Dietary fibre and gastrointestinal disease

Management of Colonic Diverticulitis Tailored to Location and Severity: Comparison of the Right and the Left Colon

Purpose

This study assessed optimal management of colonic diverticulitis as functions of disease location and severity and factors associated with complicated diverticulitis.

Methods

This retrospective review analyzed 202 patients diagnosed between 2007 and 2014 at Chonbuk National University Hospital, South Korea, with colonic diverticulitis by using abdominopelvic computed tomography. Diverticulitis location was determined, and disease severity was categorized using the modified Hinchey classification.

Results

Patients included 108 males (53.5%) and 94 females (46.5%); of these, 167 patients (82.7%) were diagnosed with right-sided and 35 (17.3%) with left-sided colonic diverticulitis. Of the 167 patients with right-sided colonic diverticulitis, 12 (7.2%) had complicated and 155 (92.8%) had uncomplicated diverticulitis; of these, 157 patients (94.0%) were successfully managed conservatively. Of the 35 patients with left-sided colonic diverticulitis, 23 (65.7%) had complicated and 12 (34.3%) had uncomplicated diverticulitis; of these, 23 patients (65.7%) were managed surgically. Among patients with right-sided diverticulitis, those with complicated disease were significantly older (54.3 ± 12.7 years vs. 42.5 ± 13.4 years, P = 0.004) and more likely to be smokers (66.7% vs. 32.9%, P = 0.027) than those with uncomplicated disease. However, among patients with left-sided diverticulitis, those with complicated disease had significantly lower body mass index (BMI; 21.9 ± 4.7 kg/m² vs. 25.8 ± 4.3 kg/m², P = 0.021) than those with uncomplicated disease.

Conclusion

Conservative management may be effective in patients with right-sided diverticulitis and patients with uncomplicated left-sided colonic diverticulitis. Surgical management may be required for patients with complicated left-sided diverticulitis. Factors associated with complicated diverticulitis include older age, smoking and lower BMI.

Constipation and pregnancy

Constipation is a common symptom during pregnancy. The majority of cases are simple constipation that occurs due to a combination of hormonal and mechanical factors affecting normal GI function. However, a number of women suffer from constipation prior to conception and find their symptoms worsen during pregnancy. Patients with simple constipation can usually be treated by explanation, reassurance and advice. Medications are best avoided but if necessary should be taken under supervision using best available evidence. It is important that all patients be evaluated by detailed history, physical examination and basic investigations to outrule GI pathology that may be present in a small number of cases. Those whose symptoms predated their pregnancy should be fully evaluated after the puerperium.

The effect of combat rations on bowel habits in a combat environment

BACKGROUND

Combat rations have long been suspected to affect the bowel habits of deployed soldiers by causing significant constipation. This may create morbidity and result in decreased troop readiness. In a uniform population of deployed combat soldiers, we sought to determine the effect of combat rations on changes in bowel habits.

METHODS

Over a 4-month period from December 2001 through March 2002, 118 soldiers were followed prospectively using a bowel habit diary. Soldiers were evaluated by age, race, gender, past medical history, ration intake, and medications including fiber use. Subjects were then screened for changes in diarrhea and constipation. We performed an analysis to determine predictors for changing habits.

RESULTS

There were 108 males and 10 females. Mean follow-up was 42.6 +/- 23.1 days. Groups were comparable in demographics, time in the combat zone, and fluid/fiber intake (P = not significant [NS]). No change in habits were found in 58%, 19% had an increase in constipation, 13% had an increase in diarrhea, and 10% had increase in both diarrhea and constipation, while 8% had improvements.

CONCLUSION

Combat rations and environment have variable effects on bowel habits, with no loss in workdays. Although 64% of subjects experienced either no change or improvement, and 36% had worsened symptoms, this appears unrelated to ration or fiber intake.

Coping strategies, illness perception, anxiety and depression of patients with idiopathic constipation: a population-based study

BACKGROUND

Functional constipation has important psychological elements.

AIM

To investigate the prevalence of functional constipation in an Asian population, and the interplay among functional constipation, anxiety/depression, perception and coping strategies.

METHODS

An interview of 3282 patients was made by telephone survey. Constipation was diagnosed by Rome II criteria. Coping ability and anxiety/depression were assessed by validated questionnaires.

RESULTS

Fourteen percent of the interviewees had constipation. Anxiety and depression scores were higher in constipated than in healthy subjects (P < 0.0001 and < 0.0001), and in female than male patients (P = 0.02 and < 0.0001). Patients who were aware of their symptoms perceived greater impact on their lives (P < 0.001). Frequent use of coping strategies associated with lower anxiety scores (P < 0.0001). Female were more frequently aware of the symptoms (P = 0.004), less frequently used coping strategies (P = 0.008). Regression analysis showed that female and high anxiety level were the independent factors for predicting the perception of constipation, whereas anxiety was the only independent factor for predicting the use of coping strategies.

CONCLUSION

Constipation associated with anxiety and depression is prevalent in the general Asian population. Female sex and anxiety are important aetiological factors in constipation, affecting perception and the use of coping strategies.

Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting

BACKGROUND

Gastro-oesophageal reflux disease (GERD) and constipation have a major impact on public health; however, the wide variety of treatment options presents difficulties for recommending therapy. Lack of definitive guidelines in pharmacy and general practice medicine further exacerbates the decision dilemma.

AIMS

To address these issues, a panel of experts discussed the principles and practice of treating GERD and constipation in the general population and in pregnancy, with the aim of developing respective treatment guidelines.

RESULTS

The panel recommended antacids 'on-demand' as the first-line over-the-counter treatment in reflux, and as rescue medication for immediate relief when reflux breaks through with proton pump inhibitors. Calcium/magnesium-based antacids were recommended as the treatment of choice for pregnant women because of their good safety profile. In constipation, current data do not distinguish a hierarchy between polyethylene glycol (PEG)-based laxatives and other first-line treatments, although limitations are associated with stimulant- and bulk-forming laxatives. Where data are available, PEG is superior to lactulose in terms of efficacy. In pregnancy, PEG-based laxatives meet the criteria for the ideal treatment.

CONCLUSIONS

The experts developed algorithms that present healthcare professionals with clear treatment options and management strategies for GERD and constipation in pharmacy and general practice medicine.

Medical management of diverticular disease

Diverticular disease is a common disorder affecting 30-55% of the population in the developed world. It has been described as "a deficiency disease of Western civilization", a theory that has been proposed since it was observed that diverticular disease was uncommon in African and other developing countries where dietary fibre consumption was high. At the turn of the century the medical treatment of colonic diverticulosis involved the avoidance of "roughage", which was felt to exacerbate the problem. However, the use of high fibre diets in the prevention and treatment of the symptoms of diverticular disease has now become commonplace, and the development of this practice is discussed in this chapter.

Sociodemographic and lifestyle factors associated with constipation in an elderly Asian community

OBJECTIVE

We surveyed elderly individuals in an Asian community to determine the prevalence of constipation and its association with sociodemographic and lifestyle factors. This information will be used to plan a health promotion program for the elderly.

METHODS

A random sample of 2807 residents aged > or = 60 yr in Singapore were interviewed in their homes, using a standardized questionnaire. The response rate was 87.4% (n = 2454).

RESULTS

The overall age- and gender-adjusted prevalence rate of functional constipation was 11.6 per 100 persons (95% confidence interval [CI], 11.4-11.7). There were no gender or ethnic differences in constipation rates. Increased rates of constipation were significantly associated with advancing age. We found a significant dose-response relationship of increased constipation rates with decreased intake of rice, increased intake of Chinese tea, and number of chronic illnesses and medications, after controlling for potential confounders. Constipation was also significantly associated with lower intake of fruits and vegetables, but no dose-response gradient was seen.

CONCLUSIONS

Patients taking many medications should be monitored for constipation and given advice to avoid constipating factors. Further studies are needed to establish the causal-effect relationship of rice and Chinese tea with constipation.

Bulking fibre prevents translocation to mesenteric lymph nodes of an efficiently translocating Escherichia coli strain in rats

BACKGROUND

starvation for 24 h prior to experimental haemorrhage increases bacterial translocation in rats. Forty-eight hours starvation alone causes pronounced microbiological changes in caecal contents and a marked increase in bacterial adherence to caecal epithelium. The aim of the present study was to examine whether bulking fibre prevents these microbiological changes induced by starvation, i.e. mucosal adherence and/or bacterial translocation with and without haemorrhage in rats.

METHODS

32 rats were inoculated with the translocating Escherichia coli strain Kl-C1. Groups of these rats were then starved for 48 h with or without access to bulking fibre. An additional group of rats was given bulking fibre and subjected to haemorrhage. A control group was untreated and given regular food. Samples were taken from caecal contents, caecal epithelium, mesenteric lymph nodes and blood. A biochemical fingerprinting method was used to characterize and compare E. coli strains in all samples.

RESULTS

ingestion of bulking fibre alone for 48 h significantly reduced the frequency of Kl-C1 both in caecal contents and on caecal epithelium and completely prevented translocation of the strain, compared to starvation without bulking fibre for 48 h. Enforced stress (haemorrhage) increased bacterial translocation to the same level as starvation for 48 h. E. coli phenotypes found in mesenteric lymph nodes were also found adhering to the caecal epithelium.

CONCLUSIONS

The presence of bulking fibre in gut lumen, by unknown mechanisms, reduces the frequency of an inoculated translocating strain of E. coli in caecal contents and on caecal epithelium and prevents its translocation to mesenteric lymph nodes.

Effectiveness of bran supplement on the bowel management of elderly rehabilitation patients

1. Constipation is a common problem in the elderly that affects up to 20% of those 65 years and older. 2. Patients receiving the fiber supplement had a significantly lower number of bowel agents per day as compared to the control patients. 3. Side effects from the additional fiber occurred in a subgroup of patients; thus, institution of additional fiber to the diets of ill, physically dependent patients is best done gradually and with close monitoring.

Effects of a water-soluble ethylhydroxyethyl cellulose on gut physiology, bacteriology, and bacterial translocation in acute liver failure

Bacterial infection and bacteremia are common complications in patients with acute liver failure. Bacterial translocation from the gut has been suggested to be a major cause of bacterial infections in experimental acute liver failure. In the present study, a water-soluble ethylhydroxyethyl cellulose (EHEC) was administered orally 1 and 24 hours prior to 90% hepatectomy in the rat in order to prevent bacterial translocation in experimental acute liver failure induced by subtotal liver resection in the rat. Ninety percent hepatectomy alone resulted in 80 to 100% translocation to mesenteric lymph nodes or blood 2 and 4 hours after operation. There was no translocation in rats undergoing sham operation or 90% hepatectomy with EHEC administration prior to operation (p < .01). Bacterial overgrowth, increased bacterial adherence onto the intestinal surface, and diminished intestinal and mucosal mass were also observed in animals with subtotal liver resection, but not in those administered EHEC. A delayed 2-hour intestinal transit time occurred in both groups receiving subtotal liver resection, with or without oral EHEC. EHEC inhibited bacterial growth and DNA synthesis and altered bacterial surface properties after 1-hour incubation with bacteria in vitro, an interaction that was not further influenced by time. These results imply that EHEC may alter enterobacterial capacities of metabolism, proliferation, and invasion by effects on the bacterial surface. Furthermore, EHEC seems to possess a trophic action on the intestine, though without enhancing the intestinal motility.

Water-soluble ethylhydroxyethyl cellulose: a new agent against bacterial translocation from the gut after major liver resection

BACKGROUND

Bacterial translocation from the gut to extraintestinal sites has been demonstrated as a mechanism explaining bacterial infectious complications after various insults.

METHODS

To explore the potential therapeutic value of water-soluble ethylhydroxyethyl cellulose (EHEC). Its effects on macrophage phagocytic capacity, bacterial adherence on the intestinal surface, and bacterial growth were evaluated both in vivo and in vitro.

RESULTS

Preoperative administration of EHEC reduced the incidence of bacterial translocation from the gut to mesenteric lymph nodes and blood and prevented overgrowth by enteric bacteria after 70% or 90% hepatectomy. Uptake of macrophages harvested from blood decreased after intravenous administration of EHEC. EHEC diminished the otherwise increased bacterial adherence on the intestinal surface induced by major liver resection. EHEC in bacterial cultures for over 1 h was capable of inhibiting bacterial growth and delaying bacterial DNA synthesis in vitro.

CONCLUSIONS

The present study indicates that EHEC could be a potential agent for the prevention of gut-origin sepsis.

Water-soluble ethylhydroxyethyl cellulose prevents bacterial translocation induced by major liver resection in the rat

Enteric bacteria might act as pathogens, translocating across the intestinal barrier to extraintestinal sites after major liver resection. In the current study, water-soluble ethylhydroxyethyl cellulose (EHEC) was administered before hepatectomy to evaluate the influence on bacterial translocation induced by major liver resection, phagocytic capacity by visceral and circulating macrophages, enteric bacterial population, and bacterial adherence on the intestinal surface in rats subjected to sham operation or to 70% or 90% hepatectomy. Oral or intravenous (IV) administration of EHEC reduced the incidence of bacterial translocation to mesenteric lymph nodes (MLN) and blood after major liver resection. Oral EHEC appeared more effective than IV administration in protecting against bacterial translocation to MLN in animals with 90% hepatectomy. Ethylhydroxyethyl cellulose (oral and IV) significantly diminished intestinal macrophage uptake capacity of 125I-labeled, heat-killed Escherichia coli as compared with animals without EHEC administration. Overgrowth or colonization of enteric bacteria after major liver resection could be prevented by oral or IV EHEC. Adherence of 14C-labeled, alive E. coli on the intestinal mucosa decreased after EHEC treatment in animals subjected to major liver resection. Systemic arterial pressure and intestinal blood flow markedly decreased from 1 hour and on after 90% hepatectomy. Intravenous administration of EHEC did not improve these alterations. Bacterial hydrophobicity and surface negative charge were significantly reduced 1 hour after bacterial culture with EHEC. Thus, EHEC appears to be a potent agent preventing translocation of enteric bacteria from the gut after major liver resection, by altering the surface characters of enteric bacteria, balancing the enteric microflora, inhibiting bacterial attachment onto the intestinal surface, and blocking phagocytosis by intestinal macrophages.

Are the physical and TABP risk factors for heart disease unique to CHD?

Scores of 40 hospitalized CHD patients on 11 Type A-related and 7 physical CHD risk factors were compared to those of 40 hospitalized non-CHD patients. Family history for CHD was the only physical risk factor for which a significant difference was found. CHD patients scored significantly higher on all seven interview-measured Type A and Type A subcomponent variables. Only two of the four Jenkins Activity Survey-measured Type A variables produced significant differences, with one higher for non-CHD subjects. It was concluded that some CHD risk scores also may be associated with other diseases, to the experience of being seriously ill, and/or to the experience of hospitalization.

Does ispaghula husk stimulate the entire colon in diverticular disease?

The effect of ispaghula husk on colonic motility of the right and left side was examined in 10 patients with left sided diverticular disease using an untethered pressure sensitive radiotelemetry capsule. After treatment, ispaghula husk reduced mouth to rectum transit by a median of 8.8 hours and the time to midtransverse colon by five hours. In the right colon there was an increase in the median percentage activity of 7% and the median number of pressure waves greater than 5 mm Hg/hour rose by 35.3. Motility changes in the left colon were less pronounced. Five of the seven patients with abdominal pain and six of the nine patients with altered bowel habit responded to treatment. These results suggest that it is ispaghula husk's action on the right unaffected colon which alleviates the symptoms of left sided diverticular disease.

Increased cholecystectomy rates in Saudi Arabia

Gallstones have become increasingly prevalent in Saudi Arabia, where cholecystectomy is now one of the commonest major abdominal operations. 2854 people underwent cholecystectomy in the 14 hospitals of the country's Eastern Province in the years 1977 to 1986. During this period the overall frequency of cholecystectomy increased by 978%, a finding not explained by the 67% increase in population or the 87% increase in other operations. Simultaneously, the average daily individual consumption of total calories, fat, and sugar increased by 81%, 197%, and 164%, respectively, and consumption of high-fibre grain fell by 75%. This striking increase in the frequency of cholecystectomy, which presumably reflects the incidence of gallstones, cannot be explained by demographic changes and seems more closely linked to the concomitant changes in dietary habits.

Management of constipation. 1. High fibre diets work

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