Chronic constipation--is the work-up worth the cost?

BACKGROUND: Chronic constipation can be a disabling condition that may require colectomy. Evaluation has been included as a way to select appropriate patients for colectomy and may also be extensive, unrevealing, and costly. AIMS: This study was undertaken to determine the cost and use of evaluation and outcome of patients with chronic constipation. METHODS: Patients with chronic constipation were reviewed for severity of symptoms, diagnostic studies performed, treatment, and outcome. The costs of the diagnostic studies were determined at our institution. Fifty-one patients were identified with chronic constipation; all were referred by other physicians. Mean age was 54 (range, 21-81) years; 59 percent were females. Average number of bowel movements per week was two (range, 0-4), and average duration of symptoms was five years (range, 1-20). Forty-three of 51 (84 percent) colonoscopies or barium enemas were normal. Thirteen of 51 (25 percent) colonic transit studies were abnormal. Twenty-six of 51 (51 percent) patients underwent defecography; 12 (46 percent) were abnormal. Thirty-seven of 51 (74 percent) underwent anal manometry; 5 (14 percent) were abnormal. One of 18 (6 percent) rectal biopsies demonstrated Hirschsprung's disease. Overall, 8 patients (16 percent) were diagnosed with outlet obstruction, 12 (24 percent) with colonic inertia, and 31 (61 percent) with constipation of unclear etiology. Overall mean cost of diagnosis was $2,752 (range, $1,150-$4,792). Fiber, cathartics, or biofeedback therapy was successful in 33 of 51 (65 percent) patients. Among the remaining 18 patients, 12 underwent surgery, of which 10 were successful. The remaining eight patients were constipated, despite treatment. CONCLUSION: A cost of $140,369 was expended on extensive diagnostic tests, from which 12 of 51 (23 percent) patients benefited. Exhaustive diagnostic evaluation of constipation is costly, and its benefits are unclear.

Colonoscopy in the elderly. Low risk, high yield.

An evaluation of the utility, morbidity, and patient tolerance of colonoscopy in elderly (> or = 70 years) patients was undertaken and compared to data for a similar group of younger patients (50-70 years) who underwent colonoscopy during the same 48 months. Data reviewed for both groups included demographics, indications for colonoscopy, effectiveness of bowel preparation, colonoscopy completion, endoscopic findings, and complications. The mean age of the entire 656-patient population was 69 +/- 10 years; 87 (25%) of the 354 elderly patients were greater than 80 years of age and the average age of the 302-member control group was 59.8 +/- 5.8 years. Indications for colonoscopy were the same in both groups and included rectal bleeding, 134 (20%); prior colorectal operation, 115 (18%); a history of adenomatous polyps, 82 (12%); guaiac-positive stools, 49 (8%); abnormal finding on barium enema, 19 (3%); and miscellaneous other gastrointestinal symptoms, 151 (23%). Screening colonoscopy was performed in 106 (16%). Colonoscopy was successfully completed to the cecum or the ileocolic anastomosis in 85% (555/656) of the entire population. Only 78% (275/354) of elderly patients had colonoscopy successfully completed compared to 93% (281/302) of their younger counterparts (P = 0.001). Elderly patients were significantly more likely to have an abnormality than younger patients (74% vs 60%, P < 0.05). Malignant colorectal neoplasia was more common in the elderly (6% vs 2%, P = 0.03); however, benign neoplasia was equally present in both age groups (30% vs 27%, P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns and prognosis of Clostridium difficile colitis.

UNLABELLED: The incidence of Clostridium difficile colitis has increased during recent years, presumably because of liberal use of broad-spectrum antibiotic regimens. METHODS: A retrospective review to determine patterns of C. difficile colitis development, morbidity, and treatment results was undertaken. During an 18-month period, 90 patients were diagnosed with C. difficile colitis by fecal toxin assays. Patient demographics, symptoms, previously administered antibiotic regimens, diagnostic evaluations, treatment modalities, morbidity, and mortality were identified, entered into a computer data base, and analyzed. RESULTS: The mean age was 58 years; males outnumbered females 1.2:1. Among 90 patients, 41 (46 percent) developed C. difficile colitis after surgical procedures. Eighty (89 percent) patients received antibiotic therapy before developing C. difficile colitis: 35 (44 percent) for documented infections and 45 (56 percent) as empiric or prophylactic therapy. Cephalosporins, penicillins, quinolones, vancomycin, and aminoglycosides were the most frequently administered antibiotic classes prior to C. difficile colitis diagnosis. Ten (11 percent) patients developed C. difficile colitis without previous antibiotic therapy. Eighty-two (91 percent) patients presented with diarrhea, while eight (9 percent) had fever only. Primary C. difficile colitis treatment for both groups included vancomycin (66 percent), metronidazole (24 percent), or both drugs (10 percent). Ten (11 percent) patients received no treatment. No patient developed toxic colitis or megacolon. Colonoscopy was performed in four (4 percent) patients; pseudomembranes were identified in one (25 percent) patient. There was one C. difficile colitis recurrence after treatment, but no C. difficile colitis-associated morbidity. Mortality (14 patients, 16 percent) was not related to C. difficile colitis, but to underlying illness. No difference in patient age, sex, previous antibiotic administration, serum albumin, total days hospitalized, duration of C. difficile colitis antibiotic therapy, C. difficile colitis treatment regimens, or mortality was identified between nonsurgical and surgical patients. The white blood cell count was significantly lower in the nonsurgical group however. Clostridium difficile colitis developed most commonly after antibiotic administration with symptoms of diarrhea, but did occur without previous antibiotic administration or diarrhea. CONCLUSION: Despite the clinical setting, C. difficile colitis had no associated morbidity and treatment was highly effective. Mortality was related to underlying medical illness, not C. difficile colitis.

Pruritus ani. Causes and concerns.

PURPOSE: The aim of this study was to determine how frequently pruritus ani (PA) is a symptom secondary to benign or malignant colon and anorectal pathology. METHODS: One hundred nine patients with PA as the only presenting symptom were prospectively evaluated over a two-year period. All patients underwent anoscopy, rigid proctoscopy, and colonoscopy and were treated for PA. Patient data were entered into a computer data base and analyzed. RESULTS: The mean age was 52.1 years; males outnumbered females 2:1. The mean duration of symptoms was 6.1 weeks. Mean coffee intake was four cups per day. Forty-five percent of patients smoked and 45 percent drank alcohol daily. Thirty-five percent had an abnormal proctosigmoidoscopy or colonoscopy. Twenty-seven (25 percent) patients had primary pruritus and 82 (75 percent) patients had coexisting colon or anorectal pathology. The PA-associated neoplasia included rectal cancer (11 percent), anal cancer (6 percent), adenomatous polyps (4 percent), and colon cancer (2 percent). Hemorrhoids (20 percent) and anal fissures (12 percent) were the most common pruritus-related anorectal diseases. Among the 23 percent of patients with PA and neoplasia, pruritic symptoms were present longer compared with those with PA and anorectal disease < 0.001 and primary pruritus (P < 0.0001). All patients with primary PA were initially treated with dietary fibers, steroid cream, and drying agents. The recurrence rate for primary pruritus was twice that for anorectal disease (P < 0.0001). CONCLUSIONS: PA responds to treatment in 89 percent of patients, while 11 percent are refractory to treatment. Symptoms suggestive of pruritus ani, especially those of long duration, should alert the surgeon to the potential for proximal colon and anorectal neoplasia.

Advanced colorectal neoplasia in the high-risk elderly patient: is surgical resection justified?

A review of the perioperative morbidity and mortality and long-term survival in elderly and high-risk patients with colorectal neoplasia was undertaken. Elderly high-risk patients with localized disease were compared with those with advanced disease. Over a five-year period, 82 high-risk (at least one major organ system disease), or elderly (age > or = 70 years) patients underwent an operation for colorectal neoplasia. Overall, 43 of 82 (52 percent) had advanced disease (obstruction, perforation, hemorrhage, or metastatic disease), while 39 of 82 (48 percent) had localized disease. The mean age of all patients was 78.2 years. Preoperative comorbid diseases included: coronary atherosclerosis, 59 (72 percent); previous myocardial infarction, 17 (21 percent); previous arrhythmia, 10 (12 percent); emphysema, 32 (39 percent); renal failure, 6 (7 percent); and cirrhosis, 3 (4 percent). At the time of surgery, 26 patients (32 percent) had metastatic disease. Six patients (7 percent) died in the perioperative period. The presence of advanced neoplasia did not significantly affect 30-day mortality. There was no difference in major morbidity between patients operated on for localized and for advanced disease. The mean actuarial 18-month survival was less for patients with advanced disease (P < 0.05). Sixty-eight patients (83 percent) are alive at a follow-up of 17.7 +/- 29 months postoperatively. The morbidity and mortality associated with resection of colorectal neoplasia in high-risk elderly patients are acceptable even in the presence of advanced disease. In select patients, resection offers the best palliation and may improve the quality of remaining life.

Pudendal neuropathy and the importance of EMG evaluation of fecal incontinence.

A prospective study was undertaken to evaluate pudendal neuropathy in fecal incontinence. Fifty-two patients (38 women and 14 men) with fecal incontinence underwent manometric and electromyographic evaluation (measurement of pudendal nerve terminal motor latency [PNTML] and sphincter muscle mapping). The average age of all patients was 54 +/- 17 years. Fifty-two percent (27/52) were found to have a pudendal neuropathy (PNTML > 2.1 milliseconds). Seventeen of these 27 patients (63 percent) had a bilateral pudendal neuropathy. Patients with a pudendal neuropathy were older than those without a neuropathy (63.7 years vs. 51.9 years; P = 0.01). Women were significantly more likely than men to have a pudendal neuropathy (P = 0.03). Nine patients had an anatomic sphincter defect identified, and six of these (67 percent) had a neuropathy; 4/6 (67 percent) had a bilateral pudendal neuropathy. In the 43 patients who did not have an anatomic sphincter defect, there was no difference in resting pressure (69 mmHg vs. 60 mmHg; P = 0.4) or maximum voluntary contraction (95 mmHg vs. 86 mmHg; P = 0.5) when patients without a neuropathy were compared with those with a neuropathy. Patients with a pudendal neuropathy had a shorter sphincter length than those without a neuropathy (3.0 cm vs. 3.9 cm; P = 0.01). Bilateral pudendal neuropathy tended to occur more frequently in women (P = 0.08) and was not associated with poorer resting pressure, maximum voluntary contraction, or shorter sphincter length. We conclude that pudendal neuropathy is a common cause of fecal incontinence, particularly in older women, and frequently occurs in association with a sphincter defect. Manometric evaluation alone is not helpful in identifying the neuropathic patient. PNTMLs should be routinely measured in the evaluation of fecal incontinence.