[Functional Exams in the gastroenterology - new developments and tips for the common practice]. / Gastroenterologische Funktionsdiagnostik ­ neue Entwicklungen und Tipps für die Praxis.

The functional gastrointestinal disorders (FGIDs) have a high prevalence and are associated with high healthcare costs. The diagnosis of these diseases could be difficult and require func-tional tests such as high-resolution manometry (HRM) of the esophagus, anorectal manometry and H2-Breathtests. Due to the COVID-19 Pandemic and the fear of infections there was a marked reduction in the number of performed exams in the last months - nevertheless some exams are necessary, in order to exclude or to diagnose important and dangerous diseases like Achalasia. Goal of this article is to present some new and relevant developments in the field. The HRM of the esophagus is the diagnostic standard for Achalasia, a rare clinical condi-tion associated to dysphagia - new European guidelines suggests a safe strategy in perform-ing the pneumatic dilatation.The intestinal methanogen overgrowth (IMO) is a clinical condition caused by a high production of methane in the small intestine due to overgrowth of Methanobrevibacter smithii, this condition could be in some patients associated with irritable bowel syndrome.

Comparison of anorectal function measured using wearable digital manometry and a high resolution manometry system.

There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence.

Transanal repair of rectocele: prospective assessment of functional outcome and quality of life.

AIM: This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments. METHOD: Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation. RESULTS: Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement. CONCLUSION: Transanal repair for rectocele improves constipation and constipation-specific QOL.

Comparison of air-filled and water-filled catheters for use in cystometric assessment.

INTRODUCTION AND HYPOTHESIS: To determine whether pressure readings measured with air-filled catheter (AFC) and water-filled catheter (WFC) systems are equivalent during cystometric assessment, especially in case of pressure measurements at Valsalva manoeuvres and coughs. METHODS: Twenty-five subjects were recruited. The commercially available 7-Fr TDOC AFC, which simultaneously reads water and air pressures in the bladder and rectum, was used to compare filling and voiding data recordings. Data were compared using paired t-tests, Bland-Altman plots and linear correlation methods, respectively. RESULTS: Pressure readings measured by the two systems showed a good correlation at Valsalva manoeuvres [R2 = 0.988, 0.968 for vesical pressure (Pves) and abdominal pressure (Pabd), respectively] and at coughs (R2 = 0.972, 0.943 for Pves and Pabd, respectively). There was a statistically significant difference between the two different measurement modalities at coughs (p < 0.01), initial resting pressure (p < 0.01) and the maximum pressure at detrusor overactivity (p < 0.01). This indicated that the difference between the two measurement modalities during Valsalva manoeuvres could reach up to 5.2 cmH2O and 8.1 cmH2O in Pves and Pabd measurements, respectively. During coughs, the difference could reach up to 20 cmH2O and 19.5 cmH2O in Pves and Pabd measurements, respectively. CONCLUSIONS: Pressure recordings from AFC and WFC systems appear to be interchangeable for some urodynamics parameters such as Pves at Valsalva manoeuvres if the baseline pressure is compensated, but not for fast-changing pressure signals such as coughs. This has to be considered when pressures are being taken with the AFC.

Rectal diameter assessment in enuretic children-exploring the association between constipation and bladder function.

OBJECTIVES: Detrusor overactivity and constipation often co-exist in children with enuresis. Constipation is known to be linked to detrusor overactivity. The voiding chart is the best non-invasive way to investigate bladder function, whereas the ultrasonographical detection of rectal dilatation is the best way to objectify constipation. We wanted to investigate a possible relationship between the rectal diameter and voiding chart data in enuretic children. METHODS: Children with therapy-resistant enuresis were retrospectively evaluated. All had completed a voiding chart for at least 48 h. The rectal diameter was assessed ultrasonographically. The cutoff for rectal dilatation was set at 30 mm. RESULTS: We evaluated 74 patients (12 girls) aged 10.2 ± 2.8 years, 35 of whom had rectal dilatation. No significant differences in voiding chart parameters were found between children with normal versus dilated rectum. Neither did urgency or a history of daytime incontinence differ between the groups. Boys were more likely to have rectal dilatation than girls (p = 0.02). CONCLUSIONS: The absence of differences regarding voiding chart data may be explained as two mechanisms neutralizing each other: behavioral factors may make the constipated children void seldom and with large volumes, whereas detrusor overactivity caused by rectal compression of the bladder may have the opposite effect. Another option may be that the voiding chart is too blunt an instrument to detect detrusor overactivity. Constipation, and thus presumably bladder dysfunction, seems to be more important in enuretic boys than girls.

Assessment of bowel and anal sphincter function after neoadjuvant chemoradiotherapy in locally advanced rectal cancer.

PURPOSE: To report long-term effects on anorectal function and bowel disorders and late toxicity rate of preoperative chemoradiotherapy in patients with locally advanced rectal cancer. METHODS: Between 2000 and 2016, 201 patients treated with different neoadjuvant schedules of chemotherapy and radiotherapy doses were retrospectively analyzed. The Memorial Sloan-Kettering Cancer Center score was used for the evaluation of anal sphincter function. RESULTS: The median follow-up time was 68 months (interquartile range 35-113 months). Radical resection was performed in 188 (93.5%) patients with a pathologic complete response rate of 26.4%. Overall sphincter function resulted excellent in 105 (52.2%) patients, good in 13 (6.5%), fair in 10 (5.0%), and poor (incontinence) in 40 (19.9%), with a persistent stoma rate of 16.4%. A further evaluation on 194 patients showed an improvement of sphincter function after 2 years in 11.9% of them. Seventy-three patients presenting stoma or poor sphincter function were re-evaluated for quality of life (QoL) indexes. Twenty-one (29%), 19 (26%), and 24 (33%) of them declared some variations concerning well-being, fatigue, and ability to perform daily activities. The 5-year overall survival, disease-free survival, and local recurrence rates were 88.0% ± 2.6%, 86.3% ± 2.5%, and 94.6% ± 1.9%, respectively. CONCLUSIONS: In our study, neoadjuvant chemoradiotherapy was associated with good results in terms of sphincter function, late toxicities, and QoL indexes. A routine use of assessment scales could contribute to a better selection of patients with increased risk of developing functional disorders who could benefit from neoadjuvant therapy.

Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review.

The purpose of this study was to assess outcome measures and cost-effectiveness of robotic colorectal resections in adult patients with inflammatory bowel disease. The Cochrane Library, PubMed/Medline and Embase databases were reviewed, using the text "robotic(s)" AND ("inflammatory bowel disease" OR "Crohn's" OR "Ulcerative Colitis"). Two investigators screened abstracts for eligibility. All English language full-text articles were reviewed for specified outcomes. Data were presented in a summarised and aggregate form, since the lack of higher-level evidence studies precluded meta-analysis. Primary outcomes included mortality and postoperative complications. Secondary outcomes included readmission rate, length of stay, conversion rate, procedure time, estimated blood loss and functional outcome. The tertiary outcome was cost-effectiveness. Eight studies (3 case-matched observational studies, 4 case series and 1 case report) met the inclusion criteria. There was no reported mortality. Overall, complications occurred in 81 patients (54%) including 30 (20%) Clavien-Dindo III-IV complications. Mean length of stay was 8.6 days. Eleven cases (7.3%) were converted to open. The mean robotic operating time was 99 min out of a mean total operating time of 298.6 min. Thirty-two patients (24.7%) were readmitted. Functional outcomes were comparable among robotic, laparoscopic and open approaches. Case-matched observational studies comparing robotic to laparoscopic surgery revealed a significantly longer procedure time; however, conversion, complication, length of stay and readmission rates were similar. The case-matched observational study comparing robotic to open surgery also revealed a longer procedure time and a higher readmission rate; postoperative complication rates and length of stay were similar. No studies compared cost-effectiveness between robotic and traditional approaches. Although robotic resections for inflammatory bowel disease are technically feasible, outcomes must be interpreted with caution due to low-quality studies.

The assessment and management of defecatory dysfunction: a critical appraisal.

PURPOSE OF REVIEW: To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research. RECENT FINDINGS: The diagnostic utility of high-resolution anorectal manometry (ARM), which has emerged as a promising tool for the diagnosis of defecatory dysfunction, appears to be questionable in differentiating disease from normal physiology. There also seems to be discrepancy between results of various tests of anorectal function in the diagnosis of defecatory dysfunction. New revisions in diagnostic criteria for defecatory dysfunction by Rome IV consortium, may enhance its diagnostic yield. Biofeedback remains to be the most effective evidence-based treatment option for patients with defecatory dysfunction. Anorectal pressure profile cannot predict or mediate the success of biofeedback. Biofeedback may improve the symptoms through central effects. SUMMARY: Despite the advances in the ARM and defecography techniques, no one test has been able to be considered as the 'gold standard' for diagnosis of defecatory dysfunction. The mechanism of action of biofeedback in defecatory dysfunction remains poorly understood.

Application of NICE guideline NG12 to the initial assessment of patients with lower gastrointestinal symptoms: not FIT for purpose?

Background The National Institute for Health and Care Excellence (NICE) published NG12 in 2015. The referral criteria for suspected colorectal cancer (CRC) caused controversy, because tests for occult blood in faeces were recommended. Faecal immunochemical tests for haemoglobin (FIT), which estimate faecal haemoglobin concentrations (f-Hb), might more than fulfil the intentions. Our aim was to compare the utility of f-Hb as the initial investigation with the NICE NG12 symptom-based guidelines. Methods Data from three studies were included. Patients had sex, age, symptoms, f-Hb and colonoscopy and histology data recorded. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of f-Hb and NG12 were calculated for all significant colorectal disease (SCD: CRC, higher risk adenoma and inflammatory bowel disease). Overall diagnostic accuracy was also estimated by the area under the receiver operating characteristic curve (AUC). Results A total of 1514 patients were included. At a cut-off of ≥10 µg Hb/g faeces, the sensitivity of f-Hb for CRC was 93.3% (95% confidence interval (CI): 80.7-98.3) with NPV of 99.7% (95%CI: 99.2-99.9). The sensitivity and NPV for SCD were 63.2% (95%CI: 56.6-69.4) and 96.0% (95%CI: 91.4-94.4), respectively. The NG12 sensitivity and NPV for SCD were 58.4% (95%CI: 51.8-64.8) and 87.6% (95%CI: 85.0-89.8), respectively. The AUC for CRC was 0.85 (95% CI: 0.87-0.90) for f-Hb versus 0.65 (95%CI: 0.58-0.73) for NG12 ( P < 0.005). For SCD, the AUC was 0.73 (95%CI: 0.69-0.77) for f-Hb versus 0.56 (95%CI: 0.52-0.60) for NG12 ( P < 0.0005). Conclusion f-Hb provides a good rule-out test for SCD and has significantly higher overall diagnostic accuracy than NG12.

Esophageal and anorectal involvement in systemic sclerosis: a systematic assessment with high resolution manometry.

OBJECTIVES: In systemic sclerosis (SSc), esophageal and anorectal involvements are frequent and often associated with each other. In clinical practice, esophageal explorations are often prescribed, while anorectal explorations are rarely proposed and therefore, under-recognised. However, it is well documented in the literature that early detection of anorectal dysfunction could delay and/or prevent the onset of symptoms such as fecal incontinence (FI). The main objective was the systematic evaluation and detection of esophageal and anorectal involvements in SSc patients. METHODS: In this monocentric retrospective study, all patients with SSc addressed in the Department of Functional Digestive Explorations, North Hospital, Marseille for esophageal and anorectal explorations were included. Self-Questionnaires, evaluating the symptoms and quality of life, were filled by patients during their visit. Explorations were performed on the same day: high resolution esophageal manometry (EHRM), 3 Dimensional high resolution anorectal manometry (3DHRARM) and endo anal sonography (EUS). RESULTS: 44 patients (41 women), mean age 59.8±12 years, were included. With regard to the symptoms, 45.5% of patients had gastro-esophageal reflux disease (GERD), 66.9% dysphagia, 65.9% constipation and 77.3% FI. The incidence of esophageal dismotility was 65.9%, anorectal and both upper and lower dysfunction were 43.2%. More than 89% patients with abnormal explorations (EHRM, 3DHRARM or both) were symptomatic. Duration of SSc and altered quality of life was correlated with the severity of digestive involvement. CONCLUSIONS: Anorectal dysfunction appears to be closely linked to esophageal involvement in SSc. Their routine screening is undoubtedly essential to limit the occurrence of severe symptoms such as FI.

[Protocol for neurophysiological studies of the pelvic floor to appraise anorectal dysfunction in patients with multiple sclerosis]. / Protocolo de estudios neurofisiológicos del suelo pélvico para la valoración de la disfunción anorrectal en pacientes con esclerosis múltiple.

INTRODUCTION: Patients with multiple sclerosis (MS) frequently develop anorectal dysfunction. The neuromuscular structures of the pelvic floor and the mechanisms of voluntary control over defecation can be compromised by the patchy lesions of MS or secondary to the patient's disability. The involvement of multiple factors limits understanding of the pathophysiology of anorectal dysfunction in MS. Specific neurophysiological tests assess the functionality of the elements of the central and peripheral nervous system involved in anorectal dysfunction. AIM: To propose a diagnostic protocol of standardised neurophysiological studies of the pelvic floor in order to characterise the pathophysiology of anorectal dysfunction in patients with MS. PATIENTS AND METHODS: The following studies were conducted on 16 patients with defined MS and who met criteria for constipation or faecal incontinence: external anal sphincter electromyography (EAS-EMG), somatosensory evoked potentials (SSEP) of the internal pudendal nerve, recording of ano-sacral reflexes and pudendal nerve neurography. RESULTS: The clinical and neurophysiological characteristics were heterogeneous. Nine patients presented constipation; two had isolated faecal incontinence; and five, a combination of both. Abolition or delay in the latency of the SSEP was the most frequent finding (n = 12), followed by the detection of paradoxical contraction (n = 11) and deficient recruitment (n = 8) in the EAS-EMG. CONCLUSIONS: The correct interpretation of each available neurophysiological test and the correlation of the findings as a whole enable us to understand the pathophysiology of anorectal dysfunction. The implementation of a protocol for neuro-physiological studies of the pelvic floor makes it possible to adjust the diagnosis by identifying the central or peripheral nervous lesion determining anorectal dysfunction in patients with MS.

TITLE: Protocolo de estudios neurofisiologicos del suelo pelvico para la valoracion de la disfuncion anorrectal en pacientes con esclerosis multiple.Introduccion. Los pacientes con esclerosis multiple (EM) frecuentemente desarrollan disfuncion anorrectal. Las estructuras neuromusculares del suelo pelvico y los mecanismos de control voluntario de la defecacion pueden afectarse por las lesiones parcheadas de la EM o secundarias a la discapacidad del paciente. La implicacion multifactorial limita la comprension de la fisiopatologia de la disfuncion anorrectal en la EM. Tests neurofisiologicos especificos valoran la funcionalidad de los elementos del sistema nervioso central y periferico implicados en las disfunciones anorrectales. Objetivo. Proponer un protocolo diagnostico de estudios neurofisiologicos estandarizados del suelo pelvico para caracterizar la fisiopatologia de la disfuncion anorrectal en los pacientes con EM. Pacientes y metodos. Se realizaron estudios de electromiografia de esfinter anal externo, potenciales evocados somatosensoriales desde el nervio pudendo interno, registro de reflejos sacros anales y neurografia del nervio pudendo a 16 pacientes con EM definida y criterios de estreñimiento o incontinencia fecal. Resultados. Las caracteristicas clinicas y neurofisiologicas fueron heterogeneas. Nueve pacientes presentaron estreñimiento; dos, incontinencia fecal aislada; y cinco, combinacion de ambos. La abolicion o el retraso de la latencia de los potenciales evocados somatosensoriales fue el hallazgo mas frecuente (n = 12), seguido de la deteccion de contraccion paradojica (n = 11) y de reclutamiento deficitario (n = 8) en la electromiografia de esfinter anal externo. Conclusiones. La correcta interpretacion de cada test neurofisiologico disponible y la correlacion de los hallazgos en conjunto permiten comprender la fisiopatologia de la disfuncion anorrectal. La protocolizacion de estudios neurofisiologicos del suelo pelvico permite ajustar el diagnostico al identificar la lesion nerviosa, central o periferica, determinante de disfuncion anorrectal en los pacientes con EM.

Assessment of rectocolonic morphology and function in patients with Chagas disease in Barcelona (Spain).

The aim of this study was to determine the relationship between colonic symptoms, radiological abnormalities, and anorectal dysfunction in patients with Chagas disease. We performed a cross-sectional study of untreated patients diagnosed with Chagas disease. All patients were evaluated clinically (by a questionnaire for colonic symptoms based on Rome III criteria) and underwent a barium enema and anorectal manometry. A control group of patients with functional constipation and without Chagas disease was included in the study. Overall, 69 patients were included in the study: 42 patients were asymptomatic and 27 patients had abdominal symptoms according to Rome III criteria. Anorectal manometry showed a higher proportion of abnormalities in symptomatic patients than in asymptomatic ones (73% versus 21%, respectively; P < 0.0001). Megarectum was detected in a similar proportion in the different subgroups regardless of the presence of symptoms or abnormalities in anorectal functions. Among non-Chagas disease patients with functional constipation, 90% had an abnormal anorectal manometry study. Patients with Chagas disease present a high proportion of constipation with dyssynergic defecation in anorectal manometry but a low prevalence of impaired rectoanal inhibitory reflex, although these abnormalities may be nonspecific for Chagas disease. The presence of megarectum is a nonspecific finding.

A new job for an old device: a novel use for nerve stimulators in anorectal malformations.

Muscle stimulation of the perineum is a crucial step in the repair of anorectal malformations. This allows the surgeon to assess muscle function and locate precisely the sphincter muscles during a pull-through operation. Presently, the device commonly used is very expensive. In searching for a cheaper and amenable device we explored utilizing the nerve stimulator MiniStim (model MS-IIIA, Life-Tech, Inc., Houston, TX) normally used for the "train of four" sign in assessing paralysis during general anesthesia. We have used this device in seven consecutive posterior sagittal anorectoplasties and compared its effectiveness with the regular muscle stimulator. In our experience, the nerve stimulator is easier to work with and is a common device in the operating theater. It gave us information that was at least equal to the regular muscle stimulator.

Endoanal ultrasound assessment of sphincter defects and thinning--correlation with anal manometry.

BACKGROUND AND STUDY AIMS: This study aims to determine if anal sphincter defects/thinning observed at endoanal ultrasound correlates with anal pressures recorded at anal manometry. PATIENTS AND METHODS: A total of 30 consecutive patients with history suggestive of anal sphincter pathology underwent anal endosonography with documentation of internal and external sphincter defects/thinning. The same patients underwent anal manometry with documentation of maximum resting and maximum squeeze pressures. Patients with a sphincter defect (SD) were compared to patients without a sphincter defect (NSD) and both groups were compared with respect to findings in manometry. The Mann-Whitney U test was used for statistical analysis. This study was approved by the Institutional Ethics Committee. RESULTS: A statistically significant correlation was found between decreased maximal resting pressure and decreased internal anal sphincter (IAS) thickness or an IAS defect. The correlation between MSP and external sphincter pathology was significantly less consistent in our study. CONCLUSION: Our study showed a statistically significant correlation between maximum resting pressure and observation of internal sphincter defects at endoanal ultrasound. The patients with documented internal sphincter defects have significantly reduced maximum resting pressures. There was however, no correlation between external sphincter defects and decrease in maximum squeeze pressure as has been observed in other studies. Until a manometry cut-off can be set to discriminate between the absence and presence of defects, both manometry and ultrasound should be offered to patients with history suggesting anal sphincter pathology.

Prevalence, clinical characteristics, and management of functional constipation at pediatric gastroenterology clinics.

The purpose of this study was to investigate the prevalence, clinical characteristics, and management of functional constipation at pediatric gastroenterology clinics. A prospective survey using the Rome III criteria was distributed to a group of parents of children with a constipation history and its control group in May 2008. The mean prevalence of constipation was 6.4%, which was similar to those in other countries. Statistically significant variables for children without constipation were that more children had a body mass index of below the 10th percentile even though they received more mother's care and ate balanced meals compared to the constipation group. Meanwhile, the constipation group frequently showed a history of constipation in infancy, picky-eating, lack of exercise, and retentive posturing. When analyzed with the Rome III criteria, the children showed greater than 60% rate of hard stools, painful stools, a history of large fecal mass in rectum, and its disappearance of constipation symptoms after passing a large stool. Our study found different approaches amongst pediatric gastroenterologists like rectal examinations, disimpaction, or drug treatment. Several factors addressed in our study can provide better guidelines for clinicians treating constipation and its future research.

Quantitative assessment of altered rectal mucosal permeability due to rectally applied nonoxynol-9, biopsy, and simulated intercourse.

BACKGROUND: Microbicide toxicity may reduce the efficacy of topical preexposure prophylaxis for human immunodeficiency virus (HIV) transmission. Noninvasive quantitative measures of microbicide toxicity would usefully inform microbicide development. METHODS: Ten subjects received 3 one-time interventions: 5 mL of Normosol-R fluid alone (negative control), 5 mL of 2% nonoxynol-9 (N-9) gel, and 5 mL of Normosol-R with coital simulation and sigmoidoscopic biopsy (CS + BX). Each dose of N-9 and Normosol-R contained 500 µCi of (99m)technetium-diethylene triamine pentaacetic acid. Plasma and urine radioactivity was assessed over 24 hours. RESULTS: The plasma radioisotope concentration peaked 1 hour after N-9 dosing. The mean maximum radioisotope concentration after N-9 receipt was 12.0 times (95% confidence interval [CI], 6.8-21.0) and 8.4 times (95% CI, 5.2-13.5) the mean concentration after Normosol-R control receipt and CS + BX receipt, respectively; paired differences persisted for 24 hours. After N-9 dosing, the urine isotope level was 3.6 times (95% CI, 1.1-11.4) the level observed 8 hours after Normosol-R control receipt and 4.0 times (95% CI, 1.4-11.4) the level observed 4 hours after CS + BX receipt. Permeability after CS + BX receipt was greater than that after Normosol-R control receipt in 0-2-hour urine specimens only (mean permeability, 2.4; 95% CI, 1.0-5.8) but was not greater in blood. CONCLUSIONS: Plasma sampling after rectal radioisotope administration provided quantitative estimates of altered mucosal permeability after chemical and mechanical stresses. Permeability testing may provide a useful noninvasive adjunct to assess the mucosal effects of candidate microbicides. Clinical Trials Registration. NCT00389311.

Assessment of rectal afferent neuronal function and brain activity in patients with constipation and rectal hyposensitivity.

BACKGROUND: Blunted rectal sensation (rectal hyposensitivity: RH) is present in almost one-quarter of patients with chronic constipation. The mechanisms of its development are not fully understood, but in a proportion, afferent dysfunction is likely. To determine if, in patients with RH, alteration of rectal sensory pathways exists, rectal evoked potentials (EPs) and inverse modeling of cortical dipoles were examined. METHODS: Rectal EPs (64 channels) were recorded in 13 patients with constipation and RH (elevated thresholds to balloon distension) and 11 healthy controls, in response to electrical stimulation of the rectum at 10 cm from the anal verge using a bipolar stimulating electrode. Stimuli were delivered at pain threshold. Evoked potential peak latencies and amplitudes were analyzed, and inverse modeling was performed on traces obtained to determine the location of cortical generators. KEY RESULTS: Pain threshold was higher in patients than controls [median 59 (range 23-80) mA vs 24 (10-55) mA; P = 0.007]. Median latency to the first negative peak was 142 (±24) ms in subjects compared with 116 (±15) ms in controls (P = 0.004). There was no difference in topographic analysis of EPs or location of cortical activity demonstrated by inverse modeling between groups. CONCLUSIONS & INFERENCES: This study is the first showing objective evidence of alteration in the rectal afferent pathway of individuals with RH and constipation. Prolonged latencies suggest a primary defect in sensory neuronal function, while cerebral processing of visceral sensory information appears normal.

Alternative procedure to shorten rectal barostat procedure for the assessment of rectal compliance and visceral perception: a feasibility study.

BACKGROUND: Barostat methodology is widely used for assessing visceral perception. Different barostat protocols are described with respect to the measurement of rectal compliance and visceral perception. The choice of protocols affects the duration, which is normally 60-90 min, and accuracy of the procedure. This study aimed to shorten the procedure by using the semi-random distension protocol for both compliance and visceral perception measurement and a correction based on rectal capacity (RC) instead of minimal distension pressure (MDP). METHODS: Twelve irritable bowel syndrome (IBS) patients (7 females) and 11 healthy controls (8 females) underwent a barostat procedure. Compliance was determined during both a staircase distension and a semi-random protocol. Visceral perception data were compared as a function of pressure or relative volume, corrected for MDP or RC, respectively. RESULTS: Compliance measurement using the semi-random protocol instead of the staircase distension protocol resulted in an overestimation in healthy volunteers, but not in IBS patients. The overall conclusion that IBS patients had a lower compliance compared to controls was not different between protocols. Data presentation of the visceral perception scores as a function of corrected volume instead of pressures corrected for MDP did not alter the conclusion that sensation scores in IBS patients were higher as compared to healthy controls. CONCLUSIONS: This study showed that barostat procedures may be shortened by approximately 20 min, without losing the ability to discriminate between healthy controls and IBS patients. A correction for RC instead of MDP may improve the accuracy of the procedure.

Comparison of temporal artery to rectal temperature measurements in children up to 24 months.

This descriptive study compared temporal artery (TA) and rectal temperature measurements, patient comfort during temperature measurements, and nursing time required to obtain temperature measurements. Study participants (n = 40) included children 0-24 months old with fever higher than 38°C, admitted to a freestanding children's hospital in the Midwest. Statistical analysis of 450 paired TA and rectal temperature measurements revealed a 0.776 correlation, mean difference of 0.03°C, and 94.7% of measurements differing by less than 1.0°C. Patient comfort, measured via the Face, Legs, Activity, Cry, Consolability Scale, was enhanced with TA thermometry compared to rectal. TA thermometry resulted in an 87% savings of nursing time.

Chronic constipation: overview and challenges.

Despite its high prevalence and cost implications, our understanding of the pathophysiology of constipation remains primitive, and available therapies have limited efficacy. The purpose of this supplement is to address critically the reasons for the current lack of understanding and to propose avenues of future research to address these deficiencies.