Introduction

Chronic diarrhoea affects 5% of the general population and has negative impacts on quality of life, but the prevalence in vulnerable older adults living in care is unknown. This study aimed to ascertain the prevalence of chronic diarrhoea in New Zealand older adults living in residential care and to explore associations between diarrhoea and medication use.

Aims & Methods

In 2021 a two-part study was conducted involving healthcare-recorded data and self-reported data from residents. The first part was a cross-sectional observational study of daily nursing records of residents living in 32 Ryman Healthcare facilities over three months. Bowel motion, anthropometric, medication and quality of life data were extracted and analysed. The prevalence of chronic diarrhoea was determined using the Rome IV criteria (at least 25% of bowels motions are type 6 or 7 on the Bristol stool chart for the last 3 months). Residents in rest home and hospital level of care at six facilities were invited to participate in the second part of the study. Residents completed Hospital Anxiety and Depression scale (HADS), the EQ-5D-3L, bowel habit and gastrointestinal symptom (ROME IV) questionnaires. Data were analysed using independent two sample T-tests and chi-square tests, p<0.05 was defined as statistically significant.

Results

The nursing records of 2411 residents were available for analysis; mean age of 87 years (SD 6.8), 70% were females (n=1682). Most lived in rest home care (n= 1140, 47%), 31% lived in hospital level of care (n= 745) and 22% were residents with dementia living in special care units (n= 536). Chronic diarrhoea was experienced by 618 (26%) residents; mean age 88 years, 68% females (n= 420, 47%). The frequency of bowel motions over the three-month period was significantly greater for the diarrhoea cohort (mean 102 bowel motions, range 26-373) compared to the normal bowel cohort (mean 85 bowel motions, range 21 – 280) (p <0.001). Polypharmacy, defined as five or more medications daily, was more likely in the residents with diarrhoea compared to residents with a normal bowel state (84 vs 48%, p= <0.001). Laxatives were administered to 66% of residents with chronic diarrhoea (404/618), 37% of whom were charted two or more different types. The most common laxative was Docusate sodium. The prevalence of chronic diarrhoea not related to laxative use was 9% (n=214). Residents experiencing diarrhoea, including those taking laxatives, were more likely to experience lower mood (18% v 12%, P< 0.01), be more at risk of pressure injuries (4% v 13%, P<0.001) and less likely to enjoy time with friends and family than residents without diarrhoea (38% v 20%, P<0.001). Weight loss was more likely in the laxative-taking diarrhoea cohort than the constipation cohort (50% v 39%, P< 0.001).
Self-reported data were collected from 110 rest-home and hospital-level care residents (mean age 88 years, SD 7.4). Chronic diarrhoea was experienced by 23 (21%) residents. Laxatives were charted to more than half of those residents (n=12, 52%). The prevalence of chronic diarrhoea not associated with laxative use was 10%; mean age 89 years (SD 4.5), 60% men (n=14), 56% living in rest home level of care (n=13).

Conclusion

Chronic diarrhoea is prevalent in care facilities and in most cases is associated with laxative use which may be inappropriate. Experiencing diarrhoea is negatively associated with QOL, mood and pressure injury risk, irrespective of the cause of diarrhoea. Prevalence is similar when obtained from nursing records and directly from residents.

Clinical Case Summary

We present the case of a 50-year-old man with six months of persistent, non-bloody watery diarrhea (8–10 episodes/day), unresponsive to antibiotics and probiotics. His past medical history was unremarkable, he took no home medications, and denied raw meat or fish consumption. Notably, he had recently started working in an animal feed production facility one month before symptom onset. Initial labs showed mild leukocytosis (10.04 x 10³/µL; ULN: 8.77) and mildly elevated CRP (7.5 mg/L; ULN: 3.4). Extensive infectious workup, including CMV serology, Quantiferon, stool cultures for Salmonella, and tests for fungi and parasites (e.g., Giardia), fecal elastase, rectal swabs for Klebsiella pneumoniae carbapenemase and Clostridium difficile returned negative. Colonoscopy and upper GI endoscopy were normal, and biopsies from all intestinal segments showed no pathological findings. He was discharged with partial improvement (3–4 bowel movements/day) and normalized CRP, but was readmitted a week later for worsening symptoms. Repeat blood work, thyroid function, serum calcitonin and inflammatory markers were within normal limits. Intestinal ultrasound showed a tubular descending colon suggestive of nonspecific left-sided colitis; other bowel segments were normal. Stool tests remained negative.Urine toxicology was positive for cannabinoids. Upon further questioning, the patient admitted to regular use over the past eight months, including during both hospitalisations (CUDIT-R score = 12). After cessation of cannabinoid use, diarrhea resolved completely. At 3-month follow-up, he was asymptomatic, with normal bowel habits and labs. He reported only sporadic cannabinoid use at present (CUDIT-R score 7). This case illustrates the potential for chronic cannabinoid use to induce persistent diarrhea mimicking infectious or inflammatory disease. Screening for substance use should be considered in chronic unexplained diarrhea.

Clinical Case Summary

We present a 78 years old male with a seven year history of loose stools and weight loss, besides frequent belching, bloating and flatulence. Previous investigations included colonoscopy, gastroscopy, SeHCAT scan and CT scan which were unremarkable apart from severe diverticulosis. His medical history includes diverticulitis episodes. Faecal elastase was low suggestive of pancreatic exocrine insufficiency. Trial of pancreatic enzyme replacement therapy led to some improvement, but he continued to report intermittent bloating.
Repeat colonoscopy was arranged. During the colonoscopy procedure, the colonoscope surprisingly entered the duodenum on passing around the sigmoid colon, suggesting the presence of a wide fistula between the colon and duodenum. Subsequent barium contrast fluoroscopy confirmed a fistulous tract between the third part of duodenum and the sigmoid-descending junction (figure 1). Upon closer review of his previous CT scans, a similar fistula tract was revealed, though it was never reported before (figure 2).
Benign Duodeno-colic Fistula (DCF) is an unusual complication of different gastrointestinal inflammatory conditions. The most common cause being perforated duodenal ulcer¹ .Other causes include IBD, regional enteritis, tuberculous lymphadenitis and duodenal diverticulum. Most frequently DCF presents with malabsorption symptoms like weight loss and diarrhoea, which may be observed in up to 80%² of cases. Colicky abdominal pain³ and eructation are also observed.
In our case the most likely cause for the DCF was severe sigmoid diverticulosis which is extremely rare. His symptom presentations are likely secondary to bacterial overgrowth.
The gold standard confirmatory test for DCF is barium contrast fluoroscopy⁴. Whilst the curative treatment for symptomatic cases being surgical correction⁵, this was deemed unnecessary as he was well and symptoms were only intermittent. He was treated with oral antibiotics when symptoms flared to good effect.

References

1. HERSHENSON, L. M. and J. B. KIRSNER. Duodenocolic Fistula. Gastroenterology, 19:864, 1951.
2. Higgins, P. M. (1963) Benign Duodenocolic Fistula. Canadian Medical Association Journal. 1963 Oct 26; 89(17): 893–895
3. Melissas J., Schoretsanitis G., Daskalakis M., Tsiftsis D.D.: Sigmoidoduodenal fistula as a rare complication of colonic carcinoma: report of a case. Surg Today 2003; 33: pp. 623-625.
4. Barton D.J., Walsh T.N., Keane T., Duignan J.P.: Malignant duodenocolic fistula. Report of a case and review of the literature. Dis Colon Rectum 1987; 30: pp. 636-637
5. Kamath AS, Iqbal CW, Pham TH, et al. Management and Outcomes of Primary Coloduodenal Fistulas. J Gastrointest Surg 2011;15(10):1706-11.

Introduction

Diarrhoea is a common condition caused by bacterial, viral, protozoal infection and certain medications.^1,2 Management of diarrhoea involves maintenance of hydration by oral or intravenous fluids, antidiarrheal drugs, probiotics etc.^3,4Saccharomyces boulardii (S. boulardii) CNCM I-745 is a probiotic which has been found to be effective in controlling pathogenic as well as antibiotic associated diarrhoea.^5,6,7 The efficacy of S boulardii CNCM I-745 was evaluated and confirmed through multiple RCTs across the globe.⁸ Though there are few real world studies from Western countries which have evaluated the effectiveness of S. boulardii CNCM I-745 in reducing duration as well as frequency of diarrhoea, such studies are scarce in the Indian population.

Aims & Methods

Aims: Primary objective was to evaluate the effectiveness of Saccharomyces boulardii (S. boulardii) CNCM I-745 in adult patients with diarrhoea. Secondary objective was to compare the effectiveness of S. boulardii CNCM I-745 and treatment modalities other than probiotics in adult patients with diarrhoea and also in subset of patients who were using concomitant antibiotics.
Methods: This is a retrospective, multicenter, comparative study analyzing electronic medical records (EMR) of 1727 adult patients with diarrhoea in India.
From the EMR database, the total number of adult patients diagnosed with diarrhoea at baseline and administered S. boulardii CNCM I-745 (test group) was 270. A control group was formed of 1457 patients who were administered any anti-diarrhoeal and /or oral rehydration therapy for managing diarrhoea excluding probiotics. Patients were enrolled at baseline with complaints of diarrhoea or loose motions with one follow up visit within 15 days. A total of 112 patients with diarrhoea at baseline in test group, and 392 patients with diarrhoea in control group, were noted to have been administered concomitant antibiotics.

Results

For the test group, the mean age was noted to be 48.54 + 16 years and for control group it was 45.84 + 16.08 years. There was female preponderance in both the control and test group (56.7% Vs 51.5%).
At follow-up, 22.2% patients in test group complained of diarrhoea Vs 84.2% in control group. Thus proportion of patients with continued diarrhoea at follow-up was significantly lower in the S Boulardii group versus the control group (p<0.05). The odds ratio for noting absence of diarrhea in test group versus control group was 18.7, with 95% confidence interval of 13.6 to 25.7.
Amongst the subset of patients who received concomitant antibiotics, 23.2% patients in test group complained of diarrhoea Vs 81.6% in control group, at follow up visit. The proportion of patients receiving concomitant antibiotics with continued diarrhoea at follow-up was significantly lower in the test group versus the control group (p<0.05). The odds ratio for noting absence of diarrhea in test group versus control group receiving concomitant antibiotics was 14.7, with 95% confidence interval of 8.8 to 24.4.

Conclusion

The effect of S. boulardii CNCM I-745 probiotic in controlling diarrhoea in Indian patients was better than anti-diarrhoeal and/or oral rehydration therapy in real-world setting, irrespective of concomitant antibiotic usage.

References

1. Philip NA, Ahmed N, Pitchumoni, CS. Spectrum of Drug-induced Chronic Diarrhea. Journal of Clinical Gastroenterology 2017;51(2):111–17.
2. Nilima, Kamath A, Shetty K, Unnikrishnan B, Kaushik S. Prevalence, patterns, and predictors of diarrhoea: a spatial-temporal comprehensive evaluation in India. BMC Public Health. 2018;18(1):1288.
3. Farthing M, Salam MA, Lindberg G et al. Acute diarrhoea in adults and children: a global perspective. J Clin Gastroenterol 2013;47:12–20.
4. Ragavan PSK, Kaur A, Kumar M, et al. Retrospective analysis of EMR database to assess the effectiveness of Saccharomyces boulardii CNCM I-745 in children with acute diarrhoea during routine clinical practice. New Microbes New Infect. 2020;38:100766.
5. Czerucka D, Piche T, Rampal P. Review article: Yeast as probiotics -- Saccharomyces boulardii. Aliment Pharmacol Ther. 2007;26:767–78.
6. Neut C, Mathieux S, Dubreuil LJ. Antibiotic susceptibility of probiotics strains: Is it reasonable to combine probiotics with antibiotics? Méd Malad infect. 2017;47:477–83.
7. Jones TF, McMillian MB, Scallan E, et al. A population-based estimate of the substantial burden of diarrhoeal disease in the United States; FoodNet, 1996–2003. Epidemiol Infect. 2007;135:293–301
8. McFarland LV, Karakan T, Karatas A. Strain-specific and outcome-specific efficacy of probiotics for the treatment of irritable bowel syndrome: A systematic review and meta-analysis. EClinicalMedicine. 2021 Nov 1;41:101154.

Disclosure

No

Introduction

The global prevalence of pediatric functional constipation (FC) varies from 1 to 30% due to the heterogeneity of the studies in terms of target population sampling, method of data acquisition, diagnostic criteria, among others. Studies conducted by Osatakul et al. and Piriyanon et al. in Thai young children, utilizing Rome III criteria, indicated prevalence rates of 1.6% and 25%, respectively. However, there is currently no study on the prevalence of FC in Thai young children using the Rome IV criteria, mainly because no standardized questionnaire exists for this age group.

Aims & Methods

The Thai version of the Rome-IV Diagnostic Questionnaire for Pediatric Functional Gastrointestinal Disorder (R4PDQ)-Toddler was developed then authorized by the Rome foundation. Guardians of children aged 6-48 months from six hospitals in five regions of Thailand from August 2023 to February 2024 were surveyed with the questionnaire composed of demographic data, the R4PDQ-Toddler for defecation, and the associated factors of FC.

Results

With a 98.1% response rate, a total of 1,874 guardians participated. The prevalence of FC was 16.1% (95% CI 14.5%-17.8%). Most presenting symptoms were painful or hard bowel movements (81.5%), large diameter stools (77.5%) and excessive stool retention (72.2%). Independent associated factors were age >1 year [aOR=3.36 (95%CI 2.29-4.94)], first-degree relative history of constipation [aOR=2.48 (95%CI 1.85-3.35, fiber supplementation [aOR=7.85 (95%CI 3.56-17.30)], and stressful life events in family [aOR=1.41 (95%CI 1.03-1.92)].

Conclusion

The prevalence of FC in Thai young children has been increased. Older age, family history of constipation, stressful life events in the family and supplementary fibers were associated factors of FC, warranting further evaluation.

References

1. Benninga MA, Nurko S, Faure C, Hyman PE, Roberts ISJ, Schechter NL. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443-55. e2.
2. Koppen IJ, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, et al. Prevalence of functional defecation disorders in children: a systematic review and meta-analysis. The Journal of pediatrics. 2018;198:121-30. e6.
3. Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World Journal of Gastroenterology. 2023;29(8):1261.

Disclosure

All authors have COI.

Introduction

Bile acid diarrhoea (BAD) is a common yet often underdiagnosed cause of chronic diarrhoea. Despite its prevalence, BAD remains frequently overlooked in clinical practice. It is estimated that up to 30% of patients with diarrhoea-predominant irritable bowel syndrome (IBS) have underlying BAD, highlighting the importance of distinguishing between these two conditions for effective management. SeHCAT testing remains the gold standard modality for diagnosing BAD. Management typically involves bile acid sequestrants; however, notable variation exists in management approaches across clinical settings.

Aims & Methods

We retrospectively reviewed all SeHCAT tests performed across Imperial College Hospitals, London between 01/01/2023 – 31/12/2023. Electronic health records were interrogated to extract patient demographics, including age, gender, and ethnicity. The results were analysed to determine the proportion of positive findings, which were subsequently stratified by severity. Corresponding management strategies were recorded to evaluate treatment patterns across clinical specialties.

Results

A total of 313 records were identified, of which 13 were excluded due to incomplete data. The average age of patients was 50 years. The predominant ethnicity was White (50.7%) and the majority of the patients were females (64.7%). Among the 300 remaining records, 154 had positive SeHCAT results with a 7 -day retention between 0 and 15%. Of these, 15.7% were categorised as having moderate bile acid malabsorption, followed by severe (13.3%), mild (11.0%), and borderline (11.3%) cases. The majority of the requests originated from Gastroenterologists (86%), with a smaller proportion from Endobariatrics (5.3%), Hepatobiliary Surgeons (3.7%), Hepatologists (2%), Colorectal Surgeons (1.3%) and other specialities (1.7%). Colestyramine was the most commonly prescribed treatment, with 91% of patients initiated on a 4g once-daily dose. Approximately 26.9% of patients on colestyramine experienced side effects, necessitating a switch to colesevelam. The common side effects noticed were abdominal bloating, abdominal cramps, constipation and reflux. Conversely, 87% of patients on colesevelam continued treatment due to better tolerability, with only 13% exhibiting no clinical improvement. The most frequently prescribed dose was 1.25g daily in 45.3% cases. Among patients with normal SeHCAT results, the majority were diagnosed with diarrhoea-predominant irritable bowel syndrome (47.3%).

Table 1: SeHCAT results

Conclusion

Bile acid diarrhoea continues to be a prevalent factor contributing to chronic diarrhoea in healthcare. While existing treatment modalities have proven effective in managing this condition, they remain poorly tolerated. Our study confirms that colesevelam demonstrates improved tolerability compared to colestyramine.

References

Walters JRF, Arasaradnam RP, Andreyev HJN, UK Bile Acid Related Diarrhoea Network. Diagnosis and management of bile acid diarrhoea: a survey of UK expert opinion and practice. Frontline Gastroenterology 2019; 11:358-363 dx.doi.org/10.1136/flgastro-2019-101301

Introduction

The need for colonoscopies in the elderly has significantly grown compared to 20 years ago. Furthermore, the issue of advanced age has long been a concern to colonoscopists. Our study aimed to evaluate the occurrence of colonoscopy-related adverse events (AEs) in older individuals.

Aims & Methods

A detailed search was conducted on October 28th, 2023, using the Pubmed, Embase, and Cochrane Library databases. Meta-analyses were performed using the generalized linear mixed model and the results were expressed for pooled rate along with relevant 95% confidence intervals (CIs).

Results

We retrieved 14748 records, of which 34 studies were included. The overall pooled rate of colonoscopy-related perforation, bleeding and death in the elderly were 0.072% (95% CI 0.051-0.102; I²=82%), 0.184% (95% CI 0.093-0.364; I²=99%), and 0.026% (95% CI 0.002-0.431; I²=0%), respectively. Patients aged over 80 years had a 2.44-fold (RR 2.44; 95% CI 1.15-5.66; I²=79%) risk of perforation and 1.24-fold (RR 1.24 95% CI 1.04-1.49; I²=0%) risk of bleeding comparing with patients aged 80 years and under. For screening purposes, the pooled rate of perforation and bleeding were 0.086% (95% CI 0.071-0.103; I²=0%) and 0.170% (95%CI 0.049-0.591; I²=96%), respectively. The rates were 0.076% (95% CI 0.029-0.202; I²=0%) and 0.166% (95% CI 0.062-0.438; I²=54%) for diagnostic purposes, respectively. In comparison to non-therapeutic colonoscopies, therapeutic colonoscopies showed a higher rate of perforation (0.044% vs. 0.004%) and bleeding (0.167% vs. 0.004%).

Conclusion

We reported on the prevalence of colonoscopy-related AEs in older adults, emphasizing concerns over the safety of colonoscopy for those aged over 80 years.