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.

Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse.

OBJECTIVES: To evaluate the structure and function of the internal (IAS) and external (EAS) anal sphincters in anoreceptive homosexual men and to determine whether anoreceptive intercourse (ARI) is associated with a higher risk of incontinence in this population. METHODS: We studied 14 anoreceptive homosexual males and 10 age-matched non-anoreceptive heterosexual males in a controlled, prospective cohort study. Subjects underwent evaluation of resting and maximum squeeze anal canal pressures (maximum squeeze pressure obtained over resting pressure) by station pull-through technique, using a manometric perfusion catheter followed by endoanal ultrasonography to evaluate the structure of the IAS and EAS. Manometry also was performed in age-matched male controls. All subjects completed a questionnaire that assessed sexual practices and bowel habits, including fecal incontinence. RESULTS: Resting pressures were significantly lower in subjects engaging in ARI (70.7 +/- 3.2 mm Hg vs. 91.4 +/- 5.2 mm Hg; mean +/- SEM, p < 0.003), whereas there was no significant difference in the mean maximum squeeze pressures, compared with controls (177.1 +/- 14.1 mm Hg vs. 151.8 +/- 19.6 mm Hg; mean +/- SEM, p = 0.32). No disruptions of the IAS or EAS were identified in either the anoreceptive or control group. Anoreceptive men tended to have thinner anal sphincters than controls, but the difference was not statistically significant. Furthermore, there were no complaints of fecal incontinence by the study subjects. CONCLUSIONS: Passive ARI is associated with decreased resting anal canal pressures, but total pressures are normal. There were no IAS or EAS defects, as well as no fecal incontinence, in our subjects. Better relaxation of the ARI subjects during anal canal manometry may explain the lower resting pressures.