Postcholecystectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III.

BACKGROUND & AIMS: Persistent abdominal pain occurs in many patients after cholecystectomy, some of whom are described as having sphincter of Oddi dysfunction (SOD). Pain in SOD type III is thought to be of biliary origin with little objective data, and treatment is often unsatisfactory. Chronic abdominal pain without a biological disease marker is similar to irritable bowel syndrome, in which many patients exhibit visceral hyperalgesia. This study tested the hypothesis that duodenal-specific visceral afferent sensitivity exists in patients with SOD type III. METHODS: Eleven patients with chronic abdominal pain after cholecystectomy and 10 controls underwent duodenal and rectal barostat studies to evaluate visceral pain perception measured with a visual analog scale. All subjects underwent psychological testing. RESULTS: Patients with SOD type III exhibited duodenal but not rectal hyperalgesia compared with controls. There were no differences in duodenal compliance between the groups. Duodenal distention reproduced symptoms in all but 1 patient. Patients showed high levels of somatization, depression, obsessive-compulsive behavior, and anxiety. CONCLUSIONS: Patients with SOD type III exhibited duodenal-specific visceral hyperalgesia, and duodenal distention reproduced symptoms in all but 1 patient. Abdominal pain in these patients may not originate exclusively from the biliary tree.

Visceral algesia in irritable bowel syndrome, fibromyalgia, and sphincter of oddi dysfunction, type III.

Visceral hyperalgesia has been demonstrated in patients with irritable bowel syndrome who are seen in tertiary care centers. It has been hypothesized that visceral hyperalgesia may be related to psychological distress associated with health care seeking behavior in these patients. Patients with fibromyalgia and sphincter of Oddi dysfunction, type III, share many demographic and psychosocial characteristics with patients with irritable bowel syndrome and provide an opportunity to test the hypothesis that rectal hyperalgesia is unique to IBS. Fifteen patients with IBS, 10 patients with fibromyalgia, 10 with sphincter of Oddi dysfunction, type III, and 12 controls underwent evaluation of rectal pain perception in response to phasic distensions and psychological testing with a self-report instrument. Patients with irritable bowel syndrome demonstrated significantly lower rectal pain thresholds and increased levels of psychologic distress compared to controls. Although sphincter of Oddi dysfunction patients also exhibited increased psychologic distress, rectal pain perception was similar to controls. Patients with fibromyalgia exhibited rectal algesia that was not significantly different from either controls or IBS. In conclusion, rectal hyperalgesia is not a function of chronic functional pain, health care seeking behavior, or psychological distress. However, it may not be specific for IBS.

Anorectal manometric characteristics in men and women with idiopathic fecal incontinence.

To characterize and compare the anorectal manometric findings of men and women with idiopathic fecal incontinence referred to a tertiary care center for pelvic floor disorders, we reviewed 86 consecutive patients who underwent anorectal manometry during a 13-month period. We determined the etiologies of all patients and analyzed men and women with no obvious cause (idiopathic). The manometric parameters included resting and squeeze anal canal pressures, duration of squeeze pressures, threshold of external anal sphincter contraction, threshold of rectal sensation, and rectal compliance. Thirty-one of 86 patients were classified as having idiopathic fecal incontinence. The mean age of the 7 male patients with idiopathic fecal incontinence was 65 years, (range, 45-78 years) and 63 years (range, 38-83 years) in the 24 women. Compared with male patients, female patients had lower sphincteric pressures and shorter squeeze durations. Both men and women frequently exhibited poor phasic response of the external anal sphincter to rectal distention. We conclude that, compared with men, women with idiopathic fecal incontinence more often exhibit abnormalities of anal sphincteric motor function. The sex-related differences in muscle mass and past traumatic events related to childbirth may partly account for these findings.

The impact of health care reform on gastroenterology fellows: are training programs preparing them for the future? American College of Gastroenterology Educational Affairs Subcommittee on Training.

OBJECTIVE: Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. METHODS: A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. RESULTS: A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1% felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform, whereas 83% of fellows felt that their program should do so. CONCLUSION: Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care.

Gastrointestinal bleeding in cirrhotic patients with hepatocellular carcinoma undergoing intrahepatic artery chemotherapy.

BACKGROUND: Hepatocellular carcinoma in cirrhotic patients increases the risk of variceal bleeding. We sought to characterize bleeding in a cirrhotic patient population undergoing intrahepatic artery chemotherapy for hepatocellular carcinoma and to determine the possible influence of this treatment on gastrointestinal bleeding. METHODS: We retrospectively reviewed 179 patients with hepatocellular carcinoma who underwent intrahepatic artery doxorubicin and cis-platinum chemotherapy to determine the incidence of gastrointestinal bleeding and compared them with 434 hepatocellular carcinoma historic controls not undergoing regional chemotherapy. RESULTS: Of the 179 patients, 27 patients (15.1%) developed upper gastrointestinal bleeding over a mean follow-up of 15.2 months; 18 of the 27 (66.7%) bled from a variceal source and 9 (33.3%) bled from a nonvariceal source: ulcer (n = 6), gastropathy (n = 1), Mallory-Weiss (n = 1), erosive gastritis (n = 1). Twenty-one patients developed bleeding after initiation of chemotherapy (14 variceal and 7 nonvariceal). The number of chemotherapy sessions among patients with variceal and nonvariceal bleeding was similar (2.1 +/- 0.4 and 4.0 +/- 1.2; p = Not significant). Patients with variceal and nonvariceal bleeding were comparable with respect to Child-Pugh classification, pTNM stage, age, time to bleeding, and gender. CONCLUSIONS: Regional intra-arterial chemotherapy for hepatocellular carcinoma is associated with a low risk of variceal bleeding. Nonvariceal sources of upper gastrointestinal bleeding in this population account for a significant component of bleeding episodes.

Gastric emptying response to variable oral erythromycin dosing in diabetic gastroparesis.

Intravenous erythromycin has been shown to improve gastric emptying in diabetic gastroparesis. Oral erythromycin also accelerates gastric emptying, but to a lesser degree. To determine if this is a dose-dependent phenomenon, gastric emptying was measured in 10 insulin-requiring diabetic patients with gastroparesis after administration of either 250 mg or 1000 mg of erythromycin or placebo. The drugs were orally administered in a randomized, double-blind fashion 30 min prior to ingestion of a meal containing [99mTc]-sulfur colloid-labeled beef stew and [111In]DTPA-labeled orange juice. Anterior and posterior gastric images were recorded for 3 hr at 15-min intervals using an externally positioned gamma camera. The results demonstrated that both doses of oral erythromycin significantly improved solid-phase gastric emptying. The mean half-emptying time of solids was decreased from 151 +/- 40 min with placebo to 58 +/- 10 min and 40 +/- 9 min with 250 mg and 1000 mg of erythromycin, respectively. However, a dose-dependent relationship was not demonstrated with the two doses of erythromycin employed. These results suggest that for most patients with diabetic gastroparesis, a single 250-mg dose of erythromycin will significantly improve gastric emptying. It is possible that a dose-dependent relationship will be demonstrated with doses of erythromycin less than 250 mg.