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PREPARATION OF THE BOWEL BY WHOLE-GUT IRRIGATION
1239
patients had non-organ-specific autoantibodies. 27 (35%) had a smooth-muscle antibody, predominantly of the IgG type, compared with 2 (3%) control subjects (r<0001). Anti-nuclear factor and reticulin antibodies also more common in the infertile patients. 6 of the infertile women had a reticulin antibody of the Ror RS types which are associated with coeliac disease.4 Immunofluorescent anti-sperm antibodies were more commonly detected in infertile patients than in controls, but the difference was not statistically significant. This high frequency in post-partum controls is comparable to results in other series.’ Of the 27 patients with smooth-muscle antibody, 8 had an associated anti-nuclear factor. There was no correlation between the occurrence of any of the other autoantibodies. was
Discussion
35% of a group of infertile women had non-organ-specific autoantibodies to smooth-muscle and 20% had antinuclear factor, the two antibodies often occurring together. On the other hand, there was no correlation between the occurrence of smooth-muscle antibodies and antibodies to spermatozoa or to reticulin. The increased frequency of the Rl or RS reticulin antibody may indicate latent coeliac disease, and these women are currently being investigated for this.8 Although the high frequency of smooth-muscle antibodies and anti-nuclear factor may suggest an autoimmune process, organ-specific autoantibodies were no more common in these women than in the post-partum controls. Autoimmune oophoritis is probably rare and occurs only in association with autoimmune disease, particularly adrenalitis.9 10 We have not tested these sera for ovarian antibodies, but such antibodies are not often found in infertile patients." Most of our patients had received "fertility" drugs, but since 8 of 11 patients who had not received these drugs had autoantibodies in their sera, it seems unlikely that the autoantibodies were drug induced. Smooth-muscle antibody may be associated with chronic liver disease, especially chronic active hepatitis, but none of our patients had clinical evidence of liver disease. Smooth-muscle antibody is also found in some viral infections, notably infectious mononucleosis12 and acute viral hepatitis. Although the smooth-muscle antibody found in acute viral hepatitis is IgM in type, it is possible that an event initiated by infection with a virus or other infectious agent and subsequently producing reproductive failure may be associated with continued production of an IgG smooth-muscle antibody such as we have found. This could presumably occur during a persistent latent infection. Mumps can produce infertility due to oophoritis, which is analogous to orchitis in the male, and one of our amenorrhoeic patients whose menstrual periods ceased after an attack of mumps had smooth-muscle antibody and anti-nuclear factor. There are also reports of infertility associated with toxoplasmosis," and the role
of T-mycoplasmainfectionofthegenitaltractin infertility is controversial. 14 We do not know whether such infections are associated with smooth-muscle antibody. Although we have no direct evidence of a viral xtiology for the reproductive failure in our patients with smooth-muscle antibody, we feel that this possibility requires further study.
We thank Mr W. Edwards for providing the control sera, Mrs C. L. Scott-Morgan for assistance with the immunological studies, and the Wessex Regional Research Committee and Wellcome Trust for
financial support. Requests for reprints should be addressed to R. W., Professorial Medical Unit, Royal South Hants Hospital, Fanshawe Street, Southampton S09 4PE.
REFERENCES
1. Franklin, R. R., Dukes, C. D. Am. J. Obstet. Gynec. 1964, 89, 6. 2. Li, T. S. Obstet. Gynec., N.Y. 1974, 44, 607. 3. Akin, A., Elstein, M. Int. J. Fertil. (in the press). 4. Stevens, F. M., Lloyd, R., Egan-Mitchell, M. J., Fottrell, P. F., Wright, R., McNicholl, B., McCarthy, C. F. Gut, 1975, 16, 598. 5. Rizzetto, M., Doniach, D. J. clin. Path. 1973, 26, 841. 6. Tung, K. S. K. Clin. exp. Immun. 1975, 20, 93. 7. Johnson, M. H., Hekman, A., Rumke, Ph. in Clinical Aspects of Immunology (edited by P. G. H. Gell, R. R. A. Coombs, and P. J. Lachmann); p. 1522. Oxford, 1975. 8. Wilson, C., Eade, O. E., Wright, R., Elstein, M., Lloyd, R. Unpublished. 9. Irvine, W. J., Chan, M. M. W., Scarth, L., Kolb, F. O., Hartog, M., Bayliss, R. I. S., Drury, M. I. Lancet, 1968, ii, 883. 10. Irvine, W. J., Chan, M. M. W., Scarth, L. Clin. exp. Immun. 1969, 4, 489. 11. Ruehsen, M. de M., Blizzard, R. M., Garcia-Bunuel, R., Jones, G. S. Am. J. Obstet. Gynec. 1972, 112, 693. 12. Holborow, E. J., Hemsted, E. M., Mead, S. V. Br. med. J. 1973, iii, 323. 13. Eckerling, B., Neri, A., Eylan, E. Fertil. Steril. 1968, 19, 883. 14. Lancet, 1973, i, 1162.
B., Mylotte,
PREPARATION OF THE BOWEL BY WHOLE-GUT IRRIGATION S. J. A. POWIS W. T. COOKE ALEXANDER-WILLIAMS
A. R. CRAPP PHYLLIS TILLOTSON
J.
Nutritional and Intestinal Unit, General Hospital, Birmingham B4 6NH
Experience with whole-gut irrigation as method of bowel preparation in eightyone patients is described. The mean (±S.D.) weight-gain during irrigation was 1·9±0·8 kg; potassium losses in the effluent after one hour (4·0±2·5 g) were not significantly altered by adding potassium chloride to the irrigant. Eight irrigations were unsatisfactory, three being due to unrecognised obstructive neoplasms. The method provided excellent preparation for colonoscopy and large-bowel resection with anastomosis and was well tolerated by the patients.
Summary
a
Introduction Hewitt et al.’ described their experience of whole-gut irrigation as a method of bowel preparation in twelve patients. After equally satisfactory results, we present our experience of eighty-one irrigations, including measurements of fluid absorption, electrolyte losses, and details of our methods modified by experience. Patients All patients undergoing colonoscopy and large-bowel resection for carcinoma or Crohn’s colitis were included, except for six patients with obstructive neoplasms and ten patients under-
going pan-proctocolectomy. indications for whole-gut Resection of large bowel
irrigation
Colonoscopy Treatment of severe constipation Air contrast barium enema Miscellaneous intestinal operations Total
1240 Sixteen patients were over 70 years of age; no clinical or laboratory evidence of renal failure.
f""") Before added » M2 After
patients had
potassium "
Is is.n. D
Methods No dietary restrictions were placed on the patients who underwent preparation the day before operation or colonic examination. A nasogastric tube (number 14 double-lumen Salem tube which allowed swallowed air to escape) was placed in the stomach, and a warmed isotonic sodium chloride solution was introduced at a rate of 3-4 1/h by the attending nurse. When defecation started the patient was seated on a wellpadded commode and the irrigation continued until the effluent was clear. Potassium chloride (4 mmol/1) was added to the irrigant of the last thirty-four patients. Initially several patients became distended and nauseated, but subsequently intramuscular metoclopramide (10 mg) was given to all patients to control these symptoms. Patients with possible cardiovascular disease were given 40 mg frusemide before irrigation. Before and after preparation, patients were weighed and blood-samples were taken for hacmatocrit estimations. Fluid balance charts were kept; aliquots of the effluent were collected hourly for sodium and potassium estimations from seven patients irrigated with saline alone and from ten patients having saline solution plus potassium chloride. No attempt was made to "sterilise" the bowel.
Results mean duration of the irrigations was 3-5 hours 2-6 hours); defalcation usually started after half (range an hour. The mean volume of irrigating fluid was 9.5 1 (range 4.5-15.0 1). Mean ±s.D. weight-gain during the
.........
of
HOURS 2-Concentrations of sodium in emuent collected hourly before and after potassium chloride (4 mmo]A) was added to the irrigant.
Fig.
The effluent
electrolyte concentrations (figs. 1 and 2) significantly altered by adding potassium chloride to the irrigant. Assuming a steady flow-rate, the total amount of potassium lost in the effluent after the first hour was 4-0±2-3g for both types of irrigant. were
not
The
procedure was 1-9±0-8 kg, indicating the amount of irrigant absorbed. The preparation was deemed excellent or good by the clinician in sixty-four cases, worthwhile but incomplete in nine, and unsatisfactory or a failure in eight. At operation there was no free fluid in the gut lumen or peritoneal cavity; the gut was collapsed and the mucosa was of normal appearance. Apart from some nausea and vomiting seen early in the series, no complications were attributable to the irrigation. The procedure was well tolerated by the patients, those who had previously undergone rectal lavage or enemas generally preferring the irrigation. The unsatisfactory preparations were due to tumours unrecognised as being obstructive (three), and adult megacolon, gross constipation, slow infusion-rate, uncooperative nursing sister, and unexplained (one each). Before added potassium S.D. 1 After I:ZZ3
"
"
Discussion The method was safe, reliable, and well tolerated by the patients; preoperative inpatient time was reduced by 2 to 3 days. Although absorption of irrigant occurred, as indicated by weight-gain and lowered haematocrit after preparation, contrary to prediction, no ill effects were observed.The volume absorbed was less than that noted by Love et al.,3 who observed a net absorption of 1-51/h in healthy volunteers. In addition to the lavage effect of the irrigating fluid, saline solution may produce a purging effect due to release of cholecystokinin-pancreozymin from the intestinal mucosa.4 The technique proved particularly suitable for patients undergoing colonscopy, perfect preparation being obtained in each case. Although contraindicated in patients with partial bowel obstruction due to neoplasm, excellent bowel preparation was obtained in six of the eight patients with severe constipation. The amount of potassium in the effluent, predominantly contained in the faeces passed during the first hour, was not regarded as an important loss. However, we now routinely add 4 mmol/1 potassium chloride to the irrigating fluid to cover the potassium loss occurring after the first hour. As a result of the outcome in this series, all patients undergoing colonoscopy or large-bowel resection with anastomisis in our unit are now prepared by whole-gut
irrigation. We thank Mr G. D. Oates and Mr N. J. Dorricott, consultant surgeons, for contributing patients to the series. Requests for reprints should be addressed to J. A.-W.
REFERENCES
t1 U U K5
1-Concentratione of potassium in emuent collected hourly before and after potassium chloride (4 mmol/l) was added to the irrigant.
Fig.
1. Hewitt, J., Rigby, J., Reeve, J., Cox, A. G. Lancet, 1973, ii, 337. 2. Nichols, R. L., Schumer, W., Nyhus, L. M. ibid. p. 735. 3. Love, A. H. G., Rohde, J. E., Abrams, M. E., Veall, N. Clin. Sci. 1973, 44, 267. 4. Harvey, R. F., Read, A. E. Lancet, 1973, ii, 185.
patients had non-organ-specific autoantibodies. 27 (35%) had a smooth-muscle antibody, predominantly of the IgG type, compared with 2 (3%) control subjects (r<0001). Anti-nuclear factor and reticulin antibodies also more common in the infertile patients. 6 of the infertile women had a reticulin antibody of the Ror RS types which are associated with coeliac disease.4 Immunofluorescent anti-sperm antibodies were more commonly detected in infertile patients than in controls, but the difference was not statistically significant. This high frequency in post-partum controls is comparable to results in other series.’ Of the 27 patients with smooth-muscle antibody, 8 had an associated anti-nuclear factor. There was no correlation between the occurrence of any of the other autoantibodies. was
Discussion
35% of a group of infertile women had non-organ-specific autoantibodies to smooth-muscle and 20% had antinuclear factor, the two antibodies often occurring together. On the other hand, there was no correlation between the occurrence of smooth-muscle antibodies and antibodies to spermatozoa or to reticulin. The increased frequency of the Rl or RS reticulin antibody may indicate latent coeliac disease, and these women are currently being investigated for this.8 Although the high frequency of smooth-muscle antibodies and anti-nuclear factor may suggest an autoimmune process, organ-specific autoantibodies were no more common in these women than in the post-partum controls. Autoimmune oophoritis is probably rare and occurs only in association with autoimmune disease, particularly adrenalitis.9 10 We have not tested these sera for ovarian antibodies, but such antibodies are not often found in infertile patients." Most of our patients had received "fertility" drugs, but since 8 of 11 patients who had not received these drugs had autoantibodies in their sera, it seems unlikely that the autoantibodies were drug induced. Smooth-muscle antibody may be associated with chronic liver disease, especially chronic active hepatitis, but none of our patients had clinical evidence of liver disease. Smooth-muscle antibody is also found in some viral infections, notably infectious mononucleosis12 and acute viral hepatitis. Although the smooth-muscle antibody found in acute viral hepatitis is IgM in type, it is possible that an event initiated by infection with a virus or other infectious agent and subsequently producing reproductive failure may be associated with continued production of an IgG smooth-muscle antibody such as we have found. This could presumably occur during a persistent latent infection. Mumps can produce infertility due to oophoritis, which is analogous to orchitis in the male, and one of our amenorrhoeic patients whose menstrual periods ceased after an attack of mumps had smooth-muscle antibody and anti-nuclear factor. There are also reports of infertility associated with toxoplasmosis," and the role
of T-mycoplasmainfectionofthegenitaltractin infertility is controversial. 14 We do not know whether such infections are associated with smooth-muscle antibody. Although we have no direct evidence of a viral xtiology for the reproductive failure in our patients with smooth-muscle antibody, we feel that this possibility requires further study.
We thank Mr W. Edwards for providing the control sera, Mrs C. L. Scott-Morgan for assistance with the immunological studies, and the Wessex Regional Research Committee and Wellcome Trust for
financial support. Requests for reprints should be addressed to R. W., Professorial Medical Unit, Royal South Hants Hospital, Fanshawe Street, Southampton S09 4PE.
REFERENCES
1. Franklin, R. R., Dukes, C. D. Am. J. Obstet. Gynec. 1964, 89, 6. 2. Li, T. S. Obstet. Gynec., N.Y. 1974, 44, 607. 3. Akin, A., Elstein, M. Int. J. Fertil. (in the press). 4. Stevens, F. M., Lloyd, R., Egan-Mitchell, M. J., Fottrell, P. F., Wright, R., McNicholl, B., McCarthy, C. F. Gut, 1975, 16, 598. 5. Rizzetto, M., Doniach, D. J. clin. Path. 1973, 26, 841. 6. Tung, K. S. K. Clin. exp. Immun. 1975, 20, 93. 7. Johnson, M. H., Hekman, A., Rumke, Ph. in Clinical Aspects of Immunology (edited by P. G. H. Gell, R. R. A. Coombs, and P. J. Lachmann); p. 1522. Oxford, 1975. 8. Wilson, C., Eade, O. E., Wright, R., Elstein, M., Lloyd, R. Unpublished. 9. Irvine, W. J., Chan, M. M. W., Scarth, L., Kolb, F. O., Hartog, M., Bayliss, R. I. S., Drury, M. I. Lancet, 1968, ii, 883. 10. Irvine, W. J., Chan, M. M. W., Scarth, L. Clin. exp. Immun. 1969, 4, 489. 11. Ruehsen, M. de M., Blizzard, R. M., Garcia-Bunuel, R., Jones, G. S. Am. J. Obstet. Gynec. 1972, 112, 693. 12. Holborow, E. J., Hemsted, E. M., Mead, S. V. Br. med. J. 1973, iii, 323. 13. Eckerling, B., Neri, A., Eylan, E. Fertil. Steril. 1968, 19, 883. 14. Lancet, 1973, i, 1162.
B., Mylotte,
PREPARATION OF THE BOWEL BY WHOLE-GUT IRRIGATION S. J. A. POWIS W. T. COOKE ALEXANDER-WILLIAMS
A. R. CRAPP PHYLLIS TILLOTSON
J.
Nutritional and Intestinal Unit, General Hospital, Birmingham B4 6NH
Experience with whole-gut irrigation as method of bowel preparation in eightyone patients is described. The mean (±S.D.) weight-gain during irrigation was 1·9±0·8 kg; potassium losses in the effluent after one hour (4·0±2·5 g) were not significantly altered by adding potassium chloride to the irrigant. Eight irrigations were unsatisfactory, three being due to unrecognised obstructive neoplasms. The method provided excellent preparation for colonoscopy and large-bowel resection with anastomosis and was well tolerated by the patients.
Summary
a
Introduction Hewitt et al.’ described their experience of whole-gut irrigation as a method of bowel preparation in twelve patients. After equally satisfactory results, we present our experience of eighty-one irrigations, including measurements of fluid absorption, electrolyte losses, and details of our methods modified by experience. Patients All patients undergoing colonoscopy and large-bowel resection for carcinoma or Crohn’s colitis were included, except for six patients with obstructive neoplasms and ten patients under-
going pan-proctocolectomy. indications for whole-gut Resection of large bowel
irrigation
Colonoscopy Treatment of severe constipation Air contrast barium enema Miscellaneous intestinal operations Total
1240 Sixteen patients were over 70 years of age; no clinical or laboratory evidence of renal failure.
f""") Before added » M2 After
patients had
potassium "
Is is.n. D
Methods No dietary restrictions were placed on the patients who underwent preparation the day before operation or colonic examination. A nasogastric tube (number 14 double-lumen Salem tube which allowed swallowed air to escape) was placed in the stomach, and a warmed isotonic sodium chloride solution was introduced at a rate of 3-4 1/h by the attending nurse. When defecation started the patient was seated on a wellpadded commode and the irrigation continued until the effluent was clear. Potassium chloride (4 mmol/1) was added to the irrigant of the last thirty-four patients. Initially several patients became distended and nauseated, but subsequently intramuscular metoclopramide (10 mg) was given to all patients to control these symptoms. Patients with possible cardiovascular disease were given 40 mg frusemide before irrigation. Before and after preparation, patients were weighed and blood-samples were taken for hacmatocrit estimations. Fluid balance charts were kept; aliquots of the effluent were collected hourly for sodium and potassium estimations from seven patients irrigated with saline alone and from ten patients having saline solution plus potassium chloride. No attempt was made to "sterilise" the bowel.
Results mean duration of the irrigations was 3-5 hours 2-6 hours); defalcation usually started after half (range an hour. The mean volume of irrigating fluid was 9.5 1 (range 4.5-15.0 1). Mean ±s.D. weight-gain during the
.........
of
HOURS 2-Concentrations of sodium in emuent collected hourly before and after potassium chloride (4 mmo]A) was added to the irrigant.
Fig.
The effluent
electrolyte concentrations (figs. 1 and 2) significantly altered by adding potassium chloride to the irrigant. Assuming a steady flow-rate, the total amount of potassium lost in the effluent after the first hour was 4-0±2-3g for both types of irrigant. were
not
The
procedure was 1-9±0-8 kg, indicating the amount of irrigant absorbed. The preparation was deemed excellent or good by the clinician in sixty-four cases, worthwhile but incomplete in nine, and unsatisfactory or a failure in eight. At operation there was no free fluid in the gut lumen or peritoneal cavity; the gut was collapsed and the mucosa was of normal appearance. Apart from some nausea and vomiting seen early in the series, no complications were attributable to the irrigation. The procedure was well tolerated by the patients, those who had previously undergone rectal lavage or enemas generally preferring the irrigation. The unsatisfactory preparations were due to tumours unrecognised as being obstructive (three), and adult megacolon, gross constipation, slow infusion-rate, uncooperative nursing sister, and unexplained (one each). Before added potassium S.D. 1 After I:ZZ3
"
"
Discussion The method was safe, reliable, and well tolerated by the patients; preoperative inpatient time was reduced by 2 to 3 days. Although absorption of irrigant occurred, as indicated by weight-gain and lowered haematocrit after preparation, contrary to prediction, no ill effects were observed.The volume absorbed was less than that noted by Love et al.,3 who observed a net absorption of 1-51/h in healthy volunteers. In addition to the lavage effect of the irrigating fluid, saline solution may produce a purging effect due to release of cholecystokinin-pancreozymin from the intestinal mucosa.4 The technique proved particularly suitable for patients undergoing colonscopy, perfect preparation being obtained in each case. Although contraindicated in patients with partial bowel obstruction due to neoplasm, excellent bowel preparation was obtained in six of the eight patients with severe constipation. The amount of potassium in the effluent, predominantly contained in the faeces passed during the first hour, was not regarded as an important loss. However, we now routinely add 4 mmol/1 potassium chloride to the irrigating fluid to cover the potassium loss occurring after the first hour. As a result of the outcome in this series, all patients undergoing colonoscopy or large-bowel resection with anastomisis in our unit are now prepared by whole-gut
irrigation. We thank Mr G. D. Oates and Mr N. J. Dorricott, consultant surgeons, for contributing patients to the series. Requests for reprints should be addressed to J. A.-W.
REFERENCES
t1 U U K5
1-Concentratione of potassium in emuent collected hourly before and after potassium chloride (4 mmol/l) was added to the irrigant.
Fig.
1. Hewitt, J., Rigby, J., Reeve, J., Cox, A. G. Lancet, 1973, ii, 337. 2. Nichols, R. L., Schumer, W., Nyhus, L. M. ibid. p. 735. 3. Love, A. H. G., Rohde, J. E., Abrams, M. E., Veall, N. Clin. Sci. 1973, 44, 267. 4. Harvey, R. F., Read, A. E. Lancet, 1973, ii, 185.