Konrad Schulze

Long-Term Efficacy of Biofeedback Therapy for Dyssynergic Defecation: Randomized Controlled Trial

OBJECTIVES:Although biofeedback therapy is effective in the short-term management of dyssynergic defecation, its long-term efficacy is unknown. Our aim was to compare the 1-year outcome of biofeedback (manometric-assisted pelvic relaxation and simulated defecation training) with standard therapy (diet, exercise, laxatives) in patients who completed 3 months of either therapy.METHODS:Stool diaries, visual analog scales (VASs), colonic transit, anorectal manometry, and balloon expulsion time were assessed at baseline, and at 1 year after each treatment. All subjects were seen at 3-month intervals and received reinforcement. Primary outcome measure (intention-to-treat analysis) was a change in the number of complete spontaneous bowel movements (CSBMs) per week. Secondary outcome measures included bowel symptoms, changes in dyssynergia, and anorectal function.RESULTS:Of 44 eligible patients with dyssynergic defecation, 26 agreed to participate in the long-term study. All 13 subjects who received biofeedback, and 7 of 13 who received standard therapy, completed 1 year; 6 failed standard therapy. The number of CSBMs per week increased significantly (P<0.001) in the biofeedback group but not in the standard group. Dyssynergia pattern normalized (P<0.001), balloon expulsion time improved (P=0.0009), defecation index increased (P<0.001), and colonic transit time normalized (P=0.01) only in the biofeedback group.CONCLUSIONS:Biofeedback therapy provided sustained improvement of bowel symptoms and anorectal function in constipated subjects with dyssynergic defecation, whereas standard therapy was largely ineffective.

Ulcerative ileitis encountered at ileo-colonoscopy: likely role of nonsteroidal agents.

BACKGROUND & AIMS Ileoscopy is increasingly practiced, but it is unclear what diagnostic and management decisions should ensue if ulcerations are encountered. METHODS The lead author identified 40 patients with ulcerative ileitis during 1900 consecutive ileoscopies in a community practice. We analyzed the clinical, endoscopic, and histopathologic findings in these patients and related them to drug usage. RESULTS Although most patients were asymptomatic, ileitis likely contributed to blood loss in 14 and to right lower quadrant pain in one. Endoscopy revealed multiple, discrete, fibrin-covered ulcerations in the prevalvular segment with patches of erythematous stippling, normal intervening mucosa, and occasional mucosal scars or webs. Histologic findings included focal superficial neutrophilic infiltrates, edema, mucosal hemorrhage, lymphatic dilatation, fibromuscular hyperplasia, prominence of the muscularis mucosae, and antral and Paneth cell metaplasia. Granulomas, fissure ulcers, and apoptosis were notably absent. No specific disease process developed in a median follow-up of 3.2 years. Thirty-three patients admitted recently taking nonsteroidal anti-inflammatory drugs (NSAIDs), notably: enteric-coated aspirin at 325 mg/day or less (19), selective cyclooxygenase-2 inhibitors (5), and nonacetylated salicylates (3). Three fourths of nonsteroidal users were taking agents with low or intermediate gastroduodenal toxicity. Lesions disappeared after drug withdrawal, and reappeared on resumption. CONCLUSIONS Ileoscopy during colonoscopy may identify an ulcerative ileitis. This lesion likely contributes to gastrointestinal blood loss and other clinical manifestations, and likely is caused by NSAID use, including those usually associated with low toxicity or at low doses. Features of NSAID-ileitis overlap with Crohns ileitis, but differentiation of the 2 entities is critical for appropriate management.

Fundic Balloon Distension Stimulates Antral and Duodenal Motility in Man

Distension of the intestine triggers the peristaltic reflex, which consists of orad contraction and aborad relaxation. Whether a similar response occurs in the human stomach is unclear. Our aim was to investigate the antral and duodenal motor response(s) to mechanical distension of the proximal stomach. In six healthy volunteers, a large compliant balloon was placed in the proximal stomach. Alongside this a water-perfused manometry probe with six sensors was placed to measure the antral and duodenal motility. Pressure activity was assessed before and during balloon distension. In five of six subjects, balloon distension triggered a salvo of antral pressure waves within 3–5 min, some of which propagated into the duodenum. The amplitude of waves was higher (P < 0.05) at the antrum than at the duodenum. The area under the curve of pressure waves was higher (P < 0.05) at the antrum than at the duodenum. In conclusion, distension of the proximal stomach, at or below the threshold for perception, evokes phasic motor activity in the antrum and duodenum. Thus, the gastric response to distension differs from that observed during the intestinal peristaltic reflex.

Eosinophilic gastroenteritis involving the ileocecal area

SummaryEosinophilic gastroenteritis, an idiopathic inflammation of the alimentary canal, is characterized by infiltration of the intestinal wall by eosinophils, massive submucosal edema, and peripheral eosinophilia. It is generally confined to the gastric antrum and proximal small intestine. A young woman had an eosinophilic infiltrate that involved the distal ileum and right colon only. Barium studies showed severe narrowing and shortening of the cecum and ascending colon. Symptoms of intestinal obstruction did not respond satisfactorily to conservative measures. Adhesions over the ileocecal area as well as thickening and induration of the terminal ileum and proximal right colon were found on hemicolectomy. The remaining intestine and the peritoneal cavity were felt to be normal. Histologic examination showed a cellular infiltrate with prominent eosinophils in the mucosa, submucosal edema and fibrosis. During a 40-month follow-up period after the hemicolectomy, the patient has not shown clear evidence of recurrence or extension of the disease to the stomach or proximal small intestine. It is concluded that idiopathic eosinophilic gastroenteritis may primarily involve the ileocecal area. In that location it must be specifically differentiated from intestinal tuberculosis, amebiasis, and Crohns disease.

Matrix Composition in Opossum Esophagus

The esophagus of mammalian species is organized into mucosa, connective tissue, and muscle, but little is known about the matrix of these layers. We studied by immunohistochemistry the distribution of collagens, fibronectin, versican, and elastin in the smooth muscle segment of the American opossum. Cryosections were exposed to specific antibodies and fluorescent-stained using conjugates of rhodamine or isothiocyanate. Staining was scored by two observers. We found that collagen I was prominent in the submucosa and in the muscular septa; collagen III formed fibrillar meshes in the lamina propria and the submucosa but was virtually absent from the epithelial and muscular layers; collagen IV was restricted to the base of the epithelium; collagen V, in contrast to collagen III, was prominent in epithelium and muscularis mucosae and sparse in muscular septa and submucosa. Fibronectin distribution followed collagen III; it formed layers in lamina propria and submucosa and strands in muscle septa and between individual muscle cells. Versican distribution followed collagen V; it was prominent in large muscle septa and formed thick sheets at the boundaries of submucosa/circular muscle and of circular/longitudinal muscle. We also determined the tissue contents of protein, hexuronic acid, and fibronectin. The mucosal layers exceeded the muscular layers in their content of hexuronic acid and fibronectin but not protein. We conclude that individual layers of the smooth muscle esophagus each have their own characteristic matrix. Lamina propria and submucosa are similar with regard to fiber orientation but lamina propria contains relatively more collagen III (small fibril) and submucosa comparatively more collagen I (large fibril). Nonfibrillar collagen V and versican are particularly prominent specifically on the boundaries between contracting muscle tissue and connective tissue framework.

Esophageal pressure topography, body position, and hiatal hernia.

Introduction: Whether body position affects lower esophageal sphincter (LES) function and detection of hiatal hernia is unknown. Moreover, the yield of high-resolution esophageal pressure topography (HREPT) when compared with endoscopy for detection of hiatal hernia is unclear. Aim: The aims of this study were to examine (a) the effects of body position (standing vs. supine) on LES function, and (b) to determine the diagnostic yield of HREPT and endoscopy for detection of hiatal hernia. Methods: A total of 50 subjects underwent both HREPT and endoscopy. The manometric/topographic changes of LES were examined in both supine and standing positions. Endoscopy assessed presence and length of hiatal hernia. Diagnostic agreement was compared between HREPT and endoscopy. Results: The resting LES pressure was higher (P=0.0001), its mean length was longer (P=0.0003), and length of high-pressure zone was longer (P=0.0001) in the standing position compared with the supine position. HREPT detected twice as many subjects with hiatal hernia in standing (P=0.0001) compared with supine position or endoscopy with significant new diagnostic information (79%). Endoscopy detection rate (34%) was similar to supine manometry with good diagnostic agreement (77%) between HREPT and endoscopy. Hiatal hernia length was longer (P=0.0001) with HREPT in standing position compared with endoscopy. Conclusions: Body position significantly affects in the LES function and its measurements. HREPT when performed on standing position offers the best yield for detection of hiatal hernia and is superior to endoscopy or supine manometry.