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

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

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

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

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

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

Different segmental transit times in patients with irritable bowel syndrome and "normal" colonic transit time: is there a correlation with symptoms?

BACKGROUND: The Rome criteria serve as gold standard for establishing a diagnosis of irritable bowel syndrome (IBS), but only represent a cluster of symptoms. On the other hand, measurement of colonic transit time (CTT) with radiopaque markers is a solid and more objective method to quantify functional abnormalities. The goal of this study was to investigate whether the IBS symptoms, as defined in the Rome II criteria, correspond to objective physiological parameters, i.e. CCTs. METHODS: The study enrolled 148 healthy control subjects and 1385 consecutive IBS patients. Transit times were measured for the whole rectocolon (overall CTT) and for 3 segments (right colon, left colon, rectosigmoid area); segmental distribution of markers and diffusion coefficients were also assessed. In order to analyze homogeneous groups, we restricted analysis to subjects with "normal" CTT (< or =70 hours). RESULTS: Six hundred forty four IBS patients (46%) and 14 control subjects (9%) had CTT >70 h and were eliminated. In subjects with CTT < or =70 h, CTT did not follow a normal (Gaussian) distribution. We identified 3 different CTT clusters in healthy controls and 4 clusters in IBS patients. Even if CTT was not significantly different between clusters, each cluster was characterized by a specific pattern of segmental colonic transit. There was a marked gender difference: women had longer overall CTT values than men, both in control and IBS patient groups (p<0.001). However, female IBS patients had significantly shorter colorectal transit times than female controls (p<0.001), as well as faster transit than in men through the left colon and rectosigmoid area. There were no significant differences in transit time between male IBS patients and male controls with the exception of a faster rectal transit in IBS patients (p<0.01). There was no association between segmental colonic transit values and sign or symptoms comprising the Rome II criteria. CONCLUSIONS: In subjects with CTT < or =70 h, CTT does not follow a normal distribution but is clustered in subgroups that can be distinguished only by measuring segmental colonic transit. Within these subgroups, there is a marked difference in transit times between IBS patients and normal subjects, suggesting that IBS patients with "normal" CTT are not "normal". The Rome II criteria do not reflect differences in segmental transit times in IBS patients with "normal" CTT. We therefore propose to evaluate segmental transit times in IBS patients with "normal" CTT, before and after treatment, in order to correctly interpretate variations in signs and symptoms. These findings have important implications in evaluating the effect of drugs on bowel function and should help define better inclusion criteria for studies evaluating new drugs for the treatment of IBS.

Does water-perfused catheter overdiagnose anismus compared to balloon probe?

BACKGROUND: The purpose of this study was to compare the manometric assessment of straining effort as if to defecate and rectoanal inhibitory reflex obtained with a rectosphincteric balloon probe and with a water-perfused catheter in the same subject. METHODS: Twelve healthy volunteers underwent two manometric assessments of anal sphincter function and electromyographic (EMG) surface recordings. one with a rectosphincteric balloon and one with a water-perfused catheter, 7 days apart in random order. RESULTS: Increased EMG activity in the external anal sphincter in the midst of the rectoanal inhibitory reflex (P < 0.001) and during straining for defecation (P < 0.001) was more frequently observed with the perfused system than with the balloon probe. There was a discrepancy between the EMG activity of the external anal sphincter and the anal pressures during straining recorded with the perfused system. Duration of the reflex elicited by rectal distension with 10 and 20 ml of air was significantly greater with the rectosphincteric balloon than with the perfused catheter (P = 0.02 and P = 0.05, respectively). CONCLUSION: Water instilled in the anal canal by the perfused system induces artifacts in EMG recording and active anal contractions. These artifacts and induced contractions could lead to an erroneous diagnosis of anismus, particularly if pelvic floor EMG is only taken into account for the diagnosis of anismus.

A simple, inexpensive, life-saving way to perform iterative laparotomy in patients with severe intra-abdominal sepsis.

Between 1 June 1993 and 31 December 1998, 17 patients underwent temporary abdominal closure with 3L urological irrigation bags, because in most cases, there was massive sepsis leading to the conclusion that primary closure was not advisable. Indicative of the seriousness of these conditions, Apache score averaged 19 (range 10-30). The technique consisted of suturing a double thickness of irrigation bags to each side of the wound, and joining the two bags in the midline with running sutures. Abdominal lavage with large quantities of fluid was performed every other day. This type of closure was used for a mean duration of 15 days. Mean length of hospitalization was 60 days. There were only three deaths (17.6%). No incisional hernia occurred after the iterative laparotomies. Deleting patients with acute pancreatitis would have reduced the death rate to only 7%. A 3L urological irrigation bag costs pound 11.60 (24.40 dollars CAN) while a Marlex mesh costs pound 81.40 (171.00 dollars CAN). We conclude that the usage of 3L urological plastic bags is a simple, safe and efficient method for temporary closure of the abdomen.

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

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

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

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

A comparative study of esophageal and anorectal motility in myotonic dystrophy.

Myotonic dystrophy may be associated with visceral abnormalities involving smooth muscle, the pathogenesis of which is not clear. Our aim was to evaluate the involvement of smooth and striated muscles at both ends of the gastrointestinal tract. Esophageal and anorectal manometric studies were performed in 13 patients and healthy controls. There was a correlation between: (1) the resting pressure in the upper esophageal sphincter and in the lower anal canal, (2) the amplitude and the coordination of contraction primary waves in the proximal and in the distal esophagus, and (3) the resting pressure in the higher anal canal and in the lower one. These results suggest that both ends of the gastrointestinal tract are disturbed in a similar fashion, both quantitatively and qualitatively and that there is a relationship between smooth and striated visceral muscle involvement in myotonic dystrophy.

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

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

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

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

Mechanisms of absorption of caseinophosphopeptide bound iron.

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

Simple clinical assessment of colonic response to food.

The colonic response to food (CRF) is an integrated function of the colon that has been poorly studied in clinical practice. This study describes a new method to measure it, based on the progress of radio-opaque markers, and shows the results in healthy subjects and in patients with irritable bowel syndrome (IBS). Thirty healthy subjects and 43 patients suffering from IBS were studied. Two studies of colonic transit time (CTT), at rest and after eating a standard test meal, were performed. CRF was quantified by calculating the variation in number of markers in each zone of interest of the large bowel using X-ray films of the abdomen taken before and after eating. The results were as follows: (1) CRF is characterised by caudal propulsion of the colonic contents in the two groups. In controls, there is emptying of the cecum-ascending colon region and filling of the distal large bowel. In IBS patients, only emptying of the left transverse colon and the splenic flexure is found. (2) IBS patients have a delayed CTT because of slowing in the right and left colon, and this is both before and after a meal. The determination of the movements of markers after eating is a simple method that is useful in clinical practice to evaluate CRF.

Colonic transit time in patients with myelomeningocele.

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

Diversion-related experimental colitis in rats.

PURPOSE: Diversion-related colitis is an inflammatory process that affects the colon and/or rectum distal to a colostomy. Its mechanisms are unknown, and many hypotheses have been considered. The aim of the present study was to create an experimental model of diversion-related colitis in rats, so in the future it will be possible to test different hypotheses. METHODS: Three groups of ten male Wistar rats were used for the study. Two groups underwent a colostomy and were kept alive for 6 or 17 weeks. One group of rats was killed at the onset of the experiment. Specimens were taken in bypassed segments in the rats who had had a colostomy and in the sigmoid colon for the control group. Histologic analysis using standard coloration, histochemical techniques, and bacterial preparation was used to find histologic or changes of colonic histology or flora. RESULTS: Exclusion was associated with vascular congestion, a decrease in length of glandular crypts (P < 0.01), and an erosion of surface epithelium; inflammation of the mucosa was absent in all control animals and present in all test animals. In contrast, the number of goblet cells was not changed by the procedure. There was also a significant change in distribution and intensity of sulfomucins and sialomucins and quantitative and qualitative changes of the colonic flora. CONCLUSION: This experimental model of diversion colitis is characterized by histologic and bacteriologic modifications comparable with those reported in humans but with different histochemical changes.

Compartmental analysis of colonic transit reveals abnormalities in constipated patients with normal transit.

1. The aims of this study were to investigate if compartmental analysis can be used to analyse colonic transit measurements and to search for a relationship between transit time and the parameters deduced from this analysis. In addition, an attempt was made to determine if such analysis could reveal a functional abnormality in patients who complain of constipation but have normal colonic transit. 2. The subjects included 11 healthy controls, 10 patients with chronic diarrhoea and 55 constipated patients. Segmental and total colonic transit time were measured using a previously described method. Compartmental analysis was based on a three-compartment system, with k1, k2 and k3 being the coefficients of diffusion out of the right colon, the left colon and the rectosigmoid area respectively. 3. Patients complaining of constipation who had delayed transit time were the only subjects to have lower values of coefficient k1 than controls. k2 was lower than normal in all patients complaining of constipation, but this decrease was more marked in subjects with delayed colonic transit time than in subjects with normal colonic transit time. All patients complaining of constipation had lower values of k3 than control subjects. 4. This study shows that analysis of colonic transit time is feasible using a simple diffusion law, and that the results are correlated to clinical data. Moreover, this analysis permits detection of abnormalities in two groups of subjects: those who complain of constipation but are labelled as having normal colonic transit time and those who have chronic diarrhoea.

Anismus as a marker of sexual abuse. Consequences of abuse on anorectal motility.

Anorectal manometry was performed in 40 women, who consulted for functional disorders of the lower gastrointestinal tract and had been sexually abused. Anismus, defined as a rise in anal pressure during straining, was observed in 39 of 40 abused women, but in only six of 20 healthy control women (P < 0.0001). Other parameters of anorectal manometry were compared with those observed in another control group composed of 31 nonabused women but with anismus, as well as the group of healthy controls. A decreased amplitude of anal voluntary contraction and an increased threshold volume in perception of rectal distension were observed in both abused and nonabused patients. A decreased amplitude of rectoanal inhibitory reflex, little rise in rectal pressure upon straining, frequent absence of initial contraction during rectal distension, and increased resting pressure at the lower part of the anal canal were observed in abused but not in nonabused patients, suggesting that these abnormalities, in association with anismus, suggest a pattern of motor activity in the anal canal that could be indicative of sexual abuse.

Colonic transit in soccer players.

To evaluate the effects of exercise on colonic function, we measured total and segmental transit times in 11 male soccer players and nine male radiology student technicians. Diet was kept constant in all subjects, who maintained their normal activities. For the soccer players, normal activities included 15 h of training and one match each week. Transit times were measured with radioopaque markers, using the multiple-ingestion, single-radiograph technique. No overall difference in large bowel transit was observed between the two groups. Right colon transit was considerably slower in the soccer players, whereas left colon and rectal transit were slightly accelerated. We conclude that an intensive sport activity only modifies regional differences in large bowel function. This may be of importance in extreme conditions, such as those experienced by marathon runners. Data should be obtained before prescribing exercise to treat constipation.

Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract.

To evaluate the links between gastrointestinal disorders and sexual abuse, we asked 344 patients consulting in a specialized tertiary care university hospital or a gastroenterologist in private practice, if they had been sexually abused. Forty per cent of patients suffering from lower functional digestive disorder gave a history of having been victims of sexual abuse in contrast to only 10% of patients with organic diseases (P < 0.0003). The prevalence was similar in private practice and in the university hospital. Abused patients were more likely to complain of constipation (P < 0.03) and diarrhoea (P < 0.04). Anismus was more frequent in patients who had been sexually abused (P < 0.02). The prevalence of abuse was four times greater in patients with lower than with upper functional motor disorders of the gastrointestinal tract (P < 0.002). This study confirms the large prevalence of a past history of sexual abuse among patients consulting for gastrointestinal tract functional disorder, and this whatever the kind of recruitment may be. It shows the association to be much stronger in patients who have a lower rather than an upper gastrointestinal dysfunction, the major complaint of abused patients being constipation and diarrhoea.