Brain fogginess, gas and bloating: a link between SIBO, probiotics and metabolic acidosis.

BACKGROUND: D-lactic acidosis is characterized by brain fogginess (BF) and elevated D-lactate and occurs in short bowel syndrome. Whether it occurs in patients with an intact gut and unexplained gas and bloating is unknown. We aimed to determine if BF, gas and bloating is associated with D-lactic acidosis and small intestinal bacterial overgrowth (SIBO). METHODS: Patients with gas, bloating, BF, intact gut, and negative endoscopic and radiological tests, and those without BF were evaluated. SIBO was assessed with glucose breath test (GBT) and duodenal aspiration/culture. Metabolic assessments included urinary D-lactic acid and blood L-lactic acid, and ammonia levels. Bowel symptoms, and gastrointestinal transit were assessed. RESULTS: Thirty patients with BF and 8 without BF were evaluated. Abdominal bloating, pain, distension and gas were the most severe symptoms and their prevalence was similar between groups. In BF group, all consumed probiotics. SIBO was more prevalent in BF than non-BF group (68 vs. 28%, p = 0.05). D-lactic acidosis was more prevalent in BF compared to non-BF group (77 vs. 25%, p = 0.006). BF was reproduced in 20/30 (66%) patients. Gastrointestinal transit was slow in 10/30 (33%) patients with BF and 2/8 (25%) without. Other metabolic tests were unremarkable. After discontinuation of probiotics and a course of antibiotics, BF resolved and gastrointestinal symptoms improved significantly (p = 0.005) in 23/30 (77%). CONCLUSIONS: We describe a syndrome of BF, gas and bloating, possibly related to probiotic use, SIBO, and D-lactic acidosis in a cohort without short bowel. Patients with BF exhibited higher prevalence of SIBO and D-lactic acidosis. Symptoms improved with antibiotics and stopping probiotics. Clinicians should recognize and treat this condition.

Anorectal Manometry in Defecatory Disorders: A Comparative Analysis of High-resolution Pressure Topography and Waveform Manometry.

BACKGROUND/AIMS: Whether high-resolution anorectal pressure topography (HRPT), having better fidelity and spatio-temporal resolution is comparable to waveform manometry (WM) in the diagnosis and characterization of defecatory disorders (DD) is not known. METHODS: Patients with chronic constipation (Rome III) were evaluated for DD with HRPT and WM during bearing-down "on-bed" without inflated rectal balloon and "on-commode (toilet)" with 60-mL inflated rectal balloon. Eleven healthy volunteers were also evaluated. RESULTS: Ninety-three of 117 screened participants (F/M = 77/16) were included. Balloon expulsion time was abnormal (＞ 60 seconds) in 56% (mean 214.4 seconds). A modest correlation between HRPT and WM was observed for sphincter length (R = 0.4) and likewise agreement between dyssynergic subtypes (κ = 0.4). During bearing down, 2 or more anal pressure-segments (distal and proximal) could be appreciated and their expansion measured with HRPT but not WM. In constipated vs healthy participants, the proximal segment was more expanded (2.0 cm vs 1.0 cm, P = 0.003) and of greater pressure (94.8 mmHg vs 54.0 mmHg, P = 0.010) during bearing down on-commode but not on-bed. CONCLUSIONS: Because of its better resolution, HRPT may identify more structural and functional abnormalities including puborectal dysfunction (proximal expansion) than WM. Bearing down on-commode with an inflated rectal balloon may provide additional dimension in characterizing DD.

Does colectomy predispose to small intestinal bacterial (SIBO) and fungal overgrowth (SIFO)?

OBJECTIVES: After subtotal colectomy, 40% of patients report chronic gastrointestinal symptoms and poor quality of life. Its etiology is unknown. We determined whether small intestinal bacterial overgrowth (SIBO) or small intestinal fungal overgrowth (SIFO) cause gastrointestinal symptoms after colectomy. METHODS: Consecutive patients with unexplained abdominal pain, gas, bloating and diarrhea (>1 year), and without colectomy (controls), and with colectomy were evaluated with symptom questionnaires, glucose breath test (GBT) and/or duodenal aspiration/culture. Baseline symptoms, prevalence of SIBO/SIFO, and response to treatment were compared between groups. RESULTS: Fifty patients with colectomy and 50 controls were evaluated. A significantly higher (p = 0.005) proportion of patients with colectomy, 31/50 (62%) had SIBO compared to controls 16/50 (32%). Patients with colectomy had significantly higher (p = 0.017) prevalence of mixed SIBO/SIFO 12/50 (24%) compared to controls 4/50 (8%). SIFO prevalence was higher in colectomy but not significant (p = 0.08). There was higher prevalence of aerobic organisms together with decreased anaerobic and mixed organisms in the colectomy group compared to controls (p = 0.008). Patients with colectomy reported significantly greater severity of diarrhea (p = 0.029), vomiting (p < 0.001), and abdominal pain (p = 0.05) compared to controls, at baseline. After antibiotics, 74% of patients with SIBO/SIFO in the colectomy and 69% in the control group improved (p = 0.69). CONCLUSION: Patients with colectomy demonstrate significantly higher prevalence of SIBO/SIFO and greater severity of gastrointestinal symptoms. Colectomy is a risk factor for SIBO/SIFO.

Corynebacterium CDC Group G Native and Prosthetic Valve Endocarditis.

We report the first case of native and recurrent prosthetic valve endocarditis with Corynebacterium CDC group G, a rarely reported cause of infective endocarditis (IE). Previously, there have been only two cases reported for prosthetic valve IE caused by these organisms. A 69-year-old female with a known history of mitral valve regurgitation presented with a 3-day history of high-grade fever, pleuritic chest pain and cough. Echocardiography confirmed findings of mitral valve thickening consistent with endocarditis, which subsequently progressed to become large and mobile vegetations. Both sets of blood cultures taken on admission were positive for Corynebacterium CDC group G. Despite removal of a long-term venous access port, the patient's presumed source of line associated bacteremia, mitral valve replacement, and aggressive antibiotic therapy, the patient had recurrence of vegetations on the prosthetic valve. She underwent replacement of her prosthetic mitral valve in the subsequent 2 weeks, before she progressed to disseminated intravascular coagulation and expired. Although they are typically considered contaminants, corynebacteria, in the appropriate clinical setting, should be recognized, identified, and treated as potentially life-threatening infections, particularly in the case of line-associated bacteremias, and native and prosthetic valve endocarditis.

Advances in the management of constipation-predominant irritable bowel syndrome: the role of linaclotide.

Constipation-predominant irritable bowel syndrome (IBS-C) is a commonly prevalent and clinically challenging disorder to treat. Until recently, most therapeutic agents had limited ability to address the complexity of symptoms inherent to the syndrome. The development of linaclotide provides a physiologically sound approach to treatment of the multiple symptoms of IBS-C. Clinical trials demonstrate the efficacy of linaclotide, and a platform to better understand the symptomatology of IBS-C. Based on recent clinical evidence, linaclotide should be considered for patients with IBS-C because it improves abdominal pain and bowel symptoms. In phase III trials, linaclotide met the US Food and Drug Administration responder endpoint with a number needed to treat (NNT) of 5.1-7.9, and European Medicines Agency coprimary endpoints at 12 weeks with a NNT of 4.39-7.69, and at 26 weeks with a NNT of 4.93-5.68. It is safe and effective, with diarrhea reported as the most common adverse effect, which leads to discontinuation of the medication in approximately 5% of patients.

Anorectal physiology and pathophysiology in the elderly.

Anorectal medical disorders facing the elderly include fecal incontinence, fecal impaction with overflow fecal incontinence, chronic constipation, dyssynergic defecation, hemorrhoids, anal fissure, and pelvic floor disorders. This article discusses the latest advances in age-related changes in morphology and function of anal sphincter, changes in cellular and molecular biology, alterations in neurotransmitters and reflexes, and their impact on functional changes of the anorectum in the elderly. These biophysiologic changes have implications for the pathophysiology of anorectal disorders. A clear understanding and working knowledge of the functional anatomy and pathophysiology will enable appropriate diagnosis and treatment of these disorders.

Hyperinsulinemia euglycemia therapy for calcium channel blocker overdose: a case report.

We report the case of a patient with calcium channel blocker toxicity who was treated successfully with hyperinsulinemia euglycemia therapy, without prior use of vasopressors. The patient was a 60-year-old man with schizoaffective disorder who presented with severe hemodynamic compromise after an intentional overdose of 5,400 mg of extended-release diltiazem. He had been admitted to the hospital twice before for attempted suicide with diltiazem and nifedipine, respectively. During the previous admissions, conventional treatments were used, and complications included hemodynamic compromise, ischemic bowel requiring ileostomy, and a prolonged hospital stay. During the current admission, the patient's clinical condition failed to improve after treatment with charcoal, fluid resuscitation, calcium, and glucagon. Eight hours after admission, hyperinsulinemia euglycemia therapy was initiated; 3 hours later, the patient's hemodynamic status showed sustained improvement. His bradycardia and hypotension resolved without cardiac pacing or vasopressors. Hyperinsulinemia euglycemia therapy is a potentially life-saving treatment for calcium channel blocker toxicity. We suggest that such therapy should be considered early, in conjunction with conventional therapy, for the treatment of calcium channel blocker overdose in patients not responding to initial treatment.

Atrioventricular dissociation after electroconvulsive therapy.

Electroconvulsive therapy (ECT) is increasingly used as a treatment for psychiatric disorders. Cardiac effects are the principal cause of medical complications in these patients. We report a case of atrioventricular (AV) dissociation that occurred after ECT that was treated with pacemaker implantation. The mechanisms contributing to the onset of AV dissociation in this patient, and the management and rationale for device therapy, in light of the most recent guidelines, are reviewed.

Practice-based learning and systems-based practice: detection and treatment monitoring of generalized anxiety and depression in primary care.

OBJECTIVES: Quality assurance/quality improvement projects are an important part of professional development in graduate medical education. The purpose of our quality improvement study was to evaluate whether (1) the Generalized Anxiety Disorder (GAD-7) scale questionnaire increases detection of anxiety and (2) the Quick Inventory for Depressive Symptomatology Self Report (QIDS-SR) increases detection of depression in a primary care setting. We also aimed to determine whether monitoring patients with depression or generalized anxiety using the QIDS-SR and GAD-7 scales influences treatment changes in the primary care setting. METHODS: Patients seen in a general internal medicine clinic between August 2008 and March 2009 were asked to fill out the QID-SR questionnaire and GAD-7 as part of a resident quality improvement project. We measured the prevalence of anxiety and depression during 6 months prior to the use of the GAD-7 and QIDS-SR instruments during the intervention period. We also compared the frequency of treatment changes initiated both 12 months prior to and during the intervention period. The aforementioned measures were performed with use of a retrospective chart review. RESULTS: The prevalence of anxiety was 15.2% in the pre-intervention period and 33.3% in the intervention period, and the prevalence of depression was 38.9% in the prescreening period and 54.8% during the screening period (P value for both was <0.001). The change in anxiety therapy was 21.6% in the prescreening period and 62.2% in the screening period (P  =  .028). The change in depression therapy was 23.2% in the pre-intervention period and 52.1% in the intervention period (P  =  .025). CONCLUSION: Routine screening for depression and anxiety may help clinicians detect previously undiagnosed anxiety and depression and also may facilitate identification of needed treatment changes. Further work is needed to determine whether routine screening improves patient outcomes.