Ethnic Differences in Anorectal Manometry Findings in Patients With Fecal Incontinence:Results From a Multiethnic Cohort According to the London Classification

Background/Aims@#Clinical rates of fecal incontinence (FI) are known to vary based on race and ethnicity. It is unclear if anorectal manometry (ARM) findings in patients with FI differ based on ethnicity. @*Methods@#High-resolution ARM studies performed between 2014-2021 due to FI at 2 hospitals with multiethnic populations were retrospectively reviewed. @*Results@#Four hundred and seventy-nine subjects were included––87 (18.2%) Arab Israelis, 76 (15.9%) immigrants from the former Soviet Union, and 316 (66.0%) Jewish Israelis. Median age was 67 years old (76.0% women: 90.4% were parous). The Arab Israeli group had higher rates of smoking, diabetes, and obesity. Over 95% of ARM’s were abnormal per the London classification including 23% with “combined anal hypotension and hypocontractility,” 36% with “anal normotension with anal hypocontractility,” 67% with “dyssynergia,” and 65% with either “rectal hyposensation” or “borderline rectal hyposensation.” On univariate analyses, significant differences between the ethnic groups were noted in the rates of “anal hypotension with normal contractility,” “combined anal hypotension with anal hypocontractility,” and “dyssynergia.” In multivariate logistic regression analyses controlling for age, gender, parity, smoking, diabetes, and obesity, the Arab Israeli group remained several times more likely to have “combined anal hypotension and hypocontractibility” compared to the other groups. @*Conclusions@#Ethnicity impacts ARM findings in patients with FI. The reason for this is unclear and future studies on ethnically diverse populations evaluating the clinical relevance of these findings are warranted.

Benign Hepatic Tumors: From Incidental Imaging Finding to Clinical Management / 가정의학회지

Benign hepatic tumors (BHTs) are commonly detected as incidental finding mainly due to the frequent utilization of imaging modalities, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Rigorous clinical evaluation, with a particular focus on chronic liver disease (CLD) or risk factors for CLD, medication history, physical examination for signs of CLD, blood tests, and a review of past liver radiology constitute the initial steps in the evaluation of a new liver lesion. Further, contrast-enhanced imaging using US, CT and MRI, can be used depending on the clinical scenario and their availability. The contrast-enhanced MRI provides detailed tissue assessment while avoiding exposure to radiations, although it is scarcely available and expensive. While the liver tissue-specific protocols ensure precise diagnosis, a biopsy is recommended in selected or doubtful cases. Further, most BHTs, such as hemangiomas, are harmless and do not require special management or followup, the hepatic adenomas and large or atypical cases of focal nodular hyperplasia are clinically relevant and require management/follow-up. In such cases, it is favorable to have a multidisciplinary team approach, which includes hepatologist, radiologist, hepatobiliary surgeon, and pathologist. This review aims to elaborate the current understanding of BHTs, and provide a practical guidance for primary care and practitioners of family and internal medicine for the disease evaluation and management.

Benign Hepatic Tumors: From Incidental Imaging Finding to Clinical Management / 가정의학회지

Benign hepatic tumors (BHTs) are commonly detected as incidental finding mainly due to the frequent utilization of imaging modalities, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Rigorous clinical evaluation, with a particular focus on chronic liver disease (CLD) or risk factors for CLD, medication history, physical examination for signs of CLD, blood tests, and a review of past liver radiology constitute the initial steps in the evaluation of a new liver lesion. Further, contrast-enhanced imaging using US, CT and MRI, can be used depending on the clinical scenario and their availability. The contrast-enhanced MRI provides detailed tissue assessment while avoiding exposure to radiations, although it is scarcely available and expensive. While the liver tissue-specific protocols ensure precise diagnosis, a biopsy is recommended in selected or doubtful cases. Further, most BHTs, such as hemangiomas, are harmless and do not require special management or followup, the hepatic adenomas and large or atypical cases of focal nodular hyperplasia are clinically relevant and require management/follow-up. In such cases, it is favorable to have a multidisciplinary team approach, which includes hepatologist, radiologist, hepatobiliary surgeon, and pathologist. This review aims to elaborate the current understanding of BHTs, and provide a practical guidance for primary care and practitioners of family and internal medicine for the disease evaluation and management.

Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management / 가정의학회지

Chronic constipation (CC) is a common disorder in the elderly population globally and is associated with comorbidities and negative implications on the quality of life. Constipation prevalence varies in different studies, primarily owing to the nonuniformity of the diagnostic criteria. However, 15%–30% of individuals aged >60 years are diagnosed with CC. Primary care physicians are the main healthcare providers that manage constipation in elderly patients in parallel with increased population aging and increased prevalence of constipation. Physical inactivity, polypharmacy, chronic medical conditions, rectal hyposensitivity, and defecatory disorders all play a role in the pathogenesis of CC in elderly patients. Detailed anamnesis, particularly history related to chronic medication use, with digital rectal examination may assist in identifying constipation causes. Additionally, blood tests and colonoscopy may identify organic causes of CC. Physiologic tests (i.e., anorectal manometry, colonic transit time with radiopaque markers, and defecography) can evaluate the physiologic function of the colon, rectum, and anus. However, generally, there are several causes of constipation in older patients, and an individualized approach is recommended. Treatment of chronic idiopathic constipation is empiric, based on the stepwise approach. Lifestyle advice, adjustment of chronic medications, and prescription of laxatives are the first steps of management. Several laxatives are available, and the treatment is evolving in the last decade. Biofeedback is an effective therapy especially for defecatory disorders. This review aimed to summarize the most updated knowledge for primary care physicians in the approach and management of CC in elderly patients.

Eosinophilic Esophagitis in Adults: A Concise Overview of an Evolving Disease / 가정의학회지

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease that encompasses esophageal symptoms along with eosinophilic infiltration of the esophageal epithelium. EoE is an evolving disease that has been a subject of interest to many researchers since the first studies recognized this condition as a new and distinct clinicopathological entity 25 years ago. Clinical presentation in adult patients may include dysphagia, food impaction, vomiting, and reflux symptoms. The diagnosis of EoE is based on the combination of clinical history suggestive of esophageal dysfunction, endoscopic features indicative of the disease, and histology revealing eosinophilic infiltration of the esophageal epithelium that persists after a trial of proton pump inhibitor therapy along with the exclusion of other disorders that may be associated with esophageal tissue eosinophilia. The interplay between EoE and gastroesophageal reflux disease (GERD) is complex, and differentiating these two conditions continues to be difficult and challenging in clinical practice. The mainstay treatment includes dietary modification, topical steroids, and/or endoscopic dilation. The primary care physician (PCP) plays an important role in improving patient care and quality of life by ensuring early referral and participating in management and follow-up. This article provides an overview of the current knowledge base regarding the disease including epidemiology, genetics, pathogenesis, common clinical presentations, the interplay between EoE and GERD, diagnostic approaches, and therapeutic options available to the PCP.