Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial.

AIM: The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD: This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS: Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION: SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.

Failed pelvic pouch substituted by continent ileostomy.

OBJECTIVE: The long-term failure rate of ileal pouch-anal anastomosis (IPAA) is 10-15%. When salvage surgery is unsuccessful, most surgeons prefer pouch excision with conventional ileostomy, thus sacrificing 40-50 cm of ileum. Conversion of a pelvic pouch to a continent ileostomy (CI, Kock pouch) is an alternative that preserves both the ileal surface and pouch properties. The aim of the study was to evaluate clinical outcome after the construction of a CI following a failed IPAA. METHOD: During 1984-2007, 317 patients were operated with IPAA at St Olavs Hospital and evaluated for failure, treatment and outcome. Seven patients with IPAA failure had CI. Four patients with IPAA failure referred from other hospitals underwent conversion to CI and are included in the final analysis. RESULTS: Seven patients had a CI constructed from the transposing pelvic pouch and four had the pelvic pouch removed and a new continent pouch constructed from the distal ileum. Median follow up after conversion to CI was 7 years (0-17 years). Two CI had to be removed due to fistulae. One patient needed a revision of the nipple valve due to pouch loosening. At the end of follow-up, 8 of the 11 patients were fully continent. One patient with Crohn's disease had minor leakage. CONCLUSION: In patients with pelvic pouch failure, the possibility of conversion to CI should be presented to the patient as an alternative to pouch excision and permanent ileostomy. The advantage is the continence and possibly a better body image. Construction of a CI on a new ileal segment may be considered, but the consequences of additional small bowel loss and risk of malnutrition if the Kock pouch fails should be appraised.

Long-term surgical load in patients with ileal pouch-anal anastomosis.

AIM: To evaluate surgical workload and complications in patients who had undergone restorative proctocolectomy, through long-term follow-up in one single institution. METHOD: From 1984 to 2006, 304 consecutive patients underwent Ileal Pouch-Anal Anastomosis (IPAA). There were 182 stapled and 122 hand-sewn anastomoses. A protective loop ileostomy was established in 256 patients (84%), whereas 48 patients (16%) were without a covering stoma. RESULTS: Twenty-nine patients (10%) suffered from early anastomotic leakage. A protective stoma did not prevent early anastomotic dehiscence (P = 0.11) or the number of pelvic abscesses (P = 0.09). Early complications required 20 laparotomies with creation of a diverting stoma in nine patients. There were 16 (6%) complications related to closure of the loop ileostomy. Sixty-six patients needed an additional re-operation related to the IPAA procedure. There were 20 removals of pouches and three permanent diverting stomas. The estimated removal rate at 20 years of a functioning pouch was 11% (CI +/- 6). Altogether 100 (33%) patients had one or more surgical procedures, excluding dilations of anastomotic strictures and closing of a loop ileostomy. These 100 patients underwent 187 surgical procedures. The estimated rate of a first re-operation due to complications was 52% (CI +/- 16) in 20 years. Hand-sewn anastomoses had similar complications and failure rates as stapled anastomoses. CONCLUSIONS: More than half of patients operated with restorative proctocolectomy will need surgical intervention within 20 years and the failure rate is more than 10%. The high risk of complications and failure inherent in the procedure should not be ignored.

Dietary aspects of peptic ulcer disease.

Diets modify gastric function in various ways. Fibre influences acidity, pepsin and bile acid concentrations both in vitro and in vivo. Both animal studies and clinical studies in humans give reason to believe that a diet rich in fibre may protect against the development of peptic ulceration.

Reduction of postprandial gastric acidity and pepsin concentration by ranitidine and antacids in healthy volunteers.

Small aliquots of gastric content were withdrawn every tenth minute for 7 h in 11 healthy volunteers with a maximal gastric acid output of more than 20 mmol h-1. After 20 min a steak meal was given. Ranitidine hydrochloride 100 mg administered with the meal increased postprandial gastric pH and reduced acid concentration markedly throughout the test. Two tablets of antacids with a neutralizing capacity of approximately 20 mmol per tablet 1 and 3 h after the meal reduced gastric acidity significantly less than ranitidine and did not prevent an increase in acidity to control level during the interval between the two doses. In the control experiments 40% of the pH readings during the 4 postprandial hours were at or above the pre-prandial pH levels. Antacids and ranitidine increased this to 85% and 96% respectively. Antacids had no effect after the fourth postprandial hour, had very little effect when given in addition to ranitidine, but reduced the mean four hour postprandial pepsin concentration more than ranitidine.

High dose ursodeoxycholic acid in primary sclerosing cholangitis does not prevent colorectal neoplasia.

BACKGROUND: Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) have a high risk of developing colorectal cancer and dysplasia. Ursodeoxycholic acid (UDCA) has been suggested to have chemopreventive effects on the development of colorectal cancer and dysplasia but long-term data and larger trials are lacking. AIM: To evaluate the effect of high dose (17-23 mg/kg/day) UDCA on colorectal neoplasia in a cohort of patients with PSC and IBD. METHODS: From our previous 5-year randomised controlled trial of UDCA vs. placebo in PSC, we performed a follow-up of 98 patients with concomitant IBD from entry of the trial 1996-1997 until 2009 for development of colorectal cancer or dysplasia. RESULTS: The total follow-up time was 760 person-years. Dysplasia/cancer-free survival was compared between placebo- (n = 50) and UDCA-treated (n = 48) patients. There was a similar frequency of dysplasia or cancer after 5 years between patients originally assigned to UDCA or placebo (13% vs. 16%) and no difference in dysplasia/cancer-free survival (P = 0.46, log rank test). At the end of 2009 no difference in cancer-free survival was detected, 30% of the placebo patients compared with 27% of UDCA patients had developed colorectal cancer or dysplasia. CONCLUSIONS: Long-term high dose ursodeoxycholic acid does not prevent colorectal cancer or dysplasia in patients with primary sclerosing cholangitis-associated inflammatory bowel disease.

On-demand requirements of patients with endoscopy-negative gastro-oesophageal reflux disease: H2-blocker vs. proton pump inhibitor.

BACKGROUND: It is questionable whether a symptomatic condition with few serious medical consequences requires proton pump inhibitor (PPI) treatment. If effective, a less-potent treatment may be preferable. AIM: To compare an H2-blocker in an effervescent formulation with a PPI in on-demand treatment of endoscopy-negative gastro-oesophageal reflux disease (GERD). METHODS: Included were patients with heartburn and/or acid regurgitation for at least 3 months duration, a negative endoscopy and a positive response to 7 days of lansoprazole 60 mg daily. Following pH-metry, the patients were randomized to receive either ranitidine effervescent tablets 75 mg or lansoprazole capsules 15 mg to a maximum of four per day on-demand. The numbers taken were registered monthly for 6 months. If treatment was unsuccessful (lack of efficacy or side effects), patients were registered as failures. RESULTS: One hundred and three patients were included and 63 were considered for statistical analysis; 32 on lansoprazole and 31 on ranitidine. Seventeen (55%) on ranitidine and four (13%) on lansoprazole failed. The average number of tablets per day was 1.2 in the lansoprazole group and 3.1 in the ranitidine group. CONCLUSIONS: On-demand treatment in patients with endoscopy-negative GERD gives a high success rate with a fairly low dose of PPI. The H2-blocker had significantly less success; nevertheless, almost half were satisfied with the treatment.

Surgical load and long-term outcome for patients with Kock continent ileostomy.

OBJECTIVE: The aim of the study was to evaluate the results of Kock continent ileostomy (CI) during the same period when ileal pouch-anal anastomosis was the preferred operation for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP). METHOD: During the period 1983-2002, 50 patients underwent CI. The surgical technique was unchanged during the period. Follow-up included all patients. Forty-eight patients had UC, two of these had the diagnosis later changed to Crohn's disease and two had FAP. RESULTS: Twenty-two patients had 38 reoperations, four (8%) of whom had the pouch removed. The main causes for reoperation included leakage and difficulty in intubation due to sliding of the nipple valve (42%), fistula formation (29%) and stenosis (21%). Seventeen (45%) underwent a revision of the nipple valve and the pouch and nine (24%) a local procedure. The reoperation rate was higher among patients having a conventional ileostomy converted to CI than among those having CI. As a primary procedure (P = 0.016). The risk of a second reoperation was higher for those reoperated within the first year after having a CI, than for those reoperated later (P = 0.007). CONCLUSIONS: The reoperation rate of patients with CI is high but the removal rate of the pouch is low and is not associated with a high rate of revision. CI is a good alternative to conventional ileostomy in patients not suitable for restorative proctocolectomy or where this procedure has failed.

Fiber diet and antacids in the short-term treatment of duodenal ulcer.

Eighty patients with active duodenal ulcer were randomized to a diet poor or rich in fiber for a treatment period of 4 weeks. In addition, all patients received one antacid tablet (Link, 1.1 g) four times a day (total neutralizing capacity, 120 mmol HCl/day). The ulcer healed in 27 (67.5%) of the 40 patients in the high-fiber group, compared with in 24 (60%) of the 40 patients in the low-fiber group (p less than 0.5). Ulcer symptoms did not differ significantly between groups during the 4-week treatment period. No serious side effects were recorded. Constipation, the most frequently registered side effect, was seen in 11 (27.5%) of the patients in the low-fiber group, compared within 4 (10%) in the high-fiber group (chi-square = 4.0; p less than 0.05). Patients with unhealed ulcer after 4 weeks' treatment received ranitidine instead of antacids. While they were receiving ranitidine treatment, no significant differences in healing rates were seen between the two dietary groups.

Intragastric bile acid concentrations in healthy subjects and in patients with gastric and duodenal ulcer and the influence of fiber-enriched wheat bran in patients with gastric ulcer.

Fasting and postprandial intragastric bile acid concentrations were determined in healthy subjects and in patients with gastric and duodenal ulcer. The results showed great interindividual variation and wide overlapping between groups. Mean bile acid concentrations, fasting and postprandially, were significantly higher in patients with gastric ulcer than in healthy subjects. The differences between gastric and duodenal ulcer patients and between duodenal ulcer patients and healthy subjects were not significant. Fiber-enriched wheat bran reduced bile acid concentrations significantly in patients with gastric ulcer disease.

Influence of fiber on acidity, pepsin, and bile acids in human gastric juice in vitro.

The effect of a fiber-enriched wheat bran product, Fiberform, and a guar gum, Guarem, on gastric juice acidity, pepsin, and bile acid concentration was studied in vitro. Fiberform had a slight acid-binding capacity. The fiber preparation did not bind pepsin. Both products bound bile acids. With Fiberform the amount of bile acids bound was proportional to the amount of fiber and most pronounced at low pH and high bile acid concentration.

Endoscopy-negative reflux disease: what is the value of a proton-pump inhibitor test in everyday clinical practice?

BACKGROUND: Our aim in this study was to evaluate a simple test with proton-pump inhibitor (PPI) for use in everyday clinical practice in diagnosing endoscopy-negative reflux disease. METHODS: 68 patients with heartburn and/or acid regurgitation as their main complaint, symptoms of at least 3 months' duration prior to inclusion, all with a negative gastroscopy were included. The patients were given 60 mg of lansoprazole before breakfast for 7 days. After the test week, patients had to answer one single question on a formula. 'Did you essentially, without any doubt. have less heartburn and/or acid regurgitation during the treatment?' The only alternative answers were 'Yes' or 'No'. Patients in doubt were told to answer 'No'. 24-h pH monitoring was performed at the earliest 14 days after the test. RESULTS: 65 completed the PPI test and 52 fulfilled the pH monitoring. Defined by < 4% time oesophageal pH < 4, 34 (65%) had pathological reflux. The PPI test was positive in all patients with pathological reflux but also in 17 of 18 with normal pH-metry, giving the test a sensitivity of 97% and specificity of 6%. CONCLUSION: Application of a diagnostic PPI test in clinical practice gave a high sensitivity and unusually low specificity compared to placebo-controlled studies, indicating that a test of this nature should be used with caution in everyday practice. Most patients with endoscopy-negative GORD will be diagnosed clinically. A positive test with PPI strengthens the diagnosis but has insufficient specificity to be an objective criterion alone. pH-metry should be unnecessary for the diagnosis of ENGORD in patients with typical reflux symptoms.

[Autoimmune hepatitis--a rare cause of elevated transaminases]. / Autoimmun hepatitt--en sjelden årsak til forhøyede transaminaser.

Autoimmune hepatitis is a rare chronic hepatitis of unknown etiology. Immunological changes are conspicuous, with tissue antibodies found in a high proportion of patients. There is a female preponderance of 2-3:1 and the disease often affects young people. The presenting symptoms are vague, fatigue being the most important general symptom. The diagnosis is often made at a late stage of the disease when symptoms of liver decompensation and cirrhosis are obvious. We present two cases of AIH in young women diagnosed at a late stage with advanced cirrhosis, for whom symptoms of liver disease had been intermittently present for 12 and 9 months, but wrongly attributed to presumed acute viral hepatitis acquired on holiday in the Mediterranean. In order not to miss the diagnosis, it is important to confirm suspected viral hepatitis serologically, to look for liver disease stigmata in patients with abnormal liver enzymes, and to be especially aware of the possibility of AIH in young women with concommittant or family history of other autoimmune diseases.

Influence of fiber on postprandial intragastric juice acidity, pepsin, and bile acids in healthy subjects.

The effect of a fiber-enriched wheat bran product, Fiberform, and a guar gum preparation, Guarem, on postprandial intragastric juice acidity and pepsin and bile acid concentrations was studied in healthy subjects. Fiber-enriched wheat bran prolonged significantly the meal-induced elevation of pH and decrease in pepsin. Both fiber products reduced postprandial intragastric bile acid concentration.

Relationship between ranitidine plasma levels and reduction of postprandial intragastric acidity in healthy man.

Intragastric acidity was measured for 20 min before and 6 h 40 min after a steak meal by aspiration of small aliquots of the gastric content every 10 min in 11 healty volunteers. Administration of ranitidine hydrochloride (100 mg) at the beginning of the meal reduced postprandial acidity markedly throughout the test, but there was no correlation between the percentage reduction of acidity and the concentration of ranitidine in plasma. The effect of the drug lasted much longer than would be expected from the plasma values. The results suggest that ranitidine is cleared more rapidly from the blood than from the H2-receptors of the parietal cells, and the reduction of postprandial acidity by ranitidine cannot be deduced from the plasma values of the drug.

Intragastric bile acid concentrations in patients with erosive prepyloric changes.

In the search for pathogenetic mechanisms behind EPC, intragastric bile acids were measured in 60 patients with non-ulcer dyspepsia (NUD) and grade 2 or 3 erosive prepyloric changes (EPC) and in 20 control subjects. Intragastric bile acid concentrations tended to be higher in the control subjects than in the EPC patients, but the difference did not reach statistical significance. The results neither support nor disprove the hypothesis that bile acid-induced mucosal damage may be involved in the pathogenesis of EPC.

[Gastrointestinal endoscopy in children]. / Gastrointestinale endoskopier av barn.

BACKGROUND: Abdominal pain and other gastrointestinal symptoms in children may be, but are not always due to disease. Endoscopy in general anaesthesia may be necessary in children with long-term symptoms from the gastrointestinal tract. MATERIAL AND METHODS: We present a retrospective study of all children under the age of 15 who underwent endoscopy at the Central Hospital in Akershus (SIA) in the period 1993-98. 254 gastro-, 123 colono- and 43 sigmoideoscopies were performed. A conclusive diagnosis was made following endoscopy. There were few complications to the endoscopies. RESULTS AND INTERPRETATION: Our results indicate a higher incidence of inflammatory bowel disease than in similar studies, but with the same relative rates. Celiac disease occurs at a rate similar to the Swedish epidemic in the 1980s.

[Invagination in children]. / Invaginasion hos barn.

Although rare, childhood intussusception is one of the most common causes of small bowel obstruction in infancy. In these very young patients it can sometimes be difficult to interpret the clinical signs and symptoms correctly. This retrospective study comprises 79 children (median age 7.5 months; 24% girls and 76% boys) who experienced 83 episodes of intussusception. At admission the diagnosis made by the referring physicians could be confirmed in only about one-third of the cases. A barium enema was part of the inhospital diagnostic process. Non-operative treatment was attempted in 70 patients (89%), and barium enema reduction was successful in 64%. Laparotomy was required in 33 (42%) of the patients. No mortality, bowel perforation, or any other major complications were encountered. The diagnosis of childhood intussusception seems difficult to achieve in many cases, and the interpretation of, at times vague clinical signs and symptoms remains a challenge for all clinicians who are involved in the care of these very young patients.