Rectal motility in pediatric constipation.

OBJECTIVES: Constipation is a common disorder in children, but little is known about its etiology. Rectal impedance planimetry determines segmental rectal cross-sectional area (CSA) and pressure, allowing detailed description of rectal motility. The aim of the present study was to compare rectal motility in healthy and constipated children. METHODS: We analyzed data from 10 children (1 girl) with constipation according to the Rome III criteria, mean age 8.8 years (standard deviation ±â€Š1.2), and 10 healthy children (5 girls), mean age 9.9 years (standard deviation ±â€Š1.5). CSA was determined at 3 levels (4, 5.5, and 7 cm from the anal verge). The resting rectal motility was recorded for 30 minutes followed by a distension protocol to assess compliance. Runs of phasic rectal contractions were defined as changes of >10% from baseline CSA and lasting at least 2 minutes. Rectal dimensions were expressed as mean CSA. RESULTS: A low-amplitude contraction pattern (3%-5% of baseline CSA) with a frequency of 6 to 8/minute was present in all of the children. There was significantly more time with phasic rectal contractions in constipated children (median 38%, range [0-100]) compared with healthy children (median 8.8%, range [0-57]) (P < 0.05). The rectal CSA was higher in constipated children (median 1802 mm [range 1106-2948]) compared with healthy children (1375 mm [range 437-1861]) (P < 0.05), but compliance did not differ (constipated: median 38 mm/H2O [range 12-86] vs healthy 33 mm/H2O [range 10-63]) (P = 30). CONCLUSIONS: In children with constipation, we found phasic rectal contractions for a significantly longer period compared with healthy children, and their rectum is larger than normal.

Can internal medicine specialists diagnose functional somatic disorders (FSDs)? Training and comparison with FSD specialists.

BACKGROUND: Functional somatic disorders (FSD) are a common problem across medical settings and remain challenging to diagnose and treat. Many patients with FSD undergo sequential and unnecessary extensive diagnostic work-up, which is costly for society and stressful for patients. Previous studies have shown that the empirically based FSD diagnostic entities are interrater reliable and stable over time. OBJECTIVE: The aim of this study was to investigate whether internists who have received adequate training and with sufficient time per patient could diagnose FSD. DESIGN: This was a prospective diagnostic accuracy study. The study was conducted from May 2020 to April 2022. PARTICIPANTS: The study included 27 consecutive patients referred by their general practitioner to a non-psychiatric diagnostic clinic for assessment of physical symptoms on suspicion of FSD. INTERVENTIONS: The internists received a 30-hour training course in the use of a tailored version of the SCAN interview. MAIN MEASURES: The main outcome measure was the agreement between the diagnoses of the internists and the reference diagnoses made by specialists in FSD on the basis of the full SCAN interview. KEY RESULTS: The interrater agreement between the internists and the FSD experts was substantial for any FSD (kappa = 0.63) as well as multi-organ vs. single-organ FSD (kappa = 0.73), indicating good diagnostic agreement. CONCLUSIONS: Internists with proper training and sufficient time (3-4 hours) per patient can proficiently diagnose FSD employing a tailored version of the SCAN interview for use in a non-psychiatric diagnostic setting.

Small intestinal transit in patients with liver cirrhosis and portal hypertension: a descriptive study.

BACKGROUND: Gastrointestinal dysmotility may be involved in the development of bacterial translocation and infection in patients with liver cirrhosis. The aim of the present study was to describe gastric, small intestinal and colorectal motility and transit in patients with liver cirrhosis and portal hypertension using a magnet-based Motility Tracking System (MTS-1) and standard radiopaque markers. METHODS: We included 15 patients with liver cirrhosis (8 Child-Pugh A, 6 Child-Pugh B, and 1 Child-Pugh C) and portal hypertension (11 males, median age 54 years (range 38-73), median hepatic venous pressure gradient 18 mmHg (range 12-37)), and 18 healthy controls (8 males, median age 58 years (range 34-64)). The gastric emptying time and small intestinal motility were evaluated by MTS-1, and the total gastrointestinal transit time was assessed by radiopaque markers and abdominal radiographs. RESULTS: The velocity through the proximal small intestine was significantly higher in cirrhotic patients (median 1.27 metres (m)/hour, range 0.82-2.68) than in the healthy controls (median 1.00 m/hour, range 0.46-1.88) (p = 0.03). Likewise, the magnet travelled significantly longer in both fast (p = 0.04) and slow movements (p = 0.05) in the patient group. There was no significant difference in either gastric emptying time--23 minutes (range 5-131) in patients and 29 minutes (range 10.5-182) in healthy controls (p = 0.43)--or total gastrointestinal transit time--1.6 days (range 0.5-2.9) in patients and 2.0 days (range 1.0-3.9) in healthy controls (p = 0.33). No correlation was observed between the hepatic venous pressure gradient and the velocity of the magnet through the small intestine. CONCLUSION: Patients with liver cirrhosis and portal hypertension demonstrated faster-than-normal transit through the proximal small intestine. This may be due to an overactive bowel, as suggested by previous studies.

Colonic volume in patients with functional constipation or irritable bowel syndrome determined by magnetic resonance imaging.

BACKGROUND: Functional constipation (FC) and irritable bowel syndrome constipation type (IBS-C) share many similarities, and it remains unknown whether they are distinct entities or part of the same spectrum of disease. Magnetic resonance imaging (MRI) allows quantification of intraluminal fecal volume. We hypothesized that colonic volumes of patients with FC would be larger than those of patients with IBS-C, and that both patient groups would have larger colonic volumes than healthy controls (HC). METHODS: Based on validated questionnaires, three groups of participants were classified into FC (n = 13), IBS-C (n = 10), and HC (n = 19). The colonic volume of each subject was determined by MRI. Stool consistency was described by the Bristol stool scale and colonic transit times were assessed with radiopaque makers. KEY RESULTS: Overall, total colonic volumes were different in the three groups, HC (median 629 ml, interquartile range (IQR)(562-868)), FC (864 ml, IQR(742-940)), and IBS-C (520 ml IQR(489-593)) (p = 0.001). Patients with IBS-C had lower colonic volumes than patients with FC (p = 0.001) and HC (p = 0.019), but there was no difference between FC and HC (p = 0.10). Stool consistency was similar in the two patient groups, but patients with FC had longer colonic transit time than those with IBS-C (117.6 h versus 43.2 h, p = 0.019). CONCLUSION: Patients with IBS-C have lower total colonic volumes and shorter colonic transit times than patients with FC. Future studies are needed to confirm that colonic volume allows objective distinction between the two conditions.

Gastrointestinal transit in patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis and collagen deposits. Gastrointestinal symptoms of SSc, including abdominal pain, bloating and discomfort, are common but diffuse and their pathophysiology remains obscure. AIM: To investigate the pathophysiology of abdominal pain and discomfort in individuals with SSc. METHODS: A total of 15 individuals with SSc (13 women, median age 58 years), all suffering from diffuse abdominal symptoms, and 17 healthy volunteers (12 women, median age 52 years) were evaluated with the Motility Tracking System, MTS-1, measuring gastric emptying (GE) and velocity through the small intestine. SSc patients were also examined for bacterial overgrowth using the hydrogen breath test and with radiopaque markers to determine the total gastrointestinal transit time (GITT). RESULTS: Assessed with the MTS-1, the velocity through the proximal small intestine was significantly reduced in SSc patients (median 0.525 m/h, range 0.11-1.15) when compared to healthy subjects (median 0.91 m/h, range 0.51-1.74) (p = 0.02). Prolonged GE was found in 4 SSc patients (27%) but in none of the healthy volunteers (p = 0.04). Only 3 SSc patients (21%) had positive breath tests for small intestinal bacterial overgrowth. GITT was >3 days in 8 patients (53%). Slow small intestinal transit was associated with a prolonged GITT (p < 0.05). CONCLUSION: Velocity through the small intestine is significantly reduced in SSc patients with diffuse abdominal symptoms.

Gastric transit and small intestinal transit time and motility assessed by a magnet tracking system.

BACKGROUND: Tracking an ingested magnet by the Magnet Tracking System MTS-1 (Motilis, Lausanne, Switzerland) is an easy and minimally-invasive method to assess gastrointestinal transit. The aim was to test the validity of MTS-1 for assessment of gastric transit time and small intestinal transit time, and to illustrate transit patterns detected by the system. METHODS: A small magnet was ingested and tracked by an external matrix of 16 magnetic field sensors (4 × 4) giving a position defined by 5 coordinates (position: x, y, z, and angle: θ, φ). Eight healthy subjects were each investigated three times: (1) with a small magnet mounted on a capsule endoscope (PillCam); (2) with the magnet alone and the small intestine in the fasting state; and (3) with the magnet alone and the small intestine in the postprandial state. RESULTS: Experiment (1) showed good agreement and no systematic differences between MTS-1 and capsule endoscopy when assessing gastric transit (median difference 1 min; range: 0-6 min) and small intestinal transit time (median difference 0.5 min; range: 0-52 min). Comparing experiments (1) and (2) there were no systematic differences in gastric transit or small intestinal transit when using the magnet-PillCam unit and the much smaller magnetic pill. In experiments (2) and (3), short bursts of very fast movements lasting less than 5% of the time accounted for more than half the distance covered during the first two hours in the small intestine, irrespective of whether the small intestine was in the fasting or postprandial state. The mean contraction frequency in the small intestine was significantly lower in the fasting state than in the postprandial state (9.90 min-1 vs. 10.53 min-1) (p = 0.03). CONCLUSION: MTS-1 is reliable for determination of gastric transit and small intestinal transit time. It is possible to distinguish between the mean contraction frequency of small intestine in the fasting state and in the postprandial state.

Colonic motility in patients with type 1 diabetes and gastrointestinal symptoms.

BACKGROUND: Gastrointestinal (GI) symptoms are common in patients with diabetes mellitus (DM). The electromagnetic 3D-Transit system allows assessment of regional transit times and motility patterns throughout the GI tract. We aimed to compare GI transit times and detailed motility patterns of the colon in patients with DM and GI symptoms to those of healthy controls (HC). We further aimed to determine whether any abnormalities in motility were reversible by cholinergic stimulation. METHODS: We compared 18 patients with DM with 20 HC by means of the 3D-Transit system. Patients were studied before and during oral administration of 60 mg pyridostigmine. KEY RESULTS: Compared to HC, patients had prolonged gastric emptying (DM: 3.3 hours (interquartile range (IQR) 2.6-4.6); HC: 2.3 hours (IQR 1.7-2.7) (P < .01)), colonic transit time (DM: 52.6 hours (IQR 23.3-83.0); HC: 22.4 hours (IQR 18.9-43.6) (P = .02)), and whole gut transit time (DM: 69.4 hours (IQR 32.9-103.6); HC: 30.3 hours (IQR 25.2-49.9) (P < .01)). In addition, compared to HC, patients had prolonged transit time in the ascending colon (DM: 20.5 hours (IQR 11.0-44.0); HC: 8.0 hours (IQR 3.8-21.0) (P < .05)) and more slow retrograde movements in the colon (DM: 2 movements (IQR 1-4); HC: 1 movement (IQR 0-1) (P = .01)). In patients, pyridostigmine increased the number of bowel movements (P < .01) and reduced small intestine transit times (P < .05). CONCLUSIONS: Patients with DM and GI symptoms have longer than normal GI transit times. This is only partly reversible by pyridostigmine. The increased number of retrograde colonic movements in patients could potentially explain the abnormally long transit time in proximal colon.

Normative values for region-specific colonic and gastrointestinal transit times in 111 healthy volunteers using the 3D-Transit electromagnet tracking system: Influence of age, gender, and body mass index.

BACKGROUND: The 3D-Transit electromagnet tracking system (Motilis Medica, SA, Lausanne, Switzerland) is an emerging tool for the ambulatory assessment of gastrointestinal (GI) transit and motility. Using this tool, we aimed to derive normative values for region-specific colonic and GI transit times and to assess the influence of age, gender, and body mass index (BMI). METHODS: Regional and total colonic transit times (CTT), gastric emptying (GET), small intestinal (SITT), and whole gut (WGTT) transit times were extracted from 111 healthy volunteers from the United Kingdom and Denmark (58 female; median age: 40 years [range: 21-88]). The effects of age, gender, and BMI were assessed using standard statistical methods. KEY RESULTS: The ascending, transverse, descending, and rectosigmoid colon transit times accounted for 32%, 34%, 17%, and 17% of total CTT in females, and 33%, 25%, 14%, and 28% of total CTT in males. CTT and WGTT were seen to cluster at intervals separated by approximately 24 hours, providing further evidence of the non-continuous nature of these measurements. Increasing age was associated with longer CTT (P = .021), WGTT (P < .001) ascending (P = .004), transverse (P < .001), and total right (P < .001) colon transit times, but shorter rectosigmoid (P = .004) transit time. Female gender was significantly associated with longer transverse (P = .049) and descending (P < .001) colon transit times, but shorter rectosigmoid (P < .001) transit time. Increasing BMI was significantly associated with shorter WGTT (P = .012). CONCLUSIONS AND INFERENCES: For the first time, normative reference values for region-specific colonic transit have been presented. Age, gender, and BMI were seen to have an effect on transit times.

Axial Movements and Length Changes of the Human Lower Esophageal Sphincter During Respiration and Distension-induced Secondary Peristalsis Using Functional Luminal Imaging Probe.

BACKGROUND/AIMS: Efficient transport through the esophago-gastric junction (EGJ) requires synchronized circular and longitudinal muscle contraction of the esophagus including relaxation of the lower esophageal sphincter (LES). However, there is a scarcity of technology for measuring esophagus movements in the longitudinal (axial) direction. The aim of this study is to develop new analytical tools for dynamic evaluation of the length change and axial movement of the human LES based on the functional luminal imaging probe (FLIP) technology and to present normal signatures for the selected parameters. METHODS: Six healthy volunteers without hiatal hernia were included. Data were analyzed from stepwise LES distensions at 20, 30, and 40 mL bag volumes. The bag pressure and the diameter change were used for motion analysis in the LES. The cyclic bag pressure frequency was used to distinguish dynamic changes of the LES induced by respiration and secondary peristalsis. RESULTS: Cyclic fluctuations of the LES were evoked by respiration and isovolumetric distension, with phasic changes of bag pressure, diameter, length, and axial movement of the LES narrow zone. Compared to the respiration-induced LES fluctuations, peristaltic contractions increased the contraction pressure amplitude (P ＜ 0.001), shortening (P ＜ 0.001), axial movement (P ＜ 0.001), and diameter change (P ＜ 0.01) of the narrow zone. The length of the narrow zone shortened as function of the pressure increase. CONCLUSIONS: FLIP can be used for evaluation of dynamic length changes and axial movement of the human LES. The method may shed light on abnormal longitudinal muscle activity in esophageal disorders.

[Jaundice and liver injury with cholestatic pattern after treatment with Metoprololsuccinat].

Drug-induced liver injury is a well-known adverse event to numerous medications with clinical presentations from asymptomatic liver enzyme elevation to liver failure. However, liver injury after administration with metoprolol is not common, and only few case reports have been published. This is a case report of an 80-year-old woman with liver injury with cholestatic pattern and jaundice after two months of treatment with Metoprololsuccinat. With no evidence of other disease, liver function normalized in the following months after discontinuation of Metoprololsuccinat.

Danish national guideline: Diagnosis and treatment of Irritable Bowel Syndrome.

National Danish guidelines for the diagnosis and treatment of irritable bowel syndrome (IBS) in adult patients in secondary and tertiary care have been approved by the Danish Society for Gastroenterology and Hepatology. IBS can be a positive diagnosis in patients fulfilling the Rome III criteria for IBS with no alarm signals, a normal physical examination and a normal CRP and hemoglobin. In patients < 40 years with IBS and diarrhea, a normal fecal calprotectin excludes inflammatory bowel disease with a high probability. Patients with IBS and diarrhea should be tested for celiac disease. Endoscopy is not routinely recommended. The therapeutic gain of various treatment modalities is small and most likely overestimated in older studies. However, side effects are usually mild which may justify empirical treatment. The choice of therapy based on IBS subtyping is pragmatic and there are only few trials as guidance. The significance of previous failure with another treatment modality is unclear. There is a lack of long-term treatment trials. The generalizability of the trials is poor, mainly due to selection bias.

[Irritable bowel treatment].

More than every tenth Dane have irritable bowel syndrome. The condition is diagnosed by a positive strategy including fulfilment of the Rome III criteria, absence of alarm symptoms, and if needed a few paraclinical tests. Currently, there is no cure of the disorder. Treatment is recommended on a symptom-based approach targeting the dominating symptom/symptoms. If symptoms are reduced, the quality of life is considerably improved.

Functional lumen imaging of the gastrointestinal tract.

This nonsystematic review aims to describe recent developments in the use of functional lumen imaging in the gastrointestinal tract stimulated by the introduction of the functional lumen imaging probe. When ingested food in liquid and solid form is transported along the gastrointestinal tract, sphincters provide an important role in the flow and control of these contents. Inadequate function of sphincters is the basis of many gastrointestinal diseases. Despite this, traditional methods of sphincter diagnosis and measurement such as fluoroscopy, manometry, and the barostat are limited in what they can tell us. It has long been thought that measurement of sphincter function through resistance to distension is a better approach, now more commonly known as distensibility testing. The functional lumen imaging probe is the first medical measurement device that purports in a practical way to provide geometric profiling and measurement of distensibility in sphincters. With use of impedance planimetry, an axial series of cross-sectional areas and pressure in a catheter-mounted allantoid bag are used for the calculation of distensibility parameters. The technique has been trialed in many valvular areas of the gastrointestinal tract, including the upper esophageal sphincter, the esophagogastric junction, and the anorectal region. It has shown potential in the biomechanical assessment of sphincter function and characterization of swallowing disorders, gastroesophageal reflux disease, eosinophilic esophagitis, achalasia, and fecal incontinence. From this early work, the functional lumen imaging technique has the potential to contribute to a better and more physiological understanding of narrowing regions in the gastrointestinal tract in general and sphincters in particular.

Magnet tracking allows assessment of regional gastrointestinal transit times in children.

BACKGROUND: Data on small intestinal transit time in healthy children are lacking, and normal values for gastric emptying and colonic transit time are sparse. Conventional methods, including radiopaque markers, scintigraphy, and PillCam™ involve radiation or require the child to swallow a large pill. The minimally invasive, radiation-free Motility Tracking System-1 (MTS-1) has been introduced for description of gastrointestinal motility in adults. The aim of the study was to evaluate the MTS-1 for assessment of gastrointestinal transit times and motility patterns in healthy children. METHODS: Twenty-one healthy children (nine girls), median age 10 (range 7-12) years were included. For evaluation with MTS-1, a small magnetic pill was ingested and tracked through the gastrointestinal tract by a matrix of 16 magnetic sensors placed behind a nonmagnetic bed. The children were investigated for 8 hours after swallowing the magnetic pill and again for 4 hours the following morning. After leaving the unit, each child came back after every bowel movement to determine if the pill had been expelled. RESULTS: Nineteen children could swallow the pill. Characteristic contraction patterns were identified for the stomach (three per minute), small intestine (9-11 per minute), and colon (4-5 per minute). Median total gastrointestinal transit time was 37.7 (range 9.5-95.8) hours, median gastric emptying time was 37 (range 2-142) minutes, median small intestinal transit time was 302 (range 164 to >454) minutes, and median colorectal transit time was 38.1 (range 5.6-90.0) hours. CONCLUSION: MTS-1 allows minimally invasive evaluation of gastrointestinal motility in children. Use of the method is, however, restricted by the nonambulatory setup.