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Descending perineum syndrome: Clinical and laboratory features and outcome of pelvic floor retraining
Motility and Nerve-Gut Interactions A761
April 1998 solution. After an initial control period 5 (n=3), 10 (n=8), or 50 (n=l) lag/ml capsaicin was added to the perfusate for a 60-minute test period, followed by a final control period. Absorption rates of water, sodium, potassium, chloride and bicarbonate were determined in a 30-cm segment of jejunum using a non absorbable volume marker. Results: At all 3 concentrations of capsaicin there were no significant changes in water and electrolyte absorption as compared to control periods. Two subjects who received I0 lag/ml developed abdominal cramps at the end of the 60-min test period. The subject receiving 50 pg/ml experienced crampy abdominal pain within 20 minutes and pain persisted until the end of the 60-min test period. Cramps resolved within five minutes after ending the capsaicin perfusion according to protocol. Cramps or abdominal discomfort did not develop during any of the control periods. Summary: In contrast to animal experiments, intrajejunal capsaicin does not cause secretion or alter absorption in the human jejunum in vivo. Capsaicin caused crampy abdominal pain in a concentration and time related manner. This was unexpected because capsaicin fails to evoke reactions indicative of pain in the rat. Conclusion: The present study demonstrates that in healthy volunteers abdominal pain can be elicited by chemical stimulation of the intestinal mucosa. Future studies will have to address whether capsaicin caused pain by directly stimulating nociceptive afferents in the intestinal mucosa or by stimulating excessive contraction or distention of the gut. • G3137 W H O L E GUT SENSITIVITY IN CONSTIPATION PREDOMINANT IRRITABLE BOWEL SYNDROME (CPIBS): 80 PERCENT OF PATIENTS EXHIBIT AN ABNORMALITY. 1RM Hammonds, ILA Houghton, Ipj Whorwell, 2j Morris, ICY Francis, 3j Mills. Depts of 1Medicine and 2Statistics, University Hospital of South Manchester, M20 2LR and 3Glaxo Wellcome, Stockley Park West, Uxbridge, UB11 1BT, U.K. We have recently observed that patients with diarrhoea predominant irritable bowel syndrome (DPIBS) have increased sensitivity to balloon distension throughout the length of the gastrointestinal tract, with the jejunum being the site most likely to exhibit this phenomenon (Gastroenterology 1995;108:A601). The aim of this study was to extend these observations and compare sensory and motility responses to balloon distension of the oesophagus (O), duodenum (D), jejunum (J), ileum (I), colon (C) and rectum (R) in 14 patients with CPIBS (aged 29-64 yrs, all female) with 25 healthy volunteers (aged 20-61 yrs, all female). All patients fulfilled the Rome criteria for CPIBS and had their level of anxiety assessed using the Hospital Anxiety and Depression questionnaire (abnormal scores > 10). Results With the exception of the J [vol to discomfort (ml): IBS 40(20,140) geometric mean (range) v controls 59(40,100); p=0.01], the sensory thresholds in the O [13(5,60) v 15(7.5,45); p=0.38], D [48(10,160) v 64(40,110); p=0.14], I [40 (15,150) v 54(30,110); p=0.09], C [124(50,300) v 154(60,280); p=0.26] and R [118 (40,300) v 165(80,400); p=0.06] were not significantly different between patients and controls. Comparison of individual patient sensory thresholds with the 90% control range, however, did show altered sensitivity (increased or decreased) in at least one site of the gut in 79% of patients. This was reflected by increased sensitivity in 7% of patients in O, 29% in D, 29% in J, 20% in I, 25% in C and 36% in R; and decreased sensitivity in 14% of patients in O, 7% in D, 7% in J, 10% in I, 8% in .C and 14% in R. These differences in sensitivity were not associated with differences in gut compliance between the patient and control groups for the O [compliance (ml/mmHg) at 5ml: IBS 0.41(0.16,1.19) median (range) v controls 0.31(0.14,0.87); p=0.12], D [40ml: 3.42(1.73,9.52) v 2.40(1.08,6.40); p=0.24], J [40ml: 1.89(1.30,33.30) v 2.04(0.80,4.30); p=0.82], 1 [40ml: 1.52(1.10,5.70) v 2.22(0.80,8.90); p=0.66] and C [80ml: 6.11(2.70,12.70) v 5.51(2.40,10.40); p=0.64]; although the compliance of R was greater in the patients compared with controls [80ml: 9.20(5.00,28.60) v 5.19(1.80,14.00); p=0.01]. A correlation analysis of the patients level f sensitivity with their gut compliance revealed no significant relationships [O, p=0.49, p=0.09; D, p=0.57, p=0.08; J, p=0.50, p=0.14; I, p=0.26, p=0.67; C, p=0.47, p=0.20; R p=0.27, p=0.48]. Likewise, although the patients had higher anxiety scores [9(3,16)] than controls [5(1,9); p=0.002], there was no correlation between their sensory threshold and anxiety score [O, r---0.14, p=0.64; D, r=--0.18, p=0.53; J, r=-0.38, p=0.18; I, r=0.09, p=0.82; C, r=0.02, p=0.96; R, r=-0.18, p=0.55]. Conclusions Just as in DPIBS, CPIBS patients are most likely to exhibit a perceptual change in the J. Furthermore, 80% CPIBS patients exhibited some form of sensory abnormality (increased or decreased) at some level in the gastrointestinal tract. These results lend further support to the notion that perCeptual abnormalities contribute to the pathophysiology of IBS. This research was supported in part by a grant from Glaxo Wellcome, U.K. • G3138 DESCENDING PERINEUM SYNDROME: CLINICAL AND LABORATORY FEATURES AND OUTCOME OF PELVIC FLOOR RETRAINING. G. Harewood, B. Coulie, D. Rath, J.H. Pemberton, M. Camilleri. Mayo Foundation, Rochester, MN. The descending perineum syndrome (DPS) is rarely encountered in clinical practice, and may present with either an evacuation disorder or incontinence of stool or urine. Our aim was to retrospectively analyze the Mayo Clinic experience of this disorder over the ten year period from 1987-1997.
Methods: Clinical records were used to abstract demographic features,
associations, risk factors, results on tests of anorectal manometry, scintigraphic rectal emptying with measurement of rectoanal angle at rest and during defecation, and balloon expulsion. A questionnaire was mailed to ascertain which patients underwent pelvic floor retraining at Mayo Clinic or elsewhere, and to evaluate outcome and current symptoms in 1997. Results (mean _+SD): (1) Clinical: There were 38 patients (36F, 2M) with mean age 52 -+ 15 years at presentation. Presenting symptoms werei constipation (92%), sense of incomplete rectal evacuation (84%), excessive straining (92%), digital evacuation (29%) and fecal incontinence (16%). Three patients had combined symptoms of excessive straining to defecate and fecal incontinence. Thirty-three patients underwent anorectal manometry; 24 patients underwent scintigraphic rectal evacuation. (2) Laboratory testing: Anal sphincter resting pressure 75 -+ 35 mmHg; squeeze pressure 138 -+ 45 mmHg; expulsion of a balloon from the rectum required >200g weight added in 21% of patients; scintigraphic evacuation of radiolabeled Veegum resin was 55 -+ 24% (normal >54%); change of rectoanal angle from rest to defecation position was 14.4 -+ 9.6 ° (normal >15°); perineal descent was 4.9 -+ 1.3cm (normal <4cm). Scintigraphic evacuation, rectoanal angle and perineal descent were abnormal in 21%, 50% and 79% of the patients respectively. (3) Associated riskJactors: multiparity with vaginal delivery (58%), hysterectomy and/or cystocele/rectocele repair (70%). (4) Mailed questionnaire: Seventeen patients responded. All clinical and laboratory features were not significantly different in questionnaire responders vs. nonresponders. Ten of 17 patients underwent pelvic floor retraining. At 2-year median follow-up (range 1-6 yr), 67% still experienced constipation or excessive straining. Conclusions: DPS is identifiable by clinical and relatively simple l~iboratory testing, and the most prevalent abnormality was a documented perineal descent >4.0cm. Balloon expulsion is an insensitive screening test (only 21% positive) for DPS. Symptoms persist despite pelvic floor retraining in the majority of patients who responded to a questionnaire, suggesting that current approaches to treatment for this chronic disorder of rectal evacuation are suboptimal. • G3139 IRRITABLE BOWEL SYNDROME: RESPONSES TO GASTRIC DISTENTION. M. Harnish. S. Elsenbruch, W. Orr; Lynn Health Science Institute, Oklahoma City, OK. Irritable bowel syndrome (IBS) is characterized by gastrointestinal (GI) symptoms for which no recognized organic GI etiology can be found. Recent data suggest that the pathophysiology of IBS may involve a shift in the threshold of sensitivity to visceral stimuli. This altered perception may in turn lead to altered responses in GI regulatory systems. The objective of the current study was to investigate the effect of gastric distention on gastric myoelectrical activity in IBS patient s compared to healthy individuals. Methods: Eight IBS patients and seven healthy were studied using electrogastrography (EGG). Prior to a 20 minute baseline recording (Period 1), subjects were asked to complete a visual analog scale (VAS) inquiring about how full their stomach felt. They were then given 100cc volumes of water, followed by another VAS scale. They continued to ingest water until they had reached a subjective rating on the VAS 20% greater than their baseline subjective level. A 30 minute recording period followed (Period 2). Following this recording period, subjects resumed ingesting water until they reached a point on the VAS 50% greater than their baseline subjective level. A 60 minute recording period followed (Period 3). A symptom checklist, consisting of various GI, autonomic, and somatic items, was also completed each time. Dependent variables included the dominant frequency (DF) and dominant power (DP) calculated via the spectral analysis of the EGG data, the volume of water ingested to reach each subjective level, and the number of symptoms experienced. The data were analyzed using a 2x3 ANOVA followed by comparisons using the Tukey HSD. Results: 1) The groups did not differ significantly in the amount of water ingested to reach a particular subjective rating. 2) There was a trend for DP towards a significant interaction between group and period (p<.07). Controls showed an increase in DP following ingestion of water, while the IBS patients failed to exhibit a similar change (See Fig.). The groups' DPs were significantly different following water ingestion (p<.05). 3) Both IBS patients and controls demonstrated a significant decrease in DF following ingestion of the water (p<.01). 4) IBS patients reported significantly more symptoms than controls after the water ingestion (p<.03).
• - 'O" - -IBS DP342630t
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.
0
~
Period 1 Period2
[] ....I CON Period3
Conclusions: 1) These results confirm previous findings in our lab that IBS patients fail to modulate gastric myoelectrical activity in response to a variety of stimuli. 2) Taken together, these findings suggest that IBS may involve an alteration in responses to visceral stimuli leading to a failure to demonstrate compensatory responses to gastric distention and meal ingestion.
April 1998 solution. After an initial control period 5 (n=3), 10 (n=8), or 50 (n=l) lag/ml capsaicin was added to the perfusate for a 60-minute test period, followed by a final control period. Absorption rates of water, sodium, potassium, chloride and bicarbonate were determined in a 30-cm segment of jejunum using a non absorbable volume marker. Results: At all 3 concentrations of capsaicin there were no significant changes in water and electrolyte absorption as compared to control periods. Two subjects who received I0 lag/ml developed abdominal cramps at the end of the 60-min test period. The subject receiving 50 pg/ml experienced crampy abdominal pain within 20 minutes and pain persisted until the end of the 60-min test period. Cramps resolved within five minutes after ending the capsaicin perfusion according to protocol. Cramps or abdominal discomfort did not develop during any of the control periods. Summary: In contrast to animal experiments, intrajejunal capsaicin does not cause secretion or alter absorption in the human jejunum in vivo. Capsaicin caused crampy abdominal pain in a concentration and time related manner. This was unexpected because capsaicin fails to evoke reactions indicative of pain in the rat. Conclusion: The present study demonstrates that in healthy volunteers abdominal pain can be elicited by chemical stimulation of the intestinal mucosa. Future studies will have to address whether capsaicin caused pain by directly stimulating nociceptive afferents in the intestinal mucosa or by stimulating excessive contraction or distention of the gut. • G3137 W H O L E GUT SENSITIVITY IN CONSTIPATION PREDOMINANT IRRITABLE BOWEL SYNDROME (CPIBS): 80 PERCENT OF PATIENTS EXHIBIT AN ABNORMALITY. 1RM Hammonds, ILA Houghton, Ipj Whorwell, 2j Morris, ICY Francis, 3j Mills. Depts of 1Medicine and 2Statistics, University Hospital of South Manchester, M20 2LR and 3Glaxo Wellcome, Stockley Park West, Uxbridge, UB11 1BT, U.K. We have recently observed that patients with diarrhoea predominant irritable bowel syndrome (DPIBS) have increased sensitivity to balloon distension throughout the length of the gastrointestinal tract, with the jejunum being the site most likely to exhibit this phenomenon (Gastroenterology 1995;108:A601). The aim of this study was to extend these observations and compare sensory and motility responses to balloon distension of the oesophagus (O), duodenum (D), jejunum (J), ileum (I), colon (C) and rectum (R) in 14 patients with CPIBS (aged 29-64 yrs, all female) with 25 healthy volunteers (aged 20-61 yrs, all female). All patients fulfilled the Rome criteria for CPIBS and had their level of anxiety assessed using the Hospital Anxiety and Depression questionnaire (abnormal scores > 10). Results With the exception of the J [vol to discomfort (ml): IBS 40(20,140) geometric mean (range) v controls 59(40,100); p=0.01], the sensory thresholds in the O [13(5,60) v 15(7.5,45); p=0.38], D [48(10,160) v 64(40,110); p=0.14], I [40 (15,150) v 54(30,110); p=0.09], C [124(50,300) v 154(60,280); p=0.26] and R [118 (40,300) v 165(80,400); p=0.06] were not significantly different between patients and controls. Comparison of individual patient sensory thresholds with the 90% control range, however, did show altered sensitivity (increased or decreased) in at least one site of the gut in 79% of patients. This was reflected by increased sensitivity in 7% of patients in O, 29% in D, 29% in J, 20% in I, 25% in C and 36% in R; and decreased sensitivity in 14% of patients in O, 7% in D, 7% in J, 10% in I, 8% in .C and 14% in R. These differences in sensitivity were not associated with differences in gut compliance between the patient and control groups for the O [compliance (ml/mmHg) at 5ml: IBS 0.41(0.16,1.19) median (range) v controls 0.31(0.14,0.87); p=0.12], D [40ml: 3.42(1.73,9.52) v 2.40(1.08,6.40); p=0.24], J [40ml: 1.89(1.30,33.30) v 2.04(0.80,4.30); p=0.82], 1 [40ml: 1.52(1.10,5.70) v 2.22(0.80,8.90); p=0.66] and C [80ml: 6.11(2.70,12.70) v 5.51(2.40,10.40); p=0.64]; although the compliance of R was greater in the patients compared with controls [80ml: 9.20(5.00,28.60) v 5.19(1.80,14.00); p=0.01]. A correlation analysis of the patients level f sensitivity with their gut compliance revealed no significant relationships [O, p=0.49, p=0.09; D, p=0.57, p=0.08; J, p=0.50, p=0.14; I, p=0.26, p=0.67; C, p=0.47, p=0.20; R p=0.27, p=0.48]. Likewise, although the patients had higher anxiety scores [9(3,16)] than controls [5(1,9); p=0.002], there was no correlation between their sensory threshold and anxiety score [O, r---0.14, p=0.64; D, r=--0.18, p=0.53; J, r=-0.38, p=0.18; I, r=0.09, p=0.82; C, r=0.02, p=0.96; R, r=-0.18, p=0.55]. Conclusions Just as in DPIBS, CPIBS patients are most likely to exhibit a perceptual change in the J. Furthermore, 80% CPIBS patients exhibited some form of sensory abnormality (increased or decreased) at some level in the gastrointestinal tract. These results lend further support to the notion that perCeptual abnormalities contribute to the pathophysiology of IBS. This research was supported in part by a grant from Glaxo Wellcome, U.K. • G3138 DESCENDING PERINEUM SYNDROME: CLINICAL AND LABORATORY FEATURES AND OUTCOME OF PELVIC FLOOR RETRAINING. G. Harewood, B. Coulie, D. Rath, J.H. Pemberton, M. Camilleri. Mayo Foundation, Rochester, MN. The descending perineum syndrome (DPS) is rarely encountered in clinical practice, and may present with either an evacuation disorder or incontinence of stool or urine. Our aim was to retrospectively analyze the Mayo Clinic experience of this disorder over the ten year period from 1987-1997.
Methods: Clinical records were used to abstract demographic features,
associations, risk factors, results on tests of anorectal manometry, scintigraphic rectal emptying with measurement of rectoanal angle at rest and during defecation, and balloon expulsion. A questionnaire was mailed to ascertain which patients underwent pelvic floor retraining at Mayo Clinic or elsewhere, and to evaluate outcome and current symptoms in 1997. Results (mean _+SD): (1) Clinical: There were 38 patients (36F, 2M) with mean age 52 -+ 15 years at presentation. Presenting symptoms werei constipation (92%), sense of incomplete rectal evacuation (84%), excessive straining (92%), digital evacuation (29%) and fecal incontinence (16%). Three patients had combined symptoms of excessive straining to defecate and fecal incontinence. Thirty-three patients underwent anorectal manometry; 24 patients underwent scintigraphic rectal evacuation. (2) Laboratory testing: Anal sphincter resting pressure 75 -+ 35 mmHg; squeeze pressure 138 -+ 45 mmHg; expulsion of a balloon from the rectum required >200g weight added in 21% of patients; scintigraphic evacuation of radiolabeled Veegum resin was 55 -+ 24% (normal >54%); change of rectoanal angle from rest to defecation position was 14.4 -+ 9.6 ° (normal >15°); perineal descent was 4.9 -+ 1.3cm (normal <4cm). Scintigraphic evacuation, rectoanal angle and perineal descent were abnormal in 21%, 50% and 79% of the patients respectively. (3) Associated riskJactors: multiparity with vaginal delivery (58%), hysterectomy and/or cystocele/rectocele repair (70%). (4) Mailed questionnaire: Seventeen patients responded. All clinical and laboratory features were not significantly different in questionnaire responders vs. nonresponders. Ten of 17 patients underwent pelvic floor retraining. At 2-year median follow-up (range 1-6 yr), 67% still experienced constipation or excessive straining. Conclusions: DPS is identifiable by clinical and relatively simple l~iboratory testing, and the most prevalent abnormality was a documented perineal descent >4.0cm. Balloon expulsion is an insensitive screening test (only 21% positive) for DPS. Symptoms persist despite pelvic floor retraining in the majority of patients who responded to a questionnaire, suggesting that current approaches to treatment for this chronic disorder of rectal evacuation are suboptimal. • G3139 IRRITABLE BOWEL SYNDROME: RESPONSES TO GASTRIC DISTENTION. M. Harnish. S. Elsenbruch, W. Orr; Lynn Health Science Institute, Oklahoma City, OK. Irritable bowel syndrome (IBS) is characterized by gastrointestinal (GI) symptoms for which no recognized organic GI etiology can be found. Recent data suggest that the pathophysiology of IBS may involve a shift in the threshold of sensitivity to visceral stimuli. This altered perception may in turn lead to altered responses in GI regulatory systems. The objective of the current study was to investigate the effect of gastric distention on gastric myoelectrical activity in IBS patient s compared to healthy individuals. Methods: Eight IBS patients and seven healthy were studied using electrogastrography (EGG). Prior to a 20 minute baseline recording (Period 1), subjects were asked to complete a visual analog scale (VAS) inquiring about how full their stomach felt. They were then given 100cc volumes of water, followed by another VAS scale. They continued to ingest water until they had reached a subjective rating on the VAS 20% greater than their baseline subjective level. A 30 minute recording period followed (Period 2). Following this recording period, subjects resumed ingesting water until they reached a point on the VAS 50% greater than their baseline subjective level. A 60 minute recording period followed (Period 3). A symptom checklist, consisting of various GI, autonomic, and somatic items, was also completed each time. Dependent variables included the dominant frequency (DF) and dominant power (DP) calculated via the spectral analysis of the EGG data, the volume of water ingested to reach each subjective level, and the number of symptoms experienced. The data were analyzed using a 2x3 ANOVA followed by comparisons using the Tukey HSD. Results: 1) The groups did not differ significantly in the amount of water ingested to reach a particular subjective rating. 2) There was a trend for DP towards a significant interaction between group and period (p<.07). Controls showed an increase in DP following ingestion of water, while the IBS patients failed to exhibit a similar change (See Fig.). The groups' DPs were significantly different following water ingestion (p<.05). 3) Both IBS patients and controls demonstrated a significant decrease in DF following ingestion of the water (p<.01). 4) IBS patients reported significantly more symptoms than controls after the water ingestion (p<.03).
• - 'O" - -IBS DP342630t
*p
<
.
0
~
Period 1 Period2
[] ....I CON Period3
Conclusions: 1) These results confirm previous findings in our lab that IBS patients fail to modulate gastric myoelectrical activity in response to a variety of stimuli. 2) Taken together, these findings suggest that IBS may involve an alteration in responses to visceral stimuli leading to a failure to demonstrate compensatory responses to gastric distention and meal ingestion.