It is estimated that close to 18 million adults in America—that is, about 1 in 12 persons—have fecal incontinence (FI). A range of causes have been cited: pregnancy, obstetric injury, congenital disorders, aging, neurologic disorder or primary or secondary injury to the nervous system, inflammatory bowel disease (IBD), and irritable bowel syndrome (IBS). It need not be said that FI is an extremely embarrassing disorder for a patient to contend with. The incidence of FI is probably underreported given that this is not a disorder that patients ordinarily feel comfortable discussing despite the fact that having FI is associated with a poor quality of life, especially in women.
A study by Dunivan and colleagues published in 2010 in the American Journal of Obstetrics and Gynecology found that, of 1,707 surveyed primary care patients, 36% reported symptoms of FI, although a review of the medical records of all surveyed patients found a diagnosis rate of only 3%. Meanwhile, the rate of healthcare utilization costs of surveyed patients reporting FI symptoms was 55% greater than that of continent patients. A study by Alsheik and colleagues that included an overall study population of 500 patients and was published in 2012 in Gastroenterology Research and Practice (available as an open access article at http://www.hindawi.com/journals/grp/2012/947694/) confirmed epidemiologic data: average time of onset was middle age, the overall majority of patients were women (74%), and 72% had medical or surgical risk factors for FI. Although a retrospective chart review of the 500 patients suggested a prevalence of FI of 2%, direct inquiry of each of these 500 patients regarding the presence of FI symptoms returned a prevalence rate of 12%. Of patients reporting FI symptoms on direct questioning, only 22% had ever been previously queried about it by a physician. Nearly half (48%) of patients confirming FI symptoms on direct questioning reported a poor quality of life, with an American Society of Colon and Rectal Surgeons quality-of-life questionnaire score of less than 2.5. Both Dunivan and colleagues and Alsheik and colleagues, thus, stressed the importance of screening patients, via direct inquiry, about the presence of symptoms of FI.
Now that you know which of your patients is struggling with FI because you have included discussion of it in your workup regimen, insights on office-based management are provided in this month’s issue of Gastroenterology & Hepatology in a comprehensive review by Dr. Vanessa C. Costilla and a team from the Mayo Clinic in Scottsdale, Arizona.
The topic of primary sclerosing cholangitis (PSC) is also featured in this month’s issue through original research on the impact of immunosuppression and liver transplantation for PSC in patients with IBD by Dr. Mahmoud Mosli and a team from the London Health Sciences Centre of the University of Western Ontario. In addition, Dr. Cyriel Ponsioen of the Academic Medical Center in Amsterdam, The Netherlands provides a salient overview of PSC in our Advances in Hepatology column. Also featured among our regular columns is an interview with Dr. Kenneth F. Binmoeller of the California Pacific Medical Center in San Francisco on endoscopic ultrasound–guided drainage of pancreatic fluid using fully covered self-expandable metal stents, an interview with Dr. Gary W. Falk of the University of Pennsylvania Perelman School of Medicine in Philadelphia on radiofrequency ablation for the treatment of Barrett esophagus, and an interview with Dr. Gert Van Assche of Mount Sinai Hospital in Toronto, Ontario, Canada, who provides a wealth of insights on optimizing biologic therapy in the treatment of IBD. In addition, an informative overview of the low FODMAP diet is presented through an interview with Dr. Jane G. Muir and Dr. Peter R. Gibson of the Monash University in Melbourne, Australia. Finally, this month’s featured case, submitted by Dr. Seth Lipka of the Nassau University Medical Center in East Meadow, New York and Dr. Seymour Katz of the North Shore University Hospital–Long Island Jewish Health System in Manhasset and St. Francis Hospital in Roslyn, New York, explores reversible pseudoachalasia in a patient with laparoscopic adjustable gastric banding. The case’s commentary by Dr. George A. Fielding of the New York University School of Medicine in New York City will be of special interest to physicians wanting to expand their knowledge of bariatric surgery.
May this month’s issue, rich in clinical insights, enhance your practice.
Gary R. Lichtenstein, MD, AGAF, FACP, FACG