Clinical and physiological risk factors for fecal incontinence in chronically constipated women

BACKGROUND

Fecal incontinence (FI) and chronic constipation (CC) are disabling symptoms that cause a significant public health problem. The pathophysiology of combined constipation and FI is not fully understood. Our aim was to delineate the clinical, physiological and anatomical factors that may contribute to the association of FI and CC.

METHODS

A retrospective study was performed in a pelvic floor unit in a tertiary medical center. Consecutive female patients diagnosed with CC were included, and further divided into two groups according to the co-occurrence of FI. Demographic characteristics, anorectal physiology (obtained by manometry) and pelvic anatomical pathology (as assessed by dynamic pelvic ultrasound) were recorded and subsequently compared.

RESULTS

A total of 267 women were included in the study. Of those, 62 patients (23%) had an associated FI (CCFI). The CCFI group had higher body mass index (BMI) levels and a trend toward younger average age as compared to the group without FI (CCNFI). The number of vaginal and instrumental deliveries was similar in both groups. Anal resting and squeeze pressures were significantly lower in the CCFI group (64 ± 21 vs 48 ± 18, p = 0.004 and 141 ± 136.2 vs. 97.5 ± 38.6, p = 0.02, respectively). Rectal sensation abnormalities were common, but did not differ between both groups. Dyssynergic defecation and rectocele were more common in the CCNFI group (68% vs. 51%, p = 0.04 and 39% vs. 24%, p = 0/045, respectively.

CONCLUSIONS

Lower anal pressures and higher BMI were found among women with coexisting FI and CC. Pelvic floor anatomical and functional abnormalities are common in women diagnosed with CC and FI, but dyssynergia and diagnosis of significant rectocele, which cause obstructed defecation, were more common in the CCNFI group.

The relationship between eosinophilic esophagitis and esophageal cancer

Eosinophilic esophagitis (EoE) is a disorder characterized by long-term chronic eosinophilic inflammation, which may predispose patients for malignant transformation. To determine if EoE is associated with an increased risk for esophageal cancer (EC) over time. This was a cross-sectional population-based study using the Explorys Platform. Data were collected from January 1999 to December 2014 and the search terms 'Eosinophlic esophagitis', gastroesophageal reflux disease, and Barrett's esophagus were used. The latter two served as comparison groups. The term 'malignant tumor of esophagus' was searched in Explorys and was accepted only if it was established after the aforementioned diagnoses. Analysis was performed using social science statistical software. A total of 27,183,310 subjects were included in the study. Of those 5,370 (0.02%) had the diagnosis of EoE, 25,610 (0.09%) BE, and 2,606,640 (9.59%) gastroesophageal reflux (GERD). In general, diagnosis of EC was rare prior to age 40. Therefore, subsequent analysis was done on subjects between 40 to 79 years of age (N = 20,257,480). The prevalence of EC was 0.05% (N = 2420), in BE (N = 19,640) 2.65%, and in GERD (N = 1,696,230) 0.22%. No cases of EC were identified among those with EoE. We found no significant difference or increased risk in the rate of EC in the EoE group (P = 0.575) when compared to the control population. In this largest study, we found no association between esophageal cancer and EoE. Further long-term prospective studies are needed to better characterize the relationship between EoE and esophageal malignancy.

Utilisation of surgical fundoplication for patients with gastro-oesophageal reflux disease in the USA has declined rapidly between 2009 and 2013

BACKGROUND

Surgical fundoplication has been considered to be one of the leading therapeutic modalities for gastro-oesophageal reflux disease (GERD) during the last several decades.

AIM

To determine the trend of surgical fundoplication utilisation in GERD patients during the last decade in the United States.

METHODS

Population-based study using a large nationwide database, the Explorys database system, to identify patients diagnosed with GERD and those who underwent surgical fundoplication. Using a quadratic regression model, we determined and compared the trends of surgical fundoplication utilisation annually from 2004 to 2013.

RESULTS

We identified 4 059 060 patients with the diagnosis of GERD, of whom 2343 (0.05%) underwent surgical fundoplication between 2004 and 2013. There was a significant decline in the number of surgical fundoplications performed over the last 5 years from 0.062% in 2009 to 0.047% in 2013 (P < 0.05). Female patients accounted for the majority of those who underwent fundoplication (62.52%). Caucasian patients between the ages of 18 and 65 years were the most likely group to undergo surgical fundoplication (66.28%). The number of overweight patients undergoing surgical fundoplication has been significantly increasing over the last decade (P < 0.05). Importantly, 80% of surgical patients were treated with a proton pump inhibitor (PPI) post surgical fundoplication by 2013 (P < 0.001).

CONCLUSIONS

Utilisation of surgical fundoplication in GERD patients has been steadily declining over the past 5 years. The vast majority of patients will resume PPI treatment after surgical fundoplication.

Review article: the current treatment of non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed.

AIM

To determine the value of the current therapeutic modalities for NCCP.

METHODS

Electronic (Pubmed/Medline/Cochrane central) and manual search.

RESULTS

Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients.

CONCLUSION

Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.

The 2011-2014 prevalence of eosinophilic oesophagitis in the elderly amongst 10 million patients in the United States

BACKGROUND

Eosinophilic oesophagitis (EoE) is primarily diagnosed by clinicians. There are less than a handful of epidemiological studies in EoE that have included elderly patients (>65 years).

AIM

To determine the prevalence of elderly subjects among EoE patients and compare their clinical presentation, associated conditions and treatment modalities with adult and paediatric EoE patients.

METHODS

A large nationwide database (Explorys) between January 2011 and January 2014 was used. The term 'Eosinophilic Oesophagitis' was used in the Explorys search tool. The patient population was divided into three groups, Paediatric (<18 years), Adult (18-65 years) and Elderly (>65 years).

RESULTS

We identified 4840 patients coded as EoE. The total estimated prevalence was 50.6 cases per 100 000 patients (0.05%). A total of 360 cases (7.44%) were elderly patients with an estimated prevalence rate of 18.6 cases per 100 000. Across all age groups, the majority of EoE patients were Caucasians and males. A significantly greater proportion of older patients had concomitant GERD. Dysphagia was the most common symptom among elderly EoE patients as compared with the paediatric EoE patients (P < 0.001). The proportion of elderly EoE patients with food allergies or asthma was significantly lower as compared with paediatric and adult EoE patients (P < 0.001). Oesophageal dilation and/or proton pump inhibitor treatment were the most commonly used therapeutic modalities in elderly EoE patients.

CONCLUSION

Eosinophilic oesophagitis is uncommon in elderly subjects and the clinical presentation is markedly different as compared with adults or the paediatric population.

The effect of antireflux treatment on the frequency of awakenings from sleep in patients with Gastroesophageal reflux disease

BACKGROUND

Up to half of gastroesophageal reflux disease (GERD) patients report having heartburn that awakens them from sleep during the night. Recumbent-awake and conscious awakenings from sleep during the night are commonly associated with acid reflux events. The aim of the study was to assess the effect of esomeprazole 40 mg once daily on nighttime acid reflux, frequency of conscious awakenings associated with acid reflux and the recumbent-awake period.

METHODS

Patients with heartburn and/or regurgitation at least three times a week were eligible for this study. All patients underwent upper endoscopy and were evaluated by demographic, Epworth Sleepiness scale, Berlin and GERD symptom checklist questionnaires. Subjects then underwent esophageal pH testing concomitantly with an actigraphy. All subjects were given esomeprazole 40 mg once daily for 7 days and completed a daily symptom record diary. On day 7, subjects repeated the pH test with actigraphy.

KEY RESULTS

Twenty patients (mean age of 48.95 ± 18.69, age range 20-81 years) were enrolled. Esophageal acid exposure parameters, during recumbent-awake, recumbent-asleep, and conscious awakenings were significantly improved on last day of treatment as compared to baseline (p < 0.05). However, the frequency and duration of conscious awakenings and duration of recumbent-awake period did not improve as compared to baseline (p > 0.05).

CONCLUSIONS & INFERENCES

While esomeprazole significantly reduced esophageal acid exposure during conscious awakenings and recumbent-awake and asleep periods, it did not decrease the number and duration of conscious awakening or duration of recumbent-awake period.

The relationship between length of Barrett's oesophagus mucosa and body mass index

BACKGROUND

Length of Barrett's oesophagus (BE) is a risk factor for oesophageal cancer. The underlying mechanisms that determine BE length are nor fully known.

AIM

To determine if there is a correlation between obesity and length of BE.

METHODS

Using a population-based study, 381 patients diagnosed with Barrett's oesophagus between 1999 and 2013 were included. Body mass index (BMI) at the time of BE diagnosis was calculated. Upper endoscopy reports were reviewed to obtain the length of BE. Spearman's correlation coefficient was performed to assess the strength of the relationship between Barrett's length and BMI. A multivariate logistic regression analysis was conducted to further examine the association between BMI and length of BE.

RESULTS

The adjusted odds ratio for each five-point increase in BMI was 1.5 (95% CI 1.24-1.81, P < 0.001). The mean BMI was significantly higher in patients with long segment BE as compared to patients with short segment BE (32.7 vs. 30.3, P = 0.001). There was also a positive trend in long segment BE as patients entered into higher BMI categories (Z = 4.25, P < 0.001). There was a significant correlation between BMI and length of BE (r = 0.25, P < 0.0001).

CONCLUSION

The study demonstrated a correlation between BMI and the length of Barrett's oesophagus mucosa. Thus, increased BMI is associated with longer segment of Barrett's oesophagus.

The role of pain modulators in esophageal disorders - no pain no gain

Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade.