External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study.

INTRODUCTION AND HYPOTHESIS: Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life. METHODS: Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale. RESULTS: Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported. CONCLUSIONS: In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545). PUBLIC TRIAL REGISTRY: ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.

["Do two walk together unless they have agreed to do so?"--Combining conventional and complementary medicine in the treatment of gastroparesis].

Gastroparesis is a chronic disorder of abnormal gastric motility causing considerable suffering. We describe two cases of gastroparesis which were treated by methods which were not part of routine conventional therapy, but which, nevertheless, led to significant clinical improvement. In the first case, the patient suffered from gastroparesis following a vagal injury while undergoing a lung transplant. During his illness a mega-bezoar formed, a well-described complication of gastroparesis. After conservative measures failed, and in order to avoid a surgical intervention that carried considerable risk under the circumstances, a successful trial consisting of imbibing large amounts of "Coca Cola" and acupuncture was initiated. The bezoar dissolved completely and considerable improvement of the patient's gastric motility was achieved. In the second case, the patient was a young woman suffering from idiopathic gastroparesis, which responded well to treatment with tricyclic antidepressants. Due to her intention to become pregnant, this treatment was discontinued and she was admitted to receive homeopathic treatment. After two failed attempts in finding the right homeopathic remedy to replace the conventional treatment, the third remedy (Sepia) used brought dramatic improvement in her general condition and her dyspepsia. Today, over two years after her successful homeopathic treatment, she is in the middle of her second pregnancy, without any treatment and free of complaints. These two cases are examples of simple solutions for seemingly complicated and complex conditions alleviated by an integration of conventional and complementary/alternative medicine.

Losartan reduces trinitrobenzene sulphonic acid-induced colorectal fibrosis in rats.

BACKGROUND: Intestinal fibrosis is a challenging clinical condition in several fibrostenosing enteropathies, particularly Crohn's disease. Currently, no effective preventive measures or medical therapies are available for intestinal fibrosis. Fibrosis, due to an abnormal accumulation of extracellular matrix proteins, is a chronic and progressive process mediated by cell/matrix/cytokine and growth factor interactions, but may be a reversible phenomenon. Of the several molecules regulating fibrogenesis, transforming growth factor-beta 1 (TGF-b1) appears to play a pivotal role; it is strongly induced by the local activation of angiotensin II. The levels of both TGF-b1 and angiotensin II are elevated in fibrostenosing Crohn's disease. AIMS: To evaluate the in vivo effect of losartan - an angiotensin II receptor antagonist - on the course of chronic colitis-associated fibrosis and on TGF-b1 expression. METHODS: Colitis was induced by intrarectal instillation of trinitrobenzene sulphonic acid (TNBS) (15 mg/mL) while losartan was administered orally daily by gavage (7 mg/kg/day) for 21 days. Three groups of rats were evaluated: control (n=10); TNBS treated (n=10); and TNBS + losartan treated (n=10). Inflammation and fibrosis of the colon were evaluated by macro- and microscopic score analysis. Colonic TGF-b1 levels was measured using ELISA. RESULTS: Twenty-one days after induction, losartan significantly improved the macro- and microscopic scores of fibrosis in the colonic wall and reduced TGF-b1 concentration. CONCLUSIONS: Prophylactic oral administration of losartan reduces the colorectal fibrosis complicating the TNBS-induced chronic colitis, an effect that appears to be mediated by a downregulation of TGF-b1 expression.

Dumping syndrome following nissen fundoplication in an adult patient diagnosed by continuous online 13C/12C monitoring of ¹³C-Octanoic acid breath test "a case report".

BACKGROUND: Nissen Fundoplication is a common surgical procedure performed in treating gastroesophageal reflux disease (GERD). Complications include dysphagia, gastric hypersensitivity, abnormal gastric motility, gas bloat syndrome and GERD relapse. Dumping syndrome may occur when a large volume of gastric content is delivered to the duodenum or jejunum, resulting in both gastrointestinal and vasomotor symptoms. Occasionally, dumping syndrome may be a complication in patients that have undergone nissen Fundoplication, especially in adults. The BreathID® continuous online 13C-Octanoicoctanoic acid breath test detects variations of less than 1/100,000 in the 13CO2/12CO2 ratio in exhaled air. CASE PRESENTATION: We report a case of a 38 year old male who was admitted and diagnosed with dumping syndrome following nissen Fundoplication, who was diagnosed using the BreathID® continuous online 13C-Octanoic acid breath test. CONCLUSIONS: Early performance of a gastric emptying rate breath test in symptomatic patients, following upper GI tract surgery may help in the prediction or diagnosis of nissen Fundoplication complications such as dumping syndrome.

Delayed fecal incontinence following surgery for anal fissure.

PURPOSE: The surgical treatment of chronic anal fissure is basically done by therapeutic controlled damage to the internal anal sphincter. While fecal incontinence is a well-documented early complication of anal fissure surgery, few data are available about delayed incontinence. The aim of the present study was to assess whether surgical treatment of anal fissures may contribute to the development of delayed anal incontinence. METHODS: A retrospective review of patients referred to the Pelvic Floor Laboratory for physiological evaluation of anal incontinence between 1992 and 2009. All patients, diagnosed with anal fissures, who underwent anal dilatation or partial lateral internal sphincterotomy and developed incontinence at least 4 years after the surgery were included. Controls were patients with delayed anal incontinence after obstetric injury. RESULTS: A total of 21 patients with delayed post-anal fissure surgery incontinence (nine women and 12 men) were identified. The mean (SE) age of incontinence onset in this group of patients was 51.5 (±2), which was 8 years younger than the rest of the 363 incontinent patients (p < 0.001). Time from presumed anal sphincter damage to the onset of incontinence was significantly shorter in the group of past anal-fissure-surgery patients compared to post-obstetric trauma patients (mean difference 15 years, p < 0.001). The severity of incontinence was higher in post-obstetric trauma patients. CONCLUSIONS: Fecal incontinence may present as a late complication of anal fissure surgery. Incontinence may be associated with other cofactors accumulating over time or, more likely, anal fissure surgery may accelerate the physiologic age-related weakening of the anal sphincter mechanism. Candidates for anal fissure surgery should be informed regarding this possible outcome.

[From Nebuchadnezzar to the randomized controlled trial--milestones in the development of clinical research].

The first clinical experiment is described in the bible: The prophet Daniel is reported being nourished during ten days by seeds and water only, in order to check if his physical state would deteriorate as a result of this minimal nutrition. In the 15th century, French surgeon Ambroise Parí experimented with a mixture of turpentine, egg protein and rose oil to treat combat wounds, which is thought to be the first clinical study to be reported. In the 19th century British scientist James Lind designed the first controlled prospective study with parallel groups, proving that ingesting citrus fruit prevents scurvy. A short time afterwards British scientist John Haygarth was the first to use a placebo drug in a clinical study. Important work on placebo was conducted by the American scientists Austin Flint and later by Henry K. Beecher, who showed that placebo itself has biological properties. The importance of comparative studies was first understood by French psychologist CLaude Bernard. He is considered the founder of the modern scientific method based on observation, analysis of data and examination of hypotheses. Bernard's work was based on the work of fellow Frenchman Pierre Charles Alexandre Louis, who is justly considered a founding father of modern epidemiology, and who was the first to use statistics in clinical experiments. Random distributions in clinical studies were reported even before this time, for instance in the work of the Flemish physician Johannes Baptista van Helmont. Danish Nobel prize winner Johannes Fibiger pioneered the use of selection bias in his work with diphtheria serum.

Childhood hygiene is associated with the risk for inflammatory bowel disease: a population-based study.

OBJECTIVES: The "hygiene hypothesis" postulates that individuals raised in a sanitary environment are more likely to develop inflammatory bowel disease (IBD). Several studies previously demonstrated contradictory results in this regard. We performed for the first time a population-based study on the association of surrogate markers of childhood hygiene with the risk for IBD. METHODS: A cross-sectional population-based study was undertaken. Information on number of siblings, birth order, and living in an urban versus rural environment was obtained for 399,251 Jewish adolescents at the age of 17 yr from 1998 to 2004. The study population included only subjects born in Israel. In order to control for genetic confounding, subjects were also divided according to their ethnic group as being Ashkenazi, Sephardic, or Israeli in origin. RESULTS: In total, 768 cases of inflammatory bowel disease (IBD) were diagnosed (0.19%), with 53.8% of the cases being of Ashkenazi origin. On multivariate analysis, variables significantly associated with IBD were male gender (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.24-1.67), Ashkenazi origin (OR 1.91, 95% CI 1.63-2.22), living in an urban environment (OR 1.38, 95% CI 1.02-1.78), small number of siblings in the family (for 1 sibling vs 5 or more, OR 2.63, 95% CI 1.49-4.62), and higher birth order (for birth order of 5 or higher vs 1, OR 2.35, 95% CI 1.47-3.77), showing for both variables an almost strictly highly significant monotonic association (P value for trend <0.001). CONCLUSIONS: Surrogate markers of childhood hygiene are associated with the risk for IBD, thus reinforcing the "hygiene hypothesis."

Achalasia in pregnancy.

Achalasia is a motor disorder of the esophageal smooth muscle in which the lower esophageal sphincter does not relax normally with swallowing, and the esophageal body undergoes nonperistaltic contractions. The underlying abnormality is the loss of intramural neurons. Achalasia affects men and women of all ages. Dysphagia, chest pain, and regurgitation are the main symptoms. Information on the effects of achalasia on pregnancy outcome and the effects of pregnancy on the natural course of achalasia is limited. Two studies, including 30 patients altogether, and several case reports have been published. Treatment options include nitrates, calcium channel antagonists, botulinum toxin injection, pneumatic dilation, and esophagomyotomy.

Pseudodyslipidemia: are we over-treating dyslipidemia in diabetic patients with undiagnosed gastroparesis?

Management of dyslipidemia in diabetic patients poses a major burden on both patients and healthcare providers. Gastroparesis, a condition in which gastric emptying is delayed, is a common condition in diabetes. Given the fact that normal values of plasma lipids are standardized to be measured after several hours of fasting, delayed transit of food and nutrients into the small bowel (as occurs in gastroparesis) may result in an artificial increase in plasma lipids, causing misdiagnosis of dyslipidemia (pseudodyslipidemia), and lead to overtreatment with lipid-lowering agents.

Esophageal obstruction due to enteral feed bezoar: A case report and literature review.

This paper describes a rare complication of enteral feeding, esophageal obstruction due to feeding formula bezoar, and reviews the published cases. An attempt to re-insert the nasogastric tube in a chronically ventilated 80-year-old female fed via a nasogastric tube with Jevity(®) failed. An esophagogastroduodenoscopy revealed an 18 cm-long concretion of the feeding formula, filling most of the esophageal lumen, which was removed endoscopically. Forty-two cases of feeding formula esophageal bezoars have been reported in the literature. The formation of feeding formula bezoars is triggered by acidic gastroesophageal reflux. The acidic pH in the esophagus causes clotting of the casein in the formula. Predisposing factors for bezoar formation are: mechanical ventilation, supine position, neurological diseases, diabetes mellitus, hypothyroidism, obesity and history of partial gastrectomy. Diagnosis and removal of the bezoar is done endoscopically. Feeding in a semi-recumbent position, administration of prokinetic agents and proton pump inhibitors may prevent this complication.

Long-term results of "chemical sphincterotomy" for chronic anal fissure: a prospective study.

INTRODUCTION: Pharmacologic anal sphincter relaxants promote fissure healing; however, their effect is transient and the risk of late recurrence remains uncertain. METHODS: From August 1997 to August 2002, patients with chronic anal fissure attending our outpatient clinic were treated with a protocol that included: topical isosorbide dinitrate, 2.5 mg, or nifedipine, 0.2 percent t.i.d., or the combination of both. Botulinum toxin 20 units was injected to the internal anal sphincter to those who failed. All the patients were contacted and interviewed during November to December 2002. RESULTS: Follow-up was a median of 47.43 +/- 13 (range, 4.7-60) months. A total of 455 patients completed the study; 323 patients (71 percent) healed at follow-up ending: 170 of the healed patients had one or more recurrences that responded to further treatment (37.4 percent), whereas 153 patients (33.6 percent) healed and had no recurrences. One hundred thirty-two patients (29 percent) did not heal and were referred to lateral sphincterotomy. Long intervals between symptoms appearance and treatment initiation decreased healing and increased recurrence rates (P = 0.03 and 0.01 respectively). CONCLUSIONS: Topical treatment is effective for patients with chronic anal fissure, at short-term and long-term periods. Because for many patients it is not a definitive treatment, it can be offered to those who are ready to receive repeated treatments. Longer intervals between symptom appearance and treatment initiation negatively affects fissure healing and recurrence rate.