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Bowel Diversion Surgeries: Ileostomy, Colostomy, Ileoanal Reservoir, and Continent Ileostomy. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 4p.
This fact sheet describes bowel diversion surgeries, including ileostomy, colostomy, ileoanal reservoir, and continent ileostomy. Written in nontechnical language, the fact sheet answers common questions about these bowel diversion surgeries, including a description of the surgeries, the parts of the gastrointestinal tract affected by bowel diversion surgery, when the different types of bowel diversion surgery are used, patient selection and treatment options, and postoperative care. Bowel diversion surgery allows stool to safely leave the body when, because of disease or injury, the large intestine is removed or needs time to heal. The term bowel is used to mean any portion of the small or large intestine. The type, degree, and location of bowel damage, and personal preference, are all factors in determining which bowel diversion surgery is most appropriate. Patient are encouraged to work closely with an ostomy nurse who can help patients deal with the practical, social, and psychological issues related to bowel diversion. Readers are referred to four resource organizations for more information: the Cancer Information Service of the National Cancer Institute (www.cancer.gov/cis or 1–800–422–6237); the Crohn’s and Colitis Foundation of America (www.ccfa.org or 1–800–932–2423); the United Ostomy Associations of America, Inc. (www.uoaa.org or 1–800–826–0826); and the Wound, Ostomy, and Continence Nurses Society (www.wocn.org or 1–888–224–9626). The fact sheet briefly describes the work of the National Digestive Diseases Information Clearinghouse, which provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. 3 figures.
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Diagnosis and Management of Urinary Incontinence and Functional Fecal Incontinence (Encopresis) in Children. Gastroenterology Clinics of North America. 37(3): 731-748. September 2008.
This article about the diagnosis and management of urinary incontinence and functional fecal incontinence in children is from a special issue of Gastroenterology Clinics of North America that presents updates on disorders of the pelvic floor and anorectum. The authors note that the ability to maintain normal continence for urine and stools is not achievable in all children by a certain age. Gaining control of urinary and fecal continence is a complex process, and not all steps and factors involved are fully understood. Although normal development of anatomy and physiology are prerequisites to becoming fully continent, anatomic abnormalities—such as bladder exstrophy, epispadias, ectopic ureters, and neurogenic disturbances that can usually be recognized at birth and cause incontinence—will require specialist treatment, not only to restore continence but also to preserve renal function. The authors caution that most forms of urinary incontinence are not caused by an anatomic or physiologic abnormality and, hence, are more difficult to diagnose. Their management requires a sound knowledge of bladder and bowel function. The article covers the normal development of bladder and sphincter control, pathophysiology and classification of urinary incontinence, the epidemiology of urinary incontinence, the evaluation of children with daytime incontinence and constipation, the role of urodynamic studies, nonpharmacological treatments of urinary incontinence, pharmacologic therapy of urinary incontinence, functional fecal retention and functional retentive soiling, functional nonretentive soiling, and the treatment of fecal incontinence. 1 figure. 1 table. 99 references.
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Disorders of the Pelvic Floor and Anorectum. Gastroenterology Clinics of North America. 37(3): 1-764. September 2008.
This issue of Gastroenterology Clinics of North America presents updates on disorders of the pelvic floor and anorectum. The issue is designed to increase the interdisciplinary approach to these problems, which have heretofore often been dealt with in isolation by specialists from multiple disciplines. The issue includes current concepts on the pathophysiology of symptoms, innovative diagnostic tools, and evidence-based management strategies for pelvic floor problems. Fourteen chapters cover pelvic floor anatomy and applied physiology; manometric, sensorimotor, and neurophysiologic evaluation of anorectal function; the urodynamic evaluation of the bladder and pelvic floor; radiologic evaluation of pelvic floor disorders; dyssynergic defecation and biofeedback therapy; fecal incontinence and biofeedback therapy; surgical treatment of patients with constipation and fecal incontinence; hemorrhoids and fissure in ano; rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele; the diagnosis and management of ileal pouch dysfunction; functional and chronic anorectal and pelvic pain disorders; urinary and fecal incontinence in nursing home residents; pediatric anorectal disorders; and the diagnosis and management of urinary incontinence and functional fecal incontinence, called encopresis in children. Each chapter includes black-and-white photographs and concludes with a list of references. A detailed subject index concludes the volume.
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Ileal Pouch Dysfunction: Diagnosis and Management. Gastroenterology Clinics of North America. 37(3): 669-684. September 2008.
This article about the diagnosis and management of ileal pouch dysfunction is from a special issue of Gastroenterology Clinics of North America that presents updates on disorders of the pelvic floor and anorectum. The authors explain that restorative proctocolectomy (RPC) is the elective surgical procedure of choice for most patients who have ulcerative colitis or familial adenomatous polyposis. This major advance offers a continent alternative to permanent ileostomy in these patients. However, in about 3 to 17 percent of patients, RPC results in failure, necessitating removal of the pouch or indefinite fecal diversion. The authors review the four causes of ileal pouch failure: acute and chronic sepsis, poor function for mechanical or functional reasons, mucosal inflammation or pouchitis, and neoplastic transformation. Sepsis is the most common cause of ileal pouch dysfunction. Revisional pouch surgery can be undertaken after consideration of the feasibility of success, the magnitude of the proposed operation, the overall duration of treatment, and the patient’s wishes. Because pouch excision is accompanied by complications in more than 50 percent of patients, it must be undertaken carefully, with adequate and appropriate follow-up. 3 figures. 62 references.
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Ileal Pouch-Anal Anastomosis (IPAA) for Ulcerative Colitis: Management of Complications and Follow-Up in Primary Care. Practical Gastroenterology. 32(8): 24-36. August 2008.
This article provides primary care physicians with an overview of ileal pouch-anal anastomosis (IPAA), a procedure commonly used in patients with ulcerative colitis, a type of inflammatory bowel disease (IBD). IPAA retains anal sphincter function and avoids the need for a long-term ileostomy. This procedure is chosen in acutely unwell patients who first require conventional subtotal colectomy and ileostomy, with completion proctectomy and IPAA following an interval of at least 3 months. The authors note that most patients have an excellent functional outcome, but there is considerable overall morbidity. The most common complications include pouchitis, rectal cuff inflammation, and pelvic sepsis. Anemia from iron or vitamin B12 deficiency is also common. A significant reduction in fertility occurs in female patients. The development of cancer is rare. However, long-term endoscopic surveillance is recommended. The authors encourage health care providers to be familiar with the complications that may arise in patients with IPAA to improve the long-term functional outcome of these patients. Patient care algorithms are provided for endoscopic surveillance, for the investigation of pouch dysfunction, and for managing pouchitis. 6 figures. 17 references.
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Inflammatory Bowel Disease: Therapy. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 199-214.
This chapter on inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn’s disease, is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. The author focuses on the many different medical and surgical therapies that are available for managing IBD. Medical therapies include anti-inflammatory drugs such as sulfasalazine, olsalazine, balsalazide, and mesalamine; antibiotics; corticosteroids, including budesonide; immunosuppressive medications such as azathioprine, 6-mercaptopurine, methotrexate, cyclosporine, and tacrolimus; and biotechnology medications such as infliximab and adalimumab. Surgical therapies include colectomy with ileostomy, ileoanal pouch, or Kock pouch for ulcerative colitis, and surgical resection, strictureplasty, and placement of setons for Crohn’s disease. The author notes that many of the treatments for IBD are designed to deliver medications topically to the inflamed bowel, with the goal of achieving local efficacy with minimal systemic absorption. The author reviews the anatomical classification system used for both ulcerative colitis and Crohn’s disease, stressing that knowledge of these divisions is required in order to choose the optimal drug delivery system for each individual patient. Patient care algorithms are included. 7 figures. 3 tables. 13 references.
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Role of Biologics in Refractory Pouchitis. Practical Gastroenterology. 32(7): 29-32. July 2008.
This article explores the role of biologics in treating patients with refractory pouchitis. Ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with ulcerative colitis undergoing elective restorative proctolectomy. This procedure preserves intestinal continuity and sphincter function and removes the entire colorectal mucosa. The most frequently observed long-term complication of IPAA is acute and/or chronic inflammation of the ileal reservoir, called pouchitis. The authors begin by noting that the etiology of pouchitis is still unknown, and its pathogenesis is still poorly understood. However, chronic refractory pouchitis may be associated with an unknown form of inflammatory disease of the ileum. The article reviews the diagnostic tests that are used to confirm pouchitis, including the use of wireless capsule endoscopy (WCE), and the management of pouchitis, which is primarily aimed at reducing bacterial overgrowth and inflammation. The authors caution that patients with chronic refractory pouchitis do not tend to respond to conventional available therapies and continue to experience symptoms. They briefly report on their work to evaluate the effectiveness of infliximab in patients with chronic refractory pouchitis and extensive ileal involvement. They conclude by recommending short-term therapy with infliximab for the treatment of chronic refractory pouchitis complicated by ileitis or fistulae. 27 references.
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Urinary Diversion and Bladder Substitution. IN: Konety, B.R.; et al. Smith’s General Urology. 17th ed. Columbus, OH: McGraw Hill. 2008. pp 388-403.
This chapter about urinary diversion and bladder substitution is from an updated edition of a comprehensive textbook about urology that offers an overview of the diagnosis and treatment of diseases and disorders common to the genitourinary tract. Selected patients with lower urinary tract cancers or severe functional or anatomic abnormalities of the bladder may require urinary diversion. This diversion is most often accomplished by incorporating various intestinal segments into the urinary tract to create urinary reservoirs or conduits. The authors categorize individual methods of urinary diversion by the segment of intestine used and by whether the method provides complete continence or simply acts as a conduit carrying urine from the kidney or ureter to the skin, where the urine is collected in an appliance attached to the skin. The chapter covers preoperative counseling and preparation, the intestinal conduit urinary diversion, continent urinary diversions and bladder substitution, postoperative care, and complications, including metabolic and nutritional disorders, stomal complications, continence and urinary function concerns, pyelonephritis and renal deterioration, and calculi. The chapter is illustrated with numerous black-and-white drawings and photographs. The chapter concludes with an extensive list of references, categorized by topic. 9 figures. 1 table. 57 references.
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Complications Of IBD-Related Pouch Surgery. Gastroenterology and Hepatology. 3(9): 678-680. September 2007.
This article from a series on advances in inflammatory bowel disease (IBD) answers common clinical questions about complications of IBD-related pouch surgery. Topics include the indications for colonic resection and pouch surgery, how individual patient characteristics affect the choice of surgery, patient factors besides disease state that can be used to predict outcomes in pouch surgery, the symptoms of postsurgical pouch complications, the medical options for the management of pouchitis, treatment options for patients whose pouchitis is refractory to antibiotics, and other concerns and monitoring guidelines for the management of pouch patients. IBD patients who usually are candidates for pouch surgery include those with medically refractory ulcerative colitis (UC), steroid-dependent UC, and patients with dysplasia or cancer developed from underlying UC. Pouch surgery is contraindicated in patients with Crohn’s disease (CD) because the CD will most likely recur after the pouch surgery. Surgery-related complications can include leak, abscess, sepsis, sinus, and anastomatic stricture. 7 references.
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Diversion Colitis and Pouchitis. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 667-674.
This chapter about diversion colitis and pouchitis is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the author reviews diversion colitis, which presents with anal passage of bloody mucus, occasionally associated with crampy lower abdominal pain, in patients who have undergone creation of a diverting ileostomy or colostomy for various medical indications. The ideal therapy for symptomatic diversion colitis remains reversal of the stoma and restoration of the normal fecal stream. The author discusses pouchitis, the most common long-term complication of ileal pouch anal anastomosis, which affects as many as 25 to 47 percent of patients with ulcerative colitis. Patients are usually diagnosed with pouchitis based on symptomatology; the author calls for more accurate diagnosing with pouchoscopy and biopsy. Treatment regimens include antibiotics, probiotics, topical anti-inflammatory agents, and immunosuppressive medications; surgical therapies can include fecal diversion and ultimately pouch excision. 44 references.
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Gourmet Colon Prep. Practical Gastroenterology. 31(11): 41-42, 47-57. November 2007.
This article reviews the current diet regimens used during bowel preparation for colonoscopy and offers suggestions for dietary measures that may make the bowel preparation more tolerable and thus ultimately more successful. The authors summarize selected commercially available colonoscopy preparations and their accompanying manufacturer diet and liquid recommendations. The authors review clinical trials addressing some alternative regimens for bowel preparation. Specific topics include the clear liquid diet, the use of lactose-free, fiber-free nutritional supplements, low-residue diet options, sample menus, preparations for patients who have an ileostomy or jejunostomy, and tips for improving acceptability. The authors conclude that liberalizing the preprocedure diet may not only decrease hunger during the preparation period but can also decrease the patient’s dread of such a long period without food. Emphasizing the importance of adequate fluid intake to prevent dehydration is valuable, and providing a variety of options for the liquid diet may be helpful. 11 tables. 13 references.
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Incontinence. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. New York, NY: Informa Healthcare USA. 2007. pp 37-80.
This chapter about fecal incontinence is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors describe the etiology, pathophysiology, clinical presentation, evaluation, and treatment of fecal incontinence. They stress that fecal incontinence is a disabling and distressing condition that can severely affect quality of life. The mechanism of continence is complex and depends on factors such as sphincter function, stool consistency, delivery of colonic contents, rectal capacity and compliance, anorectal sensation, and pelvic floor anatomy. The final section of the chapter reviews surgical procedures used for fecal incontinence, including perineorrhaphy, spincteroplasty, internal sphincter repair, postanal repair, total pelvic floor repair, neosphincter operations, free muscle transplantation, gluteus maximus transposition, artificial bowel sphincter, synthetic encirclement procedures, continent colonic conduit, sacral nerve stimulation, and stoma creation. The chapter includes numerous black-and-white photographs and illustrations and concludes with an extensive list of references. 27 figures. 17 tables. 239 references.
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Management of Perianal Crohn's Disease. American Journal of Gastroenterology. 102: S85-S87. 2007.
This article outlines the management of perianal Crohn’s disease, a type of inflammatory bowel disease (IBD). Perianal complications of Crohn’s disease include anal fissures, skin tags, abscesses and fistulas, and structuring of the anal canal. Patients with these complications often need combined surgical and medical therapy. Topics include the symptoms and management of fissures, skin tags, perianal abscesses and fistulas, and anal stricture. A final section briefly considers Crohn’s disease diagnosed after the patient receives an ileal pouch-anal anastomosis procedure. The author stresses that management of perianal Crohn’s disease involves treating the underlying inflammatory process as well as addressing specific complications. 17 references.
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Managing Bowel Dysfunction. Bethesda, MD: National Institutes of Health Clinical Center. June 2007. 20 p.
This patient education fact sheet reviews the management of bowel dysfunction, defined as problems with the frequency, consistence, and/or ability to control the bowel movements. People may have trouble with their bowel movements due to many factors including medications, diseases or treatments for diseases, stress, or a change in eating or exercise patterns. The fact sheet reviews the physiology of the male and female digestive systems, normal bowel function, and the diagnosis of bowel problems with laboratory tests, radiologic or ultrasonic examination, special procedures, and fecal occult blood sampling. The fact sheet describes the causes, treatment, and prevention of bowel dysfunctions, including constipation, diarrhea, and fecal incontinence. A section considers specialized surgical procedures for bowel dysfunctions, including colostomy or ileostomy. Practical tips and strategies for everyday activities, meal planning, skin care, and exercise are provided; three sample menus are included. The fact sheet concludes with a brief glossary of relevant terms. 5 figures. 3 tables.
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Managing Pouchitis. American Journal of Gastroenterology. 102: S60-S64. 2007.
After patients receive a colectomy, the ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for restorative proctocolectomy. This article describes the recommended management of pouchitis, a common complication of IPAA. The first section reviews the indications for colectomy and then outlines the complications of IPAA therapy, including pouchitis. The reported incidence of pouchitis at 12 months after ileostomy removal is 40 percent. The author goes on to discuss the diagnostic evaluation of suspected pouchitis, the different types of pouchitis, the prevention and treatment of pouchitis, and atypical pouchitis. A final section considers irritable pouch syndrome (IPS), a form of irritable bowel syndrome (IBS). The author concludes that endoscopy is the key tool for the diagnosis of pouchitis and also sometimes for therapy, such as polypectomy and stricture dilatation. 3 figures. 31 references.
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Megacolon. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 435-448.
Megacolon is defined as abnormal massive dilation of the colon and may be congenital, toxic, or acquired. This chapter about megacolon is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors discuss Chagasic megacolon; congenital megacolon, also known as Hirschsprung disease; and idiopathic megarectum and megacolon. In each section, they cover incidence, etiology and pathology, classification, symptoms, diagnostic tests, surgical treatment, possible complications, and prognosis. Diagnostic examinations used include barium enema, anorectal manometry, rectal biopsy, colonic transit studies, and cinedefecography. Surgical treatments can include colostomy, which is particularly effective in malnourished patients with a high operative risk, premature infants, stenosis or fistulas followed by unsuccessful surgery, and in patients with colonic perforation. The authors note that prognosis is related to the severity of the megacolon and to the severity of the patient’s comorbidities. The chapter includes black-and-white photographs and illustrations and concludes with a list of references. 7 figures. 3 tables. 49 references.
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Pregnant IBD Patient: What Every Gastroenterologist Should Consider. Practical Gastroenterology. 31(2): 17-27. February 2007.
The peak age of onset for inflammatory bowel disease (IBD) coincides with the peak age for conception and pregnancy. This article reviews the gastroenterological care of women of childbearing age with IBD, focusing on the effects of IBD on fertility and pregnancy. The author considers the effects of pregnancy on a woman’s IBD activity. The author stresses that active disease, not therapy, poses the greatest risk for pregnancy. The author reviews the use of common IBD medications during pregnancy, including sulfasalazine, mesalamine, metronidazole, ciprofloxacin, rifaximin, corticosteroids, budesonide, methotrexate, infliximab, adalimumab, Loperamide, and antispasmodics. Another section considers the indications for surgery in the pregnant IBD patient. The mode of delivery should be dictated by obstetric indication and necessity, but the decision should be made with the gastroenterologist to avoid complications. Cesarean section should be performed in women with active perianal disease. Ileostomy or colostomy do not preclude vaginal delivery, but if obstetric risk is present, a cesarean section should be performed. Episiotomy should be avoided if possible. The author concludes that active disease carries risk for preterm delivery and low birth weight. Patients should be in clinical remission prior to conception and flares of the IBD during pregnancy should be treated aggressively. 2 tables. 66 references.
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Refractory Ulcerative Colitis Treatment. Gastroenterology and Hepatology. 3(1): 64-69. January 2007.
This article reviews the treatment options for refractory ulcerative colitis (UC), a type of inflammatory bowel disease (IBD) that can be a clinical challenge. The authors note that in either acute or chronic refractory UC, the disease may continue to remain active, even though the patient is on appropriate therapy. Patients must be reassessed before any new medications are added to the regimen of care. Other causes of bloody diarrhea should be eliminated, and complications should be identified before new treatment approaches are started. The authors recommend the optimization of oral 5-aminosalicylic acid (5-ASA) therapy combined with rectal 5-ASA or corticosteroid suppositories, plus corticosteroid or 5-ASA enemas of foam preparations. Oral or intravenous corticosteroids can be used, but only for the short-term. Azathioprine or 6-mercaptopurine can be useful for severe chronic refractory UC; another possibility is infliximab, which can support induction and maintenance of remission for refractory UC. The authors conclude that colectomy with ileal pouch-anal anastomosis remains a valuable option for these patients because it offers both a “cure” for the disease as well as a way to eliminate the side effects associated with the medications. 3 figures. 1 table. 40 references.
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Ulcerative Colitis. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 577-624.
Ulcerative colitis (UC) is a chronic disease of inflammation confined to the mucosa and submucosa of the large bowel. This chapter about UC, one of the inflammatory bowel diseases (IBD), is from a comprehensive text that offers chapters about each of the major colonic disorders. Each chapter is coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the authors provide an overview of UC and discuss the medical aspects of UC, including epidemiology; trends among racial and ethnic groups; age and gender; the extent and severity of disease course; risk of colon cancer in patients with UC; extra-intestinal manifestations of UC; etiology and pathogenesis; genetic and environmental factors; the role of intestinal bacteria; immunopathogenesis; psychosomatic effects; clinical features; diagnostic tests used to confirm and monitor the disease; pathologic features; differential diagnosis; medical treatment; the role of nutrition; investigational therapies; and fertility, sexual function, and pregnancy in UC. A final section reviews the surgical management of patients with UC, including indications for elective and urgent surgery, subtotal and total abdominal colectomy, total proctocolectomy without restoration, continent ileostomy, and restorative proctocolectomy. The chapter includes black-and-white illustrations and photographs and concludes with an extensive list of references. 18 figures. 12 tables. 286 references.
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Current Controversies in the Surgical Management of Crohn's Disease. IN: Jewell, D.P., et al, eds. Challenges in Inflammatory Bowel Disease: Management of Crohn's Disease. Malden, MA: Blackwell Publishing Inc. pp. 232-245.
This chapter on current controversies in the surgical management of Crohn’s disease (CD) is from a textbook that addresses some of the challenges in the understanding of ulcerative colitis (UC) and CD, collectively known as inflammatory bowel disease (IBD). In this chapter, the authors discuss pouch surgery in CD, pouch surgery in indeterminate colitis, improving preoperative decision making, anal fistula in CD, medical therapy, surgical therapy, laparoscopic surgery for CD, minimizing postsurgical recurrence, and stapled ileocolic anastomoses. The authors remind readers that Crohn’s disease is incurable and as such all therapies are palliative and must be conservative. The aim is to control the patient’s symptoms with the least risk to continence, aiming for maximal rectal conservation. However, in cases where function is poor because of severe CD, about 10 percent of patients will ultimately be better served by proctectomy and permanent ileostomy. 1 table. 115 references.
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Current Controversies in the Surgical Management of Ulcerative Colitis. IN: Jewell, D.P., et al, eds. Inflammatory Bowel Disease: Management of Ulcerative Colitis. Malden, MA: Blackwell Publishing Inc. pp. 154-166.
This chapter on current controversies in the surgical management of ulcerative colitis (UC) is from a textbook that addresses some of the challenges in the understanding of UC and Crohn’s disease (CD), collectively known as IBD. In this chapter, the authors remind readers that proctocolectomy with permanent ileostomy is curative for UC. However, researchers and clinicians have searched for surgical developments that could avoid a permanent ileostomy while still providing disease management. Colectomy with ileorectal anastomosis and restorative proctocolectomy is well accepted but controversies remain on the relative indications for these procedures. The chapter first reviews issues of emergency surgery, including fulminant colitis, colectomy with ileostomy, mucous fistula, and length of rectosigmoid stump. The chapter then considers elective surgery, including choice of operation, colectomy with ileorectal anastomosis, conventional or restorative proctocolectomy, contraindications to restorative proctocolectomy, the technical aspects of surgery, rectal dissection, pouch design, mucosectomy, the number of stages, laparoscopic surgery, salvage surgery for the failing pouch, and follow-up after restorative proctocolectomy. 106 references.
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Dietary Treatment of Gastrointestinal Diseases. IN: Buchman, A., ed. Clinical Nutrition in Gastrointestinal Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 63-76.
This chapter about the dietary treatment of gastrointestinal (GI) diseases is from a comprehensive textbook that compiles available data, clinical experience, and research on the role of nutrition in the management of patients with disorders that affect the GI tract. The author defines medical nutrition therapy (MNT) as diet modification, nutrient supplementation, nutrition support, and nutrition counseling as modes of therapy for disease. The chapter focuses on dietary modifications that are used to treat hospitalized or ambulatory patients with diseases of the mouth, esophagus, stomach, intestine, liver, and pancreas. The chapter covers modifications in consistency, including the clear liquid diet, the soft low-residue diet, mechanically altered diets, and the liquid diet following oral surgery; a diet for gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD); a diet following gastrectomy, including dietary modifications for dumping syndrome, and those for gastric bypass or gastric stapling for obesity; a diet for lactose intolerance or hypolactasia; a gluten-restricted diet for celiac disease; MNT for inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, and the role of foods or dietary patterns in the etiology of IBD; a diet for ileostomy and colostomy; a diet for short bowel syndrome; a diet for acute and chronic pancreatitis; a diet to control diarrhea; a diet for constipation and diverticulosis; and sodium and protein restricted diets for liver disease, including concerns about ascites and sodium intake, and the use of protein restriction and branched chain amino acid formulas in patients with chronic liver disease and hepatic encephalopathy. The author concludes by cautioning that these diets should be used with moderation, particularly when they do not provide all nutrients. They may exacerbate existing nutrition problems and malabsorption, altered metabolism, and increased secretory losses of nutrients. 4 tables. 95 references.
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Postoperative Complications of Ileal Pouch-Anal Anastomosis for Ulcerative Colitis. Gastroenterology and Hepatology. 1(3): 167-168, 205. October 2006.
This article offers the answers to clinical questions on the postoperative complications of ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC, a type of inflammatory bowel disease). The IPAA approach features the removal of the colon, then approximately 20 to 30 centimeters of the last segment of the small intestine (the terminal ileum) is fashioned into a J-shaped reservoir, the ileal pouch. This pouch is linked to the anus, eliminating the need for an exterior collection bag. The author discusses patient selection, the short-term complications associated with IPAA, the long-term complications that can occur after IPAA, pouchitis and why it occurs, risk factors associated with the development of long-term complications, research studies undertaken to identify patients who may be at particular risk of long-term complications, and the symptoms and treatment of pouchitis. Pouchitis, a nonspecific inflammatory condition of the ileal pouch, is the most common long-term complication. The author notes that IPAA is very beneficial and improves health-related quality of life, and it has become the surgical treatment of choice following total proctocolectomy, unless there is a contraindication.
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Quality of Life After Proctocolectomy with Illeoanal Anastomosis for Patients with Ulcerative Colitis. Journal of Clinical Gastroenterology. 40(8): 669-677. September 2006.
Ulcerative colitis, a type of inflammatory bowel disease (IBD), affects approximately 250,000 to 500,000 people in the United States, with 30 percent to 40 percent of patients requiring some form of surgical intervention during the course of their disease. This article considers quality of life issues for patients with ulcerative colitis who have undergone proctocolectomy with ileoanal anastomosis. The primary reason for proctocolectomy is to manage symptoms that are not responsive to currently-available medical therapy. Health-related quality of life (QOL) in patients with severe ulcerative colitis is so poor that, after ileal J-pouch-anal anastomosis, QOL is considered to improve in most clinical studies. However, QOL and bowel function after such surgery cannot be considered normal in all patients, because a significant number still have problems with urgency, leakage, nocturnal soiling, sexual dysfunction, and pouchitis. Some patients require conversion to a permanent ileostomy after the ileoanal anastomosis fails. 3 tables. 95 references.
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Surgery for Ulcerative Colitis. New York, NY: Crohn's and Colitis Foundation of America. 2006. 3 p.
Between 25 and 40 percent of patients with ulcerative colitis (UC), a type of inflammatory bowel disease (IBD), will require surgery when they experience severe symptoms or if medical therapy fails to adequately control their symptoms. Surgery may also be indicated if complications arise. This fact sheet reviews these indications for surgery in UC and helps readers understand what to expect during and after different surgical procedures. Complications of UC which can require emergency surgical intervention include: perforation of the colon, massive bleeding in the colon, sudden severe UC, and toxic megacolon. Surgical procedures that might be used include proctocolectomy with ileostomy, and restorative proctocolectomy. The author outlines possible complications of restorative proctocolectomy, including pouchitis, bowel obstruction, and pouch failure. Readers are encouraged to prepare for any surgical procedure by optimizing their nutritional status. In addition, the use of support groups for people with ileostomies is recommended.
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Ulcerative Colitis. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2006. 6 p.
Ulcerative colitis (UC) is a disease that causes inflammation and sores (ulcers) in the lining of the rectum and colon. Inflammation in the colon causes the colon to empty frequently, causing diarrhea. UC is a type of inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the small intestine and colon. This fact sheet describes UC and its management. Written in a question-and-answer format, the fact sheet addresses the symptoms of UC, its causes; diagnostic tests to confirm the presence of UC; treatment strategies, including medications, hospitalization, and surgery; the increased risk of colon cancer in people who have had UC; and current research studies on UC. The fact sheet outlines drugs that may be prescribed for UC, including aminosalicylates, corticosteroids, and immunomodulators. Surgical options include ileostomy and ileoanal anastomosis (continent ileostomy). A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse. 1 figure.
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Urostomy and Continent Urinary Diversion. Bethesda, MD: National Kidney and Urologic Diseases Information Clearinghouse. 2006. 6 p.
A urinary diversion is a way to release urine from the body when the person cannot urinate because the urinary system is damaged or not working. A urinary diversion may be used if a person’s bladder has been removed to stop the spread of cancer or if the bladder has nerve damage. Any problem in the bladder that blocks the flow of urine and causes it to accumulate in the ureters and kidneys may result in the need for a urinary diversion. This fact sheet reviews two types of urinary diversions: urostomies and continent urinary diversions. A urostomy requires a pouch to be worn outside the body, while a continent urinary diversion involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract. The fact sheet describes the surgical techniques used for each and the level of self-care required. Specific topics include working with an ostomy nurse, changing pouches, using a catheter, cleaning, recognizing infection, the role of diet, clothing, postoperative limitations on activities, and relationships, including sexual relations. The fact sheet refers readers to the American Urological Association at www.urologyhealth.org or 1–800–746–4282 and the Wound, Ostomy and Continence Nurses Society at www.wocn.org or 1–888–224–9626 for more information. The fact sheet also includes a brief description of the activities of the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 6 figures.
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What Are the Causes and Treatment of Ileoanal Pouch Dysfunction. IN: Jewell, D.P., et al, eds. Challenges in Inflammatory Bowel Disease: Management of Ulcerative Colitis. Malden, MA: Blackwell Publishing Inc. pp. 167-178.
Ileal pouch anal anastomosis (IPAA) is a standard approach for patients who require proctocolectomy for chronic ulcerative colitis (UC). This chapter on the causes and treatment of ileoanal pouch dysfunction is from a textbook that addresses some of the challenges in the understanding of UC and Crohn’s disease (CD), collectively known as IBD. In this chapter, the authors discuss the four major factors that determine pouch function: stool frequency, continence, ability to defecate spontaneously, and ability to defer defecation. The authors focus on the etiology and treatment of ileoanal pouch dysfunction and provide algorithms for approaching the evaluation of pouch dysfunction based on presenting symptoms. Topics include pouch dysfunction caused by increased stool frequency, stool frequency as a function of pouch construction, small-bowel motility disorders, specific infections (Crohn’s disease, pelvic sepsis, pouchitis), risk factors for pouchitis, columnar cuff disorders, evacuation disorders, pouch dysfunction due to fistula formation, pouch dysfunction due to incontinence, treatment of pouch dysfunction, infection, pouch capacity and compliance, treatment of pouchitis, the role of antibiotics, anti-inflammatory agents, nutritional agents, surgical treatment of pouchitis, natural history of pouchitis, treatment of outlet obstruction, and the treatment of fistulae. The authors conclude that diagnostic evaluation of any patient with pouch dysfunction should be based on the patient’s symptoms at presentation and a systematic, logical stepwise approach undertaken, and specific treatment instituted. 71 references.
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Effects of Estrogen With and Without Progestin on Urinary Incontinence. JAMA: Journal of the American Medical Association. 293(8): 935- 948. February 2005.
This article reports on a study undertaken to assess the effects of menopausal hormone therapy on the incidence and severity of symptoms of stress, urge, and mixed urinary incontinence (UI) in healthy postmenopausal women. The study included 27,347 postmenopausal women aged 50 to 79 years enrolled between 1993 and 1998, for whom UI symptoms were known in 23,296 participants at baseline and at 1 year. Women were randomized based on hysterectomy status to active treatment or placebo in either the estrogen plus progestin or estrogen alone trials. Results showed that menopausal hormone therapy increased the incidence of all types of UI at 1 year among women who were continent at baseline. The risk was highest for stress UI, followed by mixed UI. Among women experiencing UI at baseline, frequency worsened in both trials. Amount of UI worsened at 1 year in both trials. Women receiving menopausal hormone therapy were more likely to report that UI limited their daily activity and bothered or disturbed them. The authors conclude that conjugated equine estrogen (CEE) with or without progestin should not be prescribed for the prevention or relief of UI. 1 figure. 9 tables. 37 references.
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It's An Inside Job: How to Feel Good About Your Body. Take Charge. p 20-27. Summer 2005.
In a society that places a premium on appearances, maintaining a positive body image is no feat; it is even more challenging for individuals with inflammatory bowel disease (IBD, including ulcerative colitis and Crohn's disease). Patients with IBD may be faced with scars from surgery, prescription drug side-effects such as facial puffiness and acne, fatigue, ileostomy or ostomy bags, and the need to make frequent trips to the bathroom. This article offers these patients practical ways to feel good about their bodies, no matter what. The author cautions that coping with a chronic illness can often cause a patient to magnify any emotional issues that were already present, such as low self esteem. The article includes the experiences of five members of a California IBD support group; they share their strategies for maintaining a positive body image. The author also emphasizes the important role of support groups and the benefits that they can provide. Other topics covered include modern romance and dating, the use of acupuncture, the role of massage, volunteering to help others, and creative movement. 4 figures.
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Perianal Problems in Patients with Ulcerative Colitis. Inflammatory Bowel Disease. 11(09): 856-862. September 2005.
Perianal problems in patients with inflammatory bowel disease (IBD) are usually attributed to Crohn's disease or indeterminate colitis, but not to ulcerative colitis (UC). This article notes that although perianal problems are rarely life threatening, they represent an important aspect of the care of patients with UC. The authors describe the approach and general principles of management for conditions such as hemorrhoidal disease, anal fissure, anorectal abscess and fistulae, including perianal and recto-vaginal fistulas. The authors note that perianal disease is often associated with prolonged discomfort and chronic ill health. Simple hemorrhoidal bleeding may mimic a relapse of UC, causing significant anxiety and perhaps inappropriate treatment. A final section discusses fecal incontinence. The authors conclude that a detailed history and careful perianal examination should be performed in the evaluation of all patients with UC. Anorectal abscess or fistulas in patients with UC are associated with severe disease and high complication rates after ileal pouch anal anastomosis (IPAA). Aggressive surgical approaches in patients with UC with hemorrhoids or fissures should be avoided if possible. 1 table. 62 references.
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Chronic Ulcerative Colitis. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 533-552.
Ulcerative colitis (UC), an inflammatory, ulcerating disease of the mucosa of the large intestine of unknown cause, varies in severity from a chronic, low-grade process requiring little treatment to an acute, fulminating process requiring intensive therapy. This chapter on chronic UC is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter note that therapy varies with the severity and extent of the UC and with patient factors such as age, tolerance, and response to medication, associated systemic problems, and preference or reluctance for operation. Operation continues to have a major role in the management of UC because it may save the patient's life, eliminate cancer or the long-term risk of cancer, and abolish the large intestinal disease. The development and establishment of new, sphincter-saving procedures that improve the quality of life of patients after proctocolectomy, superior stomal care, and improved stomal appliances are important considerations that currently influence decisions regarding surgical treatment. The authors review symptoms and signs, diagnosis, medical treatment, indications for surgery, surgical treatment, proctocolectomy and ileal pouch anal canal anastomosis (IPAA), proctocolectomy and Brooke ileostomy, proctocolectomy and continent ileostomy (Kock pouch), abdominal colectomy and ileorectal anastomosis, and proctocolectomy and jejunal pouch-anal canal anastomosis. The chapter is illustrated with line drawings. 6 figures. 4 tables. 43 references.
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Diet and Diarrhea. Ostomy Quarterly. 41(2): 52. Winter 2004.
The ileoanal reservoir procedure is common for patients who must have their colon removed. The reservoir (pouch) is formed from the small intestine and provides a storage place for stool in the absence of the colon. With the colon gone, large quantities of fluid are lost with the stool. Bowel movements may be ten or more times a day. This brief article helps readers with ileoanal pouches to understand how dietary changes may help them decrease the number of bowel movements they experience each day. Some of the foods reported to help slow pouch output are yogurt, applesauce, tapioca, bananas, potatoes without the skin, and cheese. The author discusses the causes of diarrhea, the importance of replacing fluid and electrolytes lost during diarrhea, concerns about sugar consumption, the use of oral rehydration solutions, dietary fiber, potassium-rich foods, and experimenting with one's own diet (including the use of a food diary for accurate recordkeeping).
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How Do J-Pouches Work?. Ostomy Quarterly. 41(2): 49. Winter 2004.
Continent bowel diversions are made by creating internal pouches, or reservoirs. Pouches created in the pelvic area (j-pouch, pull-through) are 'reconnected' to allow the normal route of evacuation. This brief article helps readers understand how j-pouches work. The author reviews the normal physiology of the small intestine and colon to describe why the pouch is so vital (to store and concentrate stool). The author explains peristalsis (of the small intestine) and the process of elimination by gravity rather than with the muscles of the rectum. Practical toileting strategies are also provided. 1 figure.
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Impact of Urinary Incontinence of Self-Concept in Children with Spina Bifida. Journal of Urology. 171(4): 1659-1662. April 2004.
Low self-concept and self-esteem are thought to be the main predictors of psychological problems in children and adolescents. Children with spina bifida are thought to be at an increased risk for low self-concept and self-esteem given their disabilities. This article reports on a study that examined the impact of urinary continence on self-concept in children with myelomeningocele. A total of 50 patients aged 7 to 19 years old with spina bifida were evaluated using the Harner self-perception profile. There were no statistically significant differences between continent patients with spina bifida and controls. Overall, children with spina bifida rated lower in scholastic competence, social acceptance, and behavioral conduct than the controls. Girls with spina bifida scored lower in perceived athleticism, physical appearance, and global self-worth than boys with spina bifida. Continent girls were self-rated higher in social acceptance and global self-worth than incontinent girls. Continent boys were self-rated higher in scholastic competence, social acceptance, physical appearance, and behavior compared to incontinent boys. The authors conclude that urologists' efforts to promote continence are likely to have a positive effect on self-concept in boys and girls with spina bifida. 3 tables. 15 references.
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Urothelial Pathology Following Reconstructive Bladder Surgery. IN: Foster, C.S. and Ross, J.S., eds. Pathology of the Urinary Bladder. Philadelphia, PA: Saunders. 2004. pp. 233-246.
An increasing number of radical cystectomies in recent years led to a growing desire for appliance-free urinary diversions to improve quality of life and body image. Patients with orthotopic neobladders usually resume their daily living activities and occupational status and are either totally continent (85 percent) or able to manage partial incontinence with pads. This chapter, from a textbook on urinary bladder pathology, reviews urothelial pathology following reconstructive bladder surgery. The authors first review current practice in bladder substitution, then discuss orthotopic neobladder, including the anatomy of the urethra in neobladder patients and female orthotopic neobladders. The next section describes remnant urethra in the male, including incidence of secondary urethral tumor, radical surgery and orthotopic neobladder, cancer or papillary tumors after orthotopic neobladder, and urethral recurrent in heterotopic versus orthotopic urinary diversions. They go on to describe remnant urethra in the female, including the incidence of secondary urethral tumor, involvement of the bladder neck, radical surgery and orthotopic neobladder, and risk factors for urethral tumor occurrence. A final section discusses upper urinary tract after intestinal bladder substitution, including antireflux mechanisms, incidence and risk factors, and diagnosis and patient management. The chapter includes full-color illustrations. 2 figures. 7 tables. 106 references.
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