Interferential therapy: a new treatment for slow transit constipation. a pilot study in adults.

AIM: The study aimed to assess, for the first time, the effectiveness of interferential therapy (IFT) in the treatment of slow transit constipation in adults and its impact on the quality of life. METHOD: All consecutive patients with slow transit constipation diagnosed by symptomology and a colonic transit time (CTT) of > 100 h measured with radiopaque markers were included in this prospective study. IFT was performed for 1 h/day over 3 months. Clinical improvement was based on the stool diary and the Knowles-Eccersley-Scott Symptom and Cleveland Clinic Constipation Scores. Quality of life was assessed with the Gastrointestinal Quality of Life Index questionnaire. RESULTS: Eleven patients with a median age of 51 years were included. At the end of the follow-up period, seven (63.6%) had significantly improved after IFT with a median of 0.66 stools per week [interquartile range (IQR) 0.33-0.66] before treatment and 1.66 (IQR 1.33-1.66) after (P = 0.007). The Knowles-Eccersley-Scott Symptom score changed from 30 (IQR 27-33) before treatment to 19 (IQR 17-26) after treatment (P = 0.005) and the Cleveland Clinic Constipation Score from 26 (IQR 25-28) to 17 (IQR 13-24; P = 0.005). The CTT improved from 103 h (IQR 101-113) to 98 h (IQR 94-107; P = 0.02). The Gastrointestinal Quality of Life Index score improved from 60 (IQR 57-63) to 95 (IQR 68-100; P = 0.005). CONCLUSION: IFT is a new non-invasive treatment for slow transit constipation. Further studies to confirm these results with longer follow-up are necessary.

How sacral nerve stimulation works in patients with faecal incontinence.

AIM: Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action. METHOD: A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found. RESULTS: We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity. CONCLUSION: The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.

Colonosphincteric electromyographic responses to sacral root stimulation: evidence for a somatosympathetic reflex.

The aim of the present study was to determine the effects of selectively stimulating the afferent fibres running in the dorsal sacral roots (S1, S2, S3) and the somatic (radial and sciatic) nerves on colonic and internal anal sphincter (IAS) electromyographic (EMG) activity in anaesthetized cats to try to understand how sacral nerve stimulation can improve fecal continence in human. Electrically stimulating the afferent fibres present in the sacral dorsal roots and somatic nerves inhibited the colonic spike potential frequency (n = 97) and increased the slow variations in the sphincteric membrane potential (n = 76). These effects were found to have disappeared after administering an alpha-noradrenergic receptor blocker (n = 64) or sectioning the sympathetic efferent fibres innervating these organs (n = 69) suggesting the involvement of the sympathetic system in the effects observed. Moreover, no significant differences were observed between the effects of sacral dorsal root vs somatic nerve stimulation on colonic and sphincteric EMG activity. In conclusion, the data obtained here show that neurostimulation applied to the sacral spinal roots may improve fecal continence by inhibiting colonic activity and enhancing IAS activity via a somatosympathetic reflex.

Supraspinal control of external anal sphincter motility: effects of vesical distension in humans and cats.

A pontine centre located near the micturition centre controlling external anal sphincter (EAS) motility via noradrenergic neurones has been described in cats. The aim of this study was to determine (i) whether a similar centre controls EAS motility in humans and (ii) whether this centre is involved in vesico-sphincteric reflexes in cats and humans. The effects of an alpha-1-adrenoceptor antagonist (nicergoline) and those of vesical distension on the electrical activity of the EAS were studied in paraplegic and non-paraplegic volunteers. The effects of vesical distension by injecting saline at physiological levels on the responses of the EAS to pudendal nerve stimulation were investigated in intact cats and cats with nerve sections. In non-paraplegic subjects, nicergoline and vesical distension abolished the activity of the EAS. These effects were no longer observed in paraplegic patients. In cats, vesical distension inhibited the reflex response of the EAS to pudendal nerve stimulation. This vesico-sphincteric reflex, which was no longer observed in spinal animals, persisted after nicergoline injection. These findings indicate that in humans, there exists a supra-spinal centre facilitating the tonic activity of the EAS via noradrenergic neurones not involved in the inhibitory vesico-sphincteric reflex.

Effects of alverine citrate on cat intestinal mechanoreceptor responses to chemical and mechanical stimuli.

BACKGROUND: Alverine citrate is commonly used in the treatment of painful affections of the colon. AIM: To determine whether alverine citrate acts on the vagal sensory endings. METHODS: Unitary recordings were performed at the level of the vagal fibres in the nodose ganglion of anaesthetized cats using extracellular glass microelectrodes, and the patterns of response to chemical and mechanical stimuli applied to identified vagal intestinal mechanoreceptors were studied. RESULTS: The intestinal mechanoreceptors located at the endings of type C vagal fibres responded mainly to mechanical stimuli (distension and contraction), but also responded to chemical substances (cholecystokinin and substance P). The most conspicuous effect of alverine (2 mg/kg) was that it significantly inhibited the pattern of vagal activity produced in response to either cholecystokinin (5-10 microg/kg), substance P (5-10 microg/kg) or phenylbiguanide (5-10 microg/kg), a 5-HT3 receptor agonist. On the other hand, the unitary vagal response to the mechanical distension was slightly enhanced by alverine, as was any spontaneous activity present. CONCLUSIONS: Based on the present data, alverine citrate can be said to decrease the sensitivity of the intestinal mechanoreceptors, which is consistent with its previously established anti-spasmodic effects.

Evidence for supraspinal nervous control of external anal sphincter motility in the cat.

The aim of this study was to investigate the role of noradrenergic descending nervous pathways in external anal sphincter motility. For this purpose, the effects of intravenously injected adrenoceptor antagonist and agonist on the tonic electrical activity of this sphincter were studied in anesthetized cats. The effects of stimulating the region of the locus coeruleus and the effects of intravenous, intracerebroventricular and intrathecal injection of the above drugs on the electromyographic responses of this muscle to pudendal nerve stimulation were also investigated. The tonic sphincteric activity and the reflex response triggered by electrically stimulating pudendal afferent nerve fibers were inhibited by alpha1-adrenoceptor antagonist nicergoline and enhanced by alpha1-adrenoceptor agonist phenylephrine. Stimulation of the locus coeruleus area either inhibited or enhanced the reflex responses. Intracerebroventricular and intrathecal injection of the alpha2-adrenoceptor agonists, morphine and leu-enkephalin decreased the amplitude of these reflex responses. All the effects of opioids were blocked by naloxone and by spinalization performed at the cervical and lumbar levels. The direct response elicited by stimulating the sphincteric motor axons was not affected either by these drugs or by the brainstem stimulation. These results suggests the existence of a pontine neuronal network controlling the motility of the external anal sphincter via noradrenergic and opioid neurons.

In vivo study of the role of muscarinic receptors in the parasympathetic control of rabbit colonic motility.

The aim of the present study was to elucidate the role of the non-M1 muscarinic receptors, in the extrinsic and intrinsic nerve control of in vivo colonic motility. Experiments were performed on the proximal colon of anaesthetized rabbits. In this species, the parasympathetic innervation of the proximal colon originates from the vagus nerves. The action of methoctramine and 4-diphenyl-acetoxy-N-methylpiperidine methobromide (4-DAMP) was studied on excitatory junction potentials (EJPs), and on inhibitory junction potentials (IJPs) elicited in smooth muscle cells by stimulating parasympathetic efferents. The effects of the same drugs on spontaneous spiking activity were also investigated. The EJPs either decreased or disappeared after intra-arterial (i.a.) administration of 4-DAMP (45 pg to 450 ng). In the presence of 4-DAMP, further intravenous (i.v.) administration of pirenzepine (0.1 mg.kg-1) had facilitatory effects on the inhibitory pathway, i.e., after abolition of the EJPs, vagal stimulation elicited IJPs. With the highest dose of 4-DAMP, vagal stimulation immediately elicited IJPs the amplitude of which still increased after pirenzepine. In the presence of 4-DAMP, the spontaneous spike discharge was not noticeably altered. Methoctramine (0.37 to 75 micrograms, i.a. or 50 micrograms to 0.2 mg.kg-1, i.v.) increased the amplitude of the EJPs, whereas it decreased that of the IJPs. In addition, at the same doses, it either initiated or increased spike discharges that were not altered by pirenzepine up to 0.2 mg.kg-1, i.v. The so-called rebound excitation occurring after IJPs was not affected by methoctramine. No change in the EJP or IJP amplitude was observed with gallamine at sufficiently high doses to paralyse striated muscles (up to 3 mg.kg-1.h-1). It is concluded that the parasympathetic excitatory pathway to smooth muscle is blocked by 4-DAMP, whereas it is facilitated by methoctramine. 4-DAMP has no effect on the inhibitory pathway which is strongly depressed by methoctramine; however, the fact that these two drugs have opposite effects indicates that 4-DAMP and methoctramine may act on different muscarinic receptor subtypes. In addition, the facilitatory effects of pirenzepine on IJPs observed in animals pre-treated with 4-DAMP, indicates that the latter drug may act on non-M1 and non-M2 (presumably M3) muscarinic receptors. Methoctramine acts on non-M1 and non-M3 (presumably M2) receptors. The spike discharge induced by methoctramine is presumably due to an increased release of acetylcholine, and possibly also of a non-cholinergic transmitter which has excitatory effects on smooth muscle, the identification of which requires further investigations.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of alverine on the spontaneous electrical activity and nervous control of the proximal colon of the rabbit.

To analyse the mechanisms of the antispasmodic action of alverine, the effects of this drug on the spontaneous motility and nervous control of the proximal colon of the rabbit were studied in vivo. The electrical activity of the colonic smooth muscle was recorded using extracellular electrodes. The parasympathetic efferents were activated by electrical stimulation of distal ends of the vagus nerves. Alverine given intravenously inhibits spike potentials without modifying the slow waves. Excitatory and inhibitory responses induced by parasympathetic efferent stimulations, as well as the hyperpolarization due to intraluminal distension, were also blocked after drug injection. Our results show that alverine is able to block the spontaneous contractions and the nervous control of rabbit proximal colon, indicating that this drug has powerful antispasmodic effects.

Effects of stimulation of vesical afferents on colonic motility in cats.

The effects of distension and isovolumetric contraction of urinary bladder on colonic motility were studied in anesthetized cats. Distension and contraction of the urinary bladder induced an inhibition of spontaneous colonic electromyographic activity and a decrease in the amplitudes of the excitatory junction potentials evoked in the colon by stimulation of the distal end of the parasympathetic nerve fibers. This inhibition was blocked by guanethidine and phentolamine. Reversely, vesical emptying resulted in an increase in colonic motility, abolished by atropine, and an increase in the amplitude of the excitatory junction potentials. Both excitatory and inhibitory reflexes disappeared after hexamethonium. The inhibitory effects of bladder distension were abolished by bilateral section of the lumbar ventral or dorsal spinal roots and after bilateral section of the lumbar colonic or hypogastric nerves. These results indicate (a) that the vesical afferents responsible for the inhibitory and excitatory reflexes run in the hypogastric and pelvic nerves respectively and (b) that the inhibitory and excitatory effects are caused by the activation of sympathetic and parasympathetic efferent nerve fibers, respectively. The supraspinal nervous structures were not implicated in these reflexes because they persisted in spinal cats.