Outcome of Colectomy for Slow-Transit Constipation in Relation to Presence of Small-Bowel Dysmotility

PURPOSE: A significant proportion of patients with slow-transit constipation have abnormal small-bowel motility. It is unclear whether abnormal small-bowel motility indicates worse results after surgery for slow-transit constipation. We studied the results of colectomy with ileorectal anastomosis in patients with normal and abnormal antroduodenal manometry findings. METHODS: Seventeen, consecutive patients who had been referred for intractable constipation and who were found to suffer from slow-transit constipation underwent subtotal colectomy. All patients underwent a set of diagnostic investigations, including whole gut transit time, anorectal manometry, antroduodenal manometry, electromyography of the anal sphincter, balloon expulsion test, and defecography. Patients were followed up after five years. RESULTS: Patients median age at the time of the operation was 46 (range, 23–70) years, and the median duration of constipation was 31 (range, 11–65) years. One patient died 21 days after the operation. Three patients developed intestinal pseudo-obstruction after the operation, and two of these died during the follow-up period. Fourteen patients were available for follow-up after a median of five (range, 4–7) years. Bowel frequency was significantly increased from a median of 0 (range, 0–2) times per week to a median of 30 (range, 10–102) times per week after surgery (P < 0.001). The incidence of abdominal pain decreased from 94 to 43 percent. Seven of 13 patients (54 percent) continued to have bloating. At long-term follow-up, 12 of 14 patients (86 percent) reported that they had an overall improvement after surgery, despite continuing pain and bloating in a significant proportion of them. The outcome of surgery was good or excellent in seven of seven patients with normal findings on antroduodenal manometry, but only five of nine patients with abnormal manometry findings attained a good result after surgery. We found a trend (P = 0.09) toward better long-term results after surgery for slow-transit constipation in patients with a normal antroduodenal manometry before the operation.     

Abnormalities in gastrointestinal motility are associated with diseases of oxidative phosphorylation in children

OBJECTIVE: Disorders of the mitochondrial electron transport chain enzymes of oxidative phosphorylation (OXPHOS) have neurologic, musculoskeletal, ophthalmologic, cardiac, and GI manifestations. Many adult and pediatric patients with disorders of OXPHOS have abnormalities in intestinal motility. The purpose of this study was to describe pediatric patients who initially presented with signs of GI dysmotility and were later evaluated and found to have a disorder of OXPHOS. METHODS: Data were collected on six patients, including initial GI and neurologic symptoms, histology of skeletal muscle biopsies, mitochondrial DNA mutational analysis, OXPHOS enzyme assay, upper GI barium imaging, technetium-99M liquid gastric emptying scan, upper GI endoscopy, esophageal manometry, and antroduodenal manometry. RESULTS: All six children presented with symptoms of GI dysmotility within 2 wk of life. Patients later developed symptoms of neurologic disorders. All patients had abnormalities in OXPHOS enzyme analysis. Muscle histology showed nonspecific changes with no ragged red fibers. Sequencing of the mitochondrial DNA showed no recognized mutations. No patient had any evidence of intestinal obstruction or malrotation by upper GI barium imaging. Four patients had delayed gastric emptying. Three patients had endoscopic and histologic evidence of esophagitis. All six had demonstrable neuropathic abnormalities by antroduodenal manometry, including the following: nonpropagated antral bursts, absent migrating motor complexes, postprandial antral hypomotility, retrograde migrating motor complexes, and tonic contractions with the migrating motor complex. CONCLUSIONS: Abnormalities in GI motility may be an early presenting sign of disorders of OXPHOS in children.     

Slow-transit constipation

INTRODUCTION: Autonomic neuropathy is thought to play a role in the pathogenesis of slow-transit constipation, but other gastrointestinal organs may also be involved, even if they are symptom-free. We investigated whether motility in gastrointestinal organs other than the colon was impaired in patients with slow-transit constipation and whether the autonomic nervous system was involved. METHODS: Twenty-one consecutive patients (18 females; median age, 46 years) with severe chronic constipation (< or = 2 defecations/week and delayed colonic transit time) were studied. Autonomic neuropathy function was tested with esophageal manometry, gastric and gallbladder emptying (fasting and postprandial motility) by ultrasonography, orocecal transit time (H2-breath test), colonic transit time (radiopaque markers), and anorectal volumetric manometry. The integrity of the autonomic nervous system was assessed by a quantitative sweat-spot test for preganglionic and postganglionic fibers, tilt-table test, and Valsalva electrocardiogram R-R ratio. RESULTS: Esophageal manometry showed gastroesophageal reflux or absence of peristalsis in five of the seven patients examined. Gallbladder dysmotility (i.e., increased fasting, postprandial residual volume, or both) was observed in 6 of 14 (43 percent) patients. Gastric emptying was decreased in 13 of 17 (76 percent) patients. Orocecal transit time was delayed in 18 of 20 (90 percent) patients; median transit time was 160 (range, 90-200) minutes. Median colonic transit time was 97 (range, 64-140) hours. Anorectal function showed abnormal rectoanal inhibitory reflex and decreased rectal sensitivity in 11 of 19 (58 percent) patients. Signs of autonomic neuropathy of the sympathetic cholinergic system were found in 14 of 18 (78 percent) patients. Only one of nine patients had vagal abnormalities detected with the Valsalva test and four of five patients with a history of orthostatic hypotension had a positive tilt-table test. CONCLUSIONS: Slow-transit constipation may be associated with impaired function of other gastrointestinal organs. More than 70 percent of patients with slow-transit constipation present some degree of autonomic neuropathy. Severe constipation may be the main complaint in patients with a systemic disease involving several organs and possibly involving the autonomic nervous system. This should be considered in the management of such cases.     

Upper gastrointestinal motor activity in patients with slow-transit constipation

Recent evidence indicates that patients complaining of severe chronic idiopathic constipation may have motor abnormalities not limited to the colon. We studied by manometric means gastric and small bowel motility in a homogeneous group of patients with chronic idiopathic constipation ie, the slow transit type. Twenty-one patients were recruited for the study and compared to 33 healthy subjects. Manometric examination was carried out for about 5 hr fasting and 1 hr after a standard meal. Analysis of the manometric tracings revealed during fasting no abnormalities in number and configuration of migrating motor complex with respect to controls. However, in 70% of patients motor abnormalities were detected, represented by bursts of nonpropagated contractions and discrete clustered contractions. After feeding, the patient group displayed a significantly shorter antral motor response to the meal with respect to controls; moreover, intestinal bursts of nonpropagated contractions were found in 19% of patients, and 14% of them had an early return of the activity fronts. We conclude that patients with slow transit constipation frequently display motor abnormalities of the upper gut. These findings further strengthen the concept that this condition may represent a panenteric disorder.     

Analysis of fasting antroduodenal manometry in children

Antroduodenal manometry has been used to determine the pathophysiology associated with signs and symptoms of gastrointestinal motility disorders. The diagnostic value of antroduodenal manomentry has been limited by the paucity of data from normal children. In this study, we compared antroduodenal manometry findings from 95 patients with symptoms suggesting a gastrointestinal motility disorder to 20 control children. Phase III of the migrating motor complex (MMC) was less frequent in patients (P<0.05), especially in those who required total parenteral nutrition (P<0.001), than in controls. Abnormal migration of phase III and short intervals between phase IIIs were more frequent in patients than in controls (P<0.01 andP<0.05, respectively). During phase II, persistent low-amplitude contractions and sustained tonic-phasic contraction were found only in parenteral-nutrition-dependent children. Short or prolonged duration of phase III, absence of phase I following phase III, tonic contractions during phase III, low amplitude of phase III contractions in a single recording site and clusters of contractions or prolonged propagating contractions during phase II were not more frequent in patients than in controls. We conclude that there are five manometric features having a clear association with pediatric gastrointestinal motility disorders: (1) absence of phase III of the MMC, (2) abnormal migration of phase III, (3) short intervals between phase III episodes, (4) persistent low-amplitude contractions, and (5) sustained tonic-phasic contractions.     

功能性消化不良及其分型组的胃窦十二指肠运动

本研究对功能性消化不症状分型的常规标准做了一些调整，并观测了３９例ＦＤ患者空腹及餐后胃窦十二指肠运动，以探讨ＦＤ患乾胃窦十二指肠运动状况及其与分型组之间的关系。结果显示〈ＦＤ患者空腹及餐后胃窦十二指肠动力减弱，在胃窦表现为运动指数、平均振幅和频率均显著低于正常组，在十二指肠表现为平均振     

Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation

Idiopathic chronic constipation is a frequent and disabling symptom, but its pathophysiological grounds are still poorly understood. In particular, there is little knowledge about the relationships between distal (anorectal area) and proximal (colonic area) motor abnormalities in this condition, especially concerning high-amplitude propagated colonic activity. For this purpose, we studied 25 patients complaining of severe idiopathic constipation and categorized them as normal- or slow-transit constipation according to colonic transit time. Twenty-five age-matched controls were also studied. Investigations included standard anorectal motility testing and prolonged (24-hr) colonic motility studies. Analysis of results showed that both groups of constipated patients displayed significantly different (P<0.05) minimum relaxation volumes of the internal anal sphincter, defecatory sensation thresholds, and maximum rectal tolerable volumes with respect to controls. Patients with normal-transit constipation also showed lower internal anal sphincter pressure with respect to slow-transit constipation and controls (P<0.001 andP<0.02, respectively). The daily number of high-amplitude propagated contractions (mass movements) as well as their amplitude and duration, was significantly reduced in both subgroups of constipated patients (P<0.02 vs controls). We conclude that (1) in normal-transit constipation, motor abnormalities are not limited to the anorectal area; (2) patients with slow-transit constipation probably have a severe neuropathic rectal defect; (3) prolonged colonic motility studies may highlight further the functional abnormalities in constipated subjects; and (4) an approach taking into account proximal and distal colon motor abnormalities might be useful to understand pathophysiological grounds of chronic constipation and lead to better therapeutic approaches.     

Ambulatory 24-hour colonic manometry in slow-transit constipation

BACKGROUND: The colonic neuromuscular dysfunction in patients with constipation and the role of colonic manometry is incompletely understood. AIM: To study prolonged colonic motility and assess its clinical significance. METHODS: Twenty-four-hour ambulatory colonic manometry was performed in 21 patients with slow-transit constipation and 20 healthy controls by placing a 6-sensor solid-state probe up to the hepatic flexure. Quantitative and qualitative manometric analysis was performed in 8-h epochs. Patients were followed up for 1 yr. RESULTS: Constipated patients showed fewer pressure waves and lower area under the curve (p < 0.05) than controls during daytime, but not at night. Colonic motility induced by waking or meal was decreased (p < 0.05) in patients. High-amplitude propagating contractions (HAPCs) occurred in 43% of patients compared to 100% of controls and with lower incidence (1.7 vs 10.1, p < 0.001) and propagation velocity (p < 0.04). Manometric features suggestive of colonic neuropathy were seen in 10, myopathy in 5, and normal profiles in 4 patients. Seven patients with colonic neuropathy underwent colectomy with improvement. The rest were managed conservatively with 50% improvement at 1 yr. CONCLUSIONS: Patients with slow-transit constipation exhibited either normal or decreased pressure activity with manometric features suggestive of colonic neuropathy or myopathy as evidenced by absent HAPC or attenuated colonic responses to meals and waking. In refractory patients, colonic manometry may be useful in characterizing the underlying pathophysiology and in guiding therapy.     

Effect of subtotal colectomy on gastric emptying of a solid meal in slow-transit constipation

BACKGROUND: Idiopathic slow-transit constipation is considered a panenteral disease in which patients may have delayed gastric emptying. The effects of total abdominal colectomy and ileorectal anastomosis on upper gut motility are unknown. The aim of this study was to evaluate gastric emptying in patients with idiopathic slow-transit constipation before and after subtotal colectomy. METHODS: Gastric emptying of a solid meal was studied by scintigraphic technique in 11 patients with idiopathic slow-transit constipation. The total colonic transit time was more than 72 hours in all patients studied, with delay in transit in all segments of the colon. The gastric emptying test was repeated 3 to 6 months after total abdominal colectomy and ileorectal anastomosis in ten of these patients. Before and after surgery, patients filled out a questionnaire to record upper gut symptoms. RESULTS: Solid gastric emptying was delayed (T1/2 > upper limit of normal) in 7 of 11 patients with idiopathic slow-transit constipation. Gastric emptying T1/2 was almost similar before and after surgery. Mean ± standard deviation was 142 ± 91 minutes before surgery and 146±67 minutes after surgery. Symptoms of vomiting and belching improved significantly after surgery. Symptoms of nausea, bloating, and pyrosis also decreased, but these changes failed to reach statistical significance. CONCLUSION: Despite a reduction in upper gut symptoms, total abdominal colectomy and ileorectal anastomosis does not improve delayed gastric emptying in patients with idiopathic slow-transit constipation.Presented in part at the meeting of the American Gastroenterological Association, Orlando, Florida, May 16 to 19, 1999.     

Abnormal colonic propagated activity in patients with slow transit constipation and constipation-predominant irritable bowel syndrome

BACKGROUND: The pathophysiological basis of constipation is still unclear, and the role of colonic dysfunction is debated, especially in irritable bowel syndrome. Objective data are quite scarce, especially concerning colonic propulsive activity. AIMS: To evaluate high- and low-amplitude colonic propulsive activity in constipated patients (slow-transit type and irritable bowel syndrome) in comparison with normal controls. PATIENTS AND METHODS: Forty-five constipated patients (35 with slow-transit constipation and 10 with constipation-predominant irritable bowel syndrome) were recruited, and their data compared to those of 18 healthy subjects. Twenty-four-hour colonic manometric recordings were obtained in the three groups of subjects, and data concerning high- and low-amplitude colonic propulsive activity were then compared. RESULTS: High-amplitude propagated contractions were significantly (p < 0.05) decreased in patients with slow-transit constipation and constipation-predominant irritable bowel syndrome with respect to controls (1.5 +/- 0.4, 3.7 +/- 2, and 6 +/- 1 events/subject/day, respectively). In slow-transit constipation, a significant decrease of contractions' amplitude was also observed. Concerning low-amplitude propagated contractions, patients with slow-transit constipation had significantly less events with respect to patients with constipation-predominant irritable bowel syndrome (46 +/- 7 vs. 87.4 +/- 19, p = 0.015); no differences were found between patients with slow-transit constipation and controls and between patients with constipation-predominant irritable bowel syndrome and controls. All three groups displayed a significant increase of low-amplitude propagated contractions after meals (6.3 +/- 2 vs. 18.2 +/- 5 for controls, p < 0.005; 6.4 +/- 1.4 vs. 16.3 +/- 2.4 for slow-transit constipation, p < 0.005; 10.5 +/- 3.2 vs. 32.6 +/- 7 for constipation-predominant irritable bowel syndrome, p = 0.001). CONCLUSIONS: Low-amplitude propagated contractions may represent an important physiologic motor event in constipated patients, reducing the severity of constipation in patients with irritable bowel syndrome and preserving a residual colonic propulsive activity in patients with slow-transit constipation.     

Gastrointestinal motor mechanisms in hyperglycaemia induced delayed gastric emptying in type I diabetes mellitus.

BACKGROUND: Hyperglycaemia delays gastric emptying, both in healthy controls and in patients with diabetes mellitus. The effect of hyperglycaemia on antroduodenal motility in diabetes has not yet been studied. AIM: To investigate the gastrointestinal motor mechanisms involved in the hyperglycaemia induced retardation of gastric emptying in patients with type I diabetes mellitus and autonomic neuropathy. In eight diabetic patients antroduodenal manometry was performed simultaneously with scintigraphic measurement of emptying of a mixed solid-liquid meal, during euglycaemia (5-8 mmol/l glucose) and hyperglycaemia (16-19 mmol/l glucose), on separate days, in random order. RESULTS: Hyperglycaemia decreased the cumulative antral motility index from 38.3 (range 24.2-47.6) to 30.8 (range 17.3-38.1) (p = 0.025) and reduced the number of antral pressure waves propagated over > or = 4.5 cm (p = 0.04). Duodenal phase III-like activity was seen irrespective of the glycaemic state (in three patients during euglycaemia and in four patients during hyperglycaemia). Hyperglycaemia significantly affected gastric emptying of the solid meal: it prolonged the lag phase from 20.0 minutes to 28.5 minutes (P = 0.02), increased the 50% emptying time from 73.5 minutes to 104.5 minutes (p = 0.03), and increased the percentage of isotope remaining in the stomach after 120 minutes from 33.5% to 46.5% (p = 0.02). The cumulative antral motility index was correlated with the 50% emptying time (r = 0.75, p = 0.02) during euglycaemia, but not during hyperglycaemia (r = 0.28, P = 0.31). Liquid emptying was not influenced by the blood glucose concentration. CONCLUSIONS: Hyperglycaemia reduces postprandial antral contractile activity and its organisation in patients with type I diabetes and autonomic neuropathy. These changes in antroduodenal motility are likely to constitute the mechanism through which gastric emptying of solids is delayed during high blood glucose concentrations in these diabetic patients.     

Longterm oral cisapride improves interdigestive antroduodenal motility in dyspeptic patients.

We have evaluated the effect of cisapride on interdigestive antroduodenal motility during a prolonged oral therapy in 20 consecutive dyspeptic subjects. Individuals with less than two migrating motor complexes (MMCs) starting from the antral region in 240 minutes and without evidence of upper gastrointestinal tract diseases were randomly treated with either cisapride (10 cases), or placebo (10 cases) for 15 days. Computerised manometry of antroduodenal region was performed for 240 minutes, in basal conditions and on the 15th day of therapy. Symptomatic evaluation of patients was also performed before and after treatment. After cisapride administration, a significant increase in the incidence of antral migrating motor complexes was noticed (p = 0.022); likewise, the motility index, calculated for phase-2 periods, appeared to be significantly higher both in the antrum and in the duodenum (p less than 0.001). Symptomatic improvement was observed in both groups, with a hardly significant (p = 0.049) reduction of dyspeptic symptoms severity only but not of frequency in cisapride treated patients v controls. We conclude that longterm oral therapy with cisapride improves interdigestive antroduodenal motor activity.     

Gastrointestinal sounds and migrating motor complex in fasted humans

OBJECTIVE: We investigated the relationships among gastrointestinal sounds, gastrointestinal manometric findings, and small intestinal transit time in healthy fasted humans. METHODS: Gastrointestinal sounds acquired with two microphones attached to the upper and lower abdominal walls of healthy subjects were quantified with a computer-aided sound analysis program. Antroduodenal contractions were recorded by manometry. Small intestinal transit time was measured by breath hydrogen testing after intraduodenal administration of lactulose. RESULTS: The sum of the gastrointestinal sound amplitudes (sound index) in both the upper and lower abdomen changed with time, coinciding with the gastric phases of the migrating motor complex. The sound indices in the upper and lower abdomen were 59.0+/-24.8 and 98.1+/-21.6 mV/min in phase 1, 95.5+/-27.9 and 127.4+/-34.9 mV/min in phase 2, and 132.8+/-12.4 and 188.5+/-73.4 mV/min in phase 3, respectively. There were no significant differences among motility phases in terms of the mean duration or frequency of each sound event. Intravenous erythromycin induced phase 3 in the stomach and doubled the sound index. Somatostatin analogue induced phase-3-like clustered contractions in the duodenum, but inhibited antral contractions and decreased the sound index. The small intestinal transit time was shorter and the sound index increased after intravenous metoclopramide, compared with controls. Scopolamine delayed small intestinal transit time and decreased the sound index. CONCLUSIONS: This study is the first to document the relationships between gastrointestinal sounds and the migrating motor complex. The chronological relation between antral motility and gastrointestinal sounds, and the dissimilar effects of erythromycin and somatostatin, suggest that antral contractions increase gastrointestinal sounds, perhaps by supplying gas into the intestine.     

Effect of intravenous amino acids on interdigestive antroduodenal motility and small bowel transit time

Background—Patients on totalparenteral nutrition have an increased risk of developing gallstonesbecause of gall bladder hypomotility. High dose amino acids may preventbiliary stasis by stimulating gall bladder emptying.
Aims—To investigate whetherintravenous amino acids also influence antroduodenal motility.
Methods—Eight healthy volunteersreceived, on three separate occasions, intravenous saline (control),low dose amino acids (LDA), or high dose amino acids (HDA).Antroduodenal motility was recorded by perfusion manometry andduodenocaecal transit time (DCTT) using the lactulose breath hydrogen test.
Results—DCTT was significantlyprolonged during LDA and HDA treatment compared with control. Theinterdigestive motor pattern was maintained and migrating motor complex(MMC) cycle length was significantly reduced during HDA compared withcontrol and LDA due to a significant reduction in phase II duration.Significantly fewer phase IIIs originated in the gastric antrum duringLDA and HDA compared with control. Duodenal phase II motility index was significantly reduced during HDA, but not during LDA, compared with control.
Conclusions—Separate intravenousinfusion of high doses of amino acids in healthy volunteers: (1)modulates interdigestive antroduodenal motility; (2) shortens MMC cyclelength due to a reduced duration of phase II with a lower contractileincidence both in the antrum and duodenum (phase I remains unchangedwhereas the effect on phase III is diverse: in the antrum phase III is suppressed and in the duodenum the frequency is increased); and (3)prolongs interdigestive DCTT.

Keywords:amino acids; antroduodenal motility; small boweltransit time; total parenteral nutrition

     

Malabsorption syndrome due to various causes is associated with antroduodenal hypomotility.

BACKGROUND: Patients with celiac disease who present with symptoms of gastrointestinal hypomotility have abnormal antroduodenal manometry. There are no data on antroduodenal manometry in malabsorption syndrome (MAS) due to causes other than celiac disease. METHODS: Fasting, post-prandial and post-octreotide antroduodenal motility parameters were compared in 18 untreated patients with MAS presenting with chronic diarrhea (tropical sprue 10, small bowel bacterial overgrowth 3, celiac disease 2, common variable immunodeficiency 1, AIDS with isosporidiasis and bacterial overgrowth 1, giardiasis 1) and 8 healthy subjects. RESULTS: Number of patients with MAS and controls having spontaneous migratory motor complexes (MMC) during fasting was comparable (11/18 vs 7/8; p=ns). Fasting contraction amplitude was weaker in MAS than in controls in the gastric antrum (median 42 [range 17-90] vs 80 [31-120] mmHg; p=0.001), proximal duodenum (50 [18-125] vs 72 [48-107]; p=0.013) and distal duodenum (45 [20-81] vs 76 [51-98]; p=0.001). In the fed state too, contraction amplitudes were weaker in patients with MAS in the antrum (32 [15-110] vs 76 [61-103] mmHg, p=0.002), proximal duodenum (57 [20-177] vs 73 [56-113]; p=0.07) and distal duodenum (45 [24-87] vs 75 [66-97]; p<0.0001). Patients with MAS had lower fasting and post-prandial antral and duodenal motility indices than healthy subjects. Intravenous octreotide induced MMC in all patients and controls. CONCLUSIONS: MAS due to various causes is associated with antroduodenal hypomotility typical of myopathic disorders.     

Abnormalities of gastrointestinal motility in children with nonulcer dyspepsia and in children with gastroesophageal reflux disease

In 11 children (mean age 44.2 months) with symptoms suggesting upper intestinal dysfunction (nonulcer dyspepsia), in nine children (mean age 27.3 months) with gastroesophageal reflux (GER) disease, and in seven controls (mean age 20.4 months) we investigated fasting [for 3 hr or until two migrating motor complexes (MMC) were observed] and fed (90 min) antroduodenal motility by means of perfused catheter system; furthermore, we measured both gastric emptying of a radiolabeled milk formula and fasting duodenogastric reflux during manometry by assessing bile salt concentration in gastric aspirates. No structural abnormalities of gastrointestinal tract and organic disorders were detected in the patients. In a high proportion of both groups of patients we found manometric abnormalities of interdigestive and fed motor patterns that were not seen in the controls: absence of antral phase III of MMC; significant decrease of antral and/or duodenal motor activity during fasting and/or fed periods; abnormal propagation or configuration of MMC phase III that was signficantly shorter than in controls; bursts of sustained fasting and/or fed phasic duodenal activity, frequently uncoordinated with adjacent gut segments. When compared to controls, the mean intragastric concentration of bile salts during all MMC phases and the mean 1-hr percent gastric activity of the radiolabeled milk were significantly higher in the two groups of patients. We conclude that in a high proportion of children with nonulcer dyspepsia and of children with GER disease, gastrointestinal manometry may reveal significant irregularities of antral and duodenal motility, which are associated with increased duodenogastric reflux and delayed gastric emptying.     

Long-Term Study on the Effects of Visual Biofeedback and Muscle Training as a Therapeutic Modality in Pelvic Floor Dyssynergia and Slow-Transit Constipation

PURPOSE: Biofeedback training has been shown as an effective therapeutic measure in patients with pelvic floor dyssynergia, at least in the short term. Long-term effects have received less attention. Moreover, its effects in patients with slow-transit constipation have been scarcely investigated. This study was designed to assess in an objective way the medium- and long-term effects of biofeedback and muscle training in patients with pelvic floor dyssynergia and slow-transit constipation. METHODS: Twenty-four patients (14 with pelvic floor dyssynergia and 10 with slow transit) meeting the Rome II criteria for constipation, and unresponsive to conventional treatments, entered the study. Clinical evaluation and anorectal manometry were performed basally and three months after a cycle of electromyographic biofeedback and muscle training; moreover, a clinical interview was obtained one year after biofeedback. Patients with slow-transit constipation also had colonic transit time reassessed at one year. RESULTS: Clinical variables (abdominal pain, straining, number of evacuations/week, use of laxatives) all significantly improved in both groups at three-month assessment; anorectal manometric variables remained unchanged, apart from a significant decrease of sensation threshold in the pelvic floor dyssynergia group and of the maximum rectal tolerable volume in the slow-transit constipation group. At one-year control, 50 percent of patients with pelvic floor dyssynergia still maintained a beneficial effect from biofeedback, whereas only 20 percent of those complaining of slow-transit constipation did so. Moreover, the latter displayed no improvement in colonic transit time. CONCLUSIONS: In our experience, patients with pelvic floor dyssynergia are likely to have continued benefit from biofeedback training in the time course, whereas its effects on slow-transit constipation seems to be maximal in the short-term course.     

Automated quantitative analysis of nocturnal jejunal motor activity identifies abnormalities in individuals and subgroups of patients with slow transit constipation

OBJECTIVE: Small bowel dysmotility has previously been demonstrated in some patients with slow transit constipation (STC), suggesting a generalized intestinal disorder. However, no study has addressed whether the incidence of small intestinal dysfunction differs between subgroups of patients in this heterogeneous population. Using appropriate methodology, we aimed to determine prospectively the proportion of individuals with abnormal small bowel motility, and to assess whether heterogeneity in terms of pattern of colonic transit delay (based on (111)In diethylene-triamine-pentaacetic acid (DTPA) isotope scintigraphy), or mode of onset (based on clinical history) is of importance. METHODS: Thirty-seven patients with STC underwent 24-h ambulatory jejunal manometry; data were compared with those obtained in 38 healthy controls. Automated quantitative analysis of seven variables of the nocturnal migrating motor complex was performed, to assess whether differences existed between groups, and whether individual patients had evidence of small intestinal dysmotility, defined as two or more measures of migrating motor complex variables outside the normal range. Four variables differed significantly between STC patients and controls: in phase III, propagation was slower, duration was longer, and contraction amplitude was higher; in phase II, contraction frequency was increased. Seven of 24 patients with a generalized pattern of colonic transit delay had abnormal small bowel motility compared with none of 13 with a left-sided delay (p < 0.04). These included four patients with chronic idiopathic symptoms and three with acquired symptoms.Approximately one third of patients with a generalized delay in colonic transit had evidence of jejunal enteric neuromuscular dysfunction. Individual patients with a left-sided colonic delay did not satisfy the criteria for nocturnal small bowel dysmotility, but as a group, some differences were noted from controls. In contrast to previous reports, evidence of generalized enteric dysmotility may be present irrespective of the mode of onset.     

A Normal Gastrointestinal Motility Excludes Chronic Intestinal Pseudoobstruction in Children

Gastrointestinal manometry has gained wide acceptance in the approach to patients with suspected enteric neuromuscular disorders. However, performing gastrointestinal manometry in these subjects without a previous exhaustive diagnostic evaluation is unjustified. Twelve children (median age: 7.0 years; range: 8 months–13 years), with clinical and x-ray features suggesting chronic intestinal pseudoobstruction, were referred to our unit for gastrointestinal manometry. The latter was performed with a perfused catheter for 5 hr in the fasting state and for 90 min after feeding. Data were compared with those recorded in eight age-matched controls. In all patients and controls, interdigestive motor complexes with propagated phases III were detected; a regular postprandial antroduodenal motor activity was also recorded. Patients and controls did not differ for fed antral and duodenal motility indexes, fed antroduodenal coordination, and length of duodenal phase III. Most of the patients showed short or prolonged bursts of nonpropagated activity in the fasting and/or fed states; in four cases fasting and/or fed sustained phasic activity was recorded. Manometric evidence of migrating motor complexes and postfeeding activity did not support the diagnosis of intestinal pseudoobstruction and suggested redirecting the diagnostic evaluation. Final diagnoses were: Munchausen syndrome-by-proxy (four cases), celiac disease (two cases), intestinal malrotation (two cases), Crohns disease (two cases), multiple food intolerance (one case), and congenital chloride-losing diarrhea (one case). It is concluded that in children with suspected chronic intestinal pseudoobstruction manometric evidence of migrating motor complexes and fed motor activity excludes an enteric neuromuscular disorder and suggests a reassessment of the diagnostic work-up. Furthermore, if gastrointestinal manometry shows migrating motor complexes and postfeeding motor activity, qualitative abnormalities of the manometric tracings do not indicate an underlying enteric neuromuscular disorder and must not be overemphasized. Patients referred for gastrointestinal manometry should previously undergo an extensive diagnostic investigation to exclude disorders mimicking chronic intestinal pseudoobstruction.     

Gastrointestinal motor function in patients with portal hypertension

BACKGROUND: Existing data on gastric emptying and small-intestinal transit rates in portal-hypertensive patients are scarce and contradictory, and so far, the motor function of the colon has not been assessed in these patients. In this study we evaluated the propulsive effect of all main segments of the gastrointestinal tract in patients with well-characterized portal hypertension. METHODS: Eight patients with a postsinusoidal hepatic pressure gradient of at least 13 mmHg and eight age- and sex-matched healthy controls participated in the study. Gastric emptying, small-intestinal transit, and colonic transit rates were evaluated in all subjects by means of a gamma camera technique. The technique was also used to measure the frequency of antral contractions. RESULTS: No difference was observed in gastric mean emptying time or small-intestinal mean transit time of liquid and solid markers between patients and controls. After 24 h, however, the geometric center of the liquid marker had a more caudal localization in the colon of the patient group than in the controls (P = 0.04); that is, the patients had a faster colonic transit. No difference was found in the frequency of antral contractions 45 min after the test meal between patients and controls. CONCLUSIONS: These data suggest that the colonic transit is often accelerated in patients with portal hypertension, whereas the motor function of the stomach and the small intestine is unaffected.