A Protocol-Driven Assessment Promotes a More Accurate Diagnosis of Irritable Bowel Syndrome.

A diverse range of conditions share symptoms commonly identified with irritable bowel syndrome. The objective of this study was to examine the diagnostic process in identifying additional diagnoses in women who are attending a clinic for evaluation of symptoms suggestive of irritable bowel syndrome. A retrospective audit was conducted of anonymous data gathered on consecutive female patients presenting to a specialist nurse-led service in Christchurch, New Zealand, with a provisional diagnosis of irritable bowel syndrome. A protocol containing routine pathology investigations and physical examination was used. Alarm features were identified and pertinent investigations were implemented. Rectocele was detected on rectal examination. Final diagnosis was noted and compared with baseline symptom data. Of 231 patients, 187 initially met Rome III criteria for irritable bowel syndrome. Red flags and abnormal investigations led to an alternate diagnosis in a further 27 patients. Of the 160 patients with irritable bowel syndrome, 31% were found to have a rectocele. They were seven times more likely to report a symptom associated with pelvic floor dysfunction (p < .0001) and four times more likely to report constipation (p = .0003). The use of a protocol including routine investigations and physical examination improves diagnostic yield. Pelvic floor dysfunction should be considered in those with unique symptom patterns and rectocele in the setting of irritable bowel syndrome.

Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet.

BACKGROUND: Women with endometriosis are frequently misdiagnosed with irritable bowel syndrome (IBS) for some time before a correct diagnosis is made. Visceral hypersensitivity is a key feature in both conditions. AIMS: To determine if there are distinct symptom patterns in women with IBS and endometriosis, and to determine the response of these women to a low FODMAP diet in comparison to those with IBS alone. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data from women attending a specialist IBS service in Christchurch New Zealand. Data from those who met Rome III criteria for IBS were sorted into two groups: concurrent endometriosis and those with IBS alone. Demographics and symptom patterns were identified from a prospective questionnaire. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet was taught to all women as the primary therapeutic intervention. Responses to the diet were noted against their ultimate disposition. RESULTS: Of the 160 women who met Rome III criteria for IBS, 36% had concurrent endometriosis. The presence of dyspareunia (P > 0.0001), referred pain (P = 0.005), bowel symptoms exacerbated by menstruation (P = 0.0004) and a family history of endometriosis (P = 0.0003) were associated with concurrent endometriosis. Seventy two percent of these women reported a >50% improvement in bowel symptoms after four weeks of a low FODMAP diet compared with 49% in those with no known endometriosis (P = 0.001, odds ratio 3.11, 95% CI, 1.5-6.2). CONCLUSIONS: Women with concurrent endometriosis and IBS report a unique symptom phenotype. The low FODMAP diet appears effective in women with gut symptoms and endometriosis.

Acquiring surgical skills: the role of the Royal Australasian College of Surgeons.

Contemporary surgeons are expected to develop and maintain competence across a range of skills far broader than that demanded of last century's surgeons. This is increasingly difficult to achieve in a competitive clinical environment in which the effectiveness of the traditional apprenticeship model can be compromised. New training paradigms must be found to ensure that the quality of surgical training is maintained and enhanced. Acquiring technical skills in the operating theatre is expensive, but training using simulations in the skills laboratory is gaining credibility and validity as a means to augment the clinical experience and accelerate training. The emerging role of surgical skills courses extends to training in behaviour and attitude. At the same time, there is a rapidly growing demand for training courses in technical surgical skills, particularly from prevocational trainees aspiring to enter surgical training. This group has been neglected by the new Surgical Education and Training programme, and re-engagement with them is now a priority. Most skills courses rely on surgeons willing to teach pro bono, and paying tutors would impose a significant additional cost on surgical training. However, recruiting enough fellows to meet the demand for tutors remains a challenge. The Royal Australasian College of Surgeons is actively engaged in supporting and developing skills training courses and programmes to address the range of skills required for surgical competence.

Laying the foundation of surgical skills for trainees (residents).

The role of the surgical skills laboratory is becoming increasingly important as surgical service needs evolve and educational processes seek to become more robust. The skills laboratory offers an opportunity to better prepare residents for their clinical rotations and to accelerate their clinical effectiveness. The Royal Australasian College of Surgeons has developed and introduced a new standardised basic surgical skills curriculum that can be delivered sustainably in centres throughout Australia and New Zealand. A technical skill set required by all surgical disciplines was compiled, and each skill was deconstructed into cognitive steps. Models were devised to simulate an application of each skill, and standardized demonstrations were created and recorded to ensure uniform teaching. Extensive resource material supports the course programme, with information for tutors, technicians, course directors and participants. Currently, clinical rotations offer inconsistent opportunities for trainees to practise their skills after the course. Recruitment and retention of tutors remains a key challenge.

Triphasic MRI of pelvic organ descent: sources of measurement error.

PURPOSE: To identify sources of error when measuring pelvic organ displacement during straining using triphasic dynamic magnetic resonance imaging (MRI). MATERIALS AND METHODS: Ten healthy nulliparous woman underwent triphasic dynamic 1.5 T pelvic MRI twice with 1 week between studies. The bladder was filled with 200 ml of a saline solution, the vagina and rectum were opacified with ultrasound gel. T2 weighted images in the sagittal plane were analysed twice by each of the two observers in a blinded fashion. Horizontal and vertical displacement of the bladder neck, bladder base, introitus vaginae, posterior fornix, cul-de sac, pouch of Douglas, anterior rectal wall, anorectal junction and change of the vaginal axis were measured eight times in each volunteer (two images, each read twice by two observers). Variance components were calculated for subject, observer, week, interactions of these three factors, and pure error. An overall standard error of measurement was calculated for a single observation by one observer on a film from one woman at one visit. RESULTS: For the majority of anatomical reference points, the range of displacements measured was wide and the overall measurement error was large. Intra-observer error and week-to-week variation within a subject were important sources of measurement error. CONCLUSION: Important sources of measurement error when using triphasic dynamic MRI to measure pelvic organ displacement during straining were identified. Recommendations to minimize those errors are made.