Colonoscopy in rural family practice.
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Colonoscopy↗
Biomedical subjects
J F Johanson
Publications and source records attributed to J F Johanson.
Association of hemorrhoidal disease with diarrheal disorders: potential pathogenic relationship?
UNLABELLED: Despite frequent occurrence of hemorrhoidal disease, its etiology remains controversial. Recent evidence suggests that diarrhea may represent a pathogenic risk factor. The present study examined prevalence of diarrheal disorders in elderly patients with hemorrhoidal disease to provide further insight into its pathogenic mechanisms. METHODS: Using 8.8 million Medicare patients hospitalized in the United States during 1987, the frequency distribution of all three-digit International Classification of Diseases codes was compared in patients with and without hemorrhoidal disease. A more frequent occurrence of a specific disorder in patients with hemorrhoidal disease compared with the general Medicare population suggests that this disorder may be pathophysiologically related or share common etiologic risk factors with hemorrhoidal disease. RESULTS: Strong associations were observed between hemorrhoidal disease and a number of diarrheal disorders, including ulcerative colitis, noninfectious gastroenteritis, and functional diarrhea. Hemorrhoidal disease was likewise closely associated with benign and malignant anorectal neoplasms. CONCLUSIONS: Results of this study must be interpreted with caution because epidemiologic studies cannot establish cause and effect relationships. Nevertheless, these data would seem to further support the pathogenic influence of diarrhea in development of hemorrhoidal disease.
Aged↗
Evaluation of post-ERCP pancreatitis: potential causes noted during controlled study of differing contrast media. Midwest Pancreaticobiliary Study Group.
BACKGROUND: Possible sources of post-ERCP pancreatitis were evaluated during a prospective, randomized, controlled study comparing different contrast media. METHODS: A total of 1979 patients were randomized and subdivided into groups during the study. Patients were grouped for comparison depending on the type of procedure performed during ERCP. Diagnostic patients studied with pancreatograms (Group I) were compared with other groups, specifically, those not studied with pancreatograms (Group IV). All patients had subjective and objective estimates of the difficulty in cannulation of both ducts. The incidence of postprocedural pancreatitis was compared between and within each group. RESULTS: In Group I there was a progressively higher incidence of pancreatitis with increased numbers of pancreatic duct injections. Patients with the highest (19.5%) frequency of pancreatitis received 10 or more injections into the pancreatic duct. Group I cases with difficult common bile duct cannulations had a higher frequency of post-ERCP pancreatitis (9.5%), as compared with the entire group (5.6%). CONCLUSIONS: There was a higher incidence of pancreatitis associated with increased manipulation around the papillary orifice, especially with multiple pancreatic duct injections. There was also a slightly higher incidence of post-ERCP pancreatitis in cases with difficult common bile duct cannulation. Endoscopists are encouraged to evaluate and develop safer cannulation techniques that minimize the number of injections into the pancreatic duct and enhance selective cannulation.
Catheterization↗
Quality and outcomes management in gastroenterology.
The delivery of medical care is undeniably changing. Resources are becoming increasingly scarce, and the progressive rise of health care expenditures needs to be restrained. Although the field of outcomes assessment is not well understood, it is increasingly being applied to the practice of medicine. The underlying goal of outcomes management should be to improve quality by identifying the most efficient use of finite resources and integrating these into practice guidelines. Although reduction of health care costs is important, it should be a secondary goal. Providers of health care must take an active role in outcomes research and management both in understanding and in implementing these techniques in medical practice. In doing so, it is essential that physicians maintain the proper emphasis on quality patient care.
Gastroenterology↗
Risk factors for fecal incontinence in a nursing home population.
Even though fecal incontinence is a leading cause of nursing home placement, risk factors contributing to its development have not been established. Identification of such factors may lead to prevention of incontinence and reduce the need for nursing home placement. A total of 388 residents of five nursing homes were included. Data regarding mental status, bowel habits, obstetrics history, and the presence, frequency, and severity of fecal incontinence were collected for each participant. Of the 388 nursing home residents, 46% were incontinent of feces. Incontinence was 1.5 times more common in males and in those younger than 65 years of age. In both univariate and multivariate analyses, diarrhea, dementia, restricted mobility, and male gender were independently associated with incontinence. In contrast to previous studies, constipation was not associated with fecal incontinence. If elimination of these risk factors leads to prevention of incontinence in even a few people, some elderly patients may not require institutionalization, which will result in improvement in their quality of life, not to mention a reduction in public health expenditures.
Adult↗
Epidemiology of fecal incontinence: the silent affliction.
OBJECTIVE: Fecal incontinence represents an embarrassing social problem, the magnitude of which remains largely unknown. The present study prospectively examined the prevalence and demographic distributions of fecal incontinence. METHODS: demographic data, in addition to information regarding the reason for visit, bowel habits, and the frequency, type, and severity of fecal incontinence, were collected from individuals at the time of visits to their primary care physician or gastroenterologist. RESULTS: Eight hundred and eighty-one individuals 18 yr or older were included in the analysis. The overall prevalence of fecal incontinence was 18.4%. When stratified by frequency, 2.7, 4.5, and 7.1% of participants admitted to incontinence daily, weekly, or once per month or less, respectively. Incontinence increased progressively with age and was 1.3 times more common in males than females. Only one-third of individuals with fecal incontinence had ever discussed the problem with a physician. CONCLUSIONS: The prevalence of fecal incontinence appears to be more common than previously appreciated. Moreover, only a minority with a physician. It would seem important to more actively pursue this "silent affliction" particularly in patients who do not readily volunteer this information.
Adolescent↗
To scope or not to scope: the role of endoscopy in the evaluation of AIDS-related diarrhea.
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AIDS-Related Opportunistic Infections↗
A national population-based study of incidence of colorectal cancer and age. Implications for screening in older Americans.
BACKGROUND: Population-based screening programs with flexible sigmoidoscopy have been advocated as a means to reduce the death rate from colorectal cancer. Because other studies have suggested a greater prevalence of lesions inaccessible to sigmoidoscopy in older patients, the expected yield of this procedure may differ in these subgroups. METHODS: A 100% sample of Medicare beneficiaries 65 years or older with a first known diagnosis of colorectal cancer in 1987 was studied. Tumor site was divided into rectum, distal colon (distal to splenic flexure) and proximal colon. The analysis was also stratified by sex, race, and presence or absence metastatic disease, and incidence rates at each site by 5-year age group were calculated. RESULTS: Among the 75,266 patients studied, the incidence of colorectal cancer increased from 1.59 patients/1000 in patients age 65-69 years to 3.87 patients/1000 in patients age 85 years and older. Although the incidence rates at all three sites increased, the increment was greatest for proximal tumors. The incidence trends with age also persisted in an analysis of only metastatic lesions. Moreover, incidence rates were consistently higher in men than in women and higher in whites than in blacks at all sites, though the age-related increase in incidence was consistent among all four groups. CONCLUSIONS: The proportion of tumors beyond the reach of sigmoidoscopy increased with age, as did the actual incidence of accessible lesions. These patterns were also consistent in subgroup analyses. As the age-related increase in incidence was observed for metastatic tumors at all sites in the colon, age-related differences in screening and diagnostic evaluation alone do not adequately explain the findings. These data underscore the need for further studies of the relative benefits of cancer screening and pathogenic factors in tumor development in different subgroups of the older population.
Age Factors↗
An improved approach to delivery of enteral nutrition in the intensive care unit.
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Aged↗
Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents.
OBJECTIVES: Constipation is widely believed to cause hemorrhoids. However, recent evidence questions the importance of constipation in the development of this common disorder. In the present study, the association of hemorrhoids with constipation and other potential risk factors was examined. METHODS: The analysis consisted of 325 consecutive patients who underwent proctoscopy at the Milwaukee VA Medical Center during 1989. Each participant was questioned regarding hemorrhoid symptoms, bowel habits, and associated medical conditions. At the time of proctoscopy, the presence or absence of hemorrhoids was recorded. RESULTS: Hemorrhoids were identified in 168 subjects; the remaining 157 served as controls. No significant association was observed between constipation and hemorrhoids. Increasing age, cirrhosis, and varicose veins likewise were not associated with hemorrhoids. In contrast, the subjective complaint of diarrhea [odds ratio 2.1; 95% confidence limits (CL) 1.2-3.7] and obesity (odds ratio 1.7; 95% CL 1.1-2.7) were significantly associated with the presence of hemorrhoids. CONCLUSION: The results of this analysis suggest that diarrhea but not constipation may represent a risk factor for the development of hemorrhoids.
Case-Control Studies↗
Eosinophilic ascites without eosinophilia: a unique presentation of serosal eosinophilic gastroenteritis.
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Ascites↗
Association of constipation with neurologic diseases.
To investigate possible etiologic influences on the development of constipation, the present study examines the concordant occurrence of constipation with other diseases. Using 8.8 million Medicare patients hospitalized in the United States during 1987, the frequency distribution of all three-digit International Classification of Diseases (ICD) codes was compared in constipated patients and patients without constipation. Most associations and the closest associations were observed between constipation and neurologic diseases, the majority of which resulted from damage to the central nervous system. Associations between constipation and disorders of the spine also involved neuronal damage. The influence of potential confounding factors such as immobility or pain on the development of constipation was assessed and found to be minimal. The frequent association of constipation with disorders involving neuronal malfunction suggests that disruption of the neural modulation of colonic motility may play an important role in the development of constipation.
Aged↗
Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy.
Despite an abundance of nonsurgical hemorrhoid therapies, none has been consistently more efficacious. By combining data from multiple clinical trials in a meta-analysis, the present study compared the efficacy and complications of infrared coagulation, injection sclerotherapy, and rubber band ligation to determine the optimal nonoperative hemorrhoid treatment. All published clinical trials comparing the three methods were identified by computer search and review of appropriate English language journals. Five trials studying 863 patients satisfied all inclusion criteria. Results demonstrated that similar numbers of patients were asymptomatic 12 months after treatment, regardless of initial therapy. However, significantly fewer patients undergoing rubber band ligation required additional treatment because symptoms had recurred. Although rubber band ligation demonstrated greater long-term efficacy, it was associated with a significantly higher incidence of posttreatment pain. In contrast, infrared coagulation was associated with both fewer and less severe complications. Thus, when all factors are considered, infrared coagulation may in fact be the optimal nonoperative hemorrhoid treatment.
Hemorrhoids↗
Segmental distribution of colonic neuropeptides in Hirschsprung's disease.
Despite continued research, the pathophysiologic mechanism responsible for functional obstruction in the aganglionic segment of bowel in Hirschsprung's disease remains controversial. Narrowing of the affected segment is thought by many investigators to be the result of loss of intrinsic inhibitory innervation. For this hypothesis to be consistent, inhibitory neuropeptides should be present in the dilating, transitional segment of bowel. In order to quantitate reported changes in peptidergic nerve staining in Hirschsprung's disease, we measured concentrations of five neuropeptides (vasoactive intestinal peptide, peptide histidine-methionine, met5-enkephalin, substance P and bombesin-like immunoreactivity) by radioimmunoassay in the affected segments of bowel from six patients with Hirschsprung's disease. Tissue extracts were prepared using gut obtained at surgery from the: (1) constricted, aganglionic segment, (2) dilating, aganglionic transitional segment and (3) dilated, proximal ganglionic segment. Concentrations of vasoactive intestinal peptide, peptide histidine-methionine, substance P and met5-enkephalin were significantly reduced in both the muscularis externa and the mucosal-submucosal layers from the constricted aganglionic segment. By contrast, concentrations of the candidate inhibitory neuropeptides, vasoactive intestinal peptide and peptide histidine-methionine, were minimally reduced in the dilating, aganglionic transitional segment. These results are consistent with the hypothesis that constriction of the aganglionic segment is due to loss of intrinsic inhibitory innervation. Concentrations of bombesin-like immunoreactivity were similar in the three segments of human gut, suggesting the presence of this immunoreactive neuropeptide in extrinsic nerve fibers.
Bombesin↗
Temporal changes in the occurrence of hemorrhoids in the United States and England.
Although numerous etiologic risk factors have been proposed, the pathogenesis of hemorrhoids remains unknown. The present investigation assesses the temporal distribution of hemorrhoids as depicted by physician visits, hospital discharges, and surgical procedures to provide further insight into potential etiologic risk factors. The analysis was based on five data sources: from the United States, the National Disease and Therapeutic Index (NDTI), the National Hospital Discharge Survey (NHDS), and the Commission on Professional Hospital Activities (CPHA); from England and Wales, the Morbidity Statistics from General Practice (MSGP) and the Hospital In-patient Enquiry (HIPE). Results demonstrated a consistent decline in all data sources from the United States. The decrease occurred in males and females similarly and was most striking in those aged 45-64 years. Physician visits and hospital discharges for hemorrhoids in England and Wales likewise declined although the decrease was not as dramatic. The consistency of the temporal distributions among the two countries, as well as among the different sources, suggests that the observed decline may, in fact, reflect an overall decrease in the occurrence of hemorrhoidal disease.
Adolescent↗
Efficient management of diarrhea in the acquired immunodeficiency syndrome (AIDS). A medical decision analysis.
STUDY OBJECTIVE: To compare the efficacy and cost effectiveness of alternative strategies for the evaluation and medical management of diarrhea in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: Medical decision analysis using a decision tree. METHODS: Three management strategies were compared: full evaluation, which included stool culture, ova and parasite examination, stain for protozoa, blood cultures, esophagogastroduodenoscopy with biopsy, and colonoscopy with biopsy; limited evaluation, which included stool culture, ova and parasite examination, stool stain for protozoa, and blood cultures; and minimal evaluation, which included only a stool culture. Treatment was based on the outcome of the diagnostic workup. Patients without a specific diagnosis were treated symptomatically with diphenoxylate hydrochloride. Nonrespondents to initial symptomatic treatment and patients with recurrent diarrhea after specific therapy were given the full evaluation. Average probabilities of diagnostic and therapeutic success were calculated from previous reports. Costs were compiled based on diagnostic and therapeutic expenditures. MEASUREMENTS AND MAIN RESULTS: Under baseline assumptions, the remission rates for diarrhea were 75.2%, 74.8%, and 74.8% in patients undergoing the full, limited, and minimal evaluations, respectively. The respective costs of the three strategies were $5419, $1997, and $1700 per patient in remission. A sensitivity analysis showed that the differences in efficacy and cost among the full, limited, and minimal strategies remained unchanged over a broad range of possible rates of diagnostic or therapeutic success. CONCLUSIONS: The minimal evaluation in all patients, with the full evaluation reserved only for nonrespondents to symptomatic treatment, is efficacious and is the most cost-effective strategy for managing AIDS-related diarrhea.
Acquired Immunodeficiency Syndrome↗
The prevalence of hemorrhoids and chronic constipation. An epidemiologic study.
Hemorrhoids are a frequently occurring disorder widely believed to be caused by chronic constipation. In the present study, the epidemiology of hemorrhoids was evaluated and compared with the epidemiology of constipation. The analysis was based on 4 data sources: from the United States, the National Health Interview Survey, the National Hospital Discharge Survey, and the National Disease and Therapeutic Index; from England and Wales, the Morbidity Statistics from General Practice. Results showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, a peak in prevalence was noted from age 45-65 yr, with a subsequent decrease after age 65 yr. The development of hemorrhoids before age 20 yr was unusual. Whites were affected more frequently than blacks, and increased prevalence rates were associated with higher socioeconomic status. This was in contrast to the epidemiology of constipation, which demonstrated an exponential increase in prevalence after age 65 yr and was more common in blacks and in families with low incomes or low social status. The data presented illustrate differences in the epidemiologic behavior of hemorrhoids and constipation, calling the presumption of causality between constipation and hemorrhoids into question.
Adult↗
Clinical epidemiology of chronic constipation.
Using health statistics from the United States and England and Wales, we review the epidemiology of constipation and possible etiologies of this disorder as suggested by its epidemiologic distribution. The analysis revealed that constipation is one of the most common chronic digestive disorders in the United States, affecting one of every 50 people. The occurrence of constipation increased with advancing age, showing an exponential increase in prevalence after the age of 65. The age distribution of constipation was similar in both sexes, but overall constipation was three times more common in women than in men. Constipation more frequently affected nonwhites than whites, and people from families with low income or less formal education. The characteristic epidemiologic pattern of constipation suggests the influence of environmental factors. Insufficient dietary fiber is widely believed to be a major cause of constipation, yet it is difficult to devise a mechanism by which dietary fiber alone could produce the marked differences observed between gender, race, and socioeconomic status. Recent evidence suggests that disruption of neural regulation of colonic motility plays an important role in the development of chronic constipation. This loss of neural regulation may result from mechanical damage to the pelvic nerves due to childbirth or pelvic surgery, exposure to environmental toxins (e.g., organochlorine insecticides or heavy metals), or possibly exposure to an infectious agent. Other environmental factors that may play a role in the pathogenesis of chronic constipation have not yet been elucidated. Consequently, studies examining the epidemiology of chronic constipation are important for providing insight into potential environmental risk factors relevant to the etiology of this disorder.
Age Factors↗