Ron Schey

Medical and Surgical Management of Pelvic Floor Disorders Affecting Defecation

Pelvic floor disorders that affect stool evacuation include structural (for example, rectocele) and functional disorders (for example, dyssynergic defecation (DD)). Meticulous history, digital rectal examination (DRE), and physiological tests such as anorectal manometry, colonic transit study, balloon expulsion, and imaging studies such as anal ultrasound, defecography, and static and dynamic magnetic resonance imaging (MRI) can facilitate an objective diagnosis and optimal treatment. Management consists of education and counseling regarding bowel function, diet, laxatives, most importantly behavioral and biofeedback therapies, and finally surgery. Randomized clinical trials have established that biofeedback therapy is effective in treating DD. Because DD may coexist with conditions such as solitary rectal ulcer syndrome (SRUS) and rectocele, before considering surgery, biofeedback therapy should be tried and an accurate assessment of the entire pelvis and its function should be performed. Several surgical approaches have been advocated for the treatment of pelvic floor disorders including open, laparoscopic, and transabdominal approach, stapled transanal rectal resection, and robotic colon and rectal resections. However, there is lack of well-controlled randomized studies and the efficacy of these surgical procedures remains to be established.

Pregnancy and Postpartum Bowel Changes: Constipation and Fecal Incontinence

Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.

Mirtazapine for symptom control in refractory gastroparesis

Introduction Gastroparesis symptoms can be severe and debilitating. Many patients do not respond to currently available treatments. Mirtazapine has been shown in case reports to reduce symptoms in gastroparesis. Aim To assess the efficacy and safety of mirtazapine in gastroparetic patients. Methods Adults with gastroparesis and poorly controlled symptoms were eligible. Participants were prescribed mirtazapine 15 mg PO qhs. Questionnaires containing the gastrointestinal cardinal symptom index (GCSI) and the clinical patient grading assessment scale (CPGAS) were completed by patients’ pretreatment, at 2 weeks, and at 4 weeks. Primary end point was nausea and vomiting response to mirtazapine using the GCSI. Secondary end point was nausea and vomiting severity assessment using the CPGAS. P-values were calculated using the paired two-tailed Student’s t-test. Intention to treat analysis was used. Results A total of 30 patients aged 19–86 years were enrolled. Of those, 24 patients (80%) completed 4 weeks of therapy. There were statistically significant improvements in nausea, vomiting, retching, and perceived loss of appetite at 2 and 4 weeks (all P-values <0.05) compared with pretreatment. There was a statistically significant improvement in the CPGAS score at week 2 (P=0.003) and week 4 (P<0.001). Of the total patients, 14 (46.7%) experienced adverse effects from mirtazapine and due to this, 6 patients stopped therapy. Conclusion Mirtazapine significantly improved both nausea and vomiting in gastroparetics after 2 and 4 weeks of treatment. Side effects led to treatment self-cessation in a fifth of patients. From these data, we conclude that mirtazapine improves nausea and vomiting, among other symptoms, in patients with gastroparesis and might be useful in select patients.

Lubiprostone for the Treatment of Adult Women with Irritable Bowel Syndrome with Constipation

Irritable bowel syndrome with constipation (IBS-C) affects approximately 5% of the population in western countries. The majority of those afflicted are women. Symptoms are often detrimental to the individuals quality of life and incur high healthcare costs to society. There is no evidence to support changes in lifestyle, laxatives or over the counter supplements. Tegaserod appeared to have promising results but was promptly removed from the market due to adverse cardiovascular events. In 2008, lubiprostone (Amitiza) was approved by the US Food and Drug Administration (FDA) for the treatment of women with IBS-C. It is thought to selectively activate type 2 chloride channels in the apical membrane of the intestinal epithelial cells leading to chloride secretion. As result, sodium and water are passively secreted generating peristalsis and laxation, without stimulating gastrointestinal smooth muscle. Several trials with predominantly female patients have shown it to be effective in the treatment of IBS-C. Overall lubiprostone was safe, well tolerated and associated with mostly benign side effects. Nausea and diarrhea were the most commonly reported. Though there are no head to head comparisons with other pharmacological agents, it is our opinion that lubiprostone should be tried as a first line pharmacotherapy for women with IBS-C at a dose of 8 μg BID. Thus far, lubiprostone offers a welcome approach to our narrow therapeutic armamentarium. Further understanding of its mechanism of action may provide additional insight into the pathophysiology of IBS-C.

Su1149 Lack of Seasonal Variation in the Incidence of Eosinophilic Esophagitis

Background: Current guidelines indicate obtaining tissue to evaluate for eosinophilic esophagitis (EoE) as an option in patients with dysphagia who receive upper endoscopy evaluation without obvious cause for their complaint. However, the utility of this practice is unclear. The primary aim of the study was to determine the diagnostic yield of pathologic evaluation for EoE in patients with normal and abnormal findings on upper gastrointestinal endoscopy at the University of Oklahoma Health Sciences Center (OUHSC). Methods: All cases with a primary indication of dysphagia from January 2006 to November 2011 were retrospectively identified using the OUHSC electronic endoscopy database. Patients who had endoscopic biopsies for pathologic evaluation of EoE during their procedure were included for analysis. The pathologic reports and endoscopic findings were independently reviewed by different physicians who were not aware of the other results, then correlated by a third investigator to determine diagnostic yield rates for patients with and without endoscopic findings suggestive of EoE. Results: A total of 3,448 upper gastrointestinal endoscopies were performed at OUHSC during the study period. 547 procedures from 527 patients, age 18 to 90, met entry criteria and were analyzed. Review of these exams revealed 284/547 (52%) with a normal upper gastrointestinal endoscopy, 85/547 (16%) with features suggestive of EoE (furrowing or longitudinal rings), 73/547 (13%) with esophagitis, 45/547 (8%) with lower esophageal strictures or Schatzki ring, and 60/547 (11%) with other findings. Pathologic review indicated 303/547 (55%) with esophagitis, 207/547 (38%) with normal mucosa, and 37/547 (7%) with EoE. Among the 37 patients diagnosed with EoE, endoscopy revealed 23 (62%) with features of EoE, 7 (19%) with normal exam, and 7 (19%) with esophageal stenosis or esophagitis. The overall pathologic yield of EoE to endoscopic findings was 23/ 85 (27%) with features suggestive of EoE, 7/284 (2%) with normal exam, and 7/178 (4%) with all other findings. Conclusions: Endoscopic biopsies for pathologic evaluation of EoE often yield positive results in patients with endoscopic features suggestive of EoE. However, the yield of biopsies in those without endoscopic features suggestive of EoE is very low and is unlikely to alter patient management with increased cost.

Post-Fundoplication Dumping Syndrome: A Frequent “Rare” Complication

Gastroparesis, caused by delayed emptying of the stomach, has been shown to be associated with Nissen fundoplication. However, symptomatic rapid emptying of the stomach is rare after Nissen fundoplication, and its treatment is often challenging. We report 2 patients with dumping-like syndrome post-fundoplication with marked improvement of symptoms after dietary management and medical treatment.

Sa2008 Efficacy and Safety of Linaclotide in Chronic Idiopathic Constipation Patients With Abdominal Bloating: Phase 3b Trial Results

Colonic motor patterns, which might become biomarkers of colonic dysmotility in constipation, are still poorly defined in humans but have been clarified including the role of myogenic, neurogenic and interstitial cells of Cajal (ICC) control systems in the rat, mouse and guinea pig. The purpose of this study was to explore the characteristics of colonic motor patterns in 8 healthy volunteers and 22 patients with chronic constipation by high-resolutionmanometry (HRM). A 36-channel Unisensor solid-state probe, 1 cm spaced, was fixed at the transversedistal colon by colonoscopy for 6-8 hours manometry recording with Medkinetic acquisition software. After 60 min baseline recording, a yogurt meal (460 g, 1400 kJ) was given to observe the gastro-colonic reflex for 90 min, thereafter 2 mg prucalopride was given to evaluate short-term effects. Results: 1) Unique to HRM recordings were the clearly definable, distinguishable and quantifiable simultaneous and propulsive contractions which all had superimposed haustral contractions; distinct from any animal model. 2) In healthy volunteers, common motor patterns included simultaneous contractions (duration of 1-3 s, 40 100 mmHg, frequency 0.5-1.7 cpm), propulsive contractions including high amplitude propulsive contractions (HAPCs; 100-250 mmHg; figure), and stationary haustral contractions (30150 mmHg) that were often rhythmic at the ICC pacemaker frequency (3 cpm). The yogurt meal and 2 mg prucalopride promoted propulsive contractions, and decreased simultaneous contractions from 7 to 2 per 30 min recording. Eight HAPCs were observed in 3 cases, with propagating distances of 8-36 cm, amplitudes of 100-220 mmHg, velocity of 53 mm/s, several HAPCs were repetitive with intervals of 60-150 sec. HAPCs usually occurred without other patterns although it happened once in between 2 simultaneous contractions. 3) In patients with chronic constipation, simultaneous and retrograde-propagating contractions of low amplitude were the main patterns, no HAPCs were observed. Simultaneous contractions (duration 1-3 s, 30 mm Hg, frequency 0.4 -1.1 cpm) were significantly promoted by yogurt (from 5 to 16 episodes / 30 min). Retrograde contractions were increased after yogurt and prucalopride, with propagating distances of 8-21 cm, 10-60 mmHg, velocity of 61 mm/s and intervals of 60-150 sec. This did not occur in healthy volunteers. 4) Flatulence was associated with simultaneous contractions; yogurt increased the episodes of flatulence in both patients and healthy volunteers. In conclusion, rhythmic low amplitude simultaneous contractions and retrograde contractions, abundance of low amplitude rhythmic haustral contractions and failure to induce HAPCs characterized chronic constipation, suggestive of enhancement of local myogenic activity and dysfunctional neurogenic control systems of propulsion.

A case of eosinophilic esophagitis discovered with positron emission tomography imaging: a case report

IntroductionEosinophilic esophagitis was first reported in 1978, and since then it has been increasingly recognized as one of the major etiologies for dysphagia, food impaction, and food regurgitation. To the best of our knowledge, no case of eosinophilic esophagitis (excluding esophageal eosinophilia not responsive to proton pump inhibitor treatment) has previously been demonstrated on the basis of positron emission tomography imaging.Case presentationA 68-year-old Caucasian man presented with dysphagia to solids with recurrent regurgitation and weight loss of 7lb within the preceding 2 months. The patient attributed these symptoms to radiation therapy he had received 1 year earlier for squamous cell cancer of the lung. The patient underwent routine follow-up positron emission tomography imaging, which showed a hypermetabolic lesion in the posterior mediastinum and was increased at the level of the midesophagus.ConclusionTo the best of our knowledge, this is the first reported case of eosinophilic esophagitis demonstrated by positron emission tomography imaging and confirmed with endoscopic evaluation and biopsies both after positron emission tomography imaging and a trial of proton pump inhibitor therapy. This could have an impact on the diagnostic evaluation of esophageal eosinophilic inflammation as well as eosinophilic infiltration of other gastrointestinal organs.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.

Curative Intent Treatment for Colorectal Cancer with Isolated Brain Metastases: A Case Report

Introduction: Brain metastases (BM) are a rare complication of colorectal cancer (CRC), typically presenting late in the course of the disease and are associated with other systemic metastases. Management of solitary brain metastases in colorectal cancer is still not well established. Case presentation: We describe the case of a 65 year-old man presenting with a solitary brain metastasis as the first sign of colon cancer. The treatment approach included surgical resection of the brain lesion followed by resection of the primary tumor, systemic chemotherapy and local radiation therapy to the BM. Conclusion: This curative intent approach has resulted in dramatically prolonged patient’s survival compared to the average reported in the literature, now nearly 2.5 years after presentation. Our case describes the feasibility of a multidisciplinary curative intent approach to solitary BM in CRC.