Is-it possible to distinguish irritable bowel syndrome with constipation from functional constipation?

BACKGROUND: The Rome III criteria classify patients complaining of constipation into two main groups: patients with functional constipation (FC) and patients with constipation predominant irritable bowel syndrome (IBS-C). The purpose of this study was to identify differences in the intensity of symptoms and total and segmental colonic transit time in these two types of patients. METHODS: We performed a prospective evaluation of 337 outpatients consecutively referred for chronic constipation and classified according to the Rome III criteria as FC or IBS-C. They were asked to report symptom intensity, on a 10-point Likert scale, for diarrhea, constipation, bloating and abdominal pain. Stool form was reported using the Bristol scale, and colonic transit time was measured by using multiple-ingestion single-marker single-film technique. Statistical analysis was completed by a discriminant analysis. RESULTS: Female gender and obstructed defecation was more frequent in IBS-C patients than in FC patients. IBS-C patients reported greater symptom intensity than FC patients, but stool form, and total and segmental colonic transit time were not different between the two groups. Multivariate logistic regression showed that only two parameters, bloating and abdominal pain, were related to the IBS-C or to the FC phenotype, and discriminant analysis showed that these two parameters were sufficient to give a correct classification of 71% of the patients. CONCLUSIONS: Our study suggests that self-evaluation of abdominal pain and bloating is more helpful than colonic transit time in classifying patient as IBS-C or FC.

Viscoelastic properties of the rectal wall in Hirschsprung's disease.

Viscoelastic properties of the rectal wall were compared with Hirschsprung's disease. The elasticity of the rectal wall after accomodation to distension was found to be significantly greater (P less than 0.001) in patients, and the time taken by the rectum to accomodate was also found to be longer (P less than 0.001). The increased elasticity correlated well with severity of the illness, but none of the parameters correlated with length of aganglionic segment. Measuring elastic properties of the rectal wall may help to assess the severity of illness in patients with Hirschsprung's disease.

Dietary fiber, bowel habits, and colonic function.

Bowel habits have different characteristics, and frequency, amount, and consistency of stools should be recorded in any study, including those on the effects of dietary fiber. Several studies suggest that addition of fiber to the diet reduces long and prolongs short transit time and increases water content of the stool. Conflicting data are difficult to reconcile, and mechanisms remain unknown.

Idiopathic disorders of fecal continence in children.

A group of 176 patients aged 2 to 15 years was investigated for idiopathic disorders of bowel function other than Hirschsprung's disease. Anorectal motility, as well as colorectal transit of radiopaque markers, were investigated. Before the end of the first month of life, 70 of the patients were constipated. Resting pressure was more unstable (P less than 0.001) and higher than normal in the rectal ampulla and upper anal canal (P less than 0.01). Retardation of markers occurred in the proximal and/or distal large bowel of 61% of the patients. The existence of functional abnormalities was demonstrated in the majority of children with idiopathic disorders of fecal continence.

Crohn's disease of the vulva.

Three patients with Crohn's disease primarily involving the large intestine had unusual abscesses of the vulvar area. At biopsy, the abscesses had classic features of the primary disease and were clearly separated from the intestinal tract. There was no fistula in the anal canal, and the perineum between the vulvar abscess and the anus was normal. One of the patients also had an early lesion of Crohn's disease in the sigmoid. The lesion appeared as a small erythematous spot without ulceration. Biopsy revealed a typical granuloma under an intact mucosa. It is concluded that Crohn's disease is not confined to the gastrointestinal tract, and that early lesions of the disease within the gastrointestinal tract are submucosal rather than mucosal.

Lipoprotein lipase steady-state mRNA levels are lower in human omental versus subcutaneous abdominal adipose tissue.

Adipose tissue synthesizes lipoprotein lipase (LPL), which helps in the postprandial clearance of triglyceride-rich lipoproteins. Because visceral adipose tissue is generally accepted as the most important metabolic tissue, we sought to verify whether there are regional differences in the expression of LPL. Samples of adipose tissue from subcutaneous and omental fat deposits were obtained from 20 adults undergoing surgery. Total adipose tissue LPL activity was measured using a conventional radioactive substrate assay. Steady-state levels of LPL mRNA were assessed using the very sensitive RNase protection assay technique with 18S ribosomal RNA as an internal control. A correlation was demonstrated between LPL activity levels in subcutaneous and omental tissue (r = .72; P < .01) and between mRNA levels at both sites (r = .47, P = .04). LPL mRNA levels were significantly lower in omental compared with subcutaneous depots (omental v subcutaneous, 1.7 +/- 0.7 v 2.1 +/- 0.7 arbitrary units [AU] over 18S, P < .05). In paired comparisons, LPL mRNA levels in omental adipose tissue were, on average, 20% +/- 7% (range, -57% to +9.0%) lower than the levels measured in subcutaneous adipose tissue (P < .05). In conclusion, these data suggest that subcutaneous adipose tissue is a reliable surrogate of the expression (activity and mRNA) of LPL in omental adipose tissue, even though omental depots express proportionally less LPL than subcutaneous depots.

Urorectodynamic evaluation of healthy volunteers.

Twelve female and 8 male healthy volunteers underwent urorectodynamic evaluation. Mean bladder capacity was 594 ml. and mean maximal vesical pressure 12.5 cm. water (H2O). Maximal bladder pressure correlated significantly with maximal mural tension (r = 0.96) but did not correlate well with bladder capacity (r = 0.20). Mean bladder volume at first desire to void was 32 per cent of mean bladder capacity. The bladder volume at the first desire did not correlate significantly with the capacity. Mean bladder pressure at 100 ml. volume was 2.9 +/- 0.4 cm. H2O (X +/- SEM). After bethanechol injection, the bladder pressure at 100 ml. volume increased by 8.8 +/- 1.2 cm. H2O (X +/- SEM) at twenty minutes. In only 1 subject did bladder pressure rise higher than 15 cm. H2O (5 per cent). Rectal pressure increased from 1.4 +/- 0.3 to 14.1 +/- 2 cm. H2O (X +/- SEM) at sixteen minutes. Electromyogram (EMG) of the external and sphincter did not follow regular pattern with vesical filling or attempt of voiding. The data obtained in these normal subjects may serve as a basis for comparison in the interpretation of data obtained in patients.

Urorectodynamics in patients with colonic inertia.

Sixteen female patients with colonic inertia and 12 control women underwent manometric evaluation of their bladder and rectal cavities. After subcutaneous injection of 0.035 mg./Kg. bethanechol, bladder intraluminal pressure increased by over 15 cm. water in 5 patients (31 per cent) and in none of the control group; maximal pressure after injection was 11.5 +/- 1.6 cm. H2O (mean +/- SE) in patients and 8.5 +/- 1 in controls (p less than 0.025). The intraluminal rectal pressure reached 23 +/- 4 cm. H2O in patients and only 11.9 +/- 1.4 in controls (p less than 0.0025). Time taken to reach a peak pressure was faster in patients both in bladder (17.4 +/- 0.7 vs. 19.8 +/- 1.2 minutes; p less than 0.01) and in the rectum 914.6 +/- 0.8 vs. 16.3 +/- 1.2; p less than 0.025). These findings and the clinical presentation suggest an autonomic neuropathic lesion in this group of patients.

Colonic transit time in patients with myelomeningocele.

To evaluate colonic motility in patients with myelomeningocele, the transit time of radiopaque markers was studied in 22 patients with myelomeningocele and 22 age and sex matched controls. Mean colonic transit time was significantly longer in patients than in controls (103.2 +/- 49 h versus 23.3 +/- 13 h; P < 10(-7). Thirteen of 22 patients with myelomeningocele were severely constipated. Six patients had constipation secondary to delayed colonic transit, particularly in the left colon, and seven had increased rectosigmoid transit. The clinical questionnaire and particularly the frequency of bowel movements did not predict colonic transit. Among 13 patients with increased colonic transit, eight had more than five bowel movements per week and, thus, six of them did not use laxatives or enemas, despite the presence of faecal incontinence. There was no relationship between colonic transit time and the level of the spinal lesion or patient mobility in patients with myelomeningocele. Rectoanal dyssynergia was found in 14 of the 22 patients, but equally often in patients with delayed rectosigmoid transit (4/7) as in the other patients (10/15) (P = ns). Uninhibited detrusor contractions were observed more often in patients with increased colonic transit time than in others (8/12 versus 1/8, P = 0.05). In the absence of a correlation between colonic transit time, clinical symptoms, anorectal motility, level of spinal lesion, patient mobility, evaluation of colonic transit of radiopaque markers should be assessed routinely in all patients with myelomeningocele to plan the most appropriate treatment, mainly in case of unhibited detrusor contractions.

Mechanisms of absorption of caseinophosphopeptide bound iron.

Binding iron (Fe) to the 1-25 caseinophosphopeptide obtained from enzyme hydrolysis of beta casein (beta CPP) improves Fe bioavailability in the rat. To assess the mechanisms involved in its absorption, a perfused, vascularized duodenal rat loop model was used in controls and in Fe-deficient (bleeding of 25% blood volume) rats. Inhibitors of oxidative phosphorylation [2-4 dinitrophenol (DNP)] and/or of endocytosis [phenylarsine oxide (PAO)] were added to the perfusion solution containing 50 microM Fe as beta CPP bound Fe (Fe-beta CPP) or gluconate (Fe Gluc). Fe-beta CPP enhanced Fe uptake, reduced mucosal storage, and improved net absorption both in controls and in deficient animals. DNP reduced uptake, mucosal storage, and net absorption by the same percentage in Fe-beta CPP and Fe Gluc perfused rats in both control and Fe-deficient animals. PAO decreased uptake, mucosal storage, and net absorption of Fe-beta CPP but not of Fe Gluc. At the end of the experiment Fe serum levels were increased only in Fe Gluc animals. These results confirm the improved bioavailability of beta CPP bound Fe. They suggest that at least part of its absorption can occur by a different pathway than usual Fe salts. Fe-beta CPP can be taken up by endocytosis and absorbed bound to amino acids or peptides.

Effects of oral pinaverium bromide on colonic response to food in irritable bowel syndrome patients.

We have recently developed a simple method to investigate the colonic response to food (CRF). This study describes the modifications of CRF induced by treatment with oral pinaverium bromide in irritable bowel syndrome (IBS) patients. Thirty healthy subjects and 43 patients suffering from IBS were studied. Colonic transit time (CTT) was measured in fasting conditions and after eating a standard test meal. Colonic response to food was quantified by calculating the variation in number of markers in each zone of interest of the large bowel between the X-ray films of the abdomen taken before and after eating. CRF is characterized by caudal propulsion of colonic contents in the two groups. In controls, there is emptying of the caecum-ascending colon region and filling of the rectosigmoid. In IBS patients, only the left transverse colon and the splenic flexure empty. Pinaverium bromide exerts no effect in controls but reverses the CRF of the right colon in IBS patients by inhibiting right colon emptying. These results suggest that the inhibitory action of pinaverium bromide on CRF may support the clinical efficacy of this calcium channel blocker in the treatment of IBS.

[Action of trimethyl 3,3-N-hexene-5-lactam on the mechanical properties of the longitudinal fibers of the rat colon. An in vitro study]. / Action du triméthyl-3,3-N-hexène-5-lactame (T.H.L.) sur les propriétés mécaniques des fibres longitudinales du colon de rat. Etude "in vitro".

The effects of trimethyl 3,3-N-hexene-5-lactam (T. H. L.) on the mechanical properties of longitudinal muscle strips of the distal rat colon were investigated through stretching, electrical stimulation and addition of pharmacologic agents. T. H. L. abolished the contraction induced by electrical stimulation and decreased amplitude of contractions induced by carbamoylcholine and serotonin. It further reduced the relaxation induced by adrenaline.

Front and rear: the pelvic floor is an integrated functional structure.

The pelvic floor is a muscular structure, pierced by the urologic, genital and distal intestinal tract. This structure is not a frozen but a functional unit. Normal function can thus be replaced by dysfunctions of several kinds, overlapping voiding, sexual, genital and defecatory behaviour. For instance, vaginismus is akin to anismus and vesicourethral dyssynergia. Recent recognition of the medicosurgical consequences of sexual abuse has shown that many urologic, genital and digestive dysfunctions are sort of a body signature of the trauma, which must be dealt with if the symptom is to disappear. If the pelvic floor is integrated, unsuspected pathology will lie outside of the spectrum of activities of a given specialty, and thus urologists, gynecologists, gastroenterologists and colorectal surgeons should not only exchange, but should also be aware of the pathologies of neighbouring specialties. This paper elaborates on a more holistic vision of pelvic floor function including sexuality. Out of this, a number of different hypotheses are elaborated in the different spheres of activities, about different pathologies, their basic cause, and how they could be dealt with.

Manometric assessment of continence after surgery for imperforate anus.

Of 49 children with imperforate anus, 23 underwent an abdominoperineal procedure for a high and seven for a low maliformation, 17 had a perineoplasty for a low and two for a high malformation. In each subject, rectal and anal sphincteric resting pressures were studied at least 1 yr after surgery. Of 30 subjects who had undergone an abdominoperineal procedure, eight were continent in contrast to 15 out of 19 patients who had had a perineoplasty (p less than 0.001). In patients who had undergone an abdominoperineal procedure, the rectal motility was of the colonic type, with waves of higher amplitude and lower frequency (p less than 0.01) than in the normal rectum in 23 cases and in most of these, peristalsis was recorded down to the anal margin. Incontinence was most frequently associated with abnormally short anal resistance, low anal pressure, reduced sensibility, weak voluntary contraction and absence of rectoanal inhibitory reflex. In the group of patients who underwent perineoplasty, continence was associated with normal mechanical parameters and normal physiologic behavior of the anal sphincter.

[Constipation caused by colonic inertia and distal obstruction: electromyographic study]. / Constipation par inertie colique et obstruction distale: étude électromyographique.

Colonic motility was evaluated in 15 patients with chronic constipation and 12 healthy subjects by both measuring the transit time of 20 radiopaque markers and recording the colonic myoelectric signals by means of a silastic tube equipped with 4 ring contact electrodes. The tube was introduced by flexible sigmoidoscopy so as the electrodes be located at 50, 40, 30 and 20 cm from the anal verge. Constipation resulted from colonic inertia in 7 patients, the markers being delayed over the whole length of the colon. In the 8 other patients, constipation was due to distal obstruction, the markers accumulating electively in the rectum. The myoelectric tracings showed in the control subjects, on one hand rhythmical stationary spike potentials that occurred at only one electrode site at a mean rate of 10 per minute; on the other hand sporadic (non-rhythmic) spike potentials that were either propagating over the colonic segment (sporadic propagating potentials) or not (sporadic non-propagating potentials). In the constipated patients, the following changes were observed: 1) the number of sporadic propagating potentials was significantly decreased in colonic inertia (2.5 +/- 1.3 bursts of spikes per hour) compared to the controls (8.5 +/- 1.1 bursts/h) or distal obstruction (7.9 +/- 1.3 bursts/h); 2) sporadic propagating potentials usually moved aborally; however, 19.8 +/- 0.9 p. 100 moved orally in colonic obstruction, while 4.6 +/- 0.2 p. 100 in the controls and 4.7 +/- 0.1 p. 100 in colonic inertia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Vasopressin and colonic motility]. / Vasopressine et motilité colique.

Vasopressin (VS) has been reported to stimulate colonic peristalsis in different therapeutic conditions. In order to determine the mechanisms involved in this effect, colonic function was studied with three different techniques staying: a) the transit time of radioopaque markers through the colon was measured in 7 healthy subjects after VS IM (0.3 U/kg of weight). A marked propulsive effect was observed. One hour after injection, 64.7 +/- 16.2 p. 100 of the markers (m +/- sem) had left the right colon vs 9.1 +/- 4.6 p. 100 after injection of NaCl (p less than 0.01) and 70.5 +/- 10.8 p. 100 of the markers emptied from the left colon vs 4.3 +/- 4.5 p. 100 after NaCl (p less than 0.01); b) an electromyographic study was carried out in 6 other healthy subjects with an intraluminal device equipped with contact electrodes, introduced into the left colon by colonoscopy. The injection of VS was followed by an increase in the number of the propagating electrical spike bursts that are known to correlate well with the propulsion of the colonic intraluminal contents. The number of bursts was 2.7 +/- 0.6 bursts/30 min after NaCl and 5.2 +/- 1.4 bursts/30 min after VS (p less than 0.02); c) finally, the outflow of ileostomies and colostomies was measured in respectively 3 and 8 subjects over one h after IM 0.3 U/kg of VS. A considerable increase in the outflow of intestinal fluids was observed: output from the colostomies was 10 +/- 10 ml/h after NaCl and 250 +/- 39 ml/h after VS (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Sigmoid motility stimulated by luminal distention. Changes in the motility response in constipation by the slowing down of left colonic transit]. / Etude de la motricité sigmoïdienne stimulée par la distension luminale. Modification de la réponse motrice dans la constipation par ralentissement du transit colique gauche.

The aim of our study was to develop a new technique of sigmoid manometry using standardized luminal distensions and to compare patterns of colonic motility following distension in normal subjects and in constipated patients. Eight subjects without colonic disturbances and 8 constipated patients with delayed transit time of the left colon as shown by radiopaque markers were investigated. Sigmoid motor activity was recorded by measuring pressure in a distending latex balloon placed at 25 cm from the anus. Inflations were maintained during 250 s and separated by 60 s recovery periods of deflation. Volumes of air (V) were increased until the patient reported abdominal pain (VMT). For each distension level, the resistance to distension of the bowel wall evaluated by the baseline adaptative pressure (P) and the contractile activity (A) quantified by planimetry of the active contractile activity (A) quantified by planimetry of the active contraction waves superimposed to P were assessed. In normal subjects, VMT was 147 +/- 9 ml. P increased linearly with V (p less than 0.03) up to 4,336 +/- 876 Pa. A increased with V until VMT/2 reached the maximum of 389 +/- 72 Pa*; for higher volumes A decreased significantly with to 166 +/- 46 Pa for VMT. Reference to controls, the constipated patients had a decreased VMT (61 +/- 4 ml). P increase at VMT (5,084 +/- 753 Pa) and A maximal value (387 +/- 176 Pa) were not different.(ABSTRACT TRUNCATED AT 250 WORDS)

On a practitioner's "being" as the true healing agent.

The healing power of a doctor comes not just from professional competence but from what the doctor is as a person.

Abdominal pain localization is associated with non-diarrheic Rome III functional gastrointestinal disorders.

BACKGROUND: Abdominal pain is common in patients with functional bowel disorders (FBDs). The aim of this study was to characterize the predominant sites of abdominal pain associated with FBD subtypes, as defined by the Rome III criteria. METHODS: A total of 584 consecutive patients attending FBD consultations in a tertiary center participated in the study. Stool form, abdominal pain location (nine abdominal segments), and pain intensity (10-point Likert scale) during the previous week were recorded. Logistic regression analysis was used to characterize the association of abdominal pain sites with specific FBD subtypes. KEY RESULTS: FBDs were associated with predominant pain sites. Irritable bowel syndrome (IBS) with constipation was associated with pain in the left flank and patients were less likely to report pain in the right hypochondrium. Patients with functional constipation reported pain in the right hypochondrium and were less likely to report pain in the left flank and left iliac site. IBS with alternating constipation and diarrhea was associated with pain in the right flank, and unsubtyped IBS with pain in the hypogastrium Patients with functional abdominal pain syndrome reported the lower right flank as predominant pain site. Patients with unspecified FBDs were least likely to report pain in the hypogastrium. Patients with functional diarrhea, IBS with diarrhea, or functional bloating did not report specific pain sites. CONCLUSIONS & INFERENCES: The results from this study provide the basis for developing new criteria allowing for the identification of homogeneous groups of patients with non-diarrheic FBDs based on characteristic sites of pain.

Non-compliance does not impair qualitative evaluation of colonic transit time.

BACKGROUND: Measurement of colonic transit time (CTT) by using radiopaque markers with the "Multiple ingestion-Single film" technique is a simple, reproducible technique to measure total and segmental CTT. However, it requires good compliance of the patients, who must ingest the capsules containing radio-opaque markers for 6 consecutive days. The purpose of this study was to estimate the error in CTT measurement if they fail to do this. METHODS: The protocol tested was to ingest 12 markers per day during 6 days and take a plain film of the abdomen on day 7. The study was done by simulation using a 3-compartiment model (right colon, left colon, rectosigmoid area). There was a set of 67,525 possibilities with possible single or double failure of markers ingestion for 6 days either 238,266 combinations for one omission, or 312,375 combinations for two omissions; the absence of omission was the reference. The analysis focused on two complementary aspects of the evaluation of omission: quantitatively, the absolute and relative error on the CTT measured and qualitatively, the diagnostic error (a delayed transit is defined by a total CTT > 65 hours). KEY RESULTS: Total and segmental CTT measured when omission occurred were greater than the reference time. The difference is particularly important, when omission occurs early during the study for all segments. Qualitative analysis showed that, for one omission of markers ingestion, a correct diagnosis of delayed colonic transit time and of the main site of delay could be obtained by the 3-compartment model in 100% of cases. For two failures of markers ingestion, "delayed" colonic transit could be regarded as normal in only 9.59% of cases; furthermore, the site of delay was correctly recognized in 83% of the cases. CONCLUSIONS & INFERENCES: Despite omission of markers ingestion for one or two days, measured CTT overestimates the absolute value of colonic transit time, the formulated diagnosis (delayed transit and site of delay) is perfectly acceptable clinically.