Oblizajek, Nicholas R.

Abstract Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.

BACKGROUND: Acute ileitis is most classically associated with inflammatory bowel disease. However, several infections can also cause inflammation or obstruction of the terminal ileum. Clinical presentation is usually acute and characterized by abdominal pain of the right abdomen. CASE REPORT: We report the case of a healthy 24 year-old man who presented with a two month history of right lower quadrant pain, nausea and emesis after returning from a trip to South Africa. Over the subsequent two months, he had continued symptoms and an ileocecal obstruction was demonstrated both on cross-sectional imaging and on colonoscopy. A stool pathogen panel was positive for Campylobacter jejuni, and he completed an empiric three-day course of azithromycin. Endoscopic biopsies were negative for histologic features of inflammatory bowel disease. After three hospitalizations for recurrent obstruction, an ileocecal resection was performed. The resection specimen revealed marked eosinophilia within the muscularis propria and submucosal fibrosis. The patient made an uneventful recovery following his surgery. CONCLUSION: Although inflammatory bowel disease should be excluded during the workup of terminal ileitis, this case illustrates the importance of including infections and post-infectious sequelae in the differential, especially in otherwise healthy patients with recent travel history.

INTRODUCTION: Early endoscopic intervention of pancreatitis with acute necrotic collection is conflicting with standard practice except in extenuating circumstances. The Atlanta criteria define necrotic collections based on the age from onset of disease as either acute necrotic collections (ANC ≤ 4 weeks) or walled-off necrosis (WON > 4 weeks). Some patients with ANCs will have clinically apparent infection of necrosis potentially necessitating infectious source control via endoscopic intervention where percutaneous drainage is technically challenging or inadequate. At present, data regarding early endoscopic intervention for acute necrotic collections is lacking. METHODS: A retrospective review of patients undergoing endoscopic intervention for pancreatic necrosis between 2008 and 2018 was performed. Included patients had definitive pancreatic/peri-pancreatic necrosis on contrast-enhanced computed tomography, signs/symptoms and laboratory evidence of pancreatitis in relation to hospital presentation, and endoscopic intervention within 28 days of symptom onset. Patients with prior percutaneous or surgical intervention were excluded. ANC cases were matched and compared to WON controls for analyzed parameters via conditional logistic regression. RESULTS: Twenty four patients were identified to have attempted drainage within 28 days of symptom onset, three of which were excluded (imaging limitations, spontaneous drainage/fistulization, unclear date of symptom onset). Demographic and clinical characteristic data are summarized in Table 1, with procedure and outcome characteristics shown in Table 2 for the 21 ANC cases in comparison to WON controls. Overall, ANC cases had slightly larger collections, with statistically significantly longer hospital stays as compared to matched WON controls ( P < 0.01); otherwise measured variables were not statistically significant between the groups. CONCLUSION: There is a paucity of data regarding the safety and efficacy of intervention of ANCs complication pancreatitis. We found in this study that there was reasonable success in clinically indicated endoscopic drainage of ANCs without significant sequelae from the procedures undertaken as compared to matched WON controls. This study demonstrates the safety of intervening on ANCs as early as 15 days if clinically indicated. Further research in regards to efficacy/safety of intervention and prognostic indicators of early intervention is required to further discern whether this applies to general practice of ANC management.

AbstractBackgroundHigh‐resolution manometry (HRM) is used to measure rectoanal pressures in defecatory disorders and fecal incontinence. This study sought to define normal values for rectoanal HRM, ascertain the effects of age and BMI on rectoanal pressures, and compare pressures in asymptomatic women with normal and prolonged balloon expulsion time (BET).MethodsHigh‐resolution manometry pressures and BET were measured in 163 asymptomatic healthy participants. Women (96) and men (47) with normal BET were used to estimate normal values and the effects of age/BMI on pressures using a Medtronic 4.2‐mm‐diameter rectoanal catheter.Key ResultsAge is associated with lower resting pressure, higher rectal pressure during evacuation, and a higher rectoanal gradient during evacuation in women and men. In women, the BET is also inversely correlated with age while the BMI is correlated with a higher threshold volume for discomfort and a longer BET. The anal squeeze pressure increment, squeeze duration, and HPZ length are higher in men than women. The rectoanal gradient during evacuation is also lower (ie, more negative) in asymptomatic women with an abnormal than a normal BET.Conclusions & InferencesThese findings provide an expanded database of normal values for anorectal HRM in men and women. Age and sex affect anal resting and squeeze pressures, respectively; rectal pressure during evacuation is also higher in older people. Less than 15% of asymptomatic people have BET >60 seconds, which is associated with manometry features of impaired evacuation.