Ursodeoxycholic acid alone or with chenodeoxycholic acid for dissolution of cholesterol gallstones: a randomized multicentre trial. The British-Italian Gallstone Study group

BACKGROUND

Combination therapy using ursodeoxycholic acid plus chenodeoxycholic acid has been advocated for dissolution of cholesterol gallstones because the two bile acids have complementary effects on biliary lipid metabolism and cholesterol solubilization.

AIM

To compare the clinical efficacy of combination therapy with ursodeoxycholic acid monotherapy.

PATIENTS AND METHODS

A total of 154 symptomatic patients with radiolucent stones (< or = 15 mm) in functioning gallbladders were enrolled from six centres in England and Italy. They were randomized to either a combination of chenodeoxycholic acid plus ursodeoxycholic acid (5 mg.day/kg each) or to ursodeoxycholic acid alone (10 mg.day/kg). Dissolution was assessed by 6-monthly oral cholecystography and ultrasonography for up to 24 months.

RESULTS

Both regimens reduced the frequency of biliary pain and there was no significant difference between them in terms of side-effects or dropout rate. Complete gallstone dissolution on an intention-to-treat basis was similar at all time intervals. At 24 months this was 28% with ursodeoxycholic acid alone and 30% with combination therapy. The mean dissolution rates at 6 and 12 months were 47% and 59% with ursodeoxycholic acid, and 44% and 59% with combination therapy, respectively.

CONCLUSION

There is no substantial difference in the efficacy of combined ursodeoxycholic acid and chenodeoxycholic acid and that of ursodeoxycholic acid alone in terms of gallstone dissolution rate, complete gallstone dissolution, or relief of biliary pain.

Risk factors for the development of gallstone recurrence following medical dissolution. The British-Italian Gallstone Study Group

OBJECTIVE

To assess risk factors for gallstone recurrence following non-surgical treatment.

DESIGN

A prospective follow-up of a multicentre cohort of post-dissolution gallstone patients.

SETTING

Six gastroenterology units in the UK and Italy.

PARTICIPANTS

One hundred and sixty-three patients with confirmed gallstone dissolution following non-surgical therapy (bile acids or lithotripsy plus bile acids), followed up by ultrasound scan and clinical assessment at 6-monthly intervals for up to 6 years (median, 25 months; range, 6-70 months).

OUTCOME MEASURES

Subject-related variables (sex, age, height, weight, body mass index), gallstone-related variables (number, diameter, presence of symptoms, months to complete stone clearance), treatment modalities (bile acid therapy, extracorporeal shock wave lithotripsy) and follow-up related variables (weight change, use of non-steroidal anti-inflammatory agents, statins, pregnancies and/or use of oestrogens) were assessed by univariate and multivariate analysis as putative risk factors for gallstone recurrence.

RESULTS

Forty-five gallstone recurrences were observed during the follow-up period. Multiple primary gallstones and length of time to achieve gallstone dissolution were the only variables associated with a significant increase in the recurrence rate. Appearance of biliary sludge during follow-up was also significantly related to development of gallstone recurrence. Use of statins or non-steroidal anti-inflammatory agents did not confer protection against recurrence.

CONCLUSIONS

Patients with primary single stones are the best candidates for non-surgical treatment of gallstones, because of a low risk of gallstone recurrence. The positive association of recurrence with biliary sludge formation and time to dissolution of primary stones may provide indirect confirmation for the role of impaired gallbladder motility in the pathogenesis of this condition.

Review article: epidemiology of gall-bladder disease--role of intestinal transit

Recent epidemiological studies have suggested that hyperinsulinaemia may be a central factor in the pathogenesis of cholesterol gallstones, explaining a probable link with physical inactivity as well as abdominal adiposity. There is also increasing evidence for the hypothesis that enrichment of bile with DCA. 'the colonic bile acid', leads to enrichment of bile with cholesterol. Biliary DCA can be raised and lowered by slowing down and speeding up colonic transit, respectively. Slow transit is characteristic of non-obese British women with gallstones and of non-obese peasants in a gallstone-prone mountain community. High biliary DCA predicts recurrence of gallstones and so does laxative usage, a pointer to constipation and therefore to slow transit. In some studies, at least, a high fibre intake is protective against gallstones. Much else besides fibre influences colonic function. Future studies of gallstone aetiology should include measurements of colonic function. Measures that speed up colonic transit should be tested for their ability to prevent gallstone formation in high-risk individuals.

Irritable bowel syndrome in general practice: prevalence, characteristics, and referral

BACKGROUND AND AIMS

Little is known about the prevalence, symptoms, diagnosis, attitude, and referral to specialists of patients with irritable bowel syndrome (IBS) in general practice. This study aimed to determine these characteristics.

METHODS

3111 patients attending 36 general practitioners (GPs) at six varied locations in and near Bristol, UK, were screened to identify those with a gastrointestinal problem. These patients (n=255) and their doctors were given questionnaires. Six months later the case notes were examined to reach criteria based diagnoses of functional bowel disorders.

RESULTS

Of 255 patients with a gastrointestinal complaint, 30% were judged to have IBS and 14% other functional disorders. Compared with 100 patients with an "organic" diagnoses, those with IBS were more often women and more often judged by their GP to be polysymptomatic and to have unexplained symptoms. The majority of patients with IBS (58%) were diagnosed as such by the GP; 22% had other functional diagnoses. Conversely, among 54 patients diagnosed as having IBS by the GPs, the criteria based diagnosis was indeed functional in 91%; only one patient had organic disease (proctitis). More patients with IBS than those with organic disease feared cancer. In most some fear remained after the visit to the doctor. On logistic regression analysis, predictors of referral to a specialist (29% referred) were denial of a role for stress, multiple tests, and frequent bowel movements.

CONCLUSIONS

Half the patients with gut complaints seen by GPs have functional disorders. These are usually recognised, and few patients are referred. In IBS, cancer fears often remain, suggesting unconfident diagnosis or inadequate explanation.

Effect of cholecystectomy on bowel function: a prospective, controlled study

BACKGROUND

Published estimates of the prevalence of postcholecystectomy diarrhoea derive from retrospective or uncontrolled data. They ignore functional bowel syndromes and possible changes in diet and drug use.

AIMS

To determine prospectively whether and how often cholecystectomy leads to changes in bowel function and bowel symptoms, especially to liquid stools, over and above any non-specific effect of laparoscopic surgery.

SUBJECTS

PATIENTS

106 adults undergoing laparoscopic cholecystectomy (85 women, 21 men).

CONTROLS

37 women undergoing laparoscopic sterilisation.

METHODS

Before and 2-6 months after surgery patients were administered questionnaires about bowel frequency, bowel symptoms, diet, and drugs, and kept records of five consecutive defecations with assessment of stool form or appearance on a seven point scale.

RESULTS

In cholecystectomised women, stated bowel frequency increased, on average by one movement a week, and fewer subjects felt that they became constipated. However, records showed no consistent change in bowel frequency, stool form, or defecatory symptoms. Six women reported diarrhoea after the operation but in only one was it clearly new and in her it was mild. Change in dietary fibre intake did not associate with change in bowel function but stopping constipating drugs did in a minority. In women being sterilised there was no consistent change in bowel function. In men having cholecystectomy no consistent changes were observed.

CONCLUSIONS

In women, cholecystectomy leads to the perception of less constipation and slightly more frequent defecations but short term recordings show no consistent change in bowel function. Clinical diarrhoea develops rarely and is not severe.

Functional bowel disorders and functional abdominal pain

The Rome diagnostic criteria for the functional bowel disorders and functional abdominal pain are used widely in research and practice. A committee consensus approach, including criticism from multinational expert reviewers, was used to revise the diagnostic criteria and update diagnosis and treatment recommendations, based on research results. The terminology was clarified and the diagnostic criteria and management recommendations were revised. A functional bowel disorder (FBD) is diagnosed by characteristic symptoms for at least 12 weeks during the preceding 12 months in the absence of a structural or biochemical explanation. The irritable bowel syndrome, functional abdominal bloating, functional constipation, and functional diarrhea are distinguished by symptom-based diagnostic criteria. Unspecified FBD lacks criteria for the other FBDs. Diagnostic testing is individualized, depending on patient age, primary symptom characteristics, and other clinical and laboratory features. Functional abdominal pain (FAP) is defined as either the FAP syndrome, which requires at least six months of pain with poor relation to gut function and loss of daily activities, or unspecified FAP, which lacks criteria for the FAP syndrome. An organic cause for the pain must be excluded, but aspects of the patient's pain behavior are of primary importance. Treatment of the FBDs relies upon confident diagnosis, explanation, and reassurance. Diet alteration, drug treatment, and psychotherapy may be beneficial, depending on the symptoms and psychological features.

The metabolic consequences of slow colonic transit

Intestinal transit has a substantial influence on the enterohepatic circulation of bile acids and steroid hormones, on colonic pH, and on short chain fatty acid concentrations in the distal colon. Slow transit is likely to favor disease processes that are related to over-efficient enterohepatic recirculation and to lack of short chain fatty acid in the distal colon. These include gallstones, large bowel cancer, and possibly breast cancer. The best-documented influence of slow colonic transit is on bile acid metabolism. Slowing colonic transit increases deoxycholate and raises cholesterol saturation of bile, making gallstone formation more likely. In this review, we also examine the evidence that slow colonic transit may be important in the etiology of large bowel and breast cancer. There is a lack of data pertaining to the relationship between colonic transit and diseases such as colon and breast cancer. Should slow colonic transit prove to be a significant factor in the etiology of such diseases, then the health of the population might benefit from dietary and lifestyle changes that speed up intestinal transit.

Roughage revisited: the effect on intestinal function of inert plastic particles of different sizes and shape

The mechanisms by which dietary fiber exerts its laxative action are not fully understood. Finely grinding wheat bran reduces its effect. Inert plastic particles are equipotent to bran if they consist of flakes or sliced tubing. It is not known whether altering the size or shape of inert particles alters their effect on intestinal function. In a randomized crossover study, 18 volunteers swallowed 24 g/day of plastic as branlike flakes or as small granules for 10-12 days with a two-week washout period between interventions. Whole-gut transit time (WGTT), orocecal transit time (OCTT), defecation frequency, stool form, stool water content, stool pH, and dietary intake were assessed. The plastic flakes caused a 24% (P < 0.001) reduction in WGTT and a 19% (P = 0.002) fall in OCTT. Resultant and appropriate changes in stool form, interdefecatory intervals (IDI), and stool weight were seen. The small granules did not cause any significant change in WGTT or OCTT, although IDI did decrease and stool output and stool form score increased. The stimulant effect of solid particles in the intestinal lumen upon transit time is influenced by the morphology of the particles.

Intestinal absorption of oestrogen: the effect of altering transit-time

OBJECTIVE

The mechanism by which a high fibre diet may reduce serum oestrogens is unknown. We hypothesized that time is a rate-limiting factor in oestrogen absorption from the colon so that changes in colonic transit-rate affect the proportion of oestrogen that is deconjugated and/or absorbed.

AIM

To determine if alteration of intestinal transit rate would influence the absorption of an oral dose of oestradiol glucuronide.

PARTICIPANTS

Twenty healthy postmenopausal women recruited by advertisement.

SETTING

Department of Medicine, Bristol Royal Infirmary.

METHODS

Volunteers consumed, in turn, wheat bran, senna, loperamide and bran shaped plastic flakes, each for 10 days with a minimum 2 week washout period between study periods, dietary intake being unchanged. Before and in the last 4 days of each intervention whole-gut transit-time, defecation frequency, stool form, stool beta-glucuronidase activity, stool pH and the absorption of a 1.5 mg dose of oestradiol glucuronide were measured.

RESULTS

Wheat bran, senna and plastic flakes led to the intended reduction in whole-gut transit-time, increase in defecatory frequency and increase in stool form score. Loperamide caused the opposite effect. The length of time the absorbed oestrogen was detectable in the serum fell with wheat bran and senna, although this was only significant for oestradiol. Oestrone, but not oestradiol, was detectable for a longer time with loperamide. Plastic flakes had no effect on either oestrogen. Areas under the curve did not change significantly but tended to fall with the three transit-accelerating agents and to rise with loperamide.

CONCLUSION

Our data indicate there is likely to be an effect of intestinal transit on the absorption of oestrogens but more refined techniques are needed to characterize this properly.

Stool form scale as a useful guide to intestinal transit time

BACKGROUND

Stool form scales are a simple method of assessing intestinal transit rate but are not widely used in clinical practice or research, possibly because of the lack of evidence that they are responsive to changes in transit time. We set out to assess the responsiveness of the Bristol stool form scale to change in transit time.

METHODS

Sixty-six volunteers had their whole-gut transit time (WGTT) measured with radiopaque marker pellets and their stools weighed, and they kept a diary of their stool form on a 7-point scale and of their defecatory frequency. WGTT was then altered with senna and loperamide, and the measurements were repeated.

RESULTS

The base-line WGTT measurements correlated with defecatory frequency (r = 0.35, P = 0.005) and with stool output (r = -0.41, P = 0.001) but best with stool form (r = -0.54, P < 0.001). When the volunteers took senna (n = 44), the WGTT decreased, whereas defecatory frequency, stool form score, and stool output increased (all, P < 0.001). With loperamide (n = 43) all measurements changed in the opposite direction. Change in WGTT from base line correlated with change in defecatory frequency (r = 0.41, P < 0.001) and with change in stool output (n = -0.54, P < 0.001) but best with change in stool form (r = -0.65, P < 0.001).

CONCLUSIONS

This study has shown that a stool form scale can be used to monitor change in intestinal function. Such scales have utility in both clinical practice and research.

Increasing butyrate concentration in the distal colon by accelerating intestinal transit

BACKGROUND

Populations at low risk of colonic cancer consume large amounts of fibre and starch and pass acid, bulky stools. One short chain fatty acid (SCFA), butyrate, is the colon's main energy source and inhibits malignant transformation in vitro.

AIM

To test the hypothesis that altering colonic transit rate alters colonic pH and the SCFA content of the stools.

PATIENTS

Thirteen healthy adults recruited by advertisement.

METHODS

Volunteers consumed, in turn, wheat bran, senna and loperamide, each for nine days with a two week washout period between study periods, dietary intake being unchanged. Before, and in the last four days of each intervention, whole gut transit time (WGTT), defaecation frequency, stool form, stool beta-glucuronidase activity, stool pH, stool SCFA concentrations and intracolonic pH (using a radiotelemetry capsule for continuous monitoring) were assessed.

RESULTS

WGTT decreased, stool, output and frequency increased with wheat bran and senna, vice versa with loperamide. The pH was similar in the distal colon and stool. Distal colonic pH fell with wheat bran and senna and tended to increase with loperamide. Faecal SCFA concentrations, including butyrate, increased with senna and fell with loperamide. With wheat bran the changes were non-significant, possibly because of the short duration of the study. Baseline WGTT correlated with faecal SCFA concentration (r = -0.511, p = 0.001), with faecal butyrate (r = -0.577, p < 0.001) and with distal colonic pH (r = 0.359, p = 0.029).

CONCLUSION

Bowel transit rate is a determinant of stool SCFA concentration including butyrate and distal colonic pH. This may explain the inter-relations between colonic cancer, dietary fibre intake, stool output, and stool pH.

Irritable bowel syndrome: the view from general practice

OBJECTIVE

To determine the attributes of the irritable bowel syndrome (IBS) in general practice as perceived by the doctors.

SUBJECTS AND METHODS

We administered a 93-item questionnaire about the terminology, diagnosis and treatment of the irritable bowel to 43 of 55 randomly selected general practitioners (28 men, 15 women).

RESULTS

General practitioners were unfamiliar with the Manning criteria for the irritable bowel syndrome. Nevertheless, most of them diagnosed the irritable bowel with reasonable confidence and it is less troublesome to them than pelvic pain, headache or backache. Their main concern was excluding organic disease (63%) and 65% believed their patients shared this concern. Nevertheless, they ordered few tests and were often (72%) prepared to make the diagnosis on the initial visit. They estimated that they referred only 14% of IBS patients to specialists, in most cases (56%) because of an unsatisfied patient and in 35% because of an uncertain diagnosis. For treatment, most (77%) chose 'explanation and reassurance'. Virtually all employed drugs, usually several.

CONCLUSION

General practitioners say they diagnose the irritable bowel syndrome with less difficulty than other common, painful disorders, but it would be helpful to find out exactly how they do so. Their confidence could be increased by use of diagnostic criteria. Patients referred to specialists are likely to be a minority of hard-to-satisfy people. The optimal approach to such patients should be developed by general practitioners and specialists together. Specialists should strive to satisfy the patient and confirm the diagnosis in the few that are referred. Drug usuage in the irritable bowel syndrome is more than is justified and should, in our view, be minimized.

The intestinal effects of bran-like plastic particles: is the concept of 'roughage' valid after all?

OBJECTIVE

The mechanisms by which dietary fibre exerts is laxative action are not fully understood. Studies using sliced plastic tubing as a fibre substitute showed a decrease in both small and large bowel transit time. The significance of these studies is hard to interpret. We set out to compare the effects on intestinal function of wheat bran with plastic flakes similar in size and flaky shape to wheat bran (and devoid of plasticizers).

DESIGN AND METHODS

Volunteers consumed coarse wheat bran then, after a washout period, plastic flakes of the same size and shape as the bran. Before and after each intervention whole-gut transit time (WGTT), defecation frequency, stool form, stool water content, stool beta-glucuronidase activity and dietary intake were assessed.

RESULTS

Twenty-nine volunteers consumed a mean of 27.1 g of raw wheat bran and 24 g of plastic flakes a day. Baseline WGTT, interdefecatory intervals (IDI), stool form, weight, output, water content, and beta-glucuronidase were similar before both interventions. Both led to a decrease in mean faecal beta-glucuronidase activity, median WGTT (bran 25.8%, plastic 28.6%) and IDI (bran 23.3% plastic 25.0%). Both also increased stool form score (bran 28.6%, plastic 21.2%) and stool output (bran 67.1%, plastic 79.0%). Stool water content only rose with wheat bran (72%-75%, P = 0.014).

CONCLUSION

Overall, plastic 'pseudobran' was as effective at altering colonic function as wheat bran at a similar dosage but with fewer particles. The mechanism is not by increased faecal water. Reduction in enzyme activity with plastic flakes suggests that the plastic led to qualitative and, probably, beneficial changes in the bacterial flora or their metabolic processes. The concept of roughage deserves to be revived.

Gallstones in a community free of obesity but prone to slow intestinal transit

OBJECTIVES

To verify anecdotal reports that gallstones were frequent in a remote community where obesity is rare and to look for possible explanations of their occurrence, including slow intestinal transit.

DESIGN

Population survey of gallbladder status and stool form.

SETTING

Two villages in Ladakh, a mountainous region of northern India; for comparison, a stratified random sample from general practitioners' lists in East Bristol.

SUBJECTS

Women aged 25-59 years, 437 in Ladakh and 974 in Bristol.

MAIN OUTCOME MEASURES

Presence of gallstones on ultrasonography and response to questionnaires about parity, the intake of dried legume seeds (pulses) and bowel function including the form or appearance of the stools on a seven-point, transit-sensitive scale. Weight, height and waist circumference were also recorded.

RESULTS

Gallstone disease was at least as frequent in Ladakh as in Bristol although Ladakhi women were uniformly slim and their weight, waist size and body mass index failed to rise with age. After adjustment for age, gallstone disease was associated with higher body mass index and waist size in Bristol but not in Ladakh. It was associated with increased parity in Bristol, but not significantly so after adjusting for age and not at all in Ladakh. Gallstone disease was not directly associated with bowel function but Ladakhis often reported their stools to be lumpy (42.4 vs. 26.5% of Bristol women) and seldom as soft or loose (6.4 vs. 42.5%), implying that their intestinal transit tends to be slow.

CONCLUSION

Gallstones can be common in a population free of obesity but prone to intestinal stasis.

Lower serum oestrogen concentrations associated with faster intestinal transit

Increased fibre intake has been shown to reduce serum oestrogen concentrations. We hypothesized that fibre exerts this effect by decreasing the time available for reabsorption of oestrogens in the colon. We tested this in volunteers by measuring changes in serum oestrogen levels in response to manipulation of intestinal transit times with senna and loperamide, then comparing the results with changes caused by wheat bran. Forty healthy premenopausal volunteers were placed at random into one of three groups. The first group took senna for two menstrual cycles then, after a washout period, took wheat bran, again for two menstrual cycles. The second group did the reverse. The third group took loperamide for two menstrual cycles. At the beginning and end of each intervention a 4-day dietary record was kept and whole-gut transit time was measured; stools were taken for measurement of pH and beta-glucuronidase activity and blood for measurement of oestrone and oestradiol and their non-protein-bound fractions and of oestrone sulphate. Senna and loperamide caused the intended alterations in intestinal transit, whereas on wheat bran supplements there was a trend towards faster transit. Serum oestrone sulphate fell with wheat bran (mean intake 19.8 g day(-1)) and with senna; total- and non-protein-bound oestrone fell with senna. No significant changes in serum oestrogens were seen with loperamide. No significant changes were seen in faecal beta-glucuronidase activity. Stool pH changed only with senna, in which case it fell. In conclusion, speeding up intestinal transit can lower serum oestrogen concentrations.

Repeated bile acid therapy for the long-term management of cholesterol gallstones

BACKGROUND/AIMS

Following non-surgical treatment, cholesterol gallstones recur in a high proportion of patients, and recurrence cannot be predicted nor effectively prevented. Our aim was to test prospectively the viability and the efficacy of repeated bile acid therapy, in which recurrent stones are diagnosed at an early stage by regular ultrasound monitoring and promptly retreated, as a strategy for the management of these patients in clinical practice.

METHODS

One hundred and seventy-two consecutive patients were recruited upon achieving complete gallstone dissolution using non-surgical therapy (bile acids or lithotripsy plus bile acids), and followed up at 6-monthly intervals by ultrasound scan. Gallstone recurrence was promptly treated by a combination of ursodeoxycholic acid plus chenodeoxycholic acid (5 mg/kg per day each) for a period of 2 years, or less if complete redissolution was achieved. Median follow-up period was 34 months (range 6-70).

RESULTS

Forty-five patients had gallstone recurrence; of these, 39 underwent one or more repeated courses of bile acid therapy (follow-up data available in 27). Gallstone recurrence rate was 15% at 1 year and 47% at 5 years. Average annual redissolution rate of recurrent gallstones (intention to treat) was 41%. The proportion of gallstone-free patients in the whole population was 88%, 84%, 77%, 78%, 75% at 1-5 years, respectively, and rose to > 90% at 3 years onwards in patients with single primary stones.

CONCLUSIONS

We conclude that repeated bile acid therapy maintains the majority of patients gallstone free, and is therefore an effective long-term management strategy, especially in patients with primary single gallstones.

Prospective, multicenter study on value of computerized tomography (CT) in gallstone disease in predicting response to bile acid therapy

The aim of the study was to assess the value of quantitative attenuation values (Hounsfield units) and of gallstone pattern by computerized tomography in predicting response to bile acid therapy. We carried out a prospective study in a multicenter setting on 90 consecutive outpatients with radiolucent gallstones. All received bile acid therapy (UDCA 10 mg/kg/day or UDCA + CDCA 5 mg/kg/day of each) up to two years. Hounsfield units for gallstones were recorded using standardized criteria and six categories of patterns were defined: hypodense, isodense, homogenously dense, laminated, rimmed and speckled. We assessed gallstone dissolution rate (percent reduction in volume), response to therapy (> 25% reduction in volume), and final outcome of therapy. Eighty-one percent of patients with hypodense/isodense and all four patients with speckled stone pattern responded to therapy, whereas none of the 10 patients with laminated/rimmed and only 45% of patients with homogenously dense stone pattern did. Complete dissolution was achieved by 68%, 50%, 35%, 0% of the hypodense/isodense, speckled, homogenously dense, rimmed/laminated gallstones, respectively. The use of Hounsfield units did not show an advantage over gallstone pattern for predicting either response or final outcome to bile acid therapy. We conclude that computerized tomography analysis of gallstones is of value in predicting response to bile acid therapy and that gallstone pattern alone predicts response in most cases without the need for quantitative assessment.

Smoking habits and lipoproteins in British women

The incidence of coronary heart disease is increasing in women. Some of this may be related to increased smoking in women over the past decades. However, the mechanism mediating the smoking-coronary heart disease link is unclear. We therefore assessed the relationship of smoking habits to fasting plasma insulin, total and low-density lipoprotein (LDL) cholesterol, triglyceride, high-density lipoprotein (HDL) cholesterol, including its subfractions HDL2 and HDL3, body mass index, and waist:hip circumference ratio in 1048 women aged 25-69 years. Compared with non-smokers, current smokers had higher plasma concentrations of LDL cholesterol by 0.2 mmol/l or 6%, total/HDL cholesterol ratio by 0.5 or 13%, triglyceride by 0.14 mmol/l or 13% and waist:hip ratio by 0.02 or 3%, but lower HDL cholesterol by 0.13 mmol/l or 9% and HDL2 cholesterol by 0.07 mmol/l or 13%, while ex-smokers had higher waist hip ratio by 0.01 or 1% but lower HDL cholesterol by 0.06 mmol/l or 4% and HDL2 cholesterol by 0.09 mmol/l or 16%. Ex-smokers for up to 5 years, compared with non-smokers, had higher plasma concentrations of total/HDL cholesterol ratio by 0.4 mmol/l or 11%, triglyceride by 0.22 mmol/l or 21% and waist hip ratio by 0.01 or 1%, but lower levels of HDL cholesterol by 0.12 mmol/l or 9% and HDL2 cholesterol by 0.14 mmol/l or 26%. Cigarette smoking is associated with adverse changes in lipoprotein levels; these changes decrease slowly after quitting.

Is extrinsic sugar a vehicle for dietary fat?

Although many guidelines to healthy eating recommend restriction of the intake of extrinsic (refined) sugar, there are concerns that such restriction might result in an increase in the amount and the proportion of dietary fats with a consequent possible increase in the risk of cardiovascular disease. We used regression analysis to examine the determinants of fat intake in subjects from a population survey who had weighed their food for 4 days. In men (n = 77) and women (n = 83), fat eaten was positively related to the intake of extrinsic sugar. When intakes were expressed as percent of calories the relation became negative. A survey in a semi-random sample of 739 men aged 40-69 yr and 976 women aged 25-69 yr showed that, in both sexes, an increase in extrinsic sugar was associated with a linear increase in the intake of sweetened fat and hence of fat combined with carbohydrate. This was due mainly to a higher intake of cakes and biscuits. Foods containing sugar and fat provided an extra 12.0 g per day of fat in the men and 13.8 g per day in the women when the highest quartile of extrinsic sugar consumers were compared with the lowest quartile. We conclude that lowering the intake of extrinsic sugar is unlikely to be associated with higher fat intake. Instead extrinsic sugar may act as a vehicle for fat intake, encouraging consumption by making the fat more palatable.

Gastric emptying of a solid meal is accelerated by the removal of dietary fibre naturally present in food

Exogenous fibre added to liquid meals delays gastric emptying. Its effect on solid meals is uncertain, and nothing is known of the effect on gastric emptying of fibre naturally present in food. This study therefore looked at gastric emptying of two different solid meals in eight healthy subjects and their blood glucose responses. The meals were exactly equivalent except for the total dietary fibre content (high fibre 20 g, low fibre 4 g of dietary fibre per 1000 kcal) and supplied 870 kcal (700 kcal women), 47% of which was from carbohydrates, 36% from fats, and 17% from proteins. Ultrasonography was used to measure antral diameters before the meal (basal), immediately after it (time 0), and at 30, 60, 120, 180, 240, and 300 minutes. In addition, subjects filled in a questionnaire on their feelings of hunger, epigastric fullness, and satiety before the meal and at hourly intervals after it. Basal and maximal postprandial antral sections were similar for the two meals (basal section: 283.9 (29.5) v 340.9 (44.7) mm2 for the low and the high fibre meal, NS; maximal postprandial section: 1726 (101.9) v 1593 (120.4) mm2, NS). Total gastric emptying time was significantly reduced by fibre removal (186.0 (15.6) v 231.7 (17.3) minutes after the low and the high fibre meal, p < 0.05). Blood glucose was higher after the low fibre meal, and the area under the glycaemic curve significantly greater (226 (23.1) v 160 (20.0) mmol/min/dl-1, p < 0.05). No difference was found in satiety or fullness feelings, but hunger returned more rapidly after the low fibre meal. In conclusion, fibre naturally present in food delays gastric emptying of a solid meal, reduces the glycaemic response, and delays the return of hunger.

Some determinants of whole-gut transit time: a population-based study

Slow whole-gut transit time may be associated with an increased risk of gallstones, and possibly bowel cancer, but its determinants are unknown. We looked for these determinants in a community-based study of 884 women aged 25-69 years and 677 men aged 40-69 years. Transit time was estimated using prospective examination of three stools and a questionnaire about bowel habit. Diet and alcohol intake were assessed using a validated food frequency questionnaire. In women < 50 years not taking oral contraceptives, mean transit time was relatively constant across 10-year age bands (62 to 63 h). In older women it was also relatively constant, but was significantly shorter (58 to 59 h), suggesting an effect of female sex hormones. In women taking oral contraceptives, mean transit-time was 6 h longer than in women of the same age not taking them (95% CI 1.4 to 10.6 h). In men drinking > 40 g alcohol/day, mean transit time was 49 h compared with 54 h in those drinking < 20 g/day (p < 0.0001). In alcohol-abstaining men, an effect of dietary NSP (non-starch polysaccharide or fibre) intake was clearly apparent. Alcohol consumption quickened transit in both sexes; oral contraceptive usage slowed it in women. Body mass index in both sexes, soluble NSP in men, and insoluble NSP in women also significantly and negatively affected transit time. The food groups which were related to transit time were potatoes and cooked fruit in men, and pulses and bread in women.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute respiratory distress secondary to Morgagni diaphragmatic herniation in an adult

Diaphragmatic hernias of the Morgagni type are generally thought to be asymptomatic in adults. This traditional assumption led to a delay in diagnosing a Morgagni hernia as the cause of acute respiratory distress in a chronic schizophrenic man. While Morgagni hernias are usually considered to be long-standing, we present radiological evidence of an acutely expanding hernia. The patient's symptoms were relieved by surgical repair of the hernia. We advise caution before dismissing Morgagni hernias in adults as being long-standing and clinically insignificant.

Evidence for the ambiguity of the term constipation: the role of irritable bowel syndrome

A satisfactory definition of constipation is elusive. An important and measurable element is slow colonic transit. Whole gut transit time, a proxy for colonic transit time, can be estimated from self recorded data on stool form and frequency. Our aim was to compare whole gut transit time with subjective definitions in the context of the general population. In a community based sample of 731 women aged 25-69 years the estimated whole gut transit time was compared with two subjective assessments of constipation-the woman's own perception and a symptom based definition proposed by an international working team (Rome definition). We have defined slow whole gut transit time as > 2 SD above the mean in women who seldom passed lumpy stools (that is, > 92 hours). Slow transit was present in 9.3% of the sample. Similar numbers met the subjective definitions (8.5% and 8.2%). However, the overlap between the three definitions was poor. Of 68 women with estimated slow transit, 28 had self perceived constipation, 20 had Rome defined constipation, and only 11 had both. Of subjects classified as constipated by the subjective definitions only 37% had slow transit; they had a high prevalence of irritable bowel symptoms. In conclusion, this study showed that the term constipation is ambiguous and often misleading and that attempts to base a definition on symptoms are misguided. In epidemiological studies, conclusions about the prevalence of constipation should be based on records of stool type and timing.

Irritable bowel syndrome in patients discharged from surgical wards with non-specific abdominal pain

A questionnaire was used to discover the prevalence of seven recognized symptoms of irritable bowel syndrome (IBS) in 96 patients who had been discharged from hospital 1-2 years previously with the diagnosis of non-specific abdominal pain. Compared with 1897 controls from a population survey in the same city, the patients were more likely to have these symptoms; the differences were statistically significant in most cases. The frequency of recurrent abdominal pain with features suggesting an intestinal origin was increased fivefold in male and fourfold in female patients (P < 0.001). Criteria for the diagnosis of IBS were present in 37 per cent of women and 19 per cent of men, versus 5 and 2 per cent respectively in controls (P < 0.001). Approximately half the patients remembered having symptoms of IBS at the time of admission and 70 per cent had had other attacks of abdominal pain. At the time of admission, the hospital notes mentioned the possibility of IBS in only 6 per cent of cases. Most patients would have welcomed an explanation for the pain at the time of their hospital admission.

An office guide to whole-gut transit time. Patients' recollection of their stool form

Forty-seven patients (ages 17-74 years, 33 women) who had irritable bowel syndrome and who attended a gastroenterology clinic had their whole-gut transit time (WGTT) assessed by an abdominal radiograph after ingesting 20 radioopaque markers on 4 consecutive days. Immediately afterward, the patients completed a questionnaire that asked about their stool form on the Bristol Scale, their bowel frequency, and whether they thought they had been experiencing diarrhea or constipation during the previous 5 days. WGTT varied from 7 to 96 h. Stool form correlated significantly with WGTT (r = -0.57, p < 0.001), whereas stool frequency did not (r = 0.31, NS). The regression equation relating WGTT to stool form was WGTT (h) = 75-10 (stool form). WGTT, stool form, and frequency were significantly different in patients reporting constipation compared with those who reported diarrhea, diarrhea and constipation, or neither, but in the last three groups these parameters were not significantly different from each other. Patients' recollection of stool form is a reasonable guide to their transit time and can be used in the office to identify pseudodiarrhea and true constipation.

Intestinal transit time in the population calculated from self made observations of defecation

STUDY OBJECTIVES

To assess the feasibility of estimating intestinal transit time in the general population using self recorded data on stool form, frequency of defecation, and the interdefecatory time interval.

DESIGN

Prospective measurement of bowel function.

SETTING

Bristol, Avon, UK between 1987 and 1989.

SUBJECTS

Subjects were drawn from 1897 people who comprised 72.2% of a stratified random sample of all men aged 40-69 years and women aged 25-69 years on the lists of 19 general medical practitioners. Altogether 1561 subjects (59.4%) recorded bowel function and a subsample of 98 (50 women and 48 men) had intestinal transit time measured.

MEASUREMENTS AND MAIN RESULTS

The interdefecatory time interval and stool form (on a validated 1-6 scale sensitive to transit time) were recorded prospectively from three consecutive defecations. In the subsample the mean intestinal transit time was measured simultaneously using a four marker, two stool x ray technique. Multiple regression analysis was used to assess the extent to which intestinal transit time could be predicted from the defecatory data. The formulas obtained were then applied to the whole study population. In women, intestinal transit time was best predicted by the formula 103-1.23 (DF)--4.69 (SFS)+0.638 (IDTI), where DF is the stated defecation frequency per week, IDTI is the interdefecatory time interval, and SFS is the sum of the three stool form scores, for which the correlation coefficient r = 0.736. For men the intestinal transit time = 79-1.33 (DF)--1.88 (SFS)+0.329 (IDTI), for which the correlation coefficient r = 0.541. The predicted intestinal transit time was longer in women than men at equivalent ages. Women of childbearing age had longer transit times than older women.

CONCLUSIONS

Observations made by untrained subjects can be used to estimate intestinal transit time in epidemiological studies. A gender related difference in transit time exists.

Bowel function and irritable bowel symptoms after hysterectomy and cholecystectomy--a population based study

Because unsubstantiated beliefs link hysterectomy and cholecystectomy with bowel function, this study examined all the women who had had these operations in a defined population (79 and 37 respectively, out of 1058) with respect to bowel habits, irritable bowel syndrome symptoms, and whole gut transit time calculated from records of three defecations. Compared with unoperated controls, women after hysterectomy were more likely to consider themselves constipated; they also strained more and admitted more often to bloating and feelings of incomplete evacuation. Their stools tended to be lumpier and, in women over 50 years, transit time was longer. When women treated by cholecystectomy were compared with women having newly discovered, asymptomatic gall stones, they more often described defecation as urgent but had no other detectable differences. In conclusion symptomatic constipation is frequent in women after hysterectomy; after cholecystectomy, bowel habit is not consistently changed but the rectum seems to be more irritable.

Straining at stool and laxative taking in an English population

A population-based sample of 834 men (ages 40-69 years) and 1058 women (25-29 years) was investigated with respect to straining to defecate, stool form, bowel habit, and use of laxatives, by means of a questionnaire and a three-stool record form. Straining was common but, contrary to standard teaching, far from universal. It was unrelated to age but was commoner in women than men. Many people underestimated how often they strained. Overall, 32% of defecations in women and 22% of defecations in men were associated with straining to start and 15% and 9%, respectively, with straining to finish. Straining was to some extent related to stool type: the lumpier a stool, the more often it elicited straining. However, it seems likely that straining in some people is just a habit. Use of laxatives was found to be less prevalent than in the past, and most people with evidence of constipation did not use them. Use of laxatives increased with age, and some older people used them inappropriately. The most popular laxatives were based on phenolphthalein, senna, or magnesium.

Perceptions and reactions of the public to diarrhoea

A questionnaire about diarrhoea and how people react to it was answered by 400 people aged 16-70 years, most of whom were in employment (77% of respondents). There was wide variation in perceptions and reactions. Older persons and people in skilled trades were more likely to consider any increased bowel looseness or frequency of their usual bowel habit as diarrhoea, compared to younger persons and people in professional and managerial positions. Over half the respondents rated a single soft stool as diarrhoea, and almost a third accepted likewise an increased frequency of defaecation. The most unpleasant aspect of diarrhoea was considered to be incontinence with soiling of underclothes. At the onset of diarrhoea, 16% of respondents would not wait even a day or two but would go straight to a pharmacist, and 8% would go direct to a doctor. Persons in professional and managerial positions were less likely to attend their doctor straight away than people in other occupational groups. The findings show that for improved clinical management and public health surveillance, health professionals should not accept the term when it is used by patients, but seek details of their defaecation patterns and the form of their stools. Improved public education is needed as to self-help, appropriate treatment and when to seek pharmaceutical and medical advice.

An explanation for gallstones in normal-weight women: slow intestinal transit

Many cases of gallstones can be explained in terms of the established risk factors, especially obesity. However, gallstones develop in some women who are not obese, and the causes are unknown. Biochemical studies have shown that slow intestinal transit is associated with lithogenic bile. We have tested the hypothesis that intestinal transit is abnormally slow in normal-weight women with gallstones. In a population survey, 1058 women aged 25-69 years, registered with general practitioners in Bristol, UK, underwent cholecystosonography. Gallstones were identified in 48 women, of whom 15 were of normal weight (body mass index < or = 25 kg/m2). These women and age-matched controls with healthy gallbladders then underwent measurement of whole-gut transit time (WGTT); the measurement was done directly when possible, or calculated from records of three defaecations. The mean WGTT was significantly longer in the women with gallstones than in the controls (82 vs 63 h; mean difference 19, 95% CI 2-37 h). Stool output was also lower in the women with gallstones (74 [SD 54] vs 141 [56] g per 24 h, p = 0.015). There was no significant difference between cases and controls in body mass index, waist-hip circumference ratio, parity, plasma triglyceride concentration, or alcohol intake. Normal-weight women with gallstones tend to have slow intestinal transit and this feature could explain why they have gallstones.

Dietary intake and sources of non-starch polysaccharide in English men and women

Up-to-date information is unavailable on intakes of non-starch polysaccharide (NSP) in Britain. We surveyed 739 men aged 40-69 years and 976 women aged 25-69 years using a validated food-frequency questionnaire focused on carbohydrates. Mean NSP intake in the three decades of men was 15.5-16.4 g/day and in the five decades of women it was 14.3-15.3 g/day, with no clear effect of age. These NSP intakes are higher than those from a 1977 survey but well short of the recent government-recommended population mean of 18 g/day. However, nine people consumed over 32 g/day. The relative contribution of food groups to NSP intake varied with age and sex. Women obtained more NSP from raw fruit and salad, brown breads and breakfast cereals. Their preference for these foods probably explains why, overall, their NSP intakes were close to those of men. Younger people and men obtained relatively more of their NSP from potatoes cooked with fat and from pulses and less from raw fruit. The largest single source of soluble NSP was potatoes and half of this came from potatoes cooked with fat. In older women raw fruit and salad were equally important. Pulses provided about 10% of soluble NSP in younger women, cooked vegetables about 10% in older women. Increased potato consumption deserves attention as a means of obtaining the metabolic benefits of a high soluble NSP intake.

Fecal weight, colon cancer risk, and dietary intake of nonstarch polysaccharides (dietary fiber)

Low fecal weight and slow bowel transit time are thought to be associated with bowel cancer risk, but few published data defining bowel habits in different communities exist. Therefore, data on stool weight were collected from 20 populations in 12 countries to define this risk more accurately, and the relationship between stool weight and dietary intake of nonstarch polysaccharides (NSP) (dietary fiber) was quantified. In 220 healthy U.K. adults undertaking careful fecal collections, median daily stool weight was 106 g/day (men, 104 g/day; women, 99 g/day; P = 0.02) and whole-gut transit time was 60 hours (men, 55 hours; women, 72 hours; P = 0.05); 17% of women, but only 1% of men, passed < 50 g stool/day. Data from other populations of the world show average stool weight to vary from 72 to 470 g/day and to be inversely related to colon cancer risk (r = -0.78). Meta-analysis of 11 studies in which daily fecal weight was measured accurately in 26 groups of people (n = 206) on controlled diets of known NSP content shows a significant correlation between fiber intake and mean daily stool weight (r = 0.84). Stool weight in many Westernized populations is low (80-120 g/day), and this is associated with increased colon cancer risk. Fecal output is increased by dietary NSP. Diets characterized by high NSP intake (approximately 18 g/day) are associated with stool weights of 150 g/day and should reduce the risk of bowel cancer.

Coronary heart disease risk factors in relation to the menopause

The incidence of coronary heart disease increases after the menopause, but the mechanism is unclear. We assessed the relationship of age to fasting plasma insulin, total triglycerides, total cholesterol, total high density lipoprotein (HDL) cholesterol, including HDL2 and HDL3 subfractions, total/HDL cholesterol ratio, body mass index and waist-hip circumference ratio in 394 women and 824 men aged 40-69 years who participated in an epidemiological survey in East Bristol. Women over the age of 50 years were assumed to be post-menopausal, this being the median age of the menopause in Britain. Compared to younger women, post-menopausal women had higher plasma triglycerides by 0.31 mmol/l (95 per cent confidence interval 0.10-0.43), higher cholesterol by 1.0 mmol/l (0.77-1.24), higher total/HDL cholesterol ratio by 0.42 (0.15-0.69), higher insulin by 2.0 mU/l (0.02-0.11), higher body mass index by 0.9 kg/m2 (0.02-1.68), and higher waist-hip ratio by 0.02 (0.01-0.03). Age-related changes in men were absent or less marked. On multiple regression analysis the increases in plasma total triglycerides, total cholesterol, high density lipoprotein cholesterol, HDL3 cholesterol and total/HDL cholesterol ratio in postmenopausal women were independent of body mass index, waist-hip ratio, cigarette habits, alcohol consumption and antihypertensive therapy. On analysis of covariance sex had a significant effect on all variables which was independent of age. We conclude that there is an increase in coronary heart disease risk factors in women as they pass through the menopause, and insulin may play a central role.

The MD thesis in the training of a consultant physician

A postal survey was carried out among the 94 consultant physicians of the South Western region (83% response rate) to ascertain their attitudes to the tradition of obtaining an MD by thesis as part of a physician's training. Most felt that the practice was questionable, and only half felt that it made an important contribution. For some, doing an MD had been a painful experience, even a waste of time. Having an MD impressed selection committees, but did not appear to alter the length of training nor the probability of obtaining a consultant post in a teaching hospital. We suggest that the MD is of limited value in judging a junior doctor's suitability to be a consultant physician.

Symptoms of irritable bowel syndrome in a British urban community: consulters and nonconsulters

Because the prevalence of the irritable bowel syndrome (IBS) in the general population is unknown, a questionnaire of intestinal symptoms was administered to a stratified random sample of 1058 women and 838 men. Subjects were asked if they had consulted a physician about such symptoms. One or more symptoms occurred frequently in 47% of women and 27% of men. Diagnosable IBS, defined as three or more symptoms, was present in 13% of women and 5% of men. Abdominal pain was the most common symptom, and recurrent intestinal pain was reported by 20% of women and 10% of men. All symptoms were more common in women except runny or watery stools. Most symptoms including pain were unrelated to age. Only half the people with diagnosable IBS had consulted a physician about it. The likelihood of consulting a physician was directly proportional to the number of symptoms and was similar in men and women after controlling for the number of symptoms. Of individual symptoms, the one most strongly associated with consulting was abdominal pain, especially in men. It is concluded that IBS is prevalent at all ages, especially in women, that it is nearly always painful, and that people with multiple symptoms are more likely to consult a physician.

Final year medical students' knowledge of practical nutrition

An entire final-class of medical students was set a 6-part question on dietary advice to patients as commonly seen in general practice. The marks were scored by a formal, agreed system. Eighty-two per cent failed though only 2% failed the whole exam. The teaching of practical nutrition needs to be improved.