Charlene M. Prather

Tegaserod accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome

BACKGROUND & AIMS This study evaluated the effects of a partial 5-hydroxytryptamine (5-HT)(4) agonist, tegaserod, on gastric small bowel and colonic transit in constipation-predominant irritable bowel syndrome (IBS). METHODS After a 1 week run-in period, 24 patients with constipation-predominant IBS were randomized to 1 week of tegaserod, 2 mg twice daily, or placebo treatment. Scintigraphic gastric emptying, small bowel transit, and colonic transit were determined before administration of study drug and after 1 week on the medication. Colonic transit was also measured using radiopaque markers and a single radiograph on day 5. RESULTS Gastric emptying was unaltered by tegaserod. Proximal colonic filling at 6 hours, a measure of orocecal transit, was accelerated by tegaserod (70.4% +/- 1.3% [mean +/- SEM] vs. placebo, 46.4 +/- 1.9; P = 0.015). Proximal colonic emptying half-time and geometric center at 48 hours were also accelerated by tegaserod compared with baseline, but not compared with placebo. Mean colonic transit time was similar in both groups at baseline and after drug administration (tegaserod, 59.5 +/- 2.1 hours; placebo, 62.1 +/- 2.1 hours). CONCLUSIONS Tegaserod accelerates orocecal transit, tends to accelerate colonic transit, and deserves further study in patients with constipation-predominant IBS.

The Irritable Bowel Syndrome: Mechanisms and a Practical Approach to Management

OBJECTIVE To develop a practical strategy that facilitates the management of patients with the irritable bowel syndrome (IBS). STUDY SELECTION AND DATA EXTRACTION Review of the pertinent literature published in major English-language journals for the last 25 years, describing the pathophysiology and treatment of subgroups of patients with IBS. RESULTS A stepwise approach for practical management of patients with suspected IBS is identified. The first step includes a combination of positive diagnosis of symptoms with limited investigations to exclude underlying structural or biochemical disorders. In the second step, therapeutic trials focus on alleviating the predominant symptoms. For patients with intractable symptoms, the third step combines novel tests to assess altered function and therapeutic trials to correct the dysfunction identified in the individual patient. CONCLUSIONS A practical approach has been developed for management of IBS. It is based on advances in our understanding of the mechanisms resulting in IBS and on targeting therapy to correct the dysfunctions in these patients.

Effects of an irritable bowel syndrome educational class on health-promoting behaviors and symptoms

Objective:The degree to which patient education in the areas of diet, exercise, and stress management can improve symptoms of irritable bowel syndrome (IBS) through healthier lifestyle behaviors is unknown. The aim of this study was to determine the effects of outpatient education on the short and long term outcomes, and the association between health-promoting behaviors and symptoms.Methods:Penders Health Promotion Model provided the theoretical framework. The study had a prospective longitudinal design. A consecutive sample of 52 adult outpatients with IBS attended a structured class that taught health-promoting modifications of lifestyle. Participants completed the Health-Promoting Lifestyle Profile (HPLP) and selected items from a Bowel Disease Questionnaire (BDQ) before the class and 1 month and 6 months later. Spearman rank correlations were used to assess the association between HPLP and symptom scores. Wilcoxon rank sum tests compared changes in scores versus their baseline values.Results:Response rates at 1 and 6 months were 75% and 83%, respectively. Results revealed significant 1- and 6 month-improvements in pain and Manning symptoms (p < 0.01) and in some HPLP scores (exercise at 1 month, p < 0.05; stress management at 6 months, p < 0.01). Significant associations were found between some, but not all, HPLP and symptom scores over time.Conclusion:A structured IBS educational class for patients with IBS improved symptoms and some health-promoting behaviors. However, relationships among specific behaviors and specific symptoms did not consistently correspond with this improvement.

Near-total completion gastrectomy for severe postvagotomy gastric stasis: Analysis of early and long-term results in 62 patients

The aim of this study was to evaluate results of completion gastrectomy for severe postgastrectomy gastric stasis. A total of 51 women and 11 men underwent completion gastrectomy for gastric stasis between 1985 and 1996; follow-up was complete in 98% at 5.4 ±-5 years. All patients had modified Visick scores preoperatively of grade III (37%) or IV (63%). Presentation included combinations of nausea, vomiting, postprandial pain, chronic abdominal pain, and chronic narcotic use. All had undergone prior vagotomy and had a median of four previous gastric operations. Hospital mortality was zero. Complications occurred in 25 patients (40%) and included the following: narcotic withdrawal syndrome (18%), ileus (10%), wound infection (5%), intestinal obstruction (2%), and anastomotic leak (5%). All or most symptoms were relieved in 43% (Visick grade I or H), but 57% of the patients remained in Visick grade HI or TV. Nausea, vomiting, and postprandial pain were reduced from 93% to 50%, 79% to 30%, and 58% to 30%, respectively (P <0.05), but chronic pain, diarrhea, and dumping syndrome were not significantly affected. Univariate analysis revealed no preoperative characteristic to be predictive of good outcome. Logistic regression analysis suggested that the combination of nausea, need for total parenteral nutrition, and retained food in the stomach predicted a poor outcome (P <0.05). Completion gastrectomy is successful in 43% of patients. The combination of nausea, need for total parenteral nutrition, and retained food at endoscopy are negative prognostic factors.

Evaluation and Treatment of Constipation and Fecal Impaction in Adults

Constipation is a common complaint that physicians encounter. Understanding the patients definition of constipation and focusing the history and physical examination provide clues to the underlying cause. Initially, an empiric treatment trial is recommended. For patients with warning symptoms or those in whom treatment fails, a limited diagnostic work-up is suggested. Tests of physiologic function are reserved for patients whose condition is refractory to therapy. Fecal impaction can be considered extreme constipation. The pathophysiologic features of fecal impaction are discussed, and recommendations are provided for treatment and prevention.

Videoendoscopic diagnosis of esophageal motility disorders

BACKGROUND Esophageal motility disorders are usually diagnosed by manometry. We evaluated videoendoscopy as a diagnostic test. METHODS In this study, 20 patients with achalasia, 13 with scleroderma, and 33 control subjects had a standard endoscopic examination followed by protocol videotaping of swallows to observe contractions in the esophagus and in the lower esophageal sphincter. Tapes were later reviewed by 2 blinded observers who recorded their motility findings and diagnoses. RESULTS In the mid esophagus at 25 cm, lumen-occluding peristaltic contractions were identified in 26 of 33 control subjects versus 1 of 20 achalasia (p < 0.001) and 3 of 13 scleroderma patients (p < 0.005). As viewed in the lower esophagus, the lower esophageal sphincter opened normally in 31 of 33 control subjects versus 1 of 20 achalasia (p < 0.001). In scleroderma, the sphincter never closed in 12 of 13 patients (p < 0. 001 versus control subjects). A diagnostic sequence of sphincter opening followed by contraction in the esophageal body and subsequent sphincter closing was seen in 33 of 33 control subjects, 2 of 20 achalasia, and 1 of 13 scleroderma patients (both, p < 0. 001). The observers made the correct diagnosis in 96% of cases. CONCLUSIONS Achalasia and esophageal scleroderma can be identified by endoscopic observation of motility. This procedure may represent an adjunctive diagnostic test to manometry.

Antral axial forces postprandially and after erythromycin in organic and functional dysmotilities

Our aims were to measure antral axial forces in patients with suspected upper gut dysmotilities and to compare the number of antral contractions detected by an axial force catheter and by manometric sensors in the distal antrum and pylorus. Fifteen patients (2 men, 13 women; mean age 42 years) underwent studies for 3 hr fasting, 2 hr postprandially, and up to 60 min after intravenous erythromycin (3 mg/kg). Seven patients had gastroparesis or chronic intestinal pseudoobstruction, five functional disease, and three subacute obstruction. Postprandially, the number of peaks detected by the two methods was not significantly different; however, after erythromycin, the axial catheter detected more contractions (P=0.02). Erythromycin significantly increased the number of postprandial axial forces (from 1.2±0.3/min to 2.5±0.3/min,P≤0.01) in the whole group and in the organic dysmotility group (P=0.01). Erythromycin significantly increases the number of axial forces in functional and organic upper gut dysmotilities, but the axial force catheter is not advantageous over manometry for postprandial measurements of antral motility.

Virtual endoscopy vs real endoscopy: a comparative evaluation

Virtual endoscopy techniques have significant clinical promise for patient screening and may replace some real endoscopic examinations. Visualizations that mimic reality to an acceptable degree are a key factor for physician acceptance of virtual endoscopy. Clinicians must be able to interact with and quickly understand the visualizations. We are studying image generation paradigms and parameters within each paradigm to evaluate the important of various factors in the clinical utility of virtual endoscopy. By involving clinicians at each step of the study, we seek to better understand the parameters that clinicians find most important, and to evaluate the strengths and weaknesses of each image generation paradigm.

The Anatomy and Physiology of the Upper Esophageal Sphincter in the Opossum Model

As the field of otolaryngology expands, understanding of pharyngoesophageal swallowing disorders has become increasingly more important. In previous studies the opossum has been suggested to be the prototype animal model for the study of esophageal motility. The goal of this study was to standardize its use in experimental evaluation of pharyngoesophageal swallowing disorders. Neck exploration of 13 animals revealed consistent anatomic findings that are similar to those of humans. The cricopharyngeous muscle is approximately 3 mm wide and consists of fibers that arise from the cricoid cartilage on one side and loop around to insert into the cricoid cartilage on the opposite side. The inferior constrictor consists of oblique fibers that arise from the lateral walls of the thyroid and insert into the posterior median raphe. This posterior median raphe has fibrous attachments to the buccopharyngeal fascia. The recurrent laryngeal nerve lies in the tracheoesophageal groove on each side of the esophagus. The muscles of the upper esophageal sphincter are striated like and in humans. Manometric evaluation of the upper esophageal sphincter was done under light anesthesia. Computerized solid-state equipment with a circumferential transducer catheter was used for 13 studies. Ten swallows for each animal were averaged, and the measured manometric parameters were compared. The mean resting upper esophageal sphincter (UES) pressure was 37 + 7.2 mm Hg, the mean residual UES pressure was 14.i + 4.5 mm Hg, and the mean duration of UES relaxation was 278 msec _+ 209 msec. The mean peak pharyngeal pressure was 179 + 43.5 mm Hg, and the mean duration of pharyngeal contraction was 455.11 _+ 81.7 msec. The mean time for the commencement of UES relation began 56.2 _+ 86.2 msec after the beginning of pharyngeal contraction and ended 114.6 +_ 88.7 msec prior to the end of pharyngeal contraction. On the basis of these studies, we conclude that solid-state equipment with a circumferential transducer is an excellent means of measuring the dynamics of the complex events of swallowing. The opossum provides an excellent basis for the basic science study of normal and abnormal swallowing in an animal model.