Rapid intestinal transit in chronic pancreatitis is associated with vagal and sympathetic denervation

April 1998

Motility and Nerve-Gut Interactions A827

G3394

BIOFEEDBACK TRAINING IN ELDERLY PATIENTS WITH FECAL INCONTINENCE. Y.Ron A.Lukovetski A. Rosen S.Birkenfeld J. Wardi. Y.Avni. Gastroenterology Dep. The E. Wolfson Medical Center, Holon and Sackler School of Medicine, Tel-Aviv University, Israel. Backeround : Fecal incontinence is common among elderly patients. Its incidence is estimated to be 10 % in this population. Therapy consists of medical, surgical and behavioral modalities. Aim: Evaluation of the efficacy of biofeedback training in patients with fecal incontinence Methods: Eighteen consecutive patients, 3 men (16.6 %) mean age 62 and 15 women (83.4 %) mean age 69 were referred because of fecal incontinence. Past medical history revealed obstetric trauma in 9/15 (60%), pelvic operations in 11/18 (61%), diabetes melitus in 3/18 (16.6%), past constipation in 2/18(10.1%) and combined fecal and urinary incontinence in 3/18 (16.6%). All patients underwent anorectal manometry. 50% had decreased mean resting pressure and 44 % decrease maximal squeeze pressure. Instability of squeeze pressure was found in 55% of patients. Pudendal nerve terminal motor latency was performed in 15 patients. Bilateral neuropathy was observed in 9/15 (60%), unilateral neuropathy in 6/15 (40%). Endoanal ultrasound was performed in 15 patients, combined intemal and external sphincter defects were found in 6/15 (40%), external sphincter defects in 4/15 (26.6%), internal sphincter damage in 3/15 (20%) and normal ultrasound was diagnosed in 2. Video proctography was performed in 9 patients. Anismus was diagnosed in 9/18 (50%), perineal descent in 2 and total rectal prolapse in 1. Biofeedback protocol included improving anorectal sensation, squeeze pressure, endurance and relaxation of puborectalis in patients with coexistance of anismus. An average of 5 sessions (3-9) lasting 20 minutes each, once weekly were conducted. Home practice was highly encouraged Results: 6/18 (33.3%) of patients reported a substantial improvement of 80% with near total disappearance of incontinence. 7/18 (38.8%) gained partial response - an overall response rate of 72%. 5/18 (27.7%) patients reported no response. Two patients out of13 that showed an improvement during the therapy period deteriorated and 1 out of 5 patient that did not respond to therapy improved after an average follow-up of one year. Conclusions: Biofeedback training in elderly patients with fecal incontinence offers an efficient, harmless and cheap modality of therapy with durable response. No correlation was found between the patient's prospects of responding to biofeedback training and any of the physiological parameters tested. G3395

BOTULINUM

TOXIN

A

IN THERAPY OF PARADOXICAL P U B O R E C T A L I S SYNDROME. ~.Ron, A.Lukovetski, Y.Avni, Z.Halpem. Gastroenterology Dept. The E. Wolfson Medical Center, Holon and Sackler School of Medicine, Tel-Aviv University, Israel. Background: Paradoxical puborectalis syndrome is one of the most common and troublesome causes of constipation. Standard therapy with laxatives or biofeedback training have conflicting results. Operative treatment gives poor results and was practically abandoned. Aim: Evaluation of the efficacy of Botulinum Toxin A (Botox) injection to the puborectalis muscle in patients with paradoxical puborectalis syndrome. Methods: Ten patients, 5 men (mean age 53.4) and 5 women (mean age 32.8) with prolonged history of constipation and symptoms of outlet obstruction underwent anorectal manometry and videoproctography. All patients were found to have nonrelaxing puhorectalis on both modalities. Each patient who participated in the study underwent local injection of Botulinum Toxin A to the puborectalis - 5 units on each side and 5 units to each side of deep external anal sphincter. 4 patients (3 women) had a second injection in the same manner. Patients were followed after 1, 4, 12 and 24 weeks by which time they were assessed for weekly evacuation, presence of straining, anal pain and incontinence that were recorded on visual analogue scale. Anal manometry with balloon expulsion test was performed on each meeting. By 5 months videoprogtography was performed. Results: Eight patients achieved normal pattern of relaxation on manometry 5 of whom, after the first week. Balloon expulsion was achieved in 3 patients (30%). Video proctography was performed in 7 patients (5 men), improvement in evacuation time and anorectal angle was observed in 4 of them. Symptom improvement of 41% on straining index was recorded and sustained. Anorectal pain was not observed. No complications were noticed due to Botulinum Toxin A injection. Conclusion: These results suggest an improvement of 80% in relaxation on anorectal manometry and 30% success rate on balloon expulsion test following Botox injection to patients suffering from Paradoxical Puborectalis Syndrome. Discrepancy between puhorectalis relaxation on manometry and balloon expulsion could reflect either low sensitivity of manometry or the coexistance of anorectal motility disorder in addition to nonrelaxing puborectalis.

• G3396 RAPID INTESTINAL TRANSIT IN CHRONIC PANCREATITIS IS ASSOCIATED WITH VAGAL AND SYMPATHETIC DENERVATION. L. Rosa-e-Silva, L.E.A. Troncon, R.B. Oliveira, F.J.H.N. Braga, L. Gallo Jr. and M.C. Foss, Faculdade de Medicina de Ribeir~o Preto, Universidade de S~o Paulo, Brazil. In a previous work we have shown that patients with chronic pancreatitis (CP) and autonomic neuropathy (NA) have rapid intestinal transit of liquids. This work aimed to study the relationships between vagal and sympathetic denervation and transit rates through proximal and distal small bowel in CP. Subjects included 37 patients with CP and 18 healthy controls. Fasted subjects ingested a liquid meal (250 mL; 437 Kcal) labelled with 18 MBq of Tc-phytate. Abdominal scans were serially taken for 180 rain with a gamma camera. Counts from regions of interest over the small intestine yield measurement of the times of meal arrival to the proximal (tPSB) and distal small bowel (tDSB), and to the cecum (tCecum). All subjects underwent 3 tests of cardiovascular (CV) nerve function (respiratory arrythmia, passive tilting and Valsalva manoeuver), which yielded 5 parameters related to CV autonomic control. Vagal activity was assessed by beat-to-beat variation during respiration (RV) and the initial heart rate variation after tilting (TV). Sympathetic dysfunction was indicated by postural hypotension (PH) after tilting. Based on abnormal results in any 2 out of the 5 CV parameters, 17 CP patients were regarded as having NA (group CP-NA). CV tests were normal in the remaining 20 CP patients (group CP). In controls, tPSB was 13 min; 3-70 rain (median; range), tDSB was 30 rain; 12-83 min, and tCecum was 102 rain; 50-180 rain. In the CP group, tPSB (15 rain; 2-34 rain) and tDSB (33 rain; 5-64 rain) and tCecum (97 rain; 29->180 rain) were similar to controls. In the CP-NA group, tPSB (12 rain; 1-45 rain) did not differ (p>0.20) from CP and controls, but both tDSB (18 rain; 4-60 rain) and tCecum (40 rain; 10-103 rain) were lower (p<0.02) than in CP and controls. Among all CP patients, tDSB correlated significantly with both RV (Rs=0.38, p=0.02) and TV (Rs=0.40, p<0.01), but did not correlate with PH. The tCecum correlated significantly with both RV (Rs=0.51, p<0.01) and TV (Rs=0.38, p<0.02) as well as with PH (Rs=0.54, p<0.01). We concluded that in patients with chronic pancreatitis and autonomic neuropathy rapid transit through the proximal small bowel is associated with vagal dysfunction whereas accelerated distal small bowel transit is associated with both vagal and sympathetic denervation. • G3397 CEREBRAL ACTIVATION AFTER CHEMICAL AND MECHANICAL STIMULATION OF THE HUMAN OESOPHAGUS. Roscher. S.1, Renner, B. l, Kuhlbusch, R.2, Frieling, T. 2, Kobal, G. 1 Enck, p.2, 1Department of Experimental and Clinical Pharmacology and Toxicology, University of Erlangen-Niirnberg, 2Department of Gastroenterology, Heinrich Heine University of DUsseldorf, Germany. The study aimed to compare a) chemosensory and mechanical evoked potentials (EPS) from the upper and lower human oesophagus and b) perception with amplitudes and latencies of chemical and mechanical EPs recorded from the two sites. Methods: Seven healthy volunteers (3 females, 4 males, 27 to 47 years) participated in the study consisting of 2 sessions in which the lower and upper esophagus (just above the lower oesophageal sphincter and I0 cm proximal, respectively) were stimulated. The sequence of phasic stimulation (150 msec, ISI 20 sec) for both sessions was 15 mechanical stimuli by air, followed by 15 chemical stimuli of acetic acid (99%), and again 15 stimuli of air administered through a naso-oesophageal tube. Chemical and mechanical EPs were recorded from 3 positions (Fz,Cz,Pz, according to the international 10/20 system) referenced against linked earlobes (AI+A2). Stimulus related EEG segments of 2048 ms duration at a sampling rate of 250 Hz were recorded starting 400 ms prior to stimulus onset. Measurements contaminated with eye-blink artifacts were discarded. EPs amplitudes P1N1 and N1P2, and latencies of P1, N1, and P2 were measured. Intensity ratings were scaled using visual analogue scales. Results: 1. Latencies of EPs (P1,N1) were significantly shorter (p < 0.05) after chemical stimulation as compared to mechanical stimulation in the lower but not in the upper oesophagus. 2. The higher the perceived intensity of the chemical stimuli, the shorter the latencies of P1, N1, and P2, and the higher the amplitude N1P2 in the distal esophagus. However, in the upper oesophagus, the same was true only for the mechanical stimulation. Conclusion: These results indicate that the chemical sensitivity is higher in the distal as compared to the proximal oesophagus. The opposite holds true for mechanical sensitivity. Because the amplitudes of mechanical and chemical EPs showed no difference, we asssume that the latency shift of the chemical EPs in the distal oesophagus is due to a higher sensitivity for chemical stimulants in the lower oesophagus rather than to intensity alone. Obviously, different sensory pathways are activated with mechanical and with chemical stimuli at the two sites of the oesophagus. This work was supported by grants from the Deutsche Forschungsgemeinschaft