Penile and scrotal swelling in Crohn's disease: a case report.

Penile and scrotal swelling considered as metastatic Crohn's disease is described in a 23 years-old-man. Clinical features and therapeutic options of this rare manifeatation are reviewed.

Dysmotility of the small intestine in achalasia.

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.

Effects of two anticholinergic drugs, trospium chloride and biperiden, on motility and evoked potentials of the oesophagus.

BACKGROUND: Anticholinergic drugs are known to impair the motor function of the oesophagus but their effects on the oesophageal afferent pathways are unknown. AIM: To determine the effects of a peripherally-acting (trospium chloride) and a centrally-acting (biperiden) anticholinergic drug on the motility and the evoked potentials of the oesophagus. METHODS: Nine healthy volunteers were randomized to receive 1.2 mg trospium chloride (TC), 5 mg biperiden (BIP) or saline i.v. Primary peristalsis was elicited by swallowing a 5 mL water bolus and secondary peristalsis by insufflation of 20 mL air, 10 times each. Oesophageal potentials were evoked by electrical stimulation in the distal and proximal oesophagus (30 stimulations at 0.4 Hz, two runs). RESULTS: Both anticholinergic drugs reduced by a similiar amount the contraction amplitudes (TC 17 mmHg, BIP 25 mmHg, saline 67 mmHg; P < 0.01) and the rate of secondary contractions (TC 60%, BIP 70%, saline 95%; P < 0.01). In contrast, only biperiden prolonged the latencies of the evoked potentials (N1 peak, distal oesophagus: BIP 191 ms, TC 102 ms, saline 101 ms; P < 0.01; P1 peak: BIP 322 ms, TC 161 ms, saline 144 ms; P < 0.01). CONCLUSIONS: Both anticholinergic drugs depress oesophageal motility, but only the centrally-acting anticholinergic drug biperiden modifies the oesophageal evoked potentials, suggesting a central cholinergic transmission of the oesophageal afferent pathways.

Discrimination of irritable bowel syndrome by non-linear analysis of 24-h jejunal motility.

Conventional analysis of ambulatory longterm manometry of the small intestine has revealed abnormalities in patients with the irritable bowel syndrome (IBS). The aim was to use methods from non-linear dynamics, in particular the concepts of symbolic dynamics and entropy, in order to discriminate motility in IBS from healthy subjects. 24-h jejunal motility was recorded in 30 IBS patients and 30 healthy subjects. Computerized analysis of contraction amplitudes and intercontractile intervals was performed. Both time series were analysed by symbolic dynamics and entropy to quantify the degree of randomness inherent in the signal. During phase II IBS patients exhibited significantly increased entropies for the intercontractile intervals (IBS: 0.978 +/- 0.016, C: 0.965 +/- 0.020, P = 0.004) and for the contraction amplitudes (IBS: 0.978 +/- 0.008, C: 0.970 +/- 0.026, P = 0.05) compared with healthy subjects. In addition, a significantly increased mean contraction amplitude (mmHg) was found in patients (IBS: 25.2 +/- 4.8, C: 22.2 +/- 3.1, P = 0.003). Considering a combination of both parameters, a diagnostic accuracy of 82% was achieved. We conclude that phase II motility of the small intestine is more random in IBS than in health. Symbolic dynamics seems to be a promising new concept for the analysis of long-term gastrointestinal motility recordings.

The role of osmolality in the absorption of a nutrient solution.

BACKGROUND: Loss of water during enteral nutrition following massive intestinal resection may be severe. Low osmolality of oral rehydration solutions has recently been shown to mediate an increase in water absorption. AIM: To evaluate the effect of osmolality of a nutrient solution on the intraluminal duodenojejunal water flow, and the net absorption rates of total nitrogen and carbohydrate. METHODS: Eight healthy volunteers with a mean age of 27 (range 25-29) years participated in the study. Enteral nutrition (17% protein, 59% carbohydrate, 24% lipid plus 5 g/L PEG 4000) was infused (5 mL/min 2.64 kcal/min) into the descending duodenum either as a hypotonic (160 mOsmol/kg) or as an isotonic solution in a random order. Intestinal samples were aspirated 20 and 45 cm distally to the infusion point. RESULTS: Intraluminal water flow rates were significantly lower with the hypotonic solution than with the isotonic solution, both in the duodenum (4.9 +/- 0.3 vs. 6.7 +/- 0.5 mL/min; P < 0.02) and the upper jejunum (3.0 +/- 0.1 vs. 3.9 +/- 0.2 mL/min; P < 0.005). The net absorption rates of total nitrogen and carbohydrate were similar with both solutions. CONCLUSION: Low osmolality of a nutrient solution decreases intraluminal water flow rates in the upper intestine without affecting the absorption rates of total nitrogen and carbohydrate. Compared with an isotonic solution, the use of a hypotonic solution might lower the water loss in patients with extensive short bowel intestinal resection.

Different effects of white and red wine on lower esophageal sphincter pressure and gastroesophageal reflux.

BACKGROUND: White wine and beer induce gastroesophageal reflux (GER). We investigated the effects of white and red wine on lower esophageal sphincter pressure (LESP) and GER. METHODS: Twenty healthy volunteers received 300 ml white wine, red wine, or water together with a standardized meal. The LESP was continuously monitored with a Dent sleeve the 1st h postprandially, and the esophageal pH measured with a glass pH electrode. RESULTS: The LESP was decreased after intake of white wine (median, 14.9 mmHg; range, 5.6-19.5 mmHg) compared with red wine (20.4 mmHg; 13.1-22.3 mmHg; P < 0.05) and tap water (19.5 mmHg; 16.2-29.1 mmHg; P < 0.01). The fraction time esophageal pH <4 was increased after both alcoholic beverages compared with tap water (0.9%; 0.2-5.8%; P < 0.01 versus white wine, P < 0.05 versus red wine) with a greater fraction time after white wine (13.2; 0.3-58.1 ) than after red wine (2.3; 0.7-24.4; P < 0.05). The decreased sphincter pressure after white wine was accompanied by a change in the reflux pattern with increased 'stress reflux' and the occurrence of 'free reflux'. CONCLUSION: White wine and red wine exert different effects on LESP and GER.

Effect of smoking on the results of esophageal pH measurement in clinical routine.

Because data on the effects of smoking on gastroesophageal reflux are controversial, we evaluated the effect of smoking on the results of esophageal 24-hour pH-metry in clinical routine. Participants were 280 consecutive patients with symptoms suggestive of reflux disease, 78 smokers, and 202 nonsmokers. Of the smokers, 45 actually smoked during the pH measurement and 33 abstained from smoking. The frequency of reflux episodes, the fraction of time pH was < 4, and the percentage of abnormal 24-hour pH-metry results were compared among actual smokers, abstaining smokers, and nonsmokers. In actual smokers, the effect of smoking on gastroesophageal reflux was further analyzed by comparing the reflux frequency and the fraction of time that pH was < 4 for a 10-minute period before, during, and after smoking. We found no difference in reflux frequency and fraction of time that pH was < 4 among actual smokers, abstaining smokers, and nonsmokers, regardless of a normal or an abnormal pH-metry result. The percentage of patients with a pH-metry result indicating disease was similar in the three groups, at 53%, 52%, and 50%, respectively. Gastroesophageal reflux was not increased during smoking a cigarette or in the postsmoking period compared with the presmoking period. Neither being a smoker nor actually smoking a cigarette had a negative influence on gastroesophageal reflux. Thus smoking or abstaining from smoking does not modify the results of pH-metry in clinical routine.

Effect of ethanol on postprandial duodenojejunal motility in humans.

The effect of ethanol on postprandial small bowel motility was investigated in eight healthy volunteers using perfusion of nutrient solutions (17% proteins, 59% carbohydrates, 24% lipids) into the descending duodenum (5 ml/min for 120 min). An ethanol-containing solution (4% w/v, 4.06 kcal/min, 1190 mosmol/kg) was compared with the corresponding ethanol-free solution (2.64 kcal/min, 160 mosmol/kg) and another ethanol-free hyperosmolar solution adapted in caloric load and osmolality (4.06 kcal/min, 1160 mosmol/kg). Motility was recorded with a data logger and six pressure transducers at 3-cm intervals around the duodenojejunal flexure. Clustered contractions (27 +/- 4/hr) migrating aborally through the whole recording segment were the predominant motor pattern with ethanol compared with the ethanol-free (10 +/- 2/hr; P < 0.01) and the ethanol-free hyperosmolar solution (6 +/- 3/hr; P < 0.001). Other motility parameters with ethanol were not different from the ethanol-free solution, whereas the ethanol-free hyperosmolar solution showed a much less intense motor response. We conclude that ethanol does modify human postprandial duodenojejunal motility by inducing propagative motor patterns.

The effect of decaffeination of coffee on gastro-oesophageal reflux in patients with reflux disease.

BACKGROUND: Patients with reflux disease often complain of heartburn after ingestion of coffee. Induction of gastro-oesophageal reflux has been demonstrated by pH-metry following the intake of coffee in healthy volunteers. The reflux was reduced when the coffee had undergone a decaffeination process. The aim of this study was to investigate the effect of decaffeination of coffee on reflux in patients with reflux disease. METHODS: Seventeen reflux patients underwent two osesophageal 3-h pH measurements. The patients received, in a double-blind study design in a randomized order, 300 mL of either regular or decaffeinated coffee together with a standardized breakfast. The fraction time oesophageal pH < 4 was calculated during the three postprandial hours. RESULTS: For regular coffee the fraction time was calculated to a median of 17.9% with a range of 0.7-56.6%. The fraction time was significantly reduced to 3.1% (0-49.9%) after ingestion of decaffeinated coffee. CONCLUSION: The amount of gastro-oesophageal reflux induced by the intake of regular coffee in patients with reflux disease can be reduce by the decaffeination of coffee.

Ambulatory long-term jejunal manometry in diabetic patients with cardiac autonomic neuropathy.

Concerning alteration of small bowel motility in diabetic patients with autonomic neuropathy controversial data were obtained with stationary manometry and over a limited period of time. The aim of our study was to examine ambulatory 24 h jejunal motility in 15 diabetic patients with cardiac autonomic neuropathy compared with data obtained in 50 healthy controls. Twenty-four hour motility was recorded in the proximal jejunum with a portable datalogger and tube-mounted miniature pressure sensors. Diurnal and nocturnal fasting motility and the motor response to a standardized evening meal of 600 kcal were evaluated by visual and computer-aided analysis. The following abnormalities were found during fasting motility (n = number of patients): absence of phase III over 24 h (n = 2), retrograde migration or simultaneous occurrence of phase III (n = 5). During postprandial motility irregular bursts with tonic baseline elevation (n = 3) and contraction frequencies below the range of controls (n = 8) occurred. Furthermore patients exhibited an inversion of the normal relationship between phase I and phase II during nocturnal MMC-cycles, and discrete clustered contractions were diminished (P < 0.01) in the fasting and digestive state. All patients showed at least one abnormal manometric finding. We conclude that small bowel motility in diabetic autonomic neuropathy is characterized by disturbances in the generation and aboral migration of phase III, an altered circadian variability of the MMC cycle and by postprandial hypomotility.

Effect of erythromycin on postprandial gastroesophageal reflux in reflux esophagitis.

UNLABELLED: The macrolide antibiotic erythromycin has recently been reported to exert profound prokinetic properties. The aim of the study was to investigate the effect of erythromycin on postprandial gastroesophageal reflux in patients with reflux esophagitis. METHODS: In 16 patients with reflux esophagitis (according to Savary and Miller: grade I, n = 8; grade II, n = 4; grade III/IV, n = 4) two pH measurements, with and without erythromycin, were performed for three postprandial hours after lunch. Erythromycin was administered in a dose of 3.5 mg/kg intravenously just prior to lunch. RESULTS: With erythromycin, the median fraction time esophageal pH < 4 was significantly decreased (7.6% versus 18.1%; P < 0.05). This decrease was the result of a diminished frequency of reflux episodes (19 vs 25; P < 0.05) and a shortening of the median reflux duration (0.7 min vs 1.1 min; P < 0.05). CONCLUSIONS: Intravenous administration of erythromycin decreases postprandial gastroesophageal reflux in patients with reflux esophagitis.

Injection of fibrin tissue adhesive versus laser photocoagulation in the treatment of high-risk bleeding peptic ulcers: a controlled randomized study.

BACKGROUND AND STUDY AIMS: A controlled and randomized multicenter study was carried out in order to compare the efficacy of fibrin sealant and Nd:YAG laser photocoagulation in patients with high-risk arterial bleeding from peptic ulcers of the stomach and the small intestine. PATIENTS AND METHODS: In four teaching hospitals, 53 patients presenting with either active arterial ulcer bleeding (Forrest class 1 a) or a large visible vessel in the ulcer base (diameter over 2 mm, Forrest class 2 a) were treated with infiltration of epinephrine 1: 10,000 followed by the injection of fibrin tissue adhesive (n = 28), or with epinephrine plus laser photocoagulation (n = 25). Permanent hemostasis for at least seven days served as the principal end point; rebleeding, emergency surgery, and hospital mortality served as further end points. RESULTS: There were no significant differences between the study groups in terms of age, risk factors, initial hemoglobin values, number of patients showing signs of hemodynamic impairment, ulcer size and localization, or bleeding activity. Primary hemostasis was achieved in all patients. Rebleeding rates were seven of 28 and four of 25 among the patients treated with fibrin sealant and laser coagulation, respectively (not significant). There were no significant differences regarding the rates of ultimate hemostasis (24 of 28 vs. 24 of 25), emergency surgery (four of 28 vs. one of 25), or hospital mortality (0 vs. two of 25). No complications occurred with either form of treatment. Patients who had a visible vessel in the ulcer floor at the first control endoscopy had a significantly higher incidence of rebleeding, regardless of the type of endoscopic therapy. CONCLUSIONS: We conclude that both the injection of fibrin tissue adhesive and laser photocoagulation are effective methods of treating high-risk arterial peptic ulcer bleeding. As the number of high-risk patients necessary to reach significance are difficult to recruit within a reasonable period even in a multicenter study, a new meta-analysis of all studies now available should be considered.

Effect of intestinal resection on human small bowel motility.

BACKGROUND: Few data are available on adaptive changes of human small bowel motility after intestinal resection. AIM: To characterise jejunal motility after extensive and limited distal intestinal resection. METHODS: Seven patients with a short bowel syndrome after total ileal and partial jejunal resection (residual jejunal segments between 60 and 100 cm) and six patients with limited distal ileal resection (resected segment between 30 and 70 cm) underwent ambulatory 24 hour jejunal manometry 15 (6-24) months after the operation. Normal values were obtained from 50 healthy subjects. Fasting motility and the motor response to a 600 kcal solid meal were analysed visually and by a computer program. RESULTS: Limited ileal resection did not result in changed jejunal motility. After extensive distal resection, patients had a significantly shorter migrating motor complex (MMC) cycle and a significantly shorter duration of the postprandial motor response compared with controls (p < 0.005). Intestinal resection had no influence on jejunal contraction frequency and amplitude and did not lead to any abnormal motor pattern. CONCLUSION: Extensive distal resection of the small intestine produces distinct abnormalities of fasting and postprandial motility in the intestinal remnant. The shortening of digestive motility and the increased frequency of MMC cycling could contribute to malabsorption and diarrhoea in the short bowel syndrome.

Ambulatory 24-hour jejunal motility in diarrhea-predominant irritable bowel syndrome.

BACKGROUND: Whether small-bowel motility is abnormal in the irritable bowel syndrome (IBS) is a controversy at present. The aim of our study was to compare ambulatory long-term jejunal motility in 35 IBS patients with predominant diarrhea to normal values obtained in 50 healthy controls. METHODS: Twenty-four-hour motility was recorded in the proximal jejunum with a portable datalogger and tube-mounted miniature pressure sensors. Fasting motility in the waking (W) and sleeping (S) state and the motor response to a standardized evening meal of 600 kcal underwent visual and computer-aided analysis. RESULTS: Fasting motility in patients showed migrating motor complex (MMC) cycles of normal length and composition. Uninterrupted runs of discrete clustered contractions during phase II (W) occurred in 57% of patients and 52% of controls but had a significantly longer duration in patients (33 +/- 5 versus 19 +/- 7 min; p < 0.005). During phase II (W) IBS patients had an increase in aborally propagated contractions (41 +/- 2% versus 35 +/- 2%; p < 0.01) and higher contraction amplitudes (26.3 +/- 0.8 versus 23.0 +/- 0.5 mm Hg; p < 0.01). Similar differences were obtained during postprandial motility (47 +/- 3% versus 39 +/- 3%; p < 0.01, and 25.9 +/- 0.9 versus 23.8 +/- 0.05 mm Hg; p < 0.02). In three patients (8.6%) disturbed aboral migration of phase III and irregular burst activity, manometric features of chronic idiopathic intestinal pseudo-obstruction, were identified. Whereas 57% of patients had an entirely normal 24-h manometry, 43% had at least one finding not present in any healthy control. CONCLUSION: Small-intestinal motility is frequently but not universally abnormal in diarrhea-predominant IBS. The abnormal manometric findings are heterogeneous and range from subtle quantitative changes to severe qualitative abnormalities resembling chronic idiopathic intestinal pseudo-obstruction in a small subset of patients.

[Gastrointestinal amyloidosis in IgG-chi-light chain plasmacytoma. Diagnostic problems despite advanced changes]. / Gastrointestinale Amyloidose bei IgG-xi-Leichtketten-Plasmozytom. Diagnostische Probleme trotz fortgeschrittenen Befalls.

A 50-year-old man with an IgG-chi light chain multiple myeloma stage IIIA, developed--in a phase of low disease activity, after 18 months of an uncomplicated course--marked malabsorption syndrome with 20 kg weight loss, diarrhoea and meteorism. Although the H2-breath test indicated intestinal bacterial colonisation, neither antibacterial treatment with trimethoprim/sulphamethoxazole and metronidazole nor prokinetic treatment with cisapride (30 mg daily) and erythromycin (1 g twice daily) improved the symptoms. Suspected amyloidosis was not demonstrable at first, despite repeated step biopsies of stomach, duodenum and rectum. Amyloidosis of the entire gastrointestinal tract was proven only by repeated biopsies deep into the submucosa. Despite treatment of the underlying disease with melphalan and prednisone (Alexanian's scheme) the amyloidosis advanced further to involve liver, spleen, lung, kidneys and heart. The patient died, 2 years after diagnosis of the multiple myeloma, from recurrent pulmonary emboli due to atrial fibrillation.

Abnormal oesophageal pH-monitoring in patients with functional thoracic and abdominal disorders.

BACKGROUND AND OBJECTIVES: Controversial data are reported on the diagnostic yield of oesophageal pH-monitoring in clinical routine. The aim of this study was to determine the diagnostic importance of oesophageal pH-monitoring in the work-up of functional thoraco-abdominal disorders. METHODS: The prevalence of abnormalities in pH-monitoring was evaluated in 238 patients with functional complaints: typical reflux symptoms (n = 56), non-cardiac chest pain (n = 98), non-ulcer dyspepsia (n = 52), and unclassifiable abdominal pain (n = 32). A symptom index was calculated for reflux-related symptoms in patients experiencing symptoms during the measurement (n = 74). RESULTS: The rate of patients with an abnormal pH-monitoring were in patients with reflux symptoms non-cardiac chest pain, non-ulcer dyspepsia and unclassified abdominal pain 55, 50, 44 and 34%, respectively. A symptom index of at least 50% was observed in 77, 55, 50 and 60% in the four groups respectively. CONCLUSION: The high rate of abnormal oesophageal pH-monitoring and symptom related reflux events in the investigated patients emphasizes the importance of 24-hour oesophageal pH-measurement in the diagnostic work-up of functional thoracic and abdominal disorders.

Computerized analysis of ambulatory long-term small-bowel manometry.

BACKGROUND: Ambulatory long-term manometry is increasingly being used to study small-bowel motility. This study aimed to develop computer-aided data analysis including the elimination of artefacts, identification of individual phasic contractions, and analysis of aboral propagation. METHODS: Data processing included low-pass filtering, base-line adaptation, cross-comparison of channels, and application of threshold values for contraction parameters. Automated analysis was validated by a visual reference standard. RESULTS: Artefacts were related to cardiovascular and respiratory activity, changes in body posture, and contractions of the abdominal wall. Automated recognition of contractions reached a sensitivity of 92% and a positive predictive value of 88% compared with the visual standard. Mean contraction amplitude and duration of computer analysis were 96% and 93%, respectively, of the visually obtained values. Propagation analysis under ambulatory conditions showed good agreement with previous results by stationary recordings. CONCLUSIONS: Computerized analysis provided valid and reproducible data on small-bowel phasic contractile events and propagative activity by digital long-term manometry.