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Ebner DW, Burger KN, Mahoney DW, Broderick BT, Eckmann JD, Devens ME, Lowrie KL, League JB, Bering J, Kahn A, Rodriguez EA, Prichard DO, Wallace MB, Kane SV, Leighton JA, Buttar NS, Rutten LJF, Gurudu SR, Kisiel JB. Neoplasia Diagnosis After Multi-target Stool DNA Is Enhanced Among Lowest Baseline Detectors. Dig Dis Sci 2023; 68:3721-3731. [PMID: 37486445 PMCID: PMC10882559 DOI: 10.1007/s10620-023-08038-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND AND AIMS Variation in colorectal neoplasia detection limits the effectiveness of screening colonoscopy. By evaluating neoplasia detection rates of individual colonoscopists, we aimed to quantify the effects of pre-procedural knowledge of a positive (+) multi-target stool DNA (mt-sDNA) on colonoscopy quality metrics. METHODS We retrospectively identified physicians who performed a high volume of + mt-sDNA colonoscopies; colorectal neoplasia at post-mt-sDNA colonoscopy was recorded. These colonoscopists were stratified into quartiles based on baseline adenoma detection rates. Baseline colonoscopy adenoma detection rates and sessile serrated lesion detection rates were compared to post-mt-sDNA colonoscopy neoplasia diagnosis rates among each quartile. Withdrawal times were measured from negative exams. RESULTS During the study period (2014-17) the highest quartile of physicians by volume of post-mt-sDNA colonoscopies were evaluated. Among thirty-five gastroenterologists, their median screening colonoscopy adenoma detection rate was 32% (IQR, 28-39%) and serrated lesion detection rate was 13% (8-15%). After + mt-sDNA, adenoma diagnosis increased to 47% (36-56%) and serrated lesion diagnosis increased to 31% (17-42%) (both p < 0.0001). Median withdrawal time increased from 10 (7-13) to 12 (10-17) minutes (p < 0.0001) and was proportionate across quartiles. After + mt-sDNA, lower baseline detectors had disproportionately higher rates of adenoma diagnosis in female versus male patients (p = 0.048) and higher serrated neoplasia diagnosis rates among all patients (p = 0.0092). CONCLUSIONS Knowledge of + mt-sDNA enriches neoplasia diagnosis compared to average risk screening exams. Adenomatous and serrated lesion diagnosis was magnified among those with lower adenoma detection rates. Awareness of the mt-sDNA result may increase physician attention during colonoscopy. Pre-procedure knowledge of a positive mt-sDNA test improves neoplasia diagnosis rates among colonoscopists with lower baseline adenoma detection rates, independent of withdrawal time.
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Affiliation(s)
- Derek W Ebner
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kelli N Burger
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Jason D Eckmann
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Mary E Devens
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kari L Lowrie
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John B League
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Eduardo A Rodriguez
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | | | | | - Sunanda V Kane
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | | | | | - John B Kisiel
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Prichard DO, Fetzer J. Recto-anal Pressures in Constipated Men and Women Undergoing High-Resolution Anorectal Manometry. Dig Dis Sci 2023; 68:922-930. [PMID: 35727425 DOI: 10.1007/s10620-022-07590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND In constipated individuals, high-resolution anorectal manometry (HRM) may suggest the presence of a defecatory disorder. Despite known physiological differences between men and women, our understanding of functional anorectal pathophysiology is based upon predominantly female cohorts. Results are generalized to men. AIMS To evaluate whether recto-anal pressure patterns in constipated men are similar to those in constipated women. METHODS The electronic health records at Mayo Clinic, Rochester were used to identify constipated adult patients, without organic anorectal disease, who had undergone HRM and balloon expulsion testing (BET) in 2018, 2019, and 2020. Comparative analyses were performed. RESULTS Among 3,298 constipated adult patients (2,633 women, 665 men), anal and rectal pressures were higher in men. Women more likely to have HRM findings suggestive of a defecatory disorder (39% versus 20%, P < 0.001). Women were more likely to exhibit a type 4 pattern (27% versus 14%, P < 0.001), and less likely to exhibit a type 1 pattern (14% versus 38%, P < 0.001), of dyssynergia. Men were more likely to have an abnormal balloon expulsion test (BET, 34% versus 29%, P = 0.006). Nominal logistic regression demonstrates that male sex, age over 50 years, reduced recto-anal gradient during simulated evacuation, and types 2 and 4 dyssynergia are associated with an abnormal BET. CONCLUSIONS In this large retrospective study, constipated men and women exhibited different patterns of dyssynergia both in the presence and absence of an abnormal BET. These findings were independent of sex-specific baseline physiological differences.
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Affiliation(s)
- David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Jeffrey Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
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Fox JC, Feighery AM, Fetzer JR, Prichard DO. Results of Anorectal Physiological Testing in Patients with Limited English Proficiency. Dig Dis Sci 2023; 68:750-760. [PMID: 36383270 DOI: 10.1007/s10620-022-07732-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with limited English proficiency (LEP) experience barriers to healthcare. These include language barriers and difficulty accessing medical subspecialties. Consequently, patients with LEP may be underrepresented, and may be more likely to have abnormal results, among individuals referred for anorectal testing. AIMS To explore whether differences exist in the results of high-resolution anorectal manometry (HRM), rectal sensory testing (RST), and balloon expulsion testing (BET) between patients with LEP and English proficiency (EP). METHODS The electronic health records at Mayo Clinic, Rochester were used to identify constipated patients without organic anorectal disease who had undergone anorectal testing in 2018, 2019, and 2020. The language spoken by the patients was determined. HRM, RST, and BET results were compared. Nominal logistic regression explored the influence of age, gender, test operator, and LEP on the likelihood of abnormal findings. KEY RESULTS Among 3298 patients (80% female, mean age ± standard deviation 46 ± 16 years), 67 (2%) had LEP. HRM measurements were similar in LEP and EP patients. However, LEP patients were more likely to have abnormal BET and RST. Logistic regression revealed that age (older than 50 years), gender, test operator, and LEP influenced the results of BET and RST, with LEP having the strongest influence. CONCLUSIONS Results of anorectal testing in constipated patients differ between LEP and EP patients. This is likely to represent a difference in disease prevalence between these groups, for example, due to referral bias, rather than a difference in physiology or a language barrier.
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Affiliation(s)
- Jean C Fox
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Aoife M Feighery
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey R Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
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Prichard DO, Fetzer JR. Retrospective evaluation of operator bias in the performance of high-resolution anorectal manometry. Neurogastroenterol Motil 2022; 34:e14341. [PMID: 35238445 DOI: 10.1111/nmo.14341] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/21/2022] [Accepted: 02/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Measurements obtained during high-resolution anorectal manometry (HRM) are subject to operator-patient interactions. For example, standardized enhanced instruction delivered by a single operator in a test-retest fashion did not consistently increase pressures generated during dynamic maneuvers. It is probable that factors other than verbal instruction effect communication during the procedure. To investigate this hypothesis, we retrospectively examined inter-operator variance in HRM results. METHODS The electronic health records at Mayo Clinic, Rochester, were used to identify patients who had undergone HRM in 2019 and 2020. The analysis focused on constipated patients. The instructions given to the patients they had examined, and the pressure measurements obtained during HRM, by 6 different nurse operators were compared. KEY RESULTS When performing HRM on their individual patients (range 126-673), the 6 nurses used similar instructions for each of the maneuvers and sensory testing thresholds. The proportion of patients with prolonged balloon expulsion tests and the rectal sensory thresholds were similar among operators. Significant variance was seen in the mean rectoanal pressures at rest, during squeeze, and during dynamic maneuvers. The proportion of patients with manometry results suggestive of a defecatory disorder differed between operators by 18% and 28% in women <50 and >50 years old, respectively. CONCLUSIONS & INFERENCES Operators obtain significantly different results during HRM despite using similar instructions to patients. Substantial differences in the proportion of patients with manometry findings suggestive of a defecatory disorder among operators may have a significant impact on the diagnoses and therapies offered to constipated patients.
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Affiliation(s)
- David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey R Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Feighery AM, Singh D, Prichard DO. Gastrointestinal: Unusual cause of painless jaundice after cholecystectomy. J Gastroenterol Hepatol 2022; 37:1471. [PMID: 34991181 DOI: 10.1111/jgh.15770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/20/2021] [Indexed: 12/13/2022]
Affiliation(s)
- A M Feighery
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - D Singh
- Department of Gastroenterology and Hepatology, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - D O Prichard
- Department of Gastroenterology and Hepatology, Mayo Clinic Health System, La Crosse, Wisconsin, USA.,Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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White BA, Linder BJ, Szarka LA, Prichard DO. Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation. Dig Dis Sci 2022; 67:3036-3044. [PMID: 34292471 DOI: 10.1007/s10620-021-07167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS. METHODS We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction. RESULTS A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]). CONCLUSIONS Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.
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Affiliation(s)
- Bradley A White
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Lawrence A Szarka
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David O Prichard
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Kuwelker S, Prichard DO, Bailey K, Bharucha AE. Relationship between symptoms during a gastric emptying study, daily symptoms and quality of life in patients with diabetes mellitus. Neurogastroenterol Motil 2021; 33:e14154. [PMID: 33830588 PMCID: PMC8822501 DOI: 10.1111/nmo.14154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 02/27/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
AIMS Gastric emptying is of limited utility for predicting the severity of symptoms in patients with diabetes mellitus and gastrointestinal symptoms. We evaluated the extent to which symptoms recorded during a 13 C-spirulina-based gastric emptying breath test (GEBT) or scintigraphy predicting the severity of daily symptoms in diabetes mellitus. METHODS Gastric emptying, symptoms during a gastric emptying study, either scintigraphy (n = 38) or GEBT (n = 111), and daily gastrointestinal symptoms were evaluated in 149 patients with diabetes mellitus and variably severe gastrointestinal symptoms. KEY RESULTS Gastric emptying was normal, delayed, and rapid in 37%, 52%, and 9% measured with the GEBT and 55%, 34%, and 11% of patients measured with scintigraphy; differences between GEBT and scintigraphy were not significant. Daily symptoms were moderately severe or more intense in 58% and 21% of patients undergoing scintigraphy and GEBT (P < 0.0001). Symptoms during the GEBT (46%) and emptying thalf (3%) explained 50% of the variance in daily symptoms in the GEBT group. In the scintigraphy group, symptoms explained 29% of this variance; the thalf was insignificant. Patients who reported that one or more symptoms were more severe than the others during the GE study were more likely (OR 3.98, 95% CI 2.16, 7.33) to report the same symptom(s) as being the most severe in the daily diary. CONCLUSIONS Symptoms during a GEBT and to a lesser extent during scintigraphy, but not gastric emptying predict the severity of daily symptoms and may serve as a biomarker in patients with diabetes mellitus.
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Affiliation(s)
- Saatchi Kuwelker
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - David O. Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kent Bailey
- Division of Biostatistics, Mayo Clinic, Rochester, MN 55905
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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Feighery AM, Anderson BW, Prichard DO. Postprandial Nausea, Vomiting, and Abdominal Pain in a 40-Year-Old Woman. Gastroenterology 2021; 161:e1-e3. [PMID: 33545141 DOI: 10.1053/j.gastro.2021.01.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Aoife M Feighery
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - David O Prichard
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Ebner DW, Eckmann JD, Burger KN, Mahoney DW, Bering J, Kahn A, Rodriguez EA, Prichard DO, Wallace MB, Kane SV, Finney Rutten LJ, Gurudu SR, Kisiel JB. Detection of Postcolonoscopy Colorectal Neoplasia by Multi-target Stool DNA. Clin Transl Gastroenterol 2021; 12:e00375. [PMID: 34140458 PMCID: PMC8216679 DOI: 10.14309/ctg.0000000000000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Significant variability between colonoscopy operators contributes to postcolonoscopy colorectal cancers (CRCs). We aimed to estimate postcolonoscopy colorectal neoplasia (CRN) detection by multi-target stool DNA (mt-sDNA), which has not previously been studied for this purpose. METHODS In a retrospective cohort of patients with +mt-sDNA and completed follow-up colonoscopy, positive predictive value (PPV) for endpoints of any CRN, advanced adenoma, right-sided neoplasia, sessile serrated polyps (SSP), and CRC were stratified by the time since previous colonoscopy (0-9, 10, and ≥11 years). mt-sDNA PPV at ≤9 years from previous average-risk screening colonoscopy was used to estimate CRN missed at previous screening colonoscopy. RESULTS Among the 850 studied patients with +mt-sDNA after a previous negative screening colonoscopy, any CRN was found in 535 (PPV 63%). Among 107 average-risk patients having +mt-sDNA ≤9 years after last negative colonoscopy, any CRN was found in 67 (PPV 63%), advanced neoplasia in 16 (PPV 15%), right-sided CRN in 48 (PPV 46%), and SSP in 20 (PPV 19%). These rates were similar to those in 47 additional average risk persons with previous incomplete colonoscopy and in an additional 68 persons at increased CRC risk. One CRC (stage I) was found in an average risk patient who was mt-sDNA positive 6 years after negative screening colonoscopy. DISCUSSION The high PPV of mt-sDNA 0-9 years after a negative screening colonoscopy suggests that lesions were likely missed on previous examination or may have arisen de novo. mt-sDNA as an interval test after negative screening colonoscopy warrants further study.
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Affiliation(s)
- Derek W. Ebner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D. Eckmann
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelli N. Burger
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W. Mahoney
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Eduardo A. Rodriguez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David O. Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Michael B. Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Sunanda V. Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Suryakanth R. Gurudu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - John B. Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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12
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Prichard DO, Hamilton Z, Savage T, Smyth M, Penner C, Lakhani A, Carroll MW, Al Sarkhy A, Lemberg DA, Enns R, Jamieson D, Jacobson K. Capsule Endoscopy Complements Magnetic Resonance Enterography and Endoscopy in Evaluating Small Bowel Crohn's Disease. J Can Assoc Gastroenterol 2019; 3:279-287. [PMID: 33241181 PMCID: PMC7678730 DOI: 10.1093/jcag/gwz028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims Wireless capsule endoscopy (WCE) and magnetic resonance enterography (MRE) are increasingly utilized to evaluate the small bowel (SB) in Crohn's disease (CD). The primary aims were to compare the ability of WCE and MRE to detect SB inflammation in children with newly diagnosed CD, and in the terminal ileum (TI) to compare them to ileo-colonoscopy. Secondary aims were to compare diagnostic accuracy of WCE and MRE and changes in Paris classification after each study. Methods Patients (10 to 17 years of age) requiring ileo-colonoscopy for suspected CD were invited to participate. Only patients with endoscopic/histologic evidence of CD underwent MRE and WCE. SB inflammation and extent were documented and comparative analyses performed. Results Of 38 initially recruited subjects, 20 completed the study. WCE and MRE were similarly sensitive in identifying active TI inflammation (16 [80%] versus 12 [60%]) and any SB inflammation (17 [85%] versus 16 [80%]). However, WCE detected more extensive SB disease than MRE with active inflammation throughout the SB in 15 [75%] versus 1 [5%] patient (P < 0.001). Moreover, WCE was more likely to detect proximal SB disease (jejunum and ileum) compared to MRE (85% versus 50%, P = 0.04). Overall, the Paris classification changed in 65% and 85% of patients following MRE and WCE, respectively. Conclusions WCE is as sensitive as MRE for identifying active TI inflammation, but appears more sensitive in identifying more proximal SB inflammation. In the absence of concern regarding stricturing or extra-luminal disease WCE can be considered for the evaluation of suspected SB CD.
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Affiliation(s)
- David O Prichard
- Department of Gastroenterology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Department of Gastroenterology and Hepatology, Mayo Clinic Health System La Crosse - Franciscan Healthcare, La Crosse, Wisconsin, USA.,Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Hamilton
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Savage
- Department of Radiology, Royal Hospital for Sick Children, Glasgow, UK
| | - Matthew Smyth
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Carlie Penner
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Alam Lakhani
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew W Carroll
- Department of Paediatrics, Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed Al Sarkhy
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Department of Paediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Robert Enns
- Department of Gastroenterology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Douglas Jamieson
- Department of Radiology, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevan Jacobson
- Department of Paediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.,Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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13
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Kamboj AK, Stroh GR, Smoot RL, Prichard DO. A Rare Case of Recurrent Small Bowel Obstructions. Gastroenterology 2018; 155:e5-e7. [PMID: 29883583 DOI: 10.1053/j.gastro.2018.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/21/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Amrit K Kamboj
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory R Stroh
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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14
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Abstract
Constipation, a condition characterized by heterogeneous symptoms, is common in Western society. It is associated with reduced physical health, mental health, and social functioning. Because constipation is rarely due to a life-threatening disease (for example, colon cancer), current guidelines recommend empiric therapy. Limited surveys suggest that fewer than half of treated individuals are satisfied with treatment, perhaps because the efficacy of drugs is limited, they are associated with undesirable side effects, or they may not target the underlying pathophysiology. For example, although a substantial proportion of constipated patients have a defecatory disorder that is more appropriately treated with pelvic floor biofeedback therapy than with laxatives, virtually no pharmacological trials formally assessed for anorectal dysfunction. Recent advances in investigational tools have improved our understanding of the physiology and pathophysiology of colonic and defecatory functions. In particular, colonic and anorectal high-resolution manometry are now available. High-resolution anorectal manometry, which is increasingly used in clinical practice, at least in the United States, provides a refined assessment of anorectal pressures and may uncover structural abnormalities. Advances in our understanding of colonic molecular physiology have led to the development of new therapeutic agents (such as secretagogues, pro-kinetics, inhibitors of bile acid transporters and ion exchangers). However, because clinical trials compare these newer agents with placebo, their efficacy relative to traditional laxatives is unknown. This article reviews these physiologic, diagnostic, and therapeutic advances and focuses particularly on newer therapeutic agents.
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Affiliation(s)
- David O. Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program and Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
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15
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Prichard DO, Byrne AM, Murphy JO, Reynolds JV, O'Sullivan J, Feighery R, Doyle B, Eldin OS, Finn SP, Maguire A, Duff D, Kelleher DP, Long A. Deoxycholic acid promotes development of gastroesophageal reflux disease and Barrett's oesophagus by modulating integrin-αv trafficking. J Cell Mol Med 2017; 21:3612-3625. [PMID: 28941013 PMCID: PMC5706496 DOI: 10.1111/jcmm.13271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/07/2017] [Indexed: 01/14/2023] Open
Abstract
The fundamental mechanisms underlying erosive oesophagitis and subsequent development of Barrett's oesophagus (BO) are poorly understood. Here, we investigated the contribution of specific components of the gastric refluxate on adhesion molecules involved in epithelial barrier maintenance. Cell line models of squamous epithelium (HET‐1A) and BO (QH) were used to examine the effects of bile acids on cell adhesion to extracellular matrix proteins (Collagen, laminin, vitronectin, fibronectin) and expression of integrin ligands (α3, α4, α5, α6 and αν). Experimental findings were validated in human explant oesophageal biopsies, a rat model of gastroesophageal reflux disease (GORD) and in patient tissue microarrays. The bile acid deoxycholic acid (DCA) specifically reduced adhesion of HET‐1A cells to vitronectin and reduced cell‐surface expression of integrin‐ανvia effects on endocytic recycling processes. Increased expression of integrin‐αv was observed in ulcerated tissue in a rat model of GORD and in oesophagitis and Barrett's intestinal metaplasia patient tissue compared to normal squamous epithelium. Increased expression of integrin‐αν was observed in QH BO cells compared to HET‐1A cells. QH cells were resistant to DCA‐mediated loss of adhesion and reduction in cell‐surface expression of integrin‐αν. We demonstrated that a specific component of the gastric refluxate, DCA, affects the epithelial barrier through modulation of integrin αν expression, providing a novel mechanism for bile acid‐mediated erosion of oesophageal squamous epithelium and promotion of BO. Strategies aimed at preventing bile acid‐mediated erosion should be considered in the clinical management of patients with GORD.
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Affiliation(s)
- David O Prichard
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Division of Gastroenterology, Mayo Clinic Health System La Crosse - Franciscan Healthcare, La Crosse, WI, USA.,Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Anne Marie Byrne
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - James O Murphy
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Jacintha O'Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Ronan Feighery
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Brendan Doyle
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Department of Histopathology, Beaumont Hospital, Dublin 9, Ireland
| | - Osama Sharaf Eldin
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Stephen P Finn
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland.,Department of Histopathology and Morbid Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Aoife Maguire
- Department of Histopathology, St James's Hospital, Dublin 8, Ireland
| | - Deirdre Duff
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Dermot P Kelleher
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland.,Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Aideen Long
- Cell and Molecular Biology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
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16
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Prichard DO, Lee T, Parthasarathy G, Fletcher JG, Zinsmeister AR, Bharucha AE. High-resolution Anorectal Manometry for Identifying Defecatory Disorders and Rectal Structural Abnormalities in Women. Clin Gastroenterol Hepatol 2017; 15:412-420. [PMID: 27720913 PMCID: PMC5316318 DOI: 10.1016/j.cgh.2016.09.154] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/19/2016] [Accepted: 09/30/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Contrary to conventional wisdom, the rectoanal gradient during evacuation is negative in many healthy people, undermining the utility of anorectal high-resolution manometry (HRM) for diagnosing defecatory disorders. We aimed to compare HRM and magnetic resonance imaging (MRI) for assessing rectal evacuation and structural abnormalities. METHODS We performed a retrospective analysis of 118 patients (all female; 51 with constipation, 48 with fecal incontinence, and 19 with rectal prolapse; age, 53 ± 1 years) assessed by HRM, the rectal balloon expulsion test (BET), and MRI at Mayo Clinic, Rochester, Minnesota, from February 2011 through March 2013. Thirty healthy asymptomatic women (age, 37 ± 2 years) served as controls. We used principal components analysis of HRM variables to identify rectoanal pressure patterns associated with rectal prolapse and phenotypes of patients with prolapse. RESULTS Compared with patients with normal findings from the rectal BET, patients with an abnormal BET had lower median rectal pressure (36 vs 22 mm Hg, P = .002), a more negative median rectoanal gradient (-6 vs -29 mm Hg, P = .006) during evacuation, and a lower proportion of evacuation on the basis of MRI analysis (median of 40% vs 80%, P < .0001). A score derived from rectal pressure and anorectal descent during evacuation and a patulous anal canal was associated (P = .005) with large rectoceles (3 cm or larger). A principal component (PC) logistic model discriminated between patients with and without prolapse with 96% accuracy. Among patients with prolapse, there were 2 phenotypes, which were characterized by high (PC1) or low (PC2) anal pressures at rest and squeeze along with higher rectal and anal pressures (PC1) or a higher rectoanal gradient during evacuation (PC2). CONCLUSIONS In a retrospective analysis of patients assessed by HRM, measurements of rectal evacuation by anorectal HRM, BET, and MRI were correlated. HRM alone and together with anorectal descent during evacuation may identify rectal prolapse and large rectoceles, respectively, and also identify unique phenotypes of rectal prolapse.
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Affiliation(s)
- David O Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | - Taehee Lee
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | - Gopanandan Parthasarathy
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota
| | | | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota.
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