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BILE ACID MALABSORPTION AFTER CONTINENT URINARY DIVERSION WITH AN ILEAL RESERVOIR
0022-5347/98/1603-0724$03.00/0
Vol. 160, 724-727, September 1998 Printed in U.S.A.
THE JOL'RNAL OF UROLOGY Copyright 0 1998 by AMERIC.AN URoLocir.a ASSOCIATION, Ixc
BILE ACID MALABSORPTION AFTER CONTINENT URINARY DrVERSION WITH AN ILEAL RESERVOIR GUNNAR OLOFSSON, MARTHA F J k L I N G , ANDERS KILANDER, KJELL ARNE UNG OLOF JONSSON*
AND
From the Departments of Urology, Internal Medicine and Nuclear Medicine, Sahlgrenska University Hospital, Gdteborg, Sweden
ABSTRACT
Purpose: We determine the effect of urinary diversion with a Kock ileal reservoir on bile acid absorption and bowel habits. Materials and Methods: We asked 96 patients with a Kock ileal urinary reservoir to record bowel habits and abdominal symptoms for 1 week. Data on 75 patients were further analyzed. Bile acid absorption was determined in 29 healthy control subjects, in 17 before and 6 months after continent urinary diversion, and in 21, 2 to 14 years postoperatively. Bile acid absorption was considered pathological when retention of less than 10% of a n oral capsule containing selenium-75 labeled tauroselcholic acid (SeHCAT) was noted after 1 week. Results: Mean number of defecations plus or minus standard deviation was 9.4 ? 6.1 (75 cases). Of the patients 13%had 15 or more stools per week and 15%complained of always having loose stools. Mean value for the SeHCAT test was 32 5 19% preoperatively and 17 ? 16% 6 months postoperatively (p = 0.0023).The corresponding value for healthy controls was 39 -t 18%. Significant relationships were found between the results of the SeHCAT test postoperatively, and the number of stools per week and consistency of the feces. All patients with more than 10 defecations per week had a pathological SeHCAT test. Conclusions: Most patients with a n ileal urinary reservoir have fairly normal bowel habits. Bile acid absorption is significantly reduced postoperatively and approximately a third of the patients have a pathological SeHCAT test. Preoperative investigation of bowel habits is recommended and a SeHCAT test should be performed in patients with frequent, loose defecations. Other types of diversion should be offered when preoperative retention is below 10 to 20%especially in patients with impaired anal control. KEY WORDS:proctocolectomy, restorative; urinary diversion; bile acids and salts PATIENTS In the construction of a Kock ileal reservoir for continent urinary diversion or orthotopic bladder reconstruction 55 to We asked 96 patients with a Kock ileal reservoir for con70 cm. of the distal ileum are used. This part of the small tinent urinary diversion or ileal reservoir for orthotopic bladintestine is important for resorption of bile acids. Bile acids der reconstruction for 1to 20 years to record bowel habits and are recycled 6 to 10 times a day and less than 5% are excreted abdominal problems for 1week. Of the patients 82 responded in the feces daily.' Reduced resorption of bile acids in the of whom 7 were excluded from further analysis since they ileum causes abnormal high concentrations in the colon lead- used cholestyramine or high doses of morphine. Sex, divering to diarrhea due t o altered sodium absorption.2 Bile acid sion type, mean age, postoperative interval and reason for malabsorption leading to diarrhea has been reported in pa- diversion are given for the remaining 75 patients in table 1. The SeHCAT test was administered preoperatively and 6 tients with Crohn's disease after ileal resection as well as in patients treated with radiation.3 The absorption of bile acids can be measured by an oral capsule containing selenium-75 labeled tauroselcholic acid TABLE1. Patient characteristics (SeHCAT retention test). SeHCAT is the taurine conjugate of a synthetic bile acid containing the gamma emitting radionuclide selenium-75. SeHCAT has been shown to behave in 75 21 17 the enterohepatic circulation like natural taurine conjugated Total No. pts. women 13 43 11 bile acids.4 After oral administration of the radioactive tracer No. No. men 32 6 8 at least 10%should normally be retained in the body after 7 No. Continent urinary diversion 71 17 20 No. Orthotopic bladder mnstruction 4 0 1 days." We investigated the bowel habits of patients with a 56 ( 2 1 4 1 ) 56 (33-71) 55 (2%77) Kock urinary reservoir and the effects of this operation on Mean age (range) 7 (1-20) 7 (2-14) Mean F. postop. (range) bile acid absorption. No. reason for diversion:
Accepted for publication March 6,1998. * Requests for reprints: Department of Urology, SahlgrenskaUniversity Hospital, S-41345 Goteborg, Sweden. Editor's Note: This article is the fourth of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 866 and 867.
Bladder Ca Gynemlcgical Ca Neurogenic bladder disorder Interstitial cystitis Congenital malformation Other No. reason for SeHCAT test Bowel problems B12 less than 200 pmolfl.
124
33 2 25 2 9 4
7 0 8 2
-
9 3 5 2 2 0 9 12
BILE ACID MALABSORPTION AFTER DIVERSION
months postoperatively to 17 patients, and 2 to 14 years after urinary diversion to 21 (table 1).The retention test was also given to 22 women 25 to 55 years old (mean age 39) and 7 men 25 to 55 years old (mean 45) without known bowel dysfunction.
725
60 50
METHODS
The patients were asked to answer a questionnaire concerning bowel movements, consistency of feces, and occurrence of abdominal pain, abdominal distension and flatulence for 7 consecutive days. The consistency of feces was graded as firm (11, loose (2) or watery (3). Abdominal pain and distension, and flatulence were graded as none (O), mild (l), moderate (2) or severe (3). For the SeHCAT retention test a capsule containing 150 to 370 KBq. (4 t o 10 pCiJ selenium-75 labeled tauroselcholic acid was given orally to the patients. Before administration the exact activity of the capsule was measured in a Capintec* radioisotope calibrator. A gamma camera with a circular field of view and a diameter of 40 cm. was used. The energy window was set at 270 keV. with a width of 25%. Prone and supine measurements were done with the patient lying on the floor on a thin mattress, and the gamma camera was positioned 60 cm. above and centered over the upper abdominal region. The measurements were made with a circular masking ring limiting the diameter of the area of detection to 40 cm. Gamma camera measurements were made 7 days after ingesting the SeHCAT capsule, and the registration time for each projection was 1 minute. Registered counts were corrected for background and physical decay. Mean value of the counts of the 2 projections was calculated and used for calculating percent retained SeHCAT 7 days after administration. Values are given as mean plus or minus standard deviation. The Mann-Whitney U test and Wilcoxon test for paired differences were used for calculation of the statistical significance of the differences.
40
30 20 10
0 <10
10-14 10-15 >ZO
Defecations per week FIG. 1. Number of defecations per week in 75 patients with Kock ileal reservoir.
operatively were 15 ? 18% (median 9, range 0 to 68, fig. 4). The results of the SeHCAT retention test performed on norBowel habits and abdominal symptoms. Mean number of mal subjects were 39 ? 18%(median 38, range 8 t o 93, fig. 4). defecations per week was 9.4 2 6.1 (75 cases). The corre- The difference between mean values for the SeHCAT test in sponding figure was 10.0 2 7.5 for 43 women and 8.6 ? 3.4 normal subjects and patients analyzed postoperatively was for 32 men (not significant). Of the 75 patients 25 (33%) had highly significant (p
BILE ACID MALABSORPTION AFTER DIVERSION
50 40 c
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>1.7
Pre op
Consistency of the feces FIG. 2. Consistency of feces (1-normal, 75 patients with Kock ileal reservoir.
2-1oose,
3-watery)
in
malabsorption is a more common cause of chronic diarrhea than is generally appreciated. The outcome of repeated tests in the same patient is fairly consistent with a correlation coefficient of 0.93.4 Exclusion of 55 to 70 cm. of ileum from the gastrointestinal tract implies that the SeHCAT retention is reduced by 15% units as demonstrated in our study. From the slopes of the regression curves in figures 5 and 6 it can be estimated that a reduction in SeHCAT retention of this magnitude on average corresponds to 2 extra defecations per week and an increase in the consistency index of 0.2. Although the burden for patients of these changes in bowel habits might seem to be of slight importance, the difference in bowel habits for those with a pathological postoperative test compared to those with a normal test is more impressive as indicated in table 2. All patients with more than 10 defecations a week had a pathological SeHCAT retention test (fig. 5). Although most patients with loose and frequent defecations due to bile acid malabsorption respond favorably t o treatment with cholestyramine, some have persistent bowel problems and some do not tolerate cholestyramine treatment. Obviously, it would be of value if patients prone to bile acid malabsorption could be identified preoperatively. As demonstrated in figure 3 , 6 of 7 patients who postoperatively had a pathological test had a preoperative test value greater than 14%, reflecting bile acid absorption that should not result in frequent stools but loose defecation (figs. 5 and 6). It is not economically feasible to perform a preoperative SeHCAT retention test on all ileum reservoir cases. However, patients should be carefully questioned concerning bowel habits preoperatively and a test performed in those with loose, frequent stools before surgery. Other types of urinary diversion than ileum reservoir should be considered when a SeHCAT retention test is pathological or subnormal preoperatively to avoid severe postoperative problems. This test is especially important for patients with a neurogenic bladder disorder when anal sphincter control might be impaired.
Post op
FIG.3. Results of SeHCAT tests preoperatively and 6 months postoperatively in 17 patients with continent urinary diversion. Solid lines indicate patients with normal postoperative test and broken lines represent those with postoperative retention less than 10%.
14
I 0
10
20
30 SeHCAT retention. Per cent
FIG. 4. Distribution of SeHCAT test results for 38 patients postoperatively (shaded columns) and 29 without known bowel dysfunction (open columns).
The exact figure for postoperative bile acid malabsorption in these patients cannot be deduced from our study since not all were examined with the SeHCAT retention test but the data from the prospective part of the study indicate a figure of about 30 to 40%. Although bile acid malabsorption appears to be fairly common after this kind of surgery, it does not cause malnutrition. Campanello et a1 found that body mass index and total body fat fraction in patients with ileum reservoirs for up to 18 years postoperatively were close t o corresponding values reported for healthy age matched controls, indicating good general health of the patients.8 The observation that the SeHCAT retention test performed postoperatively is not correlated to abdominal pain, abdominal distension or flatulence indicates that these symptoms are not caused by bile acid malabsorption. The patients subjected to urinary diversion have been operated on for various reasons,
Y Q
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50 40
lo
demonstrated by Durrans et a1 in a retrospective study.9 In another retrospective study 8 of 14 patients treated with clam enterocystoplasty had a pathological SeHCAT test. 10 Roth et a1 compared bowel habits of patients with continent urinary diversion using either ileal or ileocecal segments." Chronic diarrhea occurred in 11%of ileal and in 23% of ileocecal resection cases. The higher incidence of diarrhea in the latter group was ascribed to reduced intestinal transit time in combination with impaired ileal absorption of bile acids. Some of these patients did not respond to cholestyramine treatment. Thus, patients who preoperatively have loose frequent stools and in whom bile acid malabsorption is suspected should not undergo ileum or ileocecal resection. For these patients we recommend a colon segment for construction of a continent reservoir or a conduit.
u)
C .o 30 c
a
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5
20
n t3
10
'0 u0
z5
0
CONCLUSIONS
0
20
10
30
40
50
60
70
Se HCAT retention. Per cent FIG.5. Relation between number of defecations per week and SeHCAT test in 26 patients postoperatively (r = 0.44, p = 0.02).
2.2
727
BILE ACID MALABSORPTION AFTER DIVERSION
1
Our study indicates that continent urinary diversion or orthotopic bladder reconstruction with a Kock ileal reservoir results in a significant reduction in the SeHCAT retention test reflecting reduced bile acid absorption. Bile acid malabsorption is demonstrated in approximately a third of the patients postoperatively. Most patients have fairly normal bowel habits. Patients who have diarrhea preoperatively should be evaluated with a SeHCAT retention test and other types of diversion should be offered when retention is below 10 to 20%, especially in those with impaired anal control. REFERENCES
h
0
c
Q)
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.-
1.4
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0
1.2 1.o
0.8
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I
10
I
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20
30
40
50
\ 60
70
Se HCAT retention. Per cent FIG. 6. Relation between consistency of feces (1-normal, %loose, 3-watery) and SeHCAT test in 26 patients postoperatively (r = 0.43, p = 0.03). TABLE2. Bowel habits and abdominal symptom scores in 26 Datients with normal or pathological SeHCAT retention test Mean 2 SD SeHCAT Normal (13 pts.) Defecationdwk. Consistency Abdominal pain Abdominal distension
6.3 2 1.2 2 0.3 c 0.5 2
Flatnlc=nrP
0.5 2
1.5 0.3 0.7 0.6 0.6
SeHCAT Pathological (13 pts.)
p Value
14.5 i 8.9 1.5 i 0.4 0.3 i 0.8 0.5 2 0.9 0.3 2 0.5
0.001 0.04 Not significant Not significant Not simificant
for example bladder carcinoma, neurogenic bladder disease and interstitial cystitis. The abdominal symptoms are probably to a large extent explained by these diagnoses. Conduit urinary diversion using only some 15 cm. of distal ileum is associated with impaired SeHCAT retention and increased bowel movements compared to normal subjects as
1. Greenberger, N. J.: Small intestine. In: Gastrointestinal Disorders: A Pathophysiologic Approach, 4th ed. Chicago: Year Book Medical Publishers, p. 121, 1989. 2. Dowling, R. H.: Bile acids in constipation and diarrhoea. In: Bile Acids in Gastroenterology. Edited by L. Barbara, R. H. Dowling, A. F. Hofmann and E. Roda. Lancaster: MTP Press, chapt. 10, pp. 157-171, 1983. 3. Boyd, G. S., Merrick, M. V., Monks, R. and Thomas, I. L.: Se-75labeled bile acid analogs, new radiopharmaceuticals for investigating the enterohepatic circulation. J . Nucl. Med., 2 2 720, 1981. 4. Fellous, K., Jian, R., Haniche, M., Marteau, P., Messing, B., Rain, J. D. and Modigliani, R.: Mesure de l'absorption ileale des sels biliaires par le test a l'homotaurocholate marque au selenium 75. Validation et signification clinique. Gastroenterol. Clin. Biol., 18: 865, 1994. 5. Sandler, R. S. and Drossman, D. A.: Bowel habits in young adults not seeking health care. Dig. Dis. Sci., 3 2 841, 1987. 6. Everhart, J. E., Go, V. L., Johannes, R. S., Fitzsimmons, S. C., Roth, H. P. and White, L. R.: A longitudinal survey of selfreported bowel habits in the United States. Dig. Dis. Sci., 34: 1153, 1989. 7. Merrick, M. V., Eastwood, M. A. and Ford, M. J.: Is bile acid malabsorption underdiamosed? An evaluation of accuracy of diagnosis-by measurement of SeHCAT retention. Brit. Med: J., 290.665, 1985. 8. Campanello, M., Herlitz, H., Lindstedt, G., Mellstrom, D., Wilske, J., k e r l u n d , S. and Jonsson, 0.: Bone mineral and related biochemical variables in patients with a Kock ileal reservoir or Bricker conduit for urinarv diversion. J . Urol.. 155 1209, 1996. 9. Durrans. D.. Wuianto.. R... Carroll. R. N. and Torrance. H. B.: Bile acid malabsorption: a complication of conduit surgery. Brit. J. Urol., 64:485, 1989. R. J., Evans, D., lo. Bannieon, J. w., Fern-Davies, H., Woodcock, J. P. and Stephenson, T. P.: Bile acid dysfunction after clam enterocystoplasty. Brit. J . Urol., 7 6 169, 1995. 11. Roth, S., Semjonow, A,, Waldner, M. and Hertle, L.: Risk of bowel dysfunction with diarrhea after continent urinary diversion with ileal and ileocecal segments. J. Urol., 154: 1696, 1995.
-
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Vol. 160, 724-727, September 1998 Printed in U.S.A.
THE JOL'RNAL OF UROLOGY Copyright 0 1998 by AMERIC.AN URoLocir.a ASSOCIATION, Ixc
BILE ACID MALABSORPTION AFTER CONTINENT URINARY DrVERSION WITH AN ILEAL RESERVOIR GUNNAR OLOFSSON, MARTHA F J k L I N G , ANDERS KILANDER, KJELL ARNE UNG OLOF JONSSON*
AND
From the Departments of Urology, Internal Medicine and Nuclear Medicine, Sahlgrenska University Hospital, Gdteborg, Sweden
ABSTRACT
Purpose: We determine the effect of urinary diversion with a Kock ileal reservoir on bile acid absorption and bowel habits. Materials and Methods: We asked 96 patients with a Kock ileal urinary reservoir to record bowel habits and abdominal symptoms for 1 week. Data on 75 patients were further analyzed. Bile acid absorption was determined in 29 healthy control subjects, in 17 before and 6 months after continent urinary diversion, and in 21, 2 to 14 years postoperatively. Bile acid absorption was considered pathological when retention of less than 10% of a n oral capsule containing selenium-75 labeled tauroselcholic acid (SeHCAT) was noted after 1 week. Results: Mean number of defecations plus or minus standard deviation was 9.4 ? 6.1 (75 cases). Of the patients 13%had 15 or more stools per week and 15%complained of always having loose stools. Mean value for the SeHCAT test was 32 5 19% preoperatively and 17 ? 16% 6 months postoperatively (p = 0.0023).The corresponding value for healthy controls was 39 -t 18%. Significant relationships were found between the results of the SeHCAT test postoperatively, and the number of stools per week and consistency of the feces. All patients with more than 10 defecations per week had a pathological SeHCAT test. Conclusions: Most patients with a n ileal urinary reservoir have fairly normal bowel habits. Bile acid absorption is significantly reduced postoperatively and approximately a third of the patients have a pathological SeHCAT test. Preoperative investigation of bowel habits is recommended and a SeHCAT test should be performed in patients with frequent, loose defecations. Other types of diversion should be offered when preoperative retention is below 10 to 20%especially in patients with impaired anal control. KEY WORDS:proctocolectomy, restorative; urinary diversion; bile acids and salts PATIENTS In the construction of a Kock ileal reservoir for continent urinary diversion or orthotopic bladder reconstruction 55 to We asked 96 patients with a Kock ileal reservoir for con70 cm. of the distal ileum are used. This part of the small tinent urinary diversion or ileal reservoir for orthotopic bladintestine is important for resorption of bile acids. Bile acids der reconstruction for 1to 20 years to record bowel habits and are recycled 6 to 10 times a day and less than 5% are excreted abdominal problems for 1week. Of the patients 82 responded in the feces daily.' Reduced resorption of bile acids in the of whom 7 were excluded from further analysis since they ileum causes abnormal high concentrations in the colon lead- used cholestyramine or high doses of morphine. Sex, divering to diarrhea due t o altered sodium absorption.2 Bile acid sion type, mean age, postoperative interval and reason for malabsorption leading to diarrhea has been reported in pa- diversion are given for the remaining 75 patients in table 1. The SeHCAT test was administered preoperatively and 6 tients with Crohn's disease after ileal resection as well as in patients treated with radiation.3 The absorption of bile acids can be measured by an oral capsule containing selenium-75 labeled tauroselcholic acid TABLE1. Patient characteristics (SeHCAT retention test). SeHCAT is the taurine conjugate of a synthetic bile acid containing the gamma emitting radionuclide selenium-75. SeHCAT has been shown to behave in 75 21 17 the enterohepatic circulation like natural taurine conjugated Total No. pts. women 13 43 11 bile acids.4 After oral administration of the radioactive tracer No. No. men 32 6 8 at least 10%should normally be retained in the body after 7 No. Continent urinary diversion 71 17 20 No. Orthotopic bladder mnstruction 4 0 1 days." We investigated the bowel habits of patients with a 56 ( 2 1 4 1 ) 56 (33-71) 55 (2%77) Kock urinary reservoir and the effects of this operation on Mean age (range) 7 (1-20) 7 (2-14) Mean F. postop. (range) bile acid absorption. No. reason for diversion:
Accepted for publication March 6,1998. * Requests for reprints: Department of Urology, SahlgrenskaUniversity Hospital, S-41345 Goteborg, Sweden. Editor's Note: This article is the fourth of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 866 and 867.
Bladder Ca Gynemlcgical Ca Neurogenic bladder disorder Interstitial cystitis Congenital malformation Other No. reason for SeHCAT test Bowel problems B12 less than 200 pmolfl.
124
33 2 25 2 9 4
7 0 8 2
-
9 3 5 2 2 0 9 12
BILE ACID MALABSORPTION AFTER DIVERSION
months postoperatively to 17 patients, and 2 to 14 years after urinary diversion to 21 (table 1).The retention test was also given to 22 women 25 to 55 years old (mean age 39) and 7 men 25 to 55 years old (mean 45) without known bowel dysfunction.
725
60 50
METHODS
The patients were asked to answer a questionnaire concerning bowel movements, consistency of feces, and occurrence of abdominal pain, abdominal distension and flatulence for 7 consecutive days. The consistency of feces was graded as firm (11, loose (2) or watery (3). Abdominal pain and distension, and flatulence were graded as none (O), mild (l), moderate (2) or severe (3). For the SeHCAT retention test a capsule containing 150 to 370 KBq. (4 t o 10 pCiJ selenium-75 labeled tauroselcholic acid was given orally to the patients. Before administration the exact activity of the capsule was measured in a Capintec* radioisotope calibrator. A gamma camera with a circular field of view and a diameter of 40 cm. was used. The energy window was set at 270 keV. with a width of 25%. Prone and supine measurements were done with the patient lying on the floor on a thin mattress, and the gamma camera was positioned 60 cm. above and centered over the upper abdominal region. The measurements were made with a circular masking ring limiting the diameter of the area of detection to 40 cm. Gamma camera measurements were made 7 days after ingesting the SeHCAT capsule, and the registration time for each projection was 1 minute. Registered counts were corrected for background and physical decay. Mean value of the counts of the 2 projections was calculated and used for calculating percent retained SeHCAT 7 days after administration. Values are given as mean plus or minus standard deviation. The Mann-Whitney U test and Wilcoxon test for paired differences were used for calculation of the statistical significance of the differences.
40
30 20 10
0 <10
10-14 10-15 >ZO
Defecations per week FIG. 1. Number of defecations per week in 75 patients with Kock ileal reservoir.
operatively were 15 ? 18% (median 9, range 0 to 68, fig. 4). The results of the SeHCAT retention test performed on norBowel habits and abdominal symptoms. Mean number of mal subjects were 39 ? 18%(median 38, range 8 t o 93, fig. 4). defecations per week was 9.4 2 6.1 (75 cases). The corre- The difference between mean values for the SeHCAT test in sponding figure was 10.0 2 7.5 for 43 women and 8.6 ? 3.4 normal subjects and patients analyzed postoperatively was for 32 men (not significant). Of the 75 patients 25 (33%) had highly significant (p
BILE ACID MALABSORPTION AFTER DIVERSION
50 40 c
5
60
0
2i
30
a
50
e
0 .c
s
40
c
L
20
l-
a 30 0
I
g
10
I
20 10
0 1-1.2
1.3-1.7
0
>1.7
Pre op
Consistency of the feces FIG. 2. Consistency of feces (1-normal, 75 patients with Kock ileal reservoir.
2-1oose,
3-watery)
in
malabsorption is a more common cause of chronic diarrhea than is generally appreciated. The outcome of repeated tests in the same patient is fairly consistent with a correlation coefficient of 0.93.4 Exclusion of 55 to 70 cm. of ileum from the gastrointestinal tract implies that the SeHCAT retention is reduced by 15% units as demonstrated in our study. From the slopes of the regression curves in figures 5 and 6 it can be estimated that a reduction in SeHCAT retention of this magnitude on average corresponds to 2 extra defecations per week and an increase in the consistency index of 0.2. Although the burden for patients of these changes in bowel habits might seem to be of slight importance, the difference in bowel habits for those with a pathological postoperative test compared to those with a normal test is more impressive as indicated in table 2. All patients with more than 10 defecations a week had a pathological SeHCAT retention test (fig. 5). Although most patients with loose and frequent defecations due to bile acid malabsorption respond favorably t o treatment with cholestyramine, some have persistent bowel problems and some do not tolerate cholestyramine treatment. Obviously, it would be of value if patients prone to bile acid malabsorption could be identified preoperatively. As demonstrated in figure 3 , 6 of 7 patients who postoperatively had a pathological test had a preoperative test value greater than 14%, reflecting bile acid absorption that should not result in frequent stools but loose defecation (figs. 5 and 6). It is not economically feasible to perform a preoperative SeHCAT retention test on all ileum reservoir cases. However, patients should be carefully questioned concerning bowel habits preoperatively and a test performed in those with loose, frequent stools before surgery. Other types of urinary diversion than ileum reservoir should be considered when a SeHCAT retention test is pathological or subnormal preoperatively to avoid severe postoperative problems. This test is especially important for patients with a neurogenic bladder disorder when anal sphincter control might be impaired.
Post op
FIG.3. Results of SeHCAT tests preoperatively and 6 months postoperatively in 17 patients with continent urinary diversion. Solid lines indicate patients with normal postoperative test and broken lines represent those with postoperative retention less than 10%.
14
I 0
10
20
30 SeHCAT retention. Per cent
FIG. 4. Distribution of SeHCAT test results for 38 patients postoperatively (shaded columns) and 29 without known bowel dysfunction (open columns).
The exact figure for postoperative bile acid malabsorption in these patients cannot be deduced from our study since not all were examined with the SeHCAT retention test but the data from the prospective part of the study indicate a figure of about 30 to 40%. Although bile acid malabsorption appears to be fairly common after this kind of surgery, it does not cause malnutrition. Campanello et a1 found that body mass index and total body fat fraction in patients with ileum reservoirs for up to 18 years postoperatively were close t o corresponding values reported for healthy age matched controls, indicating good general health of the patients.8 The observation that the SeHCAT retention test performed postoperatively is not correlated to abdominal pain, abdominal distension or flatulence indicates that these symptoms are not caused by bile acid malabsorption. The patients subjected to urinary diversion have been operated on for various reasons,
Y Q
$ fP
50 40
lo
demonstrated by Durrans et a1 in a retrospective study.9 In another retrospective study 8 of 14 patients treated with clam enterocystoplasty had a pathological SeHCAT test. 10 Roth et a1 compared bowel habits of patients with continent urinary diversion using either ileal or ileocecal segments." Chronic diarrhea occurred in 11%of ileal and in 23% of ileocecal resection cases. The higher incidence of diarrhea in the latter group was ascribed to reduced intestinal transit time in combination with impaired ileal absorption of bile acids. Some of these patients did not respond to cholestyramine treatment. Thus, patients who preoperatively have loose frequent stools and in whom bile acid malabsorption is suspected should not undergo ileum or ileocecal resection. For these patients we recommend a colon segment for construction of a continent reservoir or a conduit.
u)
C .o 30 c
a
0 Q
5
20
n t3
10
'0 u0
z5
0
CONCLUSIONS
0
20
10
30
40
50
60
70
Se HCAT retention. Per cent FIG.5. Relation between number of defecations per week and SeHCAT test in 26 patients postoperatively (r = 0.44, p = 0.02).
2.2
727
BILE ACID MALABSORPTION AFTER DIVERSION
1
Our study indicates that continent urinary diversion or orthotopic bladder reconstruction with a Kock ileal reservoir results in a significant reduction in the SeHCAT retention test reflecting reduced bile acid absorption. Bile acid malabsorption is demonstrated in approximately a third of the patients postoperatively. Most patients have fairly normal bowel habits. Patients who have diarrhea preoperatively should be evaluated with a SeHCAT retention test and other types of diversion should be offered when retention is below 10 to 20%, especially in those with impaired anal control. REFERENCES
h
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.-
1.4
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0
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0.8
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I
10
I
I
I
I
20
30
40
50
\ 60
70
Se HCAT retention. Per cent FIG. 6. Relation between consistency of feces (1-normal, %loose, 3-watery) and SeHCAT test in 26 patients postoperatively (r = 0.43, p = 0.03). TABLE2. Bowel habits and abdominal symptom scores in 26 Datients with normal or pathological SeHCAT retention test Mean 2 SD SeHCAT Normal (13 pts.) Defecationdwk. Consistency Abdominal pain Abdominal distension
6.3 2 1.2 2 0.3 c 0.5 2
Flatnlc=nrP
0.5 2
1.5 0.3 0.7 0.6 0.6
SeHCAT Pathological (13 pts.)
p Value
14.5 i 8.9 1.5 i 0.4 0.3 i 0.8 0.5 2 0.9 0.3 2 0.5
0.001 0.04 Not significant Not significant Not simificant
for example bladder carcinoma, neurogenic bladder disease and interstitial cystitis. The abdominal symptoms are probably to a large extent explained by these diagnoses. Conduit urinary diversion using only some 15 cm. of distal ileum is associated with impaired SeHCAT retention and increased bowel movements compared to normal subjects as
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