Still working to recover. Please don't edit quite yet.

Rectal malodor

From Anarchopedia
Jump to: navigation, search
This article contains content from Wikipedia
An article on this subject has been nominated for deletion on Wikipedia:
Wikipedia:Articles for deletion/
Rectal malodor
Current versions of the GNU FDL article on WP may contain information useful to the improvement of this article 		WP+
NO
DEL

Rectal malodor (or Wikipedia:rectal Wikipedia:fetor) is a pathological sign and can be defined as an offensive smell issued from the Wikipedia:anus or the Wikipedia:perianal region that cannot be explained by normal physiologic functioning. It is normal that physiological processes such as Wikipedia:flatulence and Wikipedia:defecation create a temporary malodor, however malodor that is persistent outside these events likely represents Wikipedia:pathology.

This term is offered to serve a similar role as the term Wikipedia:halitosis does at the cephalad terminus of the Wikipedia:gastrointestinal tract. Just as Wikipedia:halitosis encompasses any malodor issuing from the Wikipedia:mouth, and not just those conditions which cause Wikipedia:halitosis originating in the Wikipedia:oral cavity, but also Wikipedia:respiratory and blood borne causes of Wikipedia:halitosis; Wikipedia:rectal malodor encompasses any malodorous substance passed Wikipedia:rectally, and can represent either inappropriate expression of physiologically malodorous substances, or passage of pathologically malodorous substances, or indeed maldorous Wikipedia:perianal conditions. The causes of rectal malodor are not necessarily confined to the Wikipedia:colorectal region.

The broad scope of the term is to reflect the fact that patients will likely not have much insight into the exact cause of the symptom, and will only complain of malodor issuing from the Wikipedia:anus or the local area.

Classification[edit]

Wikipedia:Hemorrhoids are a common condition which may in some cases cause rectal malodor, e.g. if they become infected, or in some cases cause degrees of Wikipedia:fecal incontinence

Causes of rectal malodor can be considered in three general categories:

  • compromise of the seal between the gastrointestinal tract and the external environment
This includes both problems with the continence mechanisms themselves, as in Wikipedia:fecal incontinence, but also pathological communications with the external environment such as Wikipedia:fistulae. Wikipedia:Hemorrhoids that are prolapsed or Wikipedia:anal fissures are both pathoses which can interfere with anal closure and create rectal malodor may also fall into this category.
  • pathologically malodorous substances passing per rectum
This category refers to expression of substances that are pathologically malodorous. Wikipedia:Flatus and Wikipedia:feces are malodorous in health, but their odor can be altered by pathological processes. Malodorous substance passing par rectum can be gas, liquid or solid (although in reality it is volatiles given off by solid and liquid material that leads to the perception of malodor). Examples could include:
gas: intestinal gas from bacterial fermentation
liquid: liquid stool elements, pus, mucus, digested blood
solid: faeces, coagulated blood
  • maldorous perianal conditions

Some causes may fit into more than one category, and two or more different causes of Wikipedia:rectal malodor may coexist in the same patient.

File:Defecating proctogram of female showing rectocele.jpg
Wikipedia:Defecating proctogram of female showing Wikipedia:rectocele, a possible cause of obstructed defecation and/or incomplete evactuation

Differential diagnosis[edit]

The differential is with causes of malodor that are not rectal, and patients who are exhibiting oversensitivity to physiological phenomena, or even those with delusional symptoms (either attributed to Wikipedia:olfactory reference syndrome, Wikipedia:schizophrenia or organic causes of neurosensory disruption to the olfactory apparatus, a symptom called Wikipedia:parosmia). Malodor symptoms can be assumed by the patient, or by those around the patient, to be of rectal origin because they are a feculant character. There are a number of rare conditions that may present with feculent type odors that have origin from the genitals, the body generally or the mouth or nose.

Examples include:

"Fecal body odor" is a term that has emerged to describe a symptom of feculant odor that is not of rectal origin, but from the body generally and/or the breath.
"Systemic body odor" refers to multiple malodor symptoms in the same patient, that share a common cause, (usually rare Wikipedia:inborn errors of metabolism, specifically Wikipedia:inborn errors of amino acid metabolism), i.e. body odor, halitosis, and maldorous urine and reproductive fluids. The mechanism of systemic body is related to presence of malodorous volatiles in the blood, which cause blood born halitosis and may alter the odor of other excretions.

Causes[edit]

Rectal malodor is a Wikipedia:symptom, not a Wikipedia:diagnosis and represents a large number of concepts, many of which are inter-related.

Poor anal hygeine[edit]

Main article: Wikipedia:anal cleansing

In the west, the anus is usually cleansed with paper, however it has been suggested that this method is less hygienic than cleansing with moistened wipes or water, e.g. a Wikipedia:bidet. Insufficient Wikipedia:anal cleansing may leave malodours fecal residues on the anus. Nevertheless, this would only be expected to cause a transient rectal malodor, until the next cleansing activity. Sometimes patients (usually those who are obese), will complain of difficulty maintaining hygiene, and this can be related to the physiological secretions of perianal sweat glands and the anal glands themselves.[2]

Fecal incontinence[edit]

Main article: Wikipedia:fecal incontinence


Wikipedia:Fecal incontinence (FI) is an obvious cause of rectal malodor, however the clinical recognition of fecal incontinence is not always straightforward. Again, FI is not a Wikipedia:diagnosis, but Wikipedia:symptom and has an extensive list of causes. FI forms a continuous spectrum of different clinical presentations from loss of gas continence (sometimes termed anal incontinence), or loss of liquid stool (sometimes termed fecal soiling or fecal seepage) to frank solid fecal incontinence. Some refer to solid stool incontinence as complete incontinence, and anything less as partial incontinence.

Gas incontinence (anal incontinence)[edit]

Patients with gas incontinence may have no visible symptoms, yet be demonstrated to have Wikipedia:hypotonia or structural defects when investigated further. According to the most widely used severity scales for FI, the Vaisey and the Wexner index,[3] there are 3 types of incontinence, namely, gas, liquid and solid. The fecal incontinence severity index,[4] defines 4 types with the inclusion of "mucus". Involuntary passage of gas is considered by some to be the first, sometimes only, sign of FI.[5]

Patients who have gas incontinence should be differentiated from those who are continent and have abnormal flatulence (either in terms of increased volume or increased malodor).[6] Patients will frequently not think of themselves as incontinent if they lose control over gas only. In internet communities of patients who sufferer from rectal malodor-type symptoms, the term "leaky gas" has emerged.[7] This term lacks any fixed definition, and consequently is used by different patients to mean different symptom sets. Some use the term to describe an increase in volume and/or odor of flatus with no reduction of continence, others to describe what would medically be termed gas incontinence, and others use to describe a liquid sensation perianally or rectal discharge. The abbreviation LG should not be confused with the more medically recognized concept of Wikipedia:leaky gut, a state of increased intestinal permeability purported to be linked to various medical conditions.[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]

Fecal leakage (soiling, fecal seepage, anal leakage, liquid stool incontinence, encopresis)[edit]

Main article: Wikipedia:fecal leakage
Main article: Wikipedia:encopresis

Fecal leakage is the constant or intermittent involuntary loss of liquid stool or mucus. It is a separate clinical topic to rectal discharge (rectal discharge does not necessarily imply incontinence). The term Wikipedia:encopresis refers to involuntary fecal soiling, but it is a a term used in Wikipedia:pediatrics. Leakage is sometimes related to internal sphincter deficiencies, e.g. the keyhole deformity (a groove in the Wikipedia:anal canal wall). Patients complain of stains in their underwear and sometimes wear sanitary pads to attempt to manage the problem. Fecal seepage is thought to be caused by lowered resting anal tone, which is a function of the internal anal sphincter. Reports of paradoxically high resting tone in patients with fecal seepage could be explained by Wikipedia:anismus coexistence.[23] An alternative explanation is that a long anal sphincter is responsible for the high resting tone.[24] A long anal sphincter may also explain fecal seepage in males. The same paper also found that treatment of fecal seepage was less successful than treatment of true incontinence.[25]

Wikipedia:Encopresis is often coexistant with Wikipedia:anismus. The standard treatment for anismus, Wikipedia:biofeedback, is not always enough to resolve the Wikipedia:encopresis.[26]

Rectal discharge[edit]

Main article: Wikipedia:Rectal discharge

Wikipedia:Pus is often malodorous and indicates Wikipedia:infection. Although Wikipedia:mucus coats the walls of the Wikipedia:colon in health, functioning as a protective barrier and also to aid Wikipedia:peristalsis by Wikipedia:lubrication of Wikipedia:stool, when inappropriately expressed (e.g. seepage, or soiling, a type of Wikipedia:fecal incontinence), or produced in pathological quantities (usually in response to Wikipedia:inflammation and irritation), this Wikipedia:mucus may be a cause of Wikipedia:rectal malodor. To differentiate between Wikipedia:purulent discharge and mucous discharge, the colour and consistency of the fluid can be examined; pus is off white, and sometimes blood streaked, and mucus is jelly-like in consistency and a clearer yellow colour than pus. Frequently medical sources do not differentiate between the two types of discharge, instead using the general term Wikipedia:mucopurulent discharge.

The differential of rectal discharge is an extensive, but the general etiological themes are Wikipedia:infection and Wikipedia:inflammation.[27] Some lesions can cause a discharge by mechanically interfering with, or preventing the complete closure of the Wikipedia:anal canal. This type of lesion may not cause discharge intrinsically, but instead allow transit of liquid stool components and mucus. Not all rectal discharges are malodorous, but those associated with infection are perhaps more likely to be so.

Perianal Wikipedia:Crohn's disease is associated with fistulizing, fissuring and perianal abscess formation.[32]

After Wikipedia:colostomy, the distal section of bowel continues to produce mucus despite fecal diversion, often resulting in mucinous discharge.[33]

Occasionally, intestinal parasitic infection can present with discharge, for example Wikipedia:Whipworm.[34]

Flatus[edit]

Main article: Wikipedia:flatulence

Wikipedia:Flatulence can be considered normal to an extent. Where there is involuntary loss of gas, this is a type of fecal incontinence, and hence a pathological rectal malodor as the patient is not able to control the flatus, possibly leading to social difficulties. Most of the research regarding flatulence is related to increased volume of intestinal gas, which is a separate clinical entity from pathologically increased malodor of flatus. The characteristic odor of flatus has been attributed to volatile sulfur compounds (VSC), specifically Wikipedia:hydrogen sulfide, Wikipedia:methyl mercaptan and Wikipedia:dimethyl sulfide.[35] The origin of these VSCs is thought to be the fermentation activity of colonic microbiota. The significance of Wikipedia:small intestinal bacterial overgrowth, Wikipedia:lactose intolerance or Wikipedia:fructose intolerance is unknown with regards alterations in the odor of flatus. Intestinal Wikipedia:dysbiosis may increase the numbers of bacteria or alter the ecology to a community that is more productive of VSC. Diet is also likely to have a great impact on the odor of flatus between individuals, presumably diets higher in VSC and VSC precursors would lead to an increase in the odor of flatus produced, and also diets high in fermentable bacterial substrates, as described in the "Wikipedia:FODMAP" (fermentable Wikipedia:oligosaccharides, Wikipedia:disaccharides, monosaccarhides and Wikipedia:polyols) concept.[36] Diets are also described which aim to minimize undigested food residues from entering the large intestine where they can be acted upon by bacteria and act as adjuvent therapy for treatment of Wikipedia:small intestinal bacterial overgrowth.[37]

It has been shown that of all the intestinal gas produced, over 90% is reabsorbed by the gut lining. Wikipedia:Hydrogen sulfide and Wikipedia:methyl mercaptan are metabolized in specialized cecal lining tissue (to Wikipedia:thiosulfate).[38][39][40][41] It is unknown whether pathological changes in the gut lining could disrupt this mechanism and lead to increased VSC content of flatus.

Outlet obstruction (obstructed defecation)[edit]

Main article: Wikipedia:Bowel obstruction

Outlet obstruction (or obstructed defecation), is a major cause of Wikipedia:constipation, and could be defined as mechanical or functional obstruction, interfering with the normal evacuation of stool. The most common cause of functional outlet obstruction is Wikipedia:anismus. Obstructed defecation is characterized by normal colonic transit time, although it may be increased in the descending and sigmoid colon.

Many different pathological processes may obstruct defecation, for example Wikipedia:adhesions, Wikipedia:malignant and Wikipedia:benign Wikipedia:tumors, fecal loading (presence of a large amount of faeces in the rectum with stool of any consistency) [42] or Wikipedia:fecal impaction/Wikipedia:fecalomas. Essentially any phenomena that is obstructive to the normal evacuation may cause obstructive defecation and/or incomplete evacuation, including swellings, intussusceptions, Wikipedia:strictures and stenoses of the anorectal lumen.

Anismus[edit]

Main article: Wikipedia:Anismus


Wikipedia:Anismus (pelvic floor dyssynergia) is characterized by a failure of the pelvic floor to relax during attempted defecation. When contracted, the Wikipedia:puborectalis, a muscle that loops around the bowel at a point known as the anorectal ring, creates the anorectal angle. This "kink" in the bowel is responsible for gross solid continence. Normally, the pelvic floor relaxes and descends during defecation. Relaxation of puborectalis and assumption of a squatting position straightens out the anorectal angle, allowing transit of stool from the rectum to the anal canal.

Anismus can cause incomplete evacuation of stool. This has been suggested as being of importance in the etiology of fecal seepage. The paradoxical action of Wikipedia:puborectalis during defecation makes the anorectal angle more acute, making it more of a barrier to stool in the rectum. After the patient finishes their defecation, and resumes their normal activity, the puborectalis may relax because there is no longer any active straining. This can lead to portions of the retained stool descending into the anal canal. This may create the sensation of needing to defecate frequently. It is unknown whether anismus creates rectal malodor only in the presence of compromised seal to the gastrointestinal tract.

Incomplete evacuation[edit]

Main article: Wikipedia:Rectal tenesmus

The sensation of persistent rectal fullness after a bowel movement is known as tenesmus. Incomplete evacuation could be defined as retention of portion of feces after defecation has been attempted. It is a closely linked topic to obstructed defecation, but obstructed defecation does not necessarily imply incomplete evacuction. Similarly, tenesmus has many causes besides retention of stool. Incomplete evacuation has already been discussed in terms of Wikipedia:anismus and fecal seepage in the previous sections. The other mechanisms whereby incomplete evacuation is proposed to cause rectal malodor are essentially related to the theory that if a reservoir of feces is retained in the rectum, it will trigger increased mucus production and bacterial activity. Indeed feces is composed of 90% bacteria by weight, and represents a dynamic ecosystem of hundreds of different bacterial strains, which ferment undigested food residues, with Wikipedia:hydrogen and Wikipedia:methane as major byproducts.[43] Volatile sulfur compounds are also produced when proteolytic, mostly anerobic bacteria act on sulfur containing proteins, and it is these compounds that are responsible for the characteristic odor of feces (along with other comopunds such as Wikipedia:indole and Wikipedia:skatole) Stool can therefore be thought of as a mass of bacteria and waste that is highly metabolically active and which releases malodorous volatile metabolites. It is logical to theorize that if such a mass were to be retained virtually constantly in the rectum, it could lead to increased volume and/or malodor of flatus, or even a mucous discharge/fecal seepage if there is resting hypotonicity of the internal sphincter.

Examples of such "reservoir" causes of rectal malodor include non emptying Wikipedia:rectocele (usually refers to herniation of gut into vagina, but rarely may also occur posteriorly in males), Wikipedia:enterocele, sigmoidocele, cystocele, Wikipedia:megarectum and Wikipedia:megacolon, rectal inertia, Wikipedia:diverticula. Wikipedia:Rectoceles which retain stool after defecation are termed "non-emptying rectoceles".

In healthy subjects, 90-100% of the contents of the rectum was shown to empty during Wikipedia:defecation, as demonstrated by Wikipedia:defecography. [44] Incomplete evacuation could therefore be defined as less than 90% rectal emptying during defecation.

Perianal conditions[edit]

2 Wikipedia:pilonidal cysts in the Wikipedia:gluteal cleft showing mucopurulent discharge

Pilonidal disease, also known as "jeep seat" can lead to cyst or abscess formation, and perianal mucopurulent discharge.

Wikipedia:Fistulae that drain to the perianal skin can also cause a discharge which can be malodorous.

Wikipedia:Fungating malignant wounds are known to frequently produce strong malodor, and this has been attributed to the VSC Wikipedia:dimethyl trisulfide.[45] The term fungating implies a necrotic, exudating and ulcerating Wikipedia:lesion, in which malignant cells have eroded through the skin (or mucosa). These wounds are also often secondarily infected with bacteria. Malignant tumours of the anal margin and anal canal are rare, the most common being Wikipedia:squamous cell carcinoma. Cutaneous tumous affecting the region include perianal Wikipedia:malignant melanoma. Anal and perianal malignancies have low survival rate due to typical presentation at a late stage.[46]

Management[edit]

A standardized approach to all patients complaining of rectal malodor should be followed. This begins with a thorough history and examination, including a Wikipedia:digital rectal examination. It may be appropriate to order investigations on a case by case basis.

Investigations[edit]

If Wikipedia:hypotonia of the Wikipedia:anal sphincter complex is suspected, then imaging and physiological testing may be indicated, e.g. 3D endoanal Wikipedia:ultrasound and Wikipedia:anorectal manometry.

Wikipedia:Defecography will demonstrate several pathoses such as rectocele, enterocele, sigmoidocele, cystocele, anismus, diverticula, megarectum, megacolon and obstructive lesions in the rectum or anal canal such as strictures.

To investigate possible intestinal Wikipedia:dysbiosis, Wikipedia:hydrogen breath tests can be used.

Psychological impact[edit]

Given the frequently devastating psychosocial implications for patients who suffer from this symptom for any length of time, some form of counselling may be advisable, integrated with the medical and/or surgical management. It is known that the impact of the quality of life of patients with FI can also be devastating. Self-confidence, family and sexual relationships, lifestyle choices, employment and finance status were all reported to be significantly effected by FI.[47][48] Anal incontinence was reported to be associated with deteriorating psychosocial function and decreased Wikipedia:health related quality of life.[49]

Comparison with other malodor conditions and extrapolation with the perhaps greater societal stigma that is attached to rectal malodor, it is logical to assume that patients with rectal malodor are similarly affected. In Wikipedia:halitosis, patients were shown to suffer from a form of Wikipedia:social anxiety, Wikipedia:depression, and their Wikipedia:quality of life was significantly impacted by the condtion.[50][51][52]

In patients with malodorous malignant fungating wounds, malodor (along with deformity) is known to be the major patient reported reason for reduced quality of life, social isolation and embarrasment.[53][54][55][56][57]

Prolonged suffering with this symptom can lead to profound distress and psychological sequalae. Wikipedia:Olfactory reference syndrome is a disorder where the patient has a delusional belief that they emit a foul odor. It has been suggested that this condition can develop in halitosis patients, even after effective treatment has eliminated any detectable malodor.[58][59][60] It is known that in some patients with ORS, there is a delusional belief in an apparent foul rectal odor [61] These patients will not benefit from investigations and attempts at treatment, and should be identified by lack of findings on organoleptic assessment (although it should be remembered that the malodor may be intermittent, and hence the patient may not smell at the time of the consultation. Furthermore, it is known that there are many organic causes of disruption to the Wikipedia:olfactory apparatus which distort the perception of Wikipedia:odor. Wikipedia:Cacosmia, for example is sometimes seen with Wikipedia:space occupying lesions. Wikipedia:Olfactory halucinations can also occur in certain conditions, e.g. Wikipedia:schitzophrenia.

See also[edit]

References[edit]

  1. ↑ F, ({{{year}}}). "A rare cause of chronic halitosis: gastric-colic fistulae.," Gastrointestinal endoscopy, 75, 1264–5.
  2. ↑ Hopcroft, Keith; Forte, Vincent (2010). Symptom sorter, 4th ed., p. 51, Oxford: Radcliffe.
  3. ↑ RD, ({{{year}}}). "Standards for anal sphincter replacement.," Diseases of the colon and rectum, 43, 135–41.
  4. ↑ TH, ({{{year}}}). "Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.," Diseases of the colon and rectum, 42, 1525–32.
  5. ↑ (2007) The ASCRS textbook of colon and rectal surgery, p. 653, New York: Springer.
  6. ↑ J, ({{{year}}}). "FPIN's Clinical Inquiries: Effective management of flatulence.," American family physician, 79, 1098–100.
  7. ↑ IBSgroup.org sub forum "gas, leaky gas, LG, flatulence, bloating, incontinence, fecal body odor".
  8. ↑ JR, ({{{year}}}). "Possible links between intestinal permeability and food processing: A potential therapeutic niche for glutamine.," Clinics (Sao Paulo, Brazil), 65, 635–43.
  9. ↑ Y, ({{{year}}}). "Nitric oxide-mediated intestinal injury is required for alcohol-induced gut leakiness and liver damage.," Alcoholism, clinical and experimental research, 33, 1220–30.
  10. ↑ BI, ({{{year}}}). "Increased intestinal permeability as a predictor of bacterial infections in patients with decompensated liver cirrhosis and hemorrhage.," Journal of gastroenterology and hepatology, 26, 550–7.
  11. ↑ A, ({{{year}}}). "Leaky gut and autoimmune diseases.," Clinical reviews in allergy & immunology, 42, 71–8.
  12. ↑ S, ({{{year}}}). "Leaky gut and diabetes mellitus: what is the link?," Obesity reviews : an official journal of the International Association for the Study of Obesity, 12, 449–58.
  13. ↑ , ({{{year}}}). "{{{title}}}," {{{journal}}}, {{{volume}}}, .
  14. ↑ K, (2012). "Leaky gut in patients with diarrhea-predominant irritable bowel syndrome and inactive ulcerative colitis.," Digestion, 85, 40–6.
  15. ↑ TY, ({{{year}}}). "Intestinal epithelial barrier dysfunction in Crohn's disease.," Proceedings of the Society for Experimental Biology and Medicine. Society for Experimental Biology and Medicine (New York, N.Y.), 214, 318–27.
  16. ↑ M, ({{{year}}}). "Increased IgA and IgM responses against gut commensals in chronic depression: Further evidence for increased bacterial translocation or leaky gut.," Journal of affective disorders, {{{volume}}}, .
  17. ↑ Y, ({{{year}}}). "Leaky gut and the liver: A role for bacterial translocation in nonalcoholic steatohepatitis.," World journal of gastroenterology : WJG, 18, 2609–18.
  18. ↑ M, ({{{year}}}). "The cytokine hypothesis of depression: inflammation, oxidative & nitrosative stress (IO&NS) and leaky gut as new targets for adjunctive treatments in depression.," Neuro endocrinology letters, 29, 287–91.
  19. ↑ M, ({{{year}}}). "The gut-brain barrier in major depression: intestinal mucosal dysfunction with an increased translocation of LPS from gram negative enterobacteria (leaky gut) plays a role in the inflammatory pathophysiology of depression.," Neuro endocrinology letters, 29, 117–24.
  20. ↑ M, ({{{year}}}). "Normalization of leaky gut in chronic fatigue syndrome (CFS) is accompanied by a clinical improvement: effects of age, duration of illness and the translocation of LPS from gram-negative bacteria.," Neuro endocrinology letters, 29, 902–10.
  21. ↑ D, ({{{year}}}). "HIV disease progression: immune activation, microbes, and a leaky gut.," Topics in HIV medicine : a publication of the International AIDS Society, USA, 15, 114–7.
  22. ↑ L, ({{{year}}}). "Alterations of the intestinal barrier in patients with autism spectrum disorders and in their first-degree relatives.," Journal of pediatric gastroenterology and nutrition, 51, 418–24.
  23. ↑ BS, ({{{year}}}). "Fecal seepage in males with paradoxically high resting anal tone may be associated with anismus.," Diseases of the colon and rectum, 42, 824–6.
  24. ↑ CM, ({{{year}}}). "Paradoxical high anal resting pressures in men with idiopathic fecal seepage.," Diseases of the colon and rectum, 41, 593–7.
  25. ↑ SM, ({{{year}}}). "Patterns of male fecal incontinence.," Diseases of the colon and rectum, 38, 281–5.
  26. ↑ T, ({{{year}}}). "Randomised controlled trial of biofeedback training in persistent encopresis with anismus.," Archives of disease in childhood, 79, 131–5.
  27. ↑ Schueler, Stephen J. Anal discharge.
  28. ↑ PJ, ({{{year}}}). "A study of suppurative pathologies associated with chronic anal fissures.," Techniques in coloproctology, 9, 104–7.
  29. ↑ T, ({{{year}}}). "Anal condyloma acuminatum.," Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates, 32, 342–9.
  30. ↑ Knott, Laurence Gonorrhoea. Patient.co.uk.
  31. ↑ G, ({{{year}}}). "[Perianal tuberculosis: report of two cases].," Revista medica de Chile, 138, 220–2.
  32. ↑ MJ, (1996). "Fistulae and abscesses in symptomatic perianal Crohn's disease.," International journal of colorectal disease, 11, 222–6.
  33. ↑ About rectal discharge. Colostomy association.
  34. ↑ GM, ({{{year}}}). "Suppurative anal cryptitis associated with Trichuris trichiura. Report of a case.," Diseases of the colon and rectum, 30, 620–2.
  35. ↑ FL, ({{{year}}}). "Identification of gases responsible for the odour of human flatus and evaluation of a device purported to reduce this odour.," Gut, 43, 100–4.
  36. ↑ Low FODMAP diet. Shepherd works.
  37. ↑ Pimentel, Mark (2006). A new IBS solution : bacteria, the missing link in treating irritable bowel syndrome, p. 78, Sherman Oaks, CA: Health Point Press.
  38. ↑ F, ({{{year}}}). "Production and elimination of sulfur-containing gases in the rat colon.," The American journal of physiology, 274, G727-33.
  39. ↑ F, ({{{year}}}). "Insights into human colonic physiology obtained from the study of flatus composition.," The American journal of physiology, 272, G1028-33.
  40. ↑ MD, ({{{year}}}). "Detoxification of hydrogen sulfide and methanethiol in the cecal mucosa.," The Journal of clinical investigation, 104, 1107–14.
  41. ↑ J, ({{{year}}}). "Oxidation of hydrogen sulfide and methanethiol to thiosulfate by rat tissues: a specialized function of the colonic mucosa.," Biochemical pharmacology, 62, 255–9.
  42. ↑ (UK), National Collaborating Centre for Acute Care (2007). Faecal incontinence the management of faecal incontinence in adults, p. 18, London: National Collaborating Centre for Acute Care (UK).
  43. ↑ Pimentel, Mark (2006). A new IBS solution : bacteria, the missing link in treating irritable bowel syndrome, Sherman Oaks, CA: Health Point Press.
  44. ↑ (2007) The ASCRS textbook of colon and rectal surgery, p. 49, New York: Springer.
  45. ↑ M, ({{{year}}}). "Dimethyl trisulfide as a characteristic odor associated with fungating cancer wounds.," Bioscience, biotechnology, and biochemistry, 73, 2117–20.
  46. ↑ GB, ({{{year}}}). "Anal carcinoma or "just hemorrhoids"?," The American surgeon, 67, 1048–58.
  47. ↑ M, ({{{year}}}). "The impact of faecal incontinence on the quality of life.," British journal of nursing (Mark Allen Publishing), 16, 204–7.
  48. ↑ L, ({{{year}}}). "Impact of fecal incontinence on quality of life.," World journal of gastroenterology : WJG, 15, 3276–82.
  49. ↑ MD, ({{{year}}}). "Impact of anal incontinence on psychosocial function and health-related quality of life.," Digestive diseases and sciences, 52, 1627–31.
  50. ↑ V, ({{{year}}}). "A new tool measuring oral malodor quality of life.," European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, 268, 1227–32.
  51. ↑ T, ({{{year}}}). "Social anxiety disorder in genuine halitosis patients.," Health and quality of life outcomes, 9, 94.
  52. ↑ N, ({{{year}}}). "Relationship between halitosis and psychologic status.," Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics, 106, 542–7.
  53. ↑ CV, ({{{year}}}). "The effects of malodorous fungating malignant wounds on body image and quality of life.," Journal of wound care, 14, 359–62.
  54. ↑ C, ({{{year}}}). "Malodorous fungating wounds: uncertain concepts underlying the management of social isolation.," International journal of palliative nursing, 9, 216–21.
  55. ↑ SF, ({{{year}}}). "[The physical, psychological, social, and spiritual impacts of malignant fungating wounds on cancer patients].," Hu li za zhi The journal of nursing, 55, 75–80.
  56. ↑ C, ({{{year}}}). "Psychological and physical care of malodorous fungating wounds.," British journal of nursing (Mark Allen Publishing), 16, S16-24.
  57. ↑ ML, ({{{year}}}). "Psychological needs of patients when dressing a fungating wound: a literature review.," Journal of wound care, 13, 380–2.
  58. ↑ Scully, Crispian (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment, 2nd ed., Edinburgh: Churchill Livingstone.
  59. ↑ JD, ({{{year}}}). "Olfactory reference syndrome: issues for DSM-V.," Depression and anxiety, 27, 592–9.
  60. ↑ C, ({{{year}}}). "Olfactory reference syndrome: diagnostic criteria and differential diagnosis.," Journal of postgraduate medicine, 49, 328–31.
  61. ↑ OCD Center of Los Angeles.

Wikipedia:Template:Digestive system diseases

Retrieved from "http://eng.anarchopedia.org/index.php?title=Rectal_malodor&oldid=54177"