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Resolution of urinary incontinence in a chronically constipated pediatric patient with change of ventriculoperitoneal shunt position
April 1998
I n t e s t i n a l D i s o r d e r s A419
G1707 RESOLUTION OF URINARY INCONTINENCE IN A CHRONICALLY CONSTIPATED PEDIATRIC PATIENT WITH CHANGE OF VENTRICULOPERITONEAL SHUNT POSITION. R. Steffen. M. Ishitani, K. Jirousek. Departments of Pediatric Gastroenterology and Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH. A 7 year old male with congenital hydrocephalus, seizures, had undergone a ventriculoperitoneal shunt (VPS) procedure. A year ago he underwent a revision with placement of a second shunt, which was complicated by a shunt infection and difficult placement requiring a general surgery consultation at his local hospital. Subsequently he complained of lower abdominal pain and bladder spasms which were treated medically without success. He had been toilet trained for urine and stool by three years of age, and had a history of chronic constipation. The patient developed urinary incontinence upon standing and bending over, and was often noted to be wet. Radiographic examination demonstrated the functional VPS catheter had shifted to a looped position around the bladder, and the disconnected shunt tubing in the lower pelvis with its tip near the bladder. The patient had laparoscopic manipulation and revision of the VPS tubes, shifting the functional catheter away from the pelvis and removal of part of the nonfunctional catheter with resolution of the positional stress urinary incontinence and the abdominal pain. VPS catheters are known to migrate to different positions, and in unusual cases have been found in locations distant and ectopic to the abdomen. The identical urinary problems including enuresis, urinary incontinence and urinary tract infections are associated with chronic constipation in children, and are known to improve with long-term treatment of constipation. Review of the literature did not reveal any report of positional urinary incontinence associated with ventriculoperitoneal shunt devices in children or adults. • G1708 TIGHT CONTAINER FOR USSING-TYPE MEASUREMENTS ON SMALL INTESTINAL FORCEPS BIOPSY SPECIMENS. M. Stockmann1,2, A.H. Gitter 2, J.D. Schulzke 1, M. Fromm2. Depts. Of 1Gastroenterology & Infectiology and 2Clinical Physiology, UKBF, Freie Universit~it Berlin, D-12200 Berlin, Germany Although the Ussing-technique is valuable in investigating intestinal disorders, analysis of human tissue is impeded by the small size of forceps biopsy specimens. Therefore, we designed a miniaturized container with an exposed area of only 0.05 cm2, but without leak. This allowed conventional measurements as well as AC impedance analysis, and conductance scanning on endoscopically obtained forceps biopsies. Fig. 1 shows an Ussing chamber optimized for AC impedance analysis. In the center is the tripartite container with the biopsy glued on a support disc (arrow). This biopsy container provided appropriate sealing without significant edge damage (technical details can be provided by the authors). In controls, the container technique was compared with a conventional Ussing chamber on rat jejunum and rectum (Fig. 2). No differences in total tissue resistance (R), short-circuit current (lsc), and secretory response were found. In human duodenal biopsy specimens a secretory response to 10-2 M theophylline and to 10.6 M PGE2 was elicited: 1 increased from 120 -+ 14 pA/cm2 to 253 ± 36 pA/cm2 after 20 min (n=7). Conductance scanning on human rectal biopsies showed a homogeneously distributed resistance of 73 +-1 ~ocm2) and absence of edge damage. Impedance analysis gave the same R (72+ 1 ~ocm2) as conductance scanning. Epithelial and subepithelial resistances were 57-+ 1 ~ocm2 and 14 +-. 1 f~°cm2, respectively.
,. . . . . . .
u~
~ ~u
."
/
Fig. 2 ~o
Fig. I
~o lime[rrin] 1~o
~o
In conclusion, a miniaturized container is described and tested which allows
Ussing-type, impedance, intestinal biopsies.
and conductance
scanning measurements on
• G1709 PROGNOSTIC VALUE OF GASTRIC TONOMETRY IN PERFORATIONINDUCED PERITONITIS AND LAPAROSCOPIC VERSUS OPEN REPAIR IN A PIG MODEL. T Strate, C Bloechle, A Emmermann, M Wolf, C Zomig, CE Broelsch Departs. of Surgery Internal Medicine, University Hospital Eppendorf, University of Hamburg, Martinistr. 52, 20251 Hamburg, Germany Baekround: Sepsis and multi organ failure (MOF) are associated with microcirculatory disorder in splanchnic blood supplied organs. Tonometry
(pCO: or pH (pHi)- assessment of gastric mucosa) has been advocated to predict outcome in septic patients. Recently minimal invasive surgery (MIC) has gained wider acceptance and has also been used for the treatment of peritonitis due to perforated gastric ulcers and lavage of the peritoneal cavity. The aim of this study was to evaluate the prognostic value of gastric tonometry in the experimental setting of a perforation induced peritonitis in the presence of a CO z pneumoperitoneum. Methods: Pigs were randomly allocated into either a laparoscopically treated (L12, n=9) or conventionally treated (K12; n=9) group. Under general anesthesia (midazolame and ketamine) a perforation was simulated by standardized gastrotomy. After 12 h the defect was observed and peritoneal cavity lavaged (normal saline) either laparoscopically or conventionally. In addition 3 pigs served as sham groups (L12s and K12s). Gastric mucosal pHi was calculated using arterial HCO3_ concentration and mucosal pH. A tonometry nasogastric tube with an air filled balloon was used to measure the COs callibration every 10 min. A Swan Ganz catheter and arterial line were used to measure cardiac output (QT), systemic vascular resistance (SVR) and mean arterial blood pressure (MAP). Plasma endotoxin levels were assesed using the limulus test. For analgesia animals received 100 mg Tramadol im every 6 h. After 6 days animals were sacrificed. Results: Mortality in group K12 was 22% versus 78% in group L12 (p=0,045). Before the definitive procedure pHi in both K12 und L12 was 7,18_+0,03 and did not change during the procedure in K12 whereas it declined to 7,06 _+0,08 in L12. The lowest pHi-values in group L12 were significantly different from that in group K12 (p=0,021). In addition there was a significant correlation between the lowest pHi and mortality (r=0,752, p < 0,001). In K12 endotoxin level increased to a maximum of 33,6 _+8 pg/ml compared to 74,5 +-.5,3 pg/ml in L12 (p=0,038). The increase of endotoxin concentration correlated reciprocally with the fall in MAP (r =0,857), and SVR (r=0,773) and positively with the rise in QT (r =0,711; p <0,001). C o n t u s i o n s : After a 12 hour period of severe peritonitis induced by gastric perforation, mortality was significantly higher in the laparoscopically treated group of pigs when compared to the open procedure. Septic shock associated with peritonitis and subsequent MOF could accurately be predicted with gastric tonometry. In both groups the decline of pHi in septic animals that died was higher than expected. G1710 THE INHIBITION OF TIlE OX40-OX40L INTERACTION IN THE MURINE ACUTE GRAFT-VERSUS-HOST DISEASE LEADS TO A NORMALIZATION OF THE INTESTINAL MORPHOLOGY. Eckhard Sttiber, Alexander yon Freier and Ulrich R. Frlsch, I. Medizinische Universitiitsklinik, Department of Intemal Medicine, Christian-Albechts-Universit~it, Kiel, Germany
Background & Aims: Celiac disease (CD) (or: gluten-sensitive enteropathy) is an immunologically mediated disease of the intestine characterized by lymphocytic infiltrates, crypt hyperplasia and villous atrophy. With respect to the intestinal morphology, the murine T cell mediated acute semi-allogenic graft versus host disease (GvH) resembles CD and, thus, has been widely used to investigate its immune pathogenesis. Methods: Therefore, we examined the rate of crypt cell apoptosis and proliferation as well as changes in the composition of the extracellular matrix (ECM) in the pathogenesis of villous atrophy and crypt hyperplasisa in this animal model. Furthermore, to investigate the role of OX40 - an important member of the TNF-R/NGF-R superfamily of receptors and their ligands - for T cell costimulation in vivo we studied the role of the OX40-OX40L interaction for the development of mucosal atrophy. Results: We found that the rate of apoptosis as well as the number of proliferating cells compensating for the induced cell damage are significantly increased in GvH animals compared to syngenic control animals. In addition, the expression of tenascin, which is an important ECM component being involved in cell migration and cell shedding, is downregulated in GvH-animals, whereas the expression of fibronectin, laminin, collagen type IV remains unchanged. The inhibition of the OX40OX40L interaction in GvH-animals by the administration of an OX40-Ig fusion protein the development of crypt hyperplasia and villous atrophy in GvH-animals was completely prevented. However, the rate of crypt cell apoptosis and proliferation was not altered compared to GvH-animals. Moreover, tenascin expression was upregulated in OX40-Ig treated mice compared to GvH-animals, suggesting an important function of this ECM component in mucosal repair following epithelial damage. In conclusion, the OX40-OX40L interaction is crucial in the pathogenesis of the investigated T-cell mediated intestinal disease, implying an important role in human celiac disease. Furthermore, our data suggest that the ECM component tenascin is propably relevant for the regeneration and maintenance of the intestinal tissue architecture following epithelial cell damage.
I n t e s t i n a l D i s o r d e r s A419
G1707 RESOLUTION OF URINARY INCONTINENCE IN A CHRONICALLY CONSTIPATED PEDIATRIC PATIENT WITH CHANGE OF VENTRICULOPERITONEAL SHUNT POSITION. R. Steffen. M. Ishitani, K. Jirousek. Departments of Pediatric Gastroenterology and Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH. A 7 year old male with congenital hydrocephalus, seizures, had undergone a ventriculoperitoneal shunt (VPS) procedure. A year ago he underwent a revision with placement of a second shunt, which was complicated by a shunt infection and difficult placement requiring a general surgery consultation at his local hospital. Subsequently he complained of lower abdominal pain and bladder spasms which were treated medically without success. He had been toilet trained for urine and stool by three years of age, and had a history of chronic constipation. The patient developed urinary incontinence upon standing and bending over, and was often noted to be wet. Radiographic examination demonstrated the functional VPS catheter had shifted to a looped position around the bladder, and the disconnected shunt tubing in the lower pelvis with its tip near the bladder. The patient had laparoscopic manipulation and revision of the VPS tubes, shifting the functional catheter away from the pelvis and removal of part of the nonfunctional catheter with resolution of the positional stress urinary incontinence and the abdominal pain. VPS catheters are known to migrate to different positions, and in unusual cases have been found in locations distant and ectopic to the abdomen. The identical urinary problems including enuresis, urinary incontinence and urinary tract infections are associated with chronic constipation in children, and are known to improve with long-term treatment of constipation. Review of the literature did not reveal any report of positional urinary incontinence associated with ventriculoperitoneal shunt devices in children or adults. • G1708 TIGHT CONTAINER FOR USSING-TYPE MEASUREMENTS ON SMALL INTESTINAL FORCEPS BIOPSY SPECIMENS. M. Stockmann1,2, A.H. Gitter 2, J.D. Schulzke 1, M. Fromm2. Depts. Of 1Gastroenterology & Infectiology and 2Clinical Physiology, UKBF, Freie Universit~it Berlin, D-12200 Berlin, Germany Although the Ussing-technique is valuable in investigating intestinal disorders, analysis of human tissue is impeded by the small size of forceps biopsy specimens. Therefore, we designed a miniaturized container with an exposed area of only 0.05 cm2, but without leak. This allowed conventional measurements as well as AC impedance analysis, and conductance scanning on endoscopically obtained forceps biopsies. Fig. 1 shows an Ussing chamber optimized for AC impedance analysis. In the center is the tripartite container with the biopsy glued on a support disc (arrow). This biopsy container provided appropriate sealing without significant edge damage (technical details can be provided by the authors). In controls, the container technique was compared with a conventional Ussing chamber on rat jejunum and rectum (Fig. 2). No differences in total tissue resistance (R), short-circuit current (lsc), and secretory response were found. In human duodenal biopsy specimens a secretory response to 10-2 M theophylline and to 10.6 M PGE2 was elicited: 1 increased from 120 -+ 14 pA/cm2 to 253 ± 36 pA/cm2 after 20 min (n=7). Conductance scanning on human rectal biopsies showed a homogeneously distributed resistance of 73 +-1 ~ocm2) and absence of edge damage. Impedance analysis gave the same R (72+ 1 ~ocm2) as conductance scanning. Epithelial and subepithelial resistances were 57-+ 1 ~ocm2 and 14 +-. 1 f~°cm2, respectively.
,. . . . . . .
u~
~ ~u
."
/
Fig. 2 ~o
Fig. I
~o lime[rrin] 1~o
~o
In conclusion, a miniaturized container is described and tested which allows
Ussing-type, impedance, intestinal biopsies.
and conductance
scanning measurements on
• G1709 PROGNOSTIC VALUE OF GASTRIC TONOMETRY IN PERFORATIONINDUCED PERITONITIS AND LAPAROSCOPIC VERSUS OPEN REPAIR IN A PIG MODEL. T Strate, C Bloechle, A Emmermann, M Wolf, C Zomig, CE Broelsch Departs. of Surgery Internal Medicine, University Hospital Eppendorf, University of Hamburg, Martinistr. 52, 20251 Hamburg, Germany Baekround: Sepsis and multi organ failure (MOF) are associated with microcirculatory disorder in splanchnic blood supplied organs. Tonometry
(pCO: or pH (pHi)- assessment of gastric mucosa) has been advocated to predict outcome in septic patients. Recently minimal invasive surgery (MIC) has gained wider acceptance and has also been used for the treatment of peritonitis due to perforated gastric ulcers and lavage of the peritoneal cavity. The aim of this study was to evaluate the prognostic value of gastric tonometry in the experimental setting of a perforation induced peritonitis in the presence of a CO z pneumoperitoneum. Methods: Pigs were randomly allocated into either a laparoscopically treated (L12, n=9) or conventionally treated (K12; n=9) group. Under general anesthesia (midazolame and ketamine) a perforation was simulated by standardized gastrotomy. After 12 h the defect was observed and peritoneal cavity lavaged (normal saline) either laparoscopically or conventionally. In addition 3 pigs served as sham groups (L12s and K12s). Gastric mucosal pHi was calculated using arterial HCO3_ concentration and mucosal pH. A tonometry nasogastric tube with an air filled balloon was used to measure the COs callibration every 10 min. A Swan Ganz catheter and arterial line were used to measure cardiac output (QT), systemic vascular resistance (SVR) and mean arterial blood pressure (MAP). Plasma endotoxin levels were assesed using the limulus test. For analgesia animals received 100 mg Tramadol im every 6 h. After 6 days animals were sacrificed. Results: Mortality in group K12 was 22% versus 78% in group L12 (p=0,045). Before the definitive procedure pHi in both K12 und L12 was 7,18_+0,03 and did not change during the procedure in K12 whereas it declined to 7,06 _+0,08 in L12. The lowest pHi-values in group L12 were significantly different from that in group K12 (p=0,021). In addition there was a significant correlation between the lowest pHi and mortality (r=0,752, p < 0,001). In K12 endotoxin level increased to a maximum of 33,6 _+8 pg/ml compared to 74,5 +-.5,3 pg/ml in L12 (p=0,038). The increase of endotoxin concentration correlated reciprocally with the fall in MAP (r =0,857), and SVR (r=0,773) and positively with the rise in QT (r =0,711; p <0,001). C o n t u s i o n s : After a 12 hour period of severe peritonitis induced by gastric perforation, mortality was significantly higher in the laparoscopically treated group of pigs when compared to the open procedure. Septic shock associated with peritonitis and subsequent MOF could accurately be predicted with gastric tonometry. In both groups the decline of pHi in septic animals that died was higher than expected. G1710 THE INHIBITION OF TIlE OX40-OX40L INTERACTION IN THE MURINE ACUTE GRAFT-VERSUS-HOST DISEASE LEADS TO A NORMALIZATION OF THE INTESTINAL MORPHOLOGY. Eckhard Sttiber, Alexander yon Freier and Ulrich R. Frlsch, I. Medizinische Universitiitsklinik, Department of Intemal Medicine, Christian-Albechts-Universit~it, Kiel, Germany
Background & Aims: Celiac disease (CD) (or: gluten-sensitive enteropathy) is an immunologically mediated disease of the intestine characterized by lymphocytic infiltrates, crypt hyperplasia and villous atrophy. With respect to the intestinal morphology, the murine T cell mediated acute semi-allogenic graft versus host disease (GvH) resembles CD and, thus, has been widely used to investigate its immune pathogenesis. Methods: Therefore, we examined the rate of crypt cell apoptosis and proliferation as well as changes in the composition of the extracellular matrix (ECM) in the pathogenesis of villous atrophy and crypt hyperplasisa in this animal model. Furthermore, to investigate the role of OX40 - an important member of the TNF-R/NGF-R superfamily of receptors and their ligands - for T cell costimulation in vivo we studied the role of the OX40-OX40L interaction for the development of mucosal atrophy. Results: We found that the rate of apoptosis as well as the number of proliferating cells compensating for the induced cell damage are significantly increased in GvH animals compared to syngenic control animals. In addition, the expression of tenascin, which is an important ECM component being involved in cell migration and cell shedding, is downregulated in GvH-animals, whereas the expression of fibronectin, laminin, collagen type IV remains unchanged. The inhibition of the OX40OX40L interaction in GvH-animals by the administration of an OX40-Ig fusion protein the development of crypt hyperplasia and villous atrophy in GvH-animals was completely prevented. However, the rate of crypt cell apoptosis and proliferation was not altered compared to GvH-animals. Moreover, tenascin expression was upregulated in OX40-Ig treated mice compared to GvH-animals, suggesting an important function of this ECM component in mucosal repair following epithelial damage. In conclusion, the OX40-OX40L interaction is crucial in the pathogenesis of the investigated T-cell mediated intestinal disease, implying an important role in human celiac disease. Furthermore, our data suggest that the ECM component tenascin is propably relevant for the regeneration and maintenance of the intestinal tissue architecture following epithelial cell damage.