Alain Watier

Standardization of a simplified scintigraphic methodology for the assessment of gastric emptying in a multicenter setting

OBJECTIVE:Scintigraphy remains the gold standard to study gastric emptying. The technique is onerous and normal values vary between centers. Standardized protocols, although desirable, are not presently available. We validated a simplified scintigraphic protocol in a multicenter setting.METHODS:In 69 healthy volunteers from seven Canadian institutions, gastric emptying of a standard meal (99mTc- labeled beef liver) was assessed by scintigraphy every 10 min for 1 h, then every 20 min for the next 2 h. Gastric retention was fitted to a power exponential model, Propt={−(κt)β} with Propt= proportion of retention at time t, either using all 13 time intervals (conventional technique) or using measurements at 0, 1, 2, and 3 h (simplified technique).RESULTS:The power exponential model yielded identical emptying curves and T ½ values with both techniques. Gastric emptying was more rapid in men than in women < 35 yr (p < 0.01) and in younger than in older men (p < 0.005). Gastric emptying was slower in women from Québec than in women from Ontario (p < 0.04). Gastric retention was similar at 1, 2, and 3 h among the seven centers. Gastric emptying of a beef liver meal was slower than that of a low fat egg substitute (p < 0.03).CONCLUSIONS:A simpler scintigraphic approach, using four rather than 13 samples, provides results comparable to those of the conventional technique. This simpler approach provides an economical, yet accurate, alternative to the techniques presently used and is applicable to a multicenter setting.

Comparing pain modulation and autonomic responses in fibromyalgia and irritable bowel syndrome patients.

Objectives:Past studies confirm that patients with fibromyalgia (FM) and irritable bowel syndrome (IBS) show similar pain processing dysfunctions, such as reduced pain inhibition and aberrant autonomic nervous system (ANS) responses. However, patients with FM and IBS have rarely been investigated in the same study. The aim of the present study, therefore, was to compare descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls (HC). Methods:Female patients with FM (n=10), IBS (n=13), and HCs (n=10) were exposed to multiple cold water (12°C) immersions to study pain sensitivity and descending pain inhibition. Heart rate variability was also assessed during immersions. Results:Pain intensity scores were highest in FM, intermediate in IBS, and smallest in HCs. In contrast, pain inhibition was absent in FM, intermediate in IBS, and strongest in HCs. Importantly, controlling for differences in pain inhibition abolished group differences in pain sensitivity. Heart rate variability analyses confirmed that, in response to mild levels of pain, patients with FM showed greater sympathetic activity whereas HCs showed greater parasympathetic activity. Patients with IBS showed intermediate ANS responses. Discussion:Our results confirm the presence of graded levels of somatic hyperalgesia across patients with IBS and FM. A similar pattern of result was observed for pain inhibitory dysfunctions. These pain processing changes were accompanied by abnormal autonomic responses, which maintained patients (principally patients with FM) in a state of sympathetic hyperactivity. Results suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.

Urorectodynamics in patients with colonic inertia.

Sixteen female patients with colonic inertia and 12 control women underwent manometric evaluation of their bladder and rectal cavities. After subcutaneous injection of 0.035 mg./Kg. bethanechol, bladder intraluminal pressure increased by over 15 cm. water in 5 patients (31 per cent) and in none of the control group; maximal pressure after injection was 11.5 +/- 1.6 cm. H2O (mean +/- SE) in patients and 8.5 +/- 1 in controls (p less than 0.025). The intraluminal rectal pressure reached 23 +/- 4 cm. H2O in patients and only 11.9 +/- 1.4 in controls (p less than 0.0025). Time taken to reach a peak pressure was faster in patients both in bladder (17.4 +/- 0.7 vs. 19.8 +/- 1.2 minutes; p less than 0.01) and in the rectum 914.6 +/- 0.8 vs. 16.3 +/- 1.2; p less than 0.025). These findings and the clinical presentation suggest an autonomic neuropathic lesion in this group of patients.

Approche globale des douleurs pelvipérinéales chroniques : du concept de douleur d’organe à celui de dysfonctionnement des systèmes de régulation de la douleur viscérale

OBJECTIVEnAnalysis of complex pelvic and perineal pain.nnnMATERIAL AND METHODSnReview of the literature concerning the various types of functional pelvic pain.nnnRESULTSnVarious forms of pelvic pain are frequently associated: painful bladder syndrome (interstitial cystitis), irritable bowel syndrome, endometriosis pain, vulvodynia, chronic pelvic pain syndrome (chronic prostatitis). Pelvic pain is often associated with fibromyalgia or complex regional pain syndrome (reflex sympathetic dystrophy). The pathophysiological mechanisms involved in these syndromes are all very similar, suggesting a triggering element, neurogenic inflammation, reflex muscular and autonomic responses, central hypersensitization, emotional reactions and biopsychosocial consequences.nnnDISCUSSIONnThe concept of visceral pain is evolving and, in practice, complex pelvic pain can comprise neuropathic components, complex regional pain syndrome components, hypersensitization components, and emotional components closely resembling posttraumatic stress syndrome.nnnCONCLUSIONSnWhen pain cannot be explained by an organ disease, the pain must be considered to be expressed via this organ. Chronic pelvic and perineal pain can become self-perpetuating and identification of its various mechanisms can allow the proposal of individually tailored treatments.

Syndrome de l’intestin irritable, syndrome du releveur, proctalgie fugace et douleurs pelvipérinéales chroniques

OBJECTIVESnTo define functional gastrointestinal pain, irritable bowel syndrome (IBS), levator ani syndrome, proctalgia fugax, the pathophysiology of these syndromes and the treatments that can be proposed.nnnMATERIAL AND METHODSnReview of articles published on the theme based on a Medline (PubMed) search and consensus conferences selected according to their scientific relevance.nnnRESULTSnIBS is very common. Patients report abdominal pain and/or discomfort, bloating, and abnormal bowel habit (diarrhoea, constipation or both), in the absence of any structural or biochemical abnormalities. IBS has a complex, multifactorial pathophysiology, involving biological and psychosocial interactions resulting in dysregulation of the brain-gut axis associated with disorders of intestinal motility, hyperalgesia, immune disorders and disorders of the intestinal bacterial microflora and autonomic and hormonal dysfunction. Many treatments have been proposed, ranging from diet to pharmacology and psychotherapy.nnnDISCUSSIONnPatients with various types of chronic pelvic and perineal pain, especially those seen in urology departments, very often report associated IBS. This syndrome is also part of a global and integrated concept of pelviperineal dysfunction, avoiding a rigorous distinction between the posterior segment and the midline and anterior segments of the perineum.