Rectoanal reflexes and sensorimotor response in rectal hyposensitivity.

PURPOSE: Rectal hyposensitivity commonly causes anorectal disorders, but its underlying mechanism is unknown. We hypothesized that subjects with rectal hyposensitivity have altered rectoanal reflexes and/or sensorimotor response. METHODS: We performed stepwise graded balloon distensions of the rectum in 30 subjects with constipation and rectal hyposensitivity and in 23 healthy controls. Thresholds for first sensation, desire, and urgency to defecate were assessed. The lowest balloon volume that evoked rectoanal inhibitory reflex, rectoanal contractile reflex, and sensorimotor response and manometric characteristics and rectal compliance were examined. RESULTS: Reflex responses were present in all subjects. The balloon volumes were higher in subjects with rectal hyposensitivity for inducing rectoanal inhibitory reflex (P = .008) and contractile reflex (P = .001) compared with controls. All controls showed a sensorimotor response, but in 13 hyposensitive subjects (43%) the onset of sensorimotor response was associated with absent sensation and in 17 (57%), with a transient rectal sensation. Thresholds for eliciting sensorimotor response were similar between patients and controls, but the amplitude, duration, and magnitude of response were higher (P < .05) in patients. Rectal compliance was similar between controls and hyposensitive subjects with transient sensation but higher (P = .001) in subjects with absent sensation. CONCLUSIONS: Constipated subjects with rectal hyposensitivity demonstrate higher thresholds for inducing rectoanal reflexes and abnormal characteristics of sensorimotor response. These findings suggest either disruption of afferent gut-brain pathways or rectal wall dysfunction. These altered features may play a role in the pathogenesis of bowel dysfunction in rectal hyposensitivity.

Clinical practice guidelines on the diagnosis and treatment of gastroesophageal reflux disease (GERD)

In the last two decades gastroesophageal reflux disease (GERD), initially thought to be a disease only common  in the West, is described  increasingly in Asia, including the Philippines. A recent local report indicated that the prevalence of erosive esophagitis (EE), a common complication of GERD, has more than doubled, i.e., 2.9% to  6.3%,  between the two time periods of 1994-1997 and 2000-2003, respectively. GERD causes recurrent annoying symptoms which are common  reasons  for  clinic  visits  and consultations thus, it is the objective of these guidelines to provide both primary care physicians  (PCPs) and specialists a current, evidence-based, country-specific recommendations for the optimal management  of  GERD.  These  guidelines  are  intended   to   empower   PCPs   to   make   a   clinic-based diagnosis of GERD, to start an empiric acid-suppressive therapy in the appropriate patient,and direct them to select which GERD patient may need to undergo investigations to ascertain further the diagnosis of GERD or to assess outcomes of therapy. We acknowledge that studies published in the future may influence the impact on our confidence on the recommendations enumerated in  these guidelines thus, we commit to update this document when it is deemed appropriate.

Rectoanal sensorimotor response in humans during rectal distension.

PURPOSE: Rectal perception facilitates maintenance of continence and defecation. Whether perception is associated with motor changes in anorectum is unclear. We examined sensory and motor responses of the anorectum during rectal distention. METHODS: Stepwise graded rectal balloon distensions were performed in 23 healthy subjects by placing a six-sensor probe in the anorectum. Manometric changes, rectoanal reflexes, and sensory thresholds were assessed. Studies were repeated in six subjects. RESULTS: All subjects showed rectoanal inhibitory and contractile reflexes, but rectal perception was associated with an anal contractile response (sensorimotor response). In 4 subjects (17 percent) the sensorimotor response first occurred synchronously with a sensation of fullness (Group 1) and in 19 (83 percent) with a desire to defecate (Group 2). Mean balloon volume for inducing the sensorimotor response in Groups 1 and 2 were 80 +/- 14 ml and 96 +/- 26 ml (P > 0.05). The onset, amplitude, duration, and area under curve of the response were similar in both groups. At higher volumes of balloon distention, all subjects (n = 23) reported a desire and an urge to defecate. The sensorimotor response associated with an urge to defecate had higher amplitude (P = 0.01) and higher area under curve (P = 0.001) compared with that associated with a desire to defecate. Repeat studies showed good reproducibility (intraclass correlation coefficient = 0.9; P < 0.05). CONCLUSIONS: A desire to defecate is associated with a unique, consistent, and reproducible anal contractile response: the sensorimotor response. This response could play an integral role in regulating anorectal sensation and function.

Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is a behavioral disorder whose pathophysiology is incompletely understood. Likewise, its treatment, particularly the role of biofeedback therapy (BT) is unclear. AIM: To evaluate anorectal function and morphology and to assess efficacy of BT. METHODS: Eleven patients (8f) with refractory SRUS underwent symptom assessments, anorectal manometry, defecography, balloon expulsion test, and sigmoidoscopy. Physiological tests were also performed in 15 (11f) healthy controls. Subsequently, SRUS patients underwent biofeedback treatment. Symptoms and manometry were reassessed. RESULTS: Nine (82%) patients exhibited dyssynergia ( p < 0.001). Rectal sensory thresholds were decreased (p < 0.04). After biofeedback, straining effort and stool frequency decreased ( p < 0.05), and bowel satisfaction score (VAS) improved ( p < 0.001). Digital maneuvers were discontinued by all five patients and bleeding stopped in 56%. The defecation index increased ( p < 0.05), dyssynergia normalized, and balloon expulsion time decreased ( p < 0.05). There was complete healing in 4 (36%), > or =50% healing in 2 (18%), and <50% healing in 4 (36%) patients. CONCLUSIONS: SRUS associated with excessive straining, digital disimpaction, rectal hypersensitivity, dyssynergic defecation, and prolonged evacuation. BT may improve symptoms and anorectal function and facilitate healing.