The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following Obstetric Anal Sphincter Injury: use of a word picture to identify a hidden syndrome.

BACKGROUND: To identify the emotional, social and psychological consequences and recovery process of anal incontinence (AI) following obstetric anal sphincter injuries (OASIS) and explore if this can be identified as a recognisable syndrome with visual representation. METHODS: A qualitative approach was adopted for this study. Data derived from case studies (n = 81) and interviews (n = 14) with women with AI after OASIS was used to identify the emotional, social and psychological consequences of AI after OASIS. Keywords and synonyms were extracted and the power of these statements displayed as a 'word picture'. The validity and authenticity of the word picture was then assessed by: a questionnaire sent to a group of mothers who had experienced this condition (n = 16); a focus group attended by mothers (n = 14) and supported by health professionals (n = 6) and via interviews with health professionals (n = 12) who were involved with helping mothers with AI following OASIS. RESULTS: Women with AI resulting from OASIS have a specific syndrome - the 'OASIS Syndrome' - which we have uniquely visualised as a 'word picture'. They feel unclean which results in dignity loss, psychosexual morbidity, isolation, embarrassment, guilt, fear, grief, feeling low, anxiety, loss of confidence, a feeling of having been mutilated and a compromised role as a mother. Coping relies on repetitive washing (which may become a ritual), planning daily activities around toiletry needs, sharing, family support, employment if possible and attention to the baby. Recovery and healing is through care of the child and hope generated by love within the family. CONCLUSIONS: This study has identified a previously unrecognised 'OASIS Syndrome' and, by way of a new and unique 'word picture', revealed a hidden condition. There should be greater awareness by the public and profession about the 'OASIS Syndrome' and a mechanism for early identification of the condition and referral for management. This, if successful, would overcome the barrier of silence which surrounds this currently unspoken taboo.

Peritonitis following stapling of a flush ileostomy.

Peritonitis following staple stabilization of a flush ileostomy has not yet been reported in the literature. We report a case of iatrogenic injury to a loop of the ileum in an unrecognized parastomal hernia which caused peritonitis after stapling of a flush ileostomy.

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India.

OBJECTIVE: Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts. METHOD: All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database. RESULTS: One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% (P < 0.001)) and low rectal tumours (63.0% vs 50.0%) (P = 0.043), but were equally likely to undergo curative surgery compared to the older group (P = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0-2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) (P = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) (P = 0.014). CONCLUSION: The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.

Antibiotic-associated pseudomembranous colitis: pathogenesis and management.

Antibiotic-associated colitis is a potentially lethal condition which may occur quite commonly in postsurgical patients who have received prophylactic or therapeutic antimicrobial drugs. The disorder can be easily detected by assay of the specific faecal toxin. Prompt therapy by oral vancomycin is mandatory, to reduce not only mortality but also the danger of cross infection.

Review article: the management of pouchitis.

Pouchitis occurs in 10-35% of patients in the first 10 years after pouch construction for ulcerative colitis. Pouchitis must be carefully defined and should not include patients with poor function or Crohn's disease. Most patients have only a single attack of pouchitis which rapidly resolves with metronidazole. Chronic pouchitis suggests some other abnormality of function which, if responsible for persistent poor function, may necessitate pouch excision.

Ursodeoxycholic acid has no influence on function after restorative proctocolectomy in ulcerative colitis.

BACKGROUND: Poor pouch function is associated with impaired bile acid absorption and increased faecal loss of bile acids. Bile acid replacement therapy might therefore be of clinical benefit, provided that diarrhoea is not aggravated by therapy. AIM: To investigate the role of exogenous bile acid therapy in patients with poor pouch function after restorative proctocolectomy for ulcerative colitis. PATIENTS AND METHODS: Twenty ulcerative colitis patients with poor pouch function (score > 4 on a 12-point score) were recruited for inclusion to a prospective, randomized, double-blind crossover, placebo-controlled trial of ursodeoxycholic acid (10 mg/kg per day in two divided doses for 1 month). RESULTS: A total of 16 patients completed the study. There was no significant difference in the functional score or bowel frequency following treatment irrespective of whether the active treatment was given before or after placebo. CONCLUSIONS: We conclude that ursodeoxycholic acid given over 4 weeks had no influence on functional score or bowel frequency after restorative proctocolectomy for U.C.

Faecal toxin and severity of antibiotic-associated pseudomembranous colitis.

The relationship between faecal toxin titre, histological evidence of pseudomembrane in the rectum, and severity of antibiotic-associated colitis has been analysed from data on 62 patients whose faeces contained Clostridium difficile toxin. There was a significant correlation between a toxin titre of 6400 or more and the presence of pseudomembrane (p less than 005). There was no correlation between toxin titre, duration of diarrhoea, total white cell count, temperature, serum albumin or serum orosomucoid concentrations. There was, however, a significant correlation between the presence of rectal pseudomembrane and duration of diarrhoea (p less than 0.005). Exposure to clindamycin or lincomycin was also associated with a significantly higher toxin titre than that seen in patients who were given other antibiotics. The duration of diarrhoea of diarrhoea was not longer and rectal pseudomembrane did not occur more often in the patients who had received clindamycin or lincomycin.

Long-term outcome of surgical management for diffuse jejunoileal Crohn's disease.

BACKGROUND: In diffuse jejunoileal Crohn's disease, resectional surgery may lead to short-bowel syndrome. Since 1980 strictureplasty has been used for jejunoileal strictures. This study reviews the long-term outcome of surgical treatment for diffuse jejunoileal Crohn's disease. METHODS: The cases of 46 patients who required surgery for diffuse jejunoileal Crohn's disease between 1980 and 1997 were reviewed. RESULTS: Strictureplasty was used for short strictures without perforating disease (perforation, abscess, fistula). Long strictures (<20 cm) or perforating disease was treated with resection. During an initial operation, strictureplasty was used on 63 strictures in 18 patients (39%). After a median follow-up of 15 years, there were 3 deaths: 1 from postoperative sepsis, 1 from small-bowel carcinoma, and 1 from bronchogenic carcinoma. Thirty-nine patients required 113 reoperations for jejunoileal recurrence. During 75 of the 113 reoperations (66%), strictureplasty was used on 315 strictures. Only 2 patients experienced the development of short-bowel syndrome and required home parenteral nutrition. At present, 4 patients are symptomatic and require medical treatment. All other patients are asymptomatic and require neither medical treatment nor nutritional support. CONCLUSIONS: Most patients with diffuse jejunoileal Crohn's disease can be restored to good health with minimal symptoms by surgical treatment that includes strictureplasty.

Hodgkin's disease complicating Crohn's colitis.

A case of Hodgkin's disease involving an area of Crohn's colitis in a patient with a 20-year history of inflammatory bowel disease is described. The coexistence of Crohn's disease and Hodgkin's lymphoma has not been reported previously. The possible relationship between gastrointestinal lymphoma and Crohn's disease also is discussed.

Multifocal colonic carcinoma and Crohn's disease.

Multifocal colonic carcinoma occurred in a 65-year-old man with a 13 year history of colonic Crohn's disease. The relationship between solitary and multiple colonic cancer and Crohn's disease is discussed.

Identification of the presence and type of biliary microflora by immediate gram stains.

Immediate gram stains were performed on gallbladder bile aspirated at the start of an operation for biliary disease in 191 consecutive patients undergoing elective biliary surgery. The results of the gram stains were telephoned to the operating theater within 20 minutes of collection. The over-all accuracy rate of the telephone gram stain reports compared with the subsequent bile cultures was 77 percent. The incidence of false-positive results was 12 percent, and false-negative results were recorded in 7 percent. The organism was identified wrongly by the gram stain in 4 percent of patients. These results have improved with experience and the over-all accuracy rate of gram stains on bile over the last 6 months have been 87 percent.

Selecting patients requiring antibiotics in biliary surgery by immediate gram stains of bile at operation.

The value of selecting patients for antibiotic cover during biliary surgery by the use of immediate gram stains of bile was determined in a nonrandomized prospective study which compared two groups of patients. Group A consisted of 119 consecutive patients in whom antibiotics were administered during operation according to the results of immediate gram stains on bile. Group B included 101 patients, none of whom received antibiotics. In Group A gentamicin was given for gram-negative bacteria, ampicillin for gram-positive organisms, and no antibiotics were given if no bacteria were seen on the gram stain. In Group A the incidence of wound sepsis was 7 percent, compared with 22 percent in Group B (p less than 0.005). Septicemia occured in 2 percent of Group A, compared with 8 percent in Group B. It is concluded that immediate gram stains of bile will provide a means of selecting patients requiring antibiotic cover during biliary surgery; furthermore, this procedure is a practical way of reducing postoperative sepsis while avoiding unnecessary antibiotic administration.

A comparison of the penetration of two quinolones into intra-abdominal abscess.

A low-mortality model of an intra-abdominal abscess in the rat has been used to study the penetration of two quinolone agents into pus. Maximum concentrations in pus after intravenous injections were achieved at four hours (ciprofloxacin: 12.7 +/- 3.69 mg/L, fleroxacin: 2.25 +/- 1.82 mg/L), whereas fleroxacin given orally reached the maximum level at two hours (13.39 +/- 3.13 mg/L). Higher concentrations of fleroxacin were recorded in pus than in serum at each time point up to eight hours after administration, but pus levels of ciprofloxacin only exceeded serum levels after 1.5 hours. These antibiotics appear to have a unique property of high penetration into established abscesses and may have an important therapeutic role in the treatment of patients with multiple interloop abscesses.

Public awareness of risk factors and screening for colorectal cancer in Europe.

Colorectal cancer (CRC) is the commonest site for malignancy in Europe. The Commissioner for Health wishes to promote screening for colorectal, breast and cervical cancer in Europe. The aim of this study was to assess public knowledge of CRC in Europe and likely take up of free screening. To this end 20710 members of the public from 21 European countries were interviewed by means of a regular survey amongst consumers (Omnibus survey) using 13 stem questions. Forty-eight per cent thought the population were at equal risk of CRC, only 57% were aware of age and 54% of family history as risk factors. Although 70% were aware of dietary factors, only 30% knew that lack of exercise might be a risk factor. Only 51% had knowledge of CRC screening but 75% were 'very', or 'quite interested, in taking up faecal occult blood (FOB) screening if offered free. Barriers to screening were lack of awareness of risk (31%), youth (22%) and an un-anaesthetic test (19%). There was a big cultural difference in willingness of the public to discuss bowel symptoms: there was a major barrier in Finland (91%), Britain (84%), Luxembourg (82%), Poland (81%) and Portugal (80%); less of a barrier in Spain (49%), Italy (44%) and Iceland (39%). In conclusion, the challenge of achieving high compliance for CRC screening must be a major objective amongst EU member states and non-aligned countries of Europe in the next decade, because it is known that the non-compliant group are those at greatest risk of death from CRC. This study has shown that awareness of CRC is low in Europe and that an educational programme will be essential to achieve high compliance for CRC screening as a means of reducing deaths from bowel cancer.

Prospective randomized trial of single dose cefuroxime against mezlocillin in elective gastric surgery.

A prospective randomized control trial was made in 78 patients undergoing elective operations on the stomach where the viscus was opened at operation, and the efficacy of single dose intravenous prophylaxis with cefuroxime 1.5 g or mezlocillin 2 g was compared. The overall rate of sepsis was 10.2 per cent. Infection in the cefuroxime group was significantly lower (2.5 per cent) than in the mezlocillin group (18 per cent) (P less than 0.05). Four of the seven patients with infections in the mezlocillin group were due to antibiotic resistant staphylococci. The only infections in the cefuroxime group were due to an antibiotic resistant strain of Pseudomonas aeruginosa. One case of pseudomembranous colitis occurred in the cefuroxime group. In view of the high rate of resistant organisms in patients receiving mezlocillin we believe that cefuroxime remains the antibiotic of choice for patients undergoing elective gastric operations.

A prospective randomized trial to compare mezlocillin and metronidazole with cefuroxime and metronidazole as prophylaxis in elective colorectal operations.

A prospective randomized trial has compared a broad spectrum ureidopenicillin with a broad spectrum cephalosporin for prophylaxis against the aerobic organisms encountered during elective colonic surgery. Even though only two doses of antibiotics were administered the incidence of severe sepsis was low. Severe wound infection occurred in three of the patients receiving mezlocillin and metronidazole (6 per cent) compared with six in the group receiving cefuroxime and metronidazole (13 per cent). Minor wound sepsis was recorded in 24 per cent of patients receiving mezlocillin and metronidazole compared with only 11 per cent after cefuroxime and metronidazole. There were two episodes of septicaemia, one in each group, and three abscesses, all of which occurred in patients receiving metronidazole and mezlocillin. The total number of surgically related infections was, however, significantly less with cefuroxime and metronidazole (N = 13) compared with mezlocillin and metronidazole (N = 23; P less than 0.03). Escherichia coli was the principal organism responsible for surgically-related postoperative sepsis: (22 isolates: 14 mezlocillin and eight cefuroxime) all of which sensitive to the agents used. Pseudomonas aeruginosa was recovered from 10 patients (three mezlocillin and seven cefuroxime), all of the isolates were resistant to both antibiotics and were associated with severe morbidity. There were 11 isolates of Staphylococcus spp. (nine mezlocillin and two cefuroxime: P less than 0.03). Postoperative diarrhoea occurred in six patients, all were in the group receiving cefuroxime and metronidazole. (Clostridium difficile was recovered from the stool in three of which one was associated with Cl. difficile cytotoxin.)

Clinical and microbiological evaluation of piperacillin in elective biliary surgery.

Fifty patients undergoing electric biliary surgery were given piperacillin 2 g i.m. 2 h preoperatively followed by 2 g i.v. at the beginning of the operation. Venous blood and bile from the gall bladder and common bile duct were assayed for piperacillin. Blood levels exceeded 100 mg 1(-1) in all instances unless the protocol was not followed. Both gallbladder and common bile duct bile levels exceeded 50 mg 1(-1), and the only exceptions were due to poor penetration into three obstructed gallbladders. Common bile duct levels exceeded 50 mg 1(-1) even in the presence of obstructive jaundice. Only one patient developed a minor postoperative wound infection.

Metronidazole need not be combined with an aminoglycoside when used for prophylaxis in elective colorectal surgery.

A prospective randomized controlled study has compared prophylactic intravenous metronidazole alone with the combination of metronidazole and gentamicin in 100 patients having elective colorectal surgery. There was no significant difference in mortality, infection, dehiscence or postoperative stay between the antibiotic groups. Postoperative sepsis was almost entirely due to aerobic organisms but was associated with minimal morbidity. A significantly higher rate of anastomotic dehiscence and postoperative infection was seen where the quality of bowel preparation was judged to be poor.

A high incidence of bleeding is observed in a trial to determine whether addition of metronidazole is needed with latamoxef for prophylaxis in colorectal surgery.

A prospective randomized trial has compared the use of latamoxef sodium (two doses) with latamoxef and metronidazole for elective colorectal surgery. The incidence of wound infection in patients receiving latamoxef alone was 34 per cent compared with 32 per cent in patients receiving latamoxef and metronidazole. Only eight of the 36 wound infections in this study could be classified as major. Only two patients developed an intra-abdominal abscess postoperatively and there was only one episode of septicaemia. Postoperative haemorrhage was recorded in 17 patients (15 per cent). Twelve episodes of bleeding occurred in the first 97 patients who entered the trial and prolongation of the prothrombin time was recorded in eight of 16 patients. In view of these findings 10 mg vitamin K was given with each dose of latamoxef to the last group of patients. However, bleeding occurred in five of 13 patients receiving vitamin K and entry to the study was therefore discontinued.