Folate status in patients receiving maintenance doses of sulfasalazine.

Hematologic studies, including serum and RBC folate assays, were done on 45 outpatients with chronic colitis who either took sulfasalazine (n = 27) or did not use it (n = 18). Overall, sulfasalazine users and nonusers had similar mean hemoglobin, hematocrit, serum folate, and RBC folate levels. However, within the drug users, RBC folate was inversely correlated with drug dose; serum folate was not. Patients taking 2 g or more of sulfasalazine daily had lower mean RBC folate levels (221.2 +/- 27.3 ng/mL) than patients either taking less (371.7 +/- 35.0 ng/mL) or nonusers (330.3 +/- 30.3 ng/mL). Mean corpuscular volume was also related to drug dose but not to RBC folate. Although maintenance sulfasalazine use rarely causes clinically significant folate deficiency, subclinical tissue depletion occurs as a dose-related effect.

Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) presents a significant diagnostic and management challenge for primary care practitioners. Improving the accuracy and timeliness of diagnosis may result in improved quality and efficiency of care. OBJECTIVE: To systematically appraise the existing diagnostic criteria and combine the evidence with expert opinion to derive evidence- and consensus-based guidelines for a diagnostic approach to patients with suspected IBS. METHODS: We performed a systematic literature review (January 1966-April 2000) of computerized bibliographic databases. Articles meeting explicit inclusion criteria for diagnostic studies in IBS were subjected to critical appraisal, which formed the basis of guideline statements presented to an expert panel. To develop a diagnostic algorithm, an expert panel of specialists and primary care physicians was used to fill in gaps in the literature. Consensus was developed using a modified Delphi technique. RESULTS: The systematic literature review identified only 13 published studies regarding the effectiveness of competing diagnostic approaches for IBS, the accuracy of diagnostic tests, and the internal validity of current diagnostic symptom criteria. Few studies met accepted methodological criteria. While symptom criteria have been validated, the utility of endoscopic and other diagnostic interventions remains unknown. An analysis of the literature, combined with consensus from experienced clinicians, resulted in the development of a diagnostic algorithm relevant to primary care that emphasizes a symptom-based diagnostic approach, refers patients with alarm symptoms to subspecialists, and reserves radiographic, endoscopic, and other tests for referral cases. The resulting algorithm highlights the reliance on symptom criteria and comprises a primary module, 3 submodules based on the predominant symptom pattern (constipation, diarrhea, and pain) and severity level, and a subspecialist referral module. CONCLUSIONS: The dearth of available evidence highlights the need for more rigorous scientific validation to identify the most accurate methods of diagnosing IBS. Until such time, the diagnostic algorithm presented herein could inform decision making for a range of providers caring for primary care patients with abdominal discomfort or pain and altered bowel function suggestive of IBS.

Drug-induced malabsorption.

Pharmacologic agents of diverse types may alter gastrointestinal absorption of nutrients and other substances. Mechanisms underlying drug-induced absorptive defects that have been documented include: (1) a direct toxic effect causing morphologic changes in the mucosa of the small intestine; (2) inhibition of mucosal enzymes with or without morphologic evidence of mucosal damage; (3) binding and precipitation of micellar components, such as bile acids and fatty acids; and (4) alteration of the physicochemical state of another drug or dietary ion. The malabsorptive effect generally is dose-related, rather than an idiosyncratic reaction, and usually involves multiple nutrients. Certain clinical states, such as in the malnourished alcoholic may predipose the gastrointestinal tract to a drug-induced absorptive defect. For this review we discuss in detail nine commonly used drugs or types of drugs that cause malabsorption of dietary nutrients or other medications.

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.

Bronchiectasis and homozygous alpha1-antitrypsin deficiency.

A 34-year-old woman with homozygous a1-antitrypsin deficiency suffered from progressive, generalized cystic bronchiectasis. Although bronchiectasis was reported in the original monograph on the enzyme inhibitor deficiency, it has received minimal attention since then. Alpha1-antitrypsin levels should be measured in patients with severe bronchiectasis.

Irritable bowel syndrome and chronic pelvic pain.

The irritable bowel syndrome (IBS) is a common functional bowel disorder diagnosed by characteristic symptoms. It is often associated with gynecologic symptoms, especially chronic pelvic pain (CPP). IBS symptoms worsen during menstruation and are correlated with increased levels of various perimenstrual symptoms. Psychosocial factors including depression, somatization, substance abuse, and childhood abuse are similar in IBS and CPP. IBS predisposes women to undergo hysterectomy and negatively influences pain improvement postoperatively. Therefore, IBS should be considered in the differential diagnosis of CPP. Collaboration between gynecologists and gastroenterologists is needed in the care of women with CPP and IBS as well as in the conduct of additional research on the relationship of these two disorders.

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

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.

Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients.

BACKGROUND: Computed tomography (CT) demonstrates diverticulitis severity. AIM: To assess demographic, clinical and leucocyte features in association with severity. METHODS: We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast). RESULTS: Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P < .0001), leucocytosis (81.5% vs. 55.2%, P < .0001), neutrophilia (86.2% vs. 59.0%, P < .0001), 'bandemia' (18.5% vs. 5.5%, P < .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P < .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P < .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26-0.76]) and had less lower abdominal pain only (0.54 [0.29-0.99]) and more constipation (2.32 [1.27-4.23]), fever (2.13 [1.27-3.57]) and leucocytosis (2.67 [1.43-4.99]). CONCLUSIONS: Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.

Northern Baja California Indian women's concepts of illness and healing: Implications for public health and clinical practitioners.

Lay health care workers (promotores) interviewed 313 female members of remote Indian groups in northern Baja California, Mexico regarding: (1) common childhood and adult illnesses and endorsement of 'traditional' and modern therapies; (2) illness causation beliefs and knowledge of biomedical principles; and (3) the relation of ethnic identity with concepts of effective biomedical and non-biomedical therapy. The most common illnesses/symptoms reported in adults were diabetes, hypertension, high cholesterol, cold/flu, diarrhoea, low/variable blood pressure and arthritis; and in children, cold/flu, diarrhoea, bronchitis, cough, fever, empacho and dehydration. Of 285 informants, more reported at least one childhood disorder than who reported at least one adult disorder was most helped by traditional therapy [83 (29.1%) versus 44 (15.4%); P<0.0001] and both therapies [81 (28.4%) versus 42 (14.7%); P<0.001]. They reported eight naturalistic and two personalistic illness causes and manifested variable biomedical knowledge. Indian or mixed Indian/Mexican ethnic self-identity predominated, and Indian identity was unrelated to endorsement of traditional therapy. The 'biocultural synthesis' is a useful theoretical framework for viewing the findings. The Indians' pluralistic concepts have important implications for public health care workers and biomedical practitioners.

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.

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.

Bowel patterns and anxiety. Demographic factors.

In a survey of bowel patterns and anxiety on 1264 health maintenance organization (HMO) members undergoing health assessment, I found (a) Stool frequency increased with age (p = 0.001), was greater in men than women (p < 0.00001), and was greater in whites than blacks (p = 0.07); (b) Fecal incontinence increased with age in women (p < 0.001) but was not age-related in men (p > 0.10); (c) Laxative use was greater in women than men at all ages (p < 0.01), and there was an age effect on use in women (p < 0.025) but not in men (p > 0.20); (d) Bowel pattern change and abdominal pain were frequently caused by stress, and both effects declined with age in each gender (p < 0.05); (e) More women than men at all ages reported stress effects (p < 0.001), and subjects who reported either stress effect scored higher on both parts of the State-Trait Anxiety Inventory (p < 0.00001) than other people. Bowel patterns and their relation to anxiety have demographic characteristics.

Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study.

OBJECTIVES: To obtain epidemiological data on hospitalization for acute upper gastrointestinal hemorrhage (AUGIH) in a demographically defined population. METHODS: Adults hospitalized in 1991 with AUGIH [from a San Diego health maintenance organization (270,699 adult members)] were identified from discharge codes in the International Classification of Diseases, 9th Revision, Clinical Modifications, and their records were reviewed. RESULTS: There were 276 hospitalizations among 258 patients, an annual incidence rate of 102.0 hospitalizations per 100,000. Patient analysis, including the first admission of 15 patients with multiple hospitalizations, revealed rates of 128.3 in males and 65.8 in females. The rate increased with age in males (p = 0.008) and females (p = 0.001) more than 30-fold between the 3rd and 9th decades of life. AUGIH started before admission in 242 (93.8%) patients and after admission for other disorders in 16 (6.2%) patients. Endoscopy was performed in 241 (93.4%) patients. Diagnoses were: peptic ulcer, 159 (61.6%); mucosal erosive disease, 37 (14.3%); varices, 16 (6.2%); miscellaneous, 25 (9.7%); and unknown, 21 (8.1%). Peptic ulcer patients were similar to other patients (mean +/- SE) in age [60.6 +/- 1.2 vs. 60.7 +/- 1.5 yr] and gender [104 (65.4%) vs. 60 (60.6%) males], but were more often nonsteroidal anti-inflammatory drug (NSAID)-users [87 (54.7%) vs. 34 (34.3%) (p = 0.002)]. Older age, female gender, and NSAID use independently predicted gastric ulcer (p < or = 0.03). The severity of bleeding was similar in patients with peptic ulcers and in those with mucosal erosive disease and was not related to NSAID use in peptic ulcer patients. Patients whose AUGIH started after admission were older than those whose AUGIH began before admission [70.4 +/- 2.9 vs. 60.0 +/- 1.0 yr (p = 0.002)], and they had a higher mortality rate [4 (25%) vs. 9 (3.7%) (p = 0.005)]. CONCLUSIONS: 1) The annual incidence of hospitalization for AUGIH was 102.0 per 100,000, increased markedly with age, and was twice as high in males as in females. 2) Peptic ulcer was the most common cause. 3) Gastric ulcer was associated with older age, female gender, and NSAID use. 4) Mortality rates were high when AUGIH started after hospitalization for another disorder.

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. 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.

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.

Diabetic thoracic polyradiculopathy: ten patients with abdominal pain.

OBJECTIVES: Abdominal pain caused by diabetic thoracic polyradiculopathy is unfamiliar to many gastroenterologists. The aim of this study was to describe the clinical characteristics and outcome of the disorder. METHODS: Ten patients (six women) with diabetic thoracic polyradiculopathy were cared for in 20 yr. Electromyographic evidence of nerve root denervation was found in seven patients. Nine patients were followed-up at least until recovery, including four until death. RESULTS: The patients were 42-79 yr of age, had diabetes of various duration, and often had other diabetic complications, including two with previous polyradiculopathy. Pain of various types occurred. It was often worse at night and aggravated by light pressure. Pain was either unilateral or bilateral and was often accompanied by weight loss. All patients had a cutaneous sensory abnormality, and four had localized abdominal wall paresis with protrusion. Spontaneous recovery was documented in nine patients, but two had recurrent polyradiculopathy. CONCLUSIONS: Gastroenterologists should be familiar with diabetic thoracic polyradiculopathy, because its early recognition may prevent unnecessary and expensive diagnostic evaluation for a visceral cause of pain.