[Global approach to chronic pelvic and perineal pain: from the concept of organ pain to that of dysfunction of visceral pain regulation systems]. / Approche globale des douleurs pelvipérinéales chroniques: du concept de douleur d'organe à celui de dysfonctionnement des systèmes de régulation de la douleur viscérale.

OBJECTIVE: Analysis of complex pelvic and perineal pain. MATERIAL AND METHODS: Review of the literature concerning the various types of functional pelvic pain. RESULTS: Various forms of pelvic pain are frequently associated: painful bladder syndrome (interstitial cystitis), irritable bowel syndrome, endometriosis pain, vulvodynia, chronic pelvic pain syndrome (chronic prostatitis). Pelvic pain is often associated with fibromyalgia or complex regional pain syndrome (reflex sympathetic dystrophy). The pathophysiological mechanisms involved in these syndromes are all very similar, suggesting a triggering element, neurogenic inflammation, reflex muscular and autonomic responses, central hypersensitization, emotional reactions and biopsychosocial consequences. DISCUSSION: The concept of visceral pain is evolving and, in practice, complex pelvic pain can comprise neuropathic components, complex regional pain syndrome components, hypersensitization components, and emotional components closely resembling posttraumatic stress syndrome. CONCLUSIONS: When pain cannot be explained by an organ disease, the pain must be considered to be expressed via this organ. Chronic pelvic and perineal pain can become self-perpetuating and identification of its various mechanisms can allow the proposal of individually tailored treatments.

Standardization of a simplified scintigraphic methodology for the assessment of gastric emptying in a multicenter setting.

OBJECTIVE: Scintigraphy remains the gold standard to study gastric emptying. The technique is onerous and normal values vary between centers. Standardized protocols, although desirable, are not presently available. We validated a simplified scintigraphic protocol in a multicenter setting. METHODS: In 69 healthy volunteers from seven Canadian institutions, gastric emptying of a standard meal (99mTc-labeled beef liver) was assessed by scintigraphy every 10 min for 1 h, then every 20 min for the next 2 h. Gastric retention was fitted to a power exponential model, Prop(t) = (-(kappat)beta) with Prop(t) = proportion of retention at time t, either using all 13 time intervals (conventional technique) or using measurements at 0, 1, 2, and 3 h (simplified technique). RESULTS: The power exponential model yielded identical emptying curves and T 1/2 values with both techniques. Gastric emptying was more rapid in men than in women < 35 yr (p<0.01) and in younger than in older men (p<0.005). Gastric emptying was slower in women from Québec than in women from Ontario (p<0.04). Gastric retention was similar at 1, 2, and 3 h among the seven centers. Gastric emptying of a beef liver meal was slower than that of a low fat egg substitute (p<0.03). CONCLUSIONS: A simpler scintigraphic approach, using four rather than 13 samples, provides results comparable to those of the conventional technique. This simpler approach provides an economical, yet accurate, alternative to the techniques presently used and is applicable to a multicenter setting.

Colonic transit time in patients with myelomeningocele.

To evaluate colonic motility in patients with myelomeningocele, the transit time of radiopaque markers was studied in 22 patients with myelomeningocele and 22 age and sex matched controls. Mean colonic transit time was significantly longer in patients than in controls (103.2 +/- 49 h versus 23.3 +/- 13 h; P < 10(-7). Thirteen of 22 patients with myelomeningocele were severely constipated. Six patients had constipation secondary to delayed colonic transit, particularly in the left colon, and seven had increased rectosigmoid transit. The clinical questionnaire and particularly the frequency of bowel movements did not predict colonic transit. Among 13 patients with increased colonic transit, eight had more than five bowel movements per week and, thus, six of them did not use laxatives or enemas, despite the presence of faecal incontinence. There was no relationship between colonic transit time and the level of the spinal lesion or patient mobility in patients with myelomeningocele. Rectoanal dyssynergia was found in 14 of the 22 patients, but equally often in patients with delayed rectosigmoid transit (4/7) as in the other patients (10/15) (P = ns). Uninhibited detrusor contractions were observed more often in patients with increased colonic transit time than in others (8/12 versus 1/8, P = 0.05). In the absence of a correlation between colonic transit time, clinical symptoms, anorectal motility, level of spinal lesion, patient mobility, evaluation of colonic transit of radiopaque markers should be assessed routinely in all patients with myelomeningocele to plan the most appropriate treatment, mainly in case of unhibited detrusor contractions.

Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract.

To evaluate the links between gastrointestinal disorders and sexual abuse, we asked 344 patients consulting in a specialized tertiary care university hospital or a gastroenterologist in private practice, if they had been sexually abused. Forty per cent of patients suffering from lower functional digestive disorder gave a history of having been victims of sexual abuse in contrast to only 10% of patients with organic diseases (P < 0.0003). The prevalence was similar in private practice and in the university hospital. Abused patients were more likely to complain of constipation (P < 0.03) and diarrhoea (P < 0.04). Anismus was more frequent in patients who had been sexually abused (P < 0.02). The prevalence of abuse was four times greater in patients with lower than with upper functional motor disorders of the gastrointestinal tract (P < 0.002). This study confirms the large prevalence of a past history of sexual abuse among patients consulting for gastrointestinal tract functional disorder, and this whatever the kind of recruitment may be. It shows the association to be much stronger in patients who have a lower rather than an upper gastrointestinal dysfunction, the major complaint of abused patients being constipation and diarrhoea.

Spontaneous double-barrelled esophagus. Report of two cases and review of the literature.

We report two patients who suffered spontaneous dissection of the esophagus, the so-called double-barrelled esophagus. We review the literature about this unusual lesion to define its clinical picture, its possible causes, and several treatment approaches.

Constipation with colonic inertia. A manifestation of systemic disease?

Transit of radiopaque markers was delayed in the ascending colon of 51 females and 3 males treated for severe idiopathic constipation. Onset of symptoms was between age 10 and 20 in more than half of the patients. Eighteen percent had previously undergone unnecessary laparotomy for large bowel pseudoobstruction. Stool frequency ranged from 1 stool every three days to 1 every 2 months. Twenty-six percent suffered from fecal incontinence. In addition, 30% had orthostatic hypotension and 15% galactorrhea of idiopathic origin. Patients had a higher than normal anal pressure (P less than 0.001). They all had a rectoanal inhibitory reflex, but it was abnormal in 76%. In the upper esophageal sphincter, resting pressure was higher (P less than 0.02), and coordination poorer (P less than 0.05) than in normal control subjects. Incidence of spontaneous tertiary contractions in the body of the esophagus was greater than normal (P less than 0.03). In the lower esophageal sphincter, resting pressure was lower (P = 0.001) and gastroesophageal gradient weaker (P = 0.05). Closing pressure of the sphincter was lower (P less than 0.001) and coordination less adequate (P less than 0.02). After subcutaneous injection of 0.035 mg/kg bethanechol, urinary bladder intraluminal pressure increased by over 15 cm H2O in 31% of patients but never did in controls, and average maximal pressure was greater (P less than 0.025). Time taken to reach peak pressure was shorter (P less than 0.01). This study provides evidence that patients who suffer from constipation with colonic inertia also have abnormal function in other hollow viscera.(ABSTRACT TRUNCATED AT 250 WORDS)

Urorectodynamics in patients with colonic inertia.

Sixteen female patients with colonic inertia and 12 control women underwent manometric evaluation of their bladder and rectal cavities. After subcutaneous injection of 0.035 mg./Kg. bethanechol, bladder intraluminal pressure increased by over 15 cm. water in 5 patients (31 per cent) and in none of the control group; maximal pressure after injection was 11.5 +/- 1.6 cm. H2O (mean +/- SE) in patients and 8.5 +/- 1 in controls (p less than 0.025). The intraluminal rectal pressure reached 23 +/- 4 cm. H2O in patients and only 11.9 +/- 1.4 in controls (p less than 0.0025). Time taken to reach a peak pressure was faster in patients both in bladder (17.4 +/- 0.7 vs. 19.8 +/- 1.2 minutes; p less than 0.01) and in the rectum 914.6 +/- 0.8 vs. 16.3 +/- 1.2; p less than 0.025). These findings and the clinical presentation suggest an autonomic neuropathic lesion in this group of patients.

Small erythematous mucosal plaques: an endoscopic sign of Crohn's disease.

A non-ulcerated granulomatous lesion of the large bowel mucosa has been found in 11 patients, nine of whom already had or eventually developed classical features of Crohn's disease. These lesions, which are multiple, consist of small well-circumscribed raised erythematous plaques surrounded by normal mucosa. At biopsy there is focal haemorrhage of the lamina propria, rupture of the crypts, release of mucus, and frank granulomatous reaction with giant cell formation. The lesion may be reversible or be followed by the classical mucosal ulcerations. They may occur in the presence or the absence of classical lesions of Crohn's disease elsewhere in the gastrointestinal tract. As this non-ulcerated lesion may occur in isolation, it may provide the initial clue to the diagnosis of Crohn's disease.