Evaluating lleal Pouch Anal Anastomosis Function: Time to Expand Our ARM-amentarium.

BACKGROUND: Total proctocolectomy with ileal pouch anal anastomosis (IPAA) for medically refractory ulcerative colitis or dysplasia may be associated with structural and inflammatory complications. However, even in their absence, defecatory symptoms secondary to dyssynergic defecation or fecal incontinence may occur. Although anorectal manometry is well established as the diagnostic test of choice for defecatory symptoms, its utility in the assessment of patients with IPAA is less established. In this systematic review, we critically evaluate the existing evidence for anopouch manometry (APM). METHODS: A total of 393 studies were identified, of which 6 studies met all inclusion criteria. Studies were not pooled given different modalities of testing with varying outcome measures. RESULTS: Overall, less than 10% of symptomatic patients post-IPAA were referred to APM. The prevalence of dyssynergic defecation as defined by the Rome IV criteria in symptomatic patients with IPAA ranged from 47.0% to 100%. Fecal incontinence in patients with IPAA was characterized by decreased mean and maximal resting anal pressure on APM, as well as pouch hyposensitivity. The recto-anal inhibitory reflex was absent in most patients with and without incontinence. CONCLUSION: Manometry alone is an imperfect assessment of pouch function in patients with defecatory symptoms, and confirmatory testing may need to be performed with dynamic imaging.

Dyssynergic defecation and fecal incontinence are increasingly being recognized in symptomatic patients with ileal pouch anal anastomosis. Manometry alone is an imperfect assessment of pouch function in patients with defecatory symptoms, and confirmatory testing may need to be performed with dynamic imaging.

Splenic Pseudoaneursym as the Cause of Recurrent Gastrointestinal Bleeding in a Woman With Diffuse Scleroderma.

A 67-year-old woman with a 15-year history of intestinal scleroderma presented with recurrent melena. Upper endoscopies revealed a healing, non-bleeding, large gastric ulcer. After the third bleed, angiography demonstrated bleeding from a splenic artery pseudoaneurysm adjacent to the gastric ulcer. Scleroderma patients are at risk of bleeding from esophagitis or gastric arteriovenous malformations, while splenic artery pseudoaneurysms are primarily attributed to pancreatitis and trauma. This is the first reported case of gastrointestinal bleeding from a splenic artery pseudoaneurysm in a patient with intestinal scleroderma and a large gastric ulcer.

Gastroesophageal reflux disease and idiopathic pulmonary fibrosis.

Gastroesophageal reflux disease occurs with a higher prevalence in patients with idiopathic pulmonary fibrosis than in matched controls. Silent reflux occurs in about a third of patients with significant gastroesophageal reflux disease; thus, objective measurements are required to evaluate gastroesophageal reflux disease in patients with advanced lung diseases. We provide here a detailed description of acid and non-acid reflux and the diagnostic evaluation for pulmonologists and lung transplant surgeons suspecting reflux as a contributing factor in advanced lung diseases. We review the evidence for gastroesophageal reflux disease causing idiopathic pulmonary fibrosis and other select pulmonary diseases and the potential role of antireflux surgery in the management of advanced lung disease and transplant patients.

Multichannel intraluminal impedance in the evaluation of patients with persistent globus on proton pump inhibitor therapy.

OBJECTIVES: Studies suggest an association between globus sensation ("globus") and gastroesophageal reflux. Although globus often persists despite proton pump inhibitor (PPI) therapy, the role of nonacid reflux has never been determined. Our goal was to use 24-hour multichannel intraluminal impedance (pH/MII) to determine 1) reflux characteristics in patients with globus despite PPI therapy; 2) whether there are differences in reflux patterns between patients with globus and patients with heartburn alone; and 3) whether there are differences in the number of positive symptom indices when standard pH testing is compared to pH/MII. METHODS: Twenty-one adult patients with globus and 12 with heartburn symptoms alone underwent 24-hour pH/MII on PPI therapy. Reflux frequencies and characteristics were compared in both groups. For patients with globus, the symptom index and symptom sensitivity index were calculated. Logistic regression was performed to determine which reflux characteristics correlated with symptoms. RESULTS: With pH/MII, we detected 1,160 reflux episodes; 64.7% were nonacid, and 55% reached the proximal sensor. In identifying patients with positive symptom indices, pH/MII increased the yield of standard pH testing by 27.8%. Proximal reflux was a significant predictor of globus symptoms (p = .04). Nonacid reflux approached significance in predicting globus (p = .08). Compared to patients with heartburn alone, those with globus had a higher mean frequency of proximal reflux (27.76% versus 15.63%; p = .04). CONCLUSIONS: In adults on PPI therapy with refractory globus, acid reflux does not predict globus symptoms. Through detection of nonacid reflux, pH/MII increased the yield of standard pH testing in identifying positive symptom indices. Additionally, pH/MII provided important information regarding reflux-symptom correlation. Proximal reflux may be predictive of globus symptoms.