- Email: [email protected]
Anorectal phsiology can predict fecal continence in young children with operated anorectal malformations
A800 AGA ABSTRACTS
GASTROENTEROLOGYVol. 114, No. 4
• G3289 BOTULINUM TOXIN INJECTION IMPROVES SYMPTOMATIC HYPERTENSIVE LOWER ESOPHAGEAL SPHINCTER. Sajen Mathews, Hartley Cohen, Michael Kline. LAC+USC Medical Ctr., LOs Angeles, CA. Aim: To determine if decreasing lower esophageal sphincter (LES) pressure by means of botulinum toxin (BT) injection improves symptoms in patients with hypertensive LES Methods: 9 patients with hypertensive LES, defined as LES pressure > 35 mm Hg (average 41.4 mm Hg) participated. All patients suffered from dysphagia and 8 patients had chest pain. Patients received 4 quadrant injections of 25 units of botulinum toxin into the LES (total 100 units) at endoscopy. All patients had a second manometry performed 1 month later. At this time all manometric tracings pre and post study were read blindly and symptoms were assessed. Responders were defined as patients with resolution or improvement in dysphagia and/or chest pain. Results: I no.
1
'
hmJEEi I
K~i
2 ] E~ll ~l-.'--_-~ 3 . L--_ L"_'_ 34__~ ElrJ 3;11 ~ Non-responders 6 7 8 9
v
i
2 i
p
E 11 0
1
2
3
4
5
Gaotric emptying time (rain)
Responders Pt.
Aim of the study. To evaluate the relationship between gastric emptying time and antral diameter in children. Patients and methods. Ten healthy children, age range 8-12 years, have been studied, Gastric emptying time as well as antral diameter were calculated by real-time ultrasonography (2, 3). Results.
40.3 44.2 43.6 36
38 51.8 33.8 24
~
~
mEnll n 6 + 17 22 33
; ~ - - - - - ~ m
'~
EEIE E~iE EMi Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
1) Dysphagia resolved in 5 of 9 (55.5%). 2) In 4 of these 5, the LESP decreased >35% (average 44%). 3) Dysphagia did not improve in 4 of 9 (44.5%). 4) All of these had LESP decrease < 35%. (average 11%). 5) Chest pain resolved or improved in 4 of 8 (50%), average decrease 44%. Average LESP decrease in non- improved pts was 12%. 6)Pt no. 2 had return of symptoms at 5 months with LESP of 43mm Hg at that time. Pt. no. 3 also had return of symptoms at 10 months with LESP of 46 mm Hg. Conclusion: In patients with hypertensive LES who respond with a decreased LES pressure by means of botulinum toxin injection, dysphagia and chest pain improves. G3290 DOES THE GENDER HAVE INFLUENCE ON THE OUTCOME OF COLOANAL ANASTOMOSIS? C. Mathias, B.G. Wolff, J.H. Pemberton, S. Mathison, D. Ilstrup, D. Larson; Mayo Clinic and Mayo Foundation, Rochester, MN. Low anterior resection with coloanal anastomosis can be a technically challenging operation. Rectal surgery is thought to be considerably easier in women due to the larger and shallower pelvic cavity and deeper pouch of Douglas. Thus far, no study has analyzed whether the gender has any influence on the outcome of coloanal anastomosis. AIM: This study was designed to determine complication rates, functional results, and disease free survival, in both male and female patients, who underwent coloanal anastomosis (CAA) for cancer. Methods: The records of 104 patients undergoing coloanal anastomosis for cancer, between 1980 and 1993, were reviewed. Thirty patients were female. Medial distal tumor-free margins were 2.8 cm for men (range 0 to 14 cm) and 2.3 cm for women (range 0.3 to 8 cm). Follow-up was done by exam, telephone and/or questionnaire. Results: Minor complication rates were 28% for men and 10% for women (p=0.06). Major complication rates were 34% for men and 14% for women (p=0.05). Ninetyone percent of men and 75% of women were continent postoperatively (p=0.05). Forty one percent of male and 57% of females had more than three stools per day This difference was not statistically significant (p>0.05). The probability of being free of local recurrence at five years was 89% for males and 96% for females (p>0.05). Conclusion: This study indicates that in patients who have CAA, men have a higher rate of complication than women, but in turn may have a better functional outcome. G3291 SIGNIFICATIVE RELATIONSHIP BETWEEN GASTRIC EMPTYING TIME AND ANTRAL DIAMETER IN HEALTHY CHILDREN. M. Matrunola, G. Corrado, P. Rea, M. Cavaliere, C. Pacchiarotti, F. Petreschi, D. Russo, P. Capocaccia, E. Cardi. Istituto di Clinica Pediatrica - Universit~t di Roma "La Sapienza". Background. In children, several conditions (anatomic obstruction, metabolic disorders, drugs, neuronal dysfunction, muscle disease and infections) may cause delayed gastric emptying time (1).
Conclusions. These results suggest a significative relationship between gastric emptying time and antral diameter. However, further investigations are needed to confirm our data. [1] Milla PJ. In: Pediatric gastrointestinal disease, St. Louis 1996, Mosby: 543-53. [2] Bolondi L, Bortolotti M, Santi V, et al. Gastroenterology 1985; 89: 752-9. [3] Corrado G, Cavaliere M, Frandina G, et al. Ital J Gastroenterol 1996; 28: 462-9. G3292 EFFECT OF ODQ AND LY 83583 ON SOUTH AMERICAN (SA) OPOSSUM LOWER ESOPHAGEAL SPHINCTER (LES) RELAXATIONS INDUCED BY NITRERGIC NERVE ACTIVATION OR NITRIC OXIDE (NO) AND NO-DONORS. N.M. Matsuda, R.L Feitosa Jr., M.C. Lemos, R.B. Oliveira, G. Ballejo. Departments of Clfnica M6dica and Farmacologia, Faculdade de Medicina de Ribeir~o Preto, Universidade de S~o Paulo, Ribeir~o Preto (SP), Brasil. LES circular smooth muscle of SA opossum is relaxed by the activation of intramural nitrergic nerves. The identity of the neurotransmitter released as well as the cellular mechanism involved in this relaxation, however, remain to be fully elucidated. The purpose of this study was to determine the effect of the guanylate cyclase (GC) inhibitors, ODQ (H-[1,2,4]oxadizolo [4,3-a]quinoxalin- 1- one) and LY 83583 (6-anilino-5,8 quinoledione) on the relaxations induced by nitrergic nerve activation and by NO and NO-donors of isolated strips from the SA opossum LES. Electrical field stimulation (0,5 ms, 48 V, 0,5-8,0 Hz for 10 s) caused frequency-dependent relaxations of SA opossum LES muscle strips which were abolished by NO synthase inhibitors. The selective GC inhibitor of NO activated GC, ODQ (1 MM), abolished nitrergic nerve-induced relaxations at the lower frequencies (0,5 and 1 Hz) as well as the relaxations induced by HXA (hydroxylamine, 10 pM) and SNAP (S-nitroso-N-acetyl penicillamine, 10 [aM). Nerve-induced relaxations at higher frequencies (4 and 8 Hz) as well as relaxations induced by SNP (sodium nitroprusside, 3 pM), NO (0,5 mM) and DEA/NO (diethylamine/nitric oxide complex sodium, 0,1 mM) were reduced only partially by ODQ. In contrast, LY 83583 (10 JaM) inhibited partially the relaxations induced by NO but did not affect those induced by nitrergic nerve stimulation and by SNAP, DEA/NO and HXA. 8Br-cGMP (8-bromoguanosine 3',5'-cyclic monophosphate, 0, 1 mM) caused relaxations that were not affected by ODQ and LY 83583. Ttiese findings indicate that relaxations induced by nitrergic nerves activated by lower frequencies involve the activation of GC but others mechanisms participate in the relaxations induced by higher frequencies of stimulation or NO donors. This research was supported by FAPESP and CNPq. G3293 ANORECTAL PHSIOLOGY CAN PREDICT FECAL CONTINENCE IN YOUNG CHILDREN WITH OPERATED ANORECTAL MALFORMATIONS. Maxwell P, Hagger R, Bland J, Holmes K*, Kumar D. Dept. of Surgery, Dept. of Pediatric Surgery*, St George's Hospital, London, UK. Introduction: Bowel dysfunction is common in patients following surgical correction of anorectal anomalies. The degree of the disturbance is related to the level of the anatomical lesion. The role of anorectal physiology in the investigation of young children is controversial. Aim: The aim of the present study was to investigate the value of anorectal physiology and endoanal ultrasound in the evaluation of continence in young children with corrected anorectal anomalies. Methods: Seventeen patients, 13 male and 4 female, median age 5 years (iqr 6.25 years who had been born with anorectal anomalies were investigated by anorectal physiology and endoanal ultrasound. The anorectal physiology was carried out at a mean of 4.92+/-0.84 years after surgery. Two of the 17 patients had low anomalies (anal atresia/stenosis) and had been treated by simple anoplasty. The remaining patients had intermediate or high anomalies: 8 with bulbar fistula, 5 with prostatic fistula and 3 with vestibular fistula were treated by Posterior Sagittal Anorectoplasty (PSARP). Two patients had a
Motility and Nerve-Gut Interactions A801
April 1998
redo/salvage PSARP. A new clinical continence questionnaire was devised as an evolution o f the Holschneider Criteria but with additional questions regarding social hardship and the discrimination of solid from liquid stool incontinence. The questionnaire had scores allocated for each response. Results: A number of associations between measurements at anorectal manometry and the parental responses to components of the continence questionnaire were discovered. A low median maximal squeeze pressure in the anal canal was associated with incontinence for solid stool, r=0.5, p=0.0475. A low median maximal Squeeze pressure was also associated with soiling of the underpants, r=-0.5, p=0.0442. A low maximum tolerated volume of rectal distension was associated with a reduced ability to voluntarily delay defecation until convenient, r=0.65, p=0.0125. Endoanal ultrasonography identified sphincter disruptions in all cases but did not predict continence function. Condusion: Anorectal physiology techniques can be applied to young children producing results which correlate with clinical symptoms. These data suggest that anorectal physiology tests are valuable clinical tests which may assist in the planning of future treatment and corroborate patients' and parents' reports of continence function. G3294 ANTIBIOTICS MAY EXACERBATE FUNCTIONAL ABDOMINAL SYMPTOMS OVER TIME. P.R.Maxwell. M.A.Mendall, D.Kumar. St George's Hospital Medical School, London SW17, England. Background: Functional bowel diseases account for 50% gastroenterology outpatient referrals. Factors which increase their prevalence or worsen their symptoms add to the burden of their investigation and management. Antibiotics are known to produce short term diarrhoea but may have longerterm effects. Aim" The aim of our current study is to identify whether in a prospective cohort study an attendance at the General Practice combined with a prescription for antibiotics is temporally associated with the subsequent worsening of functional bowel symptoms. Methods: The general practitioners maintained a log of patients aged 16-49 attending with non-GI complaints to whom they have given a prescription for antibiotics. Each week the names were collected and comparison patients matched for age and sex were identified from the practice records. Although comparison patients had not attended on the same day as the antibiotic patients they had similar attendance habits as they were additionally matched for number of attendances over the preceding year. They had not been given a prescription for antibiotics for 1 year. Two comparison subjects were recruited for each antibiotic patient. All subjects were sent a questionnaire to establish functional abdominal symptoms and anxiety/depression using the Hospital anxiety and depression scale within 1 week of prescription. Non-responders were sent a further questionnaire. All responders were sent a second questionnaire four months later to identify any change in symptoms. Each item in the questionnaire was given a non-weighted score and these scores were added together to give a total functional symptom score (FSS) between 0 and 40 for each subject at baseline and at follow-up providing a comparable measure of functional symptom burden at both time-points. Results: Baseline and follow-up data have been obtained for 16 antibiotic subjects and 26 comparison patients. Baseline FSS was 5.9+/-0.9 in the control patients and 7.2+/-1.8 in the antibiotic subjects. At follow-up (mean interval 126+/-7 days), FSS was 4.5+/-0.7 in the control patients and 8.1+/-1.6 in the antibiotic patients. There is no statistical difference between the scores in the two groups at baseline (p=0.46, unpaired t-test) but at follow-up there is a mean difference of 3.5, p=0.03 unpaired t-test. This difference is explained by a significant improvement in FSS over the study period in the control patients (p=0.02, paired t-test) and a non-significant trend towards deterioration in the antibiotic patients. Conclusion: Functional abdominal symptoms appear to improve over time in control subjects. Patients taking antibiotics show a trend towards deterioration in their symptoms. Since functional abdominal symptoms tend to be paroxysmal, it is plausible that antibiotics act as a trigger for either inducing or exacerbating them. G3295 EARLY DIAGNOSIS OF ASPIRATION IN PATIENTS WITH STEINERT'S DISEASE BY VIDEOFLUOROSCOPY. Mazzadi S. Garcia AO, Trione M, Sajnik J, Miguel M, Caissiols A. Salis G, Chiocca JC. Gastroenterology, Neurology, and Radiology Services. Posadas Hospital. Pte Illia y Marconi, Haedo (1706), PBA, Argentina. Introduction: Steinert's disease or myotonic dystrophy (MD), is the most
common hereditary disease of the neuromuscular system in adults. Its mode of inheritance is autosomal dominant. The gastrointestinal manifestations (mainly disphagia) are also very frequent, even starting before the diagnosis of the MD. The causes of death in MD among the cases unable to sit up were 50% from respiratory involvement (respiratory failure and pneumonia) and 25% from dysphagia (i.e., aspiration pneumonia and choking). Moreover, among the cases that could sit up, 36% died from dysphagia and 15% from respiratory involvement. Dysphagia is often the cause of death in the early stage. To avoid these complications, management of swallowing is essential
in patients with MD. Objective: This study was prospective designed with the aim of showing subclinical aspiration in a group of patients with Steinert's disease. Methods: Clinical and Videofluoroscopy (VF) studies were performend in 3 patients with Steinert's desease (age: 44-24 X: 14.6, M/F: 2/1). The three patients had a subjective symptom of dysphagia. None of them complained about coughing while eating. Results: In VF study the three patients showed abnormal findings in an oral phase such as residue on the tongue (3 patients), reduced tongue control (3 patients), uncontrolled bolus or premature loss of liquid (2 patients) delayed oral onset of swallow (2 patients), peacemeal deglutition (3 patients). The three patients showed abnormality in a pharingeal phase such as vallecular residue after swallow (3 patients), residue in pyriform sinuses after swallow (3 patients), delayed onset o f laryngeal elevation (3 patients), and aspiration during swallow (3 patients), before swallow (2 patients), and after swallow (3 patients). Aspiration was more obvious when bigger amounts of barium liquid were swallowed. None of them coughed during the exam despite clear evidence of aspiration seen at VF. Conclusions: Videofluoroscopy study should be indicated in this subset of patient with Steinert's disease to detect subclinical aspiration in order to prevent the major cause of death; aspiration pneumonia. G3296 ESOPHAGEAL MOTILITY DISORDERS (EMD) IN "ESOPHAGUS FREE SYMPTOM" HIV PATIENTS. Mazzadi S, Sails G., Garcia AO., Gallo N, Sarmiento N., Daciuk L., Laplume II., Varsky C., Chiocca J.C. Gastroenterology, Endoscopy and Infectious Diseases Services. Posadas Hospital, Pte Illia y Marconi. Haedo. (1706) PBA, Argentina Esophageal opportunistic infection in AIDS is frequent due to immunity impairment caused by the virus. Infections can also be seen in motility disorders like achalasia and PSS and esophageal obstruction. HIV has a neurotropic action producing disorders in GI motility. Data about EMD due to virus is insufficient. Since we think that it may contribute to delay in esophageal clearance and development of infection, we designed this study with the aim of searching for an EMD that could be responsible for impaired clearance and ulterior development of infection. Methods: In a prospective study 8 asymptornatic HIV patients (age: 40-27, X: 32, M/F: 5/3) with normal esophageal lumen by endoscopy and biopsy were compared with 18 healthy volunteers (age: 18-41, X: 24 years, M/F: 6/12). Both groups underwent 3 lumen low compliance esophageal standard manometry. LES's pressure, amplitude, duration and velocity of esophageal contractions in the upper as well as in the lower esophagus were measured. Statistical analysis: Student t-test and Wilcoxon test Significance was accepted for P values < 0.05. Results: There was marked decrease in duration, increase in velocity of contractions in the upper esophagus and decrease in LES pressure in the patients when compared to the control group.(Table 1) Table 1 Variable LES (mmHg) APW(mmHg) DPW(s) VPW (cm/s) ADW(mmHg) DDW (s) VDW(cm/s)
Patients 13.5 (7.6) 34.47 (8.9) 2.91 (0.4) 3.86 (1.7) 60.68 (38.1) 3.66 (0.4) 4.18 (2.2)
Controls 22.8 (8.2) 42.2 (17.8) 4.15 (1.2) 2.12 (0.9) 61.5 (20.5) 4.1 (1.0) 3.5 (1.8)
P Value P < 0.01 NS P<0.001 P < 0.02 NS NS NS
Standard deviations are given in parenthesis. NS: Statistically not significant LES: lower esophageal sphincter, APW: amplitude proximal wave, DPW: duration proximal wave, VPW: velocity proximal wave, ADW: amplitude distal wave, DDW: duration distal wave, VDW: velocity distal wave. Conclusions: We believe that the esophageal motor alterations found in the present study suggest that HIV-associated neuropathy may be present in these patients and may contribute to an impaired esophageal clearance, even though a larger number of patients should be studied.
GASTROENTEROLOGYVol. 114, No. 4
• G3289 BOTULINUM TOXIN INJECTION IMPROVES SYMPTOMATIC HYPERTENSIVE LOWER ESOPHAGEAL SPHINCTER. Sajen Mathews, Hartley Cohen, Michael Kline. LAC+USC Medical Ctr., LOs Angeles, CA. Aim: To determine if decreasing lower esophageal sphincter (LES) pressure by means of botulinum toxin (BT) injection improves symptoms in patients with hypertensive LES Methods: 9 patients with hypertensive LES, defined as LES pressure > 35 mm Hg (average 41.4 mm Hg) participated. All patients suffered from dysphagia and 8 patients had chest pain. Patients received 4 quadrant injections of 25 units of botulinum toxin into the LES (total 100 units) at endoscopy. All patients had a second manometry performed 1 month later. At this time all manometric tracings pre and post study were read blindly and symptoms were assessed. Responders were defined as patients with resolution or improvement in dysphagia and/or chest pain. Results: I no.
1
'
hmJEEi I
K~i
2 ] E~ll ~l-.'--_-~ 3 . L--_ L"_'_ 34__~ ElrJ 3;11 ~ Non-responders 6 7 8 9
v
i
2 i
p
E 11 0
1
2
3
4
5
Gaotric emptying time (rain)
Responders Pt.
Aim of the study. To evaluate the relationship between gastric emptying time and antral diameter in children. Patients and methods. Ten healthy children, age range 8-12 years, have been studied, Gastric emptying time as well as antral diameter were calculated by real-time ultrasonography (2, 3). Results.
40.3 44.2 43.6 36
38 51.8 33.8 24
~
~
mEnll n 6 + 17 22 33
; ~ - - - - - ~ m
'~
EEIE E~iE EMi Y Y Y Y
Y Y Y Y
Y Y Y Y
Y Y Y Y
1) Dysphagia resolved in 5 of 9 (55.5%). 2) In 4 of these 5, the LESP decreased >35% (average 44%). 3) Dysphagia did not improve in 4 of 9 (44.5%). 4) All of these had LESP decrease < 35%. (average 11%). 5) Chest pain resolved or improved in 4 of 8 (50%), average decrease 44%. Average LESP decrease in non- improved pts was 12%. 6)Pt no. 2 had return of symptoms at 5 months with LESP of 43mm Hg at that time. Pt. no. 3 also had return of symptoms at 10 months with LESP of 46 mm Hg. Conclusion: In patients with hypertensive LES who respond with a decreased LES pressure by means of botulinum toxin injection, dysphagia and chest pain improves. G3290 DOES THE GENDER HAVE INFLUENCE ON THE OUTCOME OF COLOANAL ANASTOMOSIS? C. Mathias, B.G. Wolff, J.H. Pemberton, S. Mathison, D. Ilstrup, D. Larson; Mayo Clinic and Mayo Foundation, Rochester, MN. Low anterior resection with coloanal anastomosis can be a technically challenging operation. Rectal surgery is thought to be considerably easier in women due to the larger and shallower pelvic cavity and deeper pouch of Douglas. Thus far, no study has analyzed whether the gender has any influence on the outcome of coloanal anastomosis. AIM: This study was designed to determine complication rates, functional results, and disease free survival, in both male and female patients, who underwent coloanal anastomosis (CAA) for cancer. Methods: The records of 104 patients undergoing coloanal anastomosis for cancer, between 1980 and 1993, were reviewed. Thirty patients were female. Medial distal tumor-free margins were 2.8 cm for men (range 0 to 14 cm) and 2.3 cm for women (range 0.3 to 8 cm). Follow-up was done by exam, telephone and/or questionnaire. Results: Minor complication rates were 28% for men and 10% for women (p=0.06). Major complication rates were 34% for men and 14% for women (p=0.05). Ninetyone percent of men and 75% of women were continent postoperatively (p=0.05). Forty one percent of male and 57% of females had more than three stools per day This difference was not statistically significant (p>0.05). The probability of being free of local recurrence at five years was 89% for males and 96% for females (p>0.05). Conclusion: This study indicates that in patients who have CAA, men have a higher rate of complication than women, but in turn may have a better functional outcome. G3291 SIGNIFICATIVE RELATIONSHIP BETWEEN GASTRIC EMPTYING TIME AND ANTRAL DIAMETER IN HEALTHY CHILDREN. M. Matrunola, G. Corrado, P. Rea, M. Cavaliere, C. Pacchiarotti, F. Petreschi, D. Russo, P. Capocaccia, E. Cardi. Istituto di Clinica Pediatrica - Universit~t di Roma "La Sapienza". Background. In children, several conditions (anatomic obstruction, metabolic disorders, drugs, neuronal dysfunction, muscle disease and infections) may cause delayed gastric emptying time (1).
Conclusions. These results suggest a significative relationship between gastric emptying time and antral diameter. However, further investigations are needed to confirm our data. [1] Milla PJ. In: Pediatric gastrointestinal disease, St. Louis 1996, Mosby: 543-53. [2] Bolondi L, Bortolotti M, Santi V, et al. Gastroenterology 1985; 89: 752-9. [3] Corrado G, Cavaliere M, Frandina G, et al. Ital J Gastroenterol 1996; 28: 462-9. G3292 EFFECT OF ODQ AND LY 83583 ON SOUTH AMERICAN (SA) OPOSSUM LOWER ESOPHAGEAL SPHINCTER (LES) RELAXATIONS INDUCED BY NITRERGIC NERVE ACTIVATION OR NITRIC OXIDE (NO) AND NO-DONORS. N.M. Matsuda, R.L Feitosa Jr., M.C. Lemos, R.B. Oliveira, G. Ballejo. Departments of Clfnica M6dica and Farmacologia, Faculdade de Medicina de Ribeir~o Preto, Universidade de S~o Paulo, Ribeir~o Preto (SP), Brasil. LES circular smooth muscle of SA opossum is relaxed by the activation of intramural nitrergic nerves. The identity of the neurotransmitter released as well as the cellular mechanism involved in this relaxation, however, remain to be fully elucidated. The purpose of this study was to determine the effect of the guanylate cyclase (GC) inhibitors, ODQ (H-[1,2,4]oxadizolo [4,3-a]quinoxalin- 1- one) and LY 83583 (6-anilino-5,8 quinoledione) on the relaxations induced by nitrergic nerve activation and by NO and NO-donors of isolated strips from the SA opossum LES. Electrical field stimulation (0,5 ms, 48 V, 0,5-8,0 Hz for 10 s) caused frequency-dependent relaxations of SA opossum LES muscle strips which were abolished by NO synthase inhibitors. The selective GC inhibitor of NO activated GC, ODQ (1 MM), abolished nitrergic nerve-induced relaxations at the lower frequencies (0,5 and 1 Hz) as well as the relaxations induced by HXA (hydroxylamine, 10 pM) and SNAP (S-nitroso-N-acetyl penicillamine, 10 [aM). Nerve-induced relaxations at higher frequencies (4 and 8 Hz) as well as relaxations induced by SNP (sodium nitroprusside, 3 pM), NO (0,5 mM) and DEA/NO (diethylamine/nitric oxide complex sodium, 0,1 mM) were reduced only partially by ODQ. In contrast, LY 83583 (10 JaM) inhibited partially the relaxations induced by NO but did not affect those induced by nitrergic nerve stimulation and by SNAP, DEA/NO and HXA. 8Br-cGMP (8-bromoguanosine 3',5'-cyclic monophosphate, 0, 1 mM) caused relaxations that were not affected by ODQ and LY 83583. Ttiese findings indicate that relaxations induced by nitrergic nerves activated by lower frequencies involve the activation of GC but others mechanisms participate in the relaxations induced by higher frequencies of stimulation or NO donors. This research was supported by FAPESP and CNPq. G3293 ANORECTAL PHSIOLOGY CAN PREDICT FECAL CONTINENCE IN YOUNG CHILDREN WITH OPERATED ANORECTAL MALFORMATIONS. Maxwell P, Hagger R, Bland J, Holmes K*, Kumar D. Dept. of Surgery, Dept. of Pediatric Surgery*, St George's Hospital, London, UK. Introduction: Bowel dysfunction is common in patients following surgical correction of anorectal anomalies. The degree of the disturbance is related to the level of the anatomical lesion. The role of anorectal physiology in the investigation of young children is controversial. Aim: The aim of the present study was to investigate the value of anorectal physiology and endoanal ultrasound in the evaluation of continence in young children with corrected anorectal anomalies. Methods: Seventeen patients, 13 male and 4 female, median age 5 years (iqr 6.25 years who had been born with anorectal anomalies were investigated by anorectal physiology and endoanal ultrasound. The anorectal physiology was carried out at a mean of 4.92+/-0.84 years after surgery. Two of the 17 patients had low anomalies (anal atresia/stenosis) and had been treated by simple anoplasty. The remaining patients had intermediate or high anomalies: 8 with bulbar fistula, 5 with prostatic fistula and 3 with vestibular fistula were treated by Posterior Sagittal Anorectoplasty (PSARP). Two patients had a
Motility and Nerve-Gut Interactions A801
April 1998
redo/salvage PSARP. A new clinical continence questionnaire was devised as an evolution o f the Holschneider Criteria but with additional questions regarding social hardship and the discrimination of solid from liquid stool incontinence. The questionnaire had scores allocated for each response. Results: A number of associations between measurements at anorectal manometry and the parental responses to components of the continence questionnaire were discovered. A low median maximal squeeze pressure in the anal canal was associated with incontinence for solid stool, r=0.5, p=0.0475. A low median maximal Squeeze pressure was also associated with soiling of the underpants, r=-0.5, p=0.0442. A low maximum tolerated volume of rectal distension was associated with a reduced ability to voluntarily delay defecation until convenient, r=0.65, p=0.0125. Endoanal ultrasonography identified sphincter disruptions in all cases but did not predict continence function. Condusion: Anorectal physiology techniques can be applied to young children producing results which correlate with clinical symptoms. These data suggest that anorectal physiology tests are valuable clinical tests which may assist in the planning of future treatment and corroborate patients' and parents' reports of continence function. G3294 ANTIBIOTICS MAY EXACERBATE FUNCTIONAL ABDOMINAL SYMPTOMS OVER TIME. P.R.Maxwell. M.A.Mendall, D.Kumar. St George's Hospital Medical School, London SW17, England. Background: Functional bowel diseases account for 50% gastroenterology outpatient referrals. Factors which increase their prevalence or worsen their symptoms add to the burden of their investigation and management. Antibiotics are known to produce short term diarrhoea but may have longerterm effects. Aim" The aim of our current study is to identify whether in a prospective cohort study an attendance at the General Practice combined with a prescription for antibiotics is temporally associated with the subsequent worsening of functional bowel symptoms. Methods: The general practitioners maintained a log of patients aged 16-49 attending with non-GI complaints to whom they have given a prescription for antibiotics. Each week the names were collected and comparison patients matched for age and sex were identified from the practice records. Although comparison patients had not attended on the same day as the antibiotic patients they had similar attendance habits as they were additionally matched for number of attendances over the preceding year. They had not been given a prescription for antibiotics for 1 year. Two comparison subjects were recruited for each antibiotic patient. All subjects were sent a questionnaire to establish functional abdominal symptoms and anxiety/depression using the Hospital anxiety and depression scale within 1 week of prescription. Non-responders were sent a further questionnaire. All responders were sent a second questionnaire four months later to identify any change in symptoms. Each item in the questionnaire was given a non-weighted score and these scores were added together to give a total functional symptom score (FSS) between 0 and 40 for each subject at baseline and at follow-up providing a comparable measure of functional symptom burden at both time-points. Results: Baseline and follow-up data have been obtained for 16 antibiotic subjects and 26 comparison patients. Baseline FSS was 5.9+/-0.9 in the control patients and 7.2+/-1.8 in the antibiotic subjects. At follow-up (mean interval 126+/-7 days), FSS was 4.5+/-0.7 in the control patients and 8.1+/-1.6 in the antibiotic patients. There is no statistical difference between the scores in the two groups at baseline (p=0.46, unpaired t-test) but at follow-up there is a mean difference of 3.5, p=0.03 unpaired t-test. This difference is explained by a significant improvement in FSS over the study period in the control patients (p=0.02, paired t-test) and a non-significant trend towards deterioration in the antibiotic patients. Conclusion: Functional abdominal symptoms appear to improve over time in control subjects. Patients taking antibiotics show a trend towards deterioration in their symptoms. Since functional abdominal symptoms tend to be paroxysmal, it is plausible that antibiotics act as a trigger for either inducing or exacerbating them. G3295 EARLY DIAGNOSIS OF ASPIRATION IN PATIENTS WITH STEINERT'S DISEASE BY VIDEOFLUOROSCOPY. Mazzadi S. Garcia AO, Trione M, Sajnik J, Miguel M, Caissiols A. Salis G, Chiocca JC. Gastroenterology, Neurology, and Radiology Services. Posadas Hospital. Pte Illia y Marconi, Haedo (1706), PBA, Argentina. Introduction: Steinert's disease or myotonic dystrophy (MD), is the most
common hereditary disease of the neuromuscular system in adults. Its mode of inheritance is autosomal dominant. The gastrointestinal manifestations (mainly disphagia) are also very frequent, even starting before the diagnosis of the MD. The causes of death in MD among the cases unable to sit up were 50% from respiratory involvement (respiratory failure and pneumonia) and 25% from dysphagia (i.e., aspiration pneumonia and choking). Moreover, among the cases that could sit up, 36% died from dysphagia and 15% from respiratory involvement. Dysphagia is often the cause of death in the early stage. To avoid these complications, management of swallowing is essential
in patients with MD. Objective: This study was prospective designed with the aim of showing subclinical aspiration in a group of patients with Steinert's disease. Methods: Clinical and Videofluoroscopy (VF) studies were performend in 3 patients with Steinert's desease (age: 44-24 X: 14.6, M/F: 2/1). The three patients had a subjective symptom of dysphagia. None of them complained about coughing while eating. Results: In VF study the three patients showed abnormal findings in an oral phase such as residue on the tongue (3 patients), reduced tongue control (3 patients), uncontrolled bolus or premature loss of liquid (2 patients) delayed oral onset of swallow (2 patients), peacemeal deglutition (3 patients). The three patients showed abnormality in a pharingeal phase such as vallecular residue after swallow (3 patients), residue in pyriform sinuses after swallow (3 patients), delayed onset o f laryngeal elevation (3 patients), and aspiration during swallow (3 patients), before swallow (2 patients), and after swallow (3 patients). Aspiration was more obvious when bigger amounts of barium liquid were swallowed. None of them coughed during the exam despite clear evidence of aspiration seen at VF. Conclusions: Videofluoroscopy study should be indicated in this subset of patient with Steinert's disease to detect subclinical aspiration in order to prevent the major cause of death; aspiration pneumonia. G3296 ESOPHAGEAL MOTILITY DISORDERS (EMD) IN "ESOPHAGUS FREE SYMPTOM" HIV PATIENTS. Mazzadi S, Sails G., Garcia AO., Gallo N, Sarmiento N., Daciuk L., Laplume II., Varsky C., Chiocca J.C. Gastroenterology, Endoscopy and Infectious Diseases Services. Posadas Hospital, Pte Illia y Marconi. Haedo. (1706) PBA, Argentina Esophageal opportunistic infection in AIDS is frequent due to immunity impairment caused by the virus. Infections can also be seen in motility disorders like achalasia and PSS and esophageal obstruction. HIV has a neurotropic action producing disorders in GI motility. Data about EMD due to virus is insufficient. Since we think that it may contribute to delay in esophageal clearance and development of infection, we designed this study with the aim of searching for an EMD that could be responsible for impaired clearance and ulterior development of infection. Methods: In a prospective study 8 asymptornatic HIV patients (age: 40-27, X: 32, M/F: 5/3) with normal esophageal lumen by endoscopy and biopsy were compared with 18 healthy volunteers (age: 18-41, X: 24 years, M/F: 6/12). Both groups underwent 3 lumen low compliance esophageal standard manometry. LES's pressure, amplitude, duration and velocity of esophageal contractions in the upper as well as in the lower esophagus were measured. Statistical analysis: Student t-test and Wilcoxon test Significance was accepted for P values < 0.05. Results: There was marked decrease in duration, increase in velocity of contractions in the upper esophagus and decrease in LES pressure in the patients when compared to the control group.(Table 1) Table 1 Variable LES (mmHg) APW(mmHg) DPW(s) VPW (cm/s) ADW(mmHg) DDW (s) VDW(cm/s)
Patients 13.5 (7.6) 34.47 (8.9) 2.91 (0.4) 3.86 (1.7) 60.68 (38.1) 3.66 (0.4) 4.18 (2.2)
Controls 22.8 (8.2) 42.2 (17.8) 4.15 (1.2) 2.12 (0.9) 61.5 (20.5) 4.1 (1.0) 3.5 (1.8)
P Value P < 0.01 NS P<0.001 P < 0.02 NS NS NS
Standard deviations are given in parenthesis. NS: Statistically not significant LES: lower esophageal sphincter, APW: amplitude proximal wave, DPW: duration proximal wave, VPW: velocity proximal wave, ADW: amplitude distal wave, DDW: duration distal wave, VDW: velocity distal wave. Conclusions: We believe that the esophageal motor alterations found in the present study suggest that HIV-associated neuropathy may be present in these patients and may contribute to an impaired esophageal clearance, even though a larger number of patients should be studied.