Bowels: beliefs and behaviour

Definitions, attitudes, and management practices in relation to diarrhea during enteral nutrition: a survey of patients, nurses, and dietitians

BACKGROUND

Diarrhea is a common complication in patients receiving enteral nutrition (EN), and understanding this problem among patients and healthcare professionals is required. The aim of the study was to investigate patients', nurses', and dietitians' definitions of diarrhea during EN, the attitudes of nurses and patients toward it, and the management practices of nurses and dietitians in response to diarrhea during EN.

METHODS

Twenty-two patients receiving EN, 57 nurses, and 33 dietitians were recruited and interviewed in a cross-sectional study, using a questionnaire that had been developed following an extensive literature review and pretested for clarity.

RESULTS

The ratings assigned by the 3 groups differed significantly for all the characteristics used to define diarrhea: frequency (P = .006), quantity (P < .001), consistency (P = .003), color (P < .001), odor (P < .001), and incontinence (P < .001). Patients gave incontinence the highest rank when defining diarrhea, whereas the healthcare professionals gave fecal consistency and frequency the highest ranks. Patients and nurses rated the unpleasantness of each characteristic of diarrhea during EN differently, with patients rating incontinence and fecal frequency and nurses rating odor and changing the patients' underwear as the most unpleasant characteristics. Nurses and dietitians differed in the frequency with which they adopted various strategies to manage patients who developed diarrhea during EN.

CONCLUSIONS

Patients have different definitions and attitudes toward diarrhea during EN from those of nurses and dietitians. Patients' perceptions need to be understood and respected by healthcare professionals to improve patient-centered care.

Influences on pre-hospital delay in the diagnosis of colorectal cancer: a systematic review

Colorectal cancer is a major global health problem, with survival varying according to stage at diagnosis. Delayed diagnosis can result from patient, practitioner or hospital delay. This paper reports the results of a review of the factors influencing pre-hospital delay - the time between a patient first noticing a cancer symptom and presenting to primary care or between first presentation and referral to secondary care. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Fifty-four studies were included. Patients' non-recognition of symptom seriousness increased delay, as did symptom denial. Patient delay was greater for rectal than colon cancers and the presence of more serious symptoms, such as pain, reduced delay. There appears to be no relationship between delay and patients' age, sex or socioeconomic status. Initial misdiagnosis, inadequate examination and inaccurate investigations increased practitioner delay. Use of referral guidelines may reduce delay, although evidence is currently limited. No intervention studies were identified. If delayed diagnosis is to be reduced, there must be increased recognition of the significance of symptoms among patients, and development and evaluation of interventions that are designed to ensure appropriate diagnosis and examination by practitioners.

Delay of treatment is associated with advanced stage of rectal cancer but not of colon cancer

BACKGROUND

Dukes' stage is the most important predictor of prognosis of colorectal cancer, but the association between delay of treatment (DT) and Dukes' stage is still controversial.

METHODS

From 1 January 2001 to 31 July 2002, we conducted a population-based prospective observational study based on 733 Danish colorectal cancer patients. DT was determined through questionnaire-interviews, and Dukes' stage was obtained from medical records and pathological forms. DT was classified into three groups: short (0-60 days), intermediate (61-150 days) and long (>150 days) DT. Dukes' stage was classified into two groups: non-advanced (Dukes' stage A or B) and advanced (Dukes' stage C or D) cancer. Using relative risk (RR) the association between DT and stage was estimated, with short delay as the reference group.

RESULTS

The RR of advanced cancer was 1.0 (95% confidence intervals (CI): 0.8-1.3) for colon cancer patients with an intermediate DT, and 1.1 (95% CI: 0.9-1.4) for patients with a long DT. For rectal cancer patients the RR of advanced cancer was 1.9 (95% CI: 1.1-3.1) for patients with an intermediate DT and 2.1 (95% CI: 1.3-3.4) for patients with a long DT.

CONCLUSION

DT was strongly associated with advanced stage of rectal cancer, but not of colon cancer.

Comparison of gastrointestinal symptoms in colorectal carcinoma patients and community controls with respect to age

Early diagnosis of colorectal cancer may be delayed by the wide prevalence of gastrointestinal symptoms in the general population. This study assessed, with respect to age, the frequency of gastro-intestinal symptoms in patients with colorectal carcinoma in comparison with community controls and also compared the frequency of such symptoms between 'young' (under 70 years) and 'old' (70 year or over) subjects. Two hundred and seventy three consecutive unselected colorectal cancer patients and 273 age and sex matched community controls were interviewed in a structured manner. Among controls, the 'old' group compared with the 'young' reported abdominal pain (p < 0.05), mucous discharge (p < 0.01), faecal incontinence (p < 0.05), change in flatus production (p < 0.05) significantly more often. There were no significant differences in regularity and frequency of bowel habit by age group. All the symptoms considered were significantly more common in colorectal cancer cases than controls (except abdominal bloating), but the association was less strong in the 'old' group. This study confirms that symptoms attributable to the lower gastrointestinal tract are reported by a clinically important number of community subjects and by a significantly higher proportion of elderly people.

Irritable bowel syndrome in the general population

OBJECTIVE

To determine the prevalence of symptoms compatible with a clinical diagnosis of irritable bowel syndrome in the general population.

DESIGN

Validated postal questionnaire sent to 2280 subjects randomly selected in 10 year age bands from the lists of eight general practitioners. The Manning criteria were used to define irritable bowel syndrome.

SETTING

Urban population in Southampton and mixed urban-rural population in Andover, Hampshire.

RESULTS

A response of 71% yielded 1620 questionnaires for analysis, of which 412 (25%) reported more than six episodes of abdominal pain in the preceding year, with 350 (22%) reporting symptoms consistent with the diagnosis of irritable bowel syndrome. The male: female ratio was 1:1.38. More subjects with irritable bowel syndrome had constipation and diarrhoea and 35% with the syndrome reported rectal bleeding compared with an overall prevalence of 20%. Other symptoms and conditions including heartburn, dyspepsia, flushing, palpitations, migraine, and urinary symptoms were significantly more common in the group with irritable bowel syndrome. Abdominal pain in childhood was more common in the subjects with irritable bowel syndrome (12%) than without (3%). One third of the group with irritable bowel syndrome had sought medical advice during the study period (male:female ratio 1:1.21); consultation behaviour was influenced by age and the presence of associated symptoms, varied considerably among patients registered with different general practitioners, and was poorly correlated with symptom severity.

CONCLUSION

Symptoms consistent with a diagnosis of irritable bowel syndrome are present in almost one quarter of the general population and tend to be associated with a number of other complaints and conditions, some of which may reflect smooth muscle dysfunction.