Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents.

OBJECTIVES: Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period. METHODS: Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification. RESULTS: 1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/105 for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/105 (+126%; P<0.001) and for UC, from 1.6 to 4.1/105 (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC. CONCLUSIONS: In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

[Reproductive health care for women with spina bifida]. / Suivi gynécologique des patientes atteintes d'un spina bifida.

OBJECTIVES: Few studies have focused on reproductive health care for women with spina bifida. This subject is rarely discussed, whether in patient groups or in the medical community. However, these patients need advice and a care that is appropriate to their condition. METHODS: In association with the spina bifida reference center of the University Hospital of Rennes, we have conducted a four-year retrospective, observational study. Its aim was to analyze the characteristics of the patients' gynecological care and to adapt our practice to their needs. RESULTS: Forty-eight patients were included. We demonstrated an increased risk of precocious puberty, labia minora hypertrophy and genital prolapse. CONCLUSION: Some specific characteristics of the reproductive health care of patients with spina bifida are interesting to know. A study on a larger series of patients is needed to further analyze the obstetric, gynecological and sexological issues of these women.

Incontinence in full-thickness rectal prolapse: low level of improvement after laparoscopic rectopexy.

AIM: The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse. METHOD: Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery. RESULTS: After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (-3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients' average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence. CONCLUSION: Despite some continence improvement in two-thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.

Low sensitivity of invasive tests for the detection of Helicobacter pylori infection in patients with bleeding ulcer.

BACKGROUND: A high false negative rate for antral infection with Helicobacter pylori when assessed by rapid urease test has recently been reported in patients with bleeding ulcer. This result could partly explain the differing prevalence of H. pylori infection in bleeding and non-bleeding ulcers. AIMS: To evaluate the accuracy of a rapid urease test (UT), histology and culture for detection of H. pylori in antral biopsies from acute bleeding peptic ulcer patients using a serological test as reference. PATIENTS AND METHODS: All consecutive patients with active bleeding gastric or duodenal ulcer at endoscopic examination admitted in six university hospitals in France were considered for inclusion. Five antral biopsies were taken during the diagnostic endoscopy for UT, culture and histology. A blood sample was taken for H. pylori serology. RESULTS: One hundred and eighty one patients were included and 129 (71%) had a positive serology. The sensitivity of UT, histology and culture for detection of H. pylori infection were 41%, 33% and 34%, respectively. The sensitivity and specificity of the combination of the three invasive tests were 48.8% (95% CI: 40.2-57.4) and 90.6% (95% CI: 82. 6-99) respectively. In the 52 serologically negative patients, only 5 had at least one invasive positive test. The sensitivity of the invasive tests decreased significantly with age but was not influenced by NSAIDs intake. Of 80 patients with a positive serological test and negative histological evaluation for H. pylori, chronic antral inflammation was found in 70 patients (87%). In 46 patients with both negative serological test and H. pylori negative test according to histology, only 13 (28%) had chronic antral inflammation. CONCLUSIONS: The sensitivity of invasive tests for detection of H. pylori is low during acute ulcer bleeding, and they should be used with caution in this condition. A serological test is recommended to identify patients with H. pylori infection in spite of negative invasive tests.

Electrostimulation is not a clinically effective treatment of anal incontinence.

OBJECTIVE: To evaluate the manometric and clinical efficacies of electrostimulation to treat anal incontinence. PATIENTS AND METHODS: Thirty-three women suffering from anal incontinence self-administered anal electrostimulation twice daily for 15-min intervals for 4 months. RESULTS: After 4 months, the incontinence score decreased from 10.4+/-0.5 to 7.1+/-0.8 (P<0.001) but all patients except two remained incontinent The decrease in the incontinence score was more marked in patients receiving medical treatment for an associated bowel disorder, than in patients treated by electrostimulation alone. Anal resting pressures and the amplitude of voluntary anal contractions did not increase after 4 months. CONCLUSION: Electrostimulation decreased the incontinence score but all patients except two remained incontinent after 4 months, suggesting that electrostimulation is not a clinically effective treatment of anal incontinence.

Faecal incontinence with transitory absence of anal contraction in two sexually or physically abused women.

OBJECTIVE: To report two cases of faecal incontinence caused by transitory absence of anal voluntary contraction without anal anomalies. PATIENTS: Two women referred to our gastroenterology department with faecal incontinence. One patient had been sexually abused by her father; the other had been physically abused by her husband. RESULTS: Clinical and manometric anal contraction was absent despite normal anal endosonography and normal electrophysiological perineal study. Anal contraction was completely normalized after biofeedback, and the patients recovered from the faecal incontinence. CONCLUSION: Transitory absence of anal contraction is very uncommon as the origin of faecal incontinence. It was observed in two abused women.

Biofeedback for anismus in 15 sexually abused women.

UNLABELLED: This work aimed to see whether (1) biofeedback is useful and (2) whether it needs to be combined with psychotherapy in sexually abused patients with anismus. Fifteen women aged 41.2 +/- 4.1 years who had experienced sexual abuse in childhood (9 cases) or adulthood (6 cases) and complained of symptoms of irritable bowel disease were studied. Anismus was recorded during anorectal manometry in all cases. Patients were free to choose biofeedback and/or group psychotherapy and/or individual psychotherapy. When necessary, psychoactive drugs were prescribed after a psychiatric evaluation. Initially all the patients chose biofeedback and none accepted psychotherapy. Eight patients accepted psychotherapy after several weeks of biofeedback. Thirteen patients completed the study: 5 treated by biofeedback alone, 5 with biofeedback and group therapy, and 3 with biofeedback and individual psychotherapy. Eight women recovered completely from their symptoms, only two of whom had had biofeedback without psychotherapy. CONCLUSION: Biofeedback alone was not always sufficient to cure abused patients, but was chose initially by all the patients. It could initially be a middle path between somatic treatment and psychotherapy, at a time when patients are not yet ready to undertake the latter.

Anismus as a marker of sexual abuse. Consequences of abuse on anorectal motility.

Anorectal manometry was performed in 40 women, who consulted for functional disorders of the lower gastrointestinal tract and had been sexually abused. Anismus, defined as a rise in anal pressure during straining, was observed in 39 of 40 abused women, but in only six of 20 healthy control women (P < 0.0001). Other parameters of anorectal manometry were compared with those observed in another control group composed of 31 nonabused women but with anismus, as well as the group of healthy controls. A decreased amplitude of anal voluntary contraction and an increased threshold volume in perception of rectal distension were observed in both abused and nonabused patients. A decreased amplitude of rectoanal inhibitory reflex, little rise in rectal pressure upon straining, frequent absence of initial contraction during rectal distension, and increased resting pressure at the lower part of the anal canal were observed in abused but not in nonabused patients, suggesting that these abnormalities, in association with anismus, suggest a pattern of motor activity in the anal canal that could be indicative of sexual abuse.

Which patients taking non-aspirin non-steroidal anti-inflammatory drugs bleed? A case-control study.

OBJECTIVE: To identify risk factors for gastrointestinal bleeding (GIB) among users of non-aspirin, non-steroidal anti-inflammatory drugs (NANSAIDs). DESIGN: Case-control study. PARTICIPANTS: A total of 120 patients aged over 60 years and using NANSAIDs were hospitalized between January 1988 and September 1992 for GIB related to erosions or ulceration of the gastroduodenal mucosa. A group of 100 general practitioners selected two controls matched for age and sex, receiving NANSAIDs and without GIB, for each patient. METHODS: The same questionnaire was used to interview patients and controls about their medical history, use of NANSAIDs and other drugs, alcohol and tobacco use, recent stress and nutritional status. RESULTS: The adjusted odds ratios (OR) for the risk factors related to the pattern of NANSAID use were 3.39 [95% confidence interval (CI) 1.77-6.47] when the intake of NANSAIDs was followed by decubitus, 3.00 (95% CI 1.54-5.85) when NANSAIDs were taken before a meal, 6.05 (95% CI 2.10 17.43) with a high dose of NANSAIDs, 5.87 (95% CI 2.00-17.25) with recent NANSAID use, 3.35 (95% CI 1.47-7.64) with NANSAIDs associated with aspirin use, 3.46 (95% CI 1.15-10.36) with more than one NANSAID, and 10.70 (95% CI 1.06-108.07) when NANSAIDs were associated with corticosteroids. The patient-related risk factors and their OR were 9.94 (95% CI 3.29-24.28) for irregular food intake, 3.94 (95% CI 1.45-10.69) for previous peptic ulcer, 3.71 (95% CI 1.26-10.89) for recent weight loss, 4.44 (95% CI 1.48-13.30) for heavy alcohol abuse, 2.92 (95% CI 1.36-6.26) for recent stress and 5.26 (95% CI 1.19-23.33) for a past history of GIB. CONCLUSION: This study identified a group at 'high risk' for GIB which would benefit from the development of a prophylactic therapy.

Perineal descent at defecography in women with straining at stool: a lack of specificity or predictive value for future anal incontinence?

OBJECTIVE: To determine (1) whether patients complaining of straining at stool have pelvic floor descent and anal abnormalities similar to those of patients with anal incontinence and (2) whether these patients are prone to develop anal incontinence. METHODS: To answer the first question we used defecography to study perineal floor position at rest, during maximal contraction of the anal sphincter and during straining, and we performed anorectal manometry in 46 women with straining at stool but without anal incontinence at the beginning of the study, and in 46 women with idiopathic anal incontinence, matched for age. To answer the second question, we performed a 5-year follow-up study to determine whether anal incontinence had developed in those women with straining at stool. RESULTS: Perineal floor position at rest, during maximal contraction of the sphincter and during straining, resting pressure in the upper part of the anal canal, maximal amplitude and duration of the voluntary contraction were similar in the 46 women with straining at stool and the 46 women with idiopathic anal incontinence. In the follow-up study, 24 of the 46 women with straining at stool were contacted. The incidence of anal incontinence after 5 years was higher among these 24 women than in a control group of 20 women (13 out of 24 versus three out of 20, for women with straining at stool versus controls respectively; P < 0.01). The 13 patients with straining at stool who became incontinent had, at the initial investigation, a lower maximal amplitude of voluntary contraction, greater perineal descent at rest and less elevation of the pelvic floor during maximal contraction of the anal sphincter than the other women (P < 0.05). CONCLUSION: Women with chronic straining at stool have perineal descent at rest and during straining similar to that of incontinent women. Women with chronic straining are also prone to develop anal incontinence, suggesting that perineal descent at defecography in women with straining at stool may predict future anal incontinence.

[Results of therapeutic management of vesico-urethral and anorectal disorders in 20 patients with cauda equina syndrome]. / Résultats de la prise en charge thérapeutique des troubles vésico-sphinctériens et ano-rectaux de 20 patients ayant un syndrome de la queue de cheval.

Twenty patients (7 females and 13 males) with cauda equina lesions (12 herniated lumbar disks, 4 tumours, and 4 compression fractures of the lumbar spine), were treated according to a standardized management of their urinary and digestive symptoms, after surgery. The bladder emptying inability was managed by Crédé manoeuver facilitated by appropriate drugs completed by self intermittent catheterization. The constipation was treated by non irritant osmotic laxatives, and defecation obtained by abdominal straining, was facilitated by a suppository. All the patients recovered a sphincteric autonomy, without invalidating incontinence. Within 3 to 6 months, eleven patients improved enough bladder emptying to stop drugs and self-catheterization. None presented urinary incontinence. Within the same time, 14 had a stool daily, but medical treatment of the constipation had to be carried on in all of the 20 patients. None of the patients had incontinence for the solid stools, but only the patients who improved (spontaneously or after biofeedback therapy) the voluntary anal sphincter contraction were continent for the gaz, and liquid stools. The intermittent self-catheterization release (a complete emptying of the bladder being achieved) was more frequent after tumor treatment than after herniated disk, or compressive fracture treatment; the same release happened in case of immediate management if compared with delayed management of the urinary symptoms. Adversely, the digestive recovering was not influenced by either the etiology of the cauda equina lesions or the therapeutic management delay. Defecography demonstrated anatomical disturbances of the rectoanal apparatus such as perineal descent and/or mucosal prolapse, which could be secondary to the abdominal straining necessary to complete bladder and rectum emptying.

Nizatidine as maintenance treatment of duodenal ulcer. Clinical results.

In assessing treatments for chronic diseases such as duodenal ulcer (DU), measuring the patient's quality of life (QoL) is as important as objective measures of treatment efficacy. This study was part of a larger study assessing the QoL of patients with DU treated with nizatidine. The aim of this part of the 12-month study was to assess the clinical efficacy and the influence of maintenance therapy with nizatidine on the long-term treatment of patients with healed DU. The trial, which was open, randomized and controlled, was conducted in 177 centres throughout France. A total of 581 patients of 18 years or over with endoscopically confirmed DU were assigned to two groups. The active treatment group received nizatidine 150 mg/day for one year and the control group had no regular treatment. Both groups had free access to antacid tablets, use of which was recorded. Symptomatic relapse was treated with nizatidine 300 mg/day for 6 weeks. Clinical assessments were made every 2 months, at which times patients also recorded their symptoms. The relapse rate in the nizatidine-treated group was significantly lower than in the control group at 6 months (4.5% versus 15.3%; p < 0.0001). At 12 months the difference was still significant (8.0% versus 33.5%; p < 0.001). Antacid consumption was significantly greater in controls than in the nizatidine-treated group (44.7% versus 29.7%; p < 0.001). It is concluded that nizatidine is a safe and effective therapy for preventing DU recurrence in patients with endoscopically confirmed healed ulcers.

[Multivariate analysis of clinical signs, parameters of anorectal manometry, defecography, transit time of radiopaque markers in 76 patients complaining of fecal incontinence]. / Analyse multifactorielle des signes cliniques, des paramètres de la manométrie anorectale, de la défécographie, du temps de transit des marqueurs radio-opaques chez 76 patients se plaignant d'incontinence anale.

The aim of this study was to evaluate clinical symptoms, disease past-history, and parameters of anorectal manometry, defecography, and radiopaque pellet transit time in anal incontinence by multivariate analysis. We studied 76 patients, 68 women and 8 men, who complained of anal incontinence, excluding that due to obstetrical lesions. All patients were asked to complete a standard questionnaire. Results indicated that: a) hemorrhoidectomy, hysterectomy, and cholecystectomy appeared to play a role, b) daily incontinence for air or liquid stools is more frequent after hemorrhoidectomy, c) decreased resting pressure of the upper part of the anal canal was observed mainly after hysterectomy, d) decreased resting pressure of the upper part of the anal canal could be a factor of poor prognosis after treatment, e) anal incontinence in men was secondary to traumatic lesions of the anal sphincter in 7 of 8 cases.