A study of the effects of bowel preparation on CEA levels in patients undergoing surveillance colonoscopy.

Mechanical bowel preparation has been postulated to be another cause of "false rise' of serum carcinoembryonic antigen (CEA) levels. Furthermore, it was shown that high-risk patients for colorectal cancer had a greater rise in serum CEA after bowel preparation. To verify these findings, a prospective study of 24 consecutive patients in our surgical endoscopic unit on the effect of mechanical bowel preparation of serum CEA level as carried out from January to March 1994. Blood samples were taken before and after bowel preparation for patients undergoing surveillance colonoscopy for various reasons. Our study did not show any relationship between serum CEA levels and bowel preparation. No rise of serum CEA was found even in high-risk patients after bowel preparation.

Endoscopic Nd:YAG laser treatment of inoperable lower gastrointestinal cancer.

Many patients with colorectal cancer are not amenable to curative resection at the time of presentation. Nevertheless, palliative resection still remains as the treatment of choice in the majority of patients. A small group of patients that are poor candidates for surgical resection may benefit from some non-surgical palliative procedures to relieve their symptoms. Electrocoagulation, cryosurgery and radiotherapy are some of the non-surgical procedure used and they are associated with high morbidity and mortality. The use of Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG) laser photoablation to palliate patients with advanced colorectal carcinoma is well documented. It is associated with relatively low morbidity and perioperative mortality. It requires no anaesthesia and is the only non-surgical procedure that can be safely carried out above the peritoneal reflection. Nd:YAG laser had been used in some centres as a preresectional procedure in patient presenting with high grade obstruction. It allows proper bowel preparation followed by primary excision and anastomosis. As a palliative procedure, most patients showed rapid improvement in obstructive symptoms, bleeding and rectal discharge. The size of the lesion and circumferential extent of the tumour base correlate well with the response rate. Most patients remained asymptomatic before they succumb to the advanced disease. In our series, good palliation of obstructive symptoms was achieved in all obstructive cases with one laser treatment, bleeding tumours required an average of two sessions for complete haemostasis. In conclusion, Nd:YAG laser therapy is a safe and efficacious means for palliation of obstructive symptoms and bleeding in advanced rectal carcinoma.

Microchip implants on the anterior sacral roots in patients with spinal trauma: does it improve bowel function?

PURPOSE: This study evaluated the effect of anterior sacral roots stimulator implants on bowel function of patients with spinal cord trauma. METHOD: Eight patients with spinal cord injury and constipation had anterior sacral roots stimulator implants inserted for concomitant bladder dysfunction. Questionnaires on bowel function and anorectal manometry tests were given before and after insertion of the implants. RESULTS: Six patients achieved improvement in bowel function. Four of these patients could defecate spontaneously following stimulation. Two patients had no improvement in bowel function. Anorectal manometry studies showed a negative rectoanal pressure difference at the time of stimulation. All patients were unable to defecate during stimulation. Positive rectoanal pressure difference was recorded in the six patients who had improved bowel function. This may be attributable to the slower relaxation of the smooth rectal muscle compared with the easily fatigable striated external anal sphincter. CONCLUSION: Anterior sacral roots stimulator implants can improve bowel function in patients with spinal cord trauma.

Nitric oxide synthase activity and expression in human colorectal cancer.

The present study investigated the activity and cellular localization of individual isoenzymes of nitric oxide synthase (NOS) using immunohistochemistry and the [3H]citrulline assay in normal colorectal epithelia and neoplastic tissue. Intracellular localization of isoenzymes of NOS was detectable by immunohistochemistry in normal epithelial cells. Colorectal adenocarcinomas had a marked reduction of both Inducible NOS (iNOS) and constitutive NOS (cNOS) expression. Expression of iNOS was completely absent in tumour cells (P < 0.0001), while cNOS was reduced in 66% and absent in 34% of tumours studied when compared with controls (P < 0.0001). NOS activity using the [3H]citrulline assay was detectable in normal epithelium and was found to be reduced in tumours (P < 0.001). In addition, colonic adenomas had reduced INOS but not cNOS expression when compared with controls (P < 0.003 and P = 0.39 respectively). We conclude that NOS is present and active within the epithelium of the normal colon, with localization of the individual isoenzymes. Furthermore, there was loss of activity and expression of individual isoenzymes in colonic neoplasms.

Paradoxical puborectalis contraction is a feature of constipation in patients with multiple sclerosis.

OBJECTIVE: To study the disturbed anorectal physiology associated with constipation in multiple sclerosis. METHODS: Anorectal function in 10 patients with clinically definite multiple sclerosis and constipation has been compared with 10 normal persons and 11 patients with idiopathic constipation, without multiple sclerosis. RESULTS: All 10 constipated patients with multiple sclerosis had difficulty evacuating barium paste during defaecography. In four of these there was complete failure of puborectalis relaxation when straining to defaecate, and in another four there was incomplete puborectalis relaxation. There was no evidence of lower motor neuron involvement of pelvic floor muscles in the multiple sclerosis group. CONCLUSIONS: Paradoxical puborectalis contraction is common in patients with multiple sclerosis in whom constipation is a symptom. This may be a feature of the disturbed voluntary sphincter control mechanism, analogous to detrusor sphincter dyssnergia in the bladder.

Role of oral sodium phosphate and its effectiveness in large bowel preparation for out-patient colonoscopy.

The aim of our study was to determine the tolerance and efficacy of oral sodium phosphate compared with polyethylene glycol electrolyte (PEG) solution on out-patient colonoscopy. Seventy-nine patients (35 male, 44 female) for elective out-patient colonoscopy were randomized to receive either PEG (GoLYTELY) solution or oral sodium phosphate (Fleet PhosphoSoda) before the procedure. Patients subsequently completed a questionnaire to assess tolerance to either regimen. The endoscopists, who were blinded to the type of bowel preparation, assessed the results in terms of residual faecal content and percentage of bowel wall visualized. Sixty-seven per cent (26) of 39 patients found Phospho-Soda easy to complete, compared with 53% (21) of 40 patients with PEG (P = 0.06). There was no statistical significance between the two groups in terms of symptomatology. Colonoscopic assessment of the Phospho-Soda group showed better cleansing compared to the PEG group at all levels of the colon (P = 0.02-0.002). Phospho-Soda is just as well tolerated as a standard PEG regimen and provides better cleansing of the bowel for colonoscopy.

Chili--protective factor against peptic ulcer?

The aim of the present study was to determine the frequency and amount of chili taken by peptic ulcer patients and control subjects. One hundred three Chinese patients with peptic ulcer and 87 control patients were interviewed using a standard questionnaire. Those subjects who deliberately avoided chili use because of symptoms or advice from friends or medical practitioners were excluded. The median number of times of chili use per month was eight in the ulcer group (25-75% quartiles 1-30) compared to 24 (8-56) in the control group (P < 0.001). The median amount of chili used per month was 312 units (25-75% quartiles 38-899) in the ulcer group compared to 834 units (274-1892) in the control group (P < 0.001). The odds ratio of having peptic ulcer disease, adjusted for age, sex, analgesic use, and smoking by multiple logistic regression, was 0.47 (95% confidence intervals: 0.25-0.89) for subjects who had a higher intake of chili both in terms of frequency as well as amount used compared to those who took less chili. Our data support the hypothesis that chili use has a protective effect against peptic ulcer disease.

Prevalence of bowel dysfunction in patients with multiple sclerosis and bladder dysfunction.

Urinary dysfunction is common in cases of multiple sclerosis (MS). The close proximity of those neural pathways which control the bladder to those which control anorectal function might be expected to lead to a high coexistence of bladder and bowel symptoms. Seventy-seven consecutive patients with clinically definite MS attending a uroneurology clinic were interviewed about their bowel function. All patients had clinical evidence of spinal cord disease with varying degrees of impaired mobility and sufficiently severe disturbance of bladder control to seek medical advice. Thirty-six per cent of these patients had constipation. Twenty per cent had "current incontinence", although another 30% had had at least one episode of faecal incontinence more than 3 months previously. Some patients had both constipation and faecal incontinence. A total of 52% currently had at least one bowel symptom. The pattern of bowel symptoms did not correlate with the pattern of urinary disturbance, or the duration of MS, or the degree of disability. Bowel symptoms are common in patients with MS, but even in those with urinary dysfunction are not universal. Whereas bladder dysfunction in MS is clearly related to spinal cord disease, the neurological basis for the bowel dysfunction is less clear.

CO2 laser haemorrhoidectomy--does it alter anorectal function or decrease pain compared to conventional haemorrhoidectomy?

Carbon dioxide (CO2) laser haemorrhoidectomy is feasible and safe provided it is used with care. It is associated with a reduced requirement for post-operative analgesia. The CO2 laser caused no significant alteration in anorectal physiology.

Effect of age, sex and parity on anorectal function.

Ninety-one healthy subjects (51 women; age range 16-85 years) were studied prospectively to determine the effect of age, sex and parity on anorectal function. Maximum resting pressure, voluntary contraction pressure, rectal sensation to distension, rectal and mid-anal electrosensitivity, perineal descent, pudendal nerve terminal motor latency and fibre density of the external and sphincter were measured. Sex influenced mean(s.d.) voluntary contraction pressure (148(56) versus 95(43) cmH2O for men versus women, P < 0.0001), perineal descent on straining (1.0(0.5) versus 1.3(0.4) cm, P = 0.02) and fibre density (1.43(0.14) versus 1.52(0.15), P = 0.02). Age influenced resting pressure (r = -0.43, P = 0.0001), perineal position at rest (r = -0.55, P < or = 0.0001), mid-anal electrosensitivity (r = 0.42, P = 0.0001) and rectal electrosensitivity (r = 0.54, P < 0.0001). Parity affected mean(s.d.) voluntary contraction pressure (105(53) versus 75(20) cmH2O for nulliparous versus parous women, P = 0.04) and mid-anal electrosensitivity (5.3(2.3) versus 4.5(2.3) mA, P = 0.02). Increasing age leads to perineal descent at rest, slowed pudendal nerve conduction, a fall in resting anal pressure and decreased anorectal sensory function. Women have a lower and squeeze pressure, greater perineal descent, longer pudendal nerve terminal motor latency and a greater muscle fibre density than men. Parity leads only to lower squeeze pressure.

Aberrant expression of nitric oxide synthase in human polyps, neoplastic colonic mucosa and surrounding peritumoral normal mucosa.

The expression of nitric oxide synthase (NOS) was studied by NAD(P)H diaphorase histochemical localization method in (i) individual cells of the normal colonic mucosa (n = 13) which served as control, (ii) colonic polyps (n = 14), (iii) colonic carcinoma (n = 20) and (iv) peritumoral mucosa (2 and 5 or 10 cm away from the tumor). Four of the tumor specimens had normal epithelium adjacent to the cancer, which thus served as an internal control. The expression of NOS activity in colon cancer was significantly reduced as compared to the control group of individuals (P < 0.004); undetectable in 25%, diminished in 45%, normal in 30%. On comparing the expression in normal mucosa and polyps there was a significant reduction of the expression in polyps (P < 0.027); undetectable in 14%, reduced in 35%, normal in 51%. When compared to the peritumoral mucosa at 2 and 10 cm the tumor showed a significant reduction in expression of NOS activity (P < 0.001 and P < 0.0001 respectively). There was no significant difference seen in the expression at 2 and 10 cm (P = 0.329). The peritumoral mucosa at a distance of 2 cm away from the tumor when compared to the control mucosa showed no significant difference (P = 1.000), although there is a tendency to a high normal expression of NOS activity in the mucosa at a distance of 2 cm. Similarly, there was no significant difference between the control mucosa and the peritumoral mucosa obtained at a distance of 10 cm (P = 0.383). The expression of NOS activity in all tissues examined was abolished by preincubation of tissue with the selective NOS inhibitor L-NMMA but not with D-NMMA. Our data showed extensive and significant reduction as identified by the NAD(P)H diaphorase method in the expression of NOS activity, thereby reflecting the activity of nitric oxide in colon cancer and colonic polyps. The generalized suppression of this activity, which precedes the onset of overt neoplasia, may be an important event in colon carcinogenesis. This aberrant expression could also be compatible with the selective advantage to either tumor promotion and metastatic progression or to tumoricidal activity.

Defecography in multiple sclerosis patients with severe constipation.

PURPOSE: To evaluate defecography in assessment of anorectal function in patients with multiple sclerosis (MS) who have intractable constipation. MATERIALS AND METHODS: Eleven patients with MS and constipation (10 women, one man) underwent defecography. A total of 130 mL of barium, liquid (20 mL) and paste, was introduced into the rectum. A dab of barium marked the external anal orifice, and, in the women, a tampon soaked with contrast medium marked the vagina. Video radiographic images and supplemental 100-mm static camera images were obtained. RESULTS: During defecation, six patients had no puborectalis muscle effacement, four patients had partial effacement, and one patient had complete effacement. No rectal emptying occurred in five patients, and emptying was incomplete in the rest. Three patients developed an intussusception, and two developed a posterolateral pouch. CONCLUSION: Defecography readily demonstrates rectal outlet obstruction and the failure of the puborectalis and anal sphincter muscles to relax. These are frequent findings in MS patients with intractable constipation.

Audit of postanal repair in the treatment of fecal incontinence.

PURPOSE: The short-term results of postanal repair for idiopathic fecal incontinence are satisfactory but data on long-term outcome are lacking. This study was carried out to document the short-term and long-term results of this operation and to determine whether preoperative tests predict long-term outcome. METHODS: Thirty-six patients (33 females; mean age, 57 years) with major idiopathic fecal incontinence operated on by one surgeon were studied. Patients had resting and voluntary contraction anal pressures and pudendal nerve terminal motor latencies (PNTML) measured preoperatively. Symptoms were evaluated at 6 months after operation and again at a median of 25 (range, 6-72) months in all 36 patients. Symptoms were classified as: Group C, no improvement or worse; Group B, minor improvement; and Group A, marked improvement in comparison to the patient's preoperative symptoms. Seventeen patients had postoperative physiology performed. RESULTS: At 6 months there were 6 (17 percent) patients in Group C, 12 (33 percent) in Group B, and 18 (50 percent) in Group A. At final follow-up there were 17 (47 percent) in Group C, 9 (25 percent) in Group B, and 10 (28 percent) in Group A. Comparison of the preoperative data in the final outcome groups showed (mean +/- SE): Groups A and B vs. Group C--resting pressure, 24.6 +/- 6 cm H2O vs. 40.5 +/- 12.2 (P = 0.2), voluntary contraction pressure, 23.7 +/- 5.7 vs. 11.8 +/- 3.6 (P = 0.09), and PNTML, 3.2 +/- 0.75 mS vs. 3.3 +/- 0.99 (P = 0.8). Mean differences between post-operative and preoperative results were: resting pressure, 28 +/- 8.2 cm H2O (P = 0.003); voluntary contraction pressure, 19.5 +/- 6.7 (P = 0.01); and PNTML, -0.3 +/- 0.29 mS (P = 0.3). CONCLUSIONS: At 6 months 83 percent of patients had obtained some benefit from postanal repair but only 53 percent maintained this improvement with only 28 percent being markedly better. There was a trend toward a more favorable outcome in patients with greater squeezing pressures preoperatively but other tests were not of long-term predictive value.

Pelvic floor function in multiple sclerosis.

The aim of this study was to define pelvic floor function in patients with multiple sclerosis and bowel dysfunction, either incontinence (MSI) or defecation difficulties without incontinence (MSC). Normal controls and patients with idiopathic neurogenic faecal incontinence without multiple sclerosis (FI, disease controls) were also studied. Thirty eight multiple sclerosis patients (20 incontinent, 18 incontinent) 73 normal controls, and 91 FI patients were studied. The FI group showed the characteristic combined sensorimotor deficit previously described in these patients of low resting and voluntary contraction and pressures, increased sensory threshold to mucosal stimulation, and increased pudendal nerve terminal motor latencies and fibre densities. MSI patients had significantly lower anal resting pressures (80 (30-140) cm H2O, median (range) v 98 (30-200), normal controls, p = 0.002) and both MSC and MSI patients had significantly lower anal maximum voluntary contraction pressures (65 (0-260) cm H2O, MSC and 25 (0-100), MSI v 120 (30-300), normal controls, p = < 0.0004) and higher external anal sphincter fibre densities (1.7 (1.1-2.6), MSC and 1.7 (1.1-2.4), MSI v 1.5 (1.1-1.75), normal controls, p < 0.006) compared with normal controls but pudendal nerve terminal motor latencies were similar and no sensory deficit was found. This contrasted with the idiopathic faecal incontinent patients who, in addition to significantly higher fibre densities (1.8 (1.1-3), p = 0.001) had increased pudendal latencies (2.5 (1.1-5.5) mS v 2.08 (1.4-2.6), p = 0.001) compared with normal controls. The idiopathic faecal incontinent group had significantly lower resting anal pressures (50 (10-160) cm H2O, p=0.02) than the MSI group. Comparison with the incontinent and continent multiple sclerosis groups showed that incontinence was associated with lower voluntary anal contraction pressures (25 (0-100) v 65 (0-260), p=0.03) but that there were no other differences between these two groups. Pelvic floor function is considerably disturbed in multiple sclerosis, showing muscular weakness with preservation of peripheral motor nerve conduction, providing indirect evidence that this is mainly a result of lesions within the central nervous system.

Serum alpha interferon in children with right iliac fossa pain.

Serum alpha-interferon levels were analysed in 50 consecutive children admitted with right iliac fossa pain. Serum alpha-interferon levels were significantly raised in 33% of children without acute appendicitis when compared to 5.7% of children with histologically proven acute appendicitis and 9% of normal controls. This interesting phenomenon needs further investigation. A larger series may show it to be of clinical use in non-specific abdominal pain in childhood.

Primary repair of iatrogenic colonic perforations in unprepared colon--a report of five cases.

Primary repair of iatrogenic colonic perforations sustained during pelvic surgery was successfully undertaken in five consecutive cases who did not receive pre-operative bowel preparation. A proximal diverting colostomy was not performed following the repair. There were no instances of intra-abdominal abscess or colonic fistulation. One case developed wound infection. Post-operative recovery in all cases were mostly uneventful with a mean post-operative ileus of four days and a stay of ten days. Primary repair of iatrogenic colonic perforations in unprepared colon can be safely undertaken without a proximal diverting colostomy with acceptable morbidity.

Endoscopic Nd:YAG laser in the palliative treatment of advanced low rectal carcinoma in Singapore.

We used the Nd:YAG laser to palliate symptoms of bleeding and obstruction in 27 cases of rectal carcinoma. Twenty of these patients had advanced inoperable rectal carcinoma, three were at high surgical risk, and four refused surgery. Obstructive symptoms were the main complaint in 10 cases, while 17 patients presented with bleeding. Good palliation of obstructive symptoms was achieved in all obstructive cases with one laser treatment session. However, bleeding tumors required an average of two sessions for complete hemostasis. There were no major complications; minor complications of bleeding after treatment occurred in two patients. Good symptomatic relief was achieved in all cases. The mean survival for all patients was five months. Nd:YAG laser therapy is a safe and efficacious means for palliation of obstructive symptoms and bleeding in advanced rectal carcinoma.