Biomedical subjects

Arnold Wald

Publications and source records attributed to Arnold Wald.

8 recordsLinked to original sources

PubMed2003

Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy.

Constipation, diarrhea, and symptomatic hemorrhoids are disorders common in the general population, particularly in women. These conditions, if mild, often are self-treated with various home remedies or nonprescription preparations. Few of these patients, moreover, are referred to gastroenterologists, as primary care providers generally are confident managing these conditions, unless they are severe, refractory to conventional management, or require additional diagnostic studies.

Constipation↗

PubMed2003

Neurotrophin-3 improves functional constipation.

OBJECTIVE: Neurotrophin-3 (NT-3) is a neurotrophic factor involved in the growth, development, and function of the nervous system. In preliminary studies, s.c. recombinant methionyl-human NT-3 enhanced transit throughout the GI tract and increased stool frequency in normal and constipated subjects. Our aim was to assess 1) the dose-related effects of NT-3 on bowel function, colon transit, and symptoms of chronic constipation, and 2) its safety. METHODS: This was a double-blind, randomized, placebo-controlled phase II study. A total of 107 patients with a diagnosis of functional constipation (Rome II criteria) were randomized to receive 4 wk of double blind, s.c. injections of either placebo, 3 mg, or 9 mg NT-3 once per week (qW) or three times per week (TTW); or 9 mg NT-3 TTW for 1 wk, then qW. The primary endpoint was the change in number of spontaneous, complete bowel movements per week. Colon transit was assessed before and at end of treatment. RESULTS: Compared with placebo, patients who received 9 mg NT-3 TTW showed significant increases in frequency of spontaneous, complete bowel movements and total bowel movements, as well as dose-related softening of stool and improved ease of passage. The number of days per week without a bowel movement also decreased, colon transit improved, as did constipation-related symptoms. Weekly dosing was ineffective. Transient injection-site reactions, seen in one third of patients receiving NT-3 TTW, were the most frequent adverse event. CONCLUSIONS: NT-3, administered TTW, increased stool frequency, enhanced colon transit, and improved symptoms of chronic constipation. NT-3 seems to be a novel, safe, and effective agent for the treatment of functional constipation.

Adolescent↗

PubMed2002

Slow Transit Constipation.

The diagnosis of slow transit functional constipation is based upon diagnostic testing of patients with idiopathic constipation who responded poorly to conservative measures such as fiber supplements, fluids, and stimulant laxatives. These tests include barium enema or colonoscopy, colonic transit of radio-opaque markers, anorectal manometry, and expulsion of a water-filled balloon. Plain abdominal films can identify megacolon, which can be further characterized by barium or gastrografin studies. Colonic transit of radio-opaque markers identifies patients with slow transit with stasis of markers in the proximal colon. However, anorectal function should be characterized to exclude outlet dysfunction, which may coexist with colonic inertia. Because slow colonic transit is defined by studies during which patients consume a high-fiber diet, fiber supplements are generally not effective, nor are osmotic laxatives that consist of unabsorbed sugars. Stimulant laxatives are considered first-line therapy, although studies often show a diminished colonic motor response to such agents. There is no evidence to suggest that chronic use of such laxatives is harmful if they are used two to three times per week. Polyethylene glycol with or without electrolytes may be useful in a minority of patients, often combined with misoprostol. I prefer to start with misoprostol 200 mg every other morning and increase to tolerance or efficacy. I see no advantage in prescribing misoprostol on a TID or QID basis or even daily because it increases cramping unnecessarily. This drug is not acceptable in young women who wish to become pregnant. An alternative may be colchicine, which is reported to be effective when given as 0.6 mg TID. Long-term efficacy has not been studied. Finally, biofeedback is a risk-free approach that has been reported as effective in approximately 60% of patients with slow transit constipation in the absence of outlet dysfunction. Although difficult to understand conceptually, it is worth attempting and certainly so in patients with associated pelvic floor dyssynergia. Subtotal colectomy with ileorectal anastomosis is often effective in those patients with colonic inertia, normal anorectal function, and lack of evidence of generalized intestinal dysmotility. However, morbidity is significant both early and late in the disease process and must be balanced against current disability. Ileostomy is preferred in the presence of anorectal dysfunction or with associated impairment of continence mechanisms. Similar considerations apply to the patient with disabling functional megacolon. An alternative approach is ileostomy with disconnection of the colon, which is more acceptable to some patients who may hope for future reconnection if recovery occurs. An additional alternative approach for patients with colonic inertia or megacolon who are not good surgical risks is tube cecostomy (or in children, use of the appendix as a conduit to the cecum). This permits either decompression (in megacolon) or antegrade enemas (in colonic inertia). Our surgeons are not enthusiastic about this approach, and I have little experience with it. In general, the use of partial resections of the colon should be discouraged, because marker studies do not define pathophysiology in patients with slow transit constipation.

Journal Article↗

PubMed2002

Functional bowel disorders in inflammatory bowel disease.

Patients with IBD in remission often have ongoing gastrointestinal symptoms that are related to active inflammation. It is now apparent that functional gastrointestinal disorders may overlap with IBD and increase morbidity and diminish the quality of life of patients. Recognition and treatment of functional symptoms that may be the result of IBD are crucial in the appropriate medical management of these patients.

Gastrointestinal Diseases↗

PubMed2002

Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease significantly affects a patient's quality of life (QOL). Laparoscopic fundoplication offers an alternative to medical therapy, but few studies have compared outcomes. Our objective was to examine QOL scores in gastroesophageal reflux disease patients treated medically and surgically. STUDY DESIGN: We undertook a retrospective analysis of patients undergoing surgical or medical treatment for gastroesophageal reflux disease over a 1-year period (August 1997 to August 1998). Followup QOL was measured using the Short-Form 36, and heartburn severity was measured using the Health Related Quality of Life scale (a disease-specific instrument with a best score of 0 and a worst score of 45). RESULTS: Laparoscopic fundoplication was undertaken in 120 patients with a median age of 47 years (range 17 to 80 years). The medical cohort included 51 patients selected from the gastroenterology clinic with a median age of 48 years (range 17 to 82 years). Duration of heartburn was not significantly different, with 40 (78.4%) of the 51 medical and 98 (81.7%) of the 120 surgical patients having had symptoms for longer than 12 months. There were no operative deaths. There were 12 complications (esophageal perforation 1, pneumothorax 2, pneumonia 1, pulmonary embolus 3, other/miscellaneous 5). Mean length of stay was 1.6 days, time to oral intake 1.2 days, and return to normal activity 4.2 weeks. Routine followup was available in 118 surgical and 47 medical patients. The medical cohort had increased (p < 0.05) symptoms of heartburn (43% versus 19%), waterbrash (26% versus 8%), and regurgitation (30% versus 8%) and greater requirement for proton pump inhibitors (74% versus 19%) and propulsid (19% versus 3%) over the surgical group. Detailed outcomes were available in 101 surgical and 37 medical patients. Mean (+/-SE) Health Related Quality of Life scores were better (p < 0.05) in the surgical group (4+/-0.6 versus 21+/-1.4). More of the medical patients were dissatisfied (21.6% versus 5.9%). Short-Form 36 scores at followup were better (p < 0.05) in six of eight domains for surgical patients. CONCLUSION: Heartburn scores and global QOL scores were superior after laparoscopic fundoplication compared with medical management in this patient population. Laparoscopic fundoplication should be considered for patients who are dissatisfied with medical treatment.

Adolescent↗

PubMed2002

Psychotropic agents in irritable bowel syndrome.

The use of antidepressants to treat patients with irritable bowel syndrome (IBS) has been extended in recent years because of their possible neuromodulatory and analgesic effects, generally in doses that do not have antidepressant effects. There seems to be sufficient evidence to support the recommendation that psychotropic agents may be effective in two clinical scenarios that are not mutually exclusive. The first is in patients with IBS who have pain and related symptoms that are unresponsive to medical therapy. The second is in patients with IBS who have concomitant psychologic dysfunction. This article reviews the evidence to support these recommendations and guidelines, which may be used to optimize medical management in these patients.

Antidepressive Agents↗

PubMed2001

Outlet Dysfunction Constipation.

The diagnosis of outlet dysfunction constipation in patients with idiopathic constipation that responds poorly or not at all to conservative measures, such as fiber supplements, fluids, and stimulant laxatives, is based upon diagnostic testing. These tests include colonic transit of radio-opaque markers, anorectal manometry or electromyography, barium defecography, and expulsion of a water-filled balloon. The literature suggests that conditions such as pelvic floor dyssynergia exist but may be over-diagnosed as a laboratory artifact. In our laboratory, we screen patients with balloon expulsion studies, and then test for dyssynergia only if the result of the balloon expulsion test is abnormal. In my opinion, anal sphincter electromyogram and manometry are equivalent in establishing the diagnosis. Barium defecography is helpful in making a diagnosis of a rectocele, but I prefer to document that vaginal pressure on the rectocele significantly improves rectal evacuation. Manometry also helps to establish the presence of megarectum, hypotonia, and weak expulsion efforts. Conceptually, biofeedback training, which incorporates simulated defecation, is the most logical approach to pelvic floor dyssynergia. It incurs no risk and benefits 60% to 80% of patients. The drawbacks are the time-intensive nature of the therapy and the short-term costs, which are offset if there is sustained benefit. There is no evidence that biofeedback is helpful in children with constipation. Habit training has established benefits, but recurrences are frequent and long-term reinforcement is helpful to maintain success. Laxatives and enemas are adjunctive therapies in both habit training and biofeedback. Surgery is effective in those uncommon patients with physiologically significant rectoceles, but surgical division of the puborectalis muscle is risky and unproven. Likewise, botulinum toxin injection into the puborectalis is unproven, but the effects are rarely permanent should incontinence occur. Diagnostic measures and therapeutic success are enhanced when patients are seen in centers experienced with the evaluation of these disorders.

Journal Article↗

PubMedDate not supplied

Is chronic use of stimulant laxatives harmful to the colon?

Although stimulant laxatives cause structural damage to surface epithelial cells that is of uncertain functional significance, there is no convincing evidence that their chronic use causes structural or functional impairment of enteric nerves or intestinal smooth muscle. Nor are there reliable data to link chronic use of stimulant laxatives to colorectal cancer and other tumors. The risks of laxative abuse have been overemphasized, and this has minimized their rational use by physicians. Stimulant laxatives may be used chronically when patients fail to respond adequately to bulk or osmotic laxatives alone. These can be combined with bulk or osmotic laxatives in sufficient amounts to soften the stool, or they can be used alone, according to clinical circumstances. The dose of such agents should be titrated to effect. Bisacodyl may be used if anthraquinone laxatives are unsatisfactory.

Anthraquinones↗