted in eight ounces of ORS. The outcome variables measured included stool consistency, stomach discomfort, gas and bloating, and heartburn/indigestion. The study subjects ranked their stool consistency and the severity of their subjective symptoms at specified intervals from immediately prior to treatment, to five days post treatment. All subjects recorded their symptoms in a study diary. The study subjects also recorded the time and consistencies of all stools in their study diary. Stool consistency was compared to the picture and descriptions on the Bristol Stool Chart, and any stool rated greater than Type 4 was considered unformed. The clinical study team reviewed the study diaries with subjects during daily follow-up calls and close-out visits, and recorded the data in case report forms.

RESULTS: After receiving a single dose, Aliva treated subjects reported shorter median time to their last unformed stool (1 h 50 min) than placebo treated subjects (67 h 50 min.), a statistically significant difference [95%CI: -3178-(-2018), P = 0.000]. Aliva treated subjects also reported shorter median their time to last unformed stool (TTLUS) (1hrs 50 min) than placebo treated subjects (67 h 50 min), which was also a statistically significant difference (P = 0.000).The percentage of subjects recording TTLUS was greater for those who received Aliva vs placebo at 30 min (P = 0.027), 2 h (P = 0.000), 24 h (P = 0.000), 48 h (P = 0.000), 72 h (P = 0.000), and 5 d (P = 0.000) post dose. There were 146 study subjects 14 years old or older, which was the criteria set for reliable self-reporting of subjective symptoms. Of those 146 subjects, 142 reported stomach pain and discomfort during screening. From 90 minutes [95%CI: -1.8-(-0.01), P = 0.048] through 5 d [95%CI: -3.4-(-1.9), P = 0.000), the subjects treated with Aliva experienced significantly less stomach pain and discomfort than those who received placebo. Of those same 146 participants, 114 subjects reported gas and bloating during screening. Similarly, subjects who received Aliva experienced significantly less gas and bloating from 2 h [95%CI: -1.7-(-0.39), P = 0.030] through 5 d (95%CI: -2.0-0.42, P = 0.005) compared with the placebo arm.

CONCLUSION: In this double-blind, randomized clinical study, subjects with acute gastroenteritis receiving Aliva prebiotic showed significant and sustained improvement of multiple symptoms vs those receiving placebo.

Bariatric surgery improves urinary incontinence but not anorectal function in obese women

BACKGROUND

While the association between obesity and urinary incontinence (UI) in women has been clearly documented, the relationship with anal incontinence (AI) is less well defined; moreover, while bariatric surgery has been shown to improve UI, its effect on AI is still unclear.

METHODS

A total of 32 obese women were studied by means of PFDI-20 and PFIQ-7 questionnaires and anorectal manometry before and after bariatric surgery and compared with 71 non-obese women.

RESULTS

Obese women showed worse overall questionnaire results (OR 5.18 for PFDI-20 and 2.66 for PFIQ-7). Whereas obese women showed worse results for urinary sub-items and a higher urge UI incidence (43.8 vs 18.3 %, p = 0.013), they did not show worsening in colorecto-anal symptoms. Post-operatively, median PFDI-20 total score did not change (24.2 vs 26.6, p = ns), while there was an improvement in urinary score (14.6 vs 8.3, p < 0.001); median PFIQ-7 improved (4.8 vs 0.0, p = 0.044), but while the urinary score improved (2.4 vs 0.0, p = 0.033), the colorecto-anal score did not change significantly. Although after surgery urge UI decreased from 43.8 to 15.6 % (p = 0.029), the incidence of any AI increased from 28.1 to 40.6 % (p = ns) and flatus incontinence increased from 18.8 to 37.5 % (p = ns). Anorectal manometry did not show significant changes after surgery.

CONCLUSIONS

Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.

Colonic gas transit in patients with bloating: the effect of an electromechanical stimulator of the abdominal wall

BACKGROUND

The aim of our study was to evaluate gas retention, abdominal symptoms and changes in girth circumference in females with bloating using an active or sham abdominal wall mechanical stimulation.

METHODS

In 14 female patients, complaining of bloating (11 with irritable bowel syndrome and 3 with functional bloating according to the Rome III criteria) a gas mixture was continuously infused into the colon for 1 h (accommodation period). Abdominal perception and girth were measured. At the beginning of the 30-min period of free rectal gas evacuation (clearance period), an electromechanical device was positioned on the abdominal wall of all patients. The patients were randomly assigned to an active or a sham stimulation protocol group. Gas retention, perception and abdominal distension were measured at the end of the clearance period.

RESULTS

All patients tolerated the volume (1,440 ml) of gas infused into the colon. Abdominal perception and girth measurements was similar in both groups during the accommodation period. At the end of the clearance, the perception score and the girth changes in the active and sham stimulation groups were similar (2.8 ± 2.0 vs. 1.4 ± 1.2, p = 0.2 and 4.9 ± 4.5 vs. 2.8 ± 2.3 mm, p = 0.3 active vs. sham, respectively). Furthermore, the mechanical stimulation of the abdominal wall did not significantly reduce gas retention (495 ± 101 ml vs. 566 ± 55, active vs. sham, p = 0.1).

CONCLUSIONS

An external mechanical massage of the abdominal wall did not improve intestinal gas transit, abdominal perception and abdominal distension in our female patients complaining of functional bloating.

Bloating in gastroparesis: severity, impact, and associated factors

OBJECTIVES

Bloating is commonly reported in gastroparesis, but its prevalence, impact, and associated factors are uninvestigated. We aimed to quantify the prevalence of bloating in gastroparesis and relate its severity to clinical factors and quality of life.

METHODS

Survey, examination, and scintigraphy data were compared in 335 gastroparesis patients from 6 centers of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Gastroparesis Clinical Research Consortium. Bloating severity was stratified using Gastroparesis Cardinal Symptom Index (GCSI) bloating subscale scores.

RESULTS

Bloating severity of at least mild (GCSI ≥2) and severe (GCSI ≥4) grades were reported by 76 and 41% of patients, respectively. Bloating severity related to female gender (P<0.0001) and overweight status (P=0.04) on regression analysis and correlated with intensity of nausea, postprandial fullness, visible distention, abdominal pain, and altered bowel function (P<0.05). Disease etiology, smoking status, and gastric emptying did not relate to bloating subset (P>0.05). Disease-specific quality of life and general measures of well-being were progressively impaired with increasing bloating severity (P=0.01). Probiotic use (P=0.03) and use of antidepressants with significant norepinephrine reuptake inhibitor activity (P=0.045) use related to bloating severity; antiemetic use trended higher with worsening bloating (P=0.06).

CONCLUSIONS

Bloating is prevalent in gastroparesis and is severe in many individuals. Bloating severity relates to female gender, body weight, and intensity of other symptoms. The symptom impairs quality of life but is not influenced by gastric emptying rates. Antiemetics, probiotics, and antidepressants with significant norepinephrine reuptake inhibitor activity may affect reports of bloating. These findings provide insight into this underappreciated symptom of gastroparesis.

Probiotics for the treatment of systemic sclerosis-associated gastrointestinal bloating/ distention

OBJECTIVES

Treatment for gastrointestinal tract (GIT) disease in systemic sclerosis (SSc) is challenging as no immunosuppressive or anti-fibrotic therapy is available with clearly proven efficacy. Probiotics are viable, non-pathogenic microorganisms that are hypothesized to improve the composition of the intestinal microbiota from a potentially harmful composition to a composition that is beneficial to the host. Our hypothesis is that GIT symptoms in SSc patients with moderate bloating would improve with probiotic implementation.

METHODS

Ten patients with a moderate-to-severe distention/bloating score (1.25-3.00) on the University of California Los Angeles Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 (UCLA SCTC GIT 2.0), but otherwise stable organ disease not requiring any medication adjustment were recruited from the University of Utah Scleroderma Center. We compared the GIT 2.0 scores at baseline and after 2 months of use of Align (bifidobacterium infantis; 109 CFU per capsule) or Culturelle (lactobacillus GG; 109 CFU per capsule) using paired t-test and calculated effect size (ES).

RESULTS

Significant improvement in total GIT 2.0 score (ES = 0.82), reflux (ES = 0.33), bloating/distention (ES = 1.76), and emotional scales (ES = 0.18) were reported after two months of daily probiotic use.

CONCLUSIONS

This pilot study suggests probiotics significantly improve the reflux, distention/ bloating, and total GIT scales in SSc patients. As hypothesized, the largest effect was seen in distention/bloating scale. Probiotics may be useful for treatment of SSc-associated distention/ bloating.

[Use of the prokinetic domperidine in patients in the early postoperative period]

The work focuses on the comparison of influence of domperidone and metoclopramide on rehabilitation of motor-evacuation function of stomach and small intestine in 82 patients with post-surgical flatulent distention. For group 1 (n=50) - metoclopramide was administered intravenously from the 1st postoperative day, 10 mg 3 times a day. For group 2 (n=32) - domperidone was used from the 1st postoperative day (motilium suspension), 20 ml 4 times a day. The results of gastrointestinal tract capacity rehabilitation were evaluated using the data of peripheral electrogastroenterography, enteral balance, a complex of radial diagnostics methods. Application of domperidone in patients with post-surgical flatulent distention resulted in quicker gastrointestinal tract motor resolution.

[Prevalence of delayed gastric emptying of solids in functional dyspepsia and its relationship to symptoms]

The relationship between functional dyspepsia and delayed gastric emptying of solids is still unclear. This study evaluated the prevalence of delayed gastric emptying of solids in functional dyspepsia patients and its relationship to dyspeptic symptoms.

MATERIAL AND METHOD

142 patients with functional dyspepsia were prospectively assessed, the solid gastric emptying was measured using 13C-acid octanoic breath test and the severity of six dyspeptic symptoms (postprandial fullness, early satiety, bloating, abdominal discomfort, nausea and vomiting) was scored.

RESULTS

Gastric emptying of solids was delayed in 45 (31.7%) dyspeptic patients. Multivariate analysis showed that the presence and severity of nausea and vomiting were associated with delayed solid gastric emptying (p < 0.05). Female gender was also associated with the risk of delayed gastric emptying (p < 0.05).

CONCLUSIONS

A subset of functional dyspepsia patients has delayed gastric emptying of solids. Female sex, the presence and severity of nausea and vomiting are independently associated with delayed gastric emptying of solids in these patients.

[Gastrointestinal syndromes (3): flatulence (1)]

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

[Meteospazmil for correction of motor disorders in functional colon diseases]

This article describes meteospazmil clinical effectiveness in problem of abdominal pain syndrome and flatulence reduction at IBS and gastrointestinal diseases that are attended with secondary colon motor disorders.

[Flatufonia--or the musical anus]

The art of the musical anus is reviewed in the light of its most prominent performers and of anorectal physiological aspects related to this specific musical performance.

Jerusalem artichoke and chicory inulin in bakery products affect faecal microbiota of healthy volunteers

A study was conducted to test the effects of Jerusalem artichoke inulin (JA) or chicory inulin (CH) in snack bars on composition of faecal microbiota, concentration of faecal SCFA, bowel habit and gastrointestinal symptoms. Forty-five volunteers participated in a double-blind, randomized, placebo-controlled, parallel-group study. At the end of a 7 d run-in period, subjects were randomly assigned to three groups of fifteen subjects each, consuming either snack bars with CH or JA, or snack bars without fructans (placebo); for 7 d (adaptation period), they ingested one snack bar per day (7.7 g fructan/d) and continued for 14 d with two snack bars per day. The composition of the microbiota was monitored weekly. The consumption of CH or JA increased counts of bifidobacteria (+1.2 log10 in 21 d) and reduced Bacteroides/Prevotella in number and the Clostridium histolyticum/C. lituseburense group in frequency at the end of intervention (P < 0.05). No changes in concentration of faecal SCFA were observed. Consumption of snack bars resulted in a slight increase in stool frequency. Stool consistency was slightly affected in subjects consuming two snack bars containing CH or JA per day (P < 0.05). Consumption of CH or JA resulted in mild and sometimes moderate flatulence in a few subjects compared to placebo (P < 0.05). No structural differences were detected between CH and JA before and after processing. In conclusion, adaptation on increased doses of CH or JA in bakery products stimulates the growth of bifidobacteria and may contribute to the suppression of potential pathogenic bacteria.

Impaired intestinal gas clearance during marked hyperglycemia in patients with functional abdominal bloating

BACKGROUND

Especially in patients with functional intestinal disorders, impaired intestinal gas transit can be involved in abdominal symptom generation. We have previously demonstrated an acceleration of intestinal gas clearance in health during acute fasting hyperglycemia and hypothesize that in patients with functional abdominal bloating this mechanism may fail.

METHODS

In 14 healthy subjects and 14 patients with functional abdominal bloating we compared effects of acute fasting hyperglycemia (approximately 12 mmol/l) and during euglycemia (control studies) on intestinal gas dynamics. Gas was infused into the jejunum (12 ml/min) for 120 min while rectal gas evacuation was continuously measured; perception and abdominal girth changes were separately evaluated.

RESULTS

Marked hyperglycemia accelerated gas evacuation (-98 (53) ml 1 h intestinal gas retention) in health. In patients with functional abdominal bloating, marked hyperglycemia failed to accelerate gas transit and intestinal gas retention developed (421 (116) ml 1 h intestinal gas retention, p < 0.05 vs. health) which results in increased abdominal symptoms (perception score >3) and abdominal distension (>3 mm girth increment) as compared with control subjects (p < 0.05 for both).

CONCLUSION

Intestinal gas clearance is delayed in patients with functional abdominal bloating and the increase in gas clearance during acute hyperglycemia in healthy volunteers does not occur in these patients.

Clinical study on application of Chinese herbs during the perioperative period of laparoscopic cholecystectomy

OBJECTIVE

To explore the effect of Chinese herbs during the perioperative period of laparoscopic cholecystectomy (LC).

METHODS

Three hundred and sixty patients of chronic lithic cholecystitis (LCCT) were randomly assigned to two groups by lottery, 180 patients in each group. During the peri-operative period, the control group was treated with conventional Western medicine and placebo. The treated group was given the same conventional Western medicine and Chinese herbal decoctions, with Shitong mixture No. 1 added before LC, and Liujunzi decoction added after LC for three days. The operation time, body temperature after LC, white blood cell count, wind-breaking time after operation, as well as the changes of tongue coating in the first three post-operative days were recorded.

RESULTS

There was no significant difference between the two groups in operation time (P>0.05), while the improvement in body temperature recovery, wind-breaking time and changes of tongue coating in the treated group were better than those in the control group (P<0.01).

CONCLUSION

Applying Chinese herbs during perioperative period of LC could effectively benefit early recovery in such patients.

Functional results after radiochemotherapy and total mesorectal excision for rectal cancer

BACKGROUND AND PURPOSE

The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year after surgery.

MATERIALS AND METHODS

We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan-Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis.

RESULTS

Median evacuation score was 16.12 +/- 5.12 (range 0-28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 +/- 4.79 (range 0-20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan-Kettering score.

CONCLUSIONS

The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.

Irritable bowel syndrome and bloating

Gaseous symptoms in irritable bowel syndrome (IBS) including eructation, flatulence, and bloating occur as a consequence of excess gas production, altered gas transit, abnormal perception of normal amounts of gas within the gastrointestinal tract, or dysfunctional somatic muscle activity in the abdominal wall. Because of the prominence of gaseous complaints in IBS, recent investigations have focussed on new insights into pathogenesis and novel therapies of bloating. The evaluation of the IBS patient with unexplained gas and bloating relies on careful exclusion of organic disease with further characterisation of the underlying condition with directed functional testing. Treatment of gaseous symptomatology in IBS should be targeted to pathophysiologic defects whenever possible. Available therapies include lifestyle alterations, dietary modifications, enzyme preparations, adsorbents and agents which reduce surface tension, treatments that alter gut flora, and drugs that modulate gut transit.

Prophylactic nasogastric decompression after abdominal surgery

BACKGROUND

Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.

OBJECTIVES

To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

SEARCH STRATEGY

Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (Central), and references of included studies, from 1966 through 2006.

SELECTION CRITERIA

Patients having abdominal operations of any type, emergency or elective, who were randomised prior tot he completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.

DATA COLLECTION AND ANALYSIS

Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, subsequent ventral hernia.

MAIN RESULTS

33 studies fulfilled eligibility criteria, encompassing 5240 patients, 2628 randomised to routine tube use, and 2612 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), a decrease in pulmonary complications (p=0.01) and an insignificant trend toward increase in risk of wound infection (p=0.22) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Vomiting seemed to favour routine tube use, but with increased patient discomfort. Length of stay was shorter when no tube was used but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for this outcome. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.

AUTHORS' CONCLUSIONS

Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.

Intestinal gas in plain abdominal radiographs does not correlate with symptoms after lactulose challenge

OBSERVATION

Intestinal gas production and abdominal discomfort can be triggered by the ingestion of carbohydrates such as lactulose. Using plain abdominal radiographs, we studied whether subjective complaints after a lactulose breath test would be quantitatively related to intestinal gas volumes.

METHODS

Abdominal symptoms after the breath test were quantified by a written questionnaire and gas volumes were scored in plain abdominal radiographs, in 50 consecutive patients with unexplained, irritable bowel syndrome-like symptoms. Breath excretion of hydrogen and methane was determined in all patients.

RESULTS

Forty-two (84%) of the patients claimed that their post-breath test symptoms were a true replicate of their customary discomfort. Total symptom scores (sum of scores for pain/discomfort, borborygmi, bloating, diarrhea, constipation) or any specific symptom score were not significantly correlated to gas volume scores (r=-0.04; P=0.8 for total symptom score). The 13 (26%) methane producers had significantly higher mean gas volume scores compared with nonproducers (0.38 vs. 0.24; P=0.0008), but fewer symptoms (total symptom score 11.9 vs. 18.2; P=0.17).

CONCLUSION

Intestinal gas volume, as scored in plain abdominal radiographs, is not correlated with abdominal discomfort after lactulose challenge. Intestinal gas may not be the major cause of abdominal discomfort following carbohydrate ingestion in patients with functional gut disorders.

The risk of anal incontinence in obese women

The objectives of this study was to estimate the risk of anal incontinence in morbidly obese women and to identify risk factors associated with anal incontinence in an obese population sample. A case-control study based on the registry of a university hospital obesity unit. A consecutive sample of women with body mass index > or = 35 (obesity class II) was randomly matched by age, gender and residential county to control subjects using the computerised Register of the Total Population. Data were collected by a self-reported postal survey including detailed questions on medical and obstetrical history, obesity history, socioeconomic indices, life style factors and the validated Cleveland Clinic Incontinence Score. The questionnaire was returned by 131/179 (73%) of the cases and 453/892 (51%) of the control subjects. Compared to the control group, obese women reported a significantly increased defecation frequency (p < 0.001), inability to discriminate between flatus and faeces (p < 0.001) and flatus incontinence (p < 0.001). Compared with non-obese women, the adjusted odds ratio (OR) for flatus incontinence in morbidly obese women was 1.5 [95% confidence interval (CI) 1.1-4.1]. A history of obstetric sphincter injury was independently associated with an increased risk of flatus incontinence (OR, 4.3; 95% CI, 2.0-9.2) and incontinence of loose stools (OR, 6.6; 95% CI, 1.4-31.4). Other medical and life style interactions did not remain at significant levels in an adjusted multivariable analysis. Obese women are at increased risk for mild to moderate flatus incontinence.

Physical activity and intestinal gas clearance in patients with bloating

BACKGROUND

Patients complaining of abdominal bloating have impaired tolerance and clearance of intestinal gas loads. Mild exercise enhances intestinal clearance and prevents retention of intestinal gas loads in healthy subjects. Our aim was to evaluate the putative beneficial effects of physical activity in patients with abdominal bloating.

METHODS

In eight patients complaining of bloating, seven with irritable bowel syndrome, and one with functional bloating, according to Rome II criteria, a gas mixture was continuously infused (12 mL/min) into the jejunum for 120 min with simultaneous duodenal lipid perfusion (1 kcal/min). Gas evacuation, perception (0-6 scale), and abdominal girth were measured at 15-min intervals. Paired studies were randomly performed in the supine position during intermittent pedaling (5 min with 3-min rest intervals at 40 rpm and 0.15 kp load) versus rest (as control).

RESULTS

During rest, a significant proportion of the gas infused was retained in the gut (45 +/- 9%, P < 0.01 vs basal), but retention was significantly lower during exercise (24 +/- 7%, P < 0.05 vs rest). Gas retention during rest was associated with significant abdominal symptoms (3.6 score; P < 0.01 vs basal), and symptoms also improved during exercise (2.8 score, P < 0.05 vs rest). During the test, patients developed abdominal distension, which was related to the volume of gas retained (r = 0.68, P < 0.05).

CONCLUSION

Mild physical activity enhances intestinal gas clearance and reduces symptoms in patients complaining of abdominal bloating.

Role of colonic fermentation in the perception of colonic distention in irritable bowel syndrome and functional bloating

BACKGROUND & AIMS

Bloating represents a frequent gastrointestinal symptom, but the pathophysiologic mechanism responsible for its onset is still largely unknown. Patients very frequently attribute the sensation of bloating to the presence of excessive bowel gas, but not all patients with gas-related symptoms exhibit increased intestinal production of gas. It is therefore possible that other still unrecognized mechanisms might contribute to its pathophysiology. Our aim was to evaluate whether a subgroup of patients affected by functional abdominal bloating presents hypersensitivity to colonic fermentation.

METHODS

Sixty patients affected by functional gastrointestinal disorders (11 functional bloating, 36 constipation-predominant, and 13 diarrhea-predominant irritable bowel syndrome) and moderate to severe bloating took part in the study. Twenty sex- and age-matched healthy volunteers were enrolled as a control group. All the subjects underwent a preliminary evaluation of breath hydrogen excretion after oral lactulose. Then, on a separate day, an evaluation of sensitivity thresholds at rectal level was performed with a barostat before and after the induction of colonic fermentation with oral lactulose. A control test with electrolyte solution was also performed.

RESULTS

Both breath hydrogen excretion and mouth-to-cecum transit time did not differ between the 4 groups studied. Neither electrolyte solution nor lactulose modified sensitivity thresholds in healthy volunteers. In low hydrogen producers, basal perception and discomfort thresholds were similar to high hydrogen producers, but after lactulose both perception and discomfort thresholds were significantly reduced only in low hydrogen producers.

CONCLUSIONS

A subgroup of patients with functional gastrointestinal disorders and moderate to severe bloating might have hypersensitivity to products of colonic fermentation.

Relationship of abdominal bloating to distention in irritable bowel syndrome and effect of bowel habit

BACKGROUND & AIMS

The relationship between the sensation of bloating, often ranked as the most bothersome symptom by patients with irritable bowel syndrome (IBS), and actual distention manifest as an increase in abdominal girth is controversial. Investigation of this problem has been hampered by the lack of a reliable ambulatory technique to measure abdominal girth. The aim of this study was to use the technique of abdominal inductance plethysmography to compare diurnal variation in girth in IBS patients and healthy volunteers, relating these changes to the sensation of bloating.

METHODS

Abdominal girth was recorded for 24 hours in 20 IBS-constipation (age, 18-73 y), 20 IBS-diarrhea (age, 25-62 y) and 10 IBS-alternating (age, 21-59 y) female patients meeting Rome II criteria and 20 healthy female controls (age, 18-67 y). All subjects pursued normal daily activities, recording their symptoms of bloating and pain together with bowel habit.

RESULTS

All patients with IBS, irrespective of bowel habit, reported significantly greater bloating than controls (P < .0001). Forty-eight percent of patients also showed distention beyond the 90% control range, with this being most prominent in IBS-constipation. Bloating correlated strongly only with distention in IBS-constipation (r > or = 0.48; P < or = .02). Neither bloating nor distention in IBS was related to body mass index, age, parity, or psychologic status.

CONCLUSIONS

Abdominal distention is a clearly definable phenomenon in IBS that can reach 12 cm. However, it only occurs in half of patients reporting bloating, and the 2 only correlate in IBS-constipation. Bloating and distention may differ pathophysiologically and this appears to be reflected in the bowel habit subtype.

Can a meta-analysis answer the question: is mucosectomy and handsewn or double-stapled anastomosis better in ileal pouch-anal anastomosis?

Although ileal pouch-anal anastomosis (IPAA) is the procedure of choice for polyposis and ulcerative colitis with medically refractory disease or dysplasia, controversy exists concerning whether mucosal preservation with double-stapled (DS) IPAA is superior to mucosectomy and handsewn (HS) IPAA anastomosis for postoperative function. Prospective studies have shown no statistically significant differences. The use of meta-analysis can strengthen statistical power by combining the data from related studies. A meta-analysis was performed to determine whether there was a significant difference in functional and manometric outcome between HS-IPAA and DS-IPAA. Prospective, randomized studies were identified using a literature search. Functional outcome variables included number of normal continence, minor incontinence, nocturnal evacuation, the ability to discriminate flatus from stool, and antidiarrheal medication. Manometric outcomes included postoperative resting and squeeze anal pressures. Four prospective, randomized trials were identified. Of the 184 total patients, the HS-IPAA group included 86 patients (48 men and 38 women) and the DS-IPAA group included 98 patients (49 men and 49 women). There were no significant differences in functional outcome between HS-IPAA and DS-IPAA. In addition, there was no significant difference in sphincter resting and squeeze pressures between the two patient groups. This meta-analysis demonstrates that DS-IPAA offers no advantage in functional or manometric outcome when compared with HS-IPAA.

Nutrient modulation of intestinal gas dynamics in healthy humans: dependence on caloric content and meal consistency

The actions of nutrients on gut transit of liquids and solids have been extensively studied, but the effects of meal ingestion on intestinal gas flow are unexplored. We hypothesized that meals of varying caloric content and consistency modulate gas transit to different degrees. Nine healthy volunteers underwent jejunal perfusion of physiological gas mixtures at 12 ml.min(-1).3 h, with ingestion of nothing (control), water (240 ml), 240-kcal liquid meals, and 240-kcal solid meals at the end of the second hour in separate studies. Gas was quantified from an intrarectal catheter. After an initial lag phase, gas evacuation approached steady state by the end of the fasting period. Solid and liquid caloric meals increased total gas volumes evacuated from 5-40 min after ingestion vs. control studies (P < 0.05). These increases resulted from increased numbers of bolus gas evacuations (P < 0.05), whereas bolus volumes, pressures, and flow rates were similar for all test conditions. Solid and liquid caloric meals elicited similar effects on bolus gas dynamic parameters, whereas water did not affect these measures vs. control (NS, not significant). Both caloric meals and the noncaloric liquid meal increased continuous gas flow, which represented <2% of total gas expulsion. In conclusion, caloric meals promote bolus gas transit in healthy humans, whereas noncaloric liquids have no effect. Solids stimulate early postprandial gas dynamics to the same extent as liquid meals of similar caloric content. Thus modulatory effects of meals on intestinal gas transit depend on their caloric content but not their consistency.

Flaturia: passage of flatus at coitus. Incidence and pathogenesis

BACKGROUND/AIM

We present 18 women who under normal conditions had fecal and flatus control. They leaked flatus only during coitus. We investigated the hypothesis that these women had a concealed anal sphincteric disorder.

METHODS

Eighteen multiparous women (mean age 44.8+/-7.2 SD years) complained of involuntary passage of flatus during coitus of 4.6+/-2.4 years duration. Mean deliveries amounted to 8.2+/-2.1, of which 5.2+/-1.1 were by forceps. Patients had neither fecal nor flatus incontinence except during coitus. Nine healthy volunteers matching patients in age and number of deliveries but without coital passage of flatus were included in the study. Monitoring comprised anorectal pressure studies and external and internal anal sphincter (EAS, IAS) electromyography (EMG). Plain X-ray and barium enema studies were done to detect stools in the rectum.

RESULTS

The rectal and anal pressures at rest and on voluntary squeeze of the patients matched those of the healthy volunteers. The recto-anal inhibitory reflex (RAIR) in the patients was abnormal; it recorded on rectal contraction a significantly lower anal pressure than that of the healthy volunteers; also, the rectal contraction occurred at a volume lower than with the volunteers. The EAS EMG of patients was normal, while their IAS EMG recorded a significantly lower activity at rest and on rectal distension than those of volunteers. Stools were detected at rest in the rectum of all patients and in only two of the volunteers.

CONCLUSIONS

The distal end of the erect penis seems to buffet the lower rectum at coitus. In patients, the abnormal RAIR, the diminished IAS EMG as well as the presence of stools in the rectum at rest appear to be responsible for passage of flatus at coitus.

Impaired small bowel gas propulsion in patients with bloating during intestinal lipid infusion

OBJECTIVE

In healthy individuals, intraluminal lipids delay intestinal gas clearance, and this reflex is exaggerated in patients with irritable bowel syndrome (IBS). Our aim was to determine the site of action of abnormal lipid-induced reflexes in IBS.

METHODS

In six patients with (IBS) predominantly complaining of bloating and in six healthy subjects, a mixture of gas (N2, O2, and CO2 in venous proportions to minimize diffusion) was infused (12 mL/min) either into the jejunum or into the ileum for 2 h, with simultaneous perfusion of lipids (0.5 kcal/min) into the proximal duodenum. Rectal gas evacuation was measured by a barostat. Abdominal perception (by a 0-6 scale) and girth changes were measured at 15-min intervals. The effects of jejunal versus ileal gas infusion were compared by paired tests in random order on separate days.

RESULTS

IBS patients exhibited significant gas retention during infusion of gas into the jejunum (398 +/- 90 mL vs-210 +/- 105 mL in health, p < 0.05) but not during ileal infusion (-79 +/- 87 mL vs-79 +/- 78 mL in health, NS; p < 0.05 vs jejunal infusion). Gas retention during jejunal gas infusion in IBS patients was associated with significant abdominal distension (11 +/- 3 mm girth increment vs 0 +/- 1 mm during ileal gas infusion and 1 +/- 1 mm in health, p < 0.05 for both) and abdominal symptoms (3.6 +/- 0.6 score vs 2.6 +/- 0.7 score during ileal gas infusion and 1.6 +/- 0.5 score in health, p < 0.05 for both).

CONCLUSIONS

In IBS patients intraluminal lipids impair intestinal gas clearance because of upregulated reflex inhibition of small bowel transit, without appreciable colonic effects.

Functional findings in irritable bowel syndrome

The pathophysiology of IBS is complex and still incompletely known. Both central and peripheral factors, including psychosocial factors, abnormal GI motility and secretion, and visceral hypersensitivity, are thought to contribute to the symptoms of IBS. Several studies have demonstrated altered GI motor function in IBS patients and the pattern differs between IBS subgroups based on the predominant bowel pattern. Few studies have so far addressed GI secretion in IBS, but there are some evidence supporting altered secretion in the small intestine of IBS patients. Visceral hypersensitivity is currently considered to be perhaps the most important pathophysiological factor in IBS. Importantly, several external and internal factors can modulate visceral sensitivity, as well as GI motility, and enhanced responsiveness within the GI tract to for instance stress and nutrients has been demonstrated in IBS patients. Today IBS is viewed upon as a disorder of dysregulation of the so-called brain-gut axis, involving abnormal function in the enteric, autonomic and/or central nervous systems, with peripheral alterations probably dominating in some patients and disturbed central processing of signals from the periphery in others.

Influence of intraoperative and postoperative radiotherapy on functional outcome in patients undergoing standard and deep anterior resection for rectal cancer

PURPOSE

This study was designed to investigate the influence of intraoperative and postoperative radiotherapy on functional outcome after rectal resection for rectal cancer.

METHODS

One hundred patients who underwent deep or standard anterior resection for rectal cancer were included in this follow-up study. All patients filled out questionnaires regarding morbidity and functional outcome; a subgroup (n = 63) underwent further clinical evaluation. The results were stratified according to radiation: Group I, no radiation (n = 37); Group II, only intraoperative radiation (n = 12); Group III, intraoperative and postoperative radiation (n = 51).

RESULTS

Anal continence measured by Kirwan-Parks classification and Wexner score was significantly different within the three groups (P < 0.005, P < 0.0001), whereas continence impairment was least in Group I and greatest in Group III. Patients in Group III demonstrated a significantly worsecategory in the Kirwan-Parks classification and worse Wexner scores compared with patients in Group I (P < 0.0001). Patients only having undergone intraoperative radiotherapy had a significantly worse continence (Kirwan-Parks classification) than patients without any radiotherapy (P < 0.05). More patients after intraoperative and postoperative radiation therapy complained of fragmented stools (P < 0.05) and urgency (P < 0.05) compared with patients only having undergone surgery; the need to wear pads was higher (P = 0.001). Vector volume manometry revealed better resting sphincter function in Group I compared with Group III (P < or = 0.005).

CONCLUSIONS

Patients with anterior resection for rectal cancer who undergo full-dose radiotherapy have significantly more impairment of anorectal function than patients without radiotherapy. Patients who were only exposed to intraoperative radiotherapy showed moderate impairment of continence function, suggesting that the influence of radiotherapy on anal function may be dose-dependent and application-dependent.

Impaired viscerosomatic reflexes and abdominal-wall dystony associated with bloating

BACKGROUND & AIMS

Abdominal bloating is a frequent complaint in irritable bowel syndrome (IBS), but its underlying mechanism remains uncertain. Our aim was to determine whether the abdominal wall, specifically its adaptation to intra-abdominal volumes, plays a role.

METHODS

In 12 patients complaining of abdominal bloating (8 IBS and 4 functional bloating) and in 12 healthy controls, the effect of colonic gas load (24 mL/min rectal gas infusion for 1 hour) on perception (measured by a 0-6 scale), abdominal girth, and muscular activity was tested. With the participants sitting on an ergonomic chair and the trunk erect, multichannel electromyography was measured via bipolar surface electrodes located over the upper and lower rectus abdominis, and the external and internal oblique bilaterally.

RESULTS

In healthy controls, colonic gas loads produced subjective symptoms (score, 3.0 +/- 0.3), objective abdominal distention (girth increment, 6 +/- 1 mm), and increased the activity of the abdominal muscles (external oblique activity, 11% +/- 3% in; P < .05 vs basal). At the same infused gas volumes, the patients developed significantly more symptoms (score, 4.5 +/- 0.4) and abdominal distention (11 +/- 1 mm; P < .05 vs healthy for both). These abnormal responses were associated with failed tonic contraction of the abdominal wall (external oblique activity change, -1% +/- 4%; P value not significant vs basal) and paradoxic relaxation of the internal oblique (activity reduction, 26% +/- 7%; P < .01 vs basal).

CONCLUSIONS

In patients with bloating, abdominal perception and distention in response to intra-abdominal volume increments are exaggerated markedly and associated with muscular dystony of the abdominal wall.

Duodenal infusion of different nutrients and the site of gaseous stimulation influence intestinal gas dynamics

OBJECTIVE

Excessive intestinal gas can be involved in postprandial abdominal symptom generation, but whether the small bowel influences intestinal gas dynamics, depending on the ingested meal, remains to be demonstrated. We compare the intestinal response to a proximal and distal small intestinal gas challenge during different duodenal nutrient components.

MATERIAL AND METHODS

We randomly studied 32 healthy subjects, twice, on different days with a gas mixture infused at 12 ml/min either directly into the proximal jejunum or into the ileum; during duodenal lipids, amino acids, glucose, at 1 kcal/min each, or saline (n=8 for each group). Gas evacuation was monitored continuously and abdominal perception and girth changes were assessed.

RESULTS

In response to the jejunal gas challenge, duodenal lipids delayed intestinal gas clearance more potently than amino acids (733+/-26 ml and 541+/-108 ml final gas retention; p<0.001), but when gas was directly infused into the ileum the retained volumes were much smaller (271+/-78 ml and 96+/-51 ml; p<0.001). During duodenal glucose, intestinal gas clearance following jejunal or ileal gas infusion was not significantly influenced. Abdominal perception in response to the jejunal and ileal gas challenge only increased slightly during duodenal lipids (2.0+/-0.3 score and 2.3+/-0.6 score; p<0.05 versus control).

CONCLUSION

Postprandial intestinal gas clearance is hampered by duodenal lipids and amino acids but not by glucose. Specific inhibitory effects are more pronounced when gas is infused into the jejunum, which underlines the importance of the small intestine in postprandial gas retention.

In vivo measurement of flatulence and nutrient digestibility in dogs fed poultry by-product meal, conventional soybean meal, and low-oligosaccharide low-phytate soybean meal

OBJECTIVE

To determine an optimal window for determining peak flatulence and evaluate the effects of oligosaccharides and supplemental beta-mannanase in soybean meal-based diets on nutrient availability and flatulence.

ANIMALS

6 dogs.

PROCEDURES

Dogs were used in a 2 x 3 factorial arrangement of treatments in a 6 x 6 Latin square experiment to evaluate the digestibility, flatulence, and fecal odor metabolites of low-oligosaccharide low-phytate soybean meal (LLM), conventional soybean meal (SBM), and poultry by-product (PBP) meal diets with or without supplemental beta-mannanase (5 g/kg).

RESULTS

Enzyme supplementation had no effect on total tract dry matter (DM), nitrogen digestibility, or digestible energy; however, differences between protein sources did exist for total tract DM digestibility and digestible energy. The PBP meal had higher DM digestibility and digestible energy (mean, 0.913 and 4,255 cal/g), compared with soy-based diets (mean, 0.870 and 4,049 cal/g). No differences were detected for any treatment regardless of protein source or addition of supplemental enzyme for any flatulence components analyzed. No differences were detected for all fecal odor metabolites regardless of addition of supplemental enzyme; however, differences between protein sources were detected. The PBP meal had lower concentrations of carboxylic acids and esters and higher concentrations of heterocycles, phenols, thio and sulfides, ketones, alcohols, and indoles than LLM and SBM.

CONCLUSIONS AND CLINICAL RELEVANCE

Diets containing < 22.4 g of stachyose/kg and < 2 g of raffinose/kg did not alter digestibility or increase flatulence in dogs.

New insights into the pathophysiology of irritable bowel syndrome: implications for future treatments

Irritable bowel syndrome (IBS) is a multifactorial disorder characterized by abdominal pain and altered bowel habits. Chronic symptoms may occur due to changes in gastrointestinal motor function, enhanced perception of gut stimuli, and psychosocial factors. Recent data suggest that abnormal processing of afferent signals occurs in IBS patients. A newly recognized causative factor in a subset of IBS patients is post-infectious IBS. Altered transport of intestinal gas and bowel distention may contribute to abdominal discomfort, pain, and bloating. Changes in gut microflora have also been reported, but data remain scant. Advances have been made in our understanding of serotonin signaling and metabolism in IBS patients, in part due to the introduction of specific receptor agonists and antagonists. Finally, exciting data are emerging on genetic alterations that may contribute to the pathophysiology and treatment of IBS. Increasingly novel mechanisms are being identified that should aid in better understanding of the complex pathophysiology of IBS and developing new therapies.

Pelvic floor dysfunction after Burch colposuspension - a comprehensive study. Part II

OBJECTIVE

To evaluate the prevalence of pelvic floor dysfunction (PFD) concerning bowel function at long-term follow-up after Burch colposuspension (Bc) in relation to the bowel function in an age-matched sample of women in the general population.

METHODS AND MATERIAL

This is a follow-up study of a cohort of 190 patients who underwent Bc in 1980-1988 and 305 age-matched control women without urinary anti-incontinence surgery, randomly selected from the general population. The participants answered a postal questionnaire with detailed questions about the pelvic floor function in 1998. Univariate and multivariate analyses were performed.

RESULTS

The patients showed considerable signs of bowel dysfunction compared with the general population in the following aspects: they used the fingers to help emptying the bowel [odds ratio (OR) 3.25 (1.35-7.86)]; had feeling of incomplete emptying of the bowel [OR 2.29 (1.11-4.73)]; felt no warning before passing a motion [OR 3.04 (1.20-7.71)]; had gas incontinence [OR 1.98 (1.17-3.37); had loose stool incontinence [OR 3.67 (1.43-9.42)]; used protection against fecal leakage during daytime [OR 3.22 (1.30-7.95)]; and experienced that the bowel function affected the general well-being adversely [OR 2.15 (1.30-3.56)].

CONCLUSION

The patients who have undergone colposuspension for stress urinary incontinence have more symptoms of PFD concerning the bowel function than women without urinary anti-incontinence surgery in the general population. This affects the general well-being. A comprehensive concept of multidisciplinary assessment and treatment of PFD should be encouraged.

Intestinal gas dynamics: mechanisms and clinical relevance

Patients with functional gut disorders, irritable bowel disease, and related syndromes frequently attribute their symptoms to intestinal gas. While patients are usually convinced of their interpretation, the doctor has few arguments to confirm or refute it, and in this context intestinal gas has become a myth. Studies of intestinal gas dynamics have demonstrated subtle dysfunctions in intestinal motility. Hopefully, extension of these studies may help both in the classification of patients complaining of gas symptoms based on pathophysiological mechanisms, and in identification of objective markers to test mechanistically oriented treatment options.

The pathogenesis of bloating and visible distension in irritable bowel syndrome

Abdominal bloating is a relevant, troublesome, and poorly understood clinical problem. Despite its clinical importance, bloating remains substantially ignored, without proper clinical classification, known pathophysiology, and effective treatment. It is not even clear to what extent the complaints of individual patients correlate with objective evidence of abdominal distension, and this uncertainly regarding the subjective or objective origin of the complaints further adds to confusion. This article proposed a framework for investigating bloating, considering key factors potentially involved in its pathophysiology: distorted sensation, physical abdominal expansion, and abdominal wall dystony. Some data indicate that patients complaining of bloating have impaired transit and tolerance of intestinal gas loads. The problem does not seem to be too much gas,however, but rather abnormal responses to gas. Furthermore, abnormal control of abdominal muscle activity in these patients may contribute to objective distension. Bloating, like many other abdominal symptoms,probably represents a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients,resulting in a polymorphic clinical presentation.

Origin of gas retention and symptoms in patients with bloating

BACKGROUND & AIMS

Patients reporting abdominal bloating exhibit impaired tolerance to intestinal gas loads. The aim of this study was to identify the gut compartment responsible for gas retention.

METHODS

In 30 patients predominantly reporting abdominal bloating (24 with irritable bowel syndrome and 6 with functional bloating) and 22 healthy subjects, gas (nitrogen, carbon dioxide, and oxygen) was infused into the intestine for 2 hours while measuring rectal gas outflow. First, in 12 patients and 10 healthy subjects, gas transit (24 mL/min jejunal infusion labeled with 74 MBq bolus of 133 Xe) was measured by scintigraphy. Second, in groups of patients and healthy subjects, the effects of gas infusion (12 mL/min) in the jejunum versus ileum, jejunum versus cecum, and jejunum versus sham infusion (n=6 each) were compared by paired tests.

RESULTS

In patients, total gut transit of gas was delayed (50% clearance time, 33 +/- 4 min vs 23 +/- 4 min in healthy subjects; P <.05) owing to impaired small bowel transit (50% clearance time, 20 +/- 2 min vs 12 +/- 3 min in healthy subjects; P <.05), whereas colonic transit was normal (50% clearance time, 13 +/- 2 min vs 11 +/- 2 min in healthy subjects; not significant). Furthermore, jejunal gas infusion in patients was associated with gas retention (329 +/- 81 mL vs 88 +/- 79 mL in healthy subjects; P <.05), whereas direct ileal or colonic infusion was not (61 +/- 103 mL and -143 +/- 87 mL retention, respectively).

CONCLUSIONS

In patients reporting bloating, the small bowel is the gut region responsible for ineffective gas propulsion.

Impaired reflex control of intestinal gas transit in patients with abdominal bloating

BACKGROUND

Patients with abdominal bloating and distension exhibit impaired transit of intestinal gas which may lead to excessive gas retention and symptoms. Furthermore, we have previously shown that intestinal gas transit is normally accelerated by rectal distension. We hypothesise that in patients with functional bloating this modulatory mechanism fails and impairs gas transit.

METHODS

In 12 healthy subjects and eight patients with abdominal bloating we compared, by paired studies, the effect of rectal versus sham distension on intestinal gas transit. Gas was infused into the jejunum (12 ml/min) for three hours with simultaneous perfusion of lipids into the duodenum (Intralipid 1 kcal/min) while measuring evacuation of gas per rectum.

RESULTS

In healthy subjects, duodenal lipid infusion produced gas retention (409 (68) ml) which was prevented by rectal distension (90 (90) ml; p<0.05 v sham distension). In contrast, rectal distension in patients with abdominal bloating failed to reduce lipid induced gas retention (771 (217) ml retention during rectal distension v 730 (183) ml during sham distension; NS; p<0.05 v healthy controls for both).

CONCLUSION

Failure of distension related reflexes impairs intestinal gas propulsion and clearance in patients with abdominal bloating.

Obstetric anal sphincter injury ten years after: subjective and objective long term effects

OBJECTIVE

To establish the long term effects of obstetric anal sphincter rupture.

DESIGN

Prospective observational study.

SETTING

University hospital in Sweden.

POPULATION

Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear.

METHODS

Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement.

MAIN OUTCOME MEASURES

Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG.

RESULTS

Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P= 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P= 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P= 0.04).

CONCLUSIONS

Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.