Maximilian Bittinger

Autonomic dysfunction and the gastrointestinal tract.

Autonomic neuropathy of the gastrointestinal tract may represent a primary disorder, but much more often it is secondary due to systemic disorders like diabetes mellitus. This review gives an overview about the common clinical manifestations and the principles and limitations in diagnostic work-up of autonomic dysfunction of the gastrointestinal tract. Diagnostic evaluation usually includes a combination of screening tests for autonomic neuropathy and specialized diagnostic procedures for the detection of sequela of autonomic neuropathy in gastrointestinal motility.

Pnematic Dilation in Achalasia

Pneumatic dilation is the most common first-line therapy for the treatment of achalasia. The aim of dilation is a controlled disruption of circular muscle fibres of the lower esophageal sphincter to reduce the functional obstruction. Several types of dilators and different dilation techniques are used, but the achieved results are similar. The mean success rate is about 80% in the short term, but some patients need redilation in the further course (particularly young patients). Best long term results are obtained if the lower esophageal sphincter pressure can be reduced below 10 mmHg. Major complications are rare after pneumatic dilation; the most serious complication is esophageal perforation, which occurs at a mean rate of about 2.5%. Considering the pros and cons of other effective forms of treatment of achalasia (esophagomyotomy and intrasphincteric injection of botulinum toxin), pneumatic dilation is still the treatment of choice in the majority of patients with achalasia.

Gastric ischemia following endoscopic submucosal dissection of early gastric cancer

Procedure-related complications of gastric endoscopic submucosal dissection (ESD) mainly include bleeding and perforation. Another complication is stricture formation after ESD close to the pylorus or close to the gastroesophageal junction. We report a case of an 86-year-old patient who developed extensive gastric ischemia after ESD for early gastric cancer. We suppose that the most likely reason for the ischemia was the submucosal injection of a large volume of a mixture of glycerol (10%) and epinephrine (dilution 1: 50 000) that was used, in combination with the patient’s underlying cardiovascular comorbidity. Gastric ischemia as a complication of gastric ESD has not been described previously. A conservative treatment approach seems justifiable. However, close endoscopic follow up for early recognition and treatment of a resulting stricture is recommended.

Postprandial gastric relaxation in achalasia

Background In achalasia the incidence of autonomie neuropathy is increased, indicating that achalasia is not a disease of the oesophagus only. Little information is available concerning the function of the stomach in achalasia. We compared the postprandial gastric fundus relaxation in patients with achalasia to that of healthy controls. Methods In six patients with achalasia and six healthy controls postprandial fundus relaxation after a liquid test meal (500 ml, 500 kcal) was studied using an intragastric bag connected to an electronic barostat. The postprandia gastric relaxation was measured as an increase of intragastric bag volume; bag pressure was set at a constant level of 1 mmHg above the intra-abdominal pressure. All data are given as means ± SEM, and the Mann-Whitney test was used for statistical analysis. Results The intragastric volume before ingestion of the test meal was not different between groups. The maximum relaxation in patients with achalasia was significantly lower than in controls (132 ± 46 ml vs 238 ± 70 ml, P < 0.02). Postprandial relaxation was diminished and shortened in patients with achalasia as compared with controls. Similarly, the area under the volume curve was significantly smaller in patients with achalasia than in controls (29.8 ± 28.9 ml/h vs 102.9 ± 58.4 ml/h, P < 0.03) consistent with a diminished postprandial relaxation. Conclusion Patients with achalasia show a decreased postprandial gastric relaxation compared with healthy controls. We hypothesize that the neural damage in achalasia is not restricted to the oesophagus, but also involves the proximal stomach.

24-hour oesophageal motility in gastro-oesophageal reflux disease (GORD) : increased occurrence of simultaneous contractions

Impaired oesophageal peristalsis may play a major pathogenetic role in gastro-oesophageal reflux disease (GORD). Therefore 55 patients with suspected GORD were studied simultaneously by ambulatory 24-hour pH and pressure monitoring with three pressure transducers (3, 8 and 13 cm above the lower oesophageal sphincter) in order to to test for a relationship between oesophageal motility and GOR. Twenty-one patients (38%) had pathological reflux; these patients had significantly more simultaneous contractions than patients without pathological GOR (30.1 +/- 3.3% vs. 19.0 +/- 1.8%, P = 0.002, mean +/- SEM). Further analysis revealed a significant difference between groups in the occurrence of simultaneous contractions in the mid-oesophagus (33.7 +/- 3.8% vs. 23.9 +/- 1.8%, P = 0.012), but not in the distal oesophagus (34.4 +/- 2.7% vs. 33.9 +/- 3.1%, P = 0.90). In addition, a moderate but highly significant correlation between the rate of simultaneous contractions and reflux time was found (r = 0.463, P = 0.0005). Mean amplitude and mean duration of the contractions were no different between groups, neither in the proximal (43.4 +/- 3.3 mmHg vs. 44.9 +/- 1.9 mmHg, P = 0.68 and 2.4 +/- 0.2s vs. 2.5 +/- 0.1s, P = 0.50, respectively) nor in the distal oesophagus (48.8 +/- 4.6 mmHg vs. 54.2 +/- 3.4 mmHg, P = 0.34 and 3.0 +/- 0.2s vs. 2.9 +/- 0.2s, P = 0.71, respectively). It was concluded that pathological GOR is associated with an increased occurrence of simultaneous contractions in the mid, but not in the distal, oesophagus.

Chapter 32 Autonomic nervous system evaluation: diagnosis of rectal and lower gut dysfunction

The main symptoms of autonomic dysfunction of the lower gut are diarrhoea, constipation and faecal incontinence, but these symptoms are not specific. The main diagnostic procedures in the evaluation of the lower gut are transit studies with radiopaque markers, hydrogen breath tests, tests for the differentiation between osmotic and secretory diarrhoea (fasting test and/or stool analysis for electrolytes and osmolality), anorectal manometry and EMG of the anal sphincters.

Are endoscopic antireflux procedures useful

Endoscopic antireflux procedures are an alternative treatment for patients who do not desire medical therapy for gastroesophageal reflux disease. This Viewpoint assesses the success rates of endoscopic therapies and highlights the importance of selecting appropriate patients for this therapy.

Der Einfluß des Alters auf die Analsphinkterfunktion bei der Frau

ZusammenfassungDie Analsphinkterfunktion der Frau nimmt mit zunehmendem Alter ab; sowohl der innere als auch der äußere Analsphinkter sind betroffen. Da die Ausgangsdruckwerte bei Frauen niedriger sind als bei Männern, Geburtsschäden am N. pudendus hinzukommen können und deren Folgen sich oft erst nach der Menopause manifestieren, betrifft die anale Inkontinenz besonders häufig alte Frauen. Als aussichtsreiche Therapie steht das Analbiofeedbacktraining zur Verfügung.