Pycnogenol® supplementation improves the control of irritable bowel syndrome symptoms.

BACKGROUND: The aim of this registry was to evaluate the effects of Pycnogenol® on the main symptoms of irritable bowel syndrome (IBS) in otherwise healthy individuals. METHODS: This study included 77 healthy individuals with symptoms of IBS. The patients were divided into three groups: group 1 was treated with Buscopan (10 mg when needed), group 2 (Antispasmina col forte; 50 mg papaverine hydrochloride+10 mg belladonna extract when needed) and 3 (Pycnogenol® 150 mg/day) for 3 weeks. RESULTS: The number of painful attacks was comparable in all groups after four weeks. Mild pain on manual abdomen pressure was decreased in all groups, with the improvement in the Pycnogenol® group significantly more pronounced that in both control groups (P<0.05). Perceived abdominal bowel movements/distension were significantly relieved in group 2 (Antispasmina Col Forte) and 3 (Pycnogenol®) (P<0.05) in comparison with Buscopan (group 1). CONCLUSIONS: Pycnogenol® has shown a significant, protective and preventive activity on IBS symptoms, and thus it may represent a potential "soft" approach to IBS.

Evaluation of hyoscine N-butyl bromide efficacy on the prevention of catheter-related bladder discomfort after transurethral resection of prostate: a randomized, double-blind control trial.

BACKGROUND: Transurethral resection of prostate (TURP) is the most common treatment for benign prostatic hyperplasia (BPH). Urinary tract catheter is inserted post-operatively which results in catheter-related bladder discomfort (CRBD) in many patients. The purpose of this study was to assess the preventive effect of hyoscine N-butyl bromide on CRBD caused by a urinary tract catheter after TURP surgery in patients with BPH. METHODS: Twenty-four and twenty-six patients in the treatment and control groups were enrolled, respectively. At the end of the surgery, slow intravenous injection of 20 mg hyoscine N-butyl bromide was administered to the patients of treatment group. The severity of CRBD was followed up at five different time periods and up to 2 h after surgery. RESULTS: On arrival to PACU and after 30 min of injection, statistically significant less CRBD was seen in the treatment group comparing to the control group (P ≤ 0.05 and P ≤ 0.007). The total utilized meperidine dose during PACU stay and the time to discharge for the intervention group were significantly lower than those for the control group (P ≤ 0.0001) with no significant difference in adverse effects (P > 0.05). CONCLUSIONS: Hyoscine N-butyl bromide could reduce the severity of CRBD related to TURP in patients with BPH and their need for analgesic consumption either. It shortened the length of stay in the recovery room. Regarding its availability and low cost, it can be an effective pain relief drug for CRBD discomfort related to TURP in BPH patients.

Comparison of efficacy and safety of hyoscine butylbromide versus anisodamine for acute gastric or intestinal spasm-like pain: A randomized, double-blinded, multicenter Phase III trial.

OBJECTIVE: Acute gastric or intestinal spasm-like pain is common in clinical setting. Hyoscine butylbromide (HBB), an anti-cholinergic agent, relieves pain in stomach and bowel cramps by inhibiting smooth muscle contractility. In this study, we aimed to compare the efficacy and safety of parenteral HBB and anisodamine for treating acute gastric or intestinal pain. METHODS: In this randomized, controlled, double-blind, parallel-group, multicenter non-inferiority trial, 299 Chinese patients were randomly assigned to HBB or anisodamine in a ratio of 1:1. They were administrated a single dose of either HBB 20 mg or anisodamine 10 mg, and a second dose was given when needed. The primary end-point was the difference in pain intensity (PID) from the pre-dose baseline at 20 min after the first injection. RESULTS: Altogether 295 patients completed the protocol (153 in the HBB and 142 in the anisodamine group). For the primary end-point, the PID was -4.09 (95% confidence interval [CI]: -4.41, -3.76) for the HBB group and -3.66 (95% CI: -4.02, -3.31) for the anisodamine group (P < 0.0001 for non-inferiority). The percentage of patients with at least one adverse event was lower in the HBB group than in the anisodamine group (13.1% vs 17.6%), but there was no statistical significance (P = 0.279). The most frequent adverse events were thirst (7.8%) and dry mouth (2.6%) in the HBB group, and thirst (7.0%), dry mouth (3.5%) and nodal arrhythmia (2.1%) in the anisodamine group. CONCLUSIONS: HBB 20 mg was not inferior to anisodamine 10 mg in pain relief of patients with acute gastric or intestinal spasm-like pain. Both drugs were safe and well tolerated.

Lower esophageal sphincter relaxation by administrating hyoscine-N-butylbromide for esophageal impaction by coin - shaped foreign bodies; prospective clinical study in pediatric population.

Aim of the present study is the presentation of our experience in conservative treatment of coin-shaped, ingested foreign bodies in lower esophagus and the consideration about the indications of this method's appliance in clinical practice. From 2011 to 2014, 79 children in total (45 male - 34 female), aged from 8 months to 13 years (average 4.8 years) were admitted to our Department due to foreign body ingestion. In 21/79 patients the foreign body lodged in the esophagus, in 9 in the upper and in 12 in the lower esophagus. Cases of pre-existing esophageal stricture or of esophageal obstruction, due to sharp or linear foreign bodies or disk battery, were excluded. Finally, our study group consisted of 11 patients, aged from 10 months to 10 years (aver- age 4.6 years). The average time elapsed from the ingestion of the foreign body until the admission of the child in the Emergency Department was 4 hours. Young patients were administered suppository form of hyoscine-N-butylbromide, followed by repetition of radiograph 6 hours later. In 9 cases the ingested foreign body passed to the stomach within the first six hours, while in 2 cases no alteration of its position was noted, thus endoscopic removal followed. In these 9 cases the foreign body passed through the gastrointestinal (GI) tract and was excreted within the next 1-3 days. Smooth muscle relaxation of the lower esophageal sphincter after administration of hyoscine-N-butylbromide was successful in 82% of our patients, while the success rate in relevant publications ranges from 20 to 42%. In conclusion, it is worth noting that the pharmaceutical relaxation of the lower esophageal sphincter is a safe alternative method of treatment in cases of foreign bodies lodged in the lower esophagus, except for linear or sharp objects or coin batteries. Given that the majority of hospitals in Northern Greece lacks of pediatric gastroenterologists, while endoscopic intervention - when indicated - should be conducted early after admission, it is obvious that the proposed method becomes essential.

[Treatment of foreign body impactions in oesophagus]. / Håndtering af fremmedlegeme i øsofagus med synkestop.

Foreign body impactions in oesophagus occur frequently. The causes are oesophageal pathology (anatomical, functional or inflammatory diseases). X-ray may be performed to determine the diagnosis or suspected perforation. Treatment can be conservative with carbonated drinks and observation for up to 24 hours, as up to two thirds of the impactions pass spontaneously. There is no evidence for medical treatment with buscopane, diazepam or glucagone. Emergent endoscopy is performed at risk of perforation by erosive or sharp objects, by obstruction over 24 hours, at risk of aspiration and complete obstruction.

Factors affecting outcomes in colonoscopy.

There are many factors that influence successful outcomes in colonoscopy. The aims of this study were to evaluate these factors and determine ways to improve outcomes. All participants (N=229) who underwent planned colonoscopy between July and September 2004 were retrospectively included. Participants included 118 men and 111 women with a mean age of 59 years. Completion rate was 92%. Reasons of failure included poor bowel preparation (2.2%, p< .025), bowel looping (2.2%, p< .025), participant discomfort (1.3%), and obstructing lesion (1.3%). Mean midazolam dose was 3.8 mg. Three participants (1.3%) had midazolam alone, and all had complete colonoscopy. One hundred thirty-three participants (60.7%) had additional meperidine, with a completion rate of 94%. Eighty three participants (37.9%) had additional meperidine and Buscopan, with a completion rate reduced to 89.2%. There was no correlation between sedatives used and completion rate. Completion rate of colonoscopy in our unit was acceptable at 92%. A combination of midazolam and meperidine gave the best completion rates (94%). The two main reasons for incompletion were poor bowel preparation and excessive bowel looping.

Effects of Spascupreel versus hyoscine butylbromide for gastrointestinal cramps in children.

BACKGROUND: Gastrointestinal spasms and cramps are common in children as well as in adults. Alternative medical practices such as chiropractice and homeopathy are becoming increasingly popular in Europe and the USA. The effectiveness and tolerability of the homeopathic preparation Spascupreel was compared with that of hyoscine butylbromide treatment in children <12 years of age. METHODS: An observational cohort study in 204 children <12 years was conducted over a 1 week treatment period. The efficacy of the respective therapies were evaluated on the effect on severity of spasms and clinical symptoms (pain/cramps, sleep disturbances, distress, eating or drinking difficulties and frequent crying). Compliance was evaluated on a four-point scale from 'very good' to 'low'. Evaluation was done by the practitioner based on information given by the patient or minder. RESULTS: The analysis showed comparative improvements with the homeopathic preparation and hyoscine butylbromide therapy on severity of spasms, pain/cramps, sleep disturbances, eating or drinking difficulties, and frequent crying, all as evaluated by the practitioner. Both treatments were very well tolerated. CONCLUSIONS: For patients opting for a homeopathic therapy, Spascupreel seems to be an effective and well tolerated alternative to conventional therapies in children suffering from gastrointestinal spasms.

Efficacy of peppermint oil as an antispasmodic during endoscopic retrograde cholangiopancreatography.

BACKGROUND: During endoscopic retrograde cholangiopancreatography (ERCP), hyoscine-N-butylbromide (Buscopan) or glucagon is used to inhibit duodenal motility. However, they may cause adverse effects. Peppermint oil has an antispasmodic effect and is used as a less hazardous antispasmodic during colonoscopy and upper gastrointestinal endoscopy. The purpose of the present paper was therefore to investigate peppermint as an antispasmodic for ERCP. METHODS: Forty patients were enrolled prospectively. They were assigned to four groups according to the peppermint oil concentration and site of administration: group 1, 20 mL of 1.6% solution around duodenal papilla; group 2, 20 mL of 1.6% solution both to the antrum of the stomach and around the duodenal papilla; group 3, 20 mL of 3.2% solution around the duodenal papilla; and group 4, 3.2% solution both to the antrum and around the duodenal papilla. Glucagon or hyoscine-N-butylbromide was added when duodenal peristalsis was not adequately diminished. Sixteen patients undergoing ERCP with glucagon were employed as historical controls. RESULTS: The ERCP was attempted in all except one patient in group 2 who had bleeding from invaded tumor to the duodenum. Peppermint administration equally reduced duodenal motility in the groups. Duodenal movement was none or mild in 69.2% of patients. The ERCP was successfully performed with peppermint alone in 91.4% of patients (37/39). Glucagon or hyoscine-N-butylbromide was needed in one patient each in groups 1 and 4. Serious complications related to peppermint oil did not occur. Inhibitory effect of peppermint appears to be identical to that of glucagon. CONCLUSION: Duodenal relaxation was obtained with 20 mL of 1.6% peppermint oil solution in the duodenum, but additional administration may be required. Peppermint oil is useful as an antispasmodic agent for ERCP.

[Comparative efficiency study, safety and usage of tested drugs in patients with renal colic]. / Komparativna studija efikasnosti, sigurnosti i upotrebe ispitivanih lijekova, kod pacijenata sa renalnom kolikom.

UNLABELLED: Renal colic represents the the collection of the acute symptoms which are characterized by very intensive and antagonizing pain, so, that withstanding, it calls for fast diagnosis and precise and speedy treatment. Intervention in renal colic cases has to be based on the knowledge on the origin of pain, renal damage suffered, and also has to protect the kidney from any damaged caused by the prolonged obstruction. MATERIAL AND METHODS: This paper presents the results from prospective, analitical, comparative, ITT (intention to treat) study that has been carried out 200 ambulatory treated seperate patients with renal colic, divided into four groups, in the time period from year 2003 to 2005. In all these cases the the efficiency and the active time time of standard medications used with renal colic symptoms. RESULTS: 2 grams of Metamizol i.v. and 75 mg of Diclofenac i.m. have shown equal efficiency in pain relief, which is 6 hours after the administration of therapy, while 50 mg of Butylscopolamin i.v. requires additional analgesic treatment (p < 0.05). The effect of Metamizol is a bit stronger 15 minutes after the application than the rest of the medications, but 30 minutes after the application the effects of Metamizol and Diclofenac are almost identical. Using meta analasys and EBM (Evidence Based Medicine) parameters in regard to the side effects, the made conclusion was that Diclofenac is the medication of choice for renal colic. Reserve medication is Metamizol, while Butylscopolamin causes negative side effects in 84% of the cases, and in 24% of the cases it causes cupping of the renal colic.

Non-operative management of intestinal obstruction due to ascaris lumbricoides.

OBJECTIVE: To compare, evaluate and analyze three different non-operative modalities of treatment of intestinal obstruction due to ascaris lumbricoides. DESIGN: A non-randomized, cohort and comparative study. PLACE AND DURATION OF STUDY: Department of Pediatric Surgery, National Institute of Child Health, Karachi from March 2001 to October 2002. PATIENTS AND METHODS: A total of 45 patients with the diagnosis of intestinal obstruction due to ascaris lumbricoides were included in the study. They were divided in 3 groups of 15 patients each. Group I patients were given I/V fluids only, group II patients were given hyoscinbutylbromide in infusion and group III patients were given hypertonic saline enema. The outcome of all groups was compared in terms of improvement in obstruction and hospital stay. The data was analyzed by SPSS 11.0 by using ANOVA and HSD Tuckey test for multiple comparisons. RESULTS: The non-operative treatment was successful in all of the patients. In group III improvement of intestinal obstruction occurred in 1.6 +/- 1.11 days (p value=0.001), whereas it was 2.6 +/-1.11 days in group II and 3.4 +/-1.35 days in group I. The mean hospital stay in group III was 4 +/-1.69 days (p value=0.003), whereas it was 6.27 +/- 2.31 days in group II and 5.87 +/-1.25 days in group I. CONCLUSION: We recommend that hypertonic saline enema is a better non-operative treatment modality of intestinal obstruction, due to ascaris lumbricoides, in patients who do not have peritonitis. It is associated with early improvement of obstruction coupled with reduced hospital stay.

Peppermint oil reduces gastric spasm during upper endoscopy: a randomized, double-blind, double-dummy controlled trial.

BACKGROUND: GI endoscopy without general anesthesia causes a hyperperistaltic state in the stomach, which frequently necessitates the use of antispasmodic agents, such as hyoscine-N-butylbromide, but these drugs have side effects. Peppermint oil is harmless and acts locally to inhibit GI smooth muscle contraction. METHODS: A randomized double-blind, double-dummy, controlled trial was conducted in 100 patients to compare the antispasmodic effects of hyoscine-N-butylbromide administered intramuscularly and a placebo solution administered intraluminally by means of the endoscope, and also the effects of a placebo solution administered intramuscularly with those of a peppermint oil solution administered intraluminally. The percent change in diameter of the pyloric ring before and after the administrations was defined as the opening ratio, and the percent change in diameter between the maximally and minimally opened pyloric ring states was defined as the contraction ratio. Time until disappearance of the contraction ring(s) in the gastric antrum and side effects of the drugs were also determined. RESULTS: The opening ratio was significantly higher in the peppermint oil administration group than in the hyoscine-N-butylbromide injection group. The contraction ratio after peppermint oil administration was significantly lower than that after hyoscine-N-butylbromide injection. The time required for disappearance of the antral contraction ring(s) was shorter in the peppermint oil group (97.1 +/- 11.4) than in the hyoscine-N-butylbromide group (185.9 +/- 10.1 s; p < 0.0001). No significant side effects were associated with peppermint oil, whereas hyoscine-N-butylbromide injection produced side effects such as dry mouth, blurred vision, and urinary retention. CONCLUSIONS: Peppermint oil solution administered intraluminally can be used as an antispasmodic agent with superior efficacy and fewer side effects than hyoscine-N-butylbromide administered by intramuscular injection during upper endoscopy.

Spasmolytic effect of peppermint oil in barium during double-contrast barium enema compared with Buscopan.

AIM: To evaluate the efficacy of peppermint oil in barium as a spasmolytic agent during a double-contrast barium enema (DCBE). MATERIALS AND METHODS: A total of 383 DCBEs with positive results from occult blood tests were assessed. Patients were assigned to one of four groups: peppermint in barium (n=91), peppermint in tube (n=90), Buscopan (n=105), or no treatment (n=97). After a screening sigmoidoscopy, the DCBEs were performed using air as a distending gas. In the Buscopan group, the DCBE was performed with an intramuscular injection of 20mg Buscopan at the start of the examination. Patients in the no-treatment group underwent DCBE without any spasmolytic agent. A peppermint oil preparation (30ml) was mixed in the barium solution for patients in the peppermint-in-barium group, and the same dose of peppermint oil was included in the enema tube in the peppermint-in-tube group. The presence of spasm on a series of spot films was evaluated without information about the type of spasmolytic agent used. RESULTS: The percentage of patients in the four groups (no treatment, Buscopan, peppermint in tube, and peppermint in barium) with absence of spasm in the entire colon on the series of spot films was 13.4, 38.1, 41.8, and 37.8%, respectively. In the group using peppermint oil or Buscopan, the rate of patients with non-spasm examination was higher than that in no-treatment group (p<0.0005). Peppermint oil had the same spasmolytic effect as the systemic administration of Buscopan in the transverse and descending colon. Peppermint oil had a stronger effect in the caecum and the ascending colon than a Buscopan injection (p<0.005). There was no advantage to placing peppermint oil in the enema tube over mixing it in the barium solution. A total of 157 polyps were found during the DCBE procedures, and no differences were observed in the number of lesions among the four groups. Peppermint oil did not impair image quality. CONCLUSION: Barium solution mixed with peppermint oil was safe and effective for the elimination of colonic spasm during the DCBE procedure, and it could be used instead of Buscopan.

Blood pressure changes during barium enema.

AIMS: To document blood pressure changes during barium enema examination and to determine at what point in the examination changes are likely to occur. METHODS AND RESULTS: Blood pressure measurements were taken at seven points during the course of barium enema examination in 107 consecutive patients. We found that patients over the age of 60 years had statistically significant decreases in blood pressure when they were stood up during the course of the examination. Many of these patients were asymptomatic. Patients who had symptoms (15/107, 14%) when standing up had a degree of hypotension. The duration of barium enema examination is longer in those patients who experience symptoms. CONCLUSION: During a barium enema examination hypotension occurs at the point of standing up more frequently in patients over 60 years and in those who suffer symptoms at this time. Patients who fall into one of these groups should be considered at risk of fainting at this point in the examination. A modified technique to avoid standing should be considered in at-risk patients. Roach, S. C.et al. (2001). Clinical Radiology56, 393-396.

The influence of commonly prescribed synthetic drugs for peptic ulcer on the pharmacokinetic fate of glycyrrhizin from Shaoyao-Gancao-tang.

The influence of synthetic drugs prescribed for peptic ulcer on the pharmacokinetic fate of glycyrrhizin (GL) from Shaoyao-Gancao-tang (SGT, a traditional Chinese formulation, Shakuyaku-Kanzo-to in Japanese) was investigated in rats. Co-administration of histamine H2-receptor antagonist (cimetidine) and anticholinergic drug (scopolamine butyl bromide) with SGT didn't influence the area under the plasma concentration-time curves (AUC) of glycyrrhetic acid (GA), an active metabolite derived from GL in SGT. The AUC of GA from SGT were significantly reduced by co-administration of synthetic drugs commonly used for peptic ulcer in a triple therapy (OAM), a combination of a proton pump inhibitor (omeprazole) and two antibiotics (amoxicillin and metronidazole). We found that the reduction of AUC in OAM treatment was due to the antibacterial effect of amoxicillin and metronidazole on intestinal bacteria in rat which lead to the decrease of GL-hydrolysis activity. The present study suggests that it may not be a proper way to use triple therapy containing antibiotics simultaneously with SGT for healing of chronic ulcers.

Randomized clinical trial on the use of antispasmodic drugs in barium enema: impact on radiological practice.

PURPOSE: To assess the willingness of radiologists to change their practice when the results of a randomized clinical trial (RCT) on the use of antispasmodic drugs in barium enema are presented. MATERIALS AND METHODS: During the years 1994 and 1995 two postal questionnaires were sent to 481 practicing radiologists who were all members of the Netherlands Society of Radiology. In the first questionnaire the respondents were asked to give the characteristics of their practices in performing daily barium enema. The data from this questionnaire was used as a reference. The second questionnaire was sent to the respondents together with an abstract on the randomized clinical trial supporting the use of antispasmodic drugs in barium enema. We also indicated a preference for Buscopan over Glucagon as the antispasmodic drug. The willingness to change prescription habits was measured by comparing the data of the two questionnaires. RESULTS: Of 481 practicing radiologists, 312 responded to the first questionnaire and gave information of their prescription habits (response rate 64%). These 312 responders were sent an abstract of the RCT and were asked to fill out a second questionnaire to determine their willingness to change their practice. Two hundred and sixty-seven radiologists responded (response rate 86%). A significant number of 119 (51%) were willing to increase the use of antispasmodic drugs. A significant number of 128 (55%) chose to increase the use of Buscopan, while a significant number of 81 (32%) were willing to decrease the use of Glucagon. CONCLUSION: Direct exposure to the results of an RCT recommending the use of antispasmodic drugs in barium enema, especially Buscopan, is likely to increase its use by practicing radiologists.

Adenocarcinoma of the gastro-esophageal junction: CT for monitoring during neoadjuvant chemotherapy.

OBJECTIVE: A clinical study was performed to assess the diagnostic value of spiral CT for evaluation of response during neoadjuvant chemotherapy (CTx) in patients with adenocarcinoma of the gastro-esophageal-junction (GEJ). Results were compared to those of endoscopy. METHODS AND MATERIAL: Twenty-five patients with histologically proven adenocarcinoma of the GEJ scheduled to undergo neoadjuvant CTx were studied. Before CT examination, 1200 ml of a vanilla flavoured paraffin emulsion were applied orally to the fasting patients and 40 mg BuscopanR or 2 mg glucagon were injected i.v. for hypotonia. Iodine (100 ml) was injected automatically (3 ml/s) and the CT scan was started 10 s after complete administration of CM. For response evaluation to CTx, four standardized parameters were measured by two experienced, blinded radiologists. The results were categorized according to the WHO classification of 1981 and compared to those of endoscopy. RESULTS: In 24 of 25 patients endoscopic and computed tomographic response evaluation showed a close correlation (r = 0.96). CONCLUSION: Spiral CT with negative oral contrast agent is a suitable technique for monitoring of GEJ masses. In combination with standardized metric parameters it offers a quantitative response evaluation in patients with GEJ masses during neoadjuvant CTx.

[Ear acupuncture has a hypotonic effect on the gastrointestinal tract]. / Hipotoni efekat aurikuloakupunkture na gastrointestinalni trakt.

The effect of auricular acupuncture (AAP) on the motility and tone of gastrointestinal tract was investigated in 60 patients, by comparison of the width of corpus and antrum of the stomach, as well as duodenum before and after the application of AAP. The obtained results showed that the effects of AAP and usual drugs were equal. The fact that AAP was applied without any side effects and contraindications pointed to the possibility of its wider application in clinical practice.

Use of antispasmodic drugs in double contrast barium enema examination: glucagon or buscopan?

PURPOSE: To compare the spasmolytic effect of glucagon and buscopan in double contrast barium enema examination. PATIENTS AND METHODS: Three hundred and twenty-four consecutive patients referred for double contrast barium enema examination were randomly allocated to receive an intravenous injection of either 1 mg of glucagon, 20 mg of buscopan or physiological saline. The transit of the barium column from rectum to caecum, the quality of the radiographs and side effects were assessed blindly without knowledge of the injected drug. RESULTS: Antispasmodic drugs (glucagon or buscopan) resulted in better transit of the barium column to the caecum compared to placebo (Mann-Whitney: P < 0.05), but no differences occurred between glucagon and buscopan (Mann-Whitney: P > 0.05). Buscopan produced better distension of the rectosigmoid than glucagon or placebo (P < 0.05). Of 109 patients who received buscopan five complained of blurred vision afterwards. CONCLUSION: Because buscopan is less expensive and more effective in distending the colon than glucagon, it is preferred for the routine double contrast examination. However, patients should be warned about the possibility of temporary visual impairment.

Benefit of intravenous muscle relaxants during barium follow through.

The value of an intravenous (i.v.) smooth muscle relaxant during barium follow through (BaFT) examination has been evaluated in a prospective study of 51 patients. Spot compression films pre- and post-relaxant were compared. Relaxant-induced hypotonia improved image quality in 33 (64.8%) patients by facilitating bowel loop separation and/or graded compression. Additional diagnostic information was obtained in 14 (27.5%), and reporting confidence was improved in 19 (37.3%) patients. A marked analgesic effect occurred in seven patients with Crohn's disease, ameliorating pain that otherwise prevented full compression. Intravenous relaxants are recommended when high tone makes compression difficult, to help separate overlying loops and where pain in Crohn's disease prevents adequate compression.