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.

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.

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.

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.

Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage.

Patients with upper gastrointestinal haemorrhage (UGIH) are usually cared for in hospital. To evaluate the efficacy and safety of outpatient care of selected patients with acute non-variceal UGIH who had endoscopy, we retrospectively analysed 4.5 years' experience of patients treated without hospital admission. We developed practice guidelines for outpatient care, and prospectively studied patients treated during the first 6 months of their use. 78 (8.4%) of 933 patients in the retrospective series and 34 (24.1%) of 141 in the prospective series received outpatient care. The guidelines comprised early notification of a gastroenterologist, urgent endoscopy, clinical, laboratory, and endoscopic criteria for outpatient care, and details of care. In the prospective study patients treated as outpatients were younger than those admitted (52.8 [SE 3.6] vs 63.0 [1.5] years) and had a slightly longer time from onset of bleeding to endoscopy (2.4 [0.2] vs 2.1 [0.2] days). Outpatients were less likely to have alcoholism, other major concomitant disease, syncope or presyncope, or supine tachycardia. Outpatients had higher haemoglobin concentrations than inpatients (125 [4] vs 106 [3] g/L). Most patients in both groups had peptic ulcers. There were no complications in the retrospective series; 1 of the 34 prospective outpatients was admitted with rebleeding. All outpatients survived. The estimated hospital cost saved per outpatient was about $990. A substantial proportion of carefully selected patients with acute non-variceal UGIH can be effectively cared for without admission to hospital.

Hospital care of acute nonvariceal upper gastrointestinal bleeding: 1991 versus 1981.

Developments important to the care of upper gastrointestinal (UGI) bleeding occurred in the 1980s. We compared the features, care, and outcome of patients hospitalized with acute nonvariceal UGI bleeding in 1991 (n = 216) and 1981 (n = 105). Most patient characteristics and the hemoglobin values were similar. Final diagnoses differed, mainly because there were more peptic ulcers and fewer unknown diagnoses in 1991. More patients had endoscopy in 1991 (94%); 92% of endoscoped patients had the procedure within 24 h of admission. The hospital stay of patients without surgery or comorbidity in 1991 was 2.8 +/- 0.1 days, significantly shorter than that in 1981. In 1991 only one half of patients received blood transfusion. The hemoglobin values before transfusion (7.2 +/- 0.1 g%) and at discharge (9.8 +/- 0.1 g%) were lower in 1991; transfused patients received similar amounts of blood in the 2 years. Endoscopic hemostatic therapy was used in 25% of patients with ulcers in 1991 and in none in 1981. Rates of rebleeding (including patients readmitted for recurrent bleeding within 1 week of discharge) and surgery were similar. Mortality was 2.8% in 1991, similar to the 1981 death rate. Because of the excellent 1991 patient outcome, we continue to care for most patients with acute nonvariceal UGI bleeding with urgent endoscopy and short hospitalization.

Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates.

A study of irritable bowel-type symptoms in 1264 health examinees using a self-administered questionnaire and psychological tests revealed they are common throughout adulthood. Of affected subjects 68% were female, and those with the more severe type (> or = 3 Manning criteria) were predominantly female (80%). Fewer Asians than other racial/ethnic groups had these symptoms. Nongastrointestinal symptoms, physician visits, incontinence, laxative use, a stress effect on bowel pattern and abdominal pain, abdominal surgery, hysterectomy, childhood abuse, use of mind-altering drugs, depression, and anxiety were correlated with irritable bowel-type symptoms. Regression analysis found some of the clinical correlates were independent markers for irritable bowel-type symptoms and that sexual abuse was related to nongastrointestinal symptoms and abdominal surgery independent of irritable bowel-type symptoms. More severe irritable bowel-type symptoms were especially associated with nongastrointestinal symptoms, stress effects, sexual abuse, use of sedatives and oral narcotics, and a past alcohol problem. There are important demographic and clinical correlates with irritable bowel-type symptoms.

Long-term costs after gastroenterology consultation with endoscopy versus radiography in dyspepsia.

A randomized clinical trial assessed the medical costs during 6 months after the evaluation of dyspepsia by gastroenterology consultation with esophagogastroduodenoscopy versus barium radiography. Primary care physicians entered patients whose dyspepsia responded incompletely to empiric therapy or recurred. The consultation/endoscopy group (N = 32) was similar (p greater than 0.23) to the radiography group (N = 34) regarding age, gender, physician visits, and costs of all dyspepsia drugs and H2 blockers during 6 months before evaluation. Most patients had non-ulcer dyspepsia. Costs during the succeeding 6 months (consultation/endoscopy versus radiography groups) were physician visits ($33.1 +/- 14.5 vs. $114.2 +/- 23.3, p less than 0.005); radiologic procedures ($70.5 +/- 37.3 vs. $67.6 +/- 22.5, p greater than 0.30); all dyspepsia drugs ($30.4 +/- 10.0 vs. $100.1 +/- 36.8, p = 0.08); H2 blockers ($25.4 +/- 9.5 vs. $96.0 +/- 34.7, p = 0.06); and total cost ($134.0 +/- 43.8 vs. $435.3 +/- 93.9, p = 0.006). The higher total cost in the radiography group was partly due to the referral of 7 patients (21%) for gastroenterology consultation due to persistent dyspepsia, 6 of whom had endoscopy versus the performance of radiography in 0 of the 32 consultation/endoscopy patients (p less than 0.025). Dyspepsia self-ratings were similar.

Irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy. Relation to gynecologic features and outcome.

We identified irritable bowel syndrome (IBS) in 47.7% of 86 women having diagnostic laparoscopy for chronic pelvic pain, 39.5% of 172 women having elective hysterectomy, and 32.0% of 172 controls age-matched for the hysterectomy group (P = NS). Constipation and pain subtype IBS were more common in hysterectomy patients than controls (P less than 0.05). In laparoscopy patients, dyspareunia was more common in those with IBS than in those without it (P less than 0.05). In the hysterectomy group, more IBS patients had chronic pelvic pain (P less than 0.005), and abnormal menses (P less than 0.01). Chronic pelvic pain was more frequently the only prehysterectomy diagnosis in IBS patients (P less than 0.05), and IBS was present more often when pain was a reason for hysterectomy (P less than 0.01). One year after laparoscopy, IBS patients gave lower overall status ratings (P less than 0.01) and lower pain improvement ratings (P less than 0.05) than non-IBS patients. In women who had a hysterectomy for pain, there was less pain improvement one year later in those with the pain subtype of IBS than in non-IBS patients (P less than 0.05). IBS is associated with gynecologic symptoms and affects the symptomatic outcome of diagnostic laparoscopy and hysterectomy.

Cyclophosphamide therapy of idiopathic hepatic granulomatosis.

A 50-year-old woman presented with idiopathic hepatic granulomatosis and autoimmune hemolytic anemia. Splenectomy corrected the anemia, and the liver disorder responded to prednisone. However, her liver disease relapsed on four occasions when prednisone was tapered, including three episodes when hepatic granulomatosis was proven by biopsy. Cyclophosphamide therapy allowed prednisone withdrawal, and she has remained in clinical and biochemical remission for two years on a low dose of the drug.

Checking for "the occult" with a finger. A procedure of little value.

The performance of an occult blood test on normal-appearing feces obtained by rectal examination probably yields such high rates of false positive and false negative reactions that it is of little value in the detection of colorectal neoplasia. In acute gastrointestinal bleeding, it helps to know what the stool looks like; nevertheless, many physicians merely describe it as "heme positive" and neglect to record its gross appearance. Both of these practices should be discouraged.

Detecting colorectal neoplasms. Assessment based on hypothetical cases.

Because of the controversy surrounding the detection of colorectal neoplasia, I used 10 hypothetical, typical patients to assess the testing attitudes of 33 experienced colonoscopists. There was great disagreement on the type and frequency of the advised diagnostic investigation in some cases. The magnitude of interphysician variation in testing attitudes has major implications concerning cost and risk. This is particularly applicable to the interval between follow-up colonoscopies after polypectomy and cancer surgery, and the evaluation of patients with a positive fecal occult blood test. I reviewed the recent literature most pertinent to the patients. Although I could not derive firm guidelines for most of the cases from my review, consideration of the case management decisions, in light of available information, suggests that some gastroenterologists are testing many patients more than necessary, especially with colonoscopy.