Enrico Corazziari

U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact

Our objective was to obtain national data of the estimated prevalence, sociodemographic relationships, and health impact of persons with functional gastrointestinal disorders. We surveyed a stratified probability random sample of U.S householders selected from a data base of a national market firm (National Family Opinion, Inc.). Questions were asked about bowel symptoms, sociodemographic associations, work absenteeism, and physician visits. The sampling frame was constructed to be demographically similar to the U.S. householder population based on geographic region, age of householder, population density, household income and household size. Of 8250 mailings, 5430 were returned suitable for analysis (66% response). The survey assessed the prevalence of 20 functional gastrointestinal syndromes based on fulfillment of multinational diagnostic (Rome) criteria. Additional variables studied included: demographic status, work absenteeism, health care use, employment status, family income, geographic area of residence, population density, and number of persons in household. For this sample, 69% reported having at least one of 20 functional gastrointestinal syndromes in the previous three months. The symptoms were attributed to four major anatomic regions: esophageal (42%), gastroduodenal (26%), bowel (44%), and anorectal (26%), with considerable overlap. Females reported greater frequencies of globus, functional dysphagia, irritable bowel syndrome, functional constipation, functional abdominal pain, functional biliary pain and dyschezia; males reported greater frequencies of aerophagia and functional bloating. Symptom reporting, except for incontinence, declines with age, and low income is associated with greater symptom reporting. The rate of work/school absenteeism and physician visits is increased for those having a functional gastrointestinal disorder. Furthermore, the greatest rates are associated with those having gross fecal incontinence and certain more painful functional gastrointestinal disorders such as chronic abdominal pain, biliary pain, functional dyspepsia and IBS. Preliminary information on the prevalence, socio-demographic features and health impact is provided for persons who fulfill diagnostic criteria for functional gastrointestinal disorders.

HEPATODUODENAL BILE TRANSIT IN CHOLECYSTECTOMIZED SUBJECTS : RELATIONSHIP WITH SPHINCTER OF ODDI FUNCTION AND DIAGNOSTIC VALUE

The hepatic hilum-duodenum transit time (HHDT) was evaluated in cholecystectomized subjects to assess its relationship with the motor function of the sphincter of Oddi (SO) and its diagnostic accuracy in the detection of SO dysfunction. The study was performed in asymptomatic controls and symptomatic patients with SO dysfunction before and after sphincterotomy. HHDT showed a direct correlation with manometric SO maximal basal pressure (r=0.77;P<0.001) but not with SO phasic activity. In sphincterotomized subjects HHDT did not differ from that of the asymptomatic subjects, and HHDT, which was prolonged before sphincterotomy, normalized after sphincterotomy. HHDT had a 100% specificity and an 83% sensitivity in diagnosing SO dysfunction when compared to SO manometry. In conclusion, the cholescintigraphic HHDT is mainly related to the SO maximal basal pressure, presenting an elevated specificity and a satisfactory sensitivity in the diagnosis of SO dysfunction in cholecystectomized subjects.

Small intestine contrast ultrasonography.

The entire small bowel can be visualized on ultrasonography after ingestion of nonabsorbable, isosmotic polyethylene glycol electrolyte balanced oral solution, termed small intestine contrast ultrasonography. The aims of this study were to assess whether the ingestion of different volumes of sonographic contrast solution may differently affect (1) small bowel distention and thus its sonographic appearance and (2) the time to visualize the entire small intestine. An additional aim was to identify the minimal amount of contrast solution necessary to visualize the entire small bowel. An ultrasonographic examination of the abdomen was performed twice in six healthy subjects after the ingestion of the isosmotic polyethylene glycol solution. During the first investigation each subject was asked to drink increasing amounts of sonographic contrast solution until the jejunum was visualized at ultrasonography. During the second investigation each subject was asked to drink increasing amounts of sonographic contrast solution, not to exceed a total volume of 260 ml. At the first examination the entire small bowel was visualized 39.3 +/‐ 17 min after ingestion of 647 +/‐ 105 ml of contrast solution. At the second examination the entire small bowel was visualized 43.5 +/‐ 13.5 min (not significant with respect to the first study) after the ingestion of 239 +/‐ 32 ml of contrast solution (P < 0.01 versus the first study). The mean luminal diameter and wall thickness at three intestinal levels did not differ in the two studies and were not statistically related to the amount of ingested sonographic contrast solution. Loose stools were the only side effect and were reported after the ingestion of more than 600 ml. Ultrasonography offers reproducible information on the morphology of the contrast agent‐filled small bowel after ingestion of a wide range of volumes (175 to 820 ml) of isosmotic polyethylene glycol electrolyte balanced solution. On average, the entire small intestine could be visualized on ultrasonography by about 45 min after the ingestion of 600 ml or less of contrast solution without any side effects.

Helicobacter pylori infection in obesity and its clinical outcome after bariatric surgery

The present review summarizes the prevalence and active clinical problems in obese patients with Helicobacter pylori (H. pylori) infection, as well as the outcomes after bariatric surgery in this patient population. The involvement of H. pylori in the pathophysiology of obesity is still debated. It may be that the infection is protective against obesity, because of the gastritis-induced decrease in production and secretion of the orexigenic hormone ghrelin. However, recent epidemiological studies have failed to show an association between H. pylori infection and reduced body mass index. H. pylori infection might represent a limiting factor in the access to bariatric bypass surgery, even if high-quality evidence indicating the advantages of preoperative H. pylori screening and eradication is lacking. The clinical management of infection is complicated by the lower eradication rates with standard therapeutic regimens reported in obese patients than in the normal-weight population. Prospective clinical studies to ameliorate both H. pylori eradication rates and control the clinical outcomes of H. pylori infection after different bariatric procedures are warranted.

Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders

AIM To prospectively assess the efficacy and safety of stapled trans-anal rectal resection (STARR) compared to standard conservative treatment, and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR. METHODS Thirty patients (Female, 28; age: 51 ± 9 years) with rectocele or rectal intussusception, a defecation disorder, and functional constipation were submitted for STARR. Thirty comparable patients (Female, 30; age 53 ± 13 years), who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol, were assessed. Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment. A responder was defined as an absence of the Rome III diagnostic criteria for functional constipation. Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients, respectively. RESULTS After STARR, 53% of patients were responders; during conservative treatment, 75% were responders. After STARR, 30% of the patients reported the use of laxatives, 17% had intermittent anal pain, 13% had anal leakage, 13% required digital facilitation, 6% experienced defecatory urgency, 6% experienced fecal incontinence, and 6% required re-intervention. During macrogol therapy, 23% of the patients complained of abdominal bloating and 13% of borborygmi, and 3% required digital facilitation. No preoperative symptom, defecographic, or manometric finding predicted the outcome of STARR. Post-operative defecography showed a statistically significant reduction (P < 0.05) of the rectal diameter and rectocele. The post-operative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified, and that rectal compliance was reduced (P = 0.01). CONCLUSION STARR is not better and is less safe than macrogol in the treatment of defecation disorders. It could be considered as an alternative therapy in patients unresponsive to macrogol.

Functional magnetic resonance in the evaluation of oesophageal motility disorders.

Functional magnetic resonance imaging (fMRI) has been recently proposed for the evaluation of the esophagus. Our aim is to assess the role of fMRI as a technique to assess morphological and functional parameters of the esophagus in patients with esophageal motor disorders and in healthy controls. Subsequently, we assessed the diagnostic efficiency of fMRI in comparison to videofluoroscopic and manometric findings in the investigation of patients with esophageal motor disorders. Considering that fMRI was shown to offer valuable information on bolus transit and on the caliber of the esophagus, variations of these two parameters in the different types of esophageal motor alterations have been assessed. fMRI, compared to manometry and videofluoroscopy, showed that a deranged or absent peristalsis is significantly associated with slower transit time and with increased esophageal diameter. Although further studies are needed, fMRI represents a promising noninvasive technique for the integrated functional and morphological evaluation of esophageal motility disorders.

Further improvement after 24-month treatment with teduglutide in a patient with active Crohn’s disease and short bowel syndrome

Treatment with the glucagon-like peptide 2 (GLP-2) analog teduglutide is generally associated with clinically significant reductions (≥20% from baseline) in the parenteral nutrition (PN) volume in adult patients with short bowel syndrome (SBS) (1,2). Teduglutide has demonstrated to be safe and well tolerated, leading to restoration of intestinal functional and structural integrity. On the other hand, adverse events related to hyperplastic and hypertrophic effects have also been reported (3). Thus, patients with SBS and with fluctuations in disease activity, for example, in active Crohn’s disease (CD), have never been treated with teduglutide.

Sa1112 Pre-Operative Diarrhea and Length of Distal/Terminal Ileal Resection Do Not Predict Post-Operative Diarrhea in Crohn's Disease Patients

6 in operated patients (ns). Length of strictures was 5.6±3.4 cm at surgery, 5.7±4.1 cm at SICUS (n.s). Pre-stenotic dilatation was present in 49/81(60%) and 15/37(40.5%) strictures in non-operated and operated patients, respectively (n.s). The length and lumen diameter of strictures were 5±5 cm and 6±1 mm in non-operated and 6.6±5 cm and 5.2±1.8 mm in operated patients (n.s), respectively. There was no significant difference in the stricture site and location of CD at diagnosis, between operated and non-operated patients . Conclusions. Site, length, and degree of luminal narrowing of stricture do not differ between CD patients requiring and not requiring surgery. Severity of stricture does not appear to be the only factor of obstructive symptoms requiring surgery. It is likely that other factors contribute with stricture to indicate surgery. 1) Cosnes J et al IBD 2002; 2) Pallotta N et al IBD 2011

Sa1113 In Crohn's Disease (CD) Patients Small Bowel Prestenotic Dilatation Is Not Related to Severity Degree of Stricture

6 in operated patients (ns). Length of strictures was 5.6±3.4 cm at surgery, 5.7±4.1 cm at SICUS (n.s). Pre-stenotic dilatation was present in 49/81(60%) and 15/37(40.5%) strictures in non-operated and operated patients, respectively (n.s). The length and lumen diameter of strictures were 5±5 cm and 6±1 mm in non-operated and 6.6±5 cm and 5.2±1.8 mm in operated patients (n.s), respectively. There was no significant difference in the stricture site and location of CD at diagnosis, between operated and non-operated patients . Conclusions. Site, length, and degree of luminal narrowing of stricture do not differ between CD patients requiring and not requiring surgery. Severity of stricture does not appear to be the only factor of obstructive symptoms requiring surgery. It is likely that other factors contribute with stricture to indicate surgery. 1) Cosnes J et al IBD 2002; 2) Pallotta N et al IBD 2011

Role of TGFβ1/Smads pathway in the pathogenesis of intestinal fibrosis in Crohn’s disease

Inflammatory bowel diseases (IBD) are characterized by an intestinal fibrosis that may lead to stenosis and obstruction (Burke et al., 2007) and by disfuntions of gastrointestinal (GI) motility associated with altered functions of enteric nerves, interstitial cells of Cajal or smooth muscle (Vetuschi et al., 2006). In experimental model TGFβ1/ Smad3 signalling plays a major role in tissue fibrogenesis (Latella et al, 2009). Aim of this study was to evaluate the potential role of the TGFβ1/Smads pathway in intestinal fibrosis and to explore the possible mechanisms by which fibrogenesis induces alterations of GI motility in patients affected by CD. Evaluation of TGFβ1, CTGF, collagen I-III, Smad3/7, PDGF, C-Kit, α-SMA, and a neuronal cocktail expression and a morphometrical analysis were performed in human CD terminal ileum samples; human smooth muscle cells (HSMC) were cultured for morphofuncional and mRNA expression (RT-PCR). Histo-morphometrical evaluation of stenotic fragments showed a significantly increase of a) both intestinal fibrosis and inflammation; b) mucosa, submucosa and muscle layer thickness and c) expression of TGFβ1, CTGF, collagen I-III, Smad3, PDGF, C-Kit and α-SMA staining. HSMC obtained from stenotic tracts showed an increase of PDGF-β and collagen I-III types mRNA and an inhibition in contractile response to acetylcholine compared to pre-stenotic tracts. These data support the hypothesis that TGFβ1/Smads pathway play a central role in development and differentiation of intestinal mesenchymal cells in sustaining intestinal fibrosis in CD and could be responsible for alteration of GI motility.