W. Grant Thompson’s research while affiliated with University of Ottawa and other places

A questionnaire dealing with bowel symptoms was administered to 97 outpatients referred for air-contrast barium enema. Subsequently, the barium enema was interpreted by a radiologist who did not know the results of the questionnaire. Forty-nine had normal x-rays, and 27 had uncomplicated diverticular disease. Weight loss, rectal bleeding, abdominal pain, and pain at night were as common in those with a normal examination as in those with diverticula. Symptoms of colon dysfunction included abdominal pain relieved by defecation, altered stool frequency and consistency with pain onset, abdominal distension, feeling of incomplete evacuation after defecation, and mucus in the stool. These were equally prevalent in both groups. Therefore, no symptoms could be ascribed to the presence of diverticula.

This patient was greatly relieved to learn that she had suffered from proctalgia fugax. How reassuring to have such a euphonious and authoritative sobriquet applied to an affliction that one has suffered anonymously with for years. The term is actually a curious hybrid of Latin and Greek and was coined by T. E. H. Thaysen, a Scandinavian who most likely spoke neither language. Proctalgia fugax may be defined as a sudden, severe pain in the rectal region, lasting several seconds or minutes, which then disappears completely with no sequela and no pathologic abnormality.

Proprietary laxatives represent a multimillion dollar industry and are widely used by the apparently well population. They are traditionally classified into bulk laxatives, lubricants, stimulants, stool softeners, and osmotic laxatives. The latter 3 probably act mainly by favouring accumulation of fluids and electrolytes in the lumen of the gut. Magnesium-containing saline laxatives are believed to act by releasing cholecystokinin which, in turn, favours intraluminal fluid accumulation. Bran is not a proprietary laxative. It is a bulking agent with capacity to hold water in the stool, thereby improving bowel function. The lubricant, mineral oil (liquid paraffin), is obsolete. In constipation associated with the spastic colon, bran will transform the difficult-to-pass scybala into softer, bulkier and more easily passed stools. Atonic constipation, in which defaecation fails to be triggered by a full rectum, is less satisfactorily treated with bran. In these individuals, chronic laxative use often compounds the problem. Bowel retraining with occasional (and decreasing) use of laxatives such as bisacodyl or ‘Senokot’ (standardised senna) are often effective. Occasionally, a glycerin suppository will trigger the defaecation reflex. Patients with an acute illness, undergoing surgery or suffering from perianal disease benefit from the early institution of bran to encourage the easy passage of soft stool. Bisacodyl or ‘Senokot’ should be kept in reserve. In patients who become impacted, particularly following a barium enema, an oil retention enema followed by a tap water enema may be successful, but manual disimpaction should not be unduly delayed. Laxatives may alter the appearance of the colon mucosa and so should be avoided before sigmoidoscopy. Preparation for an air contrast barium enema or colonoscopy necessitates a 2 day program of taxation including a fluid diet. Laxatives are probably more important to modern medicine for the harm they do than for their benefit. Use of the stimulant cathartics can lead to an atonic colon in which the neuromuscular apparatus is permanently damaged. Vigorous purgation may produce a paradoxical diarrhoea complicated by electrolyte derangement, malabsorption, and protein-losing enteropathy. Other than bran, most clinicians will have little need for laxatives and their use by patients should also be discouraged.

Symptoms of functional gastrointestinal disorder were sought by a questionnaire administered to 301 apparently healthy subjects in young, middle-aged, and elderly categories. Abdominal pain, a feeling of incomplete evaculation after defecation, urgency, scybala, runny stools, straining at stool, borborygmi, distension, heartburn, and laxative use were all very common. The typical symptom pattern of the spastic irritable bowel syndrome (IBS) occurred in 13.6% of subjects. Seven percent suffered noncolonic pain that was commonly associated with heartburn. A further 3.7% had painless diarrhea without the features of the spastic IBS. Six percent suffered painless constipation. Constipation seemed to increase with age. Thus four clinically distinct functional bowel syndromes existed in almost one-third of the subjects studied. Most of these had not consulted a doctor. Hospital-based studies of the IBS derive from a selected minority of patients and may not be applicable to all sufferers.