Opportunity costs of gastrointestinal endoscopic training in Canada.

BACKGROUND: No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards. OBJECTIVE: To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training. METHODS: Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data. RESULTS: Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration. CONCLUSIONS: Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.

Stress increases descending inhibition in mouse and human colon.

BACKGROUND: A relationship between stress and the symptoms of irritable bowel syndrome (IBS) has been well established but the cellular mechanisms are poorly understood. Therefore, we investigated effects of stress and stress hormones on colonic descending inhibition and transit in mouse models and human tissues. METHODS: Stress was applied using water avoidance stress (WAS) in the animal model or mimicked using stress hormones, adrenaline (5 nM), and corticosterone (1 µM). Intracellular recordings were obtained from colonic circular smooth muscle cells in isolated smooth muscle/myenteric plexus preparations and the inhibitory junction potential (IJP) was elicited by nerve stimulation or balloon distension oral to the site of recording. KEY RESULTS: Water avoidance stress increased the number of fecal pellets compared to control (p < 0.05). WAS also caused a significant increase in IJP amplitude following balloon distension. Stress hormones also increased the IJP amplitude following nerve stimulation and balloon distension (p < 0.05) in control mice but had no effect in colons from stressed mice. No differences were observed with application of ATP between stress and control tissues, suggesting the actions of stress hormones were presynaptic. Stress hormones had a large effect in the nerve stimulated IJP in human colon (increased >50%). Immunohistochemical studies identified alpha and beta adrenergic receptor immunoreactivity on myenteric neurons in human colon. CONCLUSIONS & INFERENCES: These studies suggest that WAS and stress hormones can signal via myenteric neurons to increase inhibitory neuromuscular transmission. This could lead to greater descending relaxation, decreased transit time, and subsequent diarrhea.

Inflammation-induced hyperexcitability of nociceptive gastrointestinal DRG neurones: the role of voltage-gated ion channels.

Gastrointestinal (GI) inflammation modulates the intrinsic properties of nociceptive dorsal root ganglia neurones, which innervate the GI tract and these changes are important in the genesis of abdominal pain and visceral hyperalgesia neurones exhibit hyperexcitability characterized by a decreased threshold for activation and increased firing rate, and changes in voltages-gated Na(+) and K(+) channels play a major role in this plasticity. This review highlights emerging evidence that specific subsets of channels and signalling pathways are involved and their potential to provide novel selective therapeutics targets for the treatment of abdominal pain.

Release of nitric oxide in the central nervous system mediates tonic and phasic contraction of the cat lower oesophageal sphincter.

Nitric oxide (NO) in the brainstem is implicated in the control of swallowing and oesophageal peristalsis. This study examines the role of brainstem NO in the maintenance of lower oesophageal sphincter (LOS) tone, relaxation and contraction. In urethane-anaesthetized cats, oesophageal peristalsis and sphincter pressures were continuously monitored. Drugs were administered into the fourth ventricle. Oesophageal peristalsis and sphincter relaxation and contraction were induced by superior laryngeal nerve stimulation or intra-oesophageal balloon distention. Basal sphincter pressure was significantly reduced after the i.c.v. administration of the nitric oxide synthase (NOS) inhibitor, l-Ng-monomethyl arginine. The inhibitor's d-isomer had no significant effect on basal sphincter pressure, while l-arginine partially reversed the effect. The NOS inhibitor had no effect on sphincter relaxation, whereas the contraction of the sphincter following relaxation was significantly inhibited. Central nitric oxide synthase inhibition reduces basal LOS tone and contraction amplitude but has no effect on swallow or balloon distention induced sphincter relaxation. Therefore, central release of NO acts in the pathway to stimulate dorsal motor nucleus of the vagus neurones projecting to excitatory neurones in the sphincter. Inhibition of nitric oxide synthase in the CNS does not prevent relaxation of the LOS, suggesting that other pathways that do not utilize NO are important in the induction of LOS relaxation.

Superior laryngeal nerve stimulation in the cat: effect on oropharyngeal swallowing, oesophageal motility and lower oesophageal sphincter activity.

Superior laryngeal nerve (SLN) stimulation can activate the brainstem swallowing mechanism to produce a complete swallowing sequence consisting of oropharyngeal, oesophageal and lower oesophageal sphincter (LOS) components. However, little is known of the effect of SLN stimulation (peripheral-sensory input from the pharynx) on the characteristics of oesophageal motor activity, especially in the smooth muscle portion. The present study examined the effect of varying stimulus train length and frequency on each of the three components of the reflex. Acute studies were performed in urethane anaesthetized cats. Oesophageal motility was monitored using conventional manometric techniques, and oropharyngeal swallowing by the mylohyoid electromyogram. SLN stimulus train length (1-10 sec) and frequency (5-30 Hz) were varied independently. Increased train length or frequency resulted in (1) an increase in oropharyngeal swallowing and incidence of the complete swallowing response, (2) an increase in latency to onset of the oesophageal peristaltic wave, (3) reduction of the amplitude of the evoked peristaltic contraction in the smooth muscle portion, without altering its velocity, (4) increased LOS relaxation, and increased LOS after-contraction. The LOS contraction was abolished by atropine (100 micrograms kg-1). Therefore, increased SLN stimulation not only results in excitation of the central swallowing program and the oropharyngeal stage of swallowing, but has major effects on the oesophageal and LOS stages of swallowing. Afferent SLN stimuli can impact on the control mechanisms for each stage, to inhibit or excite the stages in different ways.

Glucagon-like peptide-1 inhibits voltage-gated potassium currents in mouse nodose ganglion neurons.

BACKGROUND: Glucagon-like peptide-1 (GLP-1) is a major hormone known to regulate glucose homeostasis and gut function, and is an important satiety mediator. These actions are at least in part mediated via an action on vagal afferent neurons. However, the mechanism by which GLP-1 activates vagal afferents remains unknown. We hypothesized that GLP-1 acts on nodose ganglion neuron voltage-gated potassium (KV) channels, increasing membrane excitability. METHODS: Employing perforated patch clamp recordings we examined the effects of GLP-1 on membrane properties as well as voltage-gated potassium currents. Extracellular recordings of jejunal afferents were performed to demonstrate the functional relevance of these effects at the nerve terminal. KEY RESULTS: Glucagon-like peptide-1 depolarized a subpopulation of nodose neurons. This membrane depolarization was used to identify neurons containing functional GLP-1 receptors. In these neurons, GLP-1 decreased rheobase and broadened the action potential, and increased the number of action potentials elicited at twice rheobase. We identified a GLP-1 sensitive current whose reversal potential shifted in a depolarizing direction when extracellular potassium was increased. We identified two macroscopic K currents, IA, an inactivating current and IK a sustained current. GLP-1 caused inhibition of these currents, IK by 45%, P < 0.05 and IA currents by 52%P < 0.01, associated with a hyperpolarizing shift of steady-state inactivation curves for both currents. In extracellular recordings of jejunal afferents, GLP-1 increased firing rate, the effect blocked by the K(+) channel antagonist 4-AP. CONCLUSIONS & INFERENCES: These experiments indicate that GLP-1 receptor activation results in vagal afferent excitation, due at least in part to inhibition of sustained and inactivating potassium currents. This mechanism may be important in satiety and glucose homeostatic signals arising from the gastrointestinal tract.

Impairment of rectal afferent mechanosensitivity in experimental diabetes in the rat.

Diabetes mellitus results in neuropathy of both somatic and visceral nerves. In diabetic patients with faecal incontinence, impaired rectal sensory function, manifested by a decreased sensitivity to balloon distention is common. This may contribute to unawareness of rectal filling and incontinence. There has been little study to date of visceral mechanosensation in experimental diabetes however. We hypothesized that experimental diabetes would impair mechanosensitivity in rectal afferent nerves. Diabetes was induced in rats by i.p. injection of streptozotocin. Controls were injected with citrate. In vitro recordings were performed from rectal afferent nerves innervating isolated segments of rectum. In control animals, three distinct populations of mechanosensitive fibres were identified. Low threshold fibres responded at low intensity stretch and reached a maximal firing rate at less than 10 g of stretch (11/24 units). Wide dynamic sensitivity units responded at low intensity stretch (<2 g) but encoded stimulus intensity in a linear fashion up to 20 g (12/24 units). High threshold units responded at greater than 5 g. In diabetic animals there was a near complete loss of LT units (1/19) and most (16/29) had properties similar to WD units. However, their response threshold was significantly increased. Firing rates in response to maximal distention did not change in diabetic animals. We conclude that experimental diabetes selectively affects the detection of low threshold 'physiologic' rectal distention, such as that which might occur during rectal filling, prior to defaecation.

The gaseous mediator, hydrogen sulphide, inhibits in vitro motor patterns in the human, rat and mouse colon and jejunum.

Hydrogen sulphide (H2S) has been recently proposed as a transmitter in the brain and peripheral tissues. Its role in the gastrointestinal tract is still unknown despite some data which suggest an involvement mediating smooth muscle relaxation. The aim of this study was to investigate the effect of this gas on intestinal segments from mouse jejunum and colon, and muscular strips from the human and rat colon. In isolated segments of mouse colon and jejunum, bath applied sodium hydrogen sulphide (NaHS) (a H2S donor) caused a concentration-dependent inhibition of spontaneous motor complexes (MCs) (IC(50) 121 micromol L(-1) in the colon and 150 micromol L(-1) in the jejunum). This inhibitory effect of NaHS on MCs was (i) unaffected by tetrodotoxin (TTX), capsaicin, pyridoxal-phosphate-6-azophenyl-2',4'-disulfonate and N-nitro-L-arginine suggesting a non-neural effect and (ii) significantly reduced by apamin 3 micromol L(-1). NaHS concentration-dependently inhibited the spontaneous motility in strips from human colon (IC(50) 261 micromol L(-1)) and rat colon (IC(50) 31 micromol L(-1)). The inhibitory effect of NaHS on colonic strips was (i) unaffected by the neural blocker TTX (1 micromol L(-1)) with IC(50) 183 micromol L(-1) for the human colon and of 26 micromol L(-1) for the rat colon and (ii) significantly reduced by glybenclamide (10 micromol L(-1)), apamin (3 micromol L(-1)) and TEA (10 mmol L(-1)) with IC(50) values of 2464, 1307 and 2421 micromol L(-1) for human strips, and 80, 167 and 674 micromol L(-1) for rat strips respectively. We conclude that H2S strongly inhibits in vitro intestinal and colonic motor patterns. This effect appears to be critically dependent on K channels particularly apamin-sensitive SK channels and glybenclamide-sensitive K (ATP) channels.

Central nervous system nitric oxide induces oropharyngeal swallowing and esophageal peristalsis in the cat.

BACKGROUND & AIMS: The functional role of brainstem nitric oxide (NO) in swallowing and esophageal peristalsis remains unknown. We examined the effects of blockade of central nervous system (CNS) NO synthase (NOS) on swallowing and on primary and secondary peristalsis. METHODS: (1) The effect of intravenous (IV) NOS inhibitor N(G)-nitro-L-arginine (L-NNA) on swallowing and swallowing-induced peristalsis was examined. (2) An NOS inhibitor (N(G)-monomethyl-L-arginine [L-NMMA]) was administered into the fourth ventricle intracerebroventricularly (ICV), and its effects on swallowing and primary and secondary peristalsis were examined. RESULTS: (1) IV L-NNA significantly reduced the number of oropharyngeal swallows and the induction of primary peristalsis in the smooth muscle portion of the esophageal body; the change was not significant within the striated muscle portion. (2) L-NMMA given ICV significantly reduced the number of oropharyngeal swallows and the incidence of primary peristalsis in both smooth and striated muscle, but the reduction in amplitude was significant only for the smooth muscle contraction. There was a significant reduction in both the amplitude and incidence of secondary peristalsis, only in the smooth muscle portion. CONCLUSIONS: CNS NO is an important neurotransmitter in the induction of oropharyngeal swallowing and esophageal peristalsis. The neural substrates mediating striated and smooth muscle peristalsis may be both anatomically and neurochemically distinct.