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The dilemma of laxative abuse
1 Breast Cancer Consensus Report. The management of newly
diagnosed early breast cancer: a national approach to breast cancer control. Med J Aust 1994; 161 (suppl). 2 Clinical practice guidleines for the management of early breast cancer. Canberra: national Health and Medical Research Council, 1995. 3 Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 1990; 301: 575-80. 4 Moorey S, Greer S. Psychological therapy for patients with cancer: a new approach. Oxford: Heinemann, 1989. 5 Greer S, Moorey S, Baruch JD, et al. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 1992; 304: 675-80. 6 Anderson BL. 7
8
9
10
11
12
Psychological interventions for cancer patients to enhance quality of life. J Consult Clin Psychol 1992; 60: 552-68. Trijsburg RW, Van Knippenberg FC, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. Psychom Med 1992; 54: 489-17. Presberg BA, Levenson JL. A survey of cancer support groups by National Cancer Institute (NCI) Clinical and Comprehensive Centres. Psycho-Oncology 1993; 2: 215-17. Mulder CL,Van Der Pompe G, Spiegel D, Antoni MH, De Vries MJ. Do psychosocial factors influence the course of breast cancer? A review of recent literature, methodological problems and future directions. Psycho-Oncology 1992; 1: 155-67. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; i: 888-91. Fawzy FI, Fawzy NW, Hyun CS, et al. Effects of an early structured psychiatric invention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 1993; 50: 681-89. Greer S, Morris T, Pettingale KW, Haybittle JL. Psychological response to breast cancer and 15-year outcome. Lancet 1990; 335: 49-50.
The dilemma of laxative abuse Chronic diarrhoea has been defined as diarrhoea that lasts for more than 4 weeks, by which time the self-limiting infectious enteritides will have resolved. However, the definition of diarrhoea per se is not clear. One suggestion is a stool weight of more than 200 g-judged according to this criterion, most of the inhabitants of Africa and even 20% of normal Scots have the condition. The symptom of an obligation to pass stool irrespective of number of times or weight is more important. In these circumstances the stool may be pellety (functional bowel disease type), normal, steatorrhoeic, or watery. The diagnosis of chronic diarrhoea can be difficult even for specialised centres.’,2 The clinical evaluation of chronic diarrhoea is essentially a two-stage procedure. First comes an outpatient investigation with a history and the standard examinations-clinical, radiographic, and endoscopic with biopsies of the colon and jejunum. Pancreatic function tests, breath hydrogen/glucose tests for bacterial colonisation, and bile acid malabsorption tests are part of this evaluation. A careful drug history-eg, with respect to mefenamic acid and alcohol-is important. If such an investigation does not provide an answer, inpatient investigations are warranted. Stool collections over 3 days during which the patient receives a normal diet give an indication of a diagnosis-eg, irritable bowel syndrome. If the patient is maintained on intravenous fluids, stool weight and water constituents are more revealing; measurement of the osmotic gap in the faecal water of such patients can be very useful. However, individual stools from a patient may differ in composition, and such differences can occur for pathological reasonseg, carbohydrate fermentation. A small osmolality gap is found with laxative abuse.’1 Using faecal water estimations (electrolytes and osmolality) Phillips and his colleagues’ have lately identified two subgroups of patients with chronic
diarrhoea. In the first-functional diarrhoea-all the tests normal. The diagnosis of factitious diarrhoea was made when laxatives were detected in the faecal water or if the faeces were deliberately diluted. The faecal was water analysed for magnesium, phosphorus, phenolphthalein, anthraquinone laxatives, and biscacodyl. An easier analysis for laxatives applies thin layer chromatography to urine. Such tests are often best conducted on arrival in the ward, or on an outpatient were
sample. Laxative abusers often have a connection with the health professions, and more recently have included anxious patients with personal views on body shaped The diagnosis of laxative abuse results in more questions than answers. And how should one set about diagnosing such cases? If the former practice wherein the ward sister rummaged through the patient’s locker looking for illicit laxatives is improper, is it appropriate to analyse faeces and urine without the patient’s permission? What is the best approach to such an exposure? An appeal has been made for medical help, yet the cause is secretly known to the patient, and now equally clandestinely by the clinician. Somehow this information has to be shared and both parties have to come to terms with this new order. As to the long-term outcome of laxative abuse, if the problem is a self-limiting fad then symptomatic and nonconfrontational treatment will suffice. If the condition is a danger to life, the burden of care must be shouldered by one professional carer with whom trust can be developed, ideally the patient’s general practitioner. Martin Eastwood Gastrointestinal Unit, Department of Medicine, Western General Hospital, Edinburgh, UK 1
2
3 4
University of Edinburgh,
Phillips S, Donaldson L, Geisler K, Pera A, Kochar R. Stool composition in factitial diarrhea: a 6-year experience with stool analysis. Ann Intern Med 1995; 123: 97-100. Read NW, Krejs GJ, Read MG, Santa Ara CA, Morawski SG, Fordtran JS. Chronic diarrhoea of unknown origin. Gastroenterology 1980; 78: 264-71. Morton J. The detection of laxative abuse. Ann Clin Biochem 1987; 24: 107-08. Neims DM, McNeill J, Giles TR, Todd F. Incidence of laxative abuse in community and bulimic populations: a descriptive review. Int J Eat
Disorder 1995; 17: 211-28. 5
Weltzin TE, Bulik CM, McConaha CW, Kaye withdrawal and anxiety in bulimia nervosa. Int 141-46.
Hazards of
WH. Laxative J Eat Disord 1995; 17:
misguided ethics committees
Most people would probably agree that the review of clinical trial protocols by independent ethics committees is an important step in the right direction, correcting past inadequacies in the conduct of research involving human subjects. Nevertheless, the work of such committees has not always been greeted with enthusiasm. Penn and Steer’ lately voiced their concern that, in the UK, "the arcane processes of current local research ethics committee procedures, are sometimes cumbersome to the point of unworkability". The problems with ethics committees are, however, not confined to Britain or limited to administrative nuisances. Far more disturbing is the fact that committees may arrive at scientifically questionable and even unethical conclusions. Consider one example. Hummel et aP reported the results of a clinical study of the peptide urodilatin in
1115
diagnosed early breast cancer: a national approach to breast cancer control. Med J Aust 1994; 161 (suppl). 2 Clinical practice guidleines for the management of early breast cancer. Canberra: national Health and Medical Research Council, 1995. 3 Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 1990; 301: 575-80. 4 Moorey S, Greer S. Psychological therapy for patients with cancer: a new approach. Oxford: Heinemann, 1989. 5 Greer S, Moorey S, Baruch JD, et al. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 1992; 304: 675-80. 6 Anderson BL. 7
8
9
10
11
12
Psychological interventions for cancer patients to enhance quality of life. J Consult Clin Psychol 1992; 60: 552-68. Trijsburg RW, Van Knippenberg FC, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. Psychom Med 1992; 54: 489-17. Presberg BA, Levenson JL. A survey of cancer support groups by National Cancer Institute (NCI) Clinical and Comprehensive Centres. Psycho-Oncology 1993; 2: 215-17. Mulder CL,Van Der Pompe G, Spiegel D, Antoni MH, De Vries MJ. Do psychosocial factors influence the course of breast cancer? A review of recent literature, methodological problems and future directions. Psycho-Oncology 1992; 1: 155-67. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; i: 888-91. Fawzy FI, Fawzy NW, Hyun CS, et al. Effects of an early structured psychiatric invention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 1993; 50: 681-89. Greer S, Morris T, Pettingale KW, Haybittle JL. Psychological response to breast cancer and 15-year outcome. Lancet 1990; 335: 49-50.
The dilemma of laxative abuse Chronic diarrhoea has been defined as diarrhoea that lasts for more than 4 weeks, by which time the self-limiting infectious enteritides will have resolved. However, the definition of diarrhoea per se is not clear. One suggestion is a stool weight of more than 200 g-judged according to this criterion, most of the inhabitants of Africa and even 20% of normal Scots have the condition. The symptom of an obligation to pass stool irrespective of number of times or weight is more important. In these circumstances the stool may be pellety (functional bowel disease type), normal, steatorrhoeic, or watery. The diagnosis of chronic diarrhoea can be difficult even for specialised centres.’,2 The clinical evaluation of chronic diarrhoea is essentially a two-stage procedure. First comes an outpatient investigation with a history and the standard examinations-clinical, radiographic, and endoscopic with biopsies of the colon and jejunum. Pancreatic function tests, breath hydrogen/glucose tests for bacterial colonisation, and bile acid malabsorption tests are part of this evaluation. A careful drug history-eg, with respect to mefenamic acid and alcohol-is important. If such an investigation does not provide an answer, inpatient investigations are warranted. Stool collections over 3 days during which the patient receives a normal diet give an indication of a diagnosis-eg, irritable bowel syndrome. If the patient is maintained on intravenous fluids, stool weight and water constituents are more revealing; measurement of the osmotic gap in the faecal water of such patients can be very useful. However, individual stools from a patient may differ in composition, and such differences can occur for pathological reasonseg, carbohydrate fermentation. A small osmolality gap is found with laxative abuse.’1 Using faecal water estimations (electrolytes and osmolality) Phillips and his colleagues’ have lately identified two subgroups of patients with chronic
diarrhoea. In the first-functional diarrhoea-all the tests normal. The diagnosis of factitious diarrhoea was made when laxatives were detected in the faecal water or if the faeces were deliberately diluted. The faecal was water analysed for magnesium, phosphorus, phenolphthalein, anthraquinone laxatives, and biscacodyl. An easier analysis for laxatives applies thin layer chromatography to urine. Such tests are often best conducted on arrival in the ward, or on an outpatient were
sample. Laxative abusers often have a connection with the health professions, and more recently have included anxious patients with personal views on body shaped The diagnosis of laxative abuse results in more questions than answers. And how should one set about diagnosing such cases? If the former practice wherein the ward sister rummaged through the patient’s locker looking for illicit laxatives is improper, is it appropriate to analyse faeces and urine without the patient’s permission? What is the best approach to such an exposure? An appeal has been made for medical help, yet the cause is secretly known to the patient, and now equally clandestinely by the clinician. Somehow this information has to be shared and both parties have to come to terms with this new order. As to the long-term outcome of laxative abuse, if the problem is a self-limiting fad then symptomatic and nonconfrontational treatment will suffice. If the condition is a danger to life, the burden of care must be shouldered by one professional carer with whom trust can be developed, ideally the patient’s general practitioner. Martin Eastwood Gastrointestinal Unit, Department of Medicine, Western General Hospital, Edinburgh, UK 1
2
3 4
University of Edinburgh,
Phillips S, Donaldson L, Geisler K, Pera A, Kochar R. Stool composition in factitial diarrhea: a 6-year experience with stool analysis. Ann Intern Med 1995; 123: 97-100. Read NW, Krejs GJ, Read MG, Santa Ara CA, Morawski SG, Fordtran JS. Chronic diarrhoea of unknown origin. Gastroenterology 1980; 78: 264-71. Morton J. The detection of laxative abuse. Ann Clin Biochem 1987; 24: 107-08. Neims DM, McNeill J, Giles TR, Todd F. Incidence of laxative abuse in community and bulimic populations: a descriptive review. Int J Eat
Disorder 1995; 17: 211-28. 5
Weltzin TE, Bulik CM, McConaha CW, Kaye withdrawal and anxiety in bulimia nervosa. Int 141-46.
Hazards of
WH. Laxative J Eat Disord 1995; 17:
misguided ethics committees
Most people would probably agree that the review of clinical trial protocols by independent ethics committees is an important step in the right direction, correcting past inadequacies in the conduct of research involving human subjects. Nevertheless, the work of such committees has not always been greeted with enthusiasm. Penn and Steer’ lately voiced their concern that, in the UK, "the arcane processes of current local research ethics committee procedures, are sometimes cumbersome to the point of unworkability". The problems with ethics committees are, however, not confined to Britain or limited to administrative nuisances. Far more disturbing is the fact that committees may arrive at scientifically questionable and even unethical conclusions. Consider one example. Hummel et aP reported the results of a clinical study of the peptide urodilatin in
1115