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Background: Acute appendicitis is the most common cause of acute abdomen. During the pandemic, to contain the spread of COVID-19, there were some integral changes in the medical processes based on the pandemic prevention policy, especially regarding emergency surgery. This study was conducted to investigate whether this pandemic also impacted the decision-making for both patients and medical personnel along with the treatment outcomes., Methods: Patients of age 18 years or older who were diagnosed clinically and radiologically with acute appendicitis between Jan 1, 2017, and Dec 31, 202,0 were reviewed. The data of 1991 cases were collected and used for this study. Two groups were formed, one group before and the other group after the outbreak. The gathered data included gender, age, appendiceal fecalith, outcomes of treatment, and long-term outcomes of non-operation (8 months follow-up). We also collected details of surgical cases from the above two groups. This data also included age, gender, appendiceal fecalith, fever, jaundice, length of onset before presenting to an emergency department (ED), anesthesia, surgery, white cell count, pathology, complications, and length of stay. We compared the above data respectively and analyzed the differences., Results: Compared to the period before the outbreak, patient visits for acute appendicitis remarkably dropped (19.8%), but surgical cases showed no change (dropped by roughly 5%). There were significant differences (P < 0.05) in failure of non-operation(after the pandemic 8.31% vs. before pandemic 3.22%), interval appendectomy(after pandemic 6.29% vs. before pandemic 12.84%), recurrence(after pandemic 23.27% vs. before pandemic 14.46%), and outcomes of recurrence. There was a significant difference (P < 0.05) in anesthesia method, surgery way, and complications( before pandemic 4.15% vs. after pandemic9.89% P < 0.05) in patients who underwent the surgery. There was no statistical difference (P > 0.05) concerning age, gender, fever, jaundice, appendiceal fecalith, white cell count, and length of onset before presenting to the ED., Conclusion: The current pandemic prevention policy is very effective, but some decision-making processes of doctor-patient have changed in the context of COVID-19 pandemic, that further influenced some treatment outcomes and might lead to a potential economic burden. It is essential to address the undue concern of everyone and optimize the treatment process., (© 2022. The Author(s).)

Background: Numerous factors contribute to advanced disease or increased complications in patients with acute appendicitis (AA). This study aimed to identify risk factors associated with AA perforation, including the effect of system time (ST) delay, after controlling for patient time (PT) delay. In this study, PT was controlled (to less than or equal to 24 h) to better understand the effect of ST delay on AA perforation., Methods: Medical records of patients who underwent surgery for AA at a tertiary referral hospital from October 2009 through September 2013 were reviewed. Data collected included demographics, body mass index, presence of fecalith, PT (i.e., duration of time from symptom onset to arrival in emergency department), and ST (i.e., duration of time from arrival in emergency department to operating room). AA was classified as simple (acute, nonperforated) versus advanced (gangrenous, perforated)., Results: Seven hundred forty-seven patients underwent surgery for AA. After excluding patients with PT > 24 h, 445 patients fit the study criteria, of which 358 patients with simple AA and 87 patients with advanced disease. Advanced appendicitis patients were older and had higher body mass index, longer PT, higher WBC, and higher incidence of fecaliths. Both groups had similar ST. Risk factors for advanced appendicitis after multiple regression analysis are age >50 y old, WBC >15,000, the presence of fecaliths, and PT delay >12 h., Conclusions: Once PT delay was limited to ≤24 h, the ST delay of >12 h did not adversely affect the incidence of advanced AA. Age >50 y, WBC >15,000, PT delay >12 h, and the presence of fecaliths were identified as risk factors associated with advanced AA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In contrast to conventional commercial poultry, which are raised primarily in controlled indoor environments, backyard poultry are typically raised in less restricted settings, potentially exposing them to a greater variety of ingestible substances, including multiple types of forage. Consequently, problems such as gastrointestinal impactions caused by ingesta have been noted in backyard poultry. To determine the prevalence of these impactions in backyard poultry, we performed a retrospective database search for autopsy submissions to the California Animal Health and Food Safety laboratory system and found that gastrointestinal impaction was associated with the death of 42 backyard poultry cases (40 chickens, 1 turkey, and 1 goose) from January 2013 to July 2018. In 32 of these 42 (76%) cases, the impaction was caused by fibrous plant material, 7 (17%) by compacted feed, and 3 (7%) by miscellaneous ingesta (tortilla, plastic, and wood shavings). The large proportion of grass impactions indicate that foraging is the predominant source of impaction material in backyard poultry, and that long grasses may be a significant health hazard for poultry. Backyard, pasture-raised, and free-range poultry producers are advised to maintain short pastures, avoid feeds that may expand in the gastrointestinal tract, and provide adequate grit to prevent impactions.

Non-operative treatment of uncomplicated appendicitis in children is gaining ground. Pending definitive evidence regarding its effectiveness, there is a call to evaluate clinical recovery after non-operative treatment. In this study, we analyzed data collected during initial admission of a multicenter prospective cohort in which children, 7-17 year, were treated non-operatively for uncomplicated appendicitis. During admission clinical parameters (pain and gastro-intestinal symptoms), inflammation parameters and sequential abdominal ultrasound were recorded. In total, 45 children were included, 42(93%) were discharged without the need for appendectomy; median [IQR] pain scores on admission were 5 [4-7], decreasing to 2 [0-3] after 1 day of treatment. Initially, 28/42 (67%) reported nausea and 19/42 (45%) vomiting; after 1 day, this was 3/42 (7%) and 1/42 (2%), respectively. White blood cell count declined from a median [IQR] of 12.9 [10.7-16.7] 10E9/L on admission to 7.0 [5.8-9.9] 10E9/L on day 1. Median [IQR] C-reactive protein levels increased from 27.5 [9-69] mg/L on admission to 48 [22-80] mg/L on day 1, declining to 21.5 [11-42] mg/L on day 2. Follow-up ultrasound showed no signs of complicated appendicitis in any of the patients.Conclusion: Clinical symptoms resolved in most children after 1 day of non-operative treatment. This suggests that non-operative treatment is a viable alternative to appendectomy regarding clinical recovery.Trail registration: NCT01356641 What is Known: • Non-operative treatment of uncomplicated appendicitis in children is safe and its use around the world is gaining ground, however high quality evidence from adequately designed randomized trials is still lacking. • Concerns have been raised regarding the potentially prolonged clinical recovery associated with non-operative treatment. What is New: • Most clinical symptoms resolve after 1 day of non-operative treatment in the majority of children.

Importance: The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals., Objective: To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis., Design: This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014., Main Outcomes and Measures: Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals., Results: A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001)., Conclusions and Relevance: More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

Background: Faecal impaction (FI) is a common problem in old people living in nursing home. Its prevalence and associated factors remain unknown in the general population., Aim: To evaluate FI prevalence in the Spanish population older than 65 years and to assess the factors associated with it., Methods: A telephone survey was carried out of a Spanish population older than 65 years random sample (N = 1000). FI was assessed using a previously validated questionnaire., Results: A total of 28,128 calls were made; 1,431 subjects were eligible and 1,000 subjects were enrollled, mean aged 74.6 ± 7.3 (65–97); 57.5% were women. At least 53 people reported FI within the past year (5.3% (CI 95%: 3.9–6.7%)). Only 0.03% met criteria for chronic constipation and faecal incontinence. FI-associated factors were constipation, female gender, reduced physical activity, and chronic renal failure (CRF)., Conclusion: FI is a prevalent problem in old Spanish population. Constipation and female gender are the main associated factors; low physical activity and CRF appear to play also a significant role. Further studies are required to confirm this association.

Goals: The aim of this study was to analyze the incidence and associated charges of fecal impaction for trends in hospital and patient demographics in emergency departments (ED) across the United States., Background: In 2010, an ICD-9-CM code (560.32) for fecal impaction was introduced, allowing for assessment of fecal impaction incidence., Study: Data were obtained from the National Emergency Department Sample records in which fecal impaction (ICD-9-CM code 560.32) was first listed as a diagnosis in 2011., Results: In 2011, there were 42,481 [95% confidence interval (CI), 39,908-45,054] fecal impaction ED visits, with an overall rate of 32 fecal impaction visits per 100,000 ED visits. Adjusted for inflation in 2014 dollars, the associated mean charge of a fecal impaction ED visit was $3060.47 (95% CI, $2943.02-$3177.92), with an aggregate national charge in the US of $130,010,772 (95% CI, $120,688,659-$139,332,885). All charges were adjusted for inflation and reported in 2014 dollars. Late elders (85+ y) had the highest rate of fecal impaction ED visits, followed by early elders (65 to 84 y). Medicare was the primary payer for the greatest number of fecal impaction ED visits accounting for nearly two thirds of visit payments., Conclusion: This study reports previously unexplored statistics on the number, frequency, and associated charges of ED visits with a primary diagnosis of fecal impaction, a condition found most commonly among elders.

Background: We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix., Methods: We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith., Results: During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10-76) years. The fecalith rate was 13%- 16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma., Conclusion: Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.

Fecal impaction (FI) is a common and potentially serious medical condition that occurs in all age groups. Children, incapacitated patients, and the institutionalized elderly are considered the highest at-risk populations. FI usually occurs in the setting of chronic or severe constipation, anatomic anorectal abnormalities, and neurogenic or functional gastrointestinal disorders. Generally, FI is a preventable disorder, and early recognition is important, as it is associated with increased morbidity, mortality, and high health care costs. Evaluation with a careful history and physical examination, in conjunction with radiologic imaging, such as an acute abdominal series or computed tomography (CT), is imperative. Prompt identification and treatment minimize the risk of complications attributable to FI, which may include bowel obstruction leading to stercoral ulcer, perforation, peritonitis, or cardiopulmonary collapse with hemodynamic instability. Treatment options include manual fragmentation and extraction of the fecal mass, distal colonic cleansing using enemas and rectal lavage with the aid of a sigmoidoscope, and/or using water-soluble contrast media such as Gastrografin to both identify the extent of the impaction and aid in cleansing and removal. Surgical resection of the involved colon or rectum is reserved for peritonitis resulting from bowel perforation. Since recurrence is common, implementing preventive measures such as increasing daily water and fiber intake, limiting medications that decrease colonic motility, using secretagogues or prokinetic agents, and treating underlying anatomic defects are highly important.

Background: There are no existing studies that provide data regarding the epidemiology of, and risk factors for, fecal impaction, either in the general population or in any sub-group of people., Objective: Estimate the prevalence of and factors associated with fecal impaction on a representative sample of the institutionalized elderly population., Design: Two-phase study. Phase 1: pilot study validating the methodology in which all residents of a single nursing home participated. Phase 2: national multi-center cross-sectional study., Setting: 34 randomly selected nursing homes., Measurements: The presence of fecal impaction and associated factors were evaluated using three different tools: data collected from medical records; a self-completion questionnaire filled out by the subjects or a proxy; and a rectal examination., Subjects: Older subjects living in nursing homes., Results: The prevalence of chronic constipation was 70.7% (95%CI: 67.3-74.1%), of which 95.9% of patients were properly diagnosed and 43.1% were properly controlled. The prevalence of FI according to patient history was 47.3% (43.6-51.0%) and 6.6% (4.7-8.5%) according to rectal examination. Controlled constipation (OR: 9.8 [5.2-18.4]) and uncontrolled constipation (OR: 37.21 [19.7-70.1]), the number of medications (OR: 1.2 [1.1-1.3]), reduced functional capacity (OR: 0.98 [0.97-0.99]) and the occasional use of NSAIDs were independent risk factors for fecal impaction., Conclusions: Constipation affects more than 70% of people living in nursing homes. Although it is properly diagnosed in more than 95% of cases, the disease is only controlled in less than 50%. Constipation, especially when not controlled, is the most significant risk factor leading to fecal impaction, which is prevalent in almost 50% of this population.

Background: Studies on the epidemiology of fecal impaction are limited by the absence of a valid and reliable instrument to identify the condition in the elderly. Our aim is to validate a questionnaire for identifying fecal impaction in the elderly and to assess the impact of cognitive impairment and the aid of a proxy on its reliability., Methods: We developed a 5 questions' questionnaire. The questionnaire was presented to twenty doctors to test its face validity. Feasibility was pre-tested with ten non institutionalized subjects who completed the questionnaire twice, once alone or with the help of a proxy, and another along with the researcher.For the validation of the questionnaire all residents in a single nursing-home were invited to participate, allowing the self-decision of using a proxy. Medical records of all subjects were abstracted without knowledge of subjects' answers and agreement between fecal impaction according to self-reported and medical records analyzed. Physical impairment was measured with the Barthel's test and cognitive impairment with the mini-mental test., Results: In the face validity only minor changes in wording were suggested. In the feasibility pre-test all subjects were able to understand and complete the questionnaire and all questions were considered appropriate and easily understandable.One-hundred and ninety-nine of the 244 residents participated in the study (mean age 86,1 ± 6,6). One hundred and forty two subjects understood all questions; not understanding them was inversely associated with cognitive impairment score (aOR: 0.86; 95% CI: 0.82-0.91). One hundred and sixty decided to use a proxy; the use of a proxy was inversely associated with educative level (0.13 (0.02-0.72), minimental's score (0.85; 0.76-0.95) and Barthel's score (0.96; 0.94-0.99). Agreement between medical records and self-completed questionnaire was 85.9% (kappa 0.72 (0,62- 0,82). Disagreement was unrelated to education and cognitive impairment., Conclusions: Our simple questionnaire is reliable for identifying fecal impaction in the elderly by self-report. Limitation imposed by cognitive impairment is minimized with the aid of a proxy.

Background: Chronic constipation (CC) is a common condition but its concurrent conditions are not well characterized. We measured the prevalence and risk of developing 15 pre-specified concurrent conditions in patients with CC., Methods: Retrospective cohort study using the Medicaid database of California, utilizing ICD-9 codes for detection of cases (CC), controls (patients with GERD) and concurrent conditions. Study period was 01/01/1995 to 06/30/2005. Index date was the date 3 months before the first physician visit for CC. Pre-index time (12 months) was compared to post-index time (12 months) to assess the association of every concurrent condition within each cohort. To account for ascertainment bias, an adjusted odds ratio was calculated by comparing the odds ratio for every concurrent condition in the CC cohort to that in the GERD cohort., Results: 147,595 patients with CC (mean age 54.2 years; 69.7% women; 36.2% white) and 142,086 patients with GERD (mean age 56.3 years; 65.3% women; 41.6% white) were evaluated. The most prevalent concurrent conditions with CC were hemorrhoids (7.6%), diverticular disease (5.9%), ano-rectal hemorrhage (4.7%), irritable bowel syndrome (3.5%) and fecal impaction (2%). When adjusted for ascertainment bias, the most notable associations with CC were Hirschsprung's disease, fecal impaction and ano-rectal conditions such as fissure, fistula, hemorrhage and ulcers., Conclusion: Chronic constipation is associated with several concurrent conditions of variable risk and prevalence. To reduce the overall burden of CC, these concurrent conditions need to be addressed.

Background: Antipsychotic are the cornerstone in the treatment of schizophrenia. They also have a number of side-effects. Constipation is thought to be common, and a potential serious side-effect, which has received little attention in recent literature., Method: We performed a retrospective study in consecutively admitted patients, between 2007 and 2009 and treated with antipsychotic medication, linking different electronic patient data to evaluate the prevalence and severity of constipation in patients with schizophrenia under routine treatment conditions., Results: Over a period of 22 months 36.3% of patients (99) received at least once a pharmacological treatment for constipation. On average medication for constipation was prescribed for 273 days. Severe cases (N = 50), non-responsive to initial treatment, got a plain x-ray of the abdomen. In 68.4% fecal impaction was found., Conclusion: A high prevalence of constipation, often severe and needing medical interventions, was confirmed during the study period. Early detection, monitoring over treatment and early intervention of constipation could prevent serious consequences such as ileus.

Objectives: To evaluate the beneficial effects of Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation., Study Design: A double-blind, placebo-controlled, randomized study was conducted from January 2008 to December 2008 in 44 consecutive infants at least 6 months old (mean age+/-SD, 8.2+/-2.4 SD; male/female, 24/20) admitted to the Gastrointestinal Endoscopy and Motility Unit of the Department of Pediatrics, University "Federico II" of Naples, with a diagnosis of functional chronic constipation. The 44 infants with chronic constipation were randomly assigned to 2 groups: group A (n=22) received supplementation with the probiotic L reuteri (DSM 17938) and group B (n=22) received an identical placebo. Primary outcome measures were frequency of bowel movements per week, stool consistency, and presence of inconsolable crying episodes, recorded in a daily diary by parents., Results: Infants receiving L reuteri (DSM 17938) had a significantly higher frequency of bowel movements than infants receiving a placebo at week 2 (P=.042), week 4 (P=.008), and week 8 (P=.027) of supplementation. In the L reuteri group, the stool consistency was reported as hard in 19 infants (86.4%) at baseline, in 11 infants (50%) at week 2, and in 4 infants (18.2%) at weeks 4 and 8. However, there was no significant difference between L reuteri and placebo groups in the stool consistency at all weeks (P=.63, week 2; P=.38, week 4; P=.48, week 8). Similarly, there was no statistically difference in the 2 groups in the presence of inconsolable crying episodes. No adverse effects were reported., Conclusions: The administration of L reuteri (DSM 17938) in infants with chronic constipation had a positive effect on bowel frequency, even when there was no improvement in stool consistency and episodes of inconsolable crying episodes. Because of their safety profile, probiotics may be an attractive option in the treatment of functional constipation., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Impaction colic is the single most common type of colic diagnosed in a large population of donkeys (more than 2000 animals) at The Donkey Sanctuary, UK and the fatality rate from the disease is high. Here we identify risk factors for impaction colic in this population during 2006 using an unmatched case control study. There were 71 cases of impaction colic and multivariable analysis identified a number of variables associated with the disease. Management factors that increased the risk of impaction included paper bedding, feeding of concentrates, limited access to pasture and increasing number of carers. In addition health variables that were associated with an increased risk of impaction colic were weight loss, recent vaccination and a number of dental abnormalities. This study has identified variables which may help to identify donkeys at high risk of impaction colic; those with a history of weight loss and with concurrent dental pathology. Furthermore the study has also identified a number of variables that may be targeted to reduce the incidence of impaction colic in this donkey population, such as modification of concentrate feeding practices and pasture access.

Purpose: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation., Methods: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings., Results: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036)., Conclusion: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.

Objective: There is no objective means to assess the obstructed defaecation syndrome (ODS), to allow evaluation of outcome or to compare the efficacy of treatment including surgery. The study aimed to validate a disease-specific index to quantify severity to allow assessment of the results of treatment in clinical trials, to permit comparison between them., Method: Seventy-six patients with ODS and 30 healthy controls entered the study after proctologic and ano-rectal physiological investigation. Hirschsprung's disease and slow transit constipation were excluded. An eight-item questionnaire with four or five possible answers was administered by two independent researchers at two different times. The ODS score was the sum of all points with a maximum possible of 31 points. Agreement between the two operators was evaluated by the Kappa coefficient for each single item. The coefficient of repeatability (CR) was assessed by the Bland and Altman plot. The internal consistency was evaluated by the Crohnbach-alpha test. A cluster analysis was carried out on each clinical finding. The Mann-Whitney U-test was used to compare median ODS score between patients and controls., Results: The ODS score of the two operators was normally distributed and strongly correlated (r = 0.89). The correlation coefficient between the score assigned to each item by two operators ranged from 0.79 to 0.98. The degree of agreement between the operators was good and the two methods were reproducible (CR = 3.13). There was a significant difference between the mean ODS score for patients and controls (t = 20.70, P < 0.001). The Crohnbach alpha value for internal reliability was +0.513. Cluster analysis showed a different profile between cluster 1 (a nonhomogenous group including rectocoele, intussusception or perineal descent), and cluster 2 (pelvic dysynergia)., Conclusion: The ODS score offers a validated severity of disease index in grading the severity of disease and monitoring the efficacy of therapy.

Background: Rectal seed bezoars in children seem to present an uncommon problem that necessitates some operative intervention., Purpose: Our objective is to determine the occurrence and clinical characteristics of rectal seed bezoars in children with fecal impaction., Methods: A retrospective review of hospital records of children with discharge diagnosis of fecal impaction was conducted from 1996 to 2005 in a university-affiliated general hospital, Results: The study group is composed 59 children. A total of 53 had rectal seed bezoars: watermelon seeds in 43 children, prickly pear seeds in 6, sunflower seeds in 3, and pumpkinseeds in 1. Six children had seedless fecal impaction. All the children with seed bezoars were of Arab origin. Fifty children were treated under general anesthesia. Of the remaining 9 children, 5 underwent digital disimpaction without general anesthesia: 3 with seedless feces and 2 with rectal seed bezoars. Four children with rectal seed bezoars evacuated spontaneously without digital disimpaction. There was summer seasonal preference for watermelon and prickly pear seed bezoars, whereas sunflower seed bezoars occurred in the spring., Conclusions: Fecal impaction owing to rectal seed bezoars is more common than previously believed. Its occurrence among Arab children alone in this study might indicate a high proportion of fecal seed bezoars throughout the Middle East. We propose that the preferred treatment should include disimpaction and irrigation of the rectal content under anesthesia. Greater awareness by primary care practitioners and parents might be beneficial in its prevention in the future.

Bed ridden patients commonly suffer a series of intestinal disorders which include: loss of appetite, swallowing disorders, a tendency to undergo gastric tract reflux, slowness in intestinal movements, accumulation of gas or fecal impactation. These contribute to an increased risk of potentially dangerous complications such as intestinal obstruction which can lead to necrosis or a perforation of different parts of the digestive tract, duodenal ulcer, hemorrhoids, or anal fissures.

Background: Colic (abdominal pain) is a clinical condition of serious concern affecting the welfare and survival of donkeys at the Donkey Sanctuary in the UK. One of the most commonly reported causes is due to impacted ingesta in the large intestine ("impaction colic"). However little is known about the incidence of, or risk factors for, this condition. Here we describe the epidemiology of colic in donkeys, specifically impaction colic. We focus on temporal aspects of the disease and we identify environmental and management related risk factors for impaction colic in UK donkeys., Results: There were 807 colic episodes in the population of 4596 donkeys between January 1st 2000 and March 31st 2005. The majority (54.8%) of episodes were due to a suspected or confirmed diagnosis of impaction of the gastrointestinal tract. The mortality risk for all colics (51.1%) was higher than reported in other equids. The incidence rate of all colics (5.9 episodes per 100 donkeys per year) and of impaction colic (3.2 episodes) was similar to that in horses. A retrospective matched case-control study of all impaction colics from January 2003 (193) indicated that older donkeys, those fed extra rations and those that previously suffered colic were at increased risk of impaction. Lighter body weight, musculo-skeletal problems, farm and dental disease were also significantly associated with a diagnosis of impaction colic., Conclusion: To our knowledge this is the first study to estimate the incidence rate of colic in a large population of donkeys in the UK. In contrast to other equids, impaction was the most commonly reported cause of colic. We identified several risk factors for impaction colic. Increasing age, extra rations and previous colic are known risk factors for colic in other equids. Results support the hypothesis that dental disease is associated with impaction colic. Musculo-skeletal problems may be associated with colic for various reasons including change in amount of exercise or time at pasture. Other associated factors (weight and farm) are the subject of further research. Identification of risk factors for impaction colic may highlight high risk donkeys and may allow intervention strategies to be introduced to reduce the incidence of the disease.

Background: Intestinal complaints are a frequent health concern for elderly people and their care providers., Aims: To explore the distinction between constipation and the subjective complaints in elderly people and to review the diagnosis, causes and treatment of constipation, fecal impaction, and fecal incontinence., Methods: Review of studies that give information on prevalence, causes, symptoms, and treatment of bowel problems in the elderly, excluding uncontrolled clinical observations., Results: Self-reported constipation and laxative use increase with age and are more common among women, blacks and people of low socio-economic level. The patient's pharmacological history is fundamental, because medications are the cause of up to 40% of chronic constipation, and are often used inappropriately. The results of most laxative trials require cautious interpretation, but fiber and laxatives are more effective than placebo against constipation. Much additional research is needed to determine the most cost-effective method of treating intestinal complaints in the elderly., Conclusions: Bowel problems in older people have a considerable impact on the quality of life and have many contributory causes that are often amenable to treatment and management. Results of therapy can be good, leading to alleviation of suffering and the ability to lead a fuller life., (Copyright 2007 S. Karger AG, Basel.)

Reasons for Performing Study: There is little information on the prevalence of, and risk factors associated with, post anaesthetic colic (PAC) in horses undergoing nonabdominal operations., Objectives: To undertake the first prospective study of prevalence of PAC and identify risk factors in its development in nonabdominal procedures., Methods: A multicentre prospective case-control study was conducted, on every horse undergoing anaesthesia for a nonabdominal procedure between April 2004 and June 2005. Colic cases were defined as any horse with recognised signs of abdominal pain within 72 h of general anaesthesia that could not be attributed to any concurrent disease. Five control horses per case were selected randomly from the study population at all hospitals. Multivariable logistic regression analysis was used to examine the relationship between predictor variables and the risk of developing PAC., Results: The estimated mean prevalence of PAC in the study population was 5.2% (95% CI, 2.8, 8.0). However, the prevalence of colic varied between each centre. The most commonly diagnosed cause of colic was impaction. Multivariable analyses showed that the centre involved and the type of surgery performed were associated with an increased risk of PAC. Preoperative food deprivation and the use of opioid drugs were confounding factors., Conclusions: Prevalence of PAC varied significantly between the 4 hospitals studied; there may be hospital-related covariates that account for this. The type of surgery performed influenced the risk of PAC., Potential Relevance: Identifying the risk factors for PAC is a prerequisite for its prevention. This study indicates horses at increased risk of PAC that might benefit from a more critical evaluation of post anaesthetic gastrointestinal function and/or the provision of preventative measures. Further investigation is required to explain the variation in prevalence of PAC between centres.

Objectives: To assess the efficacy of polyethylene glycol 3350 plus electrolytes (PEG + E; Movicol) as oral monotherapy in the treatment of faecal impaction in children, and to compare PEG + E with lactulose as maintenance therapy in a randomised trial., Patients and Methods: An initial open-label study of PEG + E in the inpatient treatment of faecal impaction (phase 1), followed by a randomised, double-blind comparison between PEG + E and lactulose for maintenance treatment of constipation over a 3-month period (phase 2) in children aged 2 to 11 years with a clinical diagnosis of faecal impaction., Results: Disimpaction on PEG + E was achieved in 58 (92%) of 63 of children (89% of 2-4 year olds and 94% of 5-11 year olds) without additional interventions. A maximum dose of 4 sachets (for 2-4 year olds) or 6 sachets (for 5-11 year olds) was required; median time to disimpaction was 6 days (range, 3-7 days). Seven children (23%) reimpacted whilst taking lactulose, whereas no children reimpacted while taking PEG + E (P = 0.011). The total incidence rate of adverse events seen was higher in the lactulose group (83%) than in the PEG + E group (64%)., Conclusions: PEG + E is safe and highly effective in the management of childhood constipation. It allows a single orally administered laxative to be used for disimpaction without recourse to invasive interventions. It is significantly more effective than lactulose as maintenance therapy, both in efficacy in treating constipation and efficacy in preventing the recurrence of faecal impaction.

Objectives: To assess the prevalence and natural history of functional gastrointestinal disorders (FGIDs) in children using the Rome Criteria., Methods: Thirteen primary care pediatricians were randomly selected from the Campania region of the Italian National Health Service. Each pediatrician completed a detailed FGID questionnaire on consecutive patients seen during a 3-month period. A total of 9660 patients aged birth to 12 years were enrolled prospectively during this 3-month period. Follow-up was performed at 1-, 3-, and 12-month intervals., Results: A total of 194 children initially met strict criteria for at least 1 FGID. A total of 72 (37.1%) children had infant regurgitation, 26 (13.4%) had functional dyspepsia, 27 (13.9%) had irritable bowel syndrome, and 66 (34.1%) had functional constipation or other defecation disorders. All children who had a diagnosis of FGIDs were reevaluated at 1, 3, and 12 months to study the natural history of the illnesses. Additional evaluation revealed 5 children who had developed an organic diagnosis. Therefore, 5 (2.5%) of 194 children who had a diagnosis of FGIDs by the Rome criteria had a change in diagnosis to an organic disease during the study period, none of whom experienced permanent sequelae., Conclusions: Of 194 children who received a prospective diagnosis of FGIDs using the Rome criteria, 97.5% continued to satisfy the diagnostic criteria or were improved at follow-up. The low prevalence of functional dyspepsia and irritable bowel syndrome in our population is most likely explained by the lack of adolescents in our sample.

Objective: Recent evidence suggests that autistic children may have significant gastrointestinal symptoms. Although constipation occurs in 2% to 5% of healthy children, its clinical diagnosis is often difficult in children with behavioral disorders. We thus aimed to assess the prevalence of fecal loading in autistic children with gastrointestinal symptoms and to identify possible predictors of constipation., Methods: We studied abdominal radiographs of 103 autistic children (87 boys) who were referred for gastroenterological assessment, in comparison with 29 control radiographs from children who were referred to the emergency department, most with abdominal pain. Radiographs were scored independently, in blinded manner, by 4 pediatric gastroenterologists and a radiologist. The severity of constipation was determined using a validated index. Details of stool habit, abdominal pain, dietary history, and laxative use were obtained from case notes., Results: The incidence of constipation in the control subjects with abdominal pain was higher than reported for normal children. Despite this, moderate or severe constipation was more frequent in the autistic group than in the control subjects (36% vs 10%). Analysis of rectosigmoid loading showed more striking differences (54.4% of autistic children had moderate/severe loading or acquired megarectum compared with 24.1% of control subjects). Multivariate regression analysis showed consumption of milk to be the strongest predictor of constipation in the autistic group, whereas stool frequency, gluten consumption, soiling, and abdominal pain were not predictive of constipation., Conclusions: Constipation is a frequent finding in children with gastrointestinal symptoms and autism, particularly in the rectosigmoid colon, often with acquired megarectum. The absence of any correlation between the clinical history and the degree of fecal impaction in autistic children confirms the importance of an abdominal radiograph in the assessment of their degree of constipation.

Purpose: To evaluate how the use of ultrasonography (US) and computed tomography (CT) has changed insights on the frequency and natural history of right colonic diverticulitis., Materials and Methods: Clinical findings, US and CT images, and clinical and surgical records in 44 patients with a final diagnosis of right colonic diverticulitis seen over 11 years were retrospectively studied., Results: Of the 44 patients, three underwent diverticulectomy, and 41 were successfully treated conservatively. Follow-up US demonstrated a consistent change in the pattern of the findings of diverticulitis over time, with eventual spontaneous evacuation of the contents of the inflamed diverticulum into the colonic lumen. Five patients had recurrent symptoms; two of them underwent elective surgery. The frequency of right colonic diverticulitis was one in 34 appendectomies, which is nine times higher than that reported to date., Conclusion: Right colonic diverticulitis is more common than has been previously reported. US and CT findings are characteristic and show a consistent pattern of changes over time. The natural history is benign, and surgical intervention can be avoided in the vast majority of patients.

Severe constipation is a well recognized symptom amongst disabled or mentally ill patients. Characteristically, these patients live without bowel movements for days and present themselves with abdominal distension and fecal impaction. Inpatient treatment is necessary frequently. Due to intestinal obstruction, diagnostic approaches are often delayed because of lack of cooperation. Data of 94 disabled patients with severe obstipation are presented. 54 patients were admitted to inpatient treatment of constipation or bowel obstruction, 40 were treated for another diagnosis but had severe constipation which required intervention. Ileus or conservatively untreatable constipation led to 16 operations in 14 patients (polypectomy 2, rectopexy 1, cecostoma 5, left hemicolectomy 3, subtotal colectomy 5). Cecostomata are considered not to be effective as definite treatment whereas colonic resection resulted in daily bowel movements.

Questionnaires were sent to all Consultant Radiologists in the UK regarding complications from barium enema examinations. The 756 respondents performed a total of 738,216 examinations over the three year period 1992 to 1994. Seventy-seven Consultants (10.2%) reported a total of 82 complications including 13 deaths: an overall mortality rate of 1 in 56,786. Only three of 30 (10%) cases of bowel perforation died, as compared with nine out of 16 (56%) cases of cardiac arrhythmia. The only remaining death was a consequence of vaginal intubation. Details of all the reported complications are recorded. This was an entirely retrospective study.

Medical records from all horses with large colon impaction admitted between 1985 and 1991 were examined. Large colon impaction was diagnosed in 147 of 1,100 (13.4%) horses with colic. One hundred thirty horses were admitted for further evaluation of acute onset of abdominal pain after having been examined and treated by referring veterinarians, and 17 horses that were hospitalized for unrelated medical problems developed large colon impaction. Female horses (92/147; 62.6%) were more commonly affected than males. The age ranged from 1 to 29 years (median, 7.1 years). Mean duration of clinical signs of abdominal pain prior to referral was 32 hours. At admittance, signs of abdominal pain were not detectable in 70/147 (48%) horses, and were mild in 50 (34%), moderate in 16 (11%), and severe in 11 (7%). Heart rate ranged from 30 to 86 beats/min (median, 44 beats/min), and most horses had a decrease in gastrointestinal sounds. Transrectal palpation was used to identify the impaction location as being the pelvic flexure in 103 (70.1%) horses, colon on the left side in 30 (20.4%) horses, and colon on the right side in 14 (9.5%) horses. All 147 horses received fluids i.v. and nonsteroidal anti-inflammatory medications or sedatives, including flunixin meglumine (124 horses, 84.3%) xylazine hydrochloride (81, 55%), butorphanol (6, 0.04%), and detomidine hydrochloride (9, 0.04%). Duration of medical treatment required to resolve the impaction ranged from 1 to 6 days (mean, 2 days). In addition to medical treatment, 24 (16.3%) horses also required surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Fecal soiling is a common complaint among school-age children. The fecal soiling is often accompanied by chronic constipation and so-called "idiopathic," "functional," or "psychogenic" megacolon, the cause of which is undetermined. The records of all children presenting to a pediatric gastroenterology clinic between 1981 and 1990 with difficult defecation were reviewed to determine the incidence of painful defecation and its relationship to chronic impaction and fecal soiling. There were 227 children; 74 were younger than 36 months of age and 153 were older than 36 months. Of the younger children, 86% presented with pain, 71% with impaction, and 97% with severe withholding. The younger children had painful defecation for a mean of 14 +/- 9 (SD) months before presentation. Of the older children, 85% presented with fecal soiling, 57% with pain, and 73% with fecal impaction, and 96% exhibited withholding; the older children had difficult defecation for a mean of 56 +/- 42 months before presentation. Sixty-three percent of the children presenting with fecal soiling had a history of painful defecation beginning before 36 months of age. Painful defecation frequently precedes chronic fecal impaction and fecal soiling in American children. Early, effective treatment of painful defecation in infancy might reduce the incidence of chronic fecal impaction and fecal soiling in school-age children.

Appendicitis is more common in developed than in developing societies and appendiceal fecaliths are thought to have an etiologic role in the disease. The geographic distribution of appendiceal fecaliths was investigated by systematic, intraoperative palpation of the appendix in patients in Toronto, Canada and Johannesburg, South Africa. The incidences of fecaliths found on pathologic sectioning of the appendix in appendicitis patients in both societies were compared. In the Canadian population, the prevalence of fecaliths in patients whose appendices were palpated incidentally was 32% versus 52% for those with appendicitis (p less than 0.01). In the African population, the prevalence of fecaliths in patients whose appendices were palpated incidentally was four per cent versus 23% for those with appendicitis (p = 0.04). The difference in prevalence of incidental appendiceal fecaliths in the two populations was statistically significant (p less than 0.005). The prevalence of fecaliths is higher in developed countries, such as Canada, than in developing countries, such as Africa, and is also higher in patients with than in those without appendicitis. These data support the theory that the low-fiber diets consumed in developed countries lead to fecalith formation, which then predisposes to appendicitis.