Reflux from ileum to colon in the dog

In four dogs we quantified the role of external (coloileal) ligaments in preventing coloileal reflux. All animals were tested under control conditions, and then two had all external ligamentous attachments between ileum and colon divided; the other pair underwent a sham operation. Coloileal reflux was quantified scintigraphically at colonic pressures of 20, 40, and 60 mm Hg, and ileal motility was recorded concurrently. During control experiments and after sham operations, no dogs showed coloileal reflux at colonic pressures of 20 and 40 mm Hg. At a colonic pressure of 60 mm Hg, two control experiments and one in a dog after sham operation resulted in reflux of 9%, 4%, and 8% of counts, respectively. In contrast, both test dogs (after division of the ligaments) refluxed 30–70% of colonic content in all of four experiments at pressure below 20 mm Hg. In control dogs and in those with a continent ileocolonic junction, ileal motility consisted of scattered clusters of phasic contractions. In dogs with coloileal reflux, these clusters occurred with a similar frequency, but they lasted longer (P <0.005). Four weeks later, ileal motility indices in control dogs were significantly less (P <0.02) than in animals with divided coloileal ligaments. These observations establish an experimental model for coloileal reflux, support the hypothesis that external ligamentous attachments help maintain continence at the ileocolonic junction, and imply that coloileal reflux changes the motor pattern of the terminal ileum.     

Anal sphincter function after intersphincteric resection and stapled ileal pouch-anal anastomosis

This study was done to determine the effect of the direct ileal pouch-anal anastomosis upon pressure and sensory components of the anal canal and ileal pouch. These findings were related to postoperative continence. Thirty-three patients with ileal pouch-anal anastomosis (25 continent, eight with episodic minor incontinence) were studied 3±0.3 and 25±5 months after ileostomy takedown. The maximum resting pressure in the anal canal was significantly lower in patients with an imperfect result (35±5 mm Hg) than in continent patients (44±5 mm Hg) (P<0.05). Postoperatively the maximum squeeze anal pressure was slightly greater in continent than in incontinent patients (99±8 mm Hg vs.87±7 mm Hg) (P>0.05). The postoperative recto-(ileo-)anal inhibitory reflex was present in 27 percent. The linear correlation between strength of rectal (ileal) distension and depth resp. duration of internal sphincter relaxation as preoperatively observed disappeared postoperatively in every group of patients. Simultaneous measurements of pouch and anal pressure in patients with imperfect results revealed a reduced positive pouch anal pressure gradient compared to the continent group. This low pouch-anal pressure gradient is thought to be responsible for the increased incidence of soiling in some of our patients.     

Effect of gastric distension and duodenal fat infusion on biliary sphincter of oddi motility in healthy volunteers

Although sphincter of Oddi (SO) dysfunction has been implicated in the pathogenesis of postcholecystectomy syndrome and pancreatitis, little is known about normal physiologic stimuli, such as intraduodenal fat on human SO motility. Furthermore, gastric distension that frequently accompanies endoscopic manometry has been shown in animal studies to affect SO motility. We evaluated the effects of intraduodenal fat and gastric distension on SO basal pressure. Asymptomatic volunteers had SO manometry performed while sequentially performing gastric distension and intraduodenal fat perfusion. Five subjects (ages 29.8±4.8 years, range 22–35 years) had a mean basal sphincter of Oddi pressure of 23.4±5 mm Hg (range 17–31 mm Hg). Injection of air into the stomach caused no appreciable change in either intragastric pressure or SO pressure. Intraduodenal fat infusion resulted in a decrease in mean SO basal pressure from 23.4±5.0 to 4.4±4.4 mm Hg (P=0.004). These results demonstrate that gastric distension does not affect SO basal pressure and that intraduodenal fat infusion reduces SO basal pressure.This work was presented in part at the Digestive Disease Week in Boston, Massachusetts, in May 1993.This work was supported in part by a research award from the American Society of Gastrointestinal Endoscopy.     

Effects of intraduodenal air insufflation on sphincter of oddi motility in conscious dogs

To investigate effects of intraduodenal air insufflation on sphincter of Oddi motility, manometric recordings were obtained during fasting from the sphincter and duodenum in four conscious dogs with duodenal cannula. At 40% of the mean cycle length of the migrating motor complex predetermined from baseline recording, 160 ml of air was injected into the duodenum. In both the sphincter and duodenum, air insufflation produced premature phase III-like activity in seven of 20 experiments (35%) or nonspecific excitatory reaction in eight (40%). In the remaining five experiments (25%), the sphincter exhibited a transient inhibitory response, while the duodenum showed the nonspecific excitatory reaction. Basal pressure of the sphincter increased immediately after air insufflation in 90% of the 20 experiments. The mean basal pressure increased from 12.3±1.6 mm Hg to 22.4±2.1 mm Hg (P<0.0001) and minimum basal pressure from 2.9±0.9 mm Hg to 4.7±0.8 mm Hg (P<0.001). These results indicate that intraduodenal air insufflation does affect motility of the sphincter of Oddi and duodenum in conscious dogs.This work was presented at the 96th Congress of the Japanese Surgical Society on April 10–12, 1996, in Chiba, Japan.     

Motilin agonist erythromycin increases human lower esophageal sphincter pressure by stimulation of cholinergic nerves

During phases II and III of the migrating motor complex, there is an increase in plasma motilin level that is synchronous with phasic and tonic contractile activity of the lower esophageal sphincter and of the stomach. The action of motilin on human lower esophageal sphincter is proposed to be mediated by cholinergic mechanisms. Recently, it has been shown that erythromycin was a motilin agonist. This study evaluated the pharmacological effects and the mechanism of action of intravenous erythromycin on esophageal motility in humans. Healthy volunteers were studied three times at seven-day intervals in a randomized, double-blind fashion. Subjects were first studied for 10 min before drug administration. Afterwards, they received blindly and randomly an intravenous injection of placebo or atropine (12 µg/kg) followed by a 20-min continuous intravenous administration of placebo or erythromycin (150 mg). The difference () between lower esophageal sphincter pressure and the duration, amplitude, and velocity of peristaltic contractions during the control period and after administration of drugs was compared. Erythromycin significantly increased (P<0.05) the lower esophageal sphincter pressure (16.8 ± 4.7 mm Hg) compared to placebo (–0.029 ± 1.4 mm Hg). Erythromycin significantly decreased peristaltic contraction velocity compared to placebo (P<0.05). The effects of erythromycin on lower esophageal sphincter pressure were completely blocked by previous administration of intravenous atropine. Erythromycin increased the number of fundic contractions compared to the placebo, but this effect was not blocked by the previous administration of atropine. Based on these observations, it is proposed that the motilin agonist erythromycin acts on the lower esophageal sphincter by stimulating cholinergic nerves but also could modify gastric motility by direct muscle stimulation.     

Sphincter of oddi manometry in healthy volunteers

In this study we describe in detail the characteristics of sphincter of Oddi motor function in a large group of healthy subjects. Studies were obtained in 50 healthy volunteers. The findings showed a sphincter of Oddi segment that had a basal pressure of 14.8±6.3 mm Hg (X±sd). Phasic contractions were superimposed on the basal pressure. They had an amplitude of 119.7±32 mm Hg, a duration of 4.7±1 sec, and a frequency of 5.7±1.2 contractions/min. In 40 subjects the propagation sequence of phasic contractions could be evaluated and were simultaneous in 53%, antegrade in 35%, and retrograde in 11% of the waves. In 20 subjects, pressure measurements done at the common bile duct sphincter were similar to those obtained at the pancreatic duct sphincter. In 10 subjects, pressure values obtained at the common bile duct sphincter within a week were similar. Our study should help to establish standards for normal manometric values of the sphincter of Oddi and emphasizes the importance of having a healthy volunteer group from which to obtain the normal values of sphincter of Oddi motor function.     

Biomechanical characteristics of the human esophagus

Biochemechanical wall properties of the human esophagus were studied. A probe, with a balloon designed for simultaneous measurement of cross-sectional area and intraluminal pressure, was placed in the esophagus 30 cm from the incisors. Tone was not detected before inflation of the balloon. When the balloon was inflated stepwise with pressures up to 40 cm H₂O (30.7 mm Hg), measurement of cross-sectional area allowed calculation of distensibility and circumferential wall tension. Balloon cross-sectional area increased linearly with increased balloon pressure. Balloon distension induced contractions, both proximal to the balloon and at the site of distension, at a balloon pressure of about 15 cm H₂O (11.5 mm Hg). The cross-sectional area for the threshold for distension induced contractions was 153±12 mm² (diameter 14 mm). At the onset of these contractions, the contraction force was 15–20 cm H₂O (11.5–15.3 mm Hg) and it increased to 47–58 cm H₂O (36.1–44 mm Hg) at a balloon pressure of 20–40 cm H₂O (15.3–30.7 mm Hg). Circumferential wall tension increased with increasing intraluminal pressure in an almost exponential manner. The pressure elastic modulus increased steeply at lower balloon pressures (10–20 cm H₂O) (7.7–11.5 mm Hg), but at higher balloon pressures (20–40 cm H₂O) (15.3–30.7 mm Hg) this increase was less. The circumferential wall tension and wall stiffness of the human esophagus increased with increasing balloon pressure and cross-sectional area. When a threshold is reached, distension induced contractions both proximal and distal to the balloon and at the distension site.This work was supported by a National Institutes of Health grant DK 11242.     

Human sphincter of oddi motility and cholecystokinin response following liver transplantation

The reported incidence of sphincter of Oddi dysfunction following orthotopic liver transplantation has ranged from 3% to 7%. If sphincteric dysfunction is unrecognized, therapy may be inappropriate; when recognized, extensive surgery may be required. To prospectively identify patients with sphincteric dysfunction, we performed sphincter of Oddi motility studies through the t-tube tract three months after transplantation. Baseline sphincter motility and response to intravenous cholecystokinin were evaluated. The results of 10 subjects are reported; nine had normal basal sphincter pressure (16±5.8 mm Hg), and all had normal frequency (3.6±1/min), amplitude (86±31 mm Hg), and duration (4.5±1 sec) of phasic contractions. One subject had an elevated basal pressure (47 mm Hg). All, including the subject with elevated basal pressure, demonstrated a normal response to intravenous cholecystokinin with significant inhibition of phasic contraction frequency and amplitude. We demonstrate that simultaneous studies of the sphincter and duodenum can be obtained via the t-tube tract, providing the opportunity for prospective evaluation of sphincteric function. We conclude that sphincter of Oddi function usually remains normal following liver transplantation with choledochocholedochostomy.     

Perception of gastric distension

Gastric distension has been used to evaluate gastric sensory function in humans, but the methodology is poorly validated and studiesin vivo comparing different distension protocols are lacking. We aimed to compare the influence of the mode of gastric distension on sensation and gastric compliance utilizing a barostat device. In seven healthy volunteers, we positioned a barostat bag in the proximal stomach and tested in random order (in triplicate) four different distension protocols: (1) standard ramp distension with 4 mm Hg pressure step increments of 20 sec duration; (2) slow ramp distension with 2 mm Hg pressure increments of 40 sec duration; (3) random distension using a pressure ramp consisting of 2 mm Hg increments of 40 sec duration with randomly interposed pressure steps 50% below the preceding pressure step; and (4) rapid random distension with 4 mm Hg pressure increments of 10 sec duration with randomly interposed pressure steps 50% below the preceding pressure step. The distension procedures yielded mean airflow rates during the different distension protocols between 2.4 ml/sec for standard ramp and 18.4 ml/sec for rapid random distension. First perception and maximal tolerable pressure were 10.9±1.1 mm Hg and 19.6±1.5 mm Hg, respectively. First perception and maximal tolerable pressures were significantly correlated (r=0.93,P<0.005). The gastric pressure at occurrence of perception and the maximal tolerated pressure were not significantly different for the different distension protocols but gastric compliance was significantly reduced during rapid ramp distension (P<0.01 vs slow ramp andP<0.05 vs random distension) but not during standard ramp distension. We conclude that gastric sensory pressure thresholds as assessed by isobaric distension are not influenced by the mode of distension. The high correlation of pressure thresholds at first perception and maximal tolerated distension suggest a single population of gastric mechano-receptors that mediate first sensation at low intensity stimulation and pain at intense stimulation.This work was supported by a grant from German Research Foundation, grant Ho 1193/3-2.     

Effects of prostaglandins E2 and 552-01552-01552-01on motility of small intestine in man

Interdigestive motility of the small intestine was examined in 23 fasted healthy volunteers following luminal administration of the prostaglandins E₂ and F₂. Motility was monitored by means of water-perfused catheters measuring intraluminal pressure changes. The registration points were located 25 cm apart, in the proximal duodenum, at the angle of Treitz, and in the jejunum. Prostaglandin E₂ administered intraduodenally delayed the initiation of the subsequent activity front. The interval to the next activity front was prolonged by a dose of 1.0 mg prostaglandin E₂ from 79.5±9.5 min to 137.1±5.0 min (P<0.01) and to 158.0±14.0 min by 2.0 mg prostaglandin E₂ (P<0.05). Also, in four of seven experiments, a progressing activity front was arrested by 2.0 mg prostaglandin E₂. Prostaglandin F₂ at 2.5 or 5.0 mg given intraduodenally induced bursts of contractions with a frequency of 17.7± 0.8 contractions per minute and an amplitude of 10 to 110 mm Hg (P<0.07). In comparison, food intake produced irregular contractions at a frequency of 5.3± 1.8 contractions per minute and an amplitude of 10 to 50 mm Hg (P<0.05). It is concluded that prostaglandin E₂ delays the initiation of activity fronts in the duodenum. In contrast, prostaglandin F₂ changes the interdigestive motility pattern to one of intense contractile activity, which is different from the postprandial motility pattern.     

Effect of an oral beta2-adrenergic agonist on lower esophageal sphincter pressure in normals and in patients with achalasia

The effect of the beta₂-adrenergic agonist, carbuterol, was studied on the lower esophageal sphincter (LES) pressure in normals and in patients with achalasia. In normals, the mean LES pressure decreased from 23.1±6.2 mm Hg (mean±sem) to 16.0±5.0 mm Hg at a 4.0-mg dose of carbuterol (P<0.05). In patients with achalasia, the mean LES pressure decreased from 50.1±5.1 mm Hg to 22.7±2.4 mm Hg after a 4.0-mg dose of carbuterol (P<0.01). The duration of action following oral administration exceeded 90 min. These studies indicate that the LES in man has beta₂-adrenergic receptors that mediate a reduction in pressure. The magnitude of LES pressure reduction in patients with achalasia suggests that this drug may be of therapeutic benefit.     

Effect of continuous rectal distention on anal resting pressure

PURPOSE: Intermittent distention of the rectum induces internal anal sphincter relaxation, but whether continuous rectal distention might affect the resting pressure of the anal canal and the frequency of internal anal sphincter relaxations has not yet been investigated. The aim of this study was to record anal pressure under resting conditions and at two levels of continuous rectal distention. METHODS: Anal pressure was recorded by means of water-perfused catheters under resting conditions and at two levels of rectal distention controlled by an electronic barostat in eight healthy subjects. RESULTS: Continuous rectal distention did not significantly change mean anal resting pressure, but it did significantly decrease the amplitude of ultraslow waves (from 29±9 mmHg under resting conditions to 23±6 and 21±3 mmHg during lesser and greater rectal distention;P=0.017 andP=0.012, respectively) and increase the frequency of internal anal sphincter relaxations (from 1.3±1.3/hour under resting conditions to 8.8±4.3/hour and 11.0±4.8/hour during lesser and greater distention;P=0.012 in both comparisons). CONCLUSIONS: The resting pressure of the anal canal is maintained during continuous rectal distention. The decreased amplitude of ultraslow waves and increased frequency of the internal anal sphincter relaxations induced by rectal distention reveal a complex functional relationship between the rectum and the anal canal.Supported by the Associazione Amici della Gastroenterologia del Padiglione Granelli and the CARIPLO Foundation.     

Colonic Crohn’s Disease in Children Does Not Respond Well to Treatment with Enteral Nutrition If the Ileum Is Not Involved

Data supporting a response to treatment with exclusive enteral nutrition in pediatric colonic Crohn’s disease are few. We examined clinical and biochemical responses of ileal, colonic, and ileocolonic Crohn’s disease and assessed the endoscopic and histological colonic mucosal response in the colonic and ileocolonic groups.We prospectively enrolled 65 children (age: 8–17 years) with acute intestinal Crohn’s disease (Pediatric Crohn’s Disease Activity Index [PCDAI] > 20). After ileocolonoscopy, gastroscopy, and a barium meal and follow-through, they were distributed into three groups (ileal, n = 12, ileocolonic, n = 39; and colonic, n = 14). All patients received exclusive polymeric feed as treatment, with a repeat endoscopy at completion of treatment. At enrollment the ileal group had significantly less severe disease (P = 0.05) compared to the colonic and ileocolonic groups. However, the colonic disease group showed the least fall in PCDAI scores at completion of treatment with enteral nutrition (P = 0.03), with the lowest remission rate (50%, vs 82.1% in the ileocolonic and 91.7% in the ileal group [χ² test, P = 0.021]). Endoscopic and histologic colonic mucosal assessment showed a posttreatment improvement in the ileocolonic (P ≤ 0.01) but not in the colonic disease group (P = ns). Children with disease in the colon respond better to enteral nutrition if the ileum is also involved. This may be due to different underlying inflammatory mechanisms. Detailed pretreatment assessment in studies of Crohn’s disease according to disease distribution with appropriate individualized tailoring of treatment may be important in this regard.     

Achalasia in the elderly

Clinical and manometric data from 13 elderly subjects with idiopathic achalasia (mean age 79±2 years) were compared with findings from younger subjects with the same disease (n=79) to see if aging altered the presentation and outcome of this motor disorder. Fewer elderly subjects complained of chest pain (27% vs 53%), and the pain was significantly less severe (P<0.01). Other presenting features (including sex, duration of symptoms, and presence and severity of dysphagia) did not differ between the groups. Across all patients, age weakly and inversely correlated with residual postdeglutitive lower esophageal sphincter (LES) pressure (R=–0.34), and residual pressure was significantly lower in the older subjects (8.0±1.3 mm Hg vs 11.9±0.8 mm Hg;P=0.02). No differences in basal LES pressure or esophageal-body contraction amplitudes were present between the groups. Initial success with pneumatic dilation was similar in the two subject groups, but the number of older subjects available for analysis was too small to draw strong conclusions. These results indicate that aging decreases the elevation of LES residual pressure that occurs with achalasia. As elderly achalasia patients also present with less chest pain, the findings may be interrelated.Supported in part by grant AMO7130 from the United States Public Health Service. Dr. Todorczuk is supported by an educational grant from Smith, Kline, and French.     

Association betweenH. pylori,duodenal mechanosensory thresholds,and small intestinal motility in chronic unexplained dyspepsia

Alterations of small intestinal sensory thresholds and small intestinal dysmotility are associated with functional dyspepsia. Because gastric and duodenal afferents partly project to the same areas, we postulated that patients with functional dyspepsia andH. pylori infection would be characterized by lower duodenal sensory thresholds. We evaluated 16 patients with functional dyspepsia and 16 age- and sex-matched controls. All patients had undergone an extensive diagnostic work-up to exclude organic lesions. Mechanosensitive function was tested in the third portion of duodenum utilizing a barostat device, and small intestinal motility was assessed before and during duodenal nutrient infusion with a five-channel low-compliance perfusion system.H. pylori status was assessed by a validated serological test. Small intestinal sensory thresholds (first perception and maximal tolerated pressure) were significantly lower in patients (21.1±2.1 and 30.9±1.8 mm Hg) compared to controls (33.0±2.2 and 38.8±0.9 mm Hg, allP<0.003). Nine of 16 patients compared with five of 16 controls wereH. pylori positive (P=0.15). Thresholds forH. pylori-negative (28.7±2.8 and 36.5±1.1 mm Hg) or -positive subjects (25.0±3.0 and 32.7±2.4 mm Hg) were overall not significantly different (P>0.3). However, in patients with defined highH. pylori titers (>50 units/ml) defineda priori, thresholds for first perception were significantly lower (14.7±2.9 mm Hg,N=5) compared to patients withH. pylori titers below this threshold (24.3±2.9 mm Hg,N=4) or withoutH. pylori infection (23.8±3.4 mm Hg,P<0.05). During duodenal nutrient infusion, the duodenal motility index increased (P<0.03). This increase was not significantly different in patients and controls or inH. pylori-negative and -positive subjects. Sensory abnormalities are present in patients with functional dyspepsia. In a small subgroup of patients with highH. pylori titers, sensory abnormalities may be linked toH. pylori infection.Supported by a grant from Deutsche Forschungsgemeinschaft, grant number Ho 1193/3-1,2 and by the Gastrointestinal Motility Research Award from the German Association of Digestive Diseases (donated by the Janssen Research Foundation).     

Lower esophageal sphincter pressure as an index of gastroesophageal acid reflux

The purpose of this study was to determine the relationship of lower esophageal sphincter (LES) pressure and the volume of acid placed into the stomach required to induce gastroesophageal reflux in man. LES pressure was recorded continuously and by station pull-through by three radially oriented catheters in both symptomatic and asymptomatic subjects during the graded infusions of 0.1 N HCl acid into the stomach. Sumptomatic subjects had a mean LES pressure of 7.5±0.7 mm Hg and refluxed at a volume of 140.0±21.0 ml. Fifty-five percent of asymptomatic subjects refluxed at a mean volume of 380.0±24.7 ml, and had a mean LES pressure of 13.8±0.4 mm Hg. Asymptomatic nonrefluxers at a volume of 500 ml of 0.1 HCL acid had a mean LES pressure of 18.9±1.1 mm Hg. The mean LES pressure and acid volumes showed statistical significance between the three groups (P<0.01). There was an excellent overall correlation between LES pressure and acid volume required to produce reflux in all subjects (r=0.91,P<0.001). Following reflux, asymptomatic but not symptomatic subjects showed a significant increase in LES pressure. These studies suggest that: (1) LES pressure does provide an accurate index of the gastroesophageal antireflux mechanism, provided that acid volume is considered; and (2) asymptomatic subjects showing acid reflux have higher LES pressures, reflux at higher volumes, and develop an LES contractile response after the reflux episode.This work was supported by a grant from the Smith Kline & French Laboratories, Philadelphia, Pennsylvania.     

Intraesophageal acid perfusion sensitizes the esophagus to mechanical distension: a Barostat study

OBJECTIVE: The pathogenesis of noncardiac chest pain is unclear. Increased gastroesophageal reflux and decreased pain thresholds to intraesophageal balloon distension have been demonstrated in a proportion of such patients. We aimed to investigate whether acid exposure sensitizes esophageal mechanoreceptors in healthy volunteers. METHODS: After an overnight fast, an infinitely compliant balloon, 4.5 cm in length and mounted on a multilumen transnasal manometry catheter, was placed 8.5 cm above the lower esophageal sphincter in 12 healthy male volunteers aged 18-39 yr. After determination of the minimal distending pressure, the balloon was inflated up to 48 mm Hg by means of a computer-controlled barostat (G & J Electronics, Canada). Graded stepwise distensions were interspersed with random decreases in pressure to two-thirds of the previous value. At each pressure level, the subjects were asked to report on sensation and the presence of pain. Baseline distension was repeated to determine reproducibility of the pressure/volume relationship and also the perception and pain thresholds. After the baseline distension sequence, the esophagus was perfused for 20 min (at 7 ml/min) with either normal saline (control) or 0.1 N hydrochloric acid at 37 degrees C on a random basis. RESULTS: Basal sensory thresholds varied widely (first perception 5-36 mm Hg, pain 8 > or = 43 mm Hg). Two subjects did not experience pain up to the maximum distending pressure (42 and 43 mm Hg, respectively, after correction for the minimal distending pressure). Esophageal body compliance was similar on repeat distension. Sensory thresholds were reproducible with different distensions (perception r = 0.99, pain r = 0.95). Saline resulted in no significant changes in perception or pain thresholds. Acid perfusion reduced first perception (median before and after acid, 15 mm Hg and 8 mm Hg, respectively, p = 0.05) and pain threshold (median before and after acid, 32.5 mm Hg and 26.5 mm Hg, respectively, p = 0.05). When compared to changes after saline perfusion, acid perfusion reduced the perception threshold (median change, -3.8 mm Hg vs 0 mm Hg, p = 0.04) and tended to reduce the pain threshold (median change, -3.75 mm Hg vs +0.75 mm Hg, p = 0.09). CONCLUSIONS: Intraesophageal balloon distension using a barostat is a reproducible method of measuring esophageal body compliance and sensory thresholds. Acute exposure to acid seems to sensitize the esophagus to perception from intraluminal balloon distension.     

Constipation after rectopexy for rectal prolapse

The pathophysiology of constipation after rectopexy remains unclear: acquired anorectal dysfunction or preoperative colonic state are, by turns, the supposed culprit. The aim of this prospective study was to characterize the colorectal motility abnormalities encountered after such a surgical procedure. Twelve patients (10 females, 2 males, aged 50.5±5.2 years) complaining of severe constipation or its worsening after orr rectopexy (OR) for rectal prolapse were studied. Each underwent detailed interrogation as to their symptoms, left colonic manometry (basal and postprandial motor indexes and their caudad gradients in the sigmoid), anorectal manometry, evacuation proctography, and colonic transit time with radiopaque markers. Results were compared to those obtained in two control groups: 10 healthy volunteers (HV) and 12 patients complaining of a rectal prolapse (RP) observed consecutively during the same period of evaluation (June 90 to December 91). Before surgery, the OR and RP groups were similar with respect to mean age, sex ratio, weekly stool frequency, subjective dyschezia and manual anal supplies, constipation symptoms, and anal incontinence. OR patients differed significantly from the RP group in having a lower weekly stool frequency (2.5±2.2 vs 5.2±3.7,P<0.01) and a higher prevalence of abdominal pain (7 vs 1 patients,P<0.05). Above the rectopexy, global (135.9±38 vs 51±30.5 hr,P<0.01) and left (61.6±10 vs 18.2 hr,P<0.01) colonic transit times were significantly higher in OR patients; moreover, the basal motor index gradient was negative in all but one case (–94.1±101 vs 177.3±131,P<0.01). The OR patients differed from HV by their prolonged segmental transit time in the right colon (24.2±14 vs 9.9±8.2 hr,P<0.01) and the negative values of the postprandial colonic motor index (–191±281 mm Hg/min vs 39.8±72 mm Hg/min,P<0.05). No postprandial peristaltic rush was observed in the OR group. Below the rectopexy, the segmental transit time in the rectosigmoid, the qualitative and quantitative rectal emptying during evacuation proctography, and the anal and rectal manometric values were not, for the most part, different between the groups. In conclusion constipation following surgical procedure of rectal prolapse seems to be related in this study to acquired sigmoid motility disturbances above the rectopexy rather than to anorectal emptying.This work has been presented at the Digestive Disease Week (American Gastroenterological Association), San Francisco, California, May 13, 1992.     

Gastroesophageal Reflux After Combined Lower Esophageal Sphincter and Diaphragmatic Crural Sling Inactivation in the Rat

This study tests the hypothesis that eitherselective or combined destruction of the loweresophageal sphincter and the diaphragmatic crural slingshould induce reflux in the rat. Pull-through perfusion manometry was performed before and after loweresophageal myectomy, crural myotomy, or both. pHmonitoring was used to detect reflux. Unmanipulated ratsserved as controls. Paired t tests were used for comparison of pre- and postoperative pressurevalues and contingency tables with Fisher's tests forexamining the association between the interventions andthe appearance of reflux. Esophageal myectomy decreased only sphincteric pressure from 25.9± 15.5 to 9 ± 6 mm Hg (P < 0.01),whereas crural myotomy decreased only sling pressurefrom 26.2 ± 13.3 to 7.3 ± 3.9 mm Hg (P< 0.01). Simultaneous performance of both procedures decreasedsphincteric and crural pressures from 20.4 ± 7.5to 7.6 ± 4.3 mm Hg (P < 0.01) and from 45.9± 20.6 to 18.2 ± 7.4 mm Hg (P < 0.01),respectively. None of the control, myectomy, or myotomy animalsshowed reflux upon pH-metry but 5/8 rats in which bothprocedures were performed had prolonged acid exposure.No esophagitis was seen. In conclusion, normal rats do not have reflux. Selective destructionof either the sphincter or the crural sling does notinduce reflux, despite causing flattening of theirrespective manometric profiles. Conversely, combined inactivation of both components issignificantly associated with reflux.     

Pathological esophageal acidification and pneumatic dilatation in achalasic patients too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 ± 4.2 to 14.6 ± 1.1 mm Hg (mean ±sem); there was, however, no difference between nonrefluxers and refluxers (14.8 ± 1.2 vs 13.8 ± 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 ± 20.9 min vs 209 ± 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 ± 4.5 vs 2.5 ± 1.8 min,P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.