Marvin M. Schuster

Operant Conditioning of Rectosphincteric Responses in the Treatment of Fecal Incontinence

Six patients with severe fecal incontinence and manomctric evidence of external-sphincter impairment were taught to produce external-sphincter contraction in synchrony with internal-sphincter relaxation. These responses were induced by rectal distention. During follow-up periods ranging from 6 months to 5 years, four of the patients remained completely continent, and the other two were definitely improved. One patient who was trained to relax her internal sphincter as well as to contract her external sphincter not only was continent but also regularly had normal bowel movements, which she had not had before. The training technic was relatively simple to apply, and learning occurred within four sessions or less. The findings highlight the importance of synchronized rectosphincteric responses in the maintenance of fecal continence, and they show that these responses can be brought under voluntary control in patients with chronic fecal incontinence, even when the incontinence is secondary to organic lesions.

Pattern recognition program for analysis of colon myoelectric and pressure data

A pattern-recognition program was developed which emulates visual scoring of colonic myoelectric and pressure recordings. It smoothes digitized data with a moving average filter, computes difference scores between successive groups of three data points, and uses the signs of these difference scores to detect the beginning and end of waves. Adjacent waves are merged if their means are closer than 1.67 times the sum of their standard deviations, and amplitude and duration criteria are used to exclude nonsignificant waves. When compared to four experienced human scorers on randomly selected records, the program agreed as well with the human scorers as they agreed with each other, and it approached the level of agreement of these observers with themselves when they were asked to rescore the same records blindly four to six weeks later. Human scorers agreed with themselves on 36–71% of myoelectric slow waves and on 42–88% of pressure waves, compared to 100% test-retest reliability for the pattern-recognition program. Frequency histograms of the duration of waves detected by the pattern-recognition program differed from the spectra generated by the fast Fourier transform (FFT) method. This pattern-recognition program provides an alternative to spectral analysis for the reliable and objective quantification of colonic myoelectric slow waves and pressure waves.

Dermatoglyphic (fingerprint) evidence for a congenital syndrome of early onset constipation and abdominal pain

Chronic idiopathic constipation and abdominal pain are the most common gastrointestinal symptoms but their cause is rarely determined; therefore, they usually are called functional. To determine if congenital factors play a role in these disorders, we examined dermatoglyphic (fingerprint) patterns, a congenital marker, in 155 consecutive patients with gastrointestinal complaints. Sixty-four percent of patients with constipation and abdominal pain before age 10 yr had one or more digital arches, compared with 10% of patients without constipation and abdominal pain (p less than 0.001). Seventy percent of constipated patients with arches had the onset of symptoms before age 10 yr compared with 23% of constipated patients without arches (p less than 0.001) and 14% of patients with symptoms other than constipation (p less than 0.001). Compared with an age- and sex-matched sample of patients without arches, patients with arches had a higher prevalence of constipation and abdominal pain before age 10 (p = 0.003), were more likely (p less than 0.001) to have chronic intestinal pseudoobstruction (an organic disorder), and were less likely (p = 0.013) to have irritable bowel syndrome (a functional disorder). Identification of a congenital marker, digital arches, associated with early onset constipation and abdominal pain may help to differentiate a congenital organic syndrome from functional disorders such as the irritable bowel syndrome.

PERCEPTION OF RECTAL DISTENSION IS NECESSARY TO PREVENT FECAL INCONTINENCE

Publisher Summary This chapter focuses on the perception of rectal distension, which is necessary to prevent fecal incontinence. External sphincter contraction is a voluntary response that has implications for the diagnostic assessment of incontinent patients. Failure to observe an external sphincter contraction following rectal distension may be a result of any of several causes such as sensory loss, motor impairment, motivation, and failure to learn. It is possible that some people, for example, patients with mental retardation, have never been taught to contract the external anal sphincter. Because all of these possibilities exist, diagnostic evaluation should include an assessment of sensory loss and an assessment of the strength of the external sphincter contraction when the patient is specifically told to squeeze voluntarily. Fecal incontinence, which occurs in institutionalized psychotic, senile, and retarded patients may be explained on the basis of social indifference, and biofeedback can be used effectively in the treatment of fecal incontinence.

Clinical significance of motor disturbances of the enterocolonic segment

ConclusionThe findings in ocular myopathy as well as in myotonic dystrophy suggest that, in many disorders, involvement which is thought to be restricted to a specific area may be more diffuse but undetectable by previously employed technics. What is needed are more refined and sensitive methods of selective study. It is hoped that the presently described technic is a step in that direction.

Autonomic dysfunction in chronic intestinal pseudo-obstruction

Fifteen tests were used to assess adrenergic, non-vagal cholinergic, and cardiovagal functions in 11 patients with chronic intestinal pseudo-obstruction (CIP). The three aims of this study were: 1) to ascertain the presence of and spectrum of autonomic involvement; 2) to assess the level of autonomic dysfunction; and 3) to compare the results of autonomic function tests with gastrointestinal motility patterns. Gastrointestinal motility displayed a neuropathic pattern in 10 patients. Adrenergic functions were abnormal in nine patients and non-vagal cholinergic functions in 10 patients. Cardiovagal functions were abnormal in only seven patients. The autonomic dysfunction was localized mostly to the postganglionic pathways. One patient, who had a myopathic pattern and muscle degeneration on small bowel biopsy, demonstrated normal responses to autonomic function tests. The patients with neuropathic CIP demonstrated wide-spread, mostly postganglionic autonomic dysfunction. Neuropathic CIP can occur with or without cardiovagal involvement.Fifteen tests were used to assess adrenergic, non-vagal cholinergic, and cardiovagal functions in 11 patients with chronic intestinal pseudo-obstruction (CIP). The three aims of this study were: 1) to ascertain the presence of and spectrum of autonomic involvement; 2) to assess the level of autonomic dysfunction; and 3) to compare the results of autonomic function tests with gastrointestinal motility patterns.Gastrointestinal motility displayed a neuropathic pattern in 10 patients. Adrenergic functions were abnormal in nine patients and non-vagal cholinergic functions in 10 patients. Cardiovagal functions were abnormal in only seven patients. The autonomic dysfunction was localized mostly to the postganglionic pathways. One patient, who had a myopathic pattern and muscle degeneration on small bowel biopsy, demonstrated normal responses to autonomic function tests.The patients with neuropathic CIP demonstrated wide-spread, mostly postganglionic autonomic dysfunction. Neuropathic CIP can occur with or without cardiovagal involvement.

Carcinosarcoma of the esophagus

A case of carcinosarcoma of the esophagus is presented with a review of the classic clinical endoscopic, radiologic, and histologic features. The polypoid pattern of growth of carcinosarcoma results in early obstruction. Local invasion or metastases occur late, if at all. The diagnosis of carcinosarcoma is suggested when biopsy or cytological washings of the pedunculated lesion reveals carcinoma, since pedunculated polypoid carcinoma of the esophagus is very unusual. This neoplasm, although rare, has a better prognosis than carcinoma of the esophagus. Early recognition based on the described characteristic features is emphasized.