Ileal pouch pressures after defecation in continent and incontinent patients.

UNLABELLED: After ileal pouch-anal anastomosis, a pouch/anal canal pressure gradient is present such that mean pressures in the anal canal exceed pressures in the pouch facilitating fecal continence. Such a relationship was not present in incontinent patients. PURPOSE: Our aim was to evaluate characteristics of pouch pressures dynamically in continent and incontinent patients following ileal pouch-anal anastomosis (IPAA). METHODS: A multichannel microtransducer catheter was positioned in eight continent patients and nine incontinent patients after IPAA. Twenty-four-hour recordings of pouch pressures and large pressure wave contractions were recorded when patients were awake, asleep, and after evacuation. RESULTS: When patients were awake, pouch pressures were similar. However, nocturnal pouch pressures were higher in the incontinent group (P < 0.05). Large pressure wave amplitude was higher in incontinent patients when awake and asleep (P < 0.05). Moreover, pouch pressures failed to decline in the incontinent group after evacuation, unlike continent patients. CONCLUSION: Compared with continent patients, incontinent patients after IPAA had persistently high phasic and basal pouch pressures at night and following pouch evacuation.

Gastrointestinal hemorrhage complicating systemic neurofibromatosis.

A case of gastrointestinal hemorrhage caused by small bowel neurofibromas in a gentleman with systemic neurofibromatosis is presented. The multiple presentations of gastrointestinal system involvement by neurofibromatosis are reviewed. Early diagnosis and localization of small bowel tumors remains a dilemma. Mesenteric angiography and early surgical intervention are recommended.

Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation.

Severe idiopathic constipation can be categorised based on physiological testing into subgroups including slow transit constipation and pelvic floor dysfunction. This study aimed to determine if colonic and psychological symptoms, or rectosigmoid transit times, could discriminate among these subgroups. Patients, categorised according to total colonic transit times and pelvic floor function testing, completed a self report questionnaire that recorded symptoms and psychological distress. Patients with normal transit constipation (n = 60) had significantly increased depression scores compared with those who had slow transit constipation (n = 70) or pelvic floor dysfunction (n = 30). The general severity index (GSI, a measure of overall psychological distress) negatively but weakly correlated with total colonic transit (r = -0.26, p < 0.01). A feeling of anal blockage was the only symptom that was associated with pelvic floor dysfunction (v normal transit constipation). Only a more regular defecation pattern, utilisation of different postures to defecate, and a feeling of incomplete evacuation were associated with slow v normal transit constipation. Psychological or colonic symptoms were not, however, significant discriminators in a multivariate analysis. Rectosigmoid transit times at 80% sensitivity had very poor specificity for discriminating pelvic floor dysfunction from other subgroups. It is concluded that clinical symptoms, psychological distress, and rectosigmoid transit times cannot be used to identify subgroups of patients with intractable constipation.

Motor determinants of incontinence after ileal pouch-anal anastomosis.

Anal canal pressure gradient and ileal pouch motor activity were studied in continent and incontinent patients after ileal pouch-anal anastomosis. A multichannel microtransducer catheter was positioned in eight continent and eight incontinent patients 15 months or more after operation and 24-h ambulatory motor activity recorded. Resting anal pressures were significantly lower for incontinent patients during the day and night. The frequency of high-pressure waves was identical in both groups, but peak pressures were higher for incontinent patients. For continent patients, each high-pressure wave was accompanied by a rapid increase in anal canal pressure such that pressure in the pouch was always less than that in the anal canal. For incontinent patients this response was often absent. Incontinent patients had lower resting pressure, more prolonged anal canal relaxation, higher amplitude high-pressure waves and a non-responsive anal canal; the anal canal pressure gradient was therefore frequently reversed.

Prolonged ambulatory recording of anorectal motility in patients with slow-transit constipation.

Our aim was to determine phasic contractile activity of the distal bowel and anus in patients with slow-transit constipation; if readily identifiable patterns were present, prolonged recordings could confirm a diagnosis of slow-transit constipation. In 12 healthy control subjects and 11 women patients with slow-transit constipation (mean colonic transit time: 120 +/- 11 hours) and normal pelvic floor function, a flexible catheter was positioned endoscopically with sensors in the sigmoid colon, rectum, and anal canal in order to perform ambulatory recordings. A motility index (MI = mm Hg/h/100) was calculated during fasting and after feeding. Overall, the rectal MI and the frequency of anal canal contractions were less in the patients with constipation compared with those in the control group (rectum: 22 +/- 5 mm Hg/h/100 in the control group versus 13 +/- 10 mm Hg/h/100 in the constipation group; anal contractions/h: 23 +/- 7 in the control group versus 3 +/- 2 in the constipation group, p < 0.05). Moreover, in response to feeding, only control subjects had a significantly increased MI and frequency of anal canal contractions. Compared with control subjects, patients with slow-transit constipation had significantly reduced motor activity in the distal bowel and anal canal. Phasic contractile activity recorded during fasting and in response to a meal may be a means of confirming the diagnosis of slow-transit constipation in patients with borderline marker transit times.

Rectal wall contractility in healthy subjects and in patients with chronic severe constipation.

OBJECTIVE: The aim of this study was to identify differences in rectal wall contractility between healthy volunteers and patients with chronic severe constipation. SUMMARY BACKGROUND DATA: Whether motor function of the rectum contributes to slow-transit constipation is unknown. Measurements of rectal contractility have been performed traditionally with perfused catheters or microtransducers. The rectal barostat is a new technique that quantifies the volume of air within an infinitely compliant intrarectal bag maintained at constant pressure; decreases in bag volume therefore reflect increases in rectal muscular contractility (tone). Increases in volume reflect decreased contractility. METHODS: Fifteen healthy volunteers (ten women and five men; mean age, 36 years) and eight patients (seven women and one man; mean age, 44 years) were studied. Barostat recordings were made for 1 hour before and after a meal. Randomly, neostigmine (0.5 mg) or glucagon (1 unit) was then given intravenously. After 1 hour, the other medication was given. RESULTS: The fasting rectal volume was similar in the patient and control groups (113 +/- 7 mL vs. 103 +/- 4 mL, respectively; p > 0.05). Compared with controls, constipated patients had a significantly lower reduction in rectal volume after a meal (constipated, 35 +/- 8% vs. controls, 65 +/- 7%; p < 0.05) and after neostigmine administration (constipated, 39 +/- 6% vs. controls, 58 +/- 6%; p < 0.05). Moreover, constipated patients had a smaller increase in rectal volume after glucagon administration than did controls (28 +/- 6% vs. 64 +/- 18%, respectively; p < 0.05. CONCLUSIONS: Changes in rectal wall contractility in response to feeding, a cholinergic agonist, and a smooth muscle relaxant were decreased in constipated patients. These findings suggest that an abnormality of rectal muscular wall contractility is present in constipated patients.

The ileal pouch operation for ulcerative colitis.

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Continence disorders.

Strategies to evaluate patients with continence disorders continue to evolve at a rapid pace. These novel methods quantify physiologic events that, in turn, facilitate increasingly accurate discrimination among the causes of incontinence and constipation. This review discusses recent advances in the causes, diagnostic approaches, and management options available for patients with continence disorders.

Intrarectal sonography. A new technique for the assessment of rectal tumors.

Preoperative staging of rectal tumors provides a selective therapeutic approach. Twenty-three patients were evaluated with prospective intrarectal sonography. Endosonography identified all 21 rectal lesions. Two patients with previous rectal carcinoma had no evidence of recurrence. Thirteen of 17 patients (76%) with rectal carcinoma were correctly staged by endosonography. A submucosal leiomyosarcoma and pararectal arachnoid cyst were correctly identified. Preoperative assessment of lymph node status was accurate in five of ten patients (50%). Results of preoperative digital rectal examination predicting rectal wall involvement correlated with pathologic findings in 11 of 15 patients (73%). Intrarectal sonography is an important staging technique for preoperative evaluation of rectal wall invasion and guides appropriate surgical intervention.

Choledochal cyst diagnosed in pregnancy.

A primigravid patient with a type 1 choledochal cyst is reported. Conservative management allowed completion of the pregnancy and vaginal delivery of a term infant. Postpartum, the choledochal cyst was excised and biliary tree drained. A review of the literature and discussion of management alternatives of choledochal cysts discovered during pregnancy is presented.

Intra-aortic balloon counterpulsation in high-risk cardiac patients undergoing noncardiac surgery.

Patients undergoing noncardiac general surgical procedures after coronary artery bypass surgery have reduced mortality compared with those operated on without prior revascularization. The urgency of the noncardiac procedure and the potential reconstructability of the coronary artery anatomy may mitigate against timely revascularization. We report the successful outcome of prophylactic intra-aortic balloon counterpulsation in three patients with coronary artery disease and impaired left ventricular function undergoing noncardiac surgical procedures. Intra-aortic balloon counterpulsation may provide myocardial protection in high-risk cardiac patients requiring noncardiac surgery initially. A review of the literature is discussed.

Mycobacterium avium intracellulare as a marker of human immunodeficiency virus disease.

Between January 1981 and December 1986, 4,178 patients were cultured for mycobacteria at a community teaching hospital in Hartford. The number of patients with positive cultures totaled 278 (6.65%). Mycobacterium other than tuberculosis (MOTT) was isolated from 228 (82%). MOTT isolation increased yearly from 1.5% of the patients in 1981 to 14.5% of the patients in 1986. Mycobacterium avium intracellulare (MAI) was the most common MOTT species isolated (197/228). Fifty-nine patients were under the age of 50, but 23 had predisposing factors for MOTT. Of the 36 who did not have an underlying condition, 25 had the human immunodeficiency virus (HIV). The isolation of MAI preceded the diagnosis of AIDS/ARC in nine patients, in 10 others it coincided with their diagnosis and in six it followed the diagnosis. Isolation of MAI in a patient under the age of 50 with no predisposing factors may suggest concommitant HIV disease.