Is autonomic dysfunction in irritable bowel syndrome subtype specific?

patients showed dyssynergia and almost all exhibited excessive pushing effort (increased intrarectal pressure) during attempted ddecation. The number of patients with blood in stool (before vs after BT) was 5 (50%) vs 0 and mucus was 2 (20%) vs 1 (10%). AMr BT, proctoscopy showed complete healing ni 3 (30%), > 50% healing in 2 (20%), <50% healing in 4 (40%) patients. Conclusions: Most patients with SRUS exhibit dyssynergia. Biofeedback Therapy improves subjective, manometric and endoscopic parameters, particularly straining effort in patients wHh SRUS. It also improves dyssynerg~a and restores normal defecation dynamics. All patients discontinued the use of digital maneuvers. BT is effective and may serve as an adjunct to the management of patients with SRUS

discon:i*~rt at }00 ml: bloating was not reported during tee study. Conclusions: An objective volumetric ~endent/crease n abdom nal girth occt rs during rectal distension

W1503

What is the Optimum Methodology" fbr Measuring Resting Anal Sphincter Pressure? Gil tan F,olt SI, Ros }tanse~/, Ca n Anr:e Badcock John Kellow Allison Malcolm 1-wo recently pub1 sbed guidelines 'ior anorectaI nranometric testing are contradictory ~x~gardingdleir tecommenda ions tot h e method for assessing resting anal sphincter pressure (pull-through vs s ationa U techniques) Aims: I To evaluate and compare three methods of measnrrng reslfr:g anal pressme in patients with constipation and pdvtc floor dysfunction (C) and { mc tonal tecal incontine~rce (FIt. 2 To determine the method(s) which best predicts C or FI Me hods: Water perhlsed a~,orectal nnmomerty was performed in 47 patients (15C, mean age 38 yrs 121: 32FI, age 56 27F) k computerised manometric technique with a 7 port muhihamen catheter ((~2De~atsleeve)with ports 0.Ycm apart was used. Each patient m~derwent each o the thllowmg assessments: I Stationary resting anal sphincter pressure over 3 minutes 2 Slow pulI~thmngh 5mm/Ysec 3 Rapid pull-through 5mrrVsec Resnlts: The mean ~vsting anal spirit:clef pressure was significantly dill%reinacross the three methods (stationary 66 +/-4mmHg, slow p'all-thmugh 96 +/-5mmHg rapid pull-through 107 +/6mmHg p<0 000i) and this held when indMdual groups of C versus FI were examined All methods were sigtt ficandy corceiated with each other (r=0 6,p=00001) Mean age was diiferem between groups (p = 00009) There was a signfllcan difference between C (stationa U 8i + / 7 , ~dow ] 18+/-9 rapid 124+/10)) arid FI (60+/-5, slow 86+/-6, rapid 100 +/o6); wber~ correc ed for age and tot correlation between methods (p = 0.015) The lower the pressure the more likev a patiel;,~ was to stifler FI (p is essential for comparison of patient groups Diamant et al Gas roente~oogy !999 Ran et al Neurogastrtwnterol Mot 2002

Resting anal sphincterpr. (ram Hg) % Anal rei~atio. Rectal pressure- strain (ram Hg) Defecation index Fecom-Balloonexpulsiontime (s) YAS score (0-100) Mean strain score Stool frequencylweek # Using digital maneuvers

After Br 87 26 71 10 51 11 4.6 2,2 19 23 64 35 14 0,4 10.6 5 0

p 0.64 0,0009 0.127 0,006 0,025 0.060 0,005 0,032

W1506 Sacral Nerve Stimulation for Severe Faecal Incontinence Anne-Marie Leroi, Francis Michot, Philippe Denis Aim: to evaluate (1) the results of temporary nerve stimulation (TNS) in 25 patients suffering from faecal incontinence (FIt; (2) the results of permanent sacral nerve stimulation (SNS) in 7 patients followed daring one year period Method: 25 patients (19 women), median age 57 years (33-76), with severe FI refractory to conventional treatment were evaluated between July, 1998 and JuIy 2002. All patients welt screened with TNS. Those who benefited underwent implantation. Bowel diary, anorectal physiological testing, endoanal ultrasonograplay', electrophysiological study', transit time study were performed before stimulation. Annrectal physiologicaI testing was performed 6 momhs and I year after implantation. Results: m 13 patients (52%) there was an improvemem of F[ during TNS. The aetiology of FI, the FI severity, the kind of FI (urge or passive), One results of tests did not help to predict the results of TNS. Twdve patients have been implanted (8 women, median age 55 years (3371)). One patient retu.sed to be implanted despite the positive TNS. Two implanted patients fared to have the same positive results after implamation than during the TNS (16%). The median number of weekly episodes of FI decreased from 42 C0-13) bdbre implantation to 0.5 (0-11.3) and 0 (0-0.5) 6 momhs and 1 year after implantation in 7 patients followed for 1 year (p=0.04). Urgency resolved C0 minute (0-5.7) versus 22.5 mint*ms (1-30) 6 months and 20 minutes (5-30) 1 year after implantation). Anorectal physiological testing did not show any significant change aher implantation. Three mlplants had to be removed, 2 for refractory pain and 1 for sepsis Conclusion: SNS is an effective treatment fro' severe refractory FI. The benefit is mamtened in the medium term. No predictive factor of TNS success could be identibed

W1504

Utility of Dynamic MR Proctography in Obstructive Defk'cation Eun:]u Chnng Seung ]ae Myang Ah Young Kim, Tae-Hoon Kim, Jin-Hrak Lee, Sub Kyl.n "fang, Weon Seor~ Hong Jin-Ho Kim, Young-if Min t h t ~ : Barium detecograpky (BD) provides information about anorecta/ motion during defecation However, il involves radiation exposure and does not visualize the peMc organs amtnd the ar,.orectum MR proc~ography was introduced to overcome these shortages, however, is nsetulness n obsuuctive defecation (OD) is still obscure The aims of this study are to assess the tti[iy of MR proctugrap~g and o characterize speci{~cMR findings in OD Methods: ]9 patie3 cm during D n 2/ 9 by MR (it) Anal canal th ckr ess of patients with OD was greater than the control /:~o~p (18 19:~v2 18 vs I5 33-~- 1 'ti ran, p<0 0001); Anal canal thickness of >18 mm were t~*md in 9/19 n OD group lowly 1/I 5 in con ~ol group) (iv) Anterior rectocele during ) was dentibed n 3 palier~ s on MR and 2 on BD (x) Rectal intussusception was rioted ii 2 parle* ts on BD (lone on MR) Conclusion: Dynamic MR proctography permits direct vis ia/izat o t o p e r < floor and perirectal slructures in real time without exposnig the patient o radar o/~ toweve , h e dynamic parat~:eters (ARZ change and vertical motion ofARJ) ~bta ned fiom MR p oc og/~apkyare not comparable to those irt BD maybe dne to position difference d~mng mane~aver Anal canal thickening on MR proctography is a novel finding which Inay be a r:buted to OD. However, fi.tthel study is needed to prove whether amfl c a r l thickening is a causa ire [acol ot OD

W1507 Behavioural Therapy (Biofeedback) for Solitary Rectal Ulcer Syndrome Improves Symptoms, Mucosal Blood Flow and Can Produce Healing Michael E. D. Jarrett, Carolynne j Yaizey, Anion V. Emmannel, Michael A. Kamm Purpose: This study" aimed to determine if there is a permanent disorder of mncosal blood flow in patients vdth Solitary Rectal Ulcer Syndrome (SRUS), or a disorder related to autonomic gut innervation and physiological function, that is reversible concomitant with successful treatment Rectal mucosal blood flow was used as a validated measure of extrinsic autonomic nerve fb.nction. Methods: 16 consecutive patients with SRUS referred to a tertiary referral centre (12 women; mean age 33 years, range 19-57) were studied. Laser Doppler mncosal flowmetry was peflonned bdbre the start of biofeedback treamlent and again after the last treatment, by the same investigator who was blind to the patient's symptoms and treatment outcome. Symptoms were documented before and afier biofeedback treatment using a standardised, prospectively applied questionnaire. Twenty-s~x healthy volunteers (17 women: mean age 36, range 18-61) were studied as controls. Results: 12 of 16 patients (75%) reported subjective symptomatic improvement alter biofeedback treatment. Five of the 16 patients (31%) had sigmoidoscopic resolution ot their ulcer Pre-treatment rectal mncosal blood flow was significantly lower m patients with SRUS compared with controls (163 (27) versus 186 (14) flux units (FU), mean (SD), p<0.01). Bioteedback resulted in a sigmticam improvement in rectal mucosal blood flow in subjects "whotelt sub/ectivdy better after biofeedback (p = 0 001), kom 165 (30) FU to 190 (.40) FU, a mean increment of 15%. i'his compared m a mean increment of 6% (not significant) ohserved m those subjects reporting no subjective improvement Conclusion: Gut directed biof~'edback is an effective behaviouraI treatment for the majority of patients with SRUS. Mucosal blood flow is l~duced to a similar level seen in normal transit constipation (Gut 2000;46:212-217), suggesting similar impaired exmnslc autonomic cholinergic nerve activity Successful outcome tbUowing biot~eedbackis associated wlth increased rectal mucosal blood flow, suggesting that improved extrinsic mnervation to the gut may be partially responsible for the response to this treatment.

W1505

Does Biofeedback Therapy hnprove Symptoms And Anorectal Function In Solitary Rectal Ulcer Syndrome (SRUS)? Ssc Ran R O z u k , M Sessnau ~be treatmen of so/iraU fecal ulcer syndrome (SRUS) is often problematic and the role of hiotcedback tbe~apy/BT) is unclear Our aim was m deterroine the efficaW of BT in patients wih SRLS Methods: Ten pa iems (nJ{-3/7 mean age = 30 yrs), with rel}actory symptoms (>4 y,,) ~mderwem syrup omatic manometric and endoscopic evaluations before and after ~T a~d kep prospec ve stool diaries Patten s scored their satisiact on with bowel tunctinn
AGA Abstracts

Before 58 26 25 26 69 29 1.71.6 45 32 36 33 2 0,8 14.5 5 5(50%/

W1508 Is Autonomic Dysfunction in Irritable Bowel Syndrome Subtype Specific? Patrick P. J. Van der Veek, Cees A. Swenne, Ad A. M. Masclee Background: Functional GPdisorders, eg. lmtable Bowel Syndrome (IBS), are associated with autunomic nervous system aherations While these are usually measured by analysis of heart rate variability, assessment of baroreflexsensltivity (BRS) is an ahernative and very

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sensitive method to determine autonomic function. In addition to effects on the sympathovagal balance, a vivid BRS reduces central pain perception and may thereby affect visceral perception. In this study, we investigated baroreflex involvement in subsets of patients with IBS. Methods: 71 lBS-patiems were included (53 F, age 42 yr; Rome I1); 28 diarrhea-type (1BS-D), 22 constipation-type (IBS-C) and 21 alternating type (IBS-A). BRS was computed t~'om continuous ECG and arterial blood pressure signals (Finapress-method) during 5 min periods of metronome respiration (15/rain). A rectal hamstat balloon was used to investigate the effect of visceral stimulation on BRS. We performed rectal pressure distensions (0-35 mmHg) to determine perception of pain and to assess BRS at 0, 15, 25 and 35 mmHg. Results: Basal BRS in IBS-D (7.9 -+ 0.9 ms/mmHg) was lower than in 1BS-A (12.1 -+ 1.6 ms/mmHg, p<0.01) and IBS-C (11.4 • 1.4 ms/mmHg, p=0.07). Subgroup differences disappeared during isobaric pressure distensions due to an increase in BRS in 1BS-D and a decrease in BRS in IBS-A and 1BS-C. BRS decreased with age (r=0.43, p<0.01) and was reduced during 35 mmHg rectal distension compared to the 0, 15 and 25 mmHg distensions (92 +- 0.6 vs. 10.2 -+ 0.7, 10.6 -+ 0.7 and 10.9 -+ 0.7 ragmmHg respectively, p<0.05). Rectal perception and (changes in) BRS were not correlated. Conclusions: IBS-D patients have a lower BRS compared to other IBS subgroups. Rectal distension at high pressures deteriorates autonomic function by reducing BRS in IBS-patients as a group. These results point to lBS-subty~ specific differences in autonomic function.

W1511

Elevated Beck Depression Inventory (BDI) Scores Predict Biofeedback Treatment Failure for Fecal Incontinence and Constipation. Steve Heymen, William E Whitehead, Yolanda Scarlett Biofeedback (BF) for fecal incontinence (FI) and pelvic floor dyssynergia type constipation (PFD) is effective for most, but not all patients (Heathen, DCR, 2001, Heymen, DCR, in review), ldemifying patient characteristics that predict treatment (Tx) hilure could improve outcomes and reduce costs by (1) indicating which patients may need adjunctive Tx to benefit and/or (2) identifying patients who are unlikely" to benefit from this costly Tx. Aim: To identify, psychological predictors of Tx outcome of BF for subjects with FI and sobjects with PFD. Methods: F1 and PFD subjects completed psychometric tests for: symptom severity (F I4I or PAC-SYM), disease specific quality, of life (FI-QOL or PAC-QOL), general quality of life (SF-36), anxiety (STAI), and depression (BD1). The primary outcome measure at 3month f-up was the answer to the question "Compared to before your enrollment in this study, have you had adequate relief of your tecal incontinence/constipation sy~nptoms? Results: 45 F1 subjects (33F, 12M, mean age = 61yrs, mean symptom duration = 5.2 y~) and 57 PFD subjects (49F, 8M, mean age = 48, mean symptom duratmn = 15.4), who had failed multiple attempts of medical management, were evaluated. -Elevated BD1 scores predicted Tx failure for all subjects ( p = 0 005, t-test). The mean BDI score was 12.6 for non-responders, vs. 8.4 for suecesstul subjects. -Considering FI and PFD subjects separately, BDI scores were significantly different between responders and non-responders with FI (0.017, t-test) and showed a trend for PFD subjects (0.053, t-tes0. -54% of subjects who scored 12 or higher on the BDI failed Tx (12-16 indicates mild clinical depression), whereas 69% who scored < 12 were successful with biofeedback Tx. -Subjects who discontinued Tx had mean 8Di scores of 16.2 (moderate depression = 17-29). -No other psychological instrument was predictive of Tx outcome. Condusions: Mild levels of depression negatively influenced the outcome of BF for F1 and PFD. However, anxiety, syraptom severity, and quality of life measures, were trot predictive of Tx outcome ibr either group. Drop-outs had BD1 scores close to moderate depression levels. Depression may have hindered the motivation or patience, necessary for BF (typically" requiring 1 - 3 months participation). Psychological Tx for depressed FI or PFD subjects should be included in Tx protocols to enhance the benefit of BF. Supported by R01DK57048, NIH GCRC # M01RR00046, Milan Pharmaceuticals, and Jansen Pharmaceuticals.

W1509 Rectal Motor and Sensory Functions in Irritable Bowel Syndrome Subtypes Rosario Cuomo, Maria Flavia Savarese, Giovanni SarneUi, Raffaella Grasso, Paola Ciamarra, Gabriele Budiflon Background. Increased visceroperception is considered a hallmark of irritable bowel syndrome (1BS). However poor data are available about the rectal sensorimotor patterns in diarrhoea and constipation prevalent-lBS subjects respectively. Aims. To investigate whether sensitivity, compliance and tone of the rectum are different between diarrhoea and constipation predominam-IBS subjects. Metbods: 5evemeen patients who fulfilled the Rome ll Criteria for IBS were enrolled; 9 patients (6 males; range 19-34 },ears) with diarrhoea predominant IBS (IBS-D) and 8 patients (4 males; range 24-37 years) with constipation predominant IBS (IBS-C) were respectively selected to undergo a rectal barostat study. After bag placement, minintal distending pressure (MDP) was firstly measured as the pressure that allows one to detect respiratory movements. Rectal compliance and sensitivity" were then assessed by isobaric distensinn with stepwise pressure increases fi'om 0 to 30 mmHg. During the distensions, subjects were asked to report: first perception, feeling of stool and urgency to detkcate. After a 30 min adaptation period, rectal tone was measured as average volume over 30 min at a level of MDP + 2mmHg. Results: In the IBS-D patients, rectal volmnes required to pemeive the sensation of stool and urgency were significantly- lower than in IBS-C patients (101 -+ 37 vs 206-+ 36 ml and 193 -+ 50 vs 326 -+ 59 ml, respectively, p<0.01 ). Any significant difference was observed when sensitivity was expressed as pressnre levels. Rectal compliance was also significamly lower in IBS-D patients than in IBS-C patients (64 +_ 1.5 vs 12.3 • 1.9 ml/mmHg, p<0.05). Average bag volume at MDP + 2 during 30 rain was significantly higher in IBS-C than IBS-D patients (119 _+6 ml vs 69 -+ 2, p<0.05). Conclusion: IBS-D patients are characterized by- increased rectal sensinvity, and by decreased compliance and adaptative relaxation compared to IBS-C subjects. Rectal hamstat studies help to distinguish groups of patients with different subtypes of IBS and support new hypothesis about IBS patbogenesis

W1512

Is Anorectal Manometry Useful in Predicting Spinal Abnormalities in Children with Constipation? Rachel Rosen, Laura Smack, Rene Andrade, Samuel Nurko We have previously shown that approximately 10% of patients with intractable constipation have spinal abnormalities on MRI. However, most children with abnormal MRls have a normal neumlogic history and physical exam; neither is a good predictor of spinal lesions on MRI. Because MRls are costly and they often require significant sedation or general anesthesia in children, it would be useful to find a screening tool to determine who has a higher likelihood of having a spinal abnormaility and, as a result, who needs to have an MRI. Aim: To determine if anorectal manometry is a useful screening test in predicting which patients will have abnormal spinal MRIs. Methods: This is a case-control study comparing the anorectal manometries of 10 children with constipation who had abnormal spinal MRIs (cases) to the manometries of 10 age-matched children with normal MRIs (controls). Results: Rectal spasms after balloon distention were noted in 60% of the patients with abnormal MRls compared to 0% of the controls (p<0.003). The maximum relaxation of the sphincter after balloon distention was achieved with a significantly smaller balloon in the cases as compared with the controls (35 -+ 20 ml vs. 60 • 23 ml; p = 0.02). The dose response curve of sphincter relaxation at ditferem balloon distentions was shifted to the let~ at small balloon volumes in those patients with abnormal MRI's; the % relaxation of the sphincter using a 10 ml balloon was 19 _+18% in the commls compared to 36 • 7% in the cases (p=0.09) and using a 20 ml balloon was 31 • 11% in the controls compared to 46 _+ 16% in the cases (p=0.03). There were no differences in the % relaxation between the cases and the controls at larger balloon sizes. There were no differences in the intra-anal pressure between cases versus controls (56_+ 15 vs. 6 0 _+ 16 mm Hg), relaxation threshold ( 7 • vs. 10-+6 ml), % maxqmnm relaxation (70_418 vs. 67• squeeze pressure (136-+47 vs. 115-+46 mm Hg), duration or latency of sphincter relaxation at diflerent balloon sizes, or balloon size at which there was no recovery with one minute of inflation (40 _+24 vs. 63 • 44 ml) Conclusions: Anorectal manometry may be useful to predict which patients will have spinal abnormalities on MR1. Rectal spasms on anorectal manometry are significant predictors of spinal abnormalities. Also, patients with spinal abnormalities have maximum sphincter relaxations with smaller balloon sizes. Airorectal manometry may be indicated as a screening test for spinal abnormalities in patients with constipation.

W1510

Within and Across Subject Reproducibility of The Multi-Electrode Array Surface EMG of Action Potentials from The External Anal Sphincter M Liu, H. Hinningboten, R. Merletti, P Enck Surface EMG (S-EMG) has previously been used for recording of motor unit action potentials (MUAP) from the external anal sphincter. We studied the reliability" of this new method within and across heahby subjects. Methods: In Study 1, we recorded 16-channel S-EMG from the external anal sphincter in 15 volunteers (1:14 male:temale, 35.5 },ears) and compared the data to those of previously investigated subjects (n = 18) (Neurogastroenterology 2002;14:P53). In Study 2, 15 of these subjects (6:9~ 30.5 }'ears) were re-investigated at a second occasion 4 to 6 months later. In both studies, MUAP of the external anal sphincter were recorded circumferentiafly from within the anal canal during maximal voluntary contraction. Data were evaluated with respect to MUAP innervation points (16-channel distributed on a 12 h clock, fithotomy position), predominant direction and length of signal travel (ventral, dorsal) and other desc:npmrs and compared between groups (study i) and within mbjects (study 2) Results: In Study 1, nearly identical MUAP descriptors were found between both groups: two major innervation zones (located at 1 to 2 h and at 7 to 10 h) (88.3 % and 67.4 %, respectively of all identilied MUAP in samples 1 and 2), with the majority ot MUAP between 7 to i0 h (61.1% and 57.7 %, resp.), travelling over an average 44 (SD: 1.7) and 4.5 (SD: 1.8) channels. None of these differences reached statistical significance. In Study 2, from all 295 MUAP identified the first nine, 205 were found at the second occasion (70%). The localization of these innervation zones was similar between both studies (1 to 2 and 7 to 10 h for 83.4 % and 91.3 %, resp. of all bIUAP). Predominated location was simdar (58 % and 67.3 %, resp. ventrally'), but travel distance was 4.1 (SD: 1.7) channels the first and 4.9 (SD: 1.7) chamrels the second time (p<0.001). Condttsion: While reproducibility ot this new technique was good across subjects~ m-invesdgatinn of the same subject showed the number of MUAP to be diflerent, as well some of its other descriptors. Th~s could reflect the tac't that -maximal volumary sphincter contraction- needs better standardization, as may need the exact level at which the MUAP were recording from within tire anal canal. (Supported by grams from the EU QLRT-2001-00218 and DFG EN 50/21-1)

W1513

Reproducibility of Anorectal Function Tests Barb Seide, Jean C. Fox, Andrew J. Croak, Alan R. Zinsmeister, Adil E Bharucha Background: Despite widespread use, the intra-individnal reproducibfity of anorectal testing on separate days is unknown. Aims: To assess mtra-indivldnal day-to-day reproducibility of anorectal tests. Methods: Subjects: 17 healthy subjects (mean age 45; range 23-90 yr) without history of obstetric trauma or symptoms of tunctional G1 disorders had anorectal testing on 2 separate days, an average of 179 (range 2-489) days apart. Tests: Anal rest and squeeze pressures were measured 3 times at 1-cm intervals by station-pull through waterperfused manometry; probe had 4 circumterential sensors at a single level (Medtmincs Inc) Values recorded by all sensors at a gp,'en level during each maneuver were averaged; the highest value was analyzed. After a conditioning distention, rectal compliance (pressurevolume curve) was measured by bamstatic inflatinn/deflatinn of a polyethylene balloon from 0-32 mmHg in 4-mm steps. Pressure-volume curves were summarized using a power exponential function that yields estimates of an instantaneous slope and a shape parameter.

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AGA Abstracts