A correlation of anal sphincter defects and sphincter pressures in patients with faecal incontinence

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Topical Capsaicin Is a Novel and Effective Treatment for Idiopathic Intractable Pruritus Ani: A Randomized, Placebo-Contrutled Study Joseph Lysy, Mirna Sistieri-lttah, Yardena Israellt, Avigail Shmueli, Eran Goldin, Hedassah Univ Hosp, Jerusalem Israel

Fecal Incontinence Following Acute Brain Injmy: Incidence, Risk Factors, and Outcomes Amy E. Foxx-Orenstein,Stephanie Kolakowsky-Hayner,Jennifer H. Marwitz, Ann H. Dunbar, Virginia Commonwealth Univ, Richmond, VA; Stuart Yablon, Mississippi Methodist Rehabilitation Ctr, Jackson, MS; Jeffrey Englander, Santa Clara Valley Medical Ctr, San Jose, CA; Gerard Francisco, The Institute for Rehabilitation and Research, Houston, "IX; David X. Cifu, Virginia Commonwealth Univ, Richmond, VA

Background:Pruritus ani is a common and embarrassingproctologic condition. The symptoms of idiopathic pruritus ani can be persistent and severe, and very difficult to treat. Capeaicin depletesSubstanceP from the peripheralneuronsand is known to be effective in the treatment of pain, as well as of several itching cutaneousdisorders, probableacting through this effect. Methods: A double-blind and placebo controlled study of topical capsaicin in the treatment of idiopathic, intractable pruritus ani was carried out. Study Design: first, a pilot, open study was done on five patients to establish the best drug concentration. Secondly, 20 patients were randomizedto receivelocally either active(cepsaicin0.006%) or placebo(white paraffin) ointement over a two month period. After the two months, the placebogroup beganto receive capssicin for two months, while the treated group continue the capeaicint r e ~ only when symptoms recurred. Results: after the first two months, B patients in the treated group (80%) and none in the placebo group, were symptom free (p =0.005) Seven out of ten patients in the placebo group became symptom free when subsequently treated with capeain. Three patients dropped out because of perineal burning due to capeaicin, one in each treatment group and one in the pilot study group. During the four month follow up, "respooder" patients needed a mean single application of capseicin every four days to remain free of symptoms. Conclusions:Capsaicin is a new, safe and highly effective treatment for severe, inetractable idiopathic pruritus ani. Substance P probably plays a key role as a mediator in pruritus ani.

694 Topical Glyneryl Tri-Nitratu [GTN] (0.2%) ve Topical OINiazem (2%) in Hie Treatment of Chronic Fissure-in-ano: A Prospective DHble-Rlind Randomiced Trial. Hemant M. Kocher, King's Coil Hosp, London United Kingdom; Marion Steward, Queen Elizabeth Hosp, King's Lynn United Kingdom; Andrew Jm Leather, King's Coil Hosp, London United Kingdom; Paul T. Collen, Queen Elizabeth Hosp, London United Kingdom Introduction: 0.2% GTN ointment has an efficacy of up to 68% in the treatrnent of chronic fissure-in-ano, with headacheas a major side effect. Diltiazem (2%) cream is expected to have fewer side-effects. Methods: A prospective double-blind randomisad twocantre trial requiring 26 patients in each group [a=O.05,/3=0.9] was instituted after approval of the local ethics committee, to compare the difference in the incidence of side-effects (primary end-point) between 0.2% GTN ointment [Group A] and 2% Diltiazem cream {SLA Pharma, UK}[Group B] for the treatment of chronic fissure-in-ano. Treatmentswere applied perianally, twice daily for 6-8 weeks. All patients gave written informed consent. Results of first 47 patients are presented.Results: Both groups were comparablein patients demographics. Nine patients violated protocol, withdrew or didnot follow-up. Table of results: Discussion: There was no significant difference in the healing or improvementof chronic flssure-in-ano between the treatments. Diltiazem caused substantially fewer headcahesthan GTN, and is therefore better tolerated in the treatment of chronic tissure-in-ano.

697 The I ~ Device In The I~asention Of Fecal Incontinence Paolo Giamoodo, Argelia Welper, Eric G. Weiss, Anthony M. Vernava III, Juan J. Nogueras, Steven D. Wexner, ClevelandClio Rorida, Fort Lauderdale,FL BACKGROUND: Treatment of severe fecal incontinence is essentially surgical. However, patients in whom surgery has failed, are high operative risks, or refuse to undergo surgery are often condemned to living with this embarrassing condition. The Procon, a relatively simple, non-surgical, impiantabledevicemay representa good solution in preventingepisodes of fecal incontinence, thus improving quality of life in these people. This device consists of a disposable, pliable, robber catheter with an infrared photointerrupter sensor and flatus vent holes on the distal tip that is connected to a beeper. The catheter is inserted in the rectum and held in place by a 20oc capacity cuff, which acts a temporary mechanical harrier to stool leakage. Stool entering the rectum is sensed by the photo interrupter sensor, which then alerts the patient of an imminent bowel movement. Voluntary evacuation is accomplishedby deflating the balloon and removing the catheter. METHODS: Patients with significant fecal incon~nanse who had undergone anorectal manometry, ultrasound and electromyography with pudendalnerveterminal motor latency asssessmentwere prospectivelyentered into this study. The Procon device was used for 14 consecutive days and a quality of life diary and a daily log of bowel activity and incontinentepisodeswere completedbeforeand after completion of the study. RESULTS: 7 patients, 5 females and 2 males with a mean age of 72.7 (range 39-81) years, were evaluated.Etiologyof incontinenceincludedidiopathic in 4, sphincterdefect in 2, and neurologicaldisorder in one patient. There was an overall significant improvementin the quality of life (p
Results Group .... A B

Recruit 23 24

Completed Healed+ Tre~m~mt improved# 20 18

12-'7 ~

~

O(IJter eee¢= 12 8

BACKGROUND:Fecal Incontinence (FI) may develop as a consequenceof traumatic brain injury. FI that persists beyond the period of early rehabilitation can be reason for a patient to remain dependent on caretakers or even institutionalized. Information regarding fecal incontinence in the acute brain injured population is not availablein the literature. OBJECTIVES: To investigate the incidence, risk factors, and outcomes of patients with FI following acute brain injury. METHODS: Medical centers in the federally sponsored Traumatic Brain Injury Model Systems supplied data from 1990-2000 that was retrospectivelyevaluatedto determine incidence, risk factors contributing to FI, and outcomes at admission and discharge from inpatient rehabilitation settings and at one-year follow-up. Main outcome measures included incidence of FI, pelvic fracture, frontal contusion, urinary tract infection (UTI), length of coma, length of post traumatic amnesia (PTA), admission Glasgowcoma scale score(GCS), length of stay, discharge disposition, and the Functional Independence Measure (FIM) scores. RESULTS: The incidence of FI ranged from 68% at admission to inpatient rehabilitation, 12.4% at rehabilitation discharge, and 5.2% at one-yearfollow-up. ANOVA'sand Chi square analysis revealedstatistically significant associationsbetweenthe incidenceof FI at rehabilitation admission and admission GCS, length of coma and PTA, length of stay, and incidence of UTI and frontal contusion. FI at rehabilitation discharge was significantly associatedwith a number of variables including age, discharge disposition, admission GCS, length of coma, PTA; length of stay, FIM scores, and incidence of pelvic fracture and frontal contusion. Significant associationswere also found between FI at one year follow-up and age, discharge and current disposition, admission GCS, length of coma, length of stay, FlU scores, and UTI (p-<.05). CONCLUSION:El is a significant problem following acute brain injury. Further studies evaluating mechanisms of FI and interventions to treat or control FI would be useful. This research is supported by a grant from the Rubin Family Brain injury Research Fund and a grant from NIDRR.

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695 A Correlation of Anal Sphincter Defects and Sphincter Pressures in Patients with Faecal incontinence. Ashish G. Prabhudesei,Devinder Kumar, Jennifer Bland, St George's Hosp, London United Kingdom Anal manometry (ARM) & endoanalultrasound (EAUS)are commonly used in the assessment of patients with faecal incontinence (FI). Often, patients with a sphincter defect shown on EAUS have normal sphincter pressures. Conversely,patientswith low sphincter pressures have normal sphincter morphology.Theaim of this study was to investigatewhether there is a correlation between defects in the internal (IAS) and/external sphincters (F_AS) & the pressuresgeneratedby these sphincters. We prospectivelycollecteddataon EAUS& manometry in 202 consecutive patients with FI (49 males, 153 females). Pa~anta were subdivided into four groups according to their sphincter morphology. Group I consisted of patients with IAS defects, Group II with F.ASdefects, Group III with a combined F_AS + IAS defect and Group IV of patients with normal sphincter morphology.Resting & squeezeanal pressures generated by these sphincters were assignedto the respectivegroups. All patients had lower than nOrmal (N>80 cm water) resting pressures. Those with a combined IAS & F_ASdefect had a significantly lower resting pressure (p120 cm water) in patients with no sphincter defects, Patientswith a combined IAS & EASdefect had significantly lower squeezepressures(p
Ba Lymphocyte Apoptosis And Bcl-2 Exprasslon In Celiac Disease Complicated With Intestinal Lymphoma Antonio Di Sabatino, GastroenterologyUnit, Univ of Pavia, Pavia Italy; Rachele Ciccocioppo, Dept of Internal Medicine, Univ of L'Aquila, L'Aquiia Italy; Simona D'AIo', Oept of ExperimentalMedicine, Univ of L'Aquila, L'Aquila Italy; Laura Ricevuti, Gastroenterology Unit, Univ of Pavia, Pavia Italy; FiorenzaBonvicini, Dept of Internal Medicine, Univ of Bologna, Bologna Italy; Maria Grazia Cifone, Dept of Experimental Medicine, Univ of L'Aquila, L'Aquiia Italy; Gino Roberto Corazza,GastroenterologyUnit, Univ of Pavia, Pavia Italy Background & Aims: Since programmedcell death controls lymphocyte homeostasis,a defect in apoptosis could result in an inappropriately long cell survival and then in malignancy.To test the hypothesisthat defectivemucoealT-lymphocyteapoptosisis involved in the pathogenesis of enteropethy-associetedT-cell lymphoma (EATL) in celiac disease(CD), we investigated lamina propria lymphocyte (LPL) apoptosis and expressionof Bcl-2, an antiapoptotic protein, in celiac patients complicated with EATL. Patients & Methods: Endoscopic biopsy specimens were obtainedfrom the second part of duodenum of 8 celiac patients with EATL,10 untreated and 10 treated uncomplicated celiac patients, and 10 consenting subjects undergoing upper gastrointestinal endoscopy for functional dyspepsia. Apogtosis detection was assessed by TUNELtechnique (Apoptag kit, Oncor). Bcl-2 expressionwas evaluatedby immunohistochemistry with the mouse monoclonal anti-human Bcl-2 antibody (DAKO) at 1:50 dilution. To

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