Position paper on transanal irrigation in chronic non-organic constipation.

The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.

Pelvic floor rehabilitation for defecation disorders.

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

State dependent effects of elevated hormone: nest site quality, corticosterone levels and reproductive performance in the common eider.

Nest shelter in incubating birds is of major importance in providing protection against unfavourable conditions such as harshness of the environment and exposure to predators. We examined the link between nest shelter, baseline corticosterone (CORT) levels and hatching success in common eiders (Somateria mollissima) incubating at nest sites with different levels of shelter. Since more sheltered nest sites could be occupied by better-quality females, we also used an experimental manipulation of nest shelter to separate the effects of the physical attributes of the nest site from those of individual quality. We compared birds with naturally sheltered nests, exposed nests and exposed nests provided with artificial nest shelters and measured clutch size, body condition, CORT levels at the end of incubation and hatching success. If nest shelter reduces CORT levels, we predicted that CORT levels would be highest at the least sheltered sites, and that the provision of artificial shelter would reduce CORT levels. We found that nest shelter was not related to CORT levels in incubating eiders. Nest shelter, however, affected body condition, with females at exposed sites losing more body mass during incubation than females at naturally and artificially sheltered nests. Interestingly however, in those birds nesting at the exposed sites, with and without artificial shelter, those with the highest CORT levels had the lowest hatching success. This relationship was not evident in females nesting at naturally sheltered sites. These results suggest that the level of nest shelter does not directly affect CORT levels in females. Instead, we suggest that the relationship between CORT levels and hatching success is state-dependent. Exposed sites are occupied by individuals that laid smaller clutches, and hence are likely to be of lower quality, and the negative effects of elevated CORT on hatching success are more pronounced in these females.

Unsedated transnasal percutaneous endoscopic gastrostomy placement in selected patients.

BACKGROUND AND STUDY AIMS: The placement of a percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for the long-term management of dysphagic patients with neurological disease or with trauma or tumors of the head and neck. It is not always possible to perform conventional upper gastrointestinal endoscopy in such patients due to stenosis and/or occlusion of the mouth or pharynx and/or partial or complete trismus. The aim of this study was to show whether transnasal esophagogastroduodenoscopy (EGD) offers a feasible and effective alternative method for PEG placement in these selected patients. PATIENTS AND METHODS: PEG placement was required for 155 patients at our institution during a 27-month period. In 12 patients oral access of an endoscope into the esophagus was not possible. Unsedated transnasal EGD (T-EGD) was then performed using an ultrathin video gastroscope, which had a distal-end diameter of 5.9 mm. A 16-Fr polyurethane PEG tube with a conical, flexible, soft distal end and a collapsible bumper was used in all cases. The Gauderer-Ponsky pull technique was used for PEG placement. RESULTS: T-EGD and perendoscopic transnasal placement of a PEG tube was successfully performed in all 12 patients. No patient required sedation during the procedure. No immediate or late-onset procedure-related complications occurred in any of the 12 patients. CONCLUSIONS: In some dysphagic patients in whom the oral route is not accessible with a standard endoscope, a transnasal endoscopic approach allows the placement of a PEG tube. In these selected patients this technique has been shown to be safe and effective and does not require the use of sedation.

Anorectal function in multiple system atrophy and Parkinson's disease.

This study was designed to investigate anorectal function in Parkinson's disease and multiple system atrophy (MSA). After a standardized interview, 17 patients with Parkinson's disease (PD) and 16 patients with multiple system atrophy (MSA) underwent anorectal manometry with a continuously perfused multi-lumen catheter, located to record pressures from the anal canal, and a balloon for rectal distension. Data were analyzed by observers blind to the neurologic diagnosis. Disease duration was shorter in the MSA than in the PD group (6+/-4 versus 10+/-5 yrs, p<0.05). Most patients reported a bowel frequency of less than three evacuations per week and some patients had fecal incontinence. Most manometric recordings disclosed an abnormal pattern during straining (a paradoxic contraction or lack of inhibition) in 13 patients with MSA and 11 patients with PD. Mean anal pressures and rectal sensitivity threshold were not significantly higher in the MSA group, whereas the inhibitory anal reflex and rectal compliance thresholds were within the normal range in both groups. Manometric patterns did not differentiate patients with MSA from patients with PD. Most patients in both groups showed an abnormal straining pattern, decreased anal tone, or both dysfunctions. In conclusion, our findings suggest that although bowel and anorectal dysfunctions do not differentiate MSA from PD, both abnormalities occur earlier and develop faster in MSA than in PD.

Scanning electron microscopy of collagen fiber orientation in the bone lamellar system in non-decalcified human samples.

Previous studies on collagen fiber orientation have led to different interpretations and theories about the fiber arrangement in the lamellar compact bone. The purpose of this investigation was to provide new and more in-depth data on fiber arrangement in the lamellar bone system in order to explain the orientation of the fiber bundles. This was carried out by applying a simple method of preparation which permitted observation of non-decalcified samples. A previously isolated Haversian system was subjected to slow bending up to reaching the fracture point. Hence, the fracture surface was observed by SEM. The same samples were also observed by polarized light microscopy. A significant alternation of fiber orientation in the adjacent lamellae was observed. Different domains of differently oriented fibers were present within the same lamella; conjugating fibers connecting adjacent lamellae were also shown. This method avoided most of the artifacts due to chemical treatment of bone samples. The results can be easily interpreted by means of the same criteria applied in mechanics for the studying of composite materials.

[Comparison of the several methods of investigation in the diagnosis of alkaline esophagitis. Considerations on 92 cases]. / Confronto tra le varie metodiche d'indagine nella diagnosi dell'esofagite alcalina. Considerazioni su 92 casi.

Up to now many controversies exist regarding the value of different diagnostic techniques available in alkaline esophagitis. The Authors studied 92 patients with histologic diagnosis of esophagitis obtained by endoscopic biopsy, by radiological study of upper gastrointestinal tract, esophageal manometry, combined 24 hour esophago-gastric pH-metry and cholangio-scintigraphy, too. These last two techniques have the highest specificity and accuracy rates. These techniques should be considered complementary and their combined employment has to be considered essential to reach the highest rate of accuracy in the diagnosis of alkaline esophagitis.