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Scintigraphic study of colonic transit after eating in patients with functional diarrhea
Motility and Nerve-Gut Interactions A739
April 1998 • G3050
PERCEIVED STRAINING AND INCOMPLETE EVACUATION PREDICT PARADOXICAL CONTRACTION OF THE PELVIC FLOOR. MD Crowell, B Lacy, MM Schuster. The M. M. Schuster Center for Digestive and Motility Disorders. The Johns Hopkins University School of Medicine, Baltimore, MD. Patients presenting with chronic constipation often complain of difficult rectal emptying including straining to start a bowel movement, straining to finish a bowel movement and incomplete evacuation. However, the relationship between perceived straining and physiologic dysfunction has not been reported. Subjective straining may also be influenced by psychological status. Aim. This study evaluated the relationship between perceived straining and paradoxical pelvic floor contractions (PC) on anorectal manometry (MANn), electromyography (EMG) and defecography (DEF). The relationship between perceived straining and psychological status was also evaluated. Method. Twenty-six patients (22f/4m;48 -+ 13 yrs) presenting with chronic dyschezia completed an evaluation of pelvic floor function by MANn, EMG, and DEF. All patients also completed a standardized Bowel Symptom Questionnaire and the SCL 90-R. Results. PC was identified in 88.5% of patients presenting with dyschezia. PC was evident on MANn in 23.1% (6/26), on DEF in 23.1% (6/26) and on both in 38.5% (10126). PC was not identified in 15.4% (4/26) patients. Straining and incomplete evacuation did not differentiate the diagnostic PC groups. Classification by defecography was not significantly associated with manometry or EMG, but manometry and EMG were significantly associated (Phi=.54). Manometry revealed significantly higher thresholds for first sensation in the DEF group only. Motor abnormalities included reduced basal anal canal pressure in the patients with PC on both MANn and DEF and increased EAS pressures with straining in the MANn and both groups. The anorectal angle at rest and the change with straining was significantly decreased in the DEF and BOTH. Straining to finish a bowel movement and incomplete evacuation were inversely correlated with anxiety (-,50 & -.48) and depression (-.54 & -.37), but no significant differences were noted between diagnostic groups. Conclusion. Perceived straining and incomplete evacuation were important predictors of paradoxical contraction on manometry and defecography. Concordance between MANn and DEF was low and may reflect important diagnostic differences. Anorectal manometry and defecography are both important tools for differentiating chronically constipated patients with rectal emptying difficulties. • G3051
DOMPERIDONE IS SUPERIOR TO CISAPRIDE IN THE TREATMENT OF GASTRIC EMPTYING DELAY AND GASTRIC DYSRHYTHMIAS IN CHILDREN WITH DIABETES MELLITUS. S.Cucchiara. A.Franzese, M.T.Franco, G.Salvia, O.Borrelli, S.Fecarotta, L.Alfonsi. Dept Pediatrics, University of Naples, Naples, Italy. Gastric emptying (GE) delay and gastric electrical abnormalities are often described in patients with diabetes mellitus. These abnormalities can produce dyspeptic symptoms and contribute to poor glycemic control. We wished to compare the effects of two prokinetic drugs, cisapride (CIS) (0.6 mg/kg/day, tid) and domperidone (DOM) (0.9 mg/kg/day, tid) in insulin dependent diabetes mellitus (IDDM) children with GE delay and gastric dysrhythmias, without autonomic neuropathy. Of 36 patients included into the study, 30 (median age: 9 years, range: 4-15 years) completed the trial. Before and at the end of the trial (4 weeks) we measured dyspeptic scoring system (vomiting, early satiety, abdominal pain, fullness; score: 0 = absent; 2 = occasionally, slight; 4 = occasionally, moderately severe; 6 = often, markedly severe), GE time of a mixed solid-liquid meal with ultrasonogruphy of the antral area and cutaneous electrogastrography (EGG). The EGG and GE time were measured during the same session. The EGG variables were: % of normal electrical rhythm (2-4 cycles per minute [cpm]), % of tachygastria (> 4 cpm), fed-to-fasting ratio of the dominant EGG power (i.e. the power of the EGG at the dominant frequency, a variable commonly thought to be the electrical counterpart of antral contractility). Fifteen patients received CIS, 15 DOM. The two groups were comparable for symptom score, degree of gastroparesis and EGG abnormalities. Results (mean _+SD): Domperidone Cisapride pre post pre post 22.0-+3.2 9 . 3 - + 3 . 4 20.9-+2.6 17.2-+3.1 217-+15.9 168-+20.1 215+19.3 208-+21.8 62.7 -+6.4 76.7 -+5,3 64.1 -+9.9 66.8 -+9.2
- Symptomscore* - GE time (minutes)* - % of normal gastric electrical activity* - % of tachygastria* 26.1 -+4.0 17.2 -+2.3 25.2 -+8.8 22.3 -+8.6 - fed/fastingEGG power* 0,8-+0.2 1 . 5 - + 0 . 4 0.75-+0.2 0.81-+0.4 p<0.01 between post- and pre-trial values for DOM group; no difference between post- and pre-trial values for CIS group.
Conclusions: in children with IDDM and gastroparesis treatment with DOM is more effective than CIS in improving both dyspeptic symptoms and gastric emptying. Since gastric dysrhythmias are usually associated with impaired contractility, normalization of gastric electrical activity by DOM seems to play a critical role in ameliorating GE time. • G3052
INHIBITION OF GASTRIC MOTILITY BY ILEAL SHORT CHAIN FATTY ACIDS IS MEDIATED BY AN HUMORAL PATHWAY ONLY. G. Cuche, C. H. M01bert. Station de Recherches Porcines, INRA, St Gilles, France. Ileal-infused short chain fatty acids (SCFA) inhibit gastric motility in pigs (Cuche et al., 1995). The aim of this study was to evaluate the relative contribution of the afferent pathways to the SCFA-induced ileal brake in conscious pigs. A possible direct effect of SCFA after blood absorption and the stimulation of intrinsic or extrinsic nervous systems will be tested successively. The direct contribution of ileal-absorbed SCFA was investigated by the evaluation of gastric motility changes following intravenous acetate infusion (30 pmolokg-l.min -1, pH=6.8, 1 hour) v s saline (4 pigs). The role of the intrinsic nervous system was tested using SCFA mixture (60% C2, 30% C3, 10% C4, 30 pmol,kg-l-min -t, pH=6.5, 1 hour) v s saline infused within isolated Babkin loops made of the last 30 cm of the ileum (4 pigs). Ileal denervated loops consisting in revascularized Babkin loops with section of original mesenteric arcades were used to evaluate the role of the extrinsic nervous system in SCFA induced ileal brake (4 pigs). SCFA mixture and saline were infused in these loops as described for the innervated loops group. In all groups, gastric motility was assessed using three strain gauges located on the proximal, distal and terminal antrum. The amplitude of contractions was expressed as % of the maximal amplitude recorded during a control phase III. Intravenous acetate infusion did not modify gastric motility (amplitude of contractions: 41 .+ 2.3 v s 39 ,+ 2.3 %) indicating that absorbed SCFA were not involved in ileal brake triggering. Gastric motility was equally inhibited during infusion of SCFA v s saline in innervated and denervated ileal loops (amplitude of contractions: 35 .+ 1.0 v s 44 .+ 1.1% and 34 - 0.7 v s 41 -+ 1.1% for innervated and denervated loops respectively). This indicates that neither the integrity of the intrinsic nor of the extrinsic nervous system was required to activate an ileal brake towards gastric motility. Since gastric motility during ileal SCFA infusions was equally inhibited after suppression of ileal intrinsic and extrinsic innervations and because intravenous SCFA was unable to trigger gastric inhibition, it is likely that an humoral pathway is responsible only for the SCFA induced ileal brake. [1] Cuche, G., Gu&in, S., Malbert, C. H. Inhibition of gastric motility by ileal short chain fatty acids is not caloric dependent. Neurogastroenterology and Motility, 7,253, 1995. • G3053 SCINTIGRAPHIC STUDY OF COLONIC TRANSIT AFTER EATING IN PATIENTS WITH FUNCTIONAL DIARRHEA. E, Cuillerier. M. L6mann, B. Coffin, B. Flouri6, C. Cellier, D. Gambini, P. Jou&, JP Barbier, JD. Rain, JC. Rambaud, R. Jian. St-Louis, St-Lazare and Laennec Hospitals, Paris, France. Our aim was to assess colonic transit after eating in patients (patients) with functional diarrhea (FD), using a simplified scintigraphic technique. Method. The study was performed in 17 patients (6 M, 21-79 yr) and 17 healthy volunteers (6 M, 21-45 yr). FD was defined as more than 3 stools per day for > 6 ran, and no abnormality at colonoscopy, duodenal and colonic biopsies and hormone measurements. In the evening preceding the study, subjects ingested a gelatin capsule coated with methacrylate and containing Amberlite ® resin pellets, labeled with 111In. After an overnight fasting, a 1000 kcal test-meal was given. Anterior and posterior images were taken every 30 rain for 4h30 and then, after a second meal, every hour for 4 hr. Radioactivity (RI) was counted in 4 colonic regions of interest (ROIs). Resulrts. (m -+SD). Colonic transit could be assessed in 15 of the 17 patients; in 2 cases, no RI was found on the abdominal area in the morning following the capsule ingestion. Colonic transit was significantly accelerated in patients with FD compared to healthy subjects, as judged by the mean curves of RI in the left colon or in the stools, or by the progression of the geometric center (areas under the curve; P<0.05); 8/15 patients were classified as having an accelerated colonic transit on the basis of a % of RI in the left colonic at the end of the study higher than the maximal value found in healthy subjects. The number of antegrade isotopic movements was similar in FD and healthy volunteers (1.8 _+0.6/subject v s 1.9 -+ 1,4) but in FD, the number of subjects with antegrade movement covering more than 2 ROIs was greater (8/15 v s 3/17; P<0.05) and the number of retrograde movements was lower (0.1 -+0.3 vs 0.3 .+ 0.5 P=0.05). Conclusion. Colonic transit after eating was accelerated in more than 50% of patients with functional diarrhea. Our results suggest that this was mainly due to a failure of a left colonic brake.
April 1998 • G3050
PERCEIVED STRAINING AND INCOMPLETE EVACUATION PREDICT PARADOXICAL CONTRACTION OF THE PELVIC FLOOR. MD Crowell, B Lacy, MM Schuster. The M. M. Schuster Center for Digestive and Motility Disorders. The Johns Hopkins University School of Medicine, Baltimore, MD. Patients presenting with chronic constipation often complain of difficult rectal emptying including straining to start a bowel movement, straining to finish a bowel movement and incomplete evacuation. However, the relationship between perceived straining and physiologic dysfunction has not been reported. Subjective straining may also be influenced by psychological status. Aim. This study evaluated the relationship between perceived straining and paradoxical pelvic floor contractions (PC) on anorectal manometry (MANn), electromyography (EMG) and defecography (DEF). The relationship between perceived straining and psychological status was also evaluated. Method. Twenty-six patients (22f/4m;48 -+ 13 yrs) presenting with chronic dyschezia completed an evaluation of pelvic floor function by MANn, EMG, and DEF. All patients also completed a standardized Bowel Symptom Questionnaire and the SCL 90-R. Results. PC was identified in 88.5% of patients presenting with dyschezia. PC was evident on MANn in 23.1% (6/26), on DEF in 23.1% (6/26) and on both in 38.5% (10126). PC was not identified in 15.4% (4/26) patients. Straining and incomplete evacuation did not differentiate the diagnostic PC groups. Classification by defecography was not significantly associated with manometry or EMG, but manometry and EMG were significantly associated (Phi=.54). Manometry revealed significantly higher thresholds for first sensation in the DEF group only. Motor abnormalities included reduced basal anal canal pressure in the patients with PC on both MANn and DEF and increased EAS pressures with straining in the MANn and both groups. The anorectal angle at rest and the change with straining was significantly decreased in the DEF and BOTH. Straining to finish a bowel movement and incomplete evacuation were inversely correlated with anxiety (-,50 & -.48) and depression (-.54 & -.37), but no significant differences were noted between diagnostic groups. Conclusion. Perceived straining and incomplete evacuation were important predictors of paradoxical contraction on manometry and defecography. Concordance between MANn and DEF was low and may reflect important diagnostic differences. Anorectal manometry and defecography are both important tools for differentiating chronically constipated patients with rectal emptying difficulties. • G3051
DOMPERIDONE IS SUPERIOR TO CISAPRIDE IN THE TREATMENT OF GASTRIC EMPTYING DELAY AND GASTRIC DYSRHYTHMIAS IN CHILDREN WITH DIABETES MELLITUS. S.Cucchiara. A.Franzese, M.T.Franco, G.Salvia, O.Borrelli, S.Fecarotta, L.Alfonsi. Dept Pediatrics, University of Naples, Naples, Italy. Gastric emptying (GE) delay and gastric electrical abnormalities are often described in patients with diabetes mellitus. These abnormalities can produce dyspeptic symptoms and contribute to poor glycemic control. We wished to compare the effects of two prokinetic drugs, cisapride (CIS) (0.6 mg/kg/day, tid) and domperidone (DOM) (0.9 mg/kg/day, tid) in insulin dependent diabetes mellitus (IDDM) children with GE delay and gastric dysrhythmias, without autonomic neuropathy. Of 36 patients included into the study, 30 (median age: 9 years, range: 4-15 years) completed the trial. Before and at the end of the trial (4 weeks) we measured dyspeptic scoring system (vomiting, early satiety, abdominal pain, fullness; score: 0 = absent; 2 = occasionally, slight; 4 = occasionally, moderately severe; 6 = often, markedly severe), GE time of a mixed solid-liquid meal with ultrasonogruphy of the antral area and cutaneous electrogastrography (EGG). The EGG and GE time were measured during the same session. The EGG variables were: % of normal electrical rhythm (2-4 cycles per minute [cpm]), % of tachygastria (> 4 cpm), fed-to-fasting ratio of the dominant EGG power (i.e. the power of the EGG at the dominant frequency, a variable commonly thought to be the electrical counterpart of antral contractility). Fifteen patients received CIS, 15 DOM. The two groups were comparable for symptom score, degree of gastroparesis and EGG abnormalities. Results (mean _+SD): Domperidone Cisapride pre post pre post 22.0-+3.2 9 . 3 - + 3 . 4 20.9-+2.6 17.2-+3.1 217-+15.9 168-+20.1 215+19.3 208-+21.8 62.7 -+6.4 76.7 -+5,3 64.1 -+9.9 66.8 -+9.2
- Symptomscore* - GE time (minutes)* - % of normal gastric electrical activity* - % of tachygastria* 26.1 -+4.0 17.2 -+2.3 25.2 -+8.8 22.3 -+8.6 - fed/fastingEGG power* 0,8-+0.2 1 . 5 - + 0 . 4 0.75-+0.2 0.81-+0.4 p<0.01 between post- and pre-trial values for DOM group; no difference between post- and pre-trial values for CIS group.
Conclusions: in children with IDDM and gastroparesis treatment with DOM is more effective than CIS in improving both dyspeptic symptoms and gastric emptying. Since gastric dysrhythmias are usually associated with impaired contractility, normalization of gastric electrical activity by DOM seems to play a critical role in ameliorating GE time. • G3052
INHIBITION OF GASTRIC MOTILITY BY ILEAL SHORT CHAIN FATTY ACIDS IS MEDIATED BY AN HUMORAL PATHWAY ONLY. G. Cuche, C. H. M01bert. Station de Recherches Porcines, INRA, St Gilles, France. Ileal-infused short chain fatty acids (SCFA) inhibit gastric motility in pigs (Cuche et al., 1995). The aim of this study was to evaluate the relative contribution of the afferent pathways to the SCFA-induced ileal brake in conscious pigs. A possible direct effect of SCFA after blood absorption and the stimulation of intrinsic or extrinsic nervous systems will be tested successively. The direct contribution of ileal-absorbed SCFA was investigated by the evaluation of gastric motility changes following intravenous acetate infusion (30 pmolokg-l.min -1, pH=6.8, 1 hour) v s saline (4 pigs). The role of the intrinsic nervous system was tested using SCFA mixture (60% C2, 30% C3, 10% C4, 30 pmol,kg-l-min -t, pH=6.5, 1 hour) v s saline infused within isolated Babkin loops made of the last 30 cm of the ileum (4 pigs). Ileal denervated loops consisting in revascularized Babkin loops with section of original mesenteric arcades were used to evaluate the role of the extrinsic nervous system in SCFA induced ileal brake (4 pigs). SCFA mixture and saline were infused in these loops as described for the innervated loops group. In all groups, gastric motility was assessed using three strain gauges located on the proximal, distal and terminal antrum. The amplitude of contractions was expressed as % of the maximal amplitude recorded during a control phase III. Intravenous acetate infusion did not modify gastric motility (amplitude of contractions: 41 .+ 2.3 v s 39 ,+ 2.3 %) indicating that absorbed SCFA were not involved in ileal brake triggering. Gastric motility was equally inhibited during infusion of SCFA v s saline in innervated and denervated ileal loops (amplitude of contractions: 35 .+ 1.0 v s 44 .+ 1.1% and 34 - 0.7 v s 41 -+ 1.1% for innervated and denervated loops respectively). This indicates that neither the integrity of the intrinsic nor of the extrinsic nervous system was required to activate an ileal brake towards gastric motility. Since gastric motility during ileal SCFA infusions was equally inhibited after suppression of ileal intrinsic and extrinsic innervations and because intravenous SCFA was unable to trigger gastric inhibition, it is likely that an humoral pathway is responsible only for the SCFA induced ileal brake. [1] Cuche, G., Gu&in, S., Malbert, C. H. Inhibition of gastric motility by ileal short chain fatty acids is not caloric dependent. Neurogastroenterology and Motility, 7,253, 1995. • G3053 SCINTIGRAPHIC STUDY OF COLONIC TRANSIT AFTER EATING IN PATIENTS WITH FUNCTIONAL DIARRHEA. E, Cuillerier. M. L6mann, B. Coffin, B. Flouri6, C. Cellier, D. Gambini, P. Jou&, JP Barbier, JD. Rain, JC. Rambaud, R. Jian. St-Louis, St-Lazare and Laennec Hospitals, Paris, France. Our aim was to assess colonic transit after eating in patients (patients) with functional diarrhea (FD), using a simplified scintigraphic technique. Method. The study was performed in 17 patients (6 M, 21-79 yr) and 17 healthy volunteers (6 M, 21-45 yr). FD was defined as more than 3 stools per day for > 6 ran, and no abnormality at colonoscopy, duodenal and colonic biopsies and hormone measurements. In the evening preceding the study, subjects ingested a gelatin capsule coated with methacrylate and containing Amberlite ® resin pellets, labeled with 111In. After an overnight fasting, a 1000 kcal test-meal was given. Anterior and posterior images were taken every 30 rain for 4h30 and then, after a second meal, every hour for 4 hr. Radioactivity (RI) was counted in 4 colonic regions of interest (ROIs). Resulrts. (m -+SD). Colonic transit could be assessed in 15 of the 17 patients; in 2 cases, no RI was found on the abdominal area in the morning following the capsule ingestion. Colonic transit was significantly accelerated in patients with FD compared to healthy subjects, as judged by the mean curves of RI in the left colon or in the stools, or by the progression of the geometric center (areas under the curve; P<0.05); 8/15 patients were classified as having an accelerated colonic transit on the basis of a % of RI in the left colonic at the end of the study higher than the maximal value found in healthy subjects. The number of antegrade isotopic movements was similar in FD and healthy volunteers (1.8 _+0.6/subject v s 1.9 -+ 1,4) but in FD, the number of subjects with antegrade movement covering more than 2 ROIs was greater (8/15 v s 3/17; P<0.05) and the number of retrograde movements was lower (0.1 -+0.3 vs 0.3 .+ 0.5 P=0.05). Conclusion. Colonic transit after eating was accelerated in more than 50% of patients with functional diarrhea. Our results suggest that this was mainly due to a failure of a left colonic brake.