Reliability.docx
- 文档编号:28203453
- 上传时间:2023-07-09
- 格式:DOCX
- 页数:16
- 大小:28.36KB
Reliability.docx
《Reliability.docx》由会员分享,可在线阅读,更多相关《Reliability.docx(16页珍藏版)》请在冰豆网上搜索。
Reliability
AnExaminationoftheReliabilityofReportedStoolFrequencyintheDiagnosisofIdiopathicConstipation
WaseemAshrafM.D.
FayeParkR.N.
JohnLofM.S.
EamonnM.M.QuigleyM.D.,F.R.C.P.
SectionofGastroenterologyandHepatology,DepartmentofInternalMedicine,UniversityofNebraskaMedicalCenter,
Omaha,Nebraska
AmericanJournalofGastroenterology-Volume91,Issue1(January1996)
Objectives:
Toinvestigatethereliabilityofreportedstoolfrequencyinthediagnosisofconstipation.Methods:
Ourcriterionforthediagnosisofidiopathicconstipationwas
3stoolsperweekfor
6months.Subjectswhobelievedthattheymetthiscriterionwereinvitedtoparticipate.Dailystoolfrequencywasrecordedovera4-wkstudyperiod,andallstoolswereweighedduringthefinalweek.Acolontransitstudyandanorectalmanometrywereperformedatthebeginningandattheendofthestudy.Results:
Onreviewofstooldiariesfrom45subjectswhodescribedchronicconstipationandwhocompletedthe4-wkstudy,only22(49%)actuallysatisfiedourcriterionforidiopathicconstipation.Theremaining23(51%)subjects,althoughdescribingconstipation,had,onaverage,6stools/wk.Ahistoryofpsychiatricillnesswas5timesmorefrequentamongthosewhosebowelsymptomscorrelatedpoorlywithobjectivemeasures.Measuresofdifficultdefecationweresimilarinthetwogroups.Meancolontransittimewassignificantlylongerandcorrelatedcloselywithstoolweightonlyinsubjectswhotrulywereconstipated(p<0.05).Anorectalmanometrywasnothelpfulindiscriminatingbetweenthosewhosatisfiedourcriterionforconstipationandthosewhodidnot.Conclusions:
Definingconstipationonthebasisofapatient'sreportedstoolfrequencymayprovemisleading;thediagnosisofidiopathicconstipationshouldbesupportedbytheuseofstooldiariesandacolontransitstudy.
Reprintrequestsandcorrespondence:
EamonnM.M.Quigley,M.D.,UniversityofNebraskaMedicalCenter,DepartmentofInternalMedicine,SectionofGastroenterologyandHepatology,600S.42ndStreet,Omaha,NE68198-2000.
ReceivedJune14,1995;acceptedSept.20,1995.
INTRODUCTION
Constipationisacommon,butoftendifficultdiagnosticandmanagement,problem.Itsdiagnosisrelies,forthemostpart,onanindividual'sperception.Mostadultsreportatleastonebowelmovementin24h[1][2][3],sothosewhodonotwillusuallydescribethemselvesasconstipated.Toothers,constipationimpliesdifficultdefecation,asexpressedbysuchsymptomsasstrainingandincompleteevacuation.Clinicalandepidemiologicalstudiesinidiopathicconstipationhavebeenlargelybasedonsuchsubjectivehistoricalevidencealone[3][4][5][6][7],sothefrequencyofself-reportedconstipationmay,therefore,besubjecttooverestimation[8][9].IntheUnitedStates,surveyshaveestimatedaprevalenceofbetween2and4%[10][11].Womenare2-3timesmorelikelytoreportconstipation[2][3][5][10][11][12][13].Constipationseemstobeafrequenthealthconcernintheelderly[14][15],agroupthatalsotendstousemorelaxatives[3][16][17].Thisgroupalsotendstoequateconstipationmorewithdifficultdefecationratherthaninfrequentstools[3][7][16][17].Thus,although,somesurveys,usingthisbroaderconceptofconstipation[14][15],havequotedaprevalencefigureforconstipationamongtheelderlyintheregionof30%,prevalencebasedonadefinitionconfinedtostoolfrequencyonlywouldfallbetween3and4%[2][18].
Toincorporatethesevariousexpressionsofconstipation,morerecentdefinitionshaveattemptedtoincludenotonlysuchtraditionalcriteriaasanaveragestoolfrequencyof
3stools/wk[2][4]butalsosymptomsconsideredindicativeofdifficultdefecationordefecatorydysfunction,suchasstraining,painondefecation,andasenseofincompleteevacuation[19].Studiesthathaveexaminedrelationshipsbetweenthesesymptompatternsandobjectivemeasuresofcolonicoranorectalfunctionhaverevealedpoorcorrelationsbetweenreportedsymptomsandwholeguttransit,forexample[9][20].Ofthesesymptoms,infrequentdefecationseemstocorrelatebestwithgutdysfunction,whereasstrainingandincompleteevacuationhaveprovenlessreliableindicatorsofdelayedtransitbecauseoftheirfrequentoccurrenceinpatientswiththeirritablebowelsyndrome[21][22]Amongthispatientpopulation,symptomscommonlyreflectalteredperceptionratherthandisturbedmotorfunction.Wepostulatedthatdiagnosticaccuracy,inthediagnosisofconstipation,mightbeimprovedbyfocusingononesymptom,namelyinfrequentbowelmovements.Ouraim,therefore,wastoexaminethereliabilityofself-reportedstoolfrequencyinthediagnosisofconstipationbyexaminingrelationshipsbetweenself-reportedconstipation,prospectivelyobtainedstooldiaries,andsuchobjectivemeasuresasstoolfrequency,stoolweight,colontransit,andanorectalmanometry.
SUBJECTSANDMETHODS
Subjectselection
Menandwomenaged19to85yrwithchronicconstipation(definedas
3stools/wkforatleast3months)were
TABLE1--PatientInclusion/ExclusionCriteria
Inclusioncriteria
Patientsincludedwere:
Fullymobileandhealthyonthebasisofmedicalhistory,physicalexaminationandroutinelaboratoryevaluations
Willingtostoplaxativesforthestudyperiod
Abletogiveinformedconsentandfollowinstructions
Exclusioncriteria
Patientsexcludedhad:
Severeconstipationrequiringcontinualuseofenemasandsuppositories
Currenthistoryoftreatmentwithconstipatingmedicationorwithunstabledosesofthiazides,beta-blockers,orestrogens
Congestiveheartfailure,unstableangina,inflammatoryboweldisease,pancreatitis,diabetesmellitus,orhypothyroidism
HistoryofmajorGIsurgeryormajorbowelobstructionrequiringmedicaltreatment
OrganicGIlesioncausingconstipation
CurrentGI,renal,pulmonary,hepatic/biliarydisease,orcancerorhistoryofamyocardialinfarctionorcoronaryarterybypassoranymajorsurgicalprocedureinthelast6months
Currenthistoryofdrugoralcoholabuse
invited,bymeansofanadvertisementinlocalnewspapersaswellasatgeneralmedicine,gastrointestinal,andgeriatricclinics,tocallinforabrieftelephoneinterview.Thosewho,byhistory,satisfiedourcriteriaformildtomoderateidiopathicconstipation(Table1)weretheninvitedtoparticipateinthe4-wkstudy.
Subjectswereinstructedtostoptakinglaxativesforatleast1wkbeforeandthroughoutthestudyperiodandwererequestednottochangetheirdietaryhabitsduringthestudy.Wedidnotattempttocontrolfordietaryfiberintake.ThestudywasapprovedbytheInstitutionalReviewBoardattheUniversityofNebraskaMedicalCenter.
Onthefirstdayofthestudy,afullmedicalhistory,completephysicalexamination,andlaboratorytests(fullbloodcount,chemistryprofile,urinalysis,andthyroidfunctiontests)wereperformedoneachpatient.Apregnancytestwascarriedoutonwomenofchildbearingpotential.
Stooldiariesandstoolweights
Duringthe4-wkperiod,subjectswereinstructedtorecordstoolfrequencyonadailybasisandwerealsorequestedtodocumenttheoccurrenceofsymptomsrelatedtodefecatoryfunction:
stoolconsistency,strainingeffort,theoccurrenceofanalpainwithdefecation,andthepresenceorabsenceofasensationofincompleteevacuation.Eachoftheseparametersofdefecatoryfunctionwasscoredonavisualanalogscalethatrangedfrom1to7forstoolconsistency,strainingeffort,andpainwithdefecation.Ascoreof1indicatedsoftbutformedstools,nostraining,andnopainondefecation,whereasascoreof7wasindicativeofpassinghard,pellet-likestools,continuousstrainingeffort,andexcruciatingpainonevacuation.However,forthesensationofcompletenessofevacuation,ascoreof1indicatedafeelingofextremefullnessdespitehavingabowelactionand7indicatedcompletesatisfactionwithevacuation.Subjectswererequiredtocollectandweigh(wetweight)alloftheirstoolsduringthefinalweekofthestudy.Standardizedstoolcontainersandweighingscaleswereprovidedforthispurpose.
Colontransitstudy
Acolontransitstudywasperformedoneachindividualonbothdays1and28.For3consecutivedaysbeforeeachstudy,subjectswereinstructedtoingestagelatincapsulecontaining202×6-mmcircular,radiopaquemarkersat9:
00AMoneachday.Aplainsupineradiographoftheabdomenwasobtained24hafteringestionofthelastmarkercapsule(i.e.,at9:
00AMonthe4thdayafterinitiationofmarkeringestion),andtheremainingmarkerswerecounted.
Anorectalmanometry
Anorectalmanometrywasalsoperformedondays1and28usingastandard8-lumencatheterassembly(Arndorfer,Inc.,Greendale,WI)withindividualsideholesradiallyarrayedat0.5-cmintervalsandwithaninflatableballoonatitsdistalend.Eachcatheterwasperfusedatarateof0.1ml/minbyalowcomplianceperfusionsystem(Arndorfer),andintraluminalpressurechangesweremonitoredbystraingaugetransducersandrecordedonaSandhillTDSrecorder(Sandhill,Inc.,Littleton,CO).Afteradigitalrectalexamination,thecatheterassemblywasinsertedintotheunpreparedrectum,andastationpull-throughprocedurewasperformedtodefinethebasalanalsphincterprofile.Then,withthecatheterrepositionedsothatthesideholesstraddledthesphincter,thepatientwasaskedtosqueeze(i.e.,voluntarilycontracttheexternalsphincter)foratleast60soruntilthepressureincrementdecayedtothelevelofbasalsphincterpressure.Oncompletionofsqueezemeasurementsandwiththecatheterinthesam
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- Reliability