Fibers in pediatric functional gastrointestinal disorders. Practical considerations from clinical cases.

Introduction: Functional gastrointestinal disorders (FGIDs) are common in children and incur high direct and indirect social costs. Partially hydrolyzed guar gum (PHGG) is a natural and water-soluble dietary fiber that is derived from guar gum. It has been proposed as complementary therapy in pediatric FGIDs, especially in chronic functional constipation and irritable bowel syndrome.Areas covered: By focusing on four clinical cases, this article illustrates the use of PHGG fiber as sole supplement ingredient or as a formula component in orally- and tube-fed children suffering from malnutrition due to FGIDs, with or without special medical conditions such as neurological disability. The formula used was a whey peptide-based nutritionally complete formula containing PHGG as a source of soluble dietary fiber. It was offered under medical supervision and after full consideration of all feeding options.Expert opinion: Implementing appropriate feeding behaviors, adapted to age and potential comorbidities, is an essential requisite for therapeutic management of FGIDs. The use of a PHGG supplement or a nutritionally complete formula containing PHGG as a source of soluble dietary fiber can be helpful to manage pediatric FGIDs.

Recomendaciones para el diagnóstico y el tratamiento de los síntomas posquirúrgicos persistentes en la enfermedad de Hirschsprung / Recommendations for the diagnosis and treatment of persistent postsurgical symptoms in Hirschsprung disease

La enfermedad de Hirschsprung ocurre en 1 de cada 5000 nacimientos. La falla de migración de las células ganglionares desde la cresta neural en dirección cefalocaudal genera su ausencia en parte o todo el colon. Se manifiesta con falta de eliminación de meconio, distensión abdominal y dificultades en la evacuación. Luego del tratamiento quirúrgico, existen complicaciones a corto y largo plazo. El objetivo de esta publicación es describir las principales causas de síntomas persistentes en los pacientes operados por enfermedad de Hirschsprung y presentar un algoritmo diagnóstico-terapéutico factible de ser realizado en nuestro medio

Hirschsprung disease is characterized by the lack of migration of intrinsic parasympathetic ganglia from neural crest and consequently absence of them at varying length of the bowel, resulting in functional obstruction. The incidence is 1 per 5000 births. After surgery, short term and long term comorbidity commonly occurs. The aim of this article is to revise the main causes of ongoing symptoms after surgery in Hirschsprung disease patients and to show a diagnostic and therapeutic algorithm that can be developed in our community

Diet Modifications in Older Women With Fecal Incontinence: A Qualitative Study.

OBJECTIVE: The aim of the study was to investigate dietary modification strategies used by community-dwelling older women to manage their fecal incontinence (FI). METHODS: We conducted a qualitative study with focus groups wherein women 65 years and older with FI shared their experiences managing the condition. We explored the following: (1) association between diet and FI symptoms, (2) dietary strategies and modifications used by older women to manage FI, and (3) patient input about disseminating diet modification information and strategies. All focus groups were audio recorded, transcribed, coded, and qualitatively analyzed to identify relevant themes. RESULTS: Twenty-one women participated in 3 focus groups. All participants were aware that diet plays a key role in their experience of FI and women described a method of "trial and error" in identifying specific aspects of their diet that contributed to their FI symptoms. Women reported modifications including avoiding or limiting several foods and food categories, changing certain methods of food preparation, as well as varying the amounts and frequency of meals to manage their FI. Women articulated several suggestions including the importance of physician input, using a balanced approach when making recommendations, and the value of sharing individual experiences. CONCLUSIONS: Older women with FI make several dietary modifications to manage their symptoms including limiting certain foods, changing methods of food preparation, and decreasing the amounts and frequency of meals. These strategies may be considered for inclusion in a diet modification plan that is culturally competent for older women with FI.

A Low FODMAP Diet May Reduce Symptoms in Patients With Fecal Incontinence.

INTRODUCTION: Fecal incontinence (FI) is a common complaint and is often associated with diarrhea and urgency. Foods high in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) cause symptoms of diarrhea and urgency. Therefore, this study assesses the impact of a low FODMAP diet on the occurrence of FI due to loose stool. METHODS: This study is a retrospective chart review of patients with FI seen in the Michigan Bowel Control Program clinic between August 2012 and December 2017. Patients who had FI with loose stool without red flag signs and who were recommended a low FODMAP diet and underwent formal dietary instruction with a Michigan Medicine dietician were included. RESULTS: Sixty-five patients with FI who underwent formal dietary teaching were included in this study. Eighty-eight percent of the patients were white, and 87% were women with a mean age of 62 years (±14 years). Additionally, the chart review showed that 35% of the patients had FI daily, 21.5% had FI weekly, and 5% had FI monthly. About 64.6% of the patients (42) had reported a reduction in their FI symptoms with the low FODMAP diet. There was no demographic or clinical characteristic that predicted the response to a low FODMAP diet. DISCUSSION: In this case series, dietary manipulation with a low FODMAP diet was a useful tool to treat patients who suffer from FI due to loose stool. Further confirmatory, prospective randomized controlled trials are required to see the true efficacy of a low FODMAP diet in patients who suffer with FI.

Role of diet in fecal incontinence: a systematic review of the literature.

INTRODUCTION AND HYPOTHESIS: The objective was to perform a systematic review of the literature to examine original research on the role of diet in fecal incontinence (FI) with a dual focus on dietary differences in FI and dietary treatments for FI. METHODS: We searched the PubMed and Embase databases for any peer-reviewed original research in English on the role of diet in FI. RESULTS: We identified 172 unique citations. After title review and exclusion of articles not reporting original research, 9 publications were included in the final review: 4 focused on dietary differences and 5 focused on dietary treatments for FI. Limited evidence indicates that macro- and micronutrient intake does not differ significantly in those with and without FI. However, certain foods were perceived to improve or exacerbate FI symptoms and these varied and were adjusted as part of self-care practices. A high-fiber diet may reduce incontinence frequency. CONCLUSIONS: Data on the pathogenesis of FI from a dietary perspective are scant. Based on the limited data, dietary differences between those with and without FI provide little insight with the exception of fiber. Further studies are needed to elucidate treatments for FI using fiber and dietary modifications.

Incidence and Characteristics of Incontinence-Associated Dermatitis in Community-Dwelling Persons With Fecal Incontinence.

PURPOSE: Little is known about the incidence and characteristics of incontinence-associated dermatitis (IAD) in community-living individuals with fecal incontinence. The primary aim of this study was to describe the incidence and characteristics of self-reported IAD among community-living individuals with fecal incontinence. The study also examined whether IAD was associated with older age, sex, presence of urinary incontinence, or fecal incontinence severity. DESIGN: Secondary data analysis was performed using a prospective cohort design. SUBJECTS AND SETTING: Data were drawn from community-living adults (n = 98) with fecal incontinence (76% female, 34% aged ≥65 years, 90% white) who participated in a study about dietary fiber supplementation and were free of IAD at the start. Thirty five percent also had urinary incontinence. METHODS: Subjects assessed their skin for IAD daily for 52 days, reporting types of IAD damage (redness, rash/fungal infection, and skin loss), location of IAD, and symptoms. They reported fecal incontinence on a diary for the first and last 14 study days. RESULTS: The incidence of IAD was 41% (40 of the 98). The fecal incontinence severity score for subjects developing IAD was 1.2 higher than those who never had IAD (P < .001). There was no significant association of IAD with age, sex, or dual fecal and urinary incontinence. Incontinence-associated dermatitis developed within 2 weeks and healed in approximately 1 week. The most common sign and symptom were redness (60% patients) and soreness (78% patients), respectively. Most subjects (85%) had IAD in one location. CONCLUSIONS: Assessing for IAD in community-living patients with fecal incontinence is important as IAD is common and causes discomfort. The relatively mild severity of IAD offers WOC nurses the opportunity for improving patient outcomes by preventing and managing this problem.

Dietary fiber supplementation for fecal incontinence: a randomized clinical trial.

Dietary fiber supplements are used to manage fecal incontinence (FI), but little is known about the fiber type to recommend or the level of effectiveness of such supplements, which appears related to the fermentability of the fiber. The aim of this single-blind, randomized controlled trial was to compare the effects of three dietary fiber supplements (carboxymethylcellulose [CMC], gum arabic [GA], or psyllium) with differing levels of fermentability to a placebo in community-living individuals incontinent of loose/liquid feces. The primary outcome was FI frequency; secondary outcomes included FI amount and consistency, supplement intolerance, and quality of life (QoL). Possible mechanisms underlying supplement effects were also examined. After a 14-day baseline, 189 subjects consumed a placebo or 16 g total fiber/day of one of the fiber supplements for 32 days. FI frequency significantly decreased after psyllium supplementation versus placebo, in both intent-to-treat and per-protocol mixed model analyses. CMC increased FI frequency. In intent-to-treat analysis, the number of FI episodes/week after supplementation was estimated to be 5.5 for Placebo, 2.5 for Psyllium, 4.3 for GA, and 6.2 for CMC. Only psyllium consumption resulted in a gel in feces. Supplement intolerance was low. QoL scores did not differ among groups. Patients with FI may experience a reduction in FI frequency after psyllium supplementation, and decreased FI frequency has been shown to be an important personal goal of treatment for patients with FI. Formation of a gel in feces appears to be a mechanism by which residual psyllium improved FI.

In vitro degradation and fermentation of three dietary fiber sources by human colonic bacteria.

Although clinical benefits of dietary fiber supplementation seem to depend partially on the extent of fiber degradation and fermentation by colonic bacteria, little is known about the effect of supplemental fiber type on bacterial metabolism. In an experiment using a nonadapted human bacterial population from three normal subjects, the extent of in vitro fermentation was greater for gum arabic (GA) than for psyllium (PSY), which was greater than that for carboxymethylcellulose (CMC). In a separate experiment, in vitro incubation with feces from 52 subjects with fecal incontinence, before and after random assignment to and consumption of one of three fiber (GA, PSY, or CMC) supplements or a placebo for 20-21 days, indicated that prior consumption of a specific fiber source did not increase its degradation by fecal bacteria. Results suggest that the colonic microbial community enriched on a particular fiber substrate can rapidly adapt to the presentation of a new fiber substrate. Clinical implications of the findings are that intake of a fiber source by humans is not expected to result in bacterial adaptation that would require continually larger and eventually intolerable amounts of fiber to achieve therapeutic benefits.

Incontinence-associated dermatitis in community-dwelling individuals with fecal incontinence.

PURPOSE: To describe the occurrence and severity of incontinence-associated dermatitis among community-dwelling individuals with fecal incontinence. DESIGN: Descriptive and comparative secondary data analysis. SUBJECTS AND SETTING: One hundred eighty-nine community-dwelling individuals with fecal incontinence who participated in a study comparing the effects of dietary fiber on fecal incontinence. METHODS: A survey on the use of absorbent products that contained questions about subjects' history of skin damage was administered at the start of the study. RESULTS: Incontinence-associated dermatitis occurred in 52.5% of the community-living individuals with fecal incontinence. The severity of incontinence-associated dermatitis was mostly mild to moderate and occurred periodically. Redness without broken skin was the most common manifestation (68%). Most individuals (95%) reported the location of skin damage to be the anal/rectal area. Those with double incontinence also reported dermatitis around the vagina or penis. Individuals with a greater severity of fecal incontinence had a greater severity of incontinence-associated dermatitis (r = 0.27, P = .000). Both the frequency of incontinence (r = 0.23, P < .002) and the amount of feces leaked (r = 0.23, P < .002) had a significant correlation with incontinence-associated dermatitis severity. There were no significant differences in the occurrence or severity of incontinence-associated dermatitis by sex, age, or presence of double incontinence. CONCLUSION: A high percentage of individuals in the community with fecal incontinence suffer from incontinence-associated dermatitis at times. This population may benefit from consultation with a WOC nurse about prevention and management of incontinence-associated dermatitis.

[Conservative therapy and minimal invasive surgery for treating faecal incontinence]. / Konservativ og minimalt invasiv kirurgisk behandling af fækal inkontinens.

Faecal incontinence should primarily be managed in a conservative way, and if this is not sufficient different options for minimally invasive surgery should be considered. Dietary regimens, fibers, constipating agents, enemas, biofeedback and colonic irrigation may be tried as first-line therapy. Posterior tibial nerve stimulation and injections of bulging agents can be offered, but the evidence is still not convincing. Sacral nerve stimulation is a well documented treatment for faecal incontinence. Magnetic anal sphincter implantation should be considered only in highly selected patients.

Diet and eating pattern modifications used by community-living adults to manage their fecal incontinence.

PURPOSE: The study aimed to describe modifications in diet and eating patterns made by community-living people to manage fecal incontinence (FI), and to compare these differences according to sex, age, and FI severity. SUBJECTS AND SETTINGS: Subjects were 188 community-living adults (77% female, 92% white, 34% aged 65 years or older) in the upper Midwest who participated in a study about managing FI with dietary fiber. METHODS: Subjects were interviewed about diet and eating pattern changes that they made to manage FI, and self-reported demographic data. FI severity was recorded daily. RESULTS: Fifty-five percent of participants perceived that some foods worsen their FI (eg, fatty or spicy foods and dairy products). More women than men (40% vs 18%, P = .008) reported avoiding foods to manage FI. A greater percentage of younger than older people believed that fatty/greasy foods (15% vs 4%) and alcohol (14% vs 3%) worsened their FI. Subjects with a higher FI severity score appeared to wait until FI was more severe before restricting caffeine than those with lower severity scores (22.2 ± 9.8 vs 11.69 ± 8.3, P = .034). One-third of subjects consumed foods rich in dietary fiber to prevent FI. Subjects also reported altered eating or cooking patterns, skipping meals, or eating at consistent times to manage FI. CONCLUSIONS: Diet modification for managing FI incorporates restriction of some foods, along with adding others foods to the diet. Nursing assessments of self-care practices for FI should include diet and eating pattern changes when developing a plan of care.

Intrauterine rectovaginal tear during a manual attempt to rotate a neonate.

Intrauterine rectovaginal tears in neonates are a rare and life-threatening complication of abnormal presentation during labor. Two previous cases have been presented in the literature, of which one had a fatal outcome. The authors present a third case of a severe rectovaginal intrauterine tear that had a favorable outcome.

Treatment of fecal incontinence with a comprehensive bowel management program.

PURPOSE: Many articles describe the antegrade continence enemas (ACEs), but few refer to a bowel management program. A successful ACE may not help a patient without such management. Valuable lessons were learned by implementation of bowel management in 495 fecally incontinent patients. METHODS: We previously reported 201 patients. Thereafter, another 294 patients participated in our program. On the basis of a contrast enema and symptoms, they were divided as follows: (a) 220 constipated patients and (b) 74 patients with tendency toward diarrhea. Colonic stool was monitored with abdominal radiographs, modifying the management according to the patient's response and radiologic findings. For constipated patients, the emphasis was on using large enemas. For patients with tendency toward diarrhea, we used small enemas, a constipating diet, loperamide, and pectin. Diagnoses included anorectal malformation (223), Hirschsprung's (36), spina bifida (12), and miscellaneous (23). RESULTS: The management was successful in 279 patients (95%)-higher in constipated patients (98%) and less successful in patients with tendency toward diarrhea (84%). CONCLUSIONS: The key to a successful bowel management program rests in tailoring the type of enema, medication, and diet to the specific type of colon. The best way to determine the effect of an enema is with an abdominal film. The ACE procedures should be recommended only after successful bowel management.

Fecal incontinence in obese women with urinary incontinence: prevalence and role of dietary fiber intake.

OBJECTIVE: This study estimates the prevalence of fecal incontinence (FI) in overweight and obese women with urinary incontinence and compares dietary intake in women with and without FI. STUDY DESIGN: A total of 336 incontinent and overweight women in the Program to Reduce Incontinence by Diet and Exercise clinical trial were included. FI was defined as monthly or greater loss of mucus, liquid, or solid stool. Dietary intake was quantified using the Block Food Frequency Questionnaire. RESULTS: Women had a mean (+/- SD) age of 53 +/- 10 years, body mass index of 36 +/- 6 kg/m(2), and 19% were African American. Prevalence of FI was 16% (n = 55). In multivariable analyses, FI was independently associated with low fiber intake, higher depressive symptoms, and increased urinary tract symptoms (all P < .05). CONCLUSION: Overweight and obese women report a high prevalence of monthly FI associated with low dietary fiber intake. Increasing dietary fiber may be a treatment for FI.

Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study.

The recruitment of community-living participants for clinical trials of sensitive topics, when the population is largely hidden and reluctant to self-identify, and the study protocols and procedures intensive, creates significant challenges to researchers. The Fiber Study is an ongoing randomized controlled clinical trial conducted to compare the effectiveness of three dietary fibers with different levels of fermentability for symptom management in community-living adults with fecal incontinence. The researchers developed a staged approach to recruitment using three primary recruitment methods and a three-phase approach to the enrollment process. We have been successful in reaching, recruiting, and enrolling participants in a clinical trial, as well as in effectively managing study resources and staff time.

Supplementation with dietary fiber improves fecal incontinence.

BACKGROUND: Human studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. OBJECTIVE: To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. METHODS: Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. RESULTS: In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. CONCLUSIONS: Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

[Functional results of ileo-anal anastomosis. The point of view of the gastroenterologist]. / Résultats fonctionnels de l'anastomose iléo-anale. Le point de vue du gastroentérologue.

Ulcerative colitis is an illness that occurs unexpectedly in a young patient, with a generally unpredictable prognosis, and there is no medication to cure it. This illness profoundly impairs the patient's professional life, family life, sex life, leading to an overall change in lifestyle, most particularly in cases of pancolitis. The majority of patients who benefit from a total colectomy for their ulcerative colitis, are those whose cases are severe, chronic, incapacitating, and who respond poorly to prolonged, appropriately administered medical treatment, mainly continuous steroid therapy. After the surgical procedure, the average number of defecations is from 5 to 6 evacuations in 24 hours, and the anal continence is good. Around 5% of patients have nocturnal leakage requiring to wear a protecting fad. Globally 9 out 10 patients are satisfied with their surgery and ileal pouch-anal anastomosis is the procedure of choice for the treatment of ulcerative colitis in subjects under 60 years of age, with a normal anal sphincter function and without neoplastic complication of the lower rectum.