Jaime Zighelboim

Visceral perception in irritable bowel syndrome : rectal and gastric responses to distension and serotonin type 3 antagonism

We wished to determine if visceral perception in the rectum and stomach is altered in patients with irritable bowel syndrome and to evaluate the effects on visceral sensation of 5-HT3 receptor blockade. Twelve community patients with diarrhea-predominant irritable bowel syndrome and 10 healthy controls were studied in a double-blind, randomized, placebo-controlled study. Using two barostats, the stomach and rectum were distended, with pressure increments of 4 mm Hg, from 10 to 26 mm Hg; visceral perception was measured on an ordinal scale of 0–10. Personality traits were measured using standard psychological methods, and somatic pain was evaluated by immersion of the nondominant hand in cold water. The effect of 5-HT3 antagonism was tested with a single intravenous dose of ondansetron at 0.15 mg/kg. Gastric perception was higher in irritable bowel syndrome, but rectal distension was perceived similarly in irritable bowel syndrome and controls. Pain tolerance to cold water was also similar in irritable bowel syndrome and controls. Ondansetron induced rectal relaxation and increased rectal compliance but did not significantly alter gastric compliance or visceral perception. Psychological test scores were similar in patients and controls. We conclude that in this group of psychologically normal patients with irritable bowel syndrome, who were not chronic health-care seekers, visceral perception was normal. Ondansetron did not alter gut perception in health or in irritable bowel syndrome.

Endoscopic Nd: YAG laser coagulation of bleeding from radiation proctopathy

Hematochezia from mucosal vascular lesions usually confined to the rectum represents an uncommon but problematic late complication of pelvic radiotherapy. We studied 47 patients with medically refractory hematochezia resulting from radiation-induced rectosigmoid mucosal vascular lesions. All lesions were endoscopically coagulated with Nd:YAG laser. Median duration of hematochezia before laser therapy was 11 months, despite previous medical treatment (98%) or bypass colostomy (6%). Within 3 to 6 months after laser treatment, the number of patients with daily hematochezia fell from 40 (85%) to 5 (11%; p < 0.001), and the median hemoglobin level increased from 9.7 gm/dl to 11.7 gm/dl (p < 0.001). Complications occurred in three patients (6%); no deaths occurred. The condition in six patients (12.8%) was not improved by laser treatment. Two patients (4%) ultimately required surgical treatment for bleeding control. On the basis of symptomatic, hematologic, and endoscopic responses, Nd:YAG laser photocoagulation controlled bleeding from radiation proctopathy in most patients with an acceptably low morbidity. Patients with sigmoid colon involvement responded less favorably. Endoscopic laser photocoagulation should be considered before surgical intervention for treatment of hematochezia from radiation proctopathy.

Primary colonic lymphoma. Clinical presentation, histopathologic features, and outcome with combination chemotherapy.

Primary colonic lymphomas are rare, but we identified 15 cases at our institution between 1973 and 1992. They comprised 5.8% of all cases of gastrointestinal lymphoma (15 of 259) and 0.16% of all cases of colon cancer (15 of 9,193) during the last 20 years. The most common presenting symptoms were abdominal pain and weight loss (40% each). In seven patients (47%), a palpable abdominal mass was noted on the initial physical examination. The most frequent site of involvement was the cecum (73%). Histologically, six (40%) were classified as high-grade and nine (60%) as intermediate-grade non-Hodgkins lymphoma. The tumors usually presented at an advanced stage: in 13 of 15 patients (87%), the lymphoma had spread to the adjacent mesentery, the regional lymph nodes, or both when first diagnosed. The 5-year survival rate was 27% for all patients and 33% (4 of 12) for patients treated with combination chemotherapy. Two patients relapsed after 8 years of complete remission. Primary colonic lymphomas have an aggressive behavior and only a marginal response to surgery and combination chemotherapy.

What are functional bowel disorders

Purpose: Visceral hypersensitivity is considered to be the most important pathophysiological marker for the functional gastrointestinal disorders (FGIDs). Studies evaluating visceral hypersensitivity in patients with FGIDs are mostly invasive and complicated. A hyperactive gag refl ex is associated with various psychosomatic disorders, and we postulated this could provide a new non-invasive disease marker in functional GI conditions. Aim: To evaluate the gag refl ex response in patients with documented functional gastrointestinal disorders and organic gastrointestinal diseases. Methods: Th e study to date included 150 patients who were referred for endoscopy. Evaluation of the gag refl ex response was standardized; a single investigator blinded to clinical status touched the posterior part of the tongue and the posterior pharyngeal wall with a cotton swab. Participants reported the perception of discomfort by a score (0-4: 0-absent, 1 mild, 2-moderate, 3-severe, 4-very severe). Also the examiner recorded participants response by an objective clinical scale (None/0: no response, Mild/1: grimace but tolerable, Moderate/2: facial fl ushing, Severe/3: facial fl ushing with cough or lacrimation, restlessness, retching, Very severe/ 4: vomiting or retching). Th e medical records of the 150 subjects were reviewed to identify the clinical diagnosis (functional, organic, healthy controls). Logistic regression was used to evaluate whether gag refl ex scores could distinguish functional disorders from organic disease or healthy controls. Results: Among 150 participants, 22 had functional GI disease (mean age, 56 +/-14), 73 had organic disease (mean age, 52 +/-14), and 55 were asymptomatic subjects (mean age, 59 +/-11). No association (univariate, or adjusted for age and gender) of subjective or objective gag refl ex scores with disease status was detected (Table). Conclusion: Th e gag refl ex does not appear to be a useful predictor for functional gastrointestinal disorders. Supported by the University of Melbourne. 1331

Methods for studying intestinal sensitivity and compliance: in vitro studies of balloons and a barostat

Abstract The aim of this study was to compare in vitro various methods for recording intestinal sensitivity and compliance. Relationships between volume and pressure were determined in segments of penrose tubing and pig gut (‘artificial intestine’) using pressure increments of 2 mmHg (0–24 mmHg). We tested two direct methods of distension of the entire segments (by syringe inflation and the Mayo barostat); we also used three different balloon devices for indirect distension (a 10 cm polyethylene barostat bag, a 10 cm latex condom balloon and a 6 cm latex condom balloon). Maximal distending diameters of the recording systems were measured by injecting from 0 to 160 mL of air. The elastic properties of the balloons were also tested by distensions in air and in rigid tubes. All recording systems accurately detected a lesser compliance of the penrose drain as compared to pig gut. In absolute terms, only the compliance measured with a polyethylene barostat bag distended with a syringe was not different from the compliance of the segment as measured directly. The bellows of our barostat and the latex balloons had significant intrinsic compliances which interfered with the recorded pressure‐volume curves. On the other hand, highly compliant plastic bags recorded most faithfully the compliance of artificial gut and that of non‐compliant rigid tubes. For comparable volumes of distension, external diameters were larger with the 6 cm latex balloon than with the 10 cm latex balloon or the 10 cm polyethylene barostat balloon. A polyethylene bag distended with a non‐compliant air injector (syringe) reflected most accurately the pressure‐volume relationships of tubular structures. The different maximal diameters assumed by the three distending devices may explain, in part, why lower volumes of distension are required to elicit symptoms with smaller distending balloons in vivo.

Response of gastric fundus to rectal distension in healthy persons

We aimed to record fundic motor activity in man using the barostat to ascertain if fundic motility is affected by rectal distension. The distal ends of two barostat tubes were placed in the gastric fundus and rectum in 10 healthy volunteers. The gastric bag was first inflated to a constant pressure level that recorded phasic motor activity as changes in volume of the air-filled bag. Baseline motor activity was recorded before, during, and after a 15-min period of constant rectal distension that was clearly perceived by all subjects but was not painful. In all subjects, continuous phasic volume changes, reflecting fundic motor activity, were recorded at a rate of 1–3/min. During rectal distension, a consistent change in mean contractile force of these phasic volume events was not detected; a decrease of more than 30% occurred in only three subjects. We conclude that fundic phasic volume changes are recordable by the barostat, but these are not substantially inhibited by rectal distension.

A patient with diarrhea, arthralgias, and fever.

A 28-year-old carpenter presented with diarrhea and abdominal pain for the past 4 months. He reported the passage of 4-6 loose stools daily, associated with crampy midabdominal pain and bloating. He also reported a 5-year history of fever. This occurred primarily in the evenings, with temperatures sometimes reaching 103’F associated with drenching sweats. In addition, there was a 5-year history of fatigue and migratory arthralgias involving the proximal interphalangeal joints, wrists, elbows, knees, ankles, tarsal areas, and metatarsophalangeal joints. The arthralgias would usually only involve a single joint at a time with pain lasting 1-4 days in a given joint area. He had been treated with enteric-coated aspirin up to 4 g/day, as wel1 as with prednisone in a dose ranging from 5 to 10 mg daily, with excellent suppression of the arthralgias, although not complete relief of the fevers. He denied use of other medications. He was married, and there was no history of sexually transmitted disease or illicit drug use. His father was Italian and mother German; there was no family history of gastrointestina1 disease. The review of systems revealed no history of gastrointestinal bleeding, weight loss, skin rash, or other symptoms. On examination, his temperature was 36.9”C. He was muscular and healthy appearing. The vita1 signs were normal. The skin and mucous membrane examinations did not reveal any abnormalities. NO pallor or clubbing was noted. Abdominal examination revealed no masses or tenderness, and recta1 examination was normal. There were several smal1 nontender axillary nodes bilaterally and several less prominent inguinal nodes, but no cervical lymphadenopathy. On cardiac auscultation, an inconstant soft systolic click was heard, but no murmurs or rubs were detected. Neurological examination was normal. Laboratory results were as fellows (normal values in parentheses): hemoglobin, 9.1 g/dL (12.9-16.6); mean corpus9.2 X lO”/L (4.1-10.9) with normal differential; platelet count, 593 X 109/L (184-370); erythrocyte sedimentation rate, 52 mm/h (0-22); reticulocytes, 1.1% (0.6-1.8); periphera1 blood smear showed microcytic red blood cells and slight abnormalities including regenerating macrocytes, schizocytes, keratocytes and stomatocytes; hemoglobin electrophoresis normal; serum iron, 9 pg/dL (50-150); total iron binding capacity, 266 pg/dL (250-400); iron saturation, 3% (14-50); vitamin B,,, 367 ng/L (281-1079); serum folate, 7.0 pg/L (2-20); sodium, 137 mEq/L (135145); potassium, 4.9 mEq/L (3.6-4.8); calcium, 9 mg/dL (8.9-10.1); phosph orus, 4.6 mg/dL (2.5-4.5); total protein, 6.1 g/dL (6.3-7.9); glucose, 78 mg/dL (70-100); alkaline phosphatase, 159 U/L (98-25 1); aspartate aminotransferase, 25 u/L (12-31); total bilirubin, 0.4 mg/dL (0.1-1.1); direct bilirubin, 0.1 mg/dL (0.0-0.3); uric acid, 4.2 mg/dL (4.3-8.0); creatinine, 1.0 mg/dL (0.8-1.2); albumin, 3.3 g/ dL (3.5-5.0); total thyroxine, 6.5 pg/dL (5.0-12.5); fecal hemoglobin, 1.6 mg/g stool (0-2); rheumatoid factor, ~30 IU/mL (0-39); antinuclear antibody negative; anti-double stranded DNA, 53 U (0-70); and rapid plasma reagin nonreactive. Stool for parasites was negative; there were some fatty crystals. Cultures of urine and blood were negative. Chest and spine radiographs were normal. An upper gastrointestinal barium series showed a normal esophagus and stomach but minimally thickened duodenal and proximal jejunal folds. A barium enema showed slightly prominent “lymphoid follicles” in the cecum and ascending colon.

Abnormalities in the shape of the duodenal loop on X-ray. Associated with idiopathic antral hypomotility?

We aimed to determine if abnormalities in the shape of the duodenal loop would be useful in identifying patients with gastroduodenal dysmotility. Retrospectively, 126 consecutive patients with suspected functional abdominal symptoms who underwent upper gastrointestinal barium x-ray studies and gastrointestinal manometry were independently evaluated. Twenty-seven patients (21%) had an abnormally shaped duodenal loop (two proximal and 25 distal) by x-ray. An abnormal duodenal loop was associated with female gender but the presenting symptoms were similar in patients with normal and abnormal loops. Antral hypomotility was significantly more common in patients with distal duodenal malrotations compared to those with a normal x-ray (56% vs 27%,P<0.01); intestinal dysmotility was not associated with the shape of the duodenal loop. The presence of an abnormally shaped duodenal loop in patients presenting with functional gastrointestinal symptoms may be a useful marker for idiopathic antral hypomotility.