Clinical relevance of antroduodenal manometry

OBJECTIVE: To evaluate the outcome of antroduodenal manometry studies and their effect on the clinical treatment of patients. DESIGN: A retrospective review of clinical antroduodenal manometric studies performed between September 1990 and March 1997 (n = 109). SETTING: Tertiary referral centre. MAIN OUTCOME MEASURES: The predominant symptom, the indication for the study, the outcome and the clinical impact were scored. A positive impact was defined as an outcome that resulted in an alteration of the management of the patient (medication, surgery, feeding), established a new diagnosis, or resulted in new investigations or in referral to another specialist. RESULTS: Full records were obtained from 91 studies in 85 patients (mean age 43 years). Nausea and vomiting were the most predominant symptoms (37.4%). In 49.5% of the cases, the test was performed due to suspicion of a generalized motor disorder. A normal outcome was found in 37 studies. Non-specific motor abnormalities were reported in 72% of the studies with an abnormal outcome. Pseudo-obstruction was diagnosed in 20%. The manometric studies resulted in a new therapy in 12.6%, a new diagnosis in 14.9%, and referral to another specialist in 8%. A positive clinical impact was found in 28.7% of the patients. CONCLUSION: Antroduodenal manometry can be a helpful diagnostic technique in a specialized centre. More research is needed to gain insight into the significance of the large number of non-specific abnormalities that are often found.     

Cd1d-dependent regulation of bacterial colonization in the intestine of mice

The accumulation of certain species of bacteria in the intestine is involved in both tissue homeostasis and immune-mediated pathologies. The host mechanisms involved in controlling intestinal colonization with commensal bacteria are poorly understood. We observed that under specific pathogen–free or germ-free conditions, intragastric administration of Pseudomonas aeruginosa, E. coli, Staphylococcus aureus, or Lactobacillus gasseri resulted in increased colonization of the small intestine and bacterial translocation in mice lacking Cd1d, an MHC class I–like molecule, compared with WT mice. In contrast, activation of Cd1d-restricted T cells (NKT cells) with α-galactosylceramide caused diminished intestinal colonization with the same bacterial strains. We also found prominent differences in the composition of intestinal microbiota, including increased adherent bacteria, in Cd1d^–/– mice in comparison to WT mice under specific pathogen–free conditions. Germ-free Cd1d^–/– mice exhibited a defect in Paneth cell granule ultrastructure and ability to degranulate after bacterial colonization. In vitro, NKT cells were shown to induce the release of lysozyme from intestinal crypts. Together, these data support a role for Cd1d in regulating intestinal colonization through mechanisms that include the control of Paneth cell function.     

Hyperglycemia Affects Gastric Electrical Rhythm and Nausea During Intraduodenal Triglyceride Infusion

Hyperglycemia slows gastric emptying andincreases the intensity of perception of gastricdistension during fasting and small intestinal nutrientstimulation. In order to examine the possibility thatabnormalities of gastric electrical rhythm may be associatedwith the effects of hyperglycemia, the gastricelectrical rhythm (cutaneous electrogastrogram) and theperception rating scores for upper gastrointestinal sensations (visual analog scale) were examined.Studies were performed during intraduodenal triglycerideinfusion in 10 healthy volunteers under euglycemic andhyperglycemic (15 mmol/liter) conditions. During fasting, hyperglycemia had no effect oneither gastric electrical rhythm or sensation.Intraduodenal triglyceride infusion was associated withan increase in bradygastria (<2.4 cpm) during botheuglycemia (33 9%) and hyperglycemia (36 ± 10%, P< 0.05 vs baseline for each). During intraduodenaltriglyceride infusion, tachygastria (>3.6 cpm) wasmore prevalent during hyperglycemia when compared toeuglycemia (25 ± 10% vs 1 ± 1%, P <0.05) and the perception rating scores for nausea andabdominal discomfort were greater during hyperglycemia(P < 0.05 for both). The intensity of nauseacorrelated with the proportion of time spent in tachygastria (r = 0.64, P < 0.01).These data are consistent with the concept thatpostprandial upper gastrointestinal symptoms in patientswith diabetes mellitus may be modulated by the bloodglucose concentration.     

Intestinal Permeability in Irritable Bowel Syndrome Patients: Effects of NSAIDs

Intestinal permeability and the effect of NSAIDs on permeability were investigated in 14 irritable bowel syndrome (IBS) patients and 15 healthy subjects. In the study, 24-h urinary recoveries of orally administered polyethylene glycols (PEGs 400, 1500, and 4000) were not significantly different in healthy subjects and IBS patients before or after NSAID ingestion. Lactulose mannitol ratios in healthy subjects and IBS patients were not significantly different. Only time-dependent monitoring of PEG excretion showed that NSAIDs enhanced intestinal permeability for PEG 4000 in healthy subjects (P = 0.050) and for PEGs 400, 1500, and 4000 in IBS patients (P = 0.012, P = 0.041, and P = 0.012, respectively). These results show that intestinal permeability in IBS patients is not different from that in healthy subjects; NSAIDs compromise intestinal permeability in IBS patients to a greater extent than in healthy subjects, which suggests that IBS is associated with an altered response of the intestinal barrier to noxious agents.     

Upper gastrointestinal responses to intraduodenal nutrient in type 1 diabetes mellitus

BACKGROUND: Abnormal nutrient-related small-intestinal feedback may contribute to disordered gastric motility and upper gastrointestinal symptoms in patients with diabetes. AIM: To evaluate the motor, sensory and incretin responses to intraduodenal nutrients in patients with type 1 diabetes and in controls. METHODS: Eight type 1 diabetes patients (two with autonomic neuropathy) and nine controls were studied during euglycaemia. A manometric catheter was positioned across the pylorus, and nutrient was infused intraduodenally (90 kcal over 30 min). Blood glucose and plasma glucagon-like peptide 1 and gastric inhibitory polypeptide were measured, and sensations were assessed with visual analogue questionnaires. RESULTS: During nutrient infusion, neither the number of antral waves nor the stimulation of phasic or basal pyloric pressures differed between patients and controls. Upper gut sensations and areas under the plasma incretin peptide curves did not differ between the groups. CONCLUSIONS: During euglycaemia, the upper gastrointestinal motor, sensory and incretin peptide responses to small-intestinal nutrient are comparable in patients with relatively uncomplicated type 1 diabetes and in healthy subjects.     

Relationship between partial gastric volumes and dyspeptic symptoms in fundoplication patients: a 3D ultrasonographic study

OBJECTIVES: Impaired gastric accommodation may induce dyspeptic symptoms in postfundoplication patients. Our aim was to assess the effect of a meal on total and partial gastric volumes in relation to dyspeptic symptoms in both dyspeptic and nondyspeptic fundoplication patients using three-dimensional (3D) ultrasonography. METHODS: Eighteen postfundoplication patients of whom eight with and ten without dyspeptic symptoms and eighteen controls were studied. Three-dimensional ultrasonographic images of the stomach were acquired and symptoms were scored while fasting and at 5, 15, 30, 45, and 60 min after ingesting of a 500-ml liquid meal. From the 3D ultrasonographic images of the stomach the total, proximal, and distal gastric volumes were computed. RESULTS: Dyspeptic and nondyspeptic fundoplication patients exhibited similar total gastric volumes at 5 min postprandially compared to controls, whereas smaller total gastric volumes were observed from 15 to 60 min postprandially (p = 0.007 and p < 0.001, respectively). Postprandial proximal/total gastric volume ratios were markedly reduced in both dyspeptic (0.39 +/- 0.016; p < 0.05) and nondyspeptic (0.38 +/- 0.016; p < 0.01) fundoplication patients compared to controls (0.47 +/- 0.008). In contrast, distal/total gastric volume ratios were larger in dyspeptic fundoplication patients (0.14 +/- 0.008) compared to both nondyspeptic fundoplication patients (0.11 +/- 0.007); p < 0.05) and controls (0.07 +/- 0.003); p < 0.001). Dyspeptic fundoplication patients had a higher postprandial score for fullness, nausea, and pain than nondyspeptic patients (p < 0.05) and controls (p < 0.05). Meal-induced distal gastric volume increase correlated significantly with the increase in fullness (r = 0.68; p < 0.01). CONCLUSIONS: After a liquid meal, fundoplication patients exhibit a larger volume of the distal stomach compared with controls. Distal stomach volume was more pronounced in dyspeptic fundoplication patients and related with the increase in postprandial fullness sensations.     

Fully automated analysis of colonic manometry recordings

The purpose of this study was to develop a computer program for fully automated analysis of all presently known motor patterns in human colonic motility recordings. Colonic pressure recordings obtained from 24 healthy volunteers were used. Algorithms were developed for the detection and numerical analysis of five types of pressure waves: antegrade, retrograde, simultaneous, high-amplitude and isolated pressure waves. Furthermore, periodical motor activity was quantified. Validation was performed by comparison with visual analysis by two experienced observers. Patterns recorded during day- and night-time were compared using multiple-factor analysis of variance with Bonferroni correction. Automated analysis correlated well with visual peak detection (r = 0.98, P <0.01) and detection of antegrade pressure waves (r = 0.98, P <0.01). Most motor patterns showed a diurnal variation. During the night, prevalences of antegrade (938 vs 455; P <0.05), retrograde (112 vs 81; P <0.05), high-amplitude (12.9 vs 1.3; P <0.05), isolated pressure waves (1114 vs 765; P <0.05), and periodic motor activity were decreased (7.33 vs 4.47%; P <0.05). However, when expressed as percentage of absolute numbers of pressure waves, prevalences remained constant. In conclusion, fully automated analysis of all hitherto described colonic motility patterns is feasible. During the night, overall wave prevalences markedly decreased, but the distribution over the various motor patterns was preserved.     

Abnormalities of left colonic motility in ambulant nonconstipated patients with irritable bowel syndrome

Our objective was to evaluate left colonic motility patterns recorded under physiological conditions during 24 hr in fully ambulant nonconstipated IBS patients compared to healthy controls. A 42-hr manometry of the left colon was performed in 11 nonconstipated IBS patients and 10 age- and sex-matched healthy volunteers. On day 1, a 6-channel, 10-cm interval, solid-state catheter was positioned. Frequency, amplitude, and motility index (MI) of segmenting pressure waves in the descending and sigmoid colon were calculated during the 24-hr study period on day 2. High-amplitude propagated contractions (HAPCs) were identified visually and their characteristics were calculated. In IBS patients a higher frequency of segmenting pressure waves was observed in the sigmoid colon compared to the descending colon (P = 0.006). In contrast, no regional differences were observed in controls. Awakening (P = 0.048) as well as having a meal (P = 0.024) was associated with a smaller increase of contraction frequency in the descending colon of IBS patients compared to controls. HAPCs occurred more frequently in IBS patients than in controls (P = 0.035$). HAPCs in IBS patients reached a more distal colonic level and occurred more frequently in clusters. Defecation in IBS patients, but not in controls was always preceded by a cluster of HAPCs. In conclusion, left colonic segmenting pressure waves and HAPC characteristics are altered in nonconstipated IBS patients.     

Colorectal visceral perception in diverticular disease

BACKGROUND AND AIMS: The pathogenesis of asymptomatic diverticular disease (ADD) and symptomatic uncomplicated diverticular disease (SUDD) has not been elucidated. The aim of our study was to assess whether altered visceral perception or abnormal compliance of the colorectal wall play a role in these clinical entities. METHODS: Ten ADD patients, 11 SUDD patients, and nine healthy controls were studied. Using a dual barostat device, sensations were scored and compliance curves obtained using stepwise intermittent isobaric distensions of the rectum and sigmoid, before and after a liquid meal. In addition, the colonic response to eating was assessed by monitoring the volumes of both barostat bags at operating pressure before and after the meal. RESULTS: In the rectum, perception was increased in the SUDD group compared with controls (p = 0.010) and the ADD group (p = 0.030). Rectal compliance curves were not different between the groups. In the sigmoid colon, perception in the pre- and postprandial periods was increased in SUDD compared with controls (p = 0.018) but not when compared with ADD. Sigmoid volume-pressure curves had comparable slopes (compliance) in all groups but were shifted downwards in SUDD compared with ADD in the preprandial period (p = 0.026). The colonic response to eating (decrease in intrabag volume) was similar in all three groups, both in the rectum and sigmoid. CONCLUSION: Symptomatic but not asymptomatic uncomplicated diverticular disease is associated with heightened perception of distension, not only in the diverticula bearing sigmoid, but also in the unaffected rectum. This hyperperception is not due to altered wall compliance.