Association between maternal inflammatory bowel disease and adverse perinatal outcomes.

OBJECTIVE: To examine whether inflammatory bowel disease (IBD) is associated with ischemic/inflammatory conditions during pregnancy. STUDY DESIGN: A retrospective cohort study using the 2000 to 2012 Kaiser Permanente Southern California maternally-linked medical records (n=395 781). The two major subtypes of IBD, ulcerative colitis and Crohn's diseases were studied. Adjusted odds ratios (ORs) were used to quantify the associations. RESULT: A pregnancy complicated by IBD was associated with increased incidence of small-for-gestational age birth (OR=1.46, 95% confidence interval (CI)=1.14 to 1.88), spontaneous preterm birth (OR=1.32, 95% CI=1.00 to 1.76) and preterm premature rupture of membranes (OR=1.95, 95% CI=1.26 to 3.02). Further stratifying by IBD subtypes, only ulcerative colitis was significantly associated with increased incidence of ischemic placental disease, spontaneous preterm birth and preterm premature rupture of membranes. CONCLUSION: The findings underscore the potential impact of maternal IBD on adverse perinatal outcomes. Clinicians should be aware that the association between IBD and adverse perinatal outcome varies by IBD subtypes.

Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients.

BACKGROUND: Computed tomography (CT) demonstrates diverticulitis severity. AIM: To assess demographic, clinical and leucocyte features in association with severity. METHODS: We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast). RESULTS: Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P < .0001), leucocytosis (81.5% vs. 55.2%, P < .0001), neutrophilia (86.2% vs. 59.0%, P < .0001), 'bandemia' (18.5% vs. 5.5%, P < .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P < .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P < .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26-0.76]) and had less lower abdominal pain only (0.54 [0.29-0.99]) and more constipation (2.32 [1.27-4.23]), fever (2.13 [1.27-3.57]) and leucocytosis (2.67 [1.43-4.99]). CONCLUSIONS: Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.

Northern Baja California Indian women's concepts of illness and healing: Implications for public health and clinical practitioners.

Lay health care workers (promotores) interviewed 313 female members of remote Indian groups in northern Baja California, Mexico regarding: (1) common childhood and adult illnesses and endorsement of 'traditional' and modern therapies; (2) illness causation beliefs and knowledge of biomedical principles; and (3) the relation of ethnic identity with concepts of effective biomedical and non-biomedical therapy. The most common illnesses/symptoms reported in adults were diabetes, hypertension, high cholesterol, cold/flu, diarrhoea, low/variable blood pressure and arthritis; and in children, cold/flu, diarrhoea, bronchitis, cough, fever, empacho and dehydration. Of 285 informants, more reported at least one childhood disorder than who reported at least one adult disorder was most helped by traditional therapy [83 (29.1%) versus 44 (15.4%); P<0.0001] and both therapies [81 (28.4%) versus 42 (14.7%); P<0.001]. They reported eight naturalistic and two personalistic illness causes and manifested variable biomedical knowledge. Indian or mixed Indian/Mexican ethnic self-identity predominated, and Indian identity was unrelated to endorsement of traditional therapy. The 'biocultural synthesis' is a useful theoretical framework for viewing the findings. The Indians' pluralistic concepts have important implications for public health care workers and biomedical practitioners.

An irritable bowel syndrome-specific symptom questionnaire: development and validation.

BACKGROUND: No self-assessment instruments are available to assess symptoms of irritable bowel syndrome (IBS). Our aim was to develop a disease-specific symptom questionnaire for use in patients with IBS. METHODS: Two-hundred-and-thirty-four patients (77% F) with a mean age of 44 years took part in a psychometric evaluation using the previously validated Gastrointestinal Symptom Rating Scale modified for use in patients with IBS (GSRS-IBS). This version was tested against several disease-specific health-related quality of life (HRQL) questionnaires. Items with a high ceiling effect, items that measured a different construct, and items showing high correlation (>0.80) to another item were removed. A confirmatory factor analysis was also performed. RESULTS: The final questionnaire included 13 items depicting problems with satiety, abdominal pain, diarrhoea, constipation and bloating. The internal consistency reliability was high, ranging from 0.74 (pain) to 0.85 (satiety). The associations between similar constructs in the GSRS-IBS and the various HRQL scores confirmed the construct validity. Pain, bloating and diarrhoea were the symptom clusters that impaired HRQL the most. CONCLUSION: The GSRS-IBS is a short and user-friendly instrument with excellent psychometric properties.

Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) presents a significant diagnostic and management challenge for primary care practitioners. Improving the accuracy and timeliness of diagnosis may result in improved quality and efficiency of care. OBJECTIVE: To systematically appraise the existing diagnostic criteria and combine the evidence with expert opinion to derive evidence- and consensus-based guidelines for a diagnostic approach to patients with suspected IBS. METHODS: We performed a systematic literature review (January 1966-April 2000) of computerized bibliographic databases. Articles meeting explicit inclusion criteria for diagnostic studies in IBS were subjected to critical appraisal, which formed the basis of guideline statements presented to an expert panel. To develop a diagnostic algorithm, an expert panel of specialists and primary care physicians was used to fill in gaps in the literature. Consensus was developed using a modified Delphi technique. RESULTS: The systematic literature review identified only 13 published studies regarding the effectiveness of competing diagnostic approaches for IBS, the accuracy of diagnostic tests, and the internal validity of current diagnostic symptom criteria. Few studies met accepted methodological criteria. While symptom criteria have been validated, the utility of endoscopic and other diagnostic interventions remains unknown. An analysis of the literature, combined with consensus from experienced clinicians, resulted in the development of a diagnostic algorithm relevant to primary care that emphasizes a symptom-based diagnostic approach, refers patients with alarm symptoms to subspecialists, and reserves radiographic, endoscopic, and other tests for referral cases. The resulting algorithm highlights the reliance on symptom criteria and comprises a primary module, 3 submodules based on the predominant symptom pattern (constipation, diarrhea, and pain) and severity level, and a subspecialist referral module. CONCLUSIONS: The dearth of available evidence highlights the need for more rigorous scientific validation to identify the most accurate methods of diagnosing IBS. Until such time, the diagnostic algorithm presented herein could inform decision making for a range of providers caring for primary care patients with abdominal discomfort or pain and altered bowel function suggestive of IBS.

Characteristics of patients with irritable bowel syndrome recruited from three sources: implications for clinical trials.

BACKGROUND: Variation in the characteristics of irritable bowel syndrome patients recruited for clinical trials from different sources could affect their response and the generalizability of trial results. AIM: To describe and compare the characteristics of three different groups of irritable bowel syndrome patients recruited into a 'mock clinical trial.' METHODS: We enrolled 245 irritable bowel syndrome patients from three sources: (i) 121 from British primary practitioners; (ii) 72 from California newspaper advertisements; and (iii) 52 from a California gastroenterologist's practice. We obtained demographic, clinical, and Hospital Anxiety and Depression (HAD) Scale data. RESULTS: Most patients were young to middle-aged women; the majority reported symptoms for > 5 years in all three groups. Subject characteristics varied among the groups. Typically, primary care patients were anxious, smokers and daily alcohol drinkers who had sought care recently for irritable bowel syndrome and tried antispasmodic drugs. Their symptoms were intermediate in severity between those of the other two groups. Advertisement subjects were the oldest, most highly educated, most often depressed, and were least likely to have sought care recently for symptoms, which were almost uniformly only moderate in severity. Gastroenterologist patients tended to be anxious and had nearly all sought care recently for symptoms, which were the most severe and most likely to include all three pain-related Rome I criteria. CONCLUSION: Recruitment methodology affects important characteristics of an irritable bowel syndrome study group.

Esophageal food impaction: epidemiology and therapy. A retrospective, observational study.

BACKGROUND: Esophageal food impaction is common, but incidence data are lacking and management is controversial. This is a survey of its epidemiology, endoscopic findings, and treatment. METHODS: A retrospective study was conducted of 194 adults with 223 episodes of esophageal food impaction in a health maintenance organization. Of these, 192 (99%) patients were followed a median of 31 months (range 1-72) post-disimpaction. RESULTS: The estimated annual incidence rate of episodes was 13.0 per 100,000, and the male:female ratio was 1.7:1. The rate increased with age, especially after the seventh decade. The bolus was meat in 189 (85%) episodes. Flexible esophagoscopy was performed initially in 222 (99.6%) episodes and permitted disimpaction in 218 (98%). The push technique was used alone or in combination with extraction in 186 (84%). Immediate dilation was performed in 172 (79%). There were no major complications. A final diagnosis was made in 171 (88%), including 151 (78%) with a Schatzki's ring or peptic stricture, and the diagnosis had changed during follow-up in 14 (7%). A diagnosis of Schatzki's ring was associated with gender (p = 0.03) and decreased with increasing age (p = 0.003), especially among women. CONCLUSIONS: Esophageal food impaction is common and can nearly always be treated safely with flexible esophagoscopy, usually with the push technique.

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.

Group psychotherapy for women molested in childhood: psychological and somatic symptoms and medical visits.

Molested women who completed a series of 16 weekly group psychotherapy sessions conducted by social workers improved substantially regarding various aspects of psychological functioning, including self-image, coping techniques, relationship issues, and mothering. In addition, there was significant improvement in all psychological symptom scales and all global indices of symptomatic distress measured by the SCL-90-R. Furthermore, the improvement was present immediately after therapy and, with the exception of the hostility score, persisted 1 year later. Although the somatization score was reduced, the number of visits for physical symptoms did not change. The patients studied manifested characteristics typical of previously surveyed women with a history of childhood abuse, including a frequent history of major surgery (Drossman et al., 1996; Longstreth & Wolde-Tsadik, 1993; Springs & Friedrich, 1992) and, in some, a previous problem with alcohol (Springs & Friedrich, 1992; Walker et al., 1995) or drugs (Longstreth & Wolde-Tsadik, 1993; Miller & McCluskey-Fawcett, 1993; Springs & Friedrich, 1992). Also, nearly one half of the subjects had irritable bowel syndrome, the prototypical functional bowel disorder (Drossman et al., 1995; Longstreth & Wolde-Tsadik, 1993; Scarinci et al., 1994; Walker et al., 1995). Most of their baseline SCL-90-R scores were > 1 SD above the nonpatient norms. A problem inherent in assessing the long-term benefit of this study and other group psychotherapy studies is the tendency for some patients to continue similar or different forms of therapy after completing the group sessions. More than one half of patients received subsequent therapy that could have influenced their status at 1-year follow-up. However, most of the symptom dimensions and all global indices were similar 1 year posttherapy in the women who did not receive more treatment as compared to results in the women who did. Patients who received additional therapy had higher somatization scores before, immediately after, and 1 year posttherapy; scores in the other group increased 1 year posttherapy. Although the indications for subsequent therapy were not surveyed, there was an association between additional psychological care seeking and somatization. Furthermore, improvement in psychological status reflected by the phobic-anxiety score immediately posttherapy may have contributed to the decision of some patients to seek subsequent therapy. In the group without additional treatment, the loss of some of the initial somatization improvement at 1 year may have contributed to the lack of reduction in medical care visits in the combined groups. We speculate that provision of additional therapy to more patients might have had a long-term effect on somatization and reduced medical visits. We obtained complete psychological data and nearly complete medical-visit data on our patients, and our survey included 1-year follow-up. Our survey did not meet rigorous methodological standards for an outcome study, however. We surveyed only a small number of patients and did not collect similar data on an untreated control group. It was not possible to distinguish health care visits for organic versus functional disorders, but such a distinction may be artificial, because psychological factors may influence health care seeking for "organic" illness. Because our measurements came from a subset of our patients who were willing to complete the survey questionnaires, we do not know how generalizable the findings are. There is increasing awareness among health care professionals that childhood sexual abuse is common and that it may have serious and long-term psychological and medical sequelae. Our data suggest that group psychotherapy by social workers for women victims may have long-lasting psychological and somatic symptom benefits. Reduction in health care usage was not found, and this outcome may require the identification and treatment of patients who need additi

Passage of a large bowel cast caused by acute ischemia: report of two cases.

PURPOSE: We report two cases of spontaneous anal passage of a large bowel 'cast' caused by acute ischemic injury. METHODS: Clinical, laboratory, endoscopic, and pathologic features were reviewed, and the literature was searched for similar cases. RESULTS: An 85-year-old male who had undergone aortic surgery recovered from rectosigmoid ischemia after undergoing a descending colostomy. A 74-year-old male with severe pancreatitis developed a postischemic sigmoid stricture but did not have operative treatment before death of pneumonia three months after the episode. A literature review revealed six cases of passage of a large bowel cast. In the eight total patients, infarcted muscularis propria was found in seven specimens, five patients had a diversion procedure, and seven survived. CONCLUSION: Passage of a large bowel cast is an extraordinary complication of ischemia that often requires diverting surgery, and most patients survive the ischemic injury.

Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series.

BACKGROUND: Acute upper gastrointestinal hemorrhage is a common reason for hospitalization. Clinical and endoscopic characteristics predict outcome. The aim of this study was to determine the characteristics and outcome of patients with acute upper gastrointestinal hemorrhage cared for without hospitalization. METHODS: One hundred seventy-six consecutive patients in a staff-model health maintenance organization were selected for outpatient care based on absolute endoscopic and non-absolute clinical criteria. Clinical and endoscopic characteristics, British national audit "risk scores," and rates of recurrent bleeding, hospitalization, and mortality were determined. RESULTS: Mean patient age (+/- SD) was 56.4 +/- 16.0 years, and 106 patients (60%) were men. One hundred one (57%) had endoscopy within 2 days of the onset of hemorrhage. The mean initial hemoglobin concentration was 11.7 +/- 2.3 mg/dL. Ninety-seven patients (55%) had a peptic ulcer, and 57 (32%) had a British risk score greater than 2. Hospitalization, recurrent bleeding, and mortality occurred in two (1%), one (1%), and zero (0%) patients, respectively, during 16.0 +/- 10.8 months of follow-up. CONCLUSIONS: Many patients with acute upper gastrointestinal hemorrhage can be safely treated as outpatients using endoscopic and clinical guidelines.

Irritable bowel syndrome. Diagnosis in the managed care era.

The common occurrence of irritable bowel syndrome underscores the importance of an accurate diagnostic evaluation without unnecessary expense. A preliminary diagnosis can usually be made with the Manning symptom criteria and additional history data in patients without warning signs of organic disease. A confident diagnosis can often be made with the addition of a physical examination and only limited laboratory and structural studies, such as a proctosigmoidoscopy and complete blood count. Tests that may be indicated in some patients include fecal examination for parasites and occult blood, dietary lactose exclusion or a lactose-hydrogen breath test, and a complete colon structural study. Other tests are occasionally indicated. Routine rectal biopsy and abdominal ultrasonography are unnecessary in patients with only typical symptoms, and large bowel motility testing is not useful. After a confident diagnosis, further testing for recurrent symptoms can be minimized. Investigation for psychosocial factors, while not necessary to diagnose irritable bowel syndrome, is important in treatment and may reduce medical costs. Misdiagnosis can result in unnecessary hysterectomy and other surgery, and it may be reduced by closer collaboration with gynecologists and general surgeons in the evaluation of patients.

Multiple esophageal webs: treatment and follow-up of seven patients.

We have treated seven patients with multiple esophageal webs without a predisposing disorder. The patients ranged in age from 34 to 61 years and had suffered from dysphagia for 4 to 26 years. None had skin disease, a history of ingestion of a potentially caustic substance, or evidence of gastroesophageal reflux disease by history or endoscopy. All patients responded to esophageal dilation, but dysphagia recurred in all during follow-up ranging from 6 months to 4 years, often requiring repeated dilation. Study of our patients and similar patients reported previously leads us to believe this unusual disorder is congenital.

Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study.

OBJECTIVES: Population-based data on the epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage (ALGIH) are lacking. This survey of the incidence, etiology, therapy, and long-term outcome of patients with ALGIH was conducted in a defined population. METHODS: In a large health maintenance organization, discharge data and colonoscopy records were used to identify adults hospitalized with ALGIH from 1990 to 1993. Data were collected by record review and telephone calls. RESULTS: Two hundred nineteen patients had 235 hospitalizations, yielding an estimated annual incidence rate of 20.5 patients/100,000 (24.2 in males versus 17.2 in females, p < .001). The rate increased > 200-fold from the third to the ninth decades of life. Diagnoses were: colonic diverticulosis, 91 (41.6%); colorectal malignancy, 20 (9.1%); ischemic colitis, 19 (8.7%); miscellaneous, 63 (28.8%); and unknown, 26 (11.9%). Eight (3.6%) patients died in the hospital (5 of 206 (2.4%) with hemorrhage before admission versus 3 of 13 (23.1%) with hemorrhage after admission, p < .001). Follow-up of 210 of 211 (99.5%) survivors was 34.0 +/- 1.1 months. In the 83 diverticulosis patients without definitive therapy, the hemorrhage recurrence rate (Kaplan-Meier method) was 9% at 1 year, 10% at 2 years, 19% at 3 years, and 25% at 4 years. In the 89 diverticulosis patients who survived hospitalization, all-cause mortality rates (none from hemorrhage) were 11% at 1 year, 15% at 2 years, 18% at 3 years, and 20% at 4 years. CONCLUSIONS: Hospitalization with ALGIH is related to age and male gender. After hemorrhage from colonic diverticulosis, the leading cause, rates of ALGIH recurrence and unrelated death are similar during the next 4 years.

Diabetic thoracic polyradiculopathy: ten patients with abdominal pain.

OBJECTIVES: Abdominal pain caused by diabetic thoracic polyradiculopathy is unfamiliar to many gastroenterologists. The aim of this study was to describe the clinical characteristics and outcome of the disorder. METHODS: Ten patients (six women) with diabetic thoracic polyradiculopathy were cared for in 20 yr. Electromyographic evidence of nerve root denervation was found in seven patients. Nine patients were followed-up at least until recovery, including four until death. RESULTS: The patients were 42-79 yr of age, had diabetes of various duration, and often had other diabetic complications, including two with previous polyradiculopathy. Pain of various types occurred. It was often worse at night and aggravated by light pressure. Pain was either unilateral or bilateral and was often accompanied by weight loss. All patients had a cutaneous sensory abnormality, and four had localized abdominal wall paresis with protrusion. Spontaneous recovery was documented in nine patients, but two had recurrent polyradiculopathy. CONCLUSIONS: Gastroenterologists should be familiar with diabetic thoracic polyradiculopathy, because its early recognition may prevent unnecessary and expensive diagnostic evaluation for a visceral cause of pain.