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sbe considered when determining the need for aggressive management upon admission ofpatients with these colitides.

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Bacterial Overgrowth and Mucosal Inflammation in Irritable Bowel SyndromeRoss N. Butler, Lauren V. Garritt, Stamatiki Kritas, Geoff Davidson

Introduction: A high prevalence of small bowel bacterial overgrowth (SBBO) has beenreported in Irritable Bowel Syndrome (IBS) patients potentially contributing to symptoms.Low grade mucosal inflammation has also been implicated in at least a subset of patients.However, no relationship has been demonstrated between inflammation and the presenceof bacterial overgrowth in IBS patients. The aim of this study was to investigate the prevalenceof SBBO in IBS patients using the combined 14C-xylose/lactulose breath test and to correlatethe presence of SBBO with mucosal inflammation assessed by faecal calprotectin levels.Methods: Forty-nine IBS patients (53.78±2.19yrs) who fulfilled the ROME II criteria and26 healthy controls (50.62±3.24yrs) were enrolled. IBS patients were further categorisedinto diarrhoea predominant (n=25), constipation predominant (n=7) or mixed IBS (n=15).After an overnight fast, all subjects underwent a 14C-xylose/lactulose breath test. Breathsamples were collected before ingestion of the test solution and at 30min intervals for 240minand analysed for 14CO2, H2 and CH4. In addition, stool samples were collected for a faecalcalprotectin assay (normal <50mg/kg stool). Results: Nineteen IBS patients (40%) and eighthealthy controls (31%) were positive for SBBO based on the combined 14C xylose/lactulosebreath test. No significant differences were seen in the occurrence of SBBO in the IBS group(p=0.46) or in any IBS symptom sub-group (p=0.65). Twelve of 41 IBS patients (29%) werepositive for faecal calprotectin compared to only 5/16 controls (31%) (p>0.05). It wasinteresting to note that 50% of the IBS patients positive for mucosal inflammation were alsopositive for SBBO. Specifically these patients were exclusively positive for the 14C xylosebreath test (p<0.05). Conclusion: In this study, SBBO was not more prevalent in IBS patientscompared with healthy age matched controls. Inflammation was present in 50% of patientswith IBS who had SBBO and in no healthy controls. The positive 14C xylose breath test inthis group of IBS patients suggests that specific colonising organisms may be responsiblefor the inflammatory response and further studies are required.

S1275

Intestinal Ischemia Due to Sodium Polystyrene Sulfonate (Kayexalate) inSorbitol: Not Just in the Very IllChristopher E. McGowan, Sumona Saha, Grant Chu, Murray B. Resnick, Steven F. Moss

Background: Sodium polystyrene sulfonate (kayexalate) has been implicated in the develop-ment of intestinal necrosis. Sorbitol, added as a cathartic agent to kayexalate preparations,may be primarily responsible. Previous studies documented bowel necrosis primarily inuremic or post-operative patients. We sought to identify additional clinical characteristicsamong patients with kayexalate-induced intestinal necrosis. Methods: Rhode Island Hospitalsurgical pathology records were reviewed to identify all gastrointestinal specimens reportedas containing kayexalate crystals from December 1998 to June 2007. Patient demographics,medical comorbidities, and the hospital courses of histologically verified cases of intestinalnecrosis were extracted from the medical records. Results: Twenty-nine patients with reportsof kayexalate crystals were identified. Thirteen of these were excluded as incidental findingswith normal mucosa. Five further patients were excluded as their symptoms began prior tokayexalate administration or because of an alternative etiology for bowel ischemia. Thus 11patients had confirmed intestinal necrosis and a temporal relationship with kayexalateadministration strongly suggestive of kayexalate-induced ischemia. Most involved the colon(n=10), 2 had small bowel involvement. Median age was 75 years (range 30-91), and 9were female. Common medical comorbidities included hypertension (n=10), chronic renalfailure (n=7), and coronary artery disease (n=6). Four patients had hyperlipidemia, 3 haddiabetes, and 3 had chronic obstructive lung disease. Only 4 patients had end-stage renaldisease requiring hemodialysis. All patients had documented hyperkalemia (range: 5.5-8.3meq/L), though only a minority had associated EKG changes (n=2), altered mental status(n=3), or nausea/vomiting (n=3) suggestive of uremia. All patients received oral kayexalatein sorbitol in doses of 45-170g. Abdominal pain (n=9), distension (n=5), and gastrointestinalbleeding (n=5) were the most common symptoms of ischemic bowel. Time to symptomsafter kayexalate ranged from less than 24 hours to 11 days. Four patients (36%) died frombowel ischemia and/or perforation. Discussion: Intestinal ischemia is a recognized risk ofkayexalate in sorbitol. Our series highlights that patients may be susceptible even in theabsence of multiple co-morbidities, end-stage renal disease, or frank uremia. When treatinghyperkalemia, alternative means of potassium reduction should be utilized and if kayexalateis absolutely necessary, other vehicles (water, syrup) should be chosen instead of kayexalatein sorbitol.

S1276

In Patients with Severe Constipation, Can We Predict Delayed Colonic TransitOn the Basis of Symptoms?Philip G. Dinning, Mike Jones, Sergio E. Fuentealba, Nicholas J. Talley, Ian J. Cook

Background: Management of and research into severe constipation is plagued by the a lackof biomarkers. Delayed colonic transit is one such marker, but it is unknown whether slowtransit constipation can be predicted on the basis of symptoms alone. Aim: To determinewhether a constellation of constipation symptoms is predictive of delayed colonic transit.Methods: 91 patients with constipation presenting to a Gastroenterology clinic with severeconstipation underwent scintigraphic measurement of colon transit and completed a validated53-item, self-report questionnaire. Factor analysis was applied to determine whether constipa-tion-related symptoms (urge, straining, pain, completeness of evacuation, stool frequencyand consistency etc), laxative use and antecedent events (eg pelvic surgery) identified distinctaspects of constipation. Logistic regression was used to relate the probability of delayedtransit to the factors so derived. The area under the receiver operating characteristic (ROC)

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curve was calculated for the model-derived predicted probabilities with scintigraphy as thereference standard. Results: Sixty six of 91 patients (73%) had delayed transit, defined as> 9% (upper limit of normal in healthy females) colonic retention at 72hr. The questionnairedata yielded a 15 factor solution; 6 of which were identified as strongly predictive of delayedtransit (AUC = 0.82; figure). These factors included a reduced urge frequency, a feeling ofconstipation, loose or watery stool (rarely hard stool), high laxative usage, upper abdominalpain, infrequency defecation and an antecedent for their constipation. Conclusion. Combina-tions of constipation symptoms are predictive of delayed colonic transit. In this knowledge,refinement of a questionnaire may prove very helpful in deciding which patients shouldundergo formal transit measurement. Supported by NHMRC Australia

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Lactulose Versus Plantago Ovata in the Treatment of Haemorrhoids and/orAnal Fissure: Open Randomized Parallel Multicenter StudyMonica Perona, Fermin Mearin, Rafael Campo, Ines Modolell, Miguel Montoro, EnriqueDominguez-Munoz

Haemorrhoids and anal fissures are very common conditions although only few studies haveevaluated its medical treatment. Aim: To compare the efficacy, acceptability and safety ofan osmotic laxative (lactulose) versus fiber (Plantago ovata) in the treatment of symptomatichaemorrhoids and/or anal fissures in patients with hard stools. Methods: Open, randomized,parallel and multicenter trial comparing a 6-weeks treatment with lactulose 15 mL (10.05g) b.i.d. (n=42) vs Plantago ovata 5 g. b.i.d. (n=38). All patients suffered from hard stools(type 1, 2 or 3 of the Bristol scale). Results: see Table 1. Conclusion: In patients withhaemorrhoids and/or anal fissure and hard stools, both lactulose and Plantago ovata areeffective and safe; results were in favour in lactulose regarding improvement in stool consist-ency and treatment acceptability. Supported by Solvay PharmaTable 1

*=p<0.05 vs basal; #=p<0.05 for lactulose vs Plantago ovata

S1278

Endoscopic Management of Chronic Radiation Proctitis - An Audit of 6 YearsExperience At a Single InstitutionMichael Swan, David Devonshire, William Sievert

Background Chronic radiation proctitis typically manifests as rectal bleeding 12 - 24 monthspost radiotherapy. No gold standard of treatment has been established although increasinglyAPC to the affected area is the endoscopic treatment of choice. Previous studies have appliedAPC conservatively, necessitating increased numbers of treatments. In our centre APC isapplied to all the affected mucosa, at an average 50W power with the aim of treating allaffected area in one setting. Method A retrospective review of 44 consecutive patients withradiation proctitis undergoing endoscopic APC treatment between January 2001-January2007 at Monash Medical Centre. Patients were identified from prospectively collected data-base of one endoscopist (DD) along with hospital records. Clinical details of underlyingconditions, time since radiotherapy and previous treatments was obtained as well as APCtreatments and clinical follow up of at least 6 months. Symptom scores and endoscopicappearance were graded using previously published scales (Zinicola et al Int J ColorectalDis 03, Tam et al Endoscopy 2000) Results Of the 44 patients, 39 were male (all hadradiotherapy for prostate cancer) and 5 females (urogenital cancers). Mean age of the patientswas 72.4 years old. Mean period between radiotherapy and first APC treatment was 24months (4 -140 months), mean number of treatments was 1.5 (1 - 6) and follow up was16 months (6 - 60). 43/44 patients had an improvement from baseline in bleeding scoreswith APC (p < 0.001). Of the 24 patients who had documented haemoglobin levels preand post APC treatment, 23 had improved or unchanged haemoglobin levels. 6 patientsrequired blood transfusions prior to therapy, only 1 required blood transfusions post APCtreatment. Of the 15 patients who had failed other therapies, all responded to APC treatment.16 patients (36%) had self limiting complications, 1/44 developed an asymptomatic stricture.Conclusions In this single centre study, APC treatment was successful in 98% of patientsincluding those who had previously failed other therapies. Large volume APC treatment ateach session resulted in a reduced number of treatments which was offset by an increasedincidence of short term complications although no increase in long term complications.