Effects of loperamide on ileoanal pouch function

Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods

The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence.

Is STEP the future for patients requiring proctocolectomy? A new therapeutic proposal from pediatric experience

We present a pediatric case of medically unmanageable juvenile colonic polyposis, initially treated with subtotal colectomy and an ileostomy followed by a proctectomy, ileal-J-pouch and serial transverse enteroplasties (STEP) of the distal ileum. The STEP procedure in an adequate length was able to control stooling of our patient.

Drug treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence (leakage of bowel motions or stool) is a common symptom which causes significant distress and reduces quality of life.

OBJECTIVES

To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of Trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearching of journals and conference proceedings (searched 21 June 2012) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials were included in this systematic review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and assessed risk of bias of the included trials.

MAIN RESULTS

Sixteen trials were identified, including 558 participants. Eleven trials were of cross-over design. Eleven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea, following ileoanal pouch or rectal surgery, or due to use of a weight-reducing drug). Two trials were amongst people with weak anal sphincters, one in participants with faecal impaction and bypass leakage, and one in geriatric patients. In one trial there was no specific cause for faecal incontinence.Seven trials tested anti-diarrhoeal drugs to reduce faecal incontinence and other bowel symptoms (loperamide, diphenoxylate plus atropine, and codeine). Six trials tested drugs that enhance anal sphincter function (phenylepinephrine gel and sodium valproate). Two trials evaluated osmotic laxatives (lactulose) for the treatment of faecal incontinence associated with constipation in geriatric patients. One trial assessed the use of zinc-aluminium ointment for faecal incontinence. No studies comparing drugs with other treatment modalities were identified.There was limited evidence that antidiarrhoeal drugs and drugs that enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. Loperamide was associated with more adverse effects (such as constipation, abdominal pain, diarrhoea, headache and nausea) than placebo. However, the dose may be titrated to the patient's symptoms to minimise side effects while achieving continence. The drugs acting on the sphincter sometimes resulted in local dermatitis, abdominal pain or nausea. Laxative use in geriatric patients reduced faecal soiling and the need for help from nurses.Zinc-aluminium ointment was associated with improved quality of life, with no reported adverse effects. However, the observed improvement in quality of life was seen in the placebo group as well as the treatment group.It should be noted that all the included trials in this review had small sample sizes and short duration of follow-up. 'Risk of bias' assessment was unclear for most of the domains as there was insufficient information. There were no data suitable for meta-analysis.

AUTHORS' CONCLUSIONS

The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which use the recommendations and principles set out in the CONSORT statement, and include clinically important outcome measures, are required.

Diarrhea in chronic inflammatory bowel diseases

Diarrhea is a common clinical feature of inflammatory bowel diseases and may be accompanied by abdominal pain, urgency, and fecal incontinence. The pathophysiology of diarrhea in these diseases is complex, but defective absorption of salt and water by the inflamed bowel is the most important mechanism involved. In addition to inflammation secondary to the disease, diarrhea may arise from a variety of other conditions. It is important to differentiate the pathophysiologic mechanisms involved in the diarrhea in the individual patient to provide the appropriate therapy. This article reviews microscopic colitis, ulcerative colitis, and Crohn's disease, focusing on diarrhea.

Summary of the causative and treatment factors of diarrhea and the use of a diarrhea assessment and treatment tool to improve patient outcomes

This article is a review of the causative factors and pharmacologic treatments of diarrhea. This information was incorporated into a Diarrhea Assessment and Treatment Tool (DATT) to guide clinicians on comprehensive diarrhea assessment and current treatment recommendations. The tool was utilized at a university-affiliated oncology institution by a clinical nurse specialist on 26 patients as a performance improvement project. Ease of use and efficacy of DATT were tested. Eighty-one percent of patients were assessed using DATT in 30 minutes or less. Seventy-nine percent of the 57 identified diarrhea classifications were not being treated upon initial assessment. Diarrhea control was achieved in 73% of the patients within 7 days or fewer when DATT was utilized. The premise of diarrhea management is that if all the causative factors are not treated, diarrhea will persist. The conclusions are that this tool will aid the clinician in a comprehensive assessment of diarrhea and provide a systematic approach to diarrhea treatment. The need for research on best practice for management of the various causative factors of diarrhea is needed.

Practical strategies for treating postsurgical bowel dysfunction

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Medical management of patients with ileal pouch anal anastomosis after restorative procto-colectomy

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis

BACKGROUND

Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage).

MATERIALS AND METHODS

Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12-64 years) and median follow-up was 36 months (range 24-144 months). The clinical notes were reviewed retrospectively.

RESULTS

The median in-patient stay was 15 days (range 9-36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula.

CONCLUSION

Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.

Effect of calcium polycarbophil on bowel function after restorative proctocolectomy for ulcerative colitis: a randomized controlled trial

The aim of the present study was to determine if calcium polycarbophil ameliorates diarrhea after ileal J-pouch anal anastomosis for ulcerative colitis. Twenty-one randomized patients were given either bifidobacterium (3 g/day) plus calcium polycarbophil (3 g/day), in the polycarbophil group (11 patients), or bifidobacterium (3 g/day), in the control group (10 patients), p.o. for 6 months. Anal manometry was performed and bowel function (stool frequency, stool consistency, and nighttime soiling) was assessed via a questionnaire before and 1, 3, and 6 months after drug administration. Eight patients were deemed eligible in each group; five patients were excluded from the study, including two patients whose stool consistency was too firm and who experienced difficulty in defecating attributed to polycarbophil. Anal manometry and stool consistency did not change with time and did not differ between the polycarbophil and the control groups. Stool frequency decreased with time in both groups and did not differ between the groups. Nighttime soiling improved with time in the polycarbophil group but did not change in the control subjects. These results suggest that polycarbophil might be able to improve nighttime soiling without obviously affecting stool frequency and consistency after ileal J-pouch anal anastomosis for ulcerative colitis.

Review article: Recent trends in diagnosis and treatment of faecal incontinence

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

Fecal incontinence: evaluation and treatment

Fecal incontinence affects men and women of all ages, leading to personal disability and high financial costs. The evaluation of the patient should clarify the pathophysiology of the symptoms and provide guidance in choosing the appropriate treatment. A comprehensive history and physical examination including endoscopic assessment is able to identify the cause of most cases of fecal incontinence. If necessary, functional methods can be used to confirm the diagnosis. Patient selection for suitable treatment is most important and should be based on clinical and physiologic findings. Conservative dietary or medical treatment is often effective, when the symptoms are mild. Biofeedback therapy is effective in most patients. It has no side effects and is well tolerated. Structural damage to the anus may be repaired by surgery, like sphincter repair, the best treatment of selective sphincter defects. Neoanal sphincters and artificial sphincters are the last possibility after failed surgery and before colostomy. They are less attractive because of technical difficulties and low success rate. A multidisciplinary approach to treatment has the potential to improve the outcome for patients with fecal incontinence.

Drug treatment for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a common symptom which causes significant distress and reduction in quality of life. Available treatment options for faecal incontinence include conservative treatments (biofeedback, pelvic floor muscle training, dietary manipulation or drug therapy) or surgical treatments (e.g. sphincter repair, post anal repair, neosphincter). Drug treatment is often given either alone or in combination with other treatment modalities.

OBJECTIVES

To assess the effects of drug therapy for the treatment of faecal incontinence. In particular, to assess the effects of individual drugs relative to placebo or other drugs, and to compare drug therapy with other treatment modalities.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2003) and the reference lists of relevant articles. Date of the most recent search: January 2003.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of the use of pharmacological agents for the treatment of faecal incontinence in adults.

DATA COLLECTION AND ANALYSIS

Working independently, reviewers selected studies from the literature, assessed the methodological quality of each trial, and extracted data.

MAIN RESULTS

Eleven trials were identified for inclusion in this review. Nine trials were of cross-over design. Seven trials included only people with faecal incontinence related to liquid stool (either chronic diarrhoea or following ileoanal pouch surgery). Three trials (total 58 participants) compared topical phenylephrine gel with placebo. Two trials (56 participants) compared loperamide with placebo. One trial (11 participants) compared loperamide oxide with placebo. One trial (15 participants) compared diphenoxylate plus atropine with placebo. One trial (17 participants) compared sodium valproate with placebo. One trial (30 participants) compared loperamide with codeine with diphenoxylate plus atropine. Two further trials (total 265 participants) assessed the use of lactulose in elderly people.No studies comparing drugs with other treatment modalities were identified. There was limited evidence that antidiarrhoeal drugs and drugs which enhance anal sphincter tone may reduce faecal incontinence in patients with liquid stools. However, the trials were small and of short duration.

REVIEWER'S CONCLUSIONS

The small number of trials identified for this review assessed several different drugs in a variety of patient populations. The focus of most of the included trials was on the treatment of diarrhoea, rather than faecal incontinence. There is little evidence to guide clinicians in the selection of drug therapies for faecal incontinence. Larger, well-designed controlled trials, which include clinically important outcome measures, are required.

Review article: the complexity of drug development for irritable bowel syndrome

Drug development for functional gastrointestinal disorders is complex. These conditions involve central and peripheral physiological changes, together with psychological factors. Methodological problems have included a poor appreciation of the physiological and psychological correlates of patients' symptoms, a lack of animal models of proven relevance, and safety issues. Government, patient pressure groups and the Internet can also influence a drug's success. Most recent interest has focused on the serotonin (5-HT) modifying drugs. Cisapride has been withdrawn in some countries because of concerns related to QT prolongation and cardiac arrhythmias. The 5-HT3 antagonists, developed to modify visceral sensation, have caused constipation; alosetron, also withdrawn, caused ischaemic colitis. The 5-HT4 agonists induce peristalsis; tegaserod and prucalopride, both delayed in their development due to issues of safety and efficacy, benefit patients with 'constipation-predominant' irritable bowel syndrome or idiopathic constipation. 5-HT1 agonists improve impaired gastric accommodation and symptoms in patients with functional dyspepsia. Antidepressants also affect serotonin metabolism. Previous examples of success in this area involved drugs targeted at peripheral receptors mediating motor function or secretion. Modification of sensory function is a much more challenging objective. The experience with serotonin modifying drugs has been mixed, and some important lessons are there to be learnt.

Non-surgical management of faecal incontinence

Faecal incontinence is a common symptom causing reduction in quality of life and social isolation. Conservative treatments should be used as first and second lines of therapy and can also be of use as adjuncts to surgical treatment. This article reviews the current status of these modalities of treatment.

Fecal incontinence

Fecal incontinence is common and socially disabling. Only a few patients with fecal incontinence present to medical practitioners. Investigative techniques have improved, and it is possible now to define accurately functional or anatomic deficits. Careful planning of treatment with the possibility of using a variety of treatment modalities is essential. Novel conservative and surgical techniques have the potential to improve the outcome for patients with fecal incontinence.

A comparison of the effect of loperamide in oral or suppository form vs placebo in patients with ileo-anal pouches

OBJECTIVE

The effect of the anti-diarrhoeal drug, loperamide hydrochloride, on bowel function in patients with an ileo-anal pouch was studied by means of a blinded, three-tailed, case-controlled and randomized crossover trial, using a daily dose of 12 mg in either oral (4 mg t.d.s.) or suppository (6 mg b.d.) form.

PATIENTS AND METHODS

Daily stool frequency was recorded in a diary and an objective measure of pouch motor function was obtained at the end of each treatment phase. Ten subjects (seven males, three females) aged 23-50 years (median 38 years) were studied 9-48 months (median 27 months) after ileostomy closure. Eight pouches had been constructed for ulcerative colitis and two for familial adenomatous polyposis (9J, 1W).

RESULTS

Mean daily stool frequency during the oral loperamide phase was lower than during both the placebo (P=0.05) and suppository (P < 0.02) phases. Stool frequency did not differ significantly between placebo and suppository phases. There was a strong inverse correlation between mean daily stool frequency and pouch capacity (r=-0.82 after both oral and suppository phases). Large isolated pouch contractions were evident in five of eight subjects studied; suppression was observed in two of the five after oral loperamide and in three of the five after loperamide suppositories. Rhythmic pouch contractions were seen in four subjects and suppression was evident after loperamide suppositories (but not after oral loperamide) in three. A daily oral dose of 12 mg loperamide significantly lowered stool frequency in pouch patients and modified some aspects of pouch contraction. Loperamide suppositories produced more prominent suppression of pouch contractions but did not lower stool frequency.

CONCLUSION

This suggests that the beneficial effect of oral loperamide is primarily due to its action on intestine proximal to the pouch itself.

Randomized, controlled trial of topical phenylephrine for fecal incontinence in patients after ileoanal pouch construction

INTRODUCTION

Fecal incontinence is experienced by some patients with an ileoanal reservoir pouch. The alpha1-adrenergic agonist phenylephrine raises resting anal sphincter pressure in healthy volunteers and may be of value in these patients.

METHODS

Twelve patients (7 female), median age 44 (range, 29-67) years were studied. All had fecal incontinence despite a noninflamed pouch of normal size and ultrasonographically structurally normal anal sphincter muscles. Patients were treated with topical 10 percent phenylephrine and placebo gels, allocated in random order in a double-blind, crossover study for two four-week periods. Before and during treatment, maximum resting anal sphincter pressure and anodermal blood flow were measured, a symptom questionnaire was completed, and incontinence score was determined using a validated scale.

RESULTS

Six of 12 (50 percent) patients improved subjectively after phenylephrine compared with one on placebo (P = 0.07). Four patients had complete cessation of incontinence with active treatment. Phenylephrine significantly reduced the incontinence score (P = 0.015). It also resulted in a significant rise in mean maximum resting anal sphincter pressure when compared with placebo (P = 0.012). For all 12 patients, mean percent subjective improvement was higher after phenylephrine compared with placebo (P = 0.04). There were no side effects.

CONCLUSIONS

Topical phenylephrine significantly improves fecal continence in patients with an ileoanal pouch. In some patients it totally eliminates nocturnal episodes. The mechanism of benefit is likely to be one of altered neural sphincter control. This is the first study of the use of a topical pharmacologic agent to treat fecal incontinence and may have a wider application.

Surgical treatment of inflammatory bowel disease

Although laparotomy with resection remains the treatment of choice for most patients who require surgery for intestinal Crohn's disease, mounting evidence supports the safety and efficacy of less traditional approaches and procedures (ie, laparoscopy, stricture-plasty). In contrast to the approach to intestinal disease, many centers are advocating a more aggressive operative approach to perianal Crohn's disease. Over the past few years, restorative proctocolectomy with ileal pouch-anal anastomosis has emerged as the operation of choice for most patients requiring surgery for ulcerative colitis. As experience with the operation grows, patient selection, technical features, and management of postoperative complications are being more clearly defined and optimized.