Comparison of Diagnosis of Esophageal Motility Disorders by Chicago Classification Versions 3.0 and 4.0

Background/Aims@#We aim to investigate the diagnostic accuracy and differences between Chicago classification version 3.0 (CC v3.0) and 4.0 (CC v4.0). @*Methods@#Patients who underwent high-resolution esophageal manometry (HRM) for suspected esophageal motility disorders were prospectively recruited between May 2020 and February 2021. The protocol of HRM studies included additional positional change and provocative testing designed by CC v4.0. @*Results@#Two hundred forty-four patients were included. The median age was 59 (interquartile range, 45-66) years, and 46.7% were males.Of these, 53.3% (n = 130) and 61.9% (n = 151) were categorized as normalcy by CC v3.0 and CC v4.0, respectively. The 15 patients diagnosed of esophagogastric junction outflow obstruction (EGJOO) by CC v3.0 was changed to normalcy by position (n = 2) and symptom (n = 13) by CC v4.0. In seven patients, the ineffective esophageal motility (IEM) diagnosis by CC v3.0 was changed to normalcy by CC v4.0. The diagnostic rate of achalasia increased from 11.1% (n = 27) to 13.9% (n = 34) by CC v4.0. Of patients diagnosed IEM by CC v3.0, 4 was changed to achalasia based on the functional lumen imaging probe (FLIP) results by CC v4.0. Three patients (2 with absent contractility and 1 with IEM in CC v3.0) were newly diagnosed with achalasia using a provocative test and barium esophagography by CC v4.0. @*Conclusions@#CC v4.0 is more rigorous than CC v3.0 for the diagnosis of EGJOO and IEM and diagnoses achalasia more accurately by using provocative tests and FLIP. Further studies on the treatment outcomes following diagnosis with CC v4.0 are needed.

Prevalence of Fructose Malabsorption in Patients With Irritable Bowel Syndrome After Excluding Small Intestinal Bacterial Overgrowth

BACKGROUND/AIMS: Fructose malabsorption (FM) mimics symptoms of irritable bowel syndrome (IBS), and its prevalence has increased. Diagnosing FM in IBS is challenging because of its overlap with small intestinal bacterial overgrowth (SIBO). We assessed the prevalence of FM by comparing patients with IBS with asymptomatic control individuals after excluding SIBO using the glucose hydrogen breath test (HBT). METHODS: Patients diagnosed with IBS and asymptomatic control individuals were enrolled prospectively. Dietary habits were assessed with the Food Frequency Questionnaire. After excluding SIBO, participants underwent HBTs with both 15 g and 25 g of fructose. RESULTS: Thirty-five patients with IBS and 35 age- and sex-matched asymptomatic control individuals were enrolled. The 15-g fructose HBT yielded positive results in 7 of the 35 (20.0%) patients with IBS and in 2 of 35 (5.7%) controls (P = 0.070). The 25-g fructose HBT was positive in 16 of the 35 (45.7%) patients with IBS and in 8 of the 35 (22.9%) controls (P = 0.040). Analysis of the Food Frequency Questionnaire responses showed no significant differences between the 2 groups in dietary intake, although patients with IBS showed a significantly higher mean fiber intake than controls (21.24 ± 11.35 g vs 15.87 ± 7.07 g, respectively, P = 0.040). CONCLUSIONS: The 25-g fructose HBT identified FM in a significantly higher percentage of SIBO-negative patients with IBS than in asymptomatic control individuals, suggesting that FM may correlate with IBS. Education regarding dietary control of foods containing fructose may be useful for the management of patients with IBS.

Diet and Nutritional Management in Functional Gastrointestinal Disorder: Constipation / 대한내과학회지

Constipation is a common functional gastrointestinal symptom, the medical treatment of which is established. However, knowledge of diet and nutritional management for constipation is lacking. Based on current studies, fiber is effective in managing chronic constipation, but care should be taken in constipated patients with gaseous bloating. Increased fluid intake is controversial but may be beneficial, especially in conjunction with a stool-bulking agent. Other diet treatments lack high-quality evidence. A well-designed study to validate the effectiveness of diet, especially Korean diet, in the treatment of chronic constipation is needed.

Electrical Stimulation Therapy in Chronic Functional Constipation: Five Years' Experience in Patients Refractory to Biofeedback Therapy and With Rectal Hyposensitivity

BACKGROUND/AIMS: Biofeedback therapy (BFT) can be unsuccessful in constipated patients, even those with pelvic floor dysfunction. Electrical stimulation therapy (EST) has been introduced as a novel therapeutic modality in patients with chronic constipation, especially those who have rectal hyposensitivity. We evaluated the efficacy of EST based on five years' clinical experience. METHODS: From January 2002 to February 2007, 159 patients underwent EST. After exclusion of 12 drop-outs, 147 (M:F = 61:86, 49 +/- 17 years) finished all treatment sessions. Among them, 88 (M:F = 29:59, 49 +/- 17 years) were refractory to BFT without rectal hyposensitivity (RH), and 59 (M:F = 32:27, 54 +/- 17 years) were those with RH. RESULTS: The overall response to EST was 59.2% (87/147) by per-protocol analysis. In the EST-responsive group, overall satisfaction improved significantly (from 7.3 +/- 3.0 to 4.3 +/- 2.5, P < 0.05). Subgroup analysis showed that the response rate was 64.8% (57/88) in patients refractory to BFT without RH, and 50.8% (30/59) in those with RH. CONCLUSIONS: EST may have additional therapeutic efficacy in patients who are refractory to BFT. EST may also be effective in patients with RH, including restoration of rectal sensation. Therefore, EST could be considered as an alternative choice in patients refractory to BFT and with or without RH.

Characteristics of Korean Patients with Constipation Who Visited a Tertiary Referral Center / 대한내과학회지

BACKGROUND/AIMS: Korean patients with constipation have differences, both among themselves and as compared to other populations, with regard to race, diet, and cultural factors and are expected to have different characteristics to those of western patients, but few studies have been conducted in this regard. We evaluated the epidemiological and physiological characteristics of patients with constipation who visited a tertiary referral center. METHODS: A total of 338 patients with constipation were included. They completed a questionnaire and took physiological tests such as defecography, colon transit time, and anorectal manometry. We classified the types of constipation according to the physiological tests and analyzed the results. RESULTS: The mean age of the study patients was 53.8 +/- 16.3 years and 42.3% of the patients were > or = 60 years old. Patients who had tried folk remedies reached 64.3%. Among the self-reported patients with constipation, 89.1% satisfied the Rome III criteria for constipation. However, 84% of the patients who did not satisfy the criteria showed abnormal results on the physiological tests. Patients with normal transit constipation, slow transit constipation, and dyssynergic defecation were 21%, 27%, and 29% of the all patients, respectively. Rectal hyposensitivity was found in 16.9% of patients and 25% of them revealed anatomic abnormalities on defecography. CONCLUSIONS: Korean patients with constipation have a tendency to delay an accurate diagnosis and treatment and to use folk remedies. As physiological tests for patients with constipation who visited a tertiary hospital showed a relatively high rate of abnormal results, such as dyssynergic defecation and anatomic problems, active physiological evaluations should be considered for such patients.

Effect of Biofeedback Therapy in Constipation According to Rectal Sensation

BACKGROUND/AIMS: The pathophysiologic mechanism of rectal hyposensitivity (RH) is not well documented, and the significance of RH in biofeedback therapy (BFT) has not been evaluated. Thus, we aimed to assess the effect of BFT in constipated patients according to the presence of RH. METHODS: Five hundred and ninety constipated patients (238 males and 352 females) underwent anorectal physiologic assessments. Of these, anorectal manometry was performed before and after BFT in 244 patients (63 RH and 181 non-RH patients). RESULTS: The success rate of BFT was 56% in the RH and 61% in the non-RH group (p=0.604). The measurements of resting pressure, squeezing pressure, desire to defecate volume, urge to defecate volume, and maximum volume were decreased after BFT in the RH group (p<0.05), whereas only resting and squeezing pressures were decreased in the non-RH group (p<0.05). Among the RH group, individuals who responded to BFT showed decreased resting pressure, squeezing pressure, desire to defecate, urge to defecate, and maximum volume and increased balloon expulsion rate; among those who did not respond to BFT, only desire to defecate volume was improved. CONCLUSIONS: In constipated patients with RH, changes of anorectal manometric findings differed in comparison to patients without RH. The responses to BFT showed both anorectal muscle relaxation and restoration of rectal sensation.

Genetic Evaluation of ALADIN Gene in Early-Onset Achalasia and Alacrima Patients

BACKGROUND/AIMS: ALADIN gene has been known to cause achalasia, alacrima, adrenal abnormalities and a progressive neurological syndrome. A considerable proportion of achalasia patients has been known to show alacrima (decreased secretion of tear). However, the genetic mechanism between achalasia and alacrima has not been defined yet. We postulated that ALADIN gene may be involved in the occurrence of early-onset achalasia; thus, we investigated the correlation of ALADIN gene in early-onset achalasia patients. METHODS: From 1989 to 2007, patients who were diagnosed as primary achalasia before age 35 were enrolled. All of the enrolled patients were asked for (1) blood sampling for DNA, (2) Shirmer test and (3) dysphagia questionnaires. RESULTS: The ALADIN gene in exon 1, 2, 10, 11 and 12 from 19 patients was investigated (M:F = 12:7). The mean age of patients at diagnosis was 27 +/- 5 (15-35) years old. Eight out of 19 (42%) showed alacrima by the positive Shirmer test. In spite of thorough exam in the genetic study, there was no definite abnormal genetic finding in this study. CONCLUSIONS: A considerable number of achalasia patients showed alacrima. Due to the limitation of this study, it is difficult to conclude that early-onset achalasia may have significant correlations with the ALADIN gene.

Clinical Characteristics of Constipation with Hypothyroidism

BACKGROUND/AIMS: Constipation is a well-recognized gastrointestinal symptom in patients with untreated hypothyroidism. Although thyroid function tests are recommended to exclude hypothyroidism in patients with constipation, there have been no reports to determine the causal relationship between thyroid function and constipation. The aim of this study was to determine the prevalence of hypothyroidism in constipated patients and the clinical features of constipation associated with hypothyroidism. METHODS: A total of 1,481 constipated patients were included. These patients were divided into overt hypothyroidism, subclinical hypothyroidism, and normal thyroid function groups based on thyroid function tests. We reviewed the clinical presentation, anorectal function, colonic transit time, defecographic findings, and response to biofeedback therapy. RESULTS: The prevalence of overt and subclinical hypothyroidism was 0.41% (men, 0.36%; women, 0.53%) and 1.76% (men, 1.28%; women 2.03%), respectively. There were no differences in total or segmental colonic transit times and subtypes of constipation among the normal thyroid function (n=54), overt hypothyroidism (n=4), and subclinical hypothyroidism groups (n=21). On anorectal manometry, the prevalence of dyssynergic defecation did not differ between the three groups. Rectal hyposensitivity was more frequent in the overt hypothyroidism group (overt hypothyroidism group, 50.0%; subclinical hypothyroidism group, 19.0%; normal thyroid function group, 20.4%) without statistical significance (P=0.372). CONCLUSIONS: The prevalence of overt and subclinical hypothyroidism in constipated patients was very low. The colonic transit time is not affected by thyroid function.

Clinical Characteristics of Constipation with Hypothyroidism

BACKGROUND/AIMS: Constipation is a well-recognized gastrointestinal symptom in patients with untreated hypothyroidism. Although thyroid function tests are recommended to exclude hypothyroidism in patients with constipation, there have been no reports to determine the causal relationship between thyroid function and constipation. The aim of this study was to determine the prevalence of hypothyroidism in constipated patients and the clinical features of constipation associated with hypothyroidism. METHODS: A total of 1,481 constipated patients were included. These patients were divided into overt hypothyroidism, subclinical hypothyroidism, and normal thyroid function groups based on thyroid function tests. We reviewed the clinical presentation, anorectal function, colonic transit time, defecographic findings, and response to biofeedback therapy. RESULTS: The prevalence of overt and subclinical hypothyroidism was 0.41% (men, 0.36%; women, 0.53%) and 1.76% (men, 1.28%; women 2.03%), respectively. There were no differences in total or segmental colonic transit times and subtypes of constipation among the normal thyroid function (n=54), overt hypothyroidism (n=4), and subclinical hypothyroidism groups (n=21). On anorectal manometry, the prevalence of dyssynergic defecation did not differ between the three groups. Rectal hyposensitivity was more frequent in the overt hypothyroidism group (overt hypothyroidism group, 50.0%; subclinical hypothyroidism group, 19.0%; normal thyroid function group, 20.4%) without statistical significance (P=0.372). CONCLUSIONS: The prevalence of overt and subclinical hypothyroidism in constipated patients was very low. The colonic transit time is not affected by thyroid function.

Usefulness of Multichannel Intraluminal Impedance-pH Metry in Children with Suspected Gastroesophageal Reflux Disease / 대한소화기학회지

BACKGROUND/AIMS: pH monitoring of the esophagus has been considered as the gold standard for the measurement of acid reflux. However, it has several limitations related to its inability to detect nonacid reflux. We conducted this study to characterize the proportion of acid and non-acid reflux events in children using pH-multichannel intraluminal impedance (MII) monitoring and to determine the correlation of the symptom index with non-acid and acid reflux events. METHOS: Seventy-five children, aged from 9 days to 12 years, underwent 24 hour pH-MII monitoring at Asan Medical Center from March 2006 to June 2007. We investigated the underlying disease and main problems related to gastroesophageal reflux (GER) of the patients, the number of acid and nonacid reflux, symptom index, symptom sensitivity index in pH monitoring only and pH-MII monitoring. RESULTS: While 2,247 reflux events were detected by MII, and only 967 reflux events were detected by pH probe alone. The percentage of acid reflux was 43% (967) and that of non-acid was 57% (1,280). The non-acid reflux increased at postprandial time (p<0.001). The symptom index increased when measured by pH-MII (31.1%) compared with those by pH probe alone (8.2%) (p=0.003). CONCLUSIONS: This study suggests that significant number of GER include non-acid reflux which cannot be detected by pH probe alone, therefore combining pH with MII monitoring is a valuable diagnostic tool for diagnosing GER in children.

Response to Biofeedback Therapy for Patients with Rectal Hyposensitivity

BACKGROUND/AIMS: Rectal hyposensitivity (RH) has been treated with conventional biofeedback therapy (BFT), whereas the effectiveness and long term results of this therapy are not known. We aimed to investigate the effectiveness of BFT for patients with RH by conducting a retrospective review of prospectively collected data. METHODS: From June 2004 to March 2007, we enrolled those RH patients who underwent BFT. BFT was performed two or three times every week. Six months after BFT, the clinical response was evaluated by subjective and objective parameters. RESULTS: A total of 82 RH patients underwent BFT. Fifty three patients finished BFT and the other 29 patients dropped out during BFT. Thirty six patients (67.9%) showed responsiveness (R) to BFT and 17 (31.5%) showed non-responsiveness (NR). The characteristics between the two groups showed no difference, except for the "desire to defecate" volume (116.1+/-25.2 in the R group vs. 140.0+/-43.9 in the NR group, p value <0.05) and the rectoanal inhibitory reflex (RAIR) (15.6+/-0.5 in the R group R vs. 27.6+/-18.2 in the NR group, p value <0.05). The R group showed a shorter colon transit time compared to NR group. At six months after BFT, a total of 20 patients were interviewed; 15 patients answered that they still had responsiveness (75%). CONCLUSIONS: The patients with RH showed a similar BFT response to that of the constipated patients. However, the patients with a more hyposensitive rectum and a longer colonic transit showed NR to BFT, suggesting RH is an important factor in BFT responsiveness.

Clinical characteristics of constipation associated with diabetes mellitus / 대한내과학회지

BACKGROUND: Constipation occurs frequently in diabetes mellitus (DM). However, there are few reports that investigated the characteristics of constipation associated with DM. The purpose of this study was to evaluate the clinical features of constipation associated with DM. METHODS: Among constipated patients who visited Asan Medical Center from January 2000 to December 2004, 45 patients with DM (DM group) and 104 patients without DM (non-DM group) were included in this study. We reviewed the clinical presentation, results of anorectal manometry, colon transit time study, and defecogram. We also analyzed the response to biofeedback therapy. RESULTS: The severity of constipation symptoms before treatment was not different between DM and non-DM group. Patients with colon transit time over 56 hours were more frequent in DM group than in non-DM group (21/45, 46.7% vs. 31/104, 29.8% ; p=0.047). Among DM group, colon transit time and the duration of DM showed positive correlation (r=0.431, p=0.003). The resting anal sphincter pressure was significantly lower in DM group than in non-DM group (43.5+/-21.5 mmHg vs. 51.7+/-22.6 mmHg ; p=0.048). The results of defecography were similar between DM and non-DM group. Successful responses to biofeedback therapy were not different between DM and non-DM group (19/34, 55.9% vs. 43/79, 54.4% ; p=0.887). CONCLUSIONS: Slow transit constipation was more frequent in DM group than in non-DM group. The successful responses to biofeedback therapy appear to be similar between DM and non-DM group.

Clinical Characteristics of Patients with Chronic Constipation after Radical Hysterectomy or Delivery / 대한소화기학회지

BACKGROUND/AIMS: This study was aimed to analyze the clinical characteristics of patients who developed constipation after radical hysterectomy or delivery and to investigate the results of biofeedback therapy for these patients. METHODS: Thirty-five chronic constipation patients with radical hysterectomy (radical hysterectomy group), 27 chronic constipation patients with delivery (delivery group) and 27 constipation patients with no history of hysterectomy or delivery (control group) were included. Clinical characteristics of these patients, including the results of biofeedback therapy, were analyzed. RESULTS: The delivery group showed higher rates of pelvic floor dyssynergia than the control group (14/27, 52% vs. 6/27, 22%; p<0.05). The prevalence of slow transit constipation was lower in the radical hysterectomy group and delivery group than in the control group (7/35, 20% and 5/27, 19% vs. 12/27, 44%; p<0.05). The prevalence of anatomical abnormalities was not different between the groups. The radical hysterectomy group showed higher rate of obstructive sensation and the delivery group showed higher rate of hard stool and digital maneuvers. The biofeedback therapy was effective in 10 out of 12 patients (91%) among the radical hysterectomy and delivery group. CONCLUSIONS: Radical hysterectomy and delivery seem to induce functional constipation, which may be caused by anorectal dysfunction such as pelvic floor dyssynergia. The biofeedback treatment was effective in functional constipation after radical hysterectomy or delivery.

Clinical Factors Associated with Response to Biofeedback Therapy for Patients with Chronic Constipation / 대한소화기학회지

BACKGROUND/AIMS: Biofeedback therapy has been widely used for the treatment of constipated patients. However, there are only a few reports about the clinical factors that can predict the effectiveness of biofeedback therapy. The aim of this study was to evaluate prognostic factors before the initiation of biofeedback treatment in constipated patients. METHODS: Biofeedback treatment was performed in 114 patients with constipation. After classifying the patients into two groups, responder and non-responder by subjective and objective parameters, univariate and multivariate analysis were performed to evaluate the factors associated with effectiveness of biofeedback therapy. RESULTS: Eighty-five patients (74.6%) responded to biofeedback therapy. Pre-treatment balloon expulsion test, paradoxical contraction on manometry, defecation index and anal residual pressure during straining were the factors that influenced the results of biofeedback treatment. On multivariate analysis, defecation index (odds ratio=67.5, p<0.05) and paradoxical contraction on manometry (odds ratio=0.053, p<0.05) were the factors that showed significant difference between the responders and non-responders. CONCLUSIONS: This study suggests that several pre-treatment prognostic factors are associated with response to biofeedback for the constipated patients. Using prognostic factors, we may be able to evaluate the patterns of pelvic floor dysfunction and responsiveness of biofeedback therapy for the patients with constipation.

A Case of Solitary Rectal Ulcer Syndrome with Characteristic Findings of Evacuation and Magnetic Resonance (MR) Defecography / 대한소화관운동학회지

Solitary rectal ulcer syndrome is an uncommon, chronic benign condition characterized by rectal bleeding, the passage of mucus, tenesmus and excessive straining during defecation. Occasionally, solitary rectal ulcer syndrome has been reported to be associated with defecation disorder such as pelvic floor dyssynergia, rectal intussusception and rectal prolapse. However, it is ambiguous how these associated defecation disorders contribute to make the rectal ulcer. We report a case of solitary rectal ulcer syndrome suggesting the pathophysiology of rectal ulcer by typical findings of evacuation defecography and MR defecography. A 40-year-old man presented with lower abdominal pain, rectal bleeding, passage of mucus and tenesmus intermittently for the past 4 years. Colonoscopy showed a large geographic and circumferential ulcer at the 10 cm distance from the anal verge. A biopsy revealed fibromuscular proliferation of laminar propria, hyperplasia of crypt and focal superficial ulceration. Finally, he was diagnosed as solitary rectal ulcer syndrome. Evacuation defecography showed paradoxical movement of puborectal sling and unusual invagination of rectal walls during defecation. In addition, rectum showed spastic movement and anterior rectal wall directly merged into posterior rectal wall making a kissing appearance. The invagination of the rectum at evacuation defecography proved to be the rectal wall thickening at MR defecography. After 9 sessions of biofeedback therapy, his defecation symptoms improved. However, ulcer was still observed without interval change.

Electrical Stimulation Effect in Constipated Patients with Impaired Rectal Sensation / 대한소화관운동학회지

BACKGROUND/AIMS: Among constipated patients, there is a subgroup of patients who complain about an absent or diminished sense of desire to defecate, suggesting that one of the causes of functional constipation may be impaired rectal sensation. Recently, electrical stimulation therapy (EST) has been used for the treatment of patients with urinary/fecal incontinence. The aim of this study was to evaluate the efficacy of EST for a subgroup of constipated patients with impaired rectal sensation. METHODS: Of the 130 patients with functional constipation as defined by Rome II criteria, 22 patients who had impaired rectal sensation (rectal desire threshold volume = 90 ml) were selected. Twelve patients were treated with EST and 10 patients with biofeedback therapy (BFT). RESULTS: The overall symptoms of the patients significantly improved after therapy in both groups (p<0.05). Interestingly, the sense of desire to defecate improved only after EST (p<0.05). Moreover, there was significant improvement in anal residual pressure after BFT solely (p<0.05). On the other hand, rectal sensory threshold volumes improved significantly after EST exclusively (p<0.05). CONCLUSIONS: This study has revealed that the efficacy of EST can be comparable to BFT in a subgroup of constipated patients, especially with impaired rectal sensation. EST could be considered an adjunctive therapeutic modality for the management of functional constipation with impaired rectal sensation.

Electrical Stimulation Effect in Constipated Patients with Impaired Rectal Sensation / 대한소화관운동학회지

BACKGROUND/AIMS: Among constipated patients, there is a subgroup of patients who complain about an absent or diminished sense of desire to defecate, suggesting that one of the causes of functional constipation may be impaired rectal sensation. Recently, electrical stimulation therapy (EST) has been used for the treatment of patients with urinary/fecal incontinence. The aim of this study was to evaluate the efficacy of EST for a subgroup of constipated patients with impaired rectal sensation. METHODS: Of the 130 patients with functional constipation as defined by Rome II criteria, 22 patients who had impaired rectal sensation (rectal desire threshold volume = 90 ml) were selected. Twelve patients were treated with EST and 10 patients with biofeedback therapy (BFT). RESULTS: The overall symptoms of the patients significantly improved after therapy in both groups (p<0.05). Interestingly, the sense of desire to defecate improved only after EST (p<0.05). Moreover, there was significant improvement in anal residual pressure after BFT solely (p<0.05). On the other hand, rectal sensory threshold volumes improved significantly after EST exclusively (p<0.05). CONCLUSIONS: This study has revealed that the efficacy of EST can be comparable to BFT in a subgroup of constipated patients, especially with impaired rectal sensation. EST could be considered an adjunctive therapeutic modality for the management of functional constipation with impaired rectal sensation.

A Case of Constipation with Decreased Rectal Sensation Improved by Electrical Stimulation Therapy Alone / 대한소화관운동학회지

Patients with intractable constipation often complain of social, physical and psychological stress. Recently, biofeedback therapy is widely used in the management of intractable constipation and improve the defecation act, particularly in cases of constipation associated with pelvic floor dyssynergia. However, some of constipated patients show only decreased rectal sensation and increased rectal compliance on the anorectal function tests. It is unclear whether the decreased rectal sensation is a cause or outcome of constipation and not known how to treat such cases. We recently experienced a 25-year-old female patient who complained of constipation. She had intractable constipation, which made her attempt a suicide. Colon transit time study and defecogram showed nonspecific findings. Her anorectal manometric findings were within normal ranges except rectal sensation and compliance. Rectal volume for desire and urge to defecate, and maximal tolerable volume were markedly increased and compliance was impossible to measure. She was treated by electrical stimulation therapy. After electrical stimulation therapy, her constipation symptoms improved dramatically. Furthermore, the desire and urge volume were decreased and the compliance became calculated. We report this constipation case with decreased rectal sensation and increased rectal compliance possibly treated by electrical stimulation therapy.

Experience of Simplified Protocols in In-Vitro Fertilization and Embryo Transfer Program / 대한산부인과학회잡지

During the past few years much effort has been put into simplifying the clinical man-agement of in-vitro fertilization/embryo transfer cycles. One important step was the intro-duction of transvaginal ultrasound-guided oocyte collection, as previously described. This study describes further simplifications in the clinical management of ovarian stimulation and luteal support, and in-vitro fertilization procedure. During the period from October 1994 to September 1995, two major simplification steps were introduced. All cycles were administe-red with a gonadotrophin-releasing hormone agonist according to a long or short protocol preventing premature LH surge. During period I (Group I, n=62 cycles), closer monitoring by several pelvic ultrasound scans and serum oestradiol was used for monitoring the ovarian stimulation ; HTF media with fetal cord serum was used for insemination, growth and tran-sfer media in IVF-ET procedure ; progesterine in oil was daily used by intramuscular injec-tion for luteal support. During period II(Group II-I, n=71 cycles), only several ultrasound scans were used for monitoring the ovarian cycle ; Medi-cult IVF media containing synthetic serum replacement was used for insemination, growth and transfer media; Progesterine in oil was used daily by intramuscular injection for luteal support. During period III(Group II-II, n=16 cycles), further simplification of the clinical management was introduced by using a intravaginal micronized progesterone(Utrogestan) for luteal support. Retrospective analysis between Group I and Group II showed no differences in the number of oocyte(13.2+/-0.8/14.6+/-1.0), fertilization rate(71.5 %/60.7 %), cleavage rate(63.6 %/57.9 %), number of embryos transfered(5.0+/-0.5/4.5+/-0.5). Ongoing pregnancy rates obta ined from the three groups(Group I, Group II-1, Group II-II) were 25.8 %, 25 % and 40 %, respectively(p=ns). But introduction of minimal monitoring gave a significant reduction in the average number of US measurements in the simplified groups(Group II) compared with the group using the conventional monitoring protocol(Group I)(3.8+/-1.0/8.7+/-2.8, p<0.05). In the above groups, five patients developed severe OHSS but there was no differenc e in the distribution. Conclusively, simplified protocols including minimal follicle monitoring only by US, IVF-ET with Medi-cult IVF media containing synthetic serum replacement and the luteal support with intravaginal micronized progesterone gave a increased efficacy of the clinical phase of IVF treatment without a reduction in the success rate.