Analysis of the operative factors related to anal exhaust time after laparoscopic surgery for benign gynecological diseases

PURPOSE

The study seeks to determine surgical factors related to anal exhaust in patients treated with laparoscopic surgery for benign gynecological diseases and to explore measures that effectively promote the rapid recovery of intestinal function in these patients.

METHODS

From June 2017 to August 2018, 155 patients with benign gynecological diseases who underwent laparoscopic surgery in our hospital were selected as study subjects. Patients were divided into two groups based on anal exhaust time: the ≤ 24-hour group and > 24-hour group. Factors related to the operation were statistically analyzed for all patients. Chi-squared tests and logistic regression were used for univariate and multivariable analyses.

RESULTS

Of 155 gynecological patients, 57 (36.8%) underwent laparoscopic ovarian cyst stripping, 48 (30.9%) underwent laparoscopic salpingectomy with/without oophorectomy, and 50 (32.3%) underwent laparoscopic myomectomy. Among all patients, 62 (40.0%) and 93 (60.0%) had anal exhaust within and after 24 h, respectively. Univariate analysis results revealed differences in the operation method (P = 0.040), intraoperative blood loss (P = 0.037), operation duration (P = 0.007), whether an abdominal drainage tube was placed (P = 0.012) and whether warm saline was used (37 °C) for abdominal washing (P = 0.013) between groups. Logistic regression analysis showed that the duration of the operation (P = 0.027) and whether warm saline was used for abdominal washing (P = 0.040) were the main factors affecting anal exhaust time.

CONCLUSION

During laparoscopy for patients with benign gynecological diseases, abdominal washing with warm water is an important factor that promotes early postoperative anal exhaust and is worthy of use in clinical practice.

[Advance in studies on effect of Glycyrrhizae Radix et Rhizoma in relieving purgative activity of Rhei Radix et Rhizoma]

Rhei Radix et Rhizoma, as a commonly used traditional Chinese medicine, has been widely applied in clinic. Its major purgative constituent is anthraquinones, which are believed to be a toxic ingredient. Glycyrrhizae Radix et Rhizoma has been reputed as the best alexipharmic to moderate medicine natures. In this paper, the effect of Glycyrrhizae Radix et Rhizoma in relieving purgative activity of Rhei Radix et Rhizoma was studied in two aspects--the boiling process and intestinal metabolism; Studies on combined administration of Glycyrrhizae Radix et Rhizoma and Rhei Radix et Rhizoma in recent years were summarized according to chemical constituent, intestinal flora, I/II phase metabolism and drug transport. However, the material basis and mechanism for their compatibility remain unclear, further studies will be made in the future.

Comparative pharmacokinetics of aloe-emodin, rhein and emodin determined by liquid chromatography-mass spectrometry after oral administration of a rhubarb peony decoction and rhubarb extract to rats

This study aimed to clarify the rationality of herbaceous compatibility of a rhubarb peony decoction (DaHuang-Mu-Dan-Tang, RPD) by comparing the pharmacokinetics of aloe-emodin, rhein and emodin in rats' plasma after oral administration of RPD and rhubarb extract. A rapid, sensitive LC-MS method was developed and validated for the determination of the plasma concentrations of the three analytes after oral administration RPD and rhubarb extract. The developed method was successfully applied to a pharmacokinetic study of aloe-emodin, rhein and emodin in rats' plasma after oral administration. Compared with administration of single rhubarb, the C(max) of rhein in RPD was decreased significantly (p < 0.05). Meanwhile, the T1/2 of aloe-emodin and emodin were increased significantly (p < 0.05) after administration of RPD. In addition, the T(max) of rhein and emodin were also increased significantly (p < 0.05) in RPD. These results indicated that the absorption of rhein in rats was suppressed after oral administration RPD. Moreover, The time for rhein and emodin to reach the peak concentration was delayed and the elimination of aloe-emodin and emodin was also postponed in RPD. This study could provide a meaningful basis for evaluating the clinical application of traditional Chinese medicine in terms of pharmacokinetics.

Beneficial health properties of psyllium and approaches to improve its functionalities

Psyllium is an excellent dietary source for both soluble and insoluble fibers and has been used in supplemental and food products for its beneficial health effects. The strong water-absorbing and gelling capacities have made it a great challenge to incorporate psyllium in foods at the level needed to claim health benefits on the label. This review is focused on the approaches to improve the functionality, sensory property, and bioactivity of psyllium. Also included is a brief summary of the health beneficial effects of psyllium, along with its possible adverse effects. The information may be useful for those in psyllium research and functional food development.

Development and validation of three stability-indicating methods for determination of bisacodyl in pure form and pharmaceutical preparations

Three new, simple, sensitive, and accurate stability-indicating methods were developed for quantitative determination of bisacodyl in the presence of its degradation products, monoacetyl bisacodyl (I) and desacetyl bisacodyl (II), in enteric coated tablets, suppositories, and raw material. The first is a spectrodensitometric method in which the drug is separated from I and II on silica gel plates using chloroform-acetone (9 + 1, v/v) as the mobile phase with ultraviolet detection of the separated bands at 223 nm over a concentration range of 0.2-1.4 microg/band for bisacodyl with mean recovery 100.35 +/- 1.923%. The second method is fourth derivative D4 spectrophotometry, which allows determination of bisacodyl in the presence of its degradation products in raw material at 223 nm using acetonitrile as the solvent with adherence to Beer's law over the concentration range 2-18 microg/mL with mean recovery 99.77+/-1.056%. In the third method, the spectrophotometric data of bisacodyl, I, and II using absolute ethanol as solvent were processed by 3 chemometric techniques: classical least-squares, principal component regression, and partial least-squares. A training set consisting of 15 mixtures containing different ratios of bisacodyl, I, and II was used for construction of the 3 models. A validation set consisting of 6 mixtures was used to validate the prediction ability of the suggested models. The 3 chemometric methods were applicable over a concentration range between 2-14microg/mL for bisacodyl with mean recovery of 99.97+/-0.865, 100.01 +/- 0.749, and 99.97 +/- 0.616% for the 3 models, respectively. The proposed methods were checked using laboratory-prepared mixtures and were successfully applied to the analysis of raw material and pharmaceutical formulations containing bisacodyl, except for the second method that applies only for raw material. The validity of the suggested procedures was further assessed by applying the standard addition technique; the recoveries obtained were in accordance with those given by the reference method.

Factitious Diarrhea Induced by Stimulant Laxatives: Accuracy of Diagnosis by a Clinical Reference Laboratory Using Thin Layer Chromatography

Background: Surreptitious ingestion of laxatives can lead to serious factitious diseases that are difficult to diagnose. Most cases involve ingestion of bisacodyl or senna. Thin layer chromatography (TLC) of urine or stool is the only commercially available test for these laxatives. Such testing is considered highly reliable, but its accuracy in clinical practice is unknown. Our aim was to evaluate the reliability of TLC laxative testing by a clinical reference laboratory in the United States.

Methods: Diarrhea was induced in healthy volunteers by ingestion of bisacodyl, senna, or a control laxative (n = 11 for each laxative group). Samples of urine and diarrheal stool were sent in blinded fashion to the clinical reference laboratory for bisacodyl and senna analysis.

Results: TLC testing for bisacodyl-induced diarrhea revealed a sensitivity of 73% and specificity of 91% when urine was tested and sensitivity and specificity of 91% and 96%, respectively, when stool was analyzed. When diarrhea was induced by senna, the TLC assay for senna failed to identify even a single urine or stool specimen as positive (zero% sensitivity).

Conclusions: Considering the expected prevalence of surreptitious laxative abuse in patients with chronic idiopathic diarrhea (2.4%–25%, depending on the clinical setting), TLC of urine or stool for bisacodyl by this reference laboratory would often produce misleading results, and testing for senna would have no clinical value. The major problems are false-positive tests for bisacodyl and false-negative tests for senna.

Urinary Excretion of Polyethylene Glycol 3350 during Colonoscopy Preparation

BACKGROUND

Whole gut lavage with a polyethylene glycol electrolyte solution (PEG) is a common bowel cleansing method for diagnostic and therapeutic colon interventions. Absorption of orally administered PEG from the gastrointestinal tract in healthy human beings is generally considered to be poor. In patients with inflammatory bowel disease (IBD), intestinal permeability and PEG absorption were previously reported to be higher than in normal subjects. In the current study, we investigated the absorption of PEG 3350 in patients undergoing routine gut lavage.

METHODS AND RESULTS

Urine specimens were collected for 8 hours in 24 patients undergoing bowel cleansing with PEG 3350 for colonoscopy. The urinary excretion of PEG 3350, measured by size exclusion chromatography, ranged between 0.01 and 0.51 % of the ingested amount, corresponding to 5.8 and 896 mg in absolute amounts, respectively. Mean PEG excretion in patients with impaired mucosa such as inflammation or ulceration of the intestine (0.24 % +/- 0.19, n = 11) was not significantly higher (p = 0.173) compared to that in subjects with macroscopically normal intestinal mucosa (0.13 % +/- 0.13, n = 13).

CONCLUSION

The results indicate that intestinal absorption of PEG 3350 is higher than previously assumed and underlies a strong inter-individual variation. Inflammatory changes of the intestine do not necessarily lead to a significantly higher permeability of PEG.

Screening Procedure for Detection of Stimulant Laxatives and/or Their Metabolites in Human Urine Using Gas Chromatography-Mass Spectrometry after Enzymatic Cleavage of Conjugates and Extractive Methylation

A gas chromatography-mass spectrometry (GC-MS)-based screening procedure was developed for the detection of stimulant laxatives and/or their metabolites in human urine after enzymatic cleavage of conjugates followed by extractive methylation. The part of the phase-transfer catalyst remaining in the organic phase was removed by solid-phase extraction on a diol phase. The compounds were separated by capillary GC and identified by computerized MS in the full scan mode. By use of mass chromatography with the ions m/z 305, 290, 335, 320, 365, 350, 311, 326, 271, and 346, the possible presence of stimulant laxatives and/or their metabolites could be indicated. The identity of positive signals in such mass chromatograms was confirmed by comparison of the peaks underlying full mass spectra with the reference spectra. This method allowed the detection of the diphenol laxatives bisacodyl, picosulfate, and phenolphthalein and of the anthraquinone laxatives contained in plant extracts and/or their metabolites in human urine samples. The overall recoveries of the stimulant laxatives and/or their metabolites ranged between 33% and 89% with a coefficient of variation of less than 15%, and the limits of detection ranged between 10 and 25 ng/mL (S/N 3) in the full scan mode. After ingestion of the lowest therapeutic dose of sodium picosulfate, its main metabolite, bisacodyl diphenol, was detectable in urine samples for 72 hours. After ingestion of the lowest therapeutic dose of a senna extract, the main metabolite of sennosides, rhein, was detectable in urine samples for 24 hours. This procedure is part of a systematic toxicological analysis procedure for acidic drugs and poisons with the modification of enzymatic cleavage of conjugates.

Lethal iatrogenic hypermagnesemia

The administration of magnesium is an effective therapeutic option in such conditions as preeclampsia, ischemic heart disease, cardiac arrhythmia, and asthma. It has also been used as a cathartic in the treatment of constipation. As a medical therapy, magnesium enjoys an acceptable safety record. Because magnesium is almost exclusively excreted in the urine, significantly elevated levels of magnesium are typically anticipated only in patients with renal dysfunction. With wider application, emerging reports suggest that additional factors such as intestinal hypomotility and chronic constipation should be considered before using magnesium to avoid toxicity.

The carbohydrate and caloric content of concomitant medications for children with epilepsy on the ketogenic diet

BACKGROUND

The ketogenic diet for children with refractory epilepsy requires a strict control of the amount of ingested carbohydrates. This can be altered by medication prescribed for the epileptic syndrome or for intercurrent illnesses. The goal of this paper is to compile the carbohydrate and caloric content of commonly used medications in this population.

METHODS

We compiled a list of frequently used medications with the help of Canadian manufacturers and the Compendium of Pharmaceuticals and Specialties. We also tested a worst case scenario calculation based on the weight of the tablet.

RESULTS

We list the carbohydrate and caloric content of 790 medications studied. Our worst case scenario gives an over-estimate in all cases, making adjustments based on this calculation in an emergency setting safe.

CONCLUSION

We propose this list as a tool for physicians, dietitians, nurses and pharmacists. The list can easily be adjusted, based on local practices and reviewed periodically.

Production of monoclonal antibodies against a major purgative component, sennoside B, their characterization and use in ELISA

For immunization, sennoside B was conjugated with bovine serum albumin. The hapten density in the antigen conjugate was determined to be 3 mol mol(-1) protein by matrix-assisted laser desorption-ionization TOF mass spectrometry. A hybridoma secreting monoclonal antibody against sennoside B was produced by fusing splenocytes from mouse immunized with the sennoside B conjugate and mouse myeloma cells. Weak cross-reactivities occurred with sennoside A which is a stereochemical isomer, and a monomer of sennoside B, rhein, but no cross-reactivity was observed with other related anthraquinones and phenolics. The range of the assay extended from 0.5 ng ml(-1) to 15 ng ml(-1) of sennoside B, and good correlation between ELISA and HPLC methods was obtained when crude extracts of rhubarb were analyzed.

Estimation of individual sennosides in plant materials and marketed formulations by an HPTLC method

Senna is a well-known drug, used in the Ayurvedic and Allopathic systems of medicine, and is a treatment for constipation. The purgative action of senna and its formulations is due to the presence of sennosides A and B. An HPTLC method has been developed for the determination of individual sennosides (A, B, C, D) without any derivatization in marketed formulations (three tablet formulations, two granule formulations and one liquid formulation) and plant materials (senna leaf and pod). The methanolic solution of a sample was applied on a pre-coated silica gel G60 F254 TLC plate (E. Merck.) and was developed using n-propanol : ethyl acetate : water : glacial acetic acid (3 : 3 : 2 : 0.1 v/v) as the mobile phase. The relative band speeds (Rf values) obtained were 0.35, 0.25, 0.61, 0.46 for sennosides A, B, C and D, respectively. The densitometric response was monitored at 366nm. Calibration curves were found to be linear in the concentration ranges 193-1356, 402-2817, 71-497 and 132-927 ng per spot for sennosides A, B, C, and D, respectively. The correlation coefficients were found to be 0.9978, 0.9987, 0.9939 and 0.9983 respectively for sennosides A, B, C and D. The result obtained with the HPTLC method for total sennoside content was compared with the results using the pharmacopoeial methods (spectrophotometric (British Pharmacopoeia) and spectrofluorimetric (United States Pharmacopeia) using the 'F' test). The results revealed no significant difference in the three different methods for estimation of total sennoside. The proposed HPTLC method was found to be simple, specific, precise, accurate and rapid. It can be used for routine quality control of sennosides or senna-containing formulations for individual sennosides.

Occurrence of emodin, chrysophanol and physcion in vegetables, herbs and liquors. Genotoxicity and anti-genotoxicity of the anthraquinones and of the whole plants

1,8-Dihydroxyanthraquinones, present in laxatives, fungi imperfecti, Chinese herbs and possibly vegetables, are in debate as human carcinogens. We screened a variety of vegetables (cabbage lettuce, beans, peas), some herbs and herbal-flavoured liquors for their content of the 'free' anthraquinones emodin, chrysophanol and physcion. For qualitative and quantitative analysis, reversed-phase HPLC (RP-LC), gas chromatography-mass spectrometry (GC-MS) and RP-LC-MS were used. The vegetables showed a large batch-to-batch variability, from 0.04 to 3.6, 5.9 and 36 mg total anthraquinone per kg fresh weight in peas, cabbage lettuce, and beans, respectively. Physcion predominated in all vegetables. In the herbs grape vine leaves, couch grass root and plantain herb, anthraquinones were above the limit of detection. Contents ranged below 1 mg/kg (dry weight). All three anthraquinones were also found in seven of 11 herbal-flavoured liquors, in a range of 0.05 mg/kg to 7.6 mg/kg. The genotoxicity of the analysed anthraquinones was investigated in the comet assay, the micronucleus test and the mutation assay in mouse lymphoma L5178Y tk+/- cells. Emodin was genotoxic, whereas chrysophanol and physcion showed no effects. Complete vegetable extract on its own did not show any effect in the micronucleus test. A lettuce extract completely abolished the induction of micronuclei by the genotoxic anthraquinone danthron. Taking into consideration the measured concentrations of anthraquinones, estimated daily intakes, the genotoxic potency, as well as protective effects of the food matrix, the analysed constituents do not represent a high priority genotoxic risk in a balanced human diet.

[Determination of sennoside A and sennoside B in formulation using capillary electrophoresis]

The determination of sennoside A (SA) and sennoside B (SB) by capillary zone electrophoresis was developed. The separation of SA and SB was performed in 100 mM of the 3-[cyclohexylamino]-1-propanesulfonic acid (CAPS) buffer (pH 10.0), and the migration time of SA and SB was found to be both less than 7 min. This method was applied to the analyses of seven commercial formulations containing SA and SB without previous treatment. The statistical comparison of the results obtained from both capillary electrophoresis and HPLC methods revealed an absolute correlation.

Investigation and diagnosis of diarrhea caused by sodium phosphate

Because there are no published reference values for fecal phosphate concentration or output, diagnosing surreptitious use of phosphate laxatives has been difficult. The purposes of this study were to determine normal fecal phosphate levels and to quantitate and chemically analyze diarrhea produced by sodium phosphate. Timed stool collections were obtained from 20 normal subjects during 25 study periods (normal controls), from 27 normal subjects with diarrhea induced by a variety of laxatives not containing phosphate during 234 study periods (diarrhea controls), and from 10 normal subjects during 14 periods after ingestion of 45 or 22.5 ml of a commercially available 66% sodium phosphate solution (Fleet Phospho-Soda). All stools were analyzed for soluble phosphate concentration, and daily output was calculated. The upper limits of normal for soluble fecal phosphate concentration and output, derived from the normal controls and diarrhea controls, respectively, were 33 mmol/liter and 15 mmol/day. Diarrhea produced by 45 ml of sodium phosphate was watery and voluminous, with fecal weights averaging 1078 g/day (range 601-1713 g/day). Measured fecal phosphate concentrations and outputs averaged 85 mmol/liter and 92 mmol/day, respectively, and all values were significantly elevated. Soft, less voluminous stools were produced with 22.5 ml of sodium phosphate but all had an abnormally high soluble phosphate concentration and 24-hr output. In conclusion, the upper limits of normal for soluble fecal phosphate concentration and output established in this study should be useful in the chemical diagnosis of phosphate-induced diarrhea.

[Sennosides Reference Standard (Control 951) of the National Institute of Health Sciences]

The "Sennosides Reference Standard (Control 951)" was prepared, which is intended to be used for the fluorophotometric assay of sennosides content in the preparation of "Sennosides". In this assay hydroxylated mono- and dianthraquinone glucosides are chelated with boric acid, and the fluorescence intensity of the chelate is determined against that of the Reference Standard (RS). In the establishment of this RS, sennosides content in the candidate material must be determined accurately by fluorophotometry. The Sennoside AB for assay, prepared as an equimolar mixture of the purified sennoside A and Sennoside B, was used as the RS for the fluorophotometry. Based on the above concept, sennosides content in the candidate was determined as calcium salts to be 60.1 +/- 1.6% by the fluorophotometry. Thus the sennosides content of this Sennosides RS was certified to be 60%. Separately, contents of Sennoside A (SA) and Sennoside B (SB) in this candidate were determined by using HPLC. As a result, the sum of SA and SB was estimated to be 38% as free acids. Thus it was suggested that about 20% of dianthraquinone glucosides other than SA and SB and anthraquinone glucosides may be included in this Sennoside RS as free acids. Analytical results on the USP Sennosides RS were also shown and discussed, compared with the present Sennosides RS.

High-performance liquid chromatographic determination of bisacodyl in pharmaceutical dosage forms marketed in Australia

HPLC methods have been developed for the assay of bisacodyl in various pharmaceutical forms. The extraction procedures are simple and the HPLC conditions separate bisacodyl from its degradation products. The chromatography was performed using a Merck LiChrospher RP-select B column, a mobile phase of 55% acetonitrile/45% 0.05 M KH2PO4 and detection by UV at 214 nm.

Comparison of reversed-phase liquid chromatography with colorimetry for analysis of phenolphthalein preparations

The high-performance liquid chromatography (HPLC) method of the United States Pharmacopeia has been compared with the colorimetric method of the British Pharmacopoeia for the assay of phenolphthalein in various preparations. Results are presented for the linearity, sensitivity and reproducibility of the two methods. The HPLC method was considered to be more convenient for routine analysis of the preparations of phenolphthalein.

Analytics of senna drugs with regard to the toxicological discussion of anthranoids

Toxicological studies indicate that two hydroxyanthraquinones (HAs), aloe-emodin and emodin, present as minor components in senna, might represent a genotoxic or cancerogenetic risk for man. Since aloe-emodin and emodin occur in senna in the free form as well as their glucosides and dianthrone glucosides, a HPLC method was established to allow the quantification of all free and glycosidic 1,8-dihydroxy anthranoids. The sum of the free HAs and their calculated content in each of their prodrug forms is defined as the potential HA content. For the comparison of different senna drugs in respect to the genotoxic risk arising from their potential aloe-emodin or emodin contents, a risk index has been established.

A rapid high-performance thin-layer chromatographic urine screen for laxative abuse

Laxative abuse, if unrecognized, can lead to unnecessary and costly investigations. The stimulants and cathartics are the most commonly abused laxatives and have the potential for causing the most long-term damage. We have optimized a solid-phase extraction coupled with high-performance thin-layer chromatography (HPTLC) to provide rapid, simple, and sensitive detection of phenolphthalein, danthron, rhein, aloin, and bisacodyl and its metabolites in urine. Positive screens have revealed laxative abuse in 3 of 42 samples from patients presenting with diarrhea of unknown origin.

[Determination of sennoside A in oriental pharmaceutical decoctions containing Rhei Rhizoma by ion-pair high-performance liquid chromatography]

A simple method using ion-pair high-performance liquid chromatography was established for the rapid and precise determination of sennoside A in oriental pharmaceutical decoctions containing Rhei Rhizoma. This method was compared with other two methods, i.e. ion-suppression and phosphate buffer methods. Sennoside A was eluted without interference in this ion-pair method, while the determination of sennoside A was interfered by co-existing components in the other two methods.

Diagnosis of the abuse of magnesium and stimulant laxatives

A reliable diagnosis of laxative abuse can only be reached by chemical analysis. We report a modified thin layer chromatography approach for the detection and confirmation of over-the-counter colonic stimulant laxatives. Potential interference by dietary and drug components chemically similar to anthraquinones was investigated and the method was found to be specific in this respect. The diagnosis of magnesium laxative abuse is more difficult since magnesium is a component of body fluids. By inducing diarrhoea with magnesium salts in volunteers we have established that the diagnosis can be made by measuring magnesium concentrations in stool water, with 30 mmol/L being an appropriate cut-off concentration.

Magnesium levels after magnesium-containing cathartics

To determine the effect on serum Mg++ levels of oral Magnesium-containing cathartics (MgCC) used in the treatment of suspected drug overdose, a prospective, non-randomized study of 24 cases of suspected drug overdose was conducted. Ten cases admitted to the observation unit were assigned to the single dose MgCC group. Fourteen cases admitted to either the ICU or the observation unit were assigned to the multiple dose MgCC group. Single dose cases received 30 gm of magnesium sulfate (MgSO4) at 0 hours. Multiple dose cases received 3 30 gm doses of MgSO4 at 0, 4, and 8 hours. Mg++ levels were measured prior to each MgSO4 dose and 1 and 4 hours after the final dose in both groups. In the single dose group, there was no difference between baseline Mg++ levels and post MgSO4 levels, and only 2/10 developed slightly elevated levels (2.2, 2.3 mEq/L). In the multiple dose group, levels increased and remained significantly higher than baseline after the second MgSO4 dose, and 9/14 developed elevated levels (2.2 to 5.0 mEq/L). All patients who developed elevated Mg++ levels had normal BUN and creatinine values. When the single and multiple dose groups were compared, baseline Mg++ levels were no different (1.68 +/- 0.21 vs 1.69 +/- 0.24, p = 0.952), but peak Mg++ levels were significantly higher in the multiple dose group (1.80 +/- 0.31 vs 2.61 +/- 0.86, p = 0.004). Cases that developed hypermagnesemia had slightly higher baseline Mg++ levels (1.78 +/- 0.22 vs 1.60 +/- 0.19 mEq/L, p = 0.041). In the multiple dose group, higher peak Mg++ levels were noted in cases involving ingestions of anticholinergic or opioid drugs (2.83 vs 1.98, p = 0.025). Hypermagnesemia developed in some cases with normal renal function, blood pressure, and urine output. We conclude that significant hypermagnesemia can occur rapidly after use of multiple dose Mg++ cathartics in standard doses in patients with normal renal function.

Factitious diarrhoea

Gastroenterologists often have to deal with patients with chronic diarrhoea. The vast majority will suffer from functional bowel syndrome. A few will present with a clear-cut organic disease. If chronic diarrhoea remains unexplained after extensive testing, if daily stool volume is high (greater than 500 g/24 h) and if the patient is female, factitious diarrhoea should be considered. Melanosis coli on sigmoidoscopy, cathartic colon on barium enema examination, a positive room search and chemical detection of the presence of specific laxatives in urine or stool may lead to the correct diagnosis. Treatment and management of such patients is difficult. Denial is the usual response to confrontation. Counselling and guidance by psychiatrists or psychologists is often not accepted by the patient. In many cases the role of the physician may be limited to preventing further potentially dangerous diagnostic and therapeutic interventions.

Bulk laxatives: their dietary fibre composition, degradation, and faecal bulking capacity in the rat

The intestinal dietary fibre degradation and faecal bulking capacity of various bulk laxatives were investigated by means of balance experiments on rats. Nitrogen, fat, and mineral excretion in faeces was also studied. The dietary fibre content of the various bulk laxatives was quite different (in g/kg dry matter): ACO fibre tablets (barley and citrus pulp), 451; Fiberform (wheat bran-based), 817; Inolaxol (sterkulia gum), 696; and Vi-Siblin (ispaghula husk), 533. The increase in faecal dry matter per 1 g dietary fibre was similar with ACO fibre tablets, Fiberform, and Vi-Siblin. Inolaxol gave a significantly (p less than 0.001) higher faecal dry-weight increment, mainly due to an increased mineral excretion. Of the dry-weight increment, 59-82% constituted undegraded dietary fibre. Thus, 68-97% of the fibre passed through the gastrointestinal tract without being degraded. All the bulk laxatives caused a similar increase in the faecal N content, whereas the increase in faecal lipids was most pronounced with Vi-Siblin. The water-holding capacity of faeces was more pronounced with Inolaxol and Vi-Siblin than with ACO fibre tablets and Fiberform.

A screening method for establishing laxative abuse

Abuse of laxatives, most of them belonging to the group of colonic stimulants or cathartics, can cause various disorders. Extensive diagnostic work can be avoided by early toxicological screening of the suspected patients with respect to laxatives. Because no screening method of this kind was available, we developed a procedure with which all phenolic and anthraquinone laxatives--except sodium picosulfate--can be detected in urine. This method is based on high-performance thin-layer chromatography in two systems after pretreatment of a 20-mL urine sample with beta-glucuronidase and subsequent column extraction. The procedure is very sensitive: at least 32 h after a single dose of bisacodyl, danthron, phenolphthalein, or sennoside, the drug can be detected in the urine. Bisoxatin and oxyphenisatin are still detectable in the urine 18 h after intake. The method is also highly specific; none of 73 other drugs interfered in either of the two chromatographic systems. This procedure can be helpful for the early diagnosis of laxative abuse.