Prevalence of Fructose Malabsorption in Patients With Irritable Bowel Syndrome After Excluding Small Intestinal Bacterial Overgrowth

BACKGROUND/AIMS: Fructose malabsorption (FM) mimics symptoms of irritable bowel syndrome (IBS), and its prevalence has increased. Diagnosing FM in IBS is challenging because of its overlap with small intestinal bacterial overgrowth (SIBO). We assessed the prevalence of FM by comparing patients with IBS with asymptomatic control individuals after excluding SIBO using the glucose hydrogen breath test (HBT). METHODS: Patients diagnosed with IBS and asymptomatic control individuals were enrolled prospectively. Dietary habits were assessed with the Food Frequency Questionnaire. After excluding SIBO, participants underwent HBTs with both 15 g and 25 g of fructose. RESULTS: Thirty-five patients with IBS and 35 age- and sex-matched asymptomatic control individuals were enrolled. The 15-g fructose HBT yielded positive results in 7 of the 35 (20.0%) patients with IBS and in 2 of 35 (5.7%) controls (P = 0.070). The 25-g fructose HBT was positive in 16 of the 35 (45.7%) patients with IBS and in 8 of the 35 (22.9%) controls (P = 0.040). Analysis of the Food Frequency Questionnaire responses showed no significant differences between the 2 groups in dietary intake, although patients with IBS showed a significantly higher mean fiber intake than controls (21.24 ± 11.35 g vs 15.87 ± 7.07 g, respectively, P = 0.040). CONCLUSIONS: The 25-g fructose HBT identified FM in a significantly higher percentage of SIBO-negative patients with IBS than in asymptomatic control individuals, suggesting that FM may correlate with IBS. Education regarding dietary control of foods containing fructose may be useful for the management of patients with IBS.

Metastatic uterine cancer looking as cervical fibroid in recurrent breast cancer woman: a case report

Metastasis to the female genital tract from extragenital primary cancer is uncommon. In this case, a 46-year-old woman was diagnosed with invasive lobular carcinoma of the left breast in 2011. She had left breast conserving surgery, chemotherapy, radiation, and hormonal therapy (gosereline and tamoxifen). However, she developed menorrhagia after interruption of hormonal therapy and incidentally, the ultrasonogram of her pelvis showed a solid, large mass in the cervix. It looked like leiomyoma. Because of massive vaginal bleeding requiring multiple blood transfusions, she underwent total hysterectomy with bilateral salpingo-oophorectomy. Unexpectedly, however, histopathological examination revealed metastatic carcinoma, consistent with breast origin.The metastatic tumor involved the uterine corpus with spreading to the endocervix, left ovary, and multiple lymphovascular invasion was present. We described the rarity and risk of metastatic uterine cancer in patient with history of malignant tumor treatment.

Spontaneous uterine rupture due to placenta percreta in the second trimester of pregnancy: a case report / 고신대학교의과대학학술지

A 32-year-old multiparous woman (gravida 2, para 2) with a history of previous cesarean section had acute abdominal pain and collapsed at 21 weeks of gestation. Exploratory laparotomy was performed because of the patient's worsening condition; ultrasound examination results were suggestive of massive hemoperitoneum, and fetus in vertex presentation with bradycardia. Uterine rupture between the left lower segment and borderline of the cervix in the anterior wall with active bleeding was confirmed. An uncomplicated classical cesarean section was performed, but the fetus was stillborn due to preterm birth. Hysterectomy was performed after the cesarean section. The patient was admitted to intensive care units for 3 days and was discharged in 12 days following delivery. Placenta percreta at the anterior lower segment of the uterus was confirmed in the pathology report.

Electrical Stimulation Therapy in Chronic Functional Constipation: Five Years' Experience in Patients Refractory to Biofeedback Therapy and With Rectal Hyposensitivity

BACKGROUND/AIMS: Biofeedback therapy (BFT) can be unsuccessful in constipated patients, even those with pelvic floor dysfunction. Electrical stimulation therapy (EST) has been introduced as a novel therapeutic modality in patients with chronic constipation, especially those who have rectal hyposensitivity. We evaluated the efficacy of EST based on five years' clinical experience. METHODS: From January 2002 to February 2007, 159 patients underwent EST. After exclusion of 12 drop-outs, 147 (M:F = 61:86, 49 +/- 17 years) finished all treatment sessions. Among them, 88 (M:F = 29:59, 49 +/- 17 years) were refractory to BFT without rectal hyposensitivity (RH), and 59 (M:F = 32:27, 54 +/- 17 years) were those with RH. RESULTS: The overall response to EST was 59.2% (87/147) by per-protocol analysis. In the EST-responsive group, overall satisfaction improved significantly (from 7.3 +/- 3.0 to 4.3 +/- 2.5, P < 0.05). Subgroup analysis showed that the response rate was 64.8% (57/88) in patients refractory to BFT without RH, and 50.8% (30/59) in those with RH. CONCLUSIONS: EST may have additional therapeutic efficacy in patients who are refractory to BFT. EST may also be effective in patients with RH, including restoration of rectal sensation. Therefore, EST could be considered as an alternative choice in patients refractory to BFT and with or without RH.

Characteristics of Korean Patients with Constipation Who Visited a Tertiary Referral Center / 대한내과학회지

BACKGROUND/AIMS: Korean patients with constipation have differences, both among themselves and as compared to other populations, with regard to race, diet, and cultural factors and are expected to have different characteristics to those of western patients, but few studies have been conducted in this regard. We evaluated the epidemiological and physiological characteristics of patients with constipation who visited a tertiary referral center. METHODS: A total of 338 patients with constipation were included. They completed a questionnaire and took physiological tests such as defecography, colon transit time, and anorectal manometry. We classified the types of constipation according to the physiological tests and analyzed the results. RESULTS: The mean age of the study patients was 53.8 +/- 16.3 years and 42.3% of the patients were > or = 60 years old. Patients who had tried folk remedies reached 64.3%. Among the self-reported patients with constipation, 89.1% satisfied the Rome III criteria for constipation. However, 84% of the patients who did not satisfy the criteria showed abnormal results on the physiological tests. Patients with normal transit constipation, slow transit constipation, and dyssynergic defecation were 21%, 27%, and 29% of the all patients, respectively. Rectal hyposensitivity was found in 16.9% of patients and 25% of them revealed anatomic abnormalities on defecography. CONCLUSIONS: Korean patients with constipation have a tendency to delay an accurate diagnosis and treatment and to use folk remedies. As physiological tests for patients with constipation who visited a tertiary hospital showed a relatively high rate of abnormal results, such as dyssynergic defecation and anatomic problems, active physiological evaluations should be considered for such patients.

Effect of Biofeedback Therapy in Constipation According to Rectal Sensation

BACKGROUND/AIMS: The pathophysiologic mechanism of rectal hyposensitivity (RH) is not well documented, and the significance of RH in biofeedback therapy (BFT) has not been evaluated. Thus, we aimed to assess the effect of BFT in constipated patients according to the presence of RH. METHODS: Five hundred and ninety constipated patients (238 males and 352 females) underwent anorectal physiologic assessments. Of these, anorectal manometry was performed before and after BFT in 244 patients (63 RH and 181 non-RH patients). RESULTS: The success rate of BFT was 56% in the RH and 61% in the non-RH group (p=0.604). The measurements of resting pressure, squeezing pressure, desire to defecate volume, urge to defecate volume, and maximum volume were decreased after BFT in the RH group (p<0.05), whereas only resting and squeezing pressures were decreased in the non-RH group (p<0.05). Among the RH group, individuals who responded to BFT showed decreased resting pressure, squeezing pressure, desire to defecate, urge to defecate, and maximum volume and increased balloon expulsion rate; among those who did not respond to BFT, only desire to defecate volume was improved. CONCLUSIONS: In constipated patients with RH, changes of anorectal manometric findings differed in comparison to patients without RH. The responses to BFT showed both anorectal muscle relaxation and restoration of rectal sensation.

Burden of Ischemic Stroke in Korea: Analysis of Disability-Adjusted Life Years Lost

BACKGROUND AND PURPOSE: Disability-adjusted life years (DALY), incorporating both disability and mortality, has been widely employed to measure regional and global burdens of stroke. Thus far, the DALY lost to stroke in a population has been estimated using only the crude population-level data; no previous study has incorporated refined data from stroke registries. The aim of this study was to integrate the stroke registry data and the population-level incidence data to project the nationwide DALY lost to ischemic stroke. METHODS: From the data of two large ischemic stroke registries, we derived an average DALY lost due to ischemic stroke for each of the following age groups: or =85 years. The nationwide ischemic stroke incidence for each age group was extracted from a cardiovascular and cerebrovascular surveillance study that analyzed the 2004 Korean Health Insurance database. RESULTS: The average DALY lost due to ischemic stroke for the age groups or =85 years was 5.07, 4.63, 4.35, 3.88, 2.88, and 1.73, respectively. By multiplying the incidence and the average DALY lost, the nationwide DALY lost was determined to be 9,952 for those or =85 years, respectively. The projected nationwide DALY lost due to 64,688 ischemic strokes in 2004 was 234,399 (121,482 for men and 113,244 for women), and the DALY lost per 100,000 person-years was 483 (500 for men and 469 for women). CONCLUSIONS: Incidence data from a population study and DALY values derived from stroke registries can be integrated to provide a more refined projection of the nationwide burden of ischemic stroke. In Korea, more than 230,000 years of healthy life are being lost annually due to ischemic stroke, and hence prompt action is imperative.

Clinical Characteristics of Constipation with Hypothyroidism

BACKGROUND/AIMS: Constipation is a well-recognized gastrointestinal symptom in patients with untreated hypothyroidism. Although thyroid function tests are recommended to exclude hypothyroidism in patients with constipation, there have been no reports to determine the causal relationship between thyroid function and constipation. The aim of this study was to determine the prevalence of hypothyroidism in constipated patients and the clinical features of constipation associated with hypothyroidism. METHODS: A total of 1,481 constipated patients were included. These patients were divided into overt hypothyroidism, subclinical hypothyroidism, and normal thyroid function groups based on thyroid function tests. We reviewed the clinical presentation, anorectal function, colonic transit time, defecographic findings, and response to biofeedback therapy. RESULTS: The prevalence of overt and subclinical hypothyroidism was 0.41% (men, 0.36%; women, 0.53%) and 1.76% (men, 1.28%; women 2.03%), respectively. There were no differences in total or segmental colonic transit times and subtypes of constipation among the normal thyroid function (n=54), overt hypothyroidism (n=4), and subclinical hypothyroidism groups (n=21). On anorectal manometry, the prevalence of dyssynergic defecation did not differ between the three groups. Rectal hyposensitivity was more frequent in the overt hypothyroidism group (overt hypothyroidism group, 50.0%; subclinical hypothyroidism group, 19.0%; normal thyroid function group, 20.4%) without statistical significance (P=0.372). CONCLUSIONS: The prevalence of overt and subclinical hypothyroidism in constipated patients was very low. The colonic transit time is not affected by thyroid function.

Clinical Characteristics of Constipation with Hypothyroidism

BACKGROUND/AIMS: Constipation is a well-recognized gastrointestinal symptom in patients with untreated hypothyroidism. Although thyroid function tests are recommended to exclude hypothyroidism in patients with constipation, there have been no reports to determine the causal relationship between thyroid function and constipation. The aim of this study was to determine the prevalence of hypothyroidism in constipated patients and the clinical features of constipation associated with hypothyroidism. METHODS: A total of 1,481 constipated patients were included. These patients were divided into overt hypothyroidism, subclinical hypothyroidism, and normal thyroid function groups based on thyroid function tests. We reviewed the clinical presentation, anorectal function, colonic transit time, defecographic findings, and response to biofeedback therapy. RESULTS: The prevalence of overt and subclinical hypothyroidism was 0.41% (men, 0.36%; women, 0.53%) and 1.76% (men, 1.28%; women 2.03%), respectively. There were no differences in total or segmental colonic transit times and subtypes of constipation among the normal thyroid function (n=54), overt hypothyroidism (n=4), and subclinical hypothyroidism groups (n=21). On anorectal manometry, the prevalence of dyssynergic defecation did not differ between the three groups. Rectal hyposensitivity was more frequent in the overt hypothyroidism group (overt hypothyroidism group, 50.0%; subclinical hypothyroidism group, 19.0%; normal thyroid function group, 20.4%) without statistical significance (P=0.372). CONCLUSIONS: The prevalence of overt and subclinical hypothyroidism in constipated patients was very low. The colonic transit time is not affected by thyroid function.

Intravenous Recombinant Tissue Plasminogen Activator Thrombolysis in a Patient with Acute Ischemic Stroke Secondary to Aortic Dissection

BACKGROUND: Acute ischemic stroke secondary to aortic dissection (AoD) is challenging in the era of thrombolysis owing to the diagnostic difficulty within a narrow time window and the high risk of complications. CASE REPORT: A 64-year-old woman with middle cerebral artery occlusion syndrome admitted to the emergency room within intravenous recombinant tissue plasminogen activator (rt-PA) time window. Her neurological symptoms improved during thrombolysis, but chest and abdominal pain developed. Repeated history-taking, physical examination, and imaging studies led to the timely diagnosis and surgical treatment of AoD, which produced a successful outcome. CONCLUSIONS: Clinical suspicion is invaluable for the diagnosis of this rare cause of stroke. Considering the stroke mechanism and complications, the risks of thrombolysis might outweigh its benefits.

Response to Biofeedback Therapy for Patients with Rectal Hyposensitivity

BACKGROUND/AIMS: Rectal hyposensitivity (RH) has been treated with conventional biofeedback therapy (BFT), whereas the effectiveness and long term results of this therapy are not known. We aimed to investigate the effectiveness of BFT for patients with RH by conducting a retrospective review of prospectively collected data. METHODS: From June 2004 to March 2007, we enrolled those RH patients who underwent BFT. BFT was performed two or three times every week. Six months after BFT, the clinical response was evaluated by subjective and objective parameters. RESULTS: A total of 82 RH patients underwent BFT. Fifty three patients finished BFT and the other 29 patients dropped out during BFT. Thirty six patients (67.9%) showed responsiveness (R) to BFT and 17 (31.5%) showed non-responsiveness (NR). The characteristics between the two groups showed no difference, except for the "desire to defecate" volume (116.1+/-25.2 in the R group vs. 140.0+/-43.9 in the NR group, p value <0.05) and the rectoanal inhibitory reflex (RAIR) (15.6+/-0.5 in the R group R vs. 27.6+/-18.2 in the NR group, p value <0.05). The R group showed a shorter colon transit time compared to NR group. At six months after BFT, a total of 20 patients were interviewed; 15 patients answered that they still had responsiveness (75%). CONCLUSIONS: The patients with RH showed a similar BFT response to that of the constipated patients. However, the patients with a more hyposensitive rectum and a longer colonic transit showed NR to BFT, suggesting RH is an important factor in BFT responsiveness.