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Barbara G, Bellini M, Portincasa P, Stanghellini V, Annibale B, Benedetti A, Cammarota G, Fries W, Usai Satta P, Corazziari ES. Bile acid diarrhea in patients with chronic diarrhea. Current appraisal and recommendations for clinical practice. Dig Liver Dis 2025; 57:680-687. [PMID: 39827025 DOI: 10.1016/j.dld.2024.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 12/14/2024] [Accepted: 12/23/2024] [Indexed: 01/22/2025]
Abstract
Bile Acid Diarrhea (BAD) is a common cause of chronic diarrhea, often accompanied by urgency, occasional fecal incontinence, abdominal pain, and fatigue. A nationwide survey has shown limited awareness of BAD within the Italian medical community, prompting a panel of experts to develop a Position Paper that outlines the most practical and cost-saving diagnostic investigations and treatments for this frequently overlooked condition. The document provides an overview of the epidemiology, pathophysiology, clinical manifestations, and classification of the different types of Bile Acid Diarrhea (BAD). A key focus is the diagnostic approach to identifying and managing the many undiagnosed BAD patients in both primary care and specialized medical settings. Finally, the paper addresses the optimal therapeutic strategies for BAD, including traditional bile acid sequestrants and newer, promising treatments.
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Affiliation(s)
- Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J)University of Bari Aldo Moro, Bari, Italy
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Roma, Italy
| | - Antonio Benedetti
- Clinic of Gastroenterology and Hepatology, Università Politecnica delle Marche, Ospedali Riuniti-University Hospital, Ancona, Italy
| | - Giovanni Cammarota
- Gastroenterology Unit, Fondazione Policlinico A Gemelli IRCCS, Catholic University of Medicine, Roma, Italy
| | - Walter Fries
- Clinical Unit of Gastroenterology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Wang Y, Li X, Cao Z, Zhou Y. The impact of alcohol consumption on the relationship between depression and chronic diarrhea: a cross-sectional study analysis on NHANES (2005-2010). Front Psychiatry 2024; 15:1393546. [PMID: 39279809 PMCID: PMC11392863 DOI: 10.3389/fpsyt.2024.1393546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/30/2024] [Indexed: 09/18/2024] Open
Abstract
Background Alcohol consumption, depression, and chronic diarrhea are all public health issues of concern, with irreversible consequences for individual health and significant economic burdens on health care systems. Previous studies have shown that depression increases the risk of developing chronic diarrhea, but few studies have explored whether alcohol consumption has an effect on the relationship between depression and chronic diarrhea. Objective To explore the effect of alcohol consumption on the relationship between depression and chronic diarrhea. Methods 12,538 adults (≥20 years) in NHANES from 2005-2010 were analyzed. Participants were stratified according to drinking status, and differences between the risk of depression and chronic diarrhea among participants who drank alcohol or not were assessed using multiple regression analysis and likelihood ratio tests. Results In this cross sectional, after adding possible confounders, the prevalence of depression with chronic diarrhea was higher in the drinking population than in the non-drinking population (OR,2.34, 95%CI:1.84-2.98 and 1.26, 95%CI:0.85-1.86), with a likelihood ratio test of P=0.024. Conclusion Our findings suggest that there is a significant association between depression and chronic diarrhea and that alcohol consumption may increase the correlation between depression and chronic diarrhea. However, these findings require further prospective studies to provide more evidence.
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Affiliation(s)
- Yongsen Wang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Gastroenterology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaotong Li
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhiqun Cao
- Gastroenterology Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yongkun Zhou
- Gastrointestinal and Hernia Surgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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Hammami A, Hassine A, Sahli J, Ghali H, Ben Saad OK, Elleuch N, Dahmani W, Braham A, Ajmi S, Ben Slama A, Jaziri H, Ksiaa M. Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison. BMC Gastroenterol 2024; 24:272. [PMID: 39160458 PMCID: PMC11331678 DOI: 10.1186/s12876-024-03352-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND There is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This "overuse" of colonoscopies has become a major burden for health care. OBJECTIVES to assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria. PATIENTS AND METHODS this cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria. RESULTS From 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153). CONCLUSIONS The updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.
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Affiliation(s)
- Aya Hammami
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Amira Hassine
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
| | - Jihene Sahli
- Department of Family and Community Medicine, Faculty of Medicine of Sousse, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
- LR12ES03, Sousse, Tunisia
| | - Hela Ghali
- Department of Prevention and Security of Care, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Omar Khalil Ben Saad
- Department of Prevention and Security of Care, Sahloul University Hospital, Sousse, Tunisia.
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia.
| | - Nour Elleuch
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Wafa Dahmani
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Ahlem Braham
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Salem Ajmi
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Aida Ben Slama
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Hanen Jaziri
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Mehdi Ksiaa
- Gastroenterology Department, Sahloul University Hospital, Sousse, Tunisia
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
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Sathiyasekaran M, Ganesh R, Natarajan S. Other Causes of Chronic Diarrhea in Children. Indian J Pediatr 2024; 91:606-613. [PMID: 38051444 DOI: 10.1007/s12098-023-04918-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 10/23/2023] [Indexed: 12/07/2023]
Abstract
Chronic diarrhea is still an important cause of morbidity and mortality in children. There are several causes of chronic diarrhea which may be due to intestinal, extra-intestinal or underlying systemic diseases. The etiology varies depending on the age of onset and may include both common and uncommon disorders. In this article some of the uncommon disorders such as immune deficiencies, intestinal lymphangiectasias, drug induced diarrhea, eosinophilic gastrointestinal disorders, endocrinopathies, neuroendocrine secretory tumors, malignancy and factitious diarrhea have been included. Though these disorders are uncommon it is essential that they are considered in select situations as detailed below and evaluated so that definitive therapy may be offered.
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Affiliation(s)
- Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology & Hepatology, Rainbow Children's Hospital, Chennai, 600015, Tamil Nadu, India
| | - R Ganesh
- Department of General Pediatrics & Inherited Metabolic Diseases, Rainbow Children's Hospital, Chennai, 600015, Tamil Nadu, India.
| | - Suresh Natarajan
- Department of General Pediatrics & Pediatric Allergy, Rainbow Children's Hospital, Chennai, 600015, Tamil Nadu, India
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Guo Y, Cao F, Li F. Impacts of pancreatic exocrine insufficiency on gut microbiota. J Zhejiang Univ Sci B 2024; 25:271-279. [PMID: 38584090 PMCID: PMC11009442 DOI: 10.1631/jzus.b2300070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/29/2023] [Indexed: 04/09/2024]
Abstract
Pancreatic exocrine insufficiency (PEI) can be induced by various kinds of diseases, including chronic pancreatitis, acute pancreatitis, and post-pancreatectomy. The main pathogenetic mechanism of PEI involves the decline of trypsin synthesis, disorder of pancreatic fluid flow, and imbalance of secretion feedback. Animal studies have shown that PEI could induce gut bacterial overgrowth and dysbiosis, with the abundance of Lactobacillus and Bifidobacterium increasing the most, which could be partially reversed by pancreatic enzyme replacement therapy. Clinical studies have also confirmed the association between PEI and the dysbiosis of gut microbiota. Pancreatic exocrine secretions and changes in duodenal pH as well as bile salt malabsorption brought about by PEI may affect and shape the abundance and composition of gut microbiota. In turn, the gut microbiota may impact the pancreatic exocrine acinus through potential bidirectional crosstalk. Going forward, more and higher-quality studies are needed that focus on the mechanism underlying the impact of PEI on the gut microbiota.
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Affiliation(s)
- Yulin Guo
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing 100053, China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing 100053, China.
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Loganathan P, Mohan BP, Ramai D, Muthusamy AK, Ponnada S, Chandan S, Schwartz DA, Adler DG. Diagnostic yield of random colon biopsy sampling in patients with chronic diarrhea and normal colonoscopy: a systematic review and meta-analysis. IGIE 2023; 2:178-198. [DOI: 10.1016/j.igie.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2025]
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Lamb R, Kahlon A, Sukumar S, Layton B. Small bowel diverticulosis: imaging appearances, complications, and pitfalls. Clin Radiol 2022; 77:264-273. [PMID: 35012738 DOI: 10.1016/j.crad.2021.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Diverticula of the small bowel can be categorised as true, with Meckel's being the only example, or false. False small bowel diverticula (SBD) are acquired through herniation of the internal layers of the bowel wall through the muscularis propria. Peri-ampullary duodenal diverticula are a well-recognised example; however, the importance of more distal SBD in the jejunum and ileum is underappreciated, and they are under-reported on cross-sectional imaging. SBD are a known cause of anaemia, malabsorption, and diarrhoea, and there are myriad complications of SBD and Meckel's diverticula, which range in severity from inflammation and perforation to haemorrhage, tumour formation, and obstruction. Before the advent of computed tomography (CT), SBD were readily diagnosed on fluoroscopic oral contrast studies; however, radiologists are less comfortable with their cross-sectional imaging appearances. This imaging review combines our experience of multiple proven cases, with illustrative diagrams and radiological images of SBD to provide distinct imaging characteristics, allowing for confident diagnosis of SBD and their numerous complications. We discuss the importance of SBD as a cause of benign, non-surgical pneumoperitoneum. We additionally provide important pitfalls to be aware of such as SBD masquerading as other abnormalities.
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Affiliation(s)
- R Lamb
- Department of Clinical Radiology, East Lancashire Hospitals Trust, Haslingden Rd, Blackburn, BB2 3HH, UK
| | - A Kahlon
- Department of Clinical Radiology, East Lancashire Hospitals Trust, Haslingden Rd, Blackburn, BB2 3HH, UK
| | - S Sukumar
- Department of Clinical Radiology, University Hospital of South Manchester, Southmoor Road, Manchester, Greater Manchester, M23 9LT, UK
| | - B Layton
- Department of Clinical Radiology, East Lancashire Hospitals Trust, Haslingden Rd, Blackburn, BB2 3HH, UK.
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Keller J, Hammer HF, Afolabi PR, Benninga M, Borrelli O, Dominguez‐Munoz E, Dumitrascu D, Goetze O, Haas SL, Hauser B, Pohl D, Salvatore S, Sonyi M, Thapar N, Verbeke K, Fox MR. European guideline on indications, performance and clinical impact of 13 C-breath tests in adult and pediatric patients: An EAGEN, ESNM, and ESPGHAN consensus, supported by EPC. United European Gastroenterol J 2021; 9:598-625. [PMID: 34128346 PMCID: PMC8259225 DOI: 10.1002/ueg2.12099] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION 13 C-breath tests are valuable, noninvasive diagnostic tests that can be widely applied for the assessment of gastroenterological symptoms and diseases. Currently, the potential of these tests is compromised by a lack of standardization regarding performance and interpretation among expert centers. METHODS This consensus-based clinical practice guideline defines the clinical indications, performance, and interpretation of 13 C-breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 43 experts from 18 European countries. Consensus on individual statements and recommendations was established if ≥ 80% of reviewers agreed and <10% disagreed. RESULTS The guideline gives an overview over general methodology of 13 C-breath testing and provides recommendations for the use of 13 C-breath tests to diagnose Helicobacter pylori infection, measure gastric emptying time, and monitor pancreatic exocrine and liver function in adult and pediatric patients. Other potential applications of 13 C-breath testing are summarized briefly. The recommendations specifically detail when and how individual 13 C-breath tests should be performed including examples for well-established test protocols, patient preparation, and reporting of test results. CONCLUSION This clinical practice guideline should improve pan-European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, this guideline identifies areas of future clinical research involving the use of 13 C-breath tests.
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Affiliation(s)
- Jutta Keller
- Department of Internal MedicineIsraelitic HospitalAcademic Hospital University of HamburgHamburgGermany
| | - Heinz F. Hammer
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Paul R. Afolabi
- NIHR Southampton Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust and University of SouthamptonSouthamptonUK
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
| | - Enrique Dominguez‐Munoz
- Department of Gastroenterology and HepatologyUniversity Hospital of Santiago de CompostelaSantiagoSpain
| | | | - Oliver Goetze
- Department of Medicine IIDivision of HepatologyUniversity Hospital WürzburgWürzburgGermany
| | - Stephan L. Haas
- Department of Upper GI DiseasesKarolinska University HospitalStockholmSweden
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and NutritionKidZ Health Castle UZ BrusselsBrusselsBelgium
| | - Daniel Pohl
- Division of Gastroenterology and HepatologyUniversity Hospital ZürichZürichSwitzerland
| | - Silvia Salvatore
- Pediatric DepartmentHospital "F. Del Ponte"University of InsubriaVareseItaly
| | - Marc Sonyi
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
- Clinic for General Medicine, Gastroenterology, and Infectious DiseasesAugustinerinnen HospitalCologneGermany
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
- Department of Gastroenterology, Hepatology and Liver TransplantationQueensland Children's HospitalBrisbaneAustralia
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal DisordersKU LeuvenLeuvenBelgium
| | - Mark R. Fox
- Division of Gastroenterology and HepatologyUniversity Hospital ZürichZürichSwitzerland
- Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal DiseasesCentre for Integrative GastroenterologyKlinik ArlesheimArlesheimSwitzerland
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Alonso-Cotoner C, Abril-Gil M, Albert-Bayo M, Mall JPG, Expósito E, González-Castro AM, Lobo B, Santos J. The Role of Purported Mucoprotectants in Dealing with Irritable Bowel Syndrome, Functional Diarrhea, and Other Chronic Diarrheal Disorders in Adults. Adv Ther 2021; 38:2054-2076. [PMID: 33738725 PMCID: PMC7971407 DOI: 10.1007/s12325-021-01676-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Chronic diarrhea is a frequent presenting symptom, both in primary care medicine and in specialized gastroenterology units. It is estimated that more than 5% of the global population suffers from chronic diarrhea. and that about 40% of these subjects are older than 60 years. The clinician is frequently faced with the need to decide which is the best therapeutic approach for these patients. While the origin of chronic diarrhea is diverse, impairment of intestinal barrier function, dysbiosis. and mucosal micro-inflammation are being increasingly recognized as underlying phenomena characterizing a variety of chronic diarrheal diseases. In addition to current pharmacological therapies, there is growing interest in alternative products such as mucoprotectants, which form a mucoadhesive film over the epithelium to reduce and protect against the development of altered intestinal permeability, dysbiosis, and mucosal micro-inflammation. This manuscript focuses on chronic diarrhea in adults, and we will review recent evidence on the ability of these natural compounds to improve symptoms associated with chronic diarrhea and to exert protective effects for the intestinal barrier.
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Affiliation(s)
- Carmen Alonso-Cotoner
- Servei de Aparell Digestiu, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Universitat Autònoma de Barcelona, Facultat de Medicina, Bellaterra, Barcelona, Spain
- CIBER de Enfermedades Hepaticas y Digestivas (CIBERHED), Instituto de Salud Carlos III, Madrid, Spain
| | - Mar Abril-Gil
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Mercé Albert-Bayo
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - John-P Ganda Mall
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Elba Expósito
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Ana M González-Castro
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Beatriz Lobo
- Servei de Aparell Digestiu, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
- Universitat Autònoma de Barcelona, Facultat de Medicina, Bellaterra, Barcelona, Spain.
| | - Javier Santos
- Servei de Aparell Digestiu, Vall d'Hebron Hospital Universitari, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Grup de Neuro-Inmuno-Gastroenterología, Unitat de Fisiología I Fisiopatología Digestiva, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
- Universitat Autònoma de Barcelona, Facultat de Medicina, Bellaterra, Barcelona, Spain.
- CIBER de Enfermedades Hepaticas y Digestivas (CIBERHED), Instituto de Salud Carlos III, Madrid, Spain.
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Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms "pancreatic exocrine insufficiency" and "Pancreaticoduodenectomy". Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
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Affiliation(s)
- Adithya M Pathanki
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Joseph A Attard
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Sarah Powell-Brett
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Bobby V M Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - John R Isaac
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Keith J Roberts
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. Clin Gastroenterol Hepatol 2020; 18:24-41.e1. [PMID: 31526844 DOI: 10.1016/j.cgh.2019.08.062] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. METHODS We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. RESULTS The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. CONCLUSIONS Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada.
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Julian R F Walters
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
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Sadowski DC, Camilleri M, Chey WD, Leontiadis GI, Marshall JK, Shaffer EA, Tse F, Walters JRF. Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea. J Can Assoc Gastroenterol 2019; 3:e10-e27. [PMID: 32010878 PMCID: PMC6985689 DOI: 10.1093/jcag/gwz038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. Methods We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists. Results The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST. Conclusions Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.
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Affiliation(s)
- Daniel C Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Grigorios I Leontiadis
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Eldon A Shaffer
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Gado A, Ebeid B, Abdelmohsen A, Gado T, Axon A. Endoscopy audit over 10 years in a community hospital in Egypt. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2017.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital, Giza, EgyptDepartment of Medicine, Bolak Eldakror Hospital, Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, EgyptDepartment of Tropical Medicine and Infectious Diseases, Beny Suef University, Beny Suef, Egypt
| | - Aida Abdelmohsen
- Department of Community Medicine, National Research Center, Giza, EgyptDepartment of Community Medicine, National Research Center, Giza, Egypt
| | - Tarek Gado
- Department of Medicine, Cairo university, Giza, EgyptDepartment of Medicine, Cairo university, Giza, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United KingdomDepartment of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom
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The investigation of chronic diarrhoea: new BSG guidance. Br J Gen Pract 2019; 69:262-264. [PMID: 31023694 DOI: 10.3399/bjgp19x702653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/20/2018] [Indexed: 10/31/2022] Open
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Hay T, Bellomo R, Rechnitzer T, See E, Ali Abdelhamid Y, Deane AM. Constipation, diarrhea, and prophylactic laxative bowel regimens in the critically ill: A systematic review and meta-analysis. J Crit Care 2019; 52:242-250. [PMID: 30665795 DOI: 10.1016/j.jcrc.2019.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/24/2018] [Accepted: 01/08/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prophylactic laxative bowel regimens may prevent constipation in enterally-fed critically ill patients. However, their use may also increase diarrhea. We performed a systematic review to: 1. Explore the epidemiology of constipation and/or diarrhea in critically ill patients; and 2. Appraise trials evaluating prophylactic laxative bowel regimens. METHODS We searched MEDLINE, Embase, and CINAHL for publications that reported constipation or diarrhea in critically ill adult patients and/or prophylactic laxative bowel regimens. RESULTS The proportion of critically ill patients experiencing constipation was reported between 20% and 83% and the proportion experiencing diarrhea was reported between 3.3% and 78%. Six studies of prophylactic laxative bowel regimens were identified but only 3 randomised controlled trials were identified, and these were subjected to meta-analysis. Compared with placebo, a prophylactic laxative bowel regimen increased the risk of diarrhea (RR 1.58, 95% CI 1.22 to 2.04) but did not reduce the risk of constipation (RR 0.39, 95% CI 0.14 to 1.05), and did not affect the duration of mechanical ventilation, duration of ICU admission, or mortality. CONCLUSIONS Constipation and diarrhea occur frequently in the critically ill but data evaluating prophylactic laxative bowel regimens in such patients are sparse and do not support their use.
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Affiliation(s)
- Tyler Hay
- The University of Melbourne, Melbourne Medical School, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Tom Rechnitzer
- Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily See
- Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia
| | | | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia; Intensive Care Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Sisay M, Bussa N, Gashaw T. Evaluation of the Antispasmodic and Antisecretory Activities of the 80% Methanol Extracts of Verbena officinalis L: Evidence From In Vivo Antidiarrheal Study. J Evid Based Integr Med 2019; 24:2515690X19853264. [PMID: 31204502 PMCID: PMC6580719 DOI: 10.1177/2515690x19853264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/25/2019] [Accepted: 05/04/2019] [Indexed: 12/29/2022] Open
Abstract
Verbena officinalis L. has a folkloric repute for the management of digestive disorders, including diarrhea. However, the safety and efficacy of the plant material has not been scientifically validated yet. This study was, therefore, aimed to evaluate the overall antidiarrheal activity of the 80% methanol extracts of V officinalis in mice. The antidiarrheal activity of the 80% methanol extracts of the roots (R-80ME) and the leaves (L-80ME) of V officinalis was tested in castor oil-induced diarrhea in mice. R-80ME was further evaluated using charcoal meal and entero-pooling. In each test, group I and group II (controls) received 10 mL/kg distilled water and standard drug (5 mg/kg loperamide), respectively, whereas groups III, IV, and V (test groups) received 100, 200, and 400 mg/kg of the 80ME, respectively. The R-80ME at 200 mg/kg (P < .01) and 400 mg/kg (P < .001) significantly delayed the onset of diarrhea compared with negative control. Both R-80ME and L-80ME at 200 and 400 mg/kg significantly decreased the frequency of wet fecal outputs (P < .01). Generally, 70.24% inhibition of the number of wet fecal output was recorded at R-80ME 400 mg/kg. Results from the charcoal meal test revealed that the R-80ME at 200 (P < .01) and 400 mg/kg (P < .001) produced a significant antimotility effect. In entero-pooling test, the R-80ME, at 200 and 400 mg/kg doses (P < .01), showed a significant decline in both the volume and weight of intestinal contents. The maximum in vivo antidiarrheal index was determined to be 95.25 at dose of 400 mg/kg R-80ME. This study demonstrated that the 80ME, mainly the root extract, produced promising antidiarrheal activity and hence provides a scientific support for acclaimed traditional use of the plant material for treatment of diarrheal diseases.
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Affiliation(s)
- Mekonnen Sisay
- School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Negussie Bussa
- Food Science and Post-harvest Technology, Haramaya University, Dire Dawa,
Ethiopia
| | - Tigist Gashaw
- School of Pharmacy, Haramaya University, Harar, Ethiopia
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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18
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Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, Major G, O'Connor M, Sanders DS, Sinha R, Smith SC, Thomas P, Walters JRF. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut 2018; 67:1380-1399. [PMID: 29653941 PMCID: PMC6204957 DOI: 10.1136/gutjnl-2017-315909] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/28/2018] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.
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Affiliation(s)
- Ramesh P Arasaradnam
- University Hospital Coventry, Coventry, UK
- Department of Applied Biological Sciences, University of Coventry, Coventry, UK
- Clinical Sciences Research Institute, University of Warwick, Warwick, UK
| | | | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mark R Fox
- University of Zürich, Zürich, Switzerland
- Abdominal Centre, St Claraspital, Basel, Switzerland
| | - Pali Hungin
- School of Medicine, Pharmacy & Health, University of Durham, Durham, UK
| | | | - Giles Major
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | | | - Rakesh Sinha
- Department of Radiology, South Warwickshire Hospitals, Warwick, UK
| | - Stephen Charles Smith
- Department of Clinical Biochemistry, Midlands and NW Bowel Cancer Screening Hub, Rugby, UK
| | - Paul Thomas
- Department of Gastroenterology, Musgrave Park Hospital, Taunton, UK
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Ernaga Lorea A, Migueliz Bermejo I, Eguílaz Esparza N, Hernández Morhain MC, Pineda Arribas J. Chronic diarrhea: The first symptom of a metastatic medullary thyroid carcinoma. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:105-107. [PMID: 28259364 DOI: 10.1016/j.gastrohep.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 06/06/2023]
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Leeds JS, Hadjivassiliou M, Tesfaye S, Sanders DS. Lower gastrointestinal symptoms are associated with worse glycemic control and quality of life in type 1 diabetes mellitus. BMJ Open Diabetes Res Care 2018; 6:e000514. [PMID: 29892338 PMCID: PMC5992466 DOI: 10.1136/bmjdrc-2018-000514] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/13/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Lower gastrointestinal symptoms are not well characterized in people with type 1 diabetes, and the effects on quality of life and glycemic control are unknown. This study aimed to determine the prevalence of lower gastrointestinal symptoms and the effects on glycemic control and quality of life, and to investigate for underlying causes. RESEARCH DESIGN AND METHODS This is a prospective, cohort study in secondary care. Patients with type 1 diabetes completed a gastrointestinal symptom questionnaire and the Short Form 36 V.2 quality of life questionnaire and had their hemoglobin A1c measured. Patients with diarrhea were offered reassessment and investigation as per the national guidelines. Controls without diabetes were used to compare symptom prevalence and quality of life scores. RESULTS 706 with type 1 diabetes (mean age 41.9 years) and 604 controls (mean age 41.9 years) were enrolled. Gastrointestinal symptoms were significantly more frequent in type 1 diabetes compared with controls, in particular constipation (OR 2.4), diarrhea (OR 2.5), alternating bowel habit (OR 2.1), abdominal pain (OR 1.4), floating stools (OR 2.7), bloating (OR 1.4) and flatulence (OR 1.3) (all p<0.05). Previous pancreatitis was more frequent in type 1 diabetes (OR 4.6), but other gastrointestinal conditions were not. Gastrointestinal symptoms were associated with poorer glycemic control (p<0.01) and worse quality of life particularly in those with diarrhea. Investigation of those with diarrhea, including those with alternating bowel habit, (n=105), identified a cause in 72.3% with subsequent change in management. CONCLUSIONS Gastrointestinal symptoms are twice as common in type 1 diabetes and associated with poorer quality of life and glycemic control. Investigation of diarrhea in people with type 1 diabetes leads to a high yield of treatable conditions and a change in management in about three-quarters.
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Affiliation(s)
- John S Leeds
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Solomon Tesfaye
- Department of Diabetes, Royal Hallamshire Hospital, Sheffield, UK
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
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Abstract
PURPOSE OF REVIEW The review examines the changing causes and the investigation of infectious and noninfectious diarrhoea in individuals with HIV. RECENT FINDINGS Despite the excellent prognosis conferred by combination antiretroviral therapy, diarrhoea is still common in HIV-positive individuals and is associated with reduced quality of life and survival. There is increasing interest in the importance of Th17 and Th22 T cells in the maintenance of mucosal immunity within the gut, and in the role of the gut microbiome in gut homeostasis. Bacterial causes of HIV-associated diarrhoea continue to be important in resource-poor settings. In other settings, sexually transmitted enteric infections such as lymphogranuloma venereum and shigellosis are increasingly reported in men who have sex with men. HIV increases the risk of such infections and the presence of antimicrobial resistance. Parasitic causes of diarrhoea are more common in individuals with uncontrolled HIV and low CD4 counts. Noninfectious causes of diarrhoea include all classes of antiretroviral therapy, which is under-recognised as a cause of poor treatment adherence. Pancreatic dysfunction is remediable and the diagnostic workup of HIV-related diarrhoea should include faecal elastase measurements. New antimotility agents such as crofelemer may be useful in managing secretory diarrhoea symptoms. SUMMARY Clinicians looking after patients with HIV should ask about diarrhoeal symptoms, which are under-reported and may have a remediable infectious or noninfectious cause.
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Turner JM, Pattni SS, Appleby RN, Walters JRF. A positive SeHCAT test results in fewer subsequent investigations in patients with chronic diarrhoea. Frontline Gastroenterol 2017; 8:279-283. [PMID: 29067154 PMCID: PMC5641851 DOI: 10.1136/flgastro-2017-100826] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 02/04/2023] Open
Abstract
UNLABELLED Chronic diarrhoea is a common condition, resulting from a number of different disorders. Bile acid diarrhoea, occurring in about a third of these patients, is often undiagnosed. We hypothesised that a positive diagnosis of bile acid diarrhoea would reduce the need for subsequent investigations for alternative diagnoses. METHODS Patients previously recruited to a study of chronic diarrhoea who had selenium homocholic acid taurine (SeHCAT) testing and subsequent follow-up at our institution were identified. In a retrospective analysis, the numbers of defined investigations undertaken from the first 3 months after SeHCAT in the following 5 years were compared. RESULTS 90 patients were identified with primary bile acid diarrhoea (SeHCAT retention <15%, n=36) or idiopathic diarrhoea (SeHCAT retention >15%, n=54). Follow-up had been performed on 29 and 39 subjects, respectively, with no differences in previous investigations or the last contact date. In the follow-up period, the proportions of these patients who had undergone endoscopic procedures (gastroscopy, colonoscopy and sigmoidoscopy) were the same. However, there was a higher proportion of patients in the SeHCAT-negative group who had other investigations, including imaging, physiological tests and blood tests (p=0.037). The use of cross-sectional imaging was significantly higher in this group (p=0.015) with greater proportions having CT (0.44 vs 0.10) and MRI (0.26 vs 0.07). Ultrasound use and the number of blood tests were higher in the SeHCAT-negative group whereas the SeHCAT-positive group attended more clinic appointments (p=0.013). CONCLUSION A positive diagnosis of bile acid diarrhoea, made by a SeHCAT test, resulted in reduced use of diagnostic investigations over the subsequent 5 years.
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Affiliation(s)
- James M Turner
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK
| | - Sanjeev S Pattni
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK,Department of Gastroenterology, Leicester Royal Infirmary, Leicester, UK
| | - Richard N Appleby
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK
| | - Julian RF Walters
- Division of Digestive Diseases, Imperial College London, Imperial College Healthcare, London, UK
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Sisay M, Engidawork E, Shibeshi W. Evaluation of the antidiarrheal activity of the leaf extracts of Myrtus communis Linn (Myrtaceae) in mice model. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 17:103. [PMID: 28183311 PMCID: PMC5301383 DOI: 10.1186/s12906-017-1625-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/06/2017] [Indexed: 12/26/2022]
Abstract
Background Myrtus communis L. has a folkloric repute for the management of diarrhea and dysentery in different parts of the world. However, the safety and efficacy of the leaf extract have not been scientifically validated in animal model. This study was, therefore, aimed to investigate the antidiarrheal effect of 80% methanol extract (80ME) and solvent fractions of the leaves of Myrtus communis L. in mice. Methods The antidiarrheal activity of the 80ME and solvent fractions was evaluated against castor oil induced diarrheal model, charcoal meal and enteropooling tests. For the 80%ME, the test groups received 100, 200 and 400 mg/kg of the extract. In case of fractions, the test groups received various doses of fractions (200, 300, 400 mg/kg and an additional dose of 800 mg/kg for the aqueous fraction (AF)), where as negative controls received the vehicle (10 ml/kg) and positive controls received loperamide (3 mg/kg). Results The 80ME at 200 mg/kg (p < 0.05) & 400 mg/kg (p < 0.01) as well as the chloroform fraction (CF) and methanol fraction (MF) at 400 mg/kg (p < 0.05) significantly delayed the onset of diarrhea. Besides, the 80ME (at all tested doses) and both of these fractions (at 300 & 400 mg/kg) significantly decreased the frequency and weight of fecal outputs. Results from the charcoal meal test revealed that the 80ME, at all doses, (p < 0.001) as well as the CF and MF at 300 mg/kg (p < 0.05) & 400 mg/kg (p < 0.001) produced a significant anti-motility effect. Similarly, in the entero-pooling test, the 80ME (at all tested doses) (p < 0.01) as well as the CF and MF (at 300 & 400 mg/kg, p < 0.05) produced a significant decline in the weight and volume of intestinal contents, whereas the AF revealed significant effect (p < 0.05) at dose of 800 mg/kg only. Conclusion The study demonstrated that the 80ME and solvent fractions contain bioactive constituents that have antidiarrheal activity. Therefore, this study provides a scientific support for the acclaimed traditional use of Myrtus communis L for the treatment of diarrheal diseases.
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Chronic Diarrhea. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Mena Bares L, Carmona Asenjo E, García Sánchez M, Moreno Ortega E, Maza Muret F, Guiote Moreno M, Santos Bueno A, Iglesias Flores E, Benítez Cantero J, Vallejo Casas J. 75SeHCAT scan in bile acid malabsorption in chronic diarrhea. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.remnie.2016.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Rees CJ, Bevan R, Zimmermann-Fraedrich K, Rutter MD, Rex D, Dekker E, Ponchon T, Bretthauer M, Regula J, Saunders B, Hassan C, Bourke MJ, Rösch T. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65:2045-2060. [PMID: 27802153 PMCID: PMC5136701 DOI: 10.1136/gutjnl-2016-312043] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 09/08/2016] [Accepted: 09/11/2016] [Indexed: 12/12/2022]
Abstract
Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.
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Affiliation(s)
- Colin J Rees
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, UK
| | - Roisin Bevan
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | | | - Matthew D Rutter
- Department of Gastroenterology, North Tees University Hospital, Stockton-on-Tees, UK
| | - Douglas Rex
- Department of Gastroenterology, Indiana University, Indianapolis, USA
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Thierry Ponchon
- Department of Gastroenterology and Hepatology, Edouard Herriot Hospital, Lyon University, Lyon, France
| | - Michael Bretthauer
- Department of Health Management and Health Economics and KG Jebsen Center for Colorectal Cancer Research, University of Oslo, Oslo, Norway
| | - Jaroslaw Regula
- Department of Gastroenterology, Medical Center for Postgraduate Education and the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Brian Saunders
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Becker SL, Yap P, Horié NS, Alirol E, Barbé B, Bhatta NK, Bhattarai NR, Bottieau E, Chatigre JK, Coulibaly JT, Fofana HKM, Jacobs J, Karki P, Khanal B, Knopp S, Koirala K, Mahendradhata Y, Mertens P, Meyanti F, Murhandarwati EH, N’Goran EK, Peeling RW, Pradhan B, Ravinetto R, Rijal S, Sacko M, Saye R, Schneeberger PHH, Schurmans C, Silué KD, Steinmann P, van Loen H, Verdonck K, van Lieshout L, von Müller L, Yao JA, Boelaert M, Chappuis F, Polman K, Utzinger J. Experiences and Lessons from a Multicountry NIDIAG Study on Persistent Digestive Disorders in the Tropics. PLoS Negl Trop Dis 2016; 10:e0004818. [PMID: 27812101 PMCID: PMC5094778 DOI: 10.1371/journal.pntd.0004818] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sören L. Becker
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Peiling Yap
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ninon S. Horié
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Emilie Alirol
- Clinical Research Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Nisha K. Bhatta
- Department of Paediatrics and Adolescent Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Narayan R. Bhattarai
- Department of Microbiology, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Jean T. Coulibaly
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d’Ivoire
- Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | | | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Prahlad Karki
- Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Basudha Khanal
- Department of Microbiology, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Stefanie Knopp
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Wolfson Wellcome Biomedical Laboratories, Department of Life Sciences, Natural History Museum, London, United Kingdom
| | - Kanika Koirala
- Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Yodi Mahendradhata
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia
| | | | - Fransiska Meyanti
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia
| | - Elsa H. Murhandarwati
- Centre for Tropical Medicine, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia
| | - Eliézer K. N’Goran
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d’Ivoire
- Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | | | - Bickram Pradhan
- Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Raffaella Ravinetto
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Suman Rijal
- Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Moussa Sacko
- Institut National de Recherche en Santé Publique, Bamako, Mali
| | - Rénion Saye
- Institut National de Recherche en Santé Publique, Bamako, Mali
| | - Pierre H. H. Schneeberger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Epidemiology and Molecular Diagnostics, Agroscope Changins Wädenswil, Wädenswil, Switzerland
- Department of Virology, Spiez Laboratory, Federal Office for Civil Protection, Spiez, Switzerland
| | - Céline Schurmans
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kigbafori D. Silué
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d’Ivoire
- Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Peter Steinmann
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Harry van Loen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lisette van Lieshout
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lutz von Müller
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Joel A. Yao
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d’Ivoire
- Département Environnement et Santé, Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Katja Polman
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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75SeHCAT scan in bile acid malabsorption in chronic diarrhoea. Rev Esp Med Nucl Imagen Mol 2016; 36:37-47. [PMID: 27765536 DOI: 10.1016/j.remn.2016.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/30/2016] [Indexed: 12/19/2022]
Abstract
Chronic diarrhoea is a common entity in daily clinical practice and it leads to a loss in these patients quality of life. It may be the main symptom of multiple ethiologies including bile acid malabsorption (BAM) which has a comparable prevalence to celiac disease. The BAM results from imbalances in the homeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease or ileal dysfunction (BAM type i), it can be considered idiopathic or primary (BAM type ii) or associated with other gastrointestinal entities (BAM type iii). Among the different diagnostic methods available, 75SeHCAT study is the primary current method due to its sensitivity, specificity, safety and low cost. The main disadvantage is that it's not available in all countries, so other diagnostic methods have appeared, such as serum measurement of FGF19 and C4, however they are significantly more complex and costly. The first-line treatment of bile acid diarrhoea is bile acid sequestrant, such as cholestyramine, which can be difficult to administer due to its poor tolerability and gastrointestinal side effects. These are less prominent with newer agents such as colesevelam. In summary, the BAM is a common entity underdiagnosed and undertreated, so it is essential to establish a diagnosis algorithm of chronic diarrhoea in which the 75SeHCAT study would be first or second line in the differential diagnosis of these patients.
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Bisschops R, De Ruyter V, Demolin G, Baert D, Moreels T, Pattyn P, Verhelst H, Lepoutre L, Arts J, Caenepeel P, Ooghe P, Codden T, Maisonobe P, Petrens E, Tack J. Lanreotide Autogel in the Treatment of Idiopathic Refractory Diarrhea: Results of an Exploratory, Controlled, Before and After, Open-label, Multicenter, Prospective Clinical Trial. Clin Ther 2016; 38:1902-1911.e2. [PMID: 27423779 DOI: 10.1016/j.clinthera.2016.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic idiopathic diarrhea is the passage of loose stools >3 times daily, or a stool weight >200 g/d, persisting for >4 weeks without clear clinical cause. Patients refractory to standard anti-diarrhetics have limited treatment options. Somatostatin analogues have the ability to reduce gastrointestinal secretions and motility. This study evaluated the efficacy and safety of lanreotide Autogel(*) 120 mg in chronic idiopathic diarrhea. METHODS Other anti-diarrhetics were not allowed during the study and were stopped at screening. Patients received lanreotide Autogel 120 mg at baseline and day 28. Stool frequency and consistency (Bristol Stool Scale) were recorded; quality of life (QoL) was assessed using the 36-item Short Form Health Survey and irritable bowel syndrome QoL questionnaires; adverse events were monitored. The primary outcome was the proportion of patients with a reduction of ≥50% or normalization to a mean of ≤3 stools/d at day 28. FINDINGS Thirty-three patients with >3 stools/d at baseline were included; mean (SD) age was 55.2 (16.4) years. Fourteen patients (42.4%) had a response to lanreotide Autogel at day 28 and 17 (51.5%) at day 56. Mean (SD) number of stools decreased significantly from 5.7 (2.2) at baseline to 3.7 (2.2) at day 56 overall (n = 32; P < 0.001). Significant and clinically meaningful improvements in disease-specific QoL were found in the overall populations. No new safety signals emerged. IMPLICATIONS Lanreotide Autogel 120 mg decreased symptoms in these patients with chronic idiopathic refractory diarrhea, and meaningfully improved QoL. These finding have to be confirmed in further clinical trials. ClinicalTrials.gov IDENTIFICATION NCT00891371; Eudract CT 2009-009356-20.
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Affiliation(s)
- Raf Bisschops
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | | | - Gauthier Demolin
- Department of Gastroenterology, CHC Clinique Saint-Joseph, Liège, Belgium
| | - Didier Baert
- Department of Gastroenterology, Maria Middelares Medical Centre, Ghent, Belgium
| | - Tom Moreels
- Department of Gastroenterology, Antwerp University Hospital, Edegem, Belgium
| | - Piet Pattyn
- Department of Abdominal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hans Verhelst
- Department of Abdominal Surgery, Oost-Limburg Hospital, Genk, Belgium
| | - Luc Lepoutre
- Department of Gastroenterology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Joris Arts
- Department of Gastroenterology, University Hospital Sint-Lucas, Brugge, Belgium
| | - Philip Caenepeel
- Department of Gastroenterology, Oost-Limburg Hospital, Genk, Belgium
| | - Patrick Ooghe
- Department of Gastroenterology, Charleroi University Hospital, Charleroi, Belgium
| | - Thierry Codden
- Department of Gastroenterology, Health Centre des Fagnes, Chimay, Belgium
| | | | | | - Jan Tack
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
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Stijnen P, Ramos-Molina B, O'Rahilly S, Creemers JWM. PCSK1 Mutations and Human Endocrinopathies: From Obesity to Gastrointestinal Disorders. Endocr Rev 2016; 37:347-71. [PMID: 27187081 DOI: 10.1210/er.2015-1117] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Prohormone convertase 1/3, encoded by the PCSK1 gene, is a serine endoprotease that is involved in the processing of a variety of proneuropeptides and prohormones. Humans who are homozygous or compound heterozygous for loss-of-function mutations in PCSK1 exhibit a variable and pleiotropic syndrome consisting of some or all of the following: obesity, malabsorptive diarrhea, hypogonadotropic hypogonadism, altered thyroid and adrenal function, and impaired regulation of plasma glucose levels in association with elevated circulating proinsulin-to-insulin ratio. Recently, more common variants in the PCSK1 gene have been found to be associated with alterations in body mass index, increased circulating proinsulin levels, and defects in glucose homeostasis. This review provides an overview of the endocrinopathies and other disorders observed in prohormone convertase 1/3-deficient patients, discusses the possible biochemical basis for these manifestations of the disease, and proposes a model whereby certain missense mutations in PCSK1 may result in proteins with a dominant negative action.
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Affiliation(s)
- Pieter Stijnen
- Laboratory for Biochemical Neuroendocrinology (P.S., B.R.-M., J.W.M.C.), Department of Human Genetics, KU Leuven, Leuven 3000, Belgium; and Medical Research Council (MRC) Metabolic Diseases Unit (S.O.), Wellcome Trust-MRC Institute of Metabolic Science, National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Bruno Ramos-Molina
- Laboratory for Biochemical Neuroendocrinology (P.S., B.R.-M., J.W.M.C.), Department of Human Genetics, KU Leuven, Leuven 3000, Belgium; and Medical Research Council (MRC) Metabolic Diseases Unit (S.O.), Wellcome Trust-MRC Institute of Metabolic Science, National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - Stephen O'Rahilly
- Laboratory for Biochemical Neuroendocrinology (P.S., B.R.-M., J.W.M.C.), Department of Human Genetics, KU Leuven, Leuven 3000, Belgium; and Medical Research Council (MRC) Metabolic Diseases Unit (S.O.), Wellcome Trust-MRC Institute of Metabolic Science, National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
| | - John W M Creemers
- Laboratory for Biochemical Neuroendocrinology (P.S., B.R.-M., J.W.M.C.), Department of Human Genetics, KU Leuven, Leuven 3000, Belgium; and Medical Research Council (MRC) Metabolic Diseases Unit (S.O.), Wellcome Trust-MRC Institute of Metabolic Science, National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, University of Cambridge, Cambridge CB2 0QQ, United Kingdom
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Wagner M, Sjöberg K, Vigren L, Olesen M, Benoni C, Toth E, Carlson M. Elevated fecal levels of eosinophil granule proteins predict collagenous colitis in patients referred to colonoscopy due to chronic non-bloody diarrhea. Scand J Gastroenterol 2016; 51:835-841. [PMID: 26854205 DOI: 10.3109/00365521.2016.1141432] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Colonoscopy with biopsy sampling is often performed to detect collagenous colitis (CC) and lymphocytic colitis (LC) in patients with chronic non-bloody diarrhea. However, the diagnostic yield is low and incurs high costs. Fecal calprotectin (FC) and myeloperoxidase (MPO) indicate intestinal inflammation in ulcerative colitis (UC) and Crohn's disease (CD). In CC, elevated fecal levels of eosinophil protein X (EPX) and eosinophil cationic protein (ECP) have been reported. We aimed to evaluate if F-EPX, F-ECP, FC, and F-MPO could predict the diagnostic outcome in patients with chronic non-bloody diarrhea referred to colonoscopy. We also evaluated serum (S) EPX and ECP in this regard. METHODS Of 67 included patients, 63 (94%) underwent colonoscopy with biopsy sampling. Fecal EPX, F-ECP, FC, F-MPO, S-EPX, and S-ECP were analyzed. RESULTS Diagnostic outcome: normal: n = 46 (73%), CC: n = 9 (14%), LC: n = 4 (6%), UC: n = 2 (3%), CD: n = 2 (3%). Higher levels of F-EPX and F-ECP were found in CC compared to a normal diagnostic outcome (p = 0.01). No change was noted in any of the fecal markers in LC. When all of the fecal markers were normal the probability of a normal diagnostic outcome was 92%. We found no differences in S-EPX and S-ECP between the groups. CONCLUSION Elevated F-EPX and F-ECP could predict CC. None of the fecal markers predicted LC. Serum-EPX and S-ECP are not useful for the diagnosis of CC, LC, UC, or CD. With normal levels in all of the analyzed fecal markers, there is a low probability of a pathologic diagnostic outcome.
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Affiliation(s)
- Michael Wagner
- a Department of Medical Sciences, Gastroenterology Research Group , Uppsala University , Uppsala , Sweden
| | - Klas Sjöberg
- b Department of Clinical Sciences, Department of Gastroenterology and Nutrition , Skåne University Hospital, Lund University , Malmö , Sweden
| | - Lina Vigren
- c Department of Medicine , Ystad Hospital , Ystad , Sweden
| | - Martin Olesen
- d Department of Pathology , University and Regional Laboratories Region Skåne, Skåne University Hospital , Malmö , Sweden
| | - Cecilia Benoni
- e Department of Clinical Sciences, Department of Medicine , Skåne University Hospital, Lund University , Malmö , Sweden
| | - Ervin Toth
- b Department of Clinical Sciences, Department of Gastroenterology and Nutrition , Skåne University Hospital, Lund University , Malmö , Sweden
| | - Marie Carlson
- a Department of Medical Sciences, Gastroenterology Research Group , Uppsala University , Uppsala , Sweden
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Grillot J, Galmiche M, Antunès O, Hébuterne X, Schneider SM. Conduite à tenir pratique pour l’exploration d’une malabsorption, d’une maldigestion, et d’une entéropathie exsudative. NUTR CLIN METAB 2016. [DOI: 10.1016/j.nupar.2016.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Summers JA, Peacock J, Coker B, McMillan V, Ofuya M, Lewis C, Keevil S, Logan R, McLaughlin J, Reid F. Multicentre prospective survey of SeHCAT provision and practice in the UK. BMJ Open Gastroenterol 2016; 3:e000091. [PMID: 27252882 PMCID: PMC4885269 DOI: 10.1136/bmjgast-2016-000091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/04/2016] [Accepted: 04/13/2016] [Indexed: 12/14/2022] Open
Abstract
Objective A clinical diagnosis of bile acid malabsorption (BAM) can be confirmed using SeHCAT (tauroselcholic (75selenium) acid), a radiolabelled synthetic bile acid. However, while BAM can be the cause of chronic diarrhoea, it is often overlooked as a potential diagnosis. Therefore, we investigated the use of SeHCAT for diagnosis of BAM in UK hospitals. Design A multicentre survey was conducted capturing centre and patient-level information detailing patient care-pathways, clinical history, SeHCAT results, treatment with bile acid sequestrants (BAS), and follow-up in clinics. Eligible data from 38 centres and 1036 patients were entered into a validated management system. Results SeHCAT protocol varied between centres, with no standardised patient positioning, and differing referral systems. Surveyed patients had a mean age of 50 years and predominantly women (65%). The mean SeHCAT retention score for all patients was 19% (95% CI 17.8% to 20.3%). However, this differed with suspected BAM type: type 1: 9% (95% CI 6.3% to 11.4%), type 2: 21% (95% CI 19.2% to 23.0%) and type 3: 22% (95% CI 19.6% to 24.2%). Centre-defined ‘abnormal’ and ‘borderline’ results represented over 50% of the survey population. BAS treatment was prescribed to only 73% of patients with abnormal results. Conclusions The study identified a lack of consistent cut-off/threshold values, with differing centre criteria for defining an ‘abnormal’ SeHCAT result. BAS prescription was not related in a simple way to the SeHCAT result, nor to the centre-defined result, highlighting a lack of clear patient care-pathways. There is a clear need for a future diagnostic accuracy study and a better understanding of optimal management pathways.
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Affiliation(s)
- Jennifer A Summers
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Janet Peacock
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Bolaji Coker
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Viktoria McMillan
- King's Technology Evaluation Centre, King's College London, London, UK; Department of Medical Engineering and Physics, King's College Hospital NHS Foundation Trust, London, UK
| | - Mercy Ofuya
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Cornelius Lewis
- King's Technology Evaluation Centre, King's College London, London, UK; Department of Medical Engineering and Physics, King's College Hospital NHS Foundation Trust, London, UK
| | - Stephen Keevil
- King's Technology Evaluation Centre, King's College London, London, UK; Department of Medical Physics, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Robert Logan
- Department of Gastroenterology , King's College Hospital NHS Foundation Trust , London , UK
| | - John McLaughlin
- Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal NHS Foundation Trust, Salford, UK; Research Committee, British Society of Gastroenterology, London, UK
| | - Fiona Reid
- Division of Health and Social Care Research, King's College London, London, UK; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
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Mottacki N, Simrén M, Bajor A. Review article: bile acid diarrhoea - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2016; 43:884-898. [PMID: 26913381 DOI: 10.1111/apt.13570] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 08/29/2015] [Accepted: 02/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile acid diarrhoea results from imbalances in the homoeostasis of bile acids in the enterohepatic circulation. It can be a consequence of ileal disease/dysfunction, associated with other GI pathology or can be idiopathic. AIMS To summarise the different types of bile acid diarrhoea and discuss the currently available diagnostic methods and treatments. RESULTS Bile acid diarrhoea is found in up to 40% of patients diagnosed as having functional diarrhoea/IBS-D, and in up to 80% of patients who have undergone ileal resection. It is likely under-diagnosed and under-treated. In idiopathic disease, errors in regulation feedback of fibroblast growth factor 19 contribute to the development of the condition. Clinical therapeutic trials for bile acid diarrhoea have been used to diagnose it, but the 75 SeHCAT test is the primary current method. It is sensitive, specific and widely available, though not in the USA. Other diagnostic methods (such as serum measurement of the bile acid intermediate 7α-hydroxy-4-cholesten-3-one, or C4) have less widespread availability and documentation, and some (such as faecal measurement of bile acids) are significantly more complex and costly. First-line treatment of bile acid diarrhoea is with the bile acid sequestrant cholestyramine, which can be difficult to administer and dose due to gastrointestinal side effects. These side effects are less prominent in newer agents such as colesevelam, which may provide higher efficacy, tolerability and compliance. CONCLUSION Bile acid diarrhoea is common, and likely under-diagnosed. Bile acid diarrhoea should be considered relatively early in the differential diagnosis of chronic diarrhoea.
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Affiliation(s)
- N Mottacki
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A Bajor
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine, Södra Älvsborgs Sjukhus, Borås, Sweden
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Hungin APS, Paxman L, Koenig K, Dalrymple J, Wicks N, Walmsley J. Prevalence, symptom patterns and management of episodic diarrhoea in the community: a population-based survey in 11 countries. Aliment Pharmacol Ther 2016; 43:586-95. [PMID: 26749499 DOI: 10.1111/apt.13513] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 05/13/2015] [Accepted: 12/11/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND The extent of episodic diarrhoea in the community is relatively unknown. AIM To ascertain the prevalence, symptoms and management behaviours associated with self-reported diarrhoea across 11 countries. METHODS Community screening surveys were conducted using quota sampling of respondents to identify a nationally representative sample of individuals suffering from 'episodic' diarrhoea (occurring once a month or more often). Second-phase in-depth surveys provided data on epidemiology, symptoms, attributed causes and management of episodic diarrhoea. RESULTS A total of 11 508 phase 1 and 6613 phase 2 surveys were completed. The prevalence of self-reported episodic diarrhoea ranged from 16% to 23% across the 11 countries. The majority of episodic diarrhoea sufferers were female (57%) and were not diagnosed with pre-existing irritable bowel syndrome (IBS); IBS diagnosis ranged from 9% in Mexico to 44% in Italy. Diarrhoea was frequently attributed to anxiety/stress, food-related causes, gastrointestinal 'sensitivity' and menstruation. Accompanying symptoms included 'stomach pain/cramping' (35-62%), 'stomach grumbling' (29-68%) and 'wind' (18-74%). The proportion of episodic sufferers who reported treating their symptoms with remedies or medications ranged between 46% in Belgium and Canada and 90% in Mexico. CONCLUSIONS A substantial proportion of the population in middle- to high-income countries report episodic diarrhoea in the absence of a pre-existing diagnosis. These symptoms are likely to be associated with substantial social and economic costs, and have implications on how best to configure and guide self-led, pharmacist-led and primary care management.
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Affiliation(s)
- A P S Hungin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Stockton-on-Tees, UK
| | | | - K Koenig
- Johnson & Johnson Ltd, Maidenhead, UK
| | - J Dalrymple
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - N Wicks
- Right Medicine Pharmacy Ltd., Stirling, Scotland
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Affiliation(s)
- Colin Rees
- South Tyneside NHS Foundation Trust, Gastroenterology Department, South Shields, United Kingdom,Corresponding author Colin Rees South Tyneside NHS TrustGastroenterology DepartmentHarton LaneSouth Shields NE34 0PLUnited Kingdom
| | - Laura Neilson
- South Tyneside NHS Foundation Trust, Gastroenterology Department, South Shields, United Kingdom
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Abstract
Diarrhoea induced by chemotherapy in cancer patients is common, causes notable morbidity and mortality, and is managed inconsistently. Previous management guidelines were based on poor evidence and neglect physiological causes of chemotherapy-induced diarrhoea. In the absence of level 1 evidence from randomised controlled trials, we developed practical guidance for clinicians based on a literature review by a multidisciplinary team of clinical oncologists, dietitians, gastroenterologists, medical oncologists, nurses, pharmacist, and a surgeon. Education of patients and their carers about the risks associated with, and management of, chemotherapy-induced diarrhoea is the foundation for optimum treatment of toxic effects. Adequate--and, if necessary, repeated--assessment, appropriate use of loperamide, and knowledge of fluid resuscitation requirements of affected patients is the second crucial step. Use of octreotide and seeking specialist advice early for patients who do not respond to treatment will reduce morbidity and mortality. In view of the burden of chemotherapy-induced diarrhoea, appropriate multidisciplinary research to assess meaningful endpoints is urgently required.
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Abstract
BACKGROUND Bariatric surgical procedures are classified by their presumed mechanisms of action: restrictive, malabsorptive or a combination of both. However, this dogma is questionable and remains unproven. We investigated post-operative changes in nutrient absorption and transit time following bariatric surgery. METHODS Participants were recruited into four groups: obese controls (body mass index (BMI) >30 kg/m2, n = 7), adjustable gastric banding (n = 6), Roux-en-Y gastric bypass (RYGB, n = 7) and biliopancreatic diversion with duodenal switch (DS, n = 5). Participants underwent sulphasalazine/sulphapyridine tests (oro-caecal transit time); fasting plasma citrulline (functional enterocyte mass); 3 days faecal collection for faecal elastase 1 (FE-1); calprotectin (FCp); faecal fatty acids (pancreatic exocrine function, gut inflammation and fat excretion, respectively); and 5 h D-xylose, L-rhamnose and lactulose test (intestinal absorption and permeability). RESULTS Age and gender were not different but BMI differed between groups (p = 0.001). No difference in oro-caecal transit time (p = 0.935) or functional enterocyte mass (p = 0.819) was detected. FCp was elevated post-RYGB vs. obese (p = 0.016) and FE-1 was reduced post-RYGB vs. obese (p = 0.002). Faecal fat concentrations were increased post-DS vs. obese (p = 0.038) and RYGB (p = 0.024) and were also higher post-RYGB vs. obese (p = 0.033). Urinary excretion of D-xylose and L-rhamnose was not different between the groups; however, lactulose/rhamnose ratio was elevated post-DS vs. other groups (all p < 0.02), suggesting increased intestinal permeability. CONCLUSIONS Following RYGB, there are surprisingly few abnormalities or indications of severe malabsorption of fats or sugars. Small bowel adaptation after bariatric surgery may be key to understanding the mechanisms responsible for the beneficial metabolic effects of these operations.
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Chan DK, Simonetto DA, Hauser SC. 60-year-old man with chronic diarrhea and peptic ulcer disease. Mayo Clin Proc 2015; 90:e1-5. [PMID: 25572206 DOI: 10.1016/j.mayocp.2014.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Daniel K Chan
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Douglas A Simonetto
- Fellow in Gastroenterology, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Stephen C Hauser
- Adviser to resident and fellow and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Abstract
Microscopic colitis (MC) is described as an inflammatory bowel disease characterized by chronic, bloodless diarrhea with normal or close to normal endoscopic findings. Histopathological examination reveals two subtypes: collagenous colitis (CC) and lymphocytic colitis (LC), which are indistinguishable clinically. The disease debuts typically in middle-aged patients, but can occur at all ages, including children. A female predominance is found in both CC and LC, but is not confirmed by others in LC. The etiology is unclear, but the disease has been assumed to be of autoimmune origin. However, several etiologies may render a microscopic inflammation in the mucosa; this is a common, universal reaction to a variety of irritants in contact with the intestinal lumen. Furthermore, some patients with a microscopic inflammation in their colonic mucosa have no symptoms, or are suffering from constipation or abdominal pain, rather than diarrhea. Recently, a discussion was initiated calling into question the overdiagnosing of symptoms and pointing out the danger of exacerbating people's perception of their ailments, of weakening their eligibility in health insurance, of overprescription of drugs, and thus the increasing cost to the society of health care. In the light of this discussion, this review will highlight histopathological and clinical features of MC, and discuss the diagnosis and management of this disease. Perhaps, the intestinal mucosa has no other mode by which to react than an inflammatory response, irrespective of the presence or absence of autoimmunity. Thus, to better identify and classify subgroups of MC, and to clarify and correctly handle the inflammatory changes, this field of research stands to benefit from a review of the results and experience gained to date.
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Affiliation(s)
- Bodil Ohlsson
- Department of Clinical Sciences, Division of Internal Medicine, Skåne University Hospital, Inga Marie Nilssons Street 32, S-205 02 Malmö, Sweden
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Hunt DP, Sahani DV, Corey KE, Masia R. Case records of the Massachusetts General Hospital. Case 30-2014. A 29-year-old man with diarrhea, nausea, and weight loss. N Engl J Med 2014; 371:1238-47. [PMID: 25251619 DOI: 10.1056/nejmcpc1405218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Poulsen JL, Brock C, Olesen AE, Nilsson M, Drewes AM. Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction. Clin Exp Gastroenterol 2014; 7:345-58. [PMID: 25278772 PMCID: PMC4179399 DOI: 10.2147/ceg.s52097] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Opioid-induced bowel dysfunction (OIBD) is a burdensome condition which limits the therapeutic benefit of analgesia. It affects the entire gastrointestinal tract, predominantly by activating opioid receptors in the enteric nervous system, resulting in a wide range of symptoms, such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation. The majority of studies evaluating OIBD focus on constipation experienced in approximately 60% of patients. Nevertheless, other presentations of OIBD seem to be equally frequent. Furthermore, laxative treatment is often insufficient, which in many patients results in decreased quality of life and discontinuation of opioid treatment. Novel mechanism-based pharmacological approaches targeting the gastrointestinal opioid receptors have been marketed recently and even more are in the pipeline. One strategy is prolonged release formulation of the opioid antagonist naloxone (which has limited systemic absorption) and oxycodone in a combined tablet. Another approach is peripherally acting, μ-opioid receptor antagonists (PAMORAs) that selectively target μ-opioid receptors in the gastrointestinal tract. However, in Europe the only PAMORA approved for OIBD is the subcutaneously administered methylnaltrexone. Alvimopan is an oral PAMORA, but only approved in the US for postoperative ileus in hospitalized patients. Finally, naloxegol is a novel, oral PAMORA expected to be approved soon. In this review, the prevalence and pathophysiology of OIBD is presented. As PAMORAs seem to be a promising approach, their potential effect is reviewed with special focus on naloxegol's pharmacological properties, data on safety, efficacy, and patient-focused perspectives. In conclusion, as naloxegol is administered orally once daily, has proven efficacious compared to placebo, has an acceptable safety profile, and can be used as add-on to existing pain treatment, it is a welcoming addition to the targeted treatment possibilities for OIBD.
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Affiliation(s)
- Jakob Lykke Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Estrup Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Matias Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark ; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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[Abdominal pain and chronic diarrhea in a 55-year-old woman]. Rev Med Interne 2014; 36:135-9. [PMID: 25225068 DOI: 10.1016/j.revmed.2014.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 08/01/2014] [Indexed: 11/23/2022]
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Lewis JM, Goodwin L, Beadsworth MBJ. The returning traveller with diarrhoea. Br J Hosp Med (Lond) 2014; 75:C133-6. [DOI: 10.12968/hmed.2014.75.9.c133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- JM Lewis
- Specialist Trainee in Infectious Diseases
| | - L Goodwin
- Specialist Trainee in Infectious Diseases
| | - MBJ Beadsworth
- Consultant in Infectious Diseases in the Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP
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Abstract
Chronic diarrhoea induced by bile acids is common and the underlying mechanisms are linked to homeostatic regulation of hepatic bile acid synthesis by fibroblast growth factor 19 (FGF19). Increasing evidence, including that from several large case series using SeHCAT (selenium homocholic acid taurine) tests for diagnosis, indicates that bile acid diarrhoea (BAD) accounts for a sizeable proportion of patients who would otherwise be diagnosed with IBS. Studies of other approaches for diagnosis of BAD have shown increased bile acid synthesis, increased faecal levels of primary bile acids, dysbiosis and different urinary volatile organic compounds when compared with healthy controls or with other diseases. The role of the ileal hormone FGF19 in BAD has been strengthened: a prospective clinical study has confirmed low FGF19 levels in BAD, and so a test to measure these levels could be developed for diagnosis. In animal models, FGF19 depletion by antibodies produces severe diarrhoea. Bile acids affect colonic function through farnesoid X receptor (FXR) and TGR5 receptors. As well as these effects in the colon, FXR-dependent stimulation of ileal FGF19 production could be a logical mechanism to provide therapeutic benefit in BAD. Further studies of FGF19 in humans hold promise in providing novel treatments for this cause of chronic diarrhoea.
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Bile acid malabsorption in chronic diarrhea: pathophysiology and treatment. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:653-9. [PMID: 24199211 DOI: 10.1155/2013/485631] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%. METHODS The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice. RESULTS BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea. CONCLUSIONS BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.
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Srinivas M, Basumani P, Podmore G, Shrimpton A, Bardhan KD. Utility of testing patients, on presentation, for serologic features of celiac disease. Clin Gastroenterol Hepatol 2014; 12:946-52. [PMID: 24262940 DOI: 10.1016/j.cgh.2013.10.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/11/2013] [Accepted: 10/30/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Celiac disease shares features of other disorders. It can be diagnosed conclusively only based on duodenal histology analysis, which is not practical for screening purposes. Serologic analysis might be used to identify candidates for biopsy analysis. We aimed to develop a simple diagnostic approach that all clinicians could follow to increase the percentage of patients accurately diagnosed with celiac disease at initial presentation. METHODS We performed a retrospective analysis of data from 752 patients (88 with celiac disease, none were IgA deficient) who attended a UK district general hospital from January 2007 through December 2008 and underwent biopsy analysis and serologic tests to measure endomyseal antibodies and IgA antibodies against tissue transglutaminase (tTG). Patients avoiding gluten in their diet were excluded. Patients were assigned to 1 of 4 groups: high-risk (based on presence of anemia, chronic diarrhea, unintentional weight loss, or dermatitis herpetiformis), low-risk (based on such factors as dyspepsia, abnormal liver function, ataxia, or chronic cough), nutrient deficiency (based on levels of iron, vitamins B12 and D, or folate), or screening (because they had type 1 diabetes or a family history of celiac disease). Patients with celiac disease were identified using the modified Marsh criteria (grades 1-3) for interpreting duodenal histology. We compared clinical category, serology profiles, and biopsy results between patients with and without celiac disease. RESULTS Celiac disease was diagnosed in 64 of 565 patients in the high-risk group (11%), 14 of 156 patients in the low-risk group (9%; P = .47 compared with high-risk group), 7 of 28 patients in the nutrient-deficiency group, and 3 of 3 patients in the screening group. Among 71 patients who tested positive for both antibodies (tTG and endomyseal antibodies), the positive predictive value for celiac disease was 97%; a negative test result for tTG had a negative predictive value of 98%. Among 708 patients with normal-looking biopsy samples, only 62 had celiac disease (9%). Among 44 patients with abnormal biopsy samples, 26 had celiac disease (59%). CONCLUSIONS Based on a retrospective analysis, patients with and without celiac disease cannot be distinguished based on clinical features. Patients who present with symptoms of celiac disease should be tested for tTG, to identify candidates for duodenal biopsy analysis.
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Affiliation(s)
- Melpakkam Srinivas
- Department of Gastroenterology, The Rotherham NHS Foundation Trust, Rotherham, South Yorkshire, United Kingdom
| | - Pandurangan Basumani
- Department of Gastroenterology, The Rotherham NHS Foundation Trust, Rotherham, South Yorkshire, United Kingdom
| | - Geoff Podmore
- Department of Immunology, The Rotherham NHS Foundation Trust, Rotherham, South Yorkshire, United Kingdom
| | - Anna Shrimpton
- Department of Immunology, The Rotherham NHS Foundation Trust, Rotherham, South Yorkshire, United Kingdom
| | - Karna Dev Bardhan
- Department of Gastroenterology, The Rotherham NHS Foundation Trust, Rotherham, South Yorkshire, United Kingdom.
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Caccaro R, D’Incà R, Martinato M, Pont ED, Pathak S, Frigo AC, Sturniolo GC. Fecal lactoferrin and intestinal permeability are effective non-invasive markers in the diagnostic work-up of chronic diarrhea. Biometals 2014; 27:1069-76. [DOI: 10.1007/s10534-014-9745-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/23/2014] [Indexed: 12/22/2022]
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Tontini GE, Pastorelli L, Spina L, Fabris F, Bruni B, Clemente C, de Nucci G, Cavallaro F, Marconi S, Neurath MF, Neumann H, Tacconi M, Vecchi M. Microscopic colitis and colorectal neoplastic lesion rate in chronic nonbloody diarrhea: a prospective, multicenter study. Inflamm Bowel Dis 2014; 20:882-91. [PMID: 24681653 DOI: 10.1097/mib.0000000000000030] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Lymphocytic and collagenous colitis are emerging as common findings in subjects undergoing colonoscopy for chronic non-bloody diarrhea (CNBD). Data concerning microscopic colitis (MC) are still limited and affected by controversial epidemiological evidences. Recent converging lines of evidence suggest that MC correlates a lower risk of colorectal neoplasia. Accordingly, we prospectively assessed MC prevalence in a multicenter cohort of subjects submitted to colonoscopy for CNBD, thereby defining whether MC influences the risk of colorectal neoplasia. METHODS Consecutive patients with CNBD of unknown origin underwent pan-colonoscopy with multiple biopsies. The prevalence of neoplastic patients in MC was compared with that observed in negative CNBD subjects. RESULTS Among 8006 colonoscopy, 305 subjects were enrolled for CNBD. Patients with CNBD were more likely to be women than men (odds ratio = 1.5; P = 0.001). Histopathology detected high prevalence of MC (16%) with a clear predominance of collagenous colitis (70%). A striking age-dependent rise in MC-associated risk was observed, depicting outstanding differences among varying age groups, as in the number needed to screen 1 new case. Gender distribution was balanced within MC patients (Female/Male = 1.5/1), especially among lymphocytic colitis (Female/Male = 1.2/1). MC patients were negatively associated with the risk of neoplastic polyps compared with negative CNBD subjects (odds ratio = 0.22; P = 0.035). CONCLUSIONS MC is the first cause of CNBD in subjects submitted to colonoscopy. Multiple biopsies are strongly recommended, even in the case of uneventful endoscopic inspection, especially for age ≥40 years. MC has a reduced risk of colorectal neoplasia, suggesting that this model of chronic inflammation plays a protective effect against colorectal carcinogenesis.
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Affiliation(s)
- Gian Eugenio Tontini
- *Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy; †Department of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany; ‡Department of Biomedical Sciences for Health, University of Milan, Milano, Italy; §Gastroenterology and Digestive Endoscopy Unit, Istituti Clinici Zucchi, Monza, Italy; ‖Pathology and Citodiagnostic Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy; and ¶Medical Department, Chiesi Farmaceutici SpA, Parma, Italy
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Kim DH, Lee D, Kim JW, Huh J, Park SH, Ha HK, Suh C, Yoon SM, Kim KJ, Choi KD, Ye BD, Byeon JS, Song HJ, Jung HY, Yang SK, Kim JH, Myung SJ. Endoscopic and clinical analysis of primary T-cell lymphoma of the gastrointestinal tract according to pathological subtype. J Gastroenterol Hepatol 2014; 29:934-43. [PMID: 24325295 DOI: 10.1111/jgh.12471] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Little is known about the clinicopathological characteristics of primary gastrointestinal T-cell lymphomas (PGITL). This study evaluated the clinical and endoscopic features of the pathological subtypes of PGITL. METHODS Forty-two lesions in 36 patients with PGITL were assessed, including 15 enteropathy-associated T-cell lymphomas (EATL), 13 peripheral T-cell lymphomas (PTCL), 10 NK/T-cell lymphomas (NK/TL), and four anaplastic large cell lymphomas (ALCL). RESULTS PTCL occurred more frequently in the stomach and duodenum and NK/TL more frequently in the small and large intestines (P = 0.009). The endoscopic features of the four subtypes were similar (P = 0.124). Fifteen of 41 lesions (36.6%) were Epstein-Barr virus (EBV) positive, with NK/TL more likely to be EBV positive than the other types (P < 0.001). First endoscopy and first computed tomography (CT) scan indicated that 65.4% and 51.4% of the lesions, respectively, were malignant, and that 43.2% and 42.3%, respectively, were GI lymphomas. The two modalities together correctly diagnosed about half of the lesions before biopsy. Intestinal perforation was associated with small bowel location (P < 0.001) and infiltrative type (P = 0.009), and was more common in NK/TL than in the other subtypes (P = 0.015). Multivariate analysis showed that higher international prognosis index (P = 0.008) and the presence of complications (P = 0.006) were associated with poor prognosis. Survival was poorer in patients with small bowel lesions than with lesions at other locations (P = 0.048). CONCLUSIONS The four main pathological types of PGITL differed in clinical characteristics. As PGITL was often not diagnosed by initial endoscopic or radiological examination, a high index of suspicion is necessary to ensure its early diagnosis.
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Affiliation(s)
- Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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