A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes.

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.

Evaluation and Treatment of Constipation in the Geriatric Population.

Chronic constipation affects one-third of the US population and occurs disproportionately in the elderly and female individuals, increasing in older individuals who are institutionalized. This condition has a significant impact on health care costs and quality of life. Clinicians need to consider primary as well as secondary causes of constipation in elderly individuals because the cause is often multifactorial. Diagnostic algorithms should eliminate red-flag symptoms that may indicate a malignancy but also consider pelvic floor dysfunction, which is more common in this age group. An appropriate treatment plan is tailored to the severity of the patient's symptoms.

Postural Tachycardia Syndrome (POTS) and the GI Tract: A Primer for the Gastroenterologist.

Postural tachycardia syndrome (POTS) is one of the most common causes of orthostatic intolerance and is being increasingly recognized in clinical practice. Gastrointestinal (GI) symptoms are reported commonly in patients with POTS and pose a considerable management challenge, making it imperative that gastroenterologists be aware of this condition and its GI comorbidities. Although the evidence presented herein does not prove causation, it does support an association between GI symptoms, GI dysmotility, and POTS. At present, the evaluation and treatment of GI symptoms in patients with POTS remains largely empirical. General measures to treat POTS may lead to improvement in both GI and non-GI symptoms. GI symptoms refractory to these measures should prompt further diagnostic evaluation of gastrointestinal dysmotility and appropriate dietary and pharmacologic management. This review focuses its attention on the involvement of the GI tract in POTS including a discussion of GI symptoms and conditions associated with POTS, followed by an analysis of abnormalities in gut physiology described in POTS, and concluding with an overview of management and suggestions for research directions.

A Case Report of Cronkhite-Canada Syndrome Complicated by Membranous Nephropathy.

Cronkhite-Canada syndrome (CCS) is a very rare disorder with less than 500 reported cases. It is characterized by extensive gastrointestinal polyposis and ectodermal anomalies including alopecia, cutaneous hyperpigmentation, and onychodystrophy. Only 3 cases of associated kidney disease (membranous nephropathy [MN]) have been reported. A 71-year-old male with CCS was referred for further evaluation of proteinuria. The patient initially presented with abdominal discomfort, weight loss, dysgeusia, skin hyperpigmentation, alopecia, and dystrophic nails. Endoscopic evaluation showed widespread gastrointestinal nodular inflammation and polyps. Histopathology was consistent with CCS. Initial treatment was with prednisone, azathioprine, and ranitidine. He had moderate clinical improvement but developed nephrotic-range proteinuria. Renal biopsy showed MN, and cyclosporine was started. The patient had significant improvement in his CCS manifestations; however, his proteinuria and renal function worsened. Rituximab was added to his regimen of cyclosporine and azathioprine, which resulted in remission of his MN, marked improvement in his polyposis, and near resolution of his cutaneous symptoms. This case represents a unique presentation of CCS associated with MN treated with rituximab. The excellent clinical response observed for both CCS and MN advocates consideration of this treatment, especially for refractory disease.

Intractable Constipation in the Elderly.

OPINION STATEMENT: Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.

Analysis of Biopsies From Duodenal Bulbs of All Endoscopy Patients Increases Detection of Abnormalities but has a Minimal Effect on Diagnosis of Celiac Disease.

BACKGROUND & AIMS: In patients with positive results from serologic tests for celiac disease, analysis of tissues samples from the duodenal bulb, in addition to those from other parts of the small bowel, might increase the diagnostic yield. However, biopsies are not routinely collected from the duodenal bulb because of concerns that villous atrophy detected there could be caused by other disorders (Brunner glands or peptic duodenitis, gastric metaplasia, shorter villi, or lymphoid follicles). We investigated whether analysis of biopsies from duodenal bulbs of all patients undergoing endoscopy (a population with a low probability for celiac disease) increases diagnoses of celiac disease. METHODS: We performed a retrospective analysis of data from 679 patients (63% female; mean age, 50 years) from whom duodenal bulb and small bowel biopsies were collected during endoscopy at 3 Mayo Clinic sites, from January 1, 2011 through December 31, 2011. Records were reviewed for age, sex, pathology findings, serology test results (HLA DQ2 or DQ), indications for biopsy analyses, and adherence to a gluten-free diet. Patients with celiac disease were identified on the basis of increased intraepithelial lymphocytosis, with or without villous atrophy and crypt hyperplasia, and results from serology tests. Findings from duodenal bulbs were compared with diagnoses using the Fisher exact test. RESULTS: Of all patients undergoing endoscopy, 16 patients (2%) were found to have celiac disease. Analysis of the duodenal bulb biopsies identified 1 patient (0.1%) with celiac disease limited to this region. Of 399 patients whose celiac serology was not known before endoscopic examination, only 2 patients had histologic changes consistent with celiac disease but not limited to duodenal bulb. Abnormal duodenal histology was detected in 265 patients (39%), most commonly in the bulb (n = 241; P < .0001). Of abnormal bulb histologies, chronic peptic duodenitis was most common (observed in 114 patients, 47%). In patients with a normal distal duodenum (n = 576), the duodenal bulb had abnormal histology in 162 (28%). CONCLUSIONS: In a low pretest probability cohort, separate sampling of the duodenal bulb had minimal effect on celiac disease detection. Abnormal histologic findings are more commonly detected in the duodenal bulb; although they do not seem to impair identification of celiac disease, their clinical implications are unclear.

Self-dilation as a treatment for resistant, benign esophageal strictures.

GOALS AND BACKGROUND: Simple benign strictures may be relieved with one to three dilation sessions. Resistant benign strictures are anatomically complex and resistant to therapy. We sought to determine the efficacy and safety of esophageal self-dilation with bougie dilators in the largest series to date. STUDY: A retrospective chart review was performed to identify patients who underwent esophageal self-dilation at two tertiary referral centers (Mayo Clinic, Scottsdale, Arizona and Mayo Clinic Rochester, Minnesota) between January 1, 2003 and June 30, 2012. Demographic details and clinical information regarding relief of dysphagia, complications, and frequency of endoscopic and self-dilation were abstracted. RESULTS: Of the 32 patients who began self-dilation for nonmalignant strictures, 30 [22 men; median (range) age, 62 years (22-86 years)] were included in the study. Median (range) follow-up was 37 months (14-281 months). Stricture etiology included radiation therapy (n = 8), anastomotic stricture (n = 9), eosinophilic esophagitis (n = 4), caustic ingestion (n = 3), photodynamic therapy (n = 2), granulation tissue (n = 2), peptic stricture (n = 1) and one patient had radiation therapy and peptic stricture. The average number (range) of physician performed dilations before self-dilation was 12 (4-55). Esophageal self-dilation was successful in treating 90 % of patients. Dysphagia score (2 vs. 1; P < 0.001), stricture diameter (median; 5 vs. 12 mm; P < 0.001) and weight (median; 73 vs. 77 kg; P < 0.001) were significantly different between EDG dilation versus self-dilation. CONCLUSIONS: Esophageal self-dilation is a safe, effective treatment for resistant, benign esophageal strictures. This management strategy should be strongly considered in this patient population.

Impact of fentanyl in lieu of meperidine on endoscopy unit efficiency: a prospective comparative study in patients undergoing EGD.

BACKGROUND: Turnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency. OBJECTIVE: To evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center. DESIGN: Prospective, comparative, quality-improvement project. SETTING: Endoscopy unit of a tertiary-care academic medical center. PATIENTS: We enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010. INTERVENTION: Moderate sedation with midazolam plus fentanyl versus meperidine. MAIN OUTCOME MEASUREMENTS: Sedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge). RESULTS: Fentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P < .001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded. LIMITATIONS: No randomization was performed. CONCLUSION: Compared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.

C-reactive protein and high-sensitivity C-reactive protein: an update for clinicians.

The measurement of C-reactive protein (CRP) using both standard and high-sensitivity CRP (hs-CRP) assays is becoming common in clinical practice. This article addresses the causes of CRP elevation and the use of different CRP assays in internal medicine, including cardiology, gastroenterology, rheumatology, infectious diseases, and oncology. We focus on the recent medical literature on the use of hs-CRP in cardiovascular disease risk stratification and management, including updated screening guidelines on the use of hs-CRP, such as those issued in 2009 by the Canadian Cardiovascular Society. We also discuss the Reynolds Risk Score, which incorporates hs-CRP and family history with more standard cardiovascular risk factors (eg, tobacco use, hypertension, and dyslipidemia) and frequently leads to improved recategorization of cardiovascular disease risk levels. As the recently completed Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial indicated that statin therapy decreases the vascular events among persons with elevated hs-CRP by half, even when cholesterol levels are low, the inclusion of information on hs-CRP values with other cardiovascular risk factors may assist physicians in medical decision making for patients.

Self dilation as a treatment for resistant benign esophageal strictures: outcome, technique, and quality of life assessment.

BACKGROUND: Resistant benign esophageal strictures can have a negative impact on patients' quality of life. A portion of these patients require frequent physician performed dilations, leading to numerous interactions with their attendant inconvenience and sense of dependence. This study demonstrates the efficacy, safety and effect on quality of life of this under-utilized technique. METHODS: A retrospective chart review was performed for all patients undergoing esophageal self dilation at our institution between January 2003 and November 2009. The impact on quality of life was evaluated using a telephone questionnaire specifically designed to explore emotional, social and financial impacts. RESULTS: Of the 11 patients who initially began self dilation for non-malignant strictures, nine are included in this study. Median follow-up was 35.4 months (range 6-168). No significant complications were reported. When asked to compare self dilation with physician performed dilation a large proportion of patients reported financial benefits, and a majority reported being more socially active. Overall quality of life improvement was reported by almost all of the participants in the study. Global scores for dysphagia and overall quality of life were significantly improved under conditions of self dilation versus physician performed dilation (P = 0.008 and P = 0.016, respectively). CONCLUSIONS: Our results suggest that esophageal self dilation can be a safe and effective treatment modality in motivated patients with benign resistant esophageal strictures. Esophageal self dilation has a positive impact on emotional, social, and financial aspects of patient's life. Self dilation should be considered a treatment option in all patients with benign resistant esophageal strictures.

Lubiprostone: evaluation of the newest medication for the treatment of adult women with constipation-predominant irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a chronic disorder that affects primarily female patients and is thought also to afflict approximately 7%-10% of the population of the Western World. Although bowel habits may change over the course of years, patients with IBS are characterized according to their predominant bowel habit, constipation (IBS-C), diarrhea (IBS-D), or mixed type (IBS-M), and treatments are focused toward the predominant symptom. Current treatments for IBS-C have included fiber, antispasmodics, osmotic and stimulant laxatives, and the now severely limited 5-HT(4) agonist tegaserod. No one agent has been universally successful in the treatment of this bothersome syndrome and the search for new agents continues. Lubiprostone (Amitiza(®)), a novel compound, is a member of a new class of agents called prostones and was approved for the treatment of chronic idiopathic constipation in 2006 at a dose of 24 µg twice daily and then in 2008 for the treatment of IBS-C in women only at a dose of 8 µg twice daily. Its purported mechanism is as a type 2 chloride channel activator, but recent evidence suggests that it may also work at the cystic fibrosis transport receptor. This article will compare the newly proposed mechanism of action of this compound to the purported mechanism and review the structure, pharmacology, safety, efficacy, and tolerability of this new therapeutic option. Clinical trial data leading to the approval of this agent for the treatment of IBS-C and the gender-based understanding of IBS, as well as this agent's place among existing and emerging therapies, will be examined.

Linaclotide, a new direction in the treatment of irritable bowel syndrome and chronic constipation.

Microbia Inc is developing the oral guanylate cyclase C agonist linaclotide, a 14mer peptide for the potential treatment of constipation-predominant irritable bowel syndrome and chronic idiopathic constipation. Phase II clinical trials are underway for both indications.