Neurogenic Bowel Dysfunction in Patients with Neurogenic Bladder

Patients with primary neurologic conditions often experience urinary and bowel dysfunction due to loss of sensory and/or motor control. Neurogenic bowel dysfunction is frequently characterized by both constipation and fecal incontinence. In general, the management of neurogenic bowel dysfunction has been less well studied than bladder dysfunction despite their close association. It is widely accepted that establishment of a multifaceted bowel regimen is the cornerstone of conservative management. Continuing assessment is necessary to determine the need for more invasive interventions. In the clinical setting, the Urologist may be the principle provider addressing bowel concerns in addition to bladder dysfunction, and furthermore, treatment of one often impacts the other. Future directions should include development of follow-up and management guidelines that address the comprehensive care of this patient population.     

Decreased Tongue Pressure Reflects Symptom of Dysphagia

The tongue plays a key role in oropharyngeal swallowing. It has been reported that maximum isometric tongue pressure decreases with age. The risk for dysphagia resulting from low tongue strength remains unclear. This study was designed to reveal the relationship between tongue pressure and clinical signs of dysphagic tongue movement and cough and to demonstrate the clinical value of tongue pressure measurement in the evaluation of swallowing function. One hundred forty-five institutionalized elderly in five nursing homes participated. Evaluation of physical activity with self-standing up capability and mental condition with Mini Mental Status Examination (MMSE) were recorded. Maximum tongue pressure was determined using a newly developed tongue pressure measurement device. Voluntary tongue movement and signs of dysphagic cough at mealtime were inspected and evaluated by one clinically experienced dentist and speech therapist. The relationship between level of tongue pressure and incidence of cough was evaluated using logistic regression analysis with physical and mental conditions as covariates. Tongue pressure as measured by the newly developed device was significantly related to the voluntary tongue movement and incidence of cough (p < 0.05). The results of this study suggest that tongue pressure measurement reflects clinical signs of dysphagic tongue movement and cough and that measurement of tongue pressure is useful for the bedside evaluation of swallowing.This study was supported by a grant-in-aid from the Ministry of Health, Labour and Welfare (tyoujyu-14-020).     

C反应蛋白反映炎症性肠病的活动性

背景：临床上评估炎症性肠病活动性的方法有临床活动度、C反应蛋白（CRP）和血沉等，三者常不一致。目的：探讨CRP评估炎症性肠病活动性的价值。方法：以Logistic回归法分析80例克罗恩病（CD）、70例溃疡性结肠炎（UC）患者血清CRP与血沉、临床活动度、内镜表现活动性、组织学活动性、低白蛋白血症、贫血、白细胞升高的关系；比较临床严重度、病变部位和药物治疗对CRP的影响。结果：CD中CRP与血沉相关；UC中CRP与血沉、外周血白细胞升高相关。CRP在活动性CD中显著升高（P〈0．01），重度CD和结肠CD中CRP升高较其他各组明显（P〈0．05）；活动性UC中CRP亦显著升高（P〈0．01），重度组中CRP升高较其他组明显（P〈0．05）。药物有效控制临床表现时．CRP显著下降（P〈0．01），复发时重新升高（P〉0．05）。结论：CRP升高更适于反映中至重度结肠CD和UC的活动性：具有快速反映药物治疗有效性的特点。     

肠易激综合征患者精神心理因素对生活质量、睡眠质量以及症状严重程度的影响

背景:肠易激综合征(IBS)患者多伴有焦虑、抑郁等精神心理障碍,但精神心理障碍对患者的影响尚未完全明确。目的:探讨IBS患者精神心理因素对生活质量、睡眠质量以及症状严重程度的影响。方法:纳入2014年11月—2015年5月安徽医科大学附属省立医院收治的IBS患者101例,采用Zung焦虑自评量表(SAS)和Zung抑郁自评量表(SDS)对患者心理状态进行评估;采用IBS生活质量量表(IBS-QOL)对患者生活质量进行评估;采用匹兹堡睡眠质量指数量表(PSQI)对患者睡眠质量进行评估;采用IBS症状严重程度量表(IBS-SSS)对患者症状严重程度进行评估。对患者精神心理因素、生活质量、睡眠质量以及症状严重程度行相关性分析。结果:57.4%(58/101)的IBS患者伴有不同程度的焦虑和(或)抑郁。101例患者IBS-QOL评分为73.28±12.79,其中以焦虑不安、忌食和健康忧虑影响最为严重。73.3%(74/101)的患者伴有不同程度的睡眠障碍,其中以日间功能障碍、睡眠质量和睡眠效率受损最为严重。101例患者中13例症状为轻度,63例为中度,25例为重度,IBS-SSS评分为253.00±72.58。相关性分析结果显示焦虑、抑郁与生活质量呈负相关(r=-0.426,P0.001;r=-0.501,P0.001),与睡眠质量呈正相关(r=0.556,P=0.000;r=0.513,P=0.000),与症状严重程度呈正相关(r=0.231,P=0.020;r=0.357,P0.001);生活质量与症状严重程度呈负相关(r=-0.417,P0.001)。结论:IBS患者具有精神心理障碍以及生活质量、睡眠质量下降的表现,且精神心理障碍愈严重,生活质量、睡眠质量受损愈明显,IBS症状愈严重。     

Ultrasound Evaluation of Small Bowel Abnormalities

By paying careful attention to technique, two identifiable patterns of small bowel pathology can be seen. These patterns, the pseudokidney sign and tubular sonolucent masses occur in both benign and malignant disease. For the pseudokidney sign to be present, lesions can occur either on a mucosal or serosal surface and extend toward the opposite surface to cause thickening of the bowel wall. Barium studies can be negative and yet a bowel lesion can indeed be present. The most important criteria for identification of these lesions is the continued presence of these masses with real-time. In the absence of real-time, repeat examinations at different times should prove these masses persistent. When these masses are identified, the examiner should carefully examine the patient to be certain that no other evidence of abnormality can be seen and to exclude the possibility of metastatic spread of disease. In those patients in which a pseudokidney is seen, the examiner should be certain that both kidneys are in normal position and that the mass is not an ectopic kidney. With the more frequent use of ultrasound as a screening tool, the identification of bowel lesions with sonography can help the clinician rapidly determine the correct diagnosis and thus save the patient considerable time and money by avoiding unnecessary diagnostic tests.     

Symptom relief with amitriptyline in the Irritable Bowel syndrome

Anti-depressants have been reported to be useful in the management of the Irritable Bowel syndrome. We studied the efficacy of amitriptyline for 12 weeks in a randomized double-blind placebocontrolled trial. Forty patients who met predefined criteria entered the trial. They received 25 mg amitriptyline for the first week, 50 mg for the second week and 75 mg nightly thereafter until the end of the 12th week. The drug and placebo groups were comparable in all major pretreatment variables. Amitriptyline was found to be significantly more effective than placebo in producing global improvement, increasing feelings of well-being, reducing abdominal pain and increasing satisfaction with bowel movements. Younger age and increasing extroversion predicted a better response to amitriptyline. Severity of depressive and anxiety symptoms and other personality variables did not influence outcome.     

Recovery of the Rectoanal Inhibitory Reflex After Restorative Proctocolectomy

PURPOSE: The rectoanal inhibitory reflex has an important role in fecal sampling and discrimination of rectal contents. The aim of this study was to determine the significance of rectoanal inhibitory reflex after restorative proctocolectomy with ileal pouch-anal anastomosis for mucosal ulcerative colitis. METHODS: The medical records of 345 patients who underwent ileal pouch-anal anastomosis from September 1988 to May 1999 were retrospectively reviewed. One hundred patients who underwent double-stapled ileal pouch-anal anastomosis and had anorectal physiology testing within 3 months before surgery as well as after ileostomy closure (mean, 23.1; range, 3–77 months) were analyzed. Anorectal physiology testing included detecting the presence of the rectoanal inhibitory reflex, sensory threshold volume, and rectal or pouch capacity and compliance. Parameters to determine incontinence included daytime and nocturnal bowel movement frequency, nocturnal spotting, status of continence for solid or liquid stool, gas, use of pads, and lifestyle alteration were surveyed in 62 of the 100 patients at a mean of 3.9 (range, 1–9.1) years to determine the incontinence score. RESULTS: Whereas the rectoanal inhibitory reflex was noted in 96 (96 percent) patients before surgery, it was found in only 53 (53 percent) after ileostomy closure (P < 0.0001). Incontinence status data was available in only 62 of the 100 patients (32 RAIR-positive; 30 RAIR-negative). There were no significant differences between the rectoanal inhibitory reflex-positive and the rectoanal inhibitory reflex-negative groups relative to the interval between surgery and manometry (22 vs. 25 months), postoperative threshold sensation volume (32 vs. 31 ml), postoperative compliance (19 vs. 12 cm H2O/ml), postoperative capacity (85 vs. 66 ml), daytime/nighttime stool frequency (6.2/2 vs. 5.5/1.5), or postoperative incontinence score (3.9 vs. 1.8). However, there were significant differences relative to the incidence of nocturnal soiling (12/30 (40 percent) vs. 23/32 (72 percent), P = 0.0012) favoring the presence of the rectoanal inhibitory reflex. CONCLUSION: Preservation of the rectoanal inhibitory reflex correlated with a decrease in the incidence of nocturnal soiling after double-stapled ileoanal reservoir construction.     

Psychological Distress and Seasonal Symptom Changes in Irritable Bowel Syndrome

Objective: It is not known whether irritable bowel syndrome (IBS) fluctuates with the seasons. We aimed to determine whether seasonal changes in symptoms occur in IBS and to examine the relationships between IBS, seasonality, and psychological factors.
Methods: A random sample of the community (n = 99) and hospital staff volunteers (n = 163) in Sydney, Australia, completed a previously validated questionnaire that measured bowel symptoms, psychosocial factors, and seasonality.
Results: IBS (n = 60; 23%) was significantly associated with somatization (by the Psychosomatic Symptom Checklist) and lifetime depression but not neuroticism (by the Eysenck Personality Questionnaire) or psychological morbidity (by the General Health Questionnaire). A seasonal variation in behavior score (measuring sleep, eating, including carbohydrate craving, weight gain, socializing, energy level, and mood by the Seasonal Pattern Assessment Questionnaire) was associated with somatization ( p < 0.001) and IBS ( p < 0.05) in a step-wise multiple regression model. Of those with IBS, 23% reported moderate or greater seasonal change in bowel symptoms. Subjects with IBS ( vs subjects with some bowel symptoms) were significantly more likely to report seasonal changes in pain and/or disturbed defecation (odds ratio = 3.2; 95% CI = 1.25-8.23); the latter was significantly associated with somatization but not the other psychological variables.
Conclusions: A subset of IBS may be seasonally determined, and this is explained in part by somatization.     

Abnormalities of Fasting Serum Concentrations of Peptide YY in the Idiopathic Inflammatory Bowel Diseases

Peptide YY has been localized within human ileocolonic endocrine cells and may contribute to the regulation of gastric secretion and gastric emptying in man. Since our previous studies had shown decreased colonic concentrations of peptide YY in the idiopathic inflammatory bowel diseases, a specific radioimmunoassay was used to measure fasting serum concentrations of peptide YY in healthy controls and in patients with adenocarcinoma of the rectum, idiopathic chronic active liver disease and hepatic cirrhosis, ulcerative colitis, and Crohn's disease. In healthy controls and in patients with adenocarcinoma of the rectum, serum concentrations of peptide YY ranged from 50 to 260 pg/ml. Serum concentrations of peptide YY in patients with hepatic cirrhosis ranged from 59 to 717 pg/ml. Serum concentrations of peptide YY in patients with ulcerative colitis were similar to healthy controls. In patients with Crohn's disease, serum concentrations of peptide YY were less than 50 pg/ml in three patients who had had a previous proctocolectomy, and were more than 260 pg/ml in 14 patients who had had previous resection of more than 48 cm of ileum or presently had symptomatic Crohn's disease subsequently requiring surgical resection of a total of more than 75 cm of ileum. These results suggest that most circulating peptide YY is released from the colorectal region. Hepatic cirrhosis, previous ileal resection, and symptomatic Crohn's disease were associated with elevation of fasting serum peptide YY. The mechanism of increased fasting serum peptide YY in patients with Crohn's disease could be the loss of an ileal inhibitory factor or possibly an increased release of colonic peptide YY in response to fat malabsorption. The effect of alteration of serum peptide YY concentrations on the pathophysiology of Crohn's disease is yet unknown.     

Symptom Provocation in Irritable Bowel Syndrome Effects of Differing Doses of Fructose-Sorbitol

The role of fructose and sorbitol, when ingested together, in the aetiology of irritable bowel syndrome (IBS) is controversial. The aims of this study in IBS patients, therefore, were to compare differences in symptom provocation with various doses of fructose-sorbitol and to relate differences in the extent of colonic hydrogen production after each dose to such symptom provocation. Two different mixtures of fructose and sorbitol-20 g fructose plus 3.5 g sorbitol ('lower' dose) and 25 g fructose plus 5 g sorbitol (‘higher’ dose)-were administered to 15 patients with IBS and to 24 healthy controls. Breath hydrogen concentrations were determined at 10-min intervals for 3 h after ingestion of each mixture, and the presence and severity of a range of gastrointestinal symptoms were recorded on a standard form before, during, and after the study. Total symptom score in IBS patients, but not controls, was greater (p > 0.05) after the higher than after the lower dose of fructose-sorbitol mixture, and, for the higher dose, symptoms were significantly greater in IBS patients than in controls (p > 0.05). Moreover, the increase in total symptom score between the higher and lower dose mixtures was of a greater magnitude (p = 0.01) in IBS patients than in controls. No significant correlation was observed between the increase in symptom score and the increase in peak hydrogen concentration or the increase in integrated hydrogen response between lower and higher dose mixtures, although these latter increases were at times substantial. We conclude that in patients with IBS who ingest fructose and sorbitol simultaneously, the degree of symptom provocation is related to the amounts present in such a mixture but is not related directly to the extent of colonic hydrogen production.     

Bowel Habit Reference Values and Abnormalities in Young Iranian Healthy Adults

The purpose of this study was to estimate the prevalence of self-reported, ROME II–defined constipation and determine the average defecation frequency and stool types in the Iranian population. A self-reported questionnaire was distributed to 1045 participants, including items intended to identify the presence of ROME II–defined functional constipation and the dominant form of stool based on the Bristol Scale. The weekly mean bowel movement frequency in men and women was 12.5 ± 7.3 and 13.8 ± 8.0, respectively (p < 0.05). A total of 87.4% of participants had a stool frequency of between 3 and 21 times per week. The prevalence of functional constipation was 32.9%, whereas only 9.6% of participants reported themselves to be constipated (level of agreement κ = 0.21, 95% confidence interval: 0.15 to 0.27). Soft or formed stool was reported in 75.7% of individuals. Functional constipation is common in the Iranian population, but its diagnosis could not rely on subjective patient complaints. Despite a higher average of bowel frequency, the previously reported normal range of defecation frequency can be applied for the Iranian population.     

Sleep-Related Autonomic Disturbances in Symptom Subgroups of Women with Irritable Bowel Syndrome

The objective was to investigate whether predominant symptom patterns in women with irritable bowel syndrome (IBS) affect autonomic activity during sleep. Seventy-five women with IBS underwent a polysomnographic sleep study. Twenty-two of the IBS patients were diarrhea-predominant (IBS-D), 33 were constipation-predominant (IBS-C), and 20 patients had alternating symptoms (IBS-A). Autonomic activity was measured by heart rate variability. The IBS-D group had significant vagal withdrawal compared to the IBS-A group during REM and non-REM sleep (P < 0.05). The IBS-D symptom subgroup had significantly (P < 0.05) greater sympathetic dominance during non-REM than IBS-A patients. Lower abdominal pain correlated with sympathetic dominance during sleep in the IBS-D group (r=0.54, P < 0.01). The IBS-D patients were physiologically distinct with regard to autonomic functioning during sleep compared to the alternating patients, but not the constipated patients. Sleep appears to unmask differences in autonomic activity that may distinguish IBS patients.     

Abnormalities of the Repolarization Characteristics of Patients with Heart Failure Progress with Symptom Severity

Background: Congestive heart failure is a common condition with high mortality. Many of these deaths are sudden and unexpected. Ventricular action potential, surface repolarization (QT interval), and dispersion of repolarization are prolonged in the failing heart, contributing to arrhythmogenesis and sudden death. We studied the relationship between QT and heart rate (RR interval) from ambulatory recordings using a novel method in patients with ischemic heart disease and varying degrees of left‐ventricular impairment (IHD) and compared them to healthy subjects (HS). We compare the degree of abnormality with the functional impairment and ejection fraction. Methods: Using a previously described automated method for continuous estimation of the QT/RR characteristic that incorporates a correction formula for compensation of QT adaptation lag (VERDA, Del Mar Reynolds Medical Ltd., Hertford, UK), we compared recordings from 41 IHD patients with age‐matched HS. Results: IHD Patients have prolonged 24‐hour mean QTo (461 ms vs 426 ms, P < 0.01), and abnormal rate dependence relative to controls (24‐hour mean slope: 0.20 vs 0.14, P < 0.001; J: 0.38 vs 0.28, P < 0.001). There is increased temporal variation in J with respect to HS. These abnormalities of repolarization increase with worsening NYHA class, but do not correlate with ejection fraction. Conclusions: The use of a universal correction formula to compare dynamic QT data in IHD patients is inappropriate. The observed progressive abnormalities may be responsible for the high incidence of sudden death through promotion of arrhythmias.     

Effects of Octreotide on Manometric Variables in Patients with Neuropathic Abnormalities of the Small Bowel

At present, there are few therapeutic options inpatients with chronic intestinal dysmotilities.Octreotide, a long-acting somatostatin analog, hasrecently been shown to be a potentially useful drug in this setting, being able to start activityfronts (AF) in the small bowel in both healthy subjectsand patients with intestinal motor disorders. We studiedthe effects of octreotide on manometric variables in 10 patients with chronic uppergastrointestinal symptoms and an intrinsic neuropathicdisorder of the small intestine. Gastrointestinalmanometry was carried out for 6 hr during fasting and 2hr after a standard 605-kcal mixed meal. Thereafteroctreotide, 50 g subcutaneously was administered andthe recording session continued for a further hour.Analysis of the tracings during fasting showed that 44% of the AF were abnormal; octreotidesignificantly increased the hourly number of AF (2± 0.26 vs 0.67 ± 0.14, P < 0.0001) andtheir duration (8.33 ± 1.3 vs 6.12 ± 0.34min, P < 0.05) with respect to the baseline (fasting) period, and the propagation velocityalso significantly slowed (3.4 ± 0.4 vs 11± 0.6 cm/min, P < 0.05). After the drug, 80%of patients displayed two AF and 10% more than two AF;the first AF after octreotide was always abnormally propagated. Analmost complete inhibition of small bowel postprandialcontractile activity was observed in 80% of patients,and the remaining 20% showed decreases. In three subjects, octreotide injection evoked theappearance of pylorospasm. From these results weconclude that octreotide could be of some benefit inpatients with neuropathic disorders of the small bowel,although it remains to be established whether it is mostuseful in patients with more severe conditions,characterized by the complete absence of AF. Theappearance of pylorospasm may contribute to the delayedgastric emptying observed after the drug isadministered.     

Sonographic Investigation of the Rectoanal Inhibitory Reflex: A Qualitative Pilot Study in Healthy Females

Purpose The rectoanal inhibitory reflex has been studied using various methods, e.g., anometry and electromyography. The aim of this study was to apply ultrasound for direct visualization of the rectoanal inhibitory reflex. Method The rectoanal inhibitory reflex was induced in ten healthy females (age range, 21–55 years) by injection of small amounts of water (7, 12, and 20 ml), into the rectum. The intra-anal pressure was measured with a microtransducer and the rectoanal inhibitory reflex was visualized with real-time transvaginal or transperineal sonography. Results The rectoanal inhibitory reflex consisted of a reduction in the intra-anal pressure and relaxation of the internal anal sphincter, manifested as an increase in the inner diameter of the internal anal sphincter from the mean of 11 to 16 mm (P < 0.001). Simultaneously, a wave of rectal contents entered the anal canal. The distance from the most distal border of the rectal contents to the anal verge decreased from a mean of 33 to 20 mm (P < 0.001). The rectoanal inhibitory reflex ended with a retrograde transport returning anal contents into the rectum. During the retrograde transport a contraction in the internal anal sphincter was observed. Conclusions The rectoanal inhibitory reflex can readily be visualized with ultrasound as a wave of rectal contents entering the anal canal. The transport into the anal canal was not of voluntary origin and could be either noticed or not noticed by the subjects. The observed retrograde transportation in the anal canal was not noted by the subjects; it is related to a contraction in the internal anal sphincter and visualized for the first time using ultrasound. Hitachi Ultrasound Holding AG, Zug, Switzerland, provided the ultrasound scanner. Presented at the World Congress on Ultrasound in Obstetrics and Gynecology, Paris, France, September 1 to 5, 2003. Reprints are not available.