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S1324 Outcomes of Colonic Motility Studies in Children With Constipation
Bilateral TSNS was performed under sedation (day case procedure) and electrodes placed in the sacral foramen that produced the best peripheral response. The electrodes were removed after a 3 week evaluation period. Patients with more than 50% improvement of baseline symptoms and recurrence of pre-stimulation symptoms were offered bilateral permanent SNS (PSNS). Paired student t-test was used to calculate the difference between the colonic transit times of the two groups. Results: 38 patients (9 men, 29 women; Mean age 42.3 years) with slow transit constipation (STC) underwent bilateral TSNS. 16/38 (40%) showed a positive response and went on to have permanent SNS (PSNS). The colonic transit time of patients with PSNS was 62.36 hrs (SD 13.48) VS 60.6 hrs (SD 11.71) for patients without PSNS (p value 0.68). Conclusion: SNS offers a reasonable alternative to invasive surgical procedures in patients with severe refractory constipation. Colonic transit times do not predict outcome of treatment. SNS should be offered to patients with severe constipation before more invasive therapies.
Usefulness of Electrocolonography for Evaluation of Colonic Motility Masako Kaji, Tetsu Tomonari, Miwako Kagawa, Azusa Saito, Miho Tsuda, Rie Harada, Tetsuo Kimura, Shinji Kitamura, Hiromi Yano, Koichi Okamoto, Miyako Niki, Toshiya Okahisa, Seisuke Okamura, Tetsuji Takayama Purpose: Mobility disorders of the alimentary tract including irritable bowel syndrome (IBS) is now increasing worldwide. Measurement of intracolonic pressure has been conventionally employed for assessment of colonic motility. However, it is very laborious and burdensome for a routine examination. Therefore, in this study, we performed electrocolonography (ECoG), an easy and simple methodology, and investigated its usefulness for evaluation of colonic motility in comparison with the conventional methodology. Method: Twenty-five well-informed healthy volunteers were enrolled. ECoG was performed using a portable electrogastrograph (NIPRO EGG, A&D, Tokyo, Japan). After detecting a sigmoid colon using external ultrasonography, 4 electrodes of ECoG were attached to the abdomen. The ECoG was recorded by a bipolar lead between the central electrode and 3 surface probe electrodes (Ch1-3) at 1-second interval with frequencies of 1.5-6.0 cpm. Mosapride (10mg) or butylscopolamine (10mg) was orally administered during the examinations. For the analysis of ECoG data, the dominant frequencies and peak powers in 3 channels were calculated using a Fast Fourier Transform. In the 3 subjects, intracolonic pressure was measured using mobility visualization system (ManoScan 360, Sierra Scientific Instruments, CA) concurrently with ECoG. A catheter with 36 pressure sensors was introduced through the anus to the sigmoid colon, and the change of the pressure at each point was recorded. Results: Colonic peristalsis at about 2 cpm (1.95 - 0.41 cpm) was observed by mobility measuring system. The pressure was significantly increased by administration of mosapride, and was decreased by butylscopolamine, consistent with the previous reports. While, a dominant frequency at 2 cpm, which represented action potential of colonic peristalsis, was observed in all channels of ECoG. The peak power of the dominant frequency was significantly increased by mosapride (pre 15.0 ± 7.38uV, after 52.0 ± 50.3uV) and was significantly decreased by butylscopolamine (pre 15.2 ± 6.27uV, after 0.35 ± 0.24uV), corresponding to the change of intracolonic pressure. The dominant frequency did not change after administration of mosapride or butylscopolamine in ECoG. Conclusion: We could detect action potential of colonic peristalsis by ECoG, an easy and simple methodology, and showed the usefulness of ECoG for assessing colonic motility.
S1326 Presumed IBS Subjects With Short Remission After Antibiotic Therapy Often Have Secondary Causes for Their Symptoms Jim Y. Chou, Robert Tabrizi, Mark Pimentel, Thomas Sokol Small intestinal bacterial overgrowth (SIBO) based on a lactulose breath test is common in subjects with irritable bowel syndrome (IBS). On this premise, multiple randomized controlled trials using antibiotic therapy have demonstrated efficacy in improving IBS symptoms. Since 2008, increasing use of antibiotic therapy has reduced the number of tertiary care referrals for antibiotic naïve IBS subjects and increased referral for antibiotic refractory symptoms. In this study, we review the workup of subjects referred for poor antibiotic response for presumed IBS. Methods: A chart review was conducted to include consecutive patients referred to a GI motility program at a tertiary care medical center from 2008 to present. Patients were included in this analysis if they had an abnormal lactulose breath test (LBT) and had a response to antibiotics with benefits lasting less than 1 month. In these subjects, the ensuing workup, past medical and surgical history, medication and clinical course were examined. The chart review was intended to determine if alternative diagnoses or explanations for the abnormal breath test and short antibiotic induced remission could be found. Results: Out of 197 charts reviewed, 101 were excluded due to negative LBT, or alternative reason for referral besides IBS and 31 were responsive to antibiotic treatment or still on treatment. Of the remaining 65 subjects who failed to have sustained remission after antibiotic therapy, 20 (30.8%) were later identified as having a alternative explanation predisposing to SIBO and early relapse. These alternative diagnoses included anatomic causes such as small bowel obstruction (n=2), rectocele/prolapse (n=3), intestinal malrotation (n= 1), small bowel diverticular disease (n=2), and volvulus (n=1). These subjects were referred for surgery. Chronic narcotic use was seen in several cases (n=3). A neuropathic causes contributed as well,including Addison's disease (n=1), scleroderma (n=1), colonic inertia (n=1) or vagotomy from laryngeal tumor surgery (n=1). Inflammatory disease was a culprit in 2 cases where ulcerative colitis (n=1) and NSAID induced intestinal ulceration (n=1) were seen. In other cases the finding was more unusual. In one patient an elevated creatine kinase and subsequent muscle biopsy demonstrated a mitochondrial myopathy. In another, atrophic gastritis and vitamin B12 deficiency. Conclusions: As the number of presumed IBS subjects treated with antibiotics grows, referral to tertiary care centers will be based on failure to respond to antibiotics. This trend will require renewed diligence in identifying an alternative explanation for the ongoing symptoms.
S1324 Outcomes of Colonic Motility Studies in Children With Constipation Fareed Ahmad, Joseph M. Croffie INTRODUCTION: Colonic motility studies have been used in the management of intractable constipation. Their usefulness in ruling out organic causes has been studied in the adult and pediatric populations. In one pediatric study, 38% of children undergoing colonic motility studies solely for constipation, with or without encopresis, had an abnormal test. AIM: To determine what percentage of children with chronic functional constipation had abnormal colonic motility study results in our institution, and how did the result influenced the management. METHODS:We conducted a retrospective review of the medical records of all patients who underwent colonic motility study at our institution, between 2000 and 2007. Areas of interest were: patient age and gender, duration of symptoms, indication for colonic motility study, prior evaluation and intervention, results of colonic motility study and subsequent intervention performed. Our criteria for abnormal colonic motility included one or more of the following: No gastrocolic reflex after a standard meal, No high amplitude propagated contractions (HAPCs), Presence of retrograde contractions, Presence of simultaneous contractions, and no contractions. RESULTS: Fourty five patients underwent colonic motility for unresponsive functional constipation with or without encopresis. Four were excluded because of incomplete data and follow-up. Twenty three (56%) were males and average age was 7.75 years (range 15 months to 17 years).Average duration of symptoms was 3 years (range: 10 months to 12 years). Of the 41 patients included, 19 (46%) had an abnormal colonic motility study. Fourteen of 19 (74%) were males. For 12 of the 19 patients, a MACE procedure (Malone antegrade continent enema) was recommended and provided beneficial results for all. Eleven of 12 parents were satisfied with the MACE intervention and would do it all over again. For the remainder of the 19 patients, more aggressive medical management with a combination of laxatives was advised; 6 out of 7 patients improved. One patient did not and was referred for MACE. CONCLUSIONS: Our study confirms the results of the previous study and indicates that approximately 40% of children who have chronic constipation, with or without encopresis, have abnormal colonic motility studies which may influence management. Children with chronic constipation, with or without encopresis, who are unresponsive to conventional management and who have normal anorectal manometry or rectal biopsies, should be referred for colonic manometry.
S1327 Colonic Manometry Results of Oral Lubiprostone Nidhi Rawal, John Desbiens, Anil Darbari BACKGROUND:Lubiprostone is an oral bicyclic fatty acid that selectively activates type-2 chloride channels, resulting in increased fluid secretion into the lumen, thereby softening the intestinal contents and accelerating small intestinal and colonic transit. Lubiprostone was approved in the US in 2006 for adults with constipation, after positive results reported from two double blind multicenter phase III studies. There has been no pediatric study to date describing the effect of lubiprostone on colonic motility demonstrated by colonic manometry. AIM: To assess for any stimulant effect of Lubiprostone on colonic motility during a 24 hour colonic manometry study. METHODS: We reviewed the colonic manometry findings on 5 consecutive patients who received oral lubiprostone during the 24-hour colonic manometry study using a 6-sensor solid state Konigsberg colonic manometry catheter and the MMS (Medical Measurement Systems USA, Inc.). The mean age of the patients was 16.6 years (range 12-22 yr). Times were recorded when the patient received any meal/medication during the study. All patients received 24 mcg of lubiprostone orally, once during the study period. Contraction amplitudes (in mmHg) were calculated by subtracting mean resting colonic pressure from the peak of colonic waves. We compared the responses to lubiprostone with findings noted in the fasting period in the proximal 2 sensors in the recto-sigmoid area, middle two sensors in the transverse colon and distal two sensors in the ascending colon/cecum as noted on serial abdominal radiographs. RESULTS: There was an increase in the amplitude of colonic contractions in all patients, and an increase in the motility index in 3/5 patients. In patients with increased amplitude, the effect was most prominently noted in the proximal sensors (recto-sigmoid area). In the latter group, motility index was enhanced in all the sensors for each of the 3 patients. CONCLUSIONS: Oral lubiprostone appears to have a stimulant effect as noted on colonic manometry in addition to the increased colonic secretion. Further double blinded randomized control trials are needed to further document the stimulant effect of lubiprostone in adolescents with constipation.
S1325 Sacral Nerve Stimulation in Idiopathic Constipation. A Single Centre Experience Usman Khan, Susan E. Green, Jeremy Cundall, Jag Varma, Yan Yiannakou Introduction: Chronic constipation can have significant disabling effects on the quality of life. A proportion of patients with chronic constipation will not respond to standard treatment. Refractory constipation is difficult to manage and often requires surgical intervention. The surgical procedures currently offered involve prolonged operations with significant potential complications. In contrast, sacral nerve stimulation (SNS) offers a minimally invasive alternative. The Durham Constipation Clinic provides a centralized multidisciplinary service and serves a population of around 400 patients with severe constipation. We offer SNS for both faecal incontinence and constipation and undertook the highest number of SNS procedures in the UK in 2008. Methods: Over a period of two years, patients presenting to a specialist constipation clinic with slow transit constipation were offered temporary SNS (TSNS). Patients were selected on the basis of fulfilling the Rome III criteria for chronic constipation and were refractory to maximal conservative therapy. All patients underwent a transit study.
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AGA Abstracts
AGA Abstracts
S1323
Usefulness of Electrocolonography for Evaluation of Colonic Motility Masako Kaji, Tetsu Tomonari, Miwako Kagawa, Azusa Saito, Miho Tsuda, Rie Harada, Tetsuo Kimura, Shinji Kitamura, Hiromi Yano, Koichi Okamoto, Miyako Niki, Toshiya Okahisa, Seisuke Okamura, Tetsuji Takayama Purpose: Mobility disorders of the alimentary tract including irritable bowel syndrome (IBS) is now increasing worldwide. Measurement of intracolonic pressure has been conventionally employed for assessment of colonic motility. However, it is very laborious and burdensome for a routine examination. Therefore, in this study, we performed electrocolonography (ECoG), an easy and simple methodology, and investigated its usefulness for evaluation of colonic motility in comparison with the conventional methodology. Method: Twenty-five well-informed healthy volunteers were enrolled. ECoG was performed using a portable electrogastrograph (NIPRO EGG, A&D, Tokyo, Japan). After detecting a sigmoid colon using external ultrasonography, 4 electrodes of ECoG were attached to the abdomen. The ECoG was recorded by a bipolar lead between the central electrode and 3 surface probe electrodes (Ch1-3) at 1-second interval with frequencies of 1.5-6.0 cpm. Mosapride (10mg) or butylscopolamine (10mg) was orally administered during the examinations. For the analysis of ECoG data, the dominant frequencies and peak powers in 3 channels were calculated using a Fast Fourier Transform. In the 3 subjects, intracolonic pressure was measured using mobility visualization system (ManoScan 360, Sierra Scientific Instruments, CA) concurrently with ECoG. A catheter with 36 pressure sensors was introduced through the anus to the sigmoid colon, and the change of the pressure at each point was recorded. Results: Colonic peristalsis at about 2 cpm (1.95 - 0.41 cpm) was observed by mobility measuring system. The pressure was significantly increased by administration of mosapride, and was decreased by butylscopolamine, consistent with the previous reports. While, a dominant frequency at 2 cpm, which represented action potential of colonic peristalsis, was observed in all channels of ECoG. The peak power of the dominant frequency was significantly increased by mosapride (pre 15.0 ± 7.38uV, after 52.0 ± 50.3uV) and was significantly decreased by butylscopolamine (pre 15.2 ± 6.27uV, after 0.35 ± 0.24uV), corresponding to the change of intracolonic pressure. The dominant frequency did not change after administration of mosapride or butylscopolamine in ECoG. Conclusion: We could detect action potential of colonic peristalsis by ECoG, an easy and simple methodology, and showed the usefulness of ECoG for assessing colonic motility.
S1326 Presumed IBS Subjects With Short Remission After Antibiotic Therapy Often Have Secondary Causes for Their Symptoms Jim Y. Chou, Robert Tabrizi, Mark Pimentel, Thomas Sokol Small intestinal bacterial overgrowth (SIBO) based on a lactulose breath test is common in subjects with irritable bowel syndrome (IBS). On this premise, multiple randomized controlled trials using antibiotic therapy have demonstrated efficacy in improving IBS symptoms. Since 2008, increasing use of antibiotic therapy has reduced the number of tertiary care referrals for antibiotic naïve IBS subjects and increased referral for antibiotic refractory symptoms. In this study, we review the workup of subjects referred for poor antibiotic response for presumed IBS. Methods: A chart review was conducted to include consecutive patients referred to a GI motility program at a tertiary care medical center from 2008 to present. Patients were included in this analysis if they had an abnormal lactulose breath test (LBT) and had a response to antibiotics with benefits lasting less than 1 month. In these subjects, the ensuing workup, past medical and surgical history, medication and clinical course were examined. The chart review was intended to determine if alternative diagnoses or explanations for the abnormal breath test and short antibiotic induced remission could be found. Results: Out of 197 charts reviewed, 101 were excluded due to negative LBT, or alternative reason for referral besides IBS and 31 were responsive to antibiotic treatment or still on treatment. Of the remaining 65 subjects who failed to have sustained remission after antibiotic therapy, 20 (30.8%) were later identified as having a alternative explanation predisposing to SIBO and early relapse. These alternative diagnoses included anatomic causes such as small bowel obstruction (n=2), rectocele/prolapse (n=3), intestinal malrotation (n= 1), small bowel diverticular disease (n=2), and volvulus (n=1). These subjects were referred for surgery. Chronic narcotic use was seen in several cases (n=3). A neuropathic causes contributed as well,including Addison's disease (n=1), scleroderma (n=1), colonic inertia (n=1) or vagotomy from laryngeal tumor surgery (n=1). Inflammatory disease was a culprit in 2 cases where ulcerative colitis (n=1) and NSAID induced intestinal ulceration (n=1) were seen. In other cases the finding was more unusual. In one patient an elevated creatine kinase and subsequent muscle biopsy demonstrated a mitochondrial myopathy. In another, atrophic gastritis and vitamin B12 deficiency. Conclusions: As the number of presumed IBS subjects treated with antibiotics grows, referral to tertiary care centers will be based on failure to respond to antibiotics. This trend will require renewed diligence in identifying an alternative explanation for the ongoing symptoms.
S1324 Outcomes of Colonic Motility Studies in Children With Constipation Fareed Ahmad, Joseph M. Croffie INTRODUCTION: Colonic motility studies have been used in the management of intractable constipation. Their usefulness in ruling out organic causes has been studied in the adult and pediatric populations. In one pediatric study, 38% of children undergoing colonic motility studies solely for constipation, with or without encopresis, had an abnormal test. AIM: To determine what percentage of children with chronic functional constipation had abnormal colonic motility study results in our institution, and how did the result influenced the management. METHODS:We conducted a retrospective review of the medical records of all patients who underwent colonic motility study at our institution, between 2000 and 2007. Areas of interest were: patient age and gender, duration of symptoms, indication for colonic motility study, prior evaluation and intervention, results of colonic motility study and subsequent intervention performed. Our criteria for abnormal colonic motility included one or more of the following: No gastrocolic reflex after a standard meal, No high amplitude propagated contractions (HAPCs), Presence of retrograde contractions, Presence of simultaneous contractions, and no contractions. RESULTS: Fourty five patients underwent colonic motility for unresponsive functional constipation with or without encopresis. Four were excluded because of incomplete data and follow-up. Twenty three (56%) were males and average age was 7.75 years (range 15 months to 17 years).Average duration of symptoms was 3 years (range: 10 months to 12 years). Of the 41 patients included, 19 (46%) had an abnormal colonic motility study. Fourteen of 19 (74%) were males. For 12 of the 19 patients, a MACE procedure (Malone antegrade continent enema) was recommended and provided beneficial results for all. Eleven of 12 parents were satisfied with the MACE intervention and would do it all over again. For the remainder of the 19 patients, more aggressive medical management with a combination of laxatives was advised; 6 out of 7 patients improved. One patient did not and was referred for MACE. CONCLUSIONS: Our study confirms the results of the previous study and indicates that approximately 40% of children who have chronic constipation, with or without encopresis, have abnormal colonic motility studies which may influence management. Children with chronic constipation, with or without encopresis, who are unresponsive to conventional management and who have normal anorectal manometry or rectal biopsies, should be referred for colonic manometry.
S1327 Colonic Manometry Results of Oral Lubiprostone Nidhi Rawal, John Desbiens, Anil Darbari BACKGROUND:Lubiprostone is an oral bicyclic fatty acid that selectively activates type-2 chloride channels, resulting in increased fluid secretion into the lumen, thereby softening the intestinal contents and accelerating small intestinal and colonic transit. Lubiprostone was approved in the US in 2006 for adults with constipation, after positive results reported from two double blind multicenter phase III studies. There has been no pediatric study to date describing the effect of lubiprostone on colonic motility demonstrated by colonic manometry. AIM: To assess for any stimulant effect of Lubiprostone on colonic motility during a 24 hour colonic manometry study. METHODS: We reviewed the colonic manometry findings on 5 consecutive patients who received oral lubiprostone during the 24-hour colonic manometry study using a 6-sensor solid state Konigsberg colonic manometry catheter and the MMS (Medical Measurement Systems USA, Inc.). The mean age of the patients was 16.6 years (range 12-22 yr). Times were recorded when the patient received any meal/medication during the study. All patients received 24 mcg of lubiprostone orally, once during the study period. Contraction amplitudes (in mmHg) were calculated by subtracting mean resting colonic pressure from the peak of colonic waves. We compared the responses to lubiprostone with findings noted in the fasting period in the proximal 2 sensors in the recto-sigmoid area, middle two sensors in the transverse colon and distal two sensors in the ascending colon/cecum as noted on serial abdominal radiographs. RESULTS: There was an increase in the amplitude of colonic contractions in all patients, and an increase in the motility index in 3/5 patients. In patients with increased amplitude, the effect was most prominently noted in the proximal sensors (recto-sigmoid area). In the latter group, motility index was enhanced in all the sensors for each of the 3 patients. CONCLUSIONS: Oral lubiprostone appears to have a stimulant effect as noted on colonic manometry in addition to the increased colonic secretion. Further double blinded randomized control trials are needed to further document the stimulant effect of lubiprostone in adolescents with constipation.
S1325 Sacral Nerve Stimulation in Idiopathic Constipation. A Single Centre Experience Usman Khan, Susan E. Green, Jeremy Cundall, Jag Varma, Yan Yiannakou Introduction: Chronic constipation can have significant disabling effects on the quality of life. A proportion of patients with chronic constipation will not respond to standard treatment. Refractory constipation is difficult to manage and often requires surgical intervention. The surgical procedures currently offered involve prolonged operations with significant potential complications. In contrast, sacral nerve stimulation (SNS) offers a minimally invasive alternative. The Durham Constipation Clinic provides a centralized multidisciplinary service and serves a population of around 400 patients with severe constipation. We offer SNS for both faecal incontinence and constipation and undertook the highest number of SNS procedures in the UK in 2008. Methods: Over a period of two years, patients presenting to a specialist constipation clinic with slow transit constipation were offered temporary SNS (TSNS). Patients were selected on the basis of fulfilling the Rome III criteria for chronic constipation and were refractory to maximal conservative therapy. All patients underwent a transit study.
S-229
AGA Abstracts
AGA Abstracts
S1323