Manometric correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis.

OBJECTIVE: To evaluate clinical and manometric characteristics of multiple sclerosis (MS) patients with anorectal dysfunction (ARD) and their influence on biofeedback outcome. PATIENTS AND METHODS: Patients were clinically and manometrically studied and compared with controls. Patients were subsequently offered to initiate biofeedback manoeuvres to improve ARD. RESULTS: Fifty-two patients with ARD, 39 women, mean age 44.96 +/- 9.26 years, mean Expanded Disability Status Scale 4.13 +/- 1.72, were evaluated. Thirty-one patients had relapsing-remitting (RR), 16 secondary progressive and five primary progressive MS. ARD complaints were constipation (67.3%), double ARD (23.1%) and isolated incontinence (9.6%). The manometric study showed significant differences in patients compared with controls in maximal contraction pressures (98.1 +/- 44.2 mm Hg versus 152.05 +/- 66.9 mm Hg, P < 0.001) and anal inhibitory reflex threshold (92.9 +/- 63.4 mL versus 40.45 +/- 11.3 mL, P < 0.001). Maximal pressure was lower in progressive forms compared with RR forms (83.1 +/- 36.2 mm Hg versus 108.2 +/- 46.7 mm Hg, P < 0.05) in relation to higher disability. Patients with paradoxical contraction (PC) (35 patients, 67.3%) showed more manometric disturbances. From a total of 18 patients performing biofeedback, those reporting some improvement (six complete, two partial) had milder manometric abnormalities. CONCLUSIONS: The most frequent manometric abnormalities in our MS patients with ARD were alterations of maximal pressures, anal inhibitory reflex and PC. Biofeedback could be more useful in patients with lower disability and manometric alterations.

Estado de mal catapléjico inducido por la retirada brusca de clomipramina / Status cataplecticus induced by abrupt withdrawal of clomipramine

INTRODUCCIÓN: La cataplejía, uno de los síntomas principales de la narcolepsia, se caracteriza por la pérdida súbita del tono muscular tras una emoción con preservación de la conciencia. Uno de sus tratamientos más eficaces es la clomipramina. El estado de mal catapléjico es aquella situación en la que los episodios de cataplejía se repiten de forma continuada durante varias horas o días. PACIENTES: Presentamos a 3 adultos afectados de narcolepsia cuya cataplejía era tratada crónicamente de forma eficaz con clorniprarnina (75-150 mg/día). Por razones diversas, en los 3 pacientes se retiró de forma brusca la clomipramina. A los 2-9 días de la supresión, los 3 pacientes sufrieron un estado de mal catapléjico invalidante al presentar un importante aumento de la frecuencia, intensidad y duración de los ataques de cataplejía que ahora eran provocados por mínimos estímulos emocionales. La reintroducción de la clomipramina o su sustitución por fluoxetina resolvió el estado catapléjico en menos de una semana. CONCLUSIÓN: En pacientes narcolépticos con cataplejía, la retirada brusca del tratamiento crónico con clomipramina puede inducir un estado de mal catapléjico. La reintroducción de la medicación anticatapléjica puede resolver esta situación (AU)

INTRODUCTION: Cataplexy is one of the main narcoleptic symptoms and is characterized by sudden loss of muscle tone triggered by emotional stimuli while consciousness is mantained. Clomipramine is an effective treatment of cataplexy. Cataplexy that occurs repeatedly for hours or days is referred to as status cataplecticus. PATIENTS: We report three adults with narcolepsy in whom cataplexy was chronically and effectively treated with c10rniprarnine (75-150 mg/day). For diverse reasons, these three patients had an abrupt withdrawal of clornipramine, and after 2.9 days patients showed an invalidant status cataplecticus characterized by a marked increase of the frequency, duration and severity of their cataplectic attacks that were now elicited by mild emotional stimuli. After introduction of anticataplectic agents (clomipramine in two patients and fluoxetine in one patient), status cataplecticus was resolved in less than a week. CONCLUSION: In patients with narcolepsy, abrupt withdrawal of chronic treatment with clomipramine may be associated with status cataplecticus. This condition may be resolved with the reintroduction of anticataplectic agents (AU)