Coinduction of nitric oxide synthase, argininosuccinate synthetase, and argininosuccinate lyase in lipopolysaccharide-treated rats. RNA blot, immunoblot, and immunohistochemical analyses

Nitric oxide (NO) is synthesized from arginine by nitric oxide synthase (NOS), and citrulline which is generated can be recycled to arginine by argininosuccinate synthetase (AS) and argininosuccinate lyase (AL). Rats were injected with bacterial lipopolysaccharide (LPS), and expression of the inducible isoform of NOS (iNOS), AS, and AL was analyzed. In RNA blot analysis, iNOS mRNA was undetectable before the LPS treatment but was induced by LPS in the lung, heart, liver, and spleen, and less strongly in the skeletal muscle and testis. AS mRNA was induced in the lung and spleen, and AL mRNA was weakly induced in these tissues. AS and AL mRNAs were abundant in the control liver and remained unchanged after the treatment. Kinetic studies showed that iNOS mRNA increased rapidly in both spleen and lung, reached a maximum 2-5 h after the treatment, and decreased thereafter. On the other hand, AS mRNA increased more slowly and reached a maximum in 6-12 h (by about 10-fold in the spleen and 2-fold in the lung). AL mRNA in the spleen and lung increased slowly and remained high up to 24 h. In immunoblot analysis, increase of iNOS protein was evident in the lung, liver, and spleen, and there was an increase of AS protein in the lung and spleen. In immunohistochemical analysis, macrophages in the spleen that were negative for iNOS and AS before LPS treatment were strongly positive for both iNOS and AS after this treatment. As iNOS, AS, and AL were coinduced in rat tissues and cells, citrulline-arginine recycling seems to be important in NO synthesis under the conditions of stimulation.

Aggressive CD5-positive diffuse large B cell lymphoma showing c-myc rearrangements developed in a patient with autoimmune hemolytic anemia

A case of CD5-positive diffuse large cell lymphoma in a patient with autoimmune hemolytic anemia (AIHA) is reported. The patient was diagnosed with AIHA in December 1988. Three and a half years later, the patient complained of fever and left sided flank pain. Abnormal lymphocytes appeared in the peripheral blood and were positive for HLA-DR, CD5, CD19, CD20, and surface immunoglobulin (mu, lambda). The pathological diagnosis of the cervical lymphnode was non-Hodgkin lymphoma; diffuse large cell type with a starry sky-like appearance. Although the 8q24 translocation was not detected by karyotypic analysis of the peripheral blood mononuclear cells (PBMNC), Southern blot analysis revealed that the c-myc rearrangements had occurred. This case showed two rearranged bands with Eco RI, Bam HI, or Bgl II digestion, and a germline band with Hin dIII digestion using a second exon fragment of the c-myc gene as a probe. Despite intensive chemotherapy, this patient died 6 months after being diagnosed with malignant lymphoma. We discuss the c-myc rearrangements in this aggressive CD5-positive diffuse large B cell lymphoma.

Complete disruption of the main pancreatic duct: a case successfully managed by percutaneous drainage

The authors report on a 7-year-old boy who sustained blunt abdominal trauma on a bicycle handlebar. A large traumatic pancreatic pseudocyst developed, for which percutaneous external drainage under ultrasound guidance was performed. Both the catheter fistulogram and endoscopic retrograde cholangiopancreatogram showed complete disruption of the main pancreatic duct. During continuous external drainage, the pseudocyst disappeared. The drainage flow decreased gradually and ceased. The patient is well, with normal endocrine and exocrine pancreatic functions, 2 years after discharge.

Establishment of the novel B acute lymphoblastic leukemia (FAB L3) cell line KHM-10B with a 13q34 abnormality and constitutive expression of c-myc and max during cell cycle

We established and characterized a new acute lymphoblastic leukemia (ALL-L3 according to FAB classification, or Burkitt's type) cell line, KHM-10B. The morphology of the patient's lymphoblasts and KHM-10B cells corresponded to that of ALL-L3 cells. The cells were positive for HLA-DR, CD19 and surface immunoglobulin (mu, lambda). Southern blot analysis revealed that the fresh lymphoblasts and KHM-10B shared the same immunoglobulin gene rearrangement. Conventional cytogenetic analysis of fresh lymphoblasts from the patient and KHM-10B cells revealed the 13q34 abnormality, the second most common additional abnormality in Burkitt's lymphoma, but no detectable 8q24 involvement. Rearrangement of the c-myc oncogene was not detected by Southern blot analysis. However, a fluorescence in situ hybridization (FISH) assay identified a t(8;22)(q24;q11). The KHM-10B cells were arrested at S phase with hydroxyurea and thymidine, and the synchronized cells progressed through the cell cycle in drug-free medium. The expression of c-myc and max was observed throughout the cell cycle, as was found in the Burkitt's lymphoma cell in Raji. Our findings indicate that FISH analysis is of diagnostic value in detecting obscure chromosomal translocations and that max, as well as c-myc, is expressed constitutively in ALL-L3 and Burkitt's lymphoma cell lines.

Expression of Fas/Apo-1 (CD95) and apoptosis in tumor cells from patients with plasma cell disorders

Fas/Apo-1 antigen (CD95) is a cell surface molecule that directly mediates apoptosis. Fas expression was studied in five plasma cell lines, 11 multiple myeloma cases, and three plasma cell leukemia (PCL) cases. Induction of apoptosis by anti-Fas antibody was studied in five plasma cell lines and fresh plasma cells from eight patients. Apoptosis was confirmed by morphologic analysis alone or in combination with DNA electrophoresis analysis. Four of the five cell lines showed Fas expression, three of which showed induction of apoptosis by anti-Fas antibody. One cell line, RPMI 8226, showed the highest sensitivity for Fas-mediated apoptosis. High bcl-2 expression was found in KMS12PE, which showed resistance to Fas-mediated apoptosis despite its Fas expression. Plasma cells from seven fresh cases, including all five cases with high serum lactate dehydrogenase (LDH), showed expression of Fas antigen. Fas-induced apoptosis was found in five cases at various levels, although significant induction of apoptosis was found in only one case. Interestingly, Fas-independent apoptosis was induced during culture without anti-Fas antibody in cases with high serum LDH. These results indicate that plasma cells from aggressive myeloma with high LDH express Fas antigen and undergo apoptosis through either Fas-mediated or Fas-independent pathways. An understanding of the mechanism of apoptosis in malignant plasma cells should contribute to investigations of the pathophysiology of and therapy for myeloma/PCL.

Yolk sac tumor in a case of testicular feminization syndrome

A 17 month old who had been diagnosed as having testicular feminization syndrome (noted during inguinal herniorrhaphy) was operated on because of an abdominal mass that had a high serum level of alpha-fetoprotein. Histologically, the lesion was a yolk sac tumor. The alpha-fetoprotein level normalized within 2 months of the surgery, through the administration of adjunctive chemotherapy containing cisplatinum. The patient is disease-free 4 years postoperatively. When performing inguinal herniorrhaphy in a girl, the surgeon should be prepared to deal with testicular feminization syndrome. If gonadal neoplasm is deniable at the time of diagnosis, careful follow-up examinations are needed until completion of the development of secondary sex characteristics.

Preparation of recombinant argininosuccinate synthetase and argininosuccinate lyase: expression of the enzymes in rat tissues

Nitric oxide (NO) is synthesized from arginine by nitric oxide synthase, generating citrulline as another product, which can be recycled to arginine by argininosuccinate synthetase and argininosuccinate lyase. Rat argininosuccinate synthetase was expressed in Escherichia coli as a fusion protein with maltose binding protein, cleaved from binding protein, and purified. The purified synthetase had no enzyme activity. Rat argininosuccinate lyase was expressed in E. coli using pET-3a as a vector, and purified. The purified enzyme had a specific enzyme activity of arginine formation of 2.6 mumol/min/mg protein at 37 degrees C, the value being somewhat lower than those of the enzyme purified from various tissues. Antibodies against these enzymes were produced in rabbits. Immunoblot analyses showed that the two enzymes are most abundant in the liver, followed by kidney and testis. Smaller amounts of the enzyme proteins were present in other tissues. RNA blot analysis showed that the argininosuccinate synthetase mRNA was most abundant in the liver and kidney, followed by testis and other tissues. On the other hand, argininosuccinate lyase mRNA was most abundant in the testis, followed by kidney and liver, and by other tissues. These results show that argininosuccinate synthetase and argininosuccinate lyase are expressed both tissue-specifically and ubiquitously, and that practically all tissues have activities to convert citrulline to arginine.

Serum amino acid disturbance in multiple myeloma with hyperammonemia

From October 1987 to November 1993 we evaluated the serum levels of ammonia and amino acids in 85 patients with multiple myeloma. Six of the 85 cases of multiple myeloma demonstrated hyperammonemia and none of the known causes of hyperammonemia, such as liver failure, could be identified in these patients. All six patients also showed serum amino acid disturbances and conscious disorders in various degrees. In this study we compared these abnormalities in multiple myeloma with those in chronic liver failure (n = 14), the basic diseases of which were liver cirrhosis in six cases and liver cirrhosis complicated hepatocellular carcinoma in eight cases. There was a marked difference in the levels of individual serum amino acids between these two groups. The level of glycine was significantly higher in the multiple myeloma group (P < 0.001); on the other hand, that of tyrosine was significantly higher in the liver failure group (P < 0.005). The histidine (P < 0.005) and arginine (P < 0.005) levels were lower in the myeloma group. The ratio of glycine to tyrosine (Gly/Tyr) was 16.7 +/- 4.85 in the myeloma group and 1.7 +/- 0.12 in the liver failure group. The ratio of glycine to tyrosine was an important criterion for differential diagnosis.

Octacosanol affects lipid metabolism in rats fed on a high-fat diet

The effect of dietary octacosanol, a long-chain alcohol, on lipid metabolism was investigated in rats fed on a high-fat diet for 20 d. The addition of octacosanol (10 g/kg diet) to the high-fat diet led to a significant reduction (P < 0.05) in the perirenal adipose tissue weight without decrease of the cell number, suggesting that octacosanol may suppress lipid accumulation in this tissue, whereas no effect was seen in the epididymal adipose tissue weight and in the lipid content in liver. Octacosanol supplementation decreased the serum triacylglycerol concentration, and enhanced the concentration of serum fatty acids, probably through inhibition of hepatic phosphatidate phosphohydrolase (EC 3.1.3.4). Though the activity of hormone-sensitive lipase (EC 3.1.1.3) was not influenced by octacosanol, higher activities of lipoprotein lipase (EC 3.1.1.34) in the perirenal adipose tissue and the total oxidation rate of fatty acid in muscle were observed. Lipid absorption was not affected by the inclusion of octacosanol. Thus, the present results suggest that the dietary incorporation of octacosanol into a high-fat diet affects some aspects of lipid metabolism.

Vitamin A regulates the expression of apolipoprotein AI and CIII genes in the rat

The effect of vitamin A on the expression of apoAI and CIII genes in intact rats was studied. In vitamin A-deficient rats, the hepatic level of apoAI mRNA was increased and enhanced by an oral administration of excess retinoic acid(RA). A similar administration to normal rats caused an increase in the apoAI mRNA level in the intestine without affecting that of hepatic mRNA. Though the hepatic level of apo CIII mRNA was not affected by the vitamin A status, the intestinal level was positively regulated by vitamin A. These findings show that vitamin A regulates the expression of apolipoprotein AI and CIII genes in a tissue-specific and complex fashion.

Establishment of a CD45-positive immature plasma cell line from an aggressive multiple myeloma with high serum lactate dehydrogenase

A myeloma cell line (KHM-11) was established from the pleural effusion of a patient with IgA-kappa type aggressive myeloma with high serum lactate dehydrogenase who was extremely resistant to vincristin, adriamycin and dexamethasone combination therapy (VAD). The morphology of fresh tumor cells and KHM-11 was plasmablast according to Greipp's criteria. In addition to the expression of regular plasma cell antigens, CD38 and PCA-1, CD45 was found on both fresh cells and KHM-11. Other T- or B-cells antigens, such as CD2, 4, 8, 19, and 20 were negative. Cytoplasmic immunoglobulin kappa light chain in KHM-11 was found by flowcytometry. Southern blot analysis revealed that fresh sample and KHM-11 shared the same immunoglobulin gene rearrangement. IL-6 was found in the culture supernatant of KHM-11, and this supernatant stimulated the growth of this cell line, indicating an IL-6 autocrine mechanism. These findings indicate that KHM-11 is a CD45-positive immature plasma cell line. As far as we know, there is no report of CD45-positive myeloma cell line. KHM-11 should be a useful tool for understanding not only the pathogenesis of aggressive multiple myeloma with high LDH but also for understanding the mechanism which underlies the terminal differentiation of B-cells.

Urinary protein fractions in healthy subjects using cellulose acetate membrane electrophoresis followed by staining with acid violet 17

We fractionated normal urinary proteins obtained from 40 healthy subjects using cellulose acetate membrane electrophoresis and stained them with Acid Violet 17. The electrophoretic patterns were classified into four groups. Each of groups I, II, III, IV had an albumin peak and 1, 2, 3, and 4 additional globulin peaks, respectively. Within-day variation study showed that the pattern was fundamentally specific to the individual, although some intermediate cases were observed. We were unable to determine which type was standard for normal subjects. However, the concentration of Tamm-Horsfall protein was speculated to be an important factor in determining the patterns. Group III showed significantly higher values than group I in urine albumin, total protein, and beta-N-acetyl-D-glucosaminidase and this group was believed to include subjects in the subclinical stage of a glomerular disease. All specimens belonging to group IV showed an obvious fraction of alpha 1 globulin which is often found in urine specimens of patients with renal diseases of tubular origin or other pathological conditions.

Establishment of a monoclonal antibody to plasma cells: a comparison with CD38 and PCA-1

A new monoclonal antibody which recognizes plasma cells was developed by utilizing two myeloma cell lines, KMS12PE (12PE) and KMS12BM (12BM), established from the pleural effusion and bone marrow, respectively, of the same patient. Since 12BM expresses CD20, CD38, and PCA-1 antigens, while 12PE has lost CD20, 12PE is considered to be phenotypically more mature than 12BM. The 12PE cells were used to immunize a BALB/c mouse and a MoAb was produced which was more reactive to 12PE than to 12BM. Thus, a clone, D2, was obtained. On Western blotting, D2 detected a single band of 54 kD under both reduced and non-reduced conditions. This antigen was not detected by Western blotting in peripheral blood lymphocytes that had been stimulated with pokeweed mitogen (PWM) for 7 days or in those not so stimulated. On flow cytometry, D2 detected a myeloma cell line, RPMI 8226. Another myeloma cell line, U266, was negative for D2 antigen. Staining various cell lines by D2 and other antiplasma cell antibodies, PCA-1 and CD38, showed that D2 is distinct from PCA-1 and CD38. The fresh myeloma cells of 14 myeloma patients were stained by D2 and for other plasma cell antigens. D2 strongly stained three samples obtained from patients with clinically aggressive myeloma, while CD38 stained all cases except one. PCA-1 was positive in nine samples and negative in five. PCA-1 expression was observed in plasma cells obtained from pleural effusion and peripheral blood, while PCA-1-negative cases were not found in such samples, suggesting that PCA-1 expression was related to extramedullary invasion. The morphology of the myeloma cells, classified according to Greipp's criteria, showed that there was no correlation between plasma cell antigen expression and plasma cell morphology. Analysis of D2 antigen expression should provide more information about the heterogeneity of myeloma cells.

Management of colorectal polyps in children

Forty-two patients each with a colorectal polyp have been treated in our hospital over the past 10 years. In twenty-two cases the polyps were noted in the rectum, nine in the sigmoid colon, seven in the descending colon and four in the transverse colon. Each patient had only one polyp. Hematochezia was the main symptom in 29 patients, prolapse of the polyp from the anus in 10, abdominal pain due to intussusception in two and no symptoms were observed in one. Auto-amputation of the polyp was considered to have occurred in five patients. Twelve rectal polyps were resected from a transanal operation, and another 25 polyps were removed endoscopically with electric cautery. We have had no experience of endoscopic complications such as bleeding or perforation. A histological examination revealed an adenoma in one patient. Other polyps were non-neoplastic and were classified as juvenile, inflammatory and hyperplastic in 30, two and four patients, respectively. There have been no recurrences of polyps to date.

Manometric evaluation of children with chronic constipation using a suction-stimulating electrode

Thirteen children with chronic constipation (8 males and 5 females, aged 1 month to 9 years) were evaluated manometrically. A suction-stimulating electrode was used to induce the rectoanal reflex electrically so as to examine the threshold voltage and latency of this reflex. The rectoanal reflex was induced in all patients by balloon dilatation of the rectum. However, electrical stimulation of the rectal mucosa triggered a reflex in only nine of them and the threshold voltage and latency was 22.2 +/- 3.6 volts (mean +/- SD, n = 9) and 2.04 +/- 0.38 seconds (n = 9), respectively. Hence, it is suggested that a suction-stimulating electrode is a useful supportive tool in manometric anorectal studies, and that disturbances in the rectal nervous system might be one of the causative factors in chronic constipation in childhood.

Manometric evaluation of gastrointestinal motility in a case of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS)

We report on a manometric study of the esophagus, stomach, duodenum, jejunum and anorectum in a case of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS). An esophageal examination showed normal esophageal contractions and a positive rectoanal reflex was obtained in an anorectal manometry. However, the continuous fasting manometric recording of the antrum, duodenum and jejunum lasting a total of 12 hours revealed a severe motility disturbance of the gastrointestinal tract. During the examination a band of low amplitude contractions was observed in the antrum only once and it was followed by small rhythmic contractions of the duodenum, but none of propagated or spontaneous contractions were seen in the jejunum.

Remnants of urachus in infants and children--the problems of diagnosis and treatment

A total of 17 cases of remnants of urachus were examined between 1981 and 1989, including 2 cases of patent urachus, 5 of urachal cyst, 9 of urachal sinus, and 1 of urachal diverticulum. A long urachal sinus was considered to be caused by the self-destruction of a cyst. While patent urachus was diagnosed in neonates with urine discharge from the umbilicus, cysts or sinuses accompanied by infection were more often found in older children. Imaging of the burrows was diagnostic in 8 out of 11 cases, ultrasound examination in 9 out of 12, and CT examination in all of 3 cases. Since this condition is frequently accompanied by malformations of the urinary system, attention must be paid to locating the accompanying anomalies. Although primary extraction was performed in 13 cases, the primary treatment of cases with highly infected cysts should be drainage, followed by secondary extraction. Furthermore, caution must be exercised to avoid hemorrhage in cases with dilation of the umbilical artery.

An infantile case of infiltrating lipoma in the buttock

This paper presents a rare case of infantile infiltrating lipoma in the buttock. The usefulness of magnetic resonance imaging of the tumor in the follow-up study is discussed.

Diagnosis of urachal anomalies in infancy and childhood by contrast fistulography, ultrasound and CT

From 1981 to 1989 seventeen cases of pediatric patients with urachal remnants have been treated at the Fukuoka Municipal Children's Hospital (2 patent urachus, 5 urachal cyst, 9 urachal sinus, 1 urachal diverticulum). The cases of patent urachus were discovered in the neonates due to a urine discharge from the umbilicus; in the older children, cysts or sinuses accompanied by an infection led to the diagnosis of the urachal anomaly. In 8 of 11 cases, fistulography established the diagnosis. In 9 of 12 cases, ultrasound imaging was diagnostically successful, as was CT in all 3 cases that were given scans.

The fate of swallowed button batteries in children

The method of treatment and fate of 41 button batteries ingested by 34 children were analysed; 31 batteries were in the stomach and 10 beyond the pylorus. In 31 batteries situated in the stomach, removal by magnet tube technique was attempted in 30 batteries, 25 being successfully taken out, while 5 failed passing through the pylorus at the duodenum. One was removed endoscopically, since a magnet tube was not available. The remaining 10 batteries in 10 children were found at different levels from the duodenum to the rectum. In addition, 5 batteries were pushed down from the stomach during magnet tube removal. These 15 batteries, located in the intestine were excreted during 35 hours. In contrast to other asymptomatic foreign bodies that are allowed to pass through the GI tract spontaneously, we feel that button batteries should be removed by magnet tube technique to avoid complications such as GI tract perforation with associated bleeding, possible mercury poisoning and burns. Magnet tube removal is a simple and safety method requiring neither anaesthesia nor admission.

Experimental free muscle transplantation to the anus using microsurgical technique--a new treatment for anal incontinence

Experimental free muscle transplantations to the anus with microneurovascular anastomoses were performed in twenty-one dogs as a model of new treatment for anal incontinence. After undergoing subtotal external sphincterectomy, gracilis muscles were transferred to the anus with microneurovascular anastomoses in Group I (n = 9), without microneurovascular anastomoses in Group II (n = 6), and the muscle transfers were not performed in Group III (n = 6). The mean anal canal pressures decreased to 24.4% of preoperative pressure at one month after subtotal external sphincterectomy. But at six months after muscle transplantation they restored up to 80.7% of preoperative pressure in Group I, 54.7% in Group II and the pressure did not restore in Group III (p less than 0.001 Group I vs Group II and III). Electromyographic study of the graft showed the electrical activity in six of seven dogs (85.7%) in Group I and electrical activity of the graft were not recognized in Group II at six months after transplantation. Histologic study of the graft showed the normal pattern of the muscle fibers in 75-80% of the graft in Group I, and fibrotic degeneration in most areas of the graft in Group II at six months after gracilis muscle transplantation.

Management of pediatric patients who have swallowed foreign objects

The clinical management of children who have swallowed foreign bodies presents a great challenge for both pediatricians and pediatric surgeons. Our 7-year experience of treating 141 patients with a history of foreign body ingestion is reported. In 114 patients, there were 122 foreign bodies present in areas from the esophagus to the rectum, as located by plain chest and abdominal x-ray examination. In two patients, a plastic toy and the plastic cap of a razor were passed with stool a few days later. In the remaining 25 patients, nothing was found. In babies under one year of age, button batteries were the most commonly swallowed foreign bodies, while coins were the most frequently swallowed objects in children over the age of three years. Seventeen foreign bodies in the esophagus were removed: seven by balloon catheter, four endoscopically, and one by a magnet tube. Four were dislodged into the stomach. Twenty nine of the 78 items present in the stomach were button batteries and 23 of the items were removed using a magnet tube. One was removed endoscopically and 5 batteries that had moved beyond the pylorus were excreted within 48 hours. Twenty four coins in the stomach were managed conservatively. Surgical intervention was required in two patients; one patient had a previous history of pyloromyotomy, and a magnet tag measuring 1.5 cm in diameter did not pass through the pylorus for 7 weeks. The other patient had swallowed a sewing needle that moved into the descending colon and abdominal pain ensued.

Rectoanal reflex induced by H2O thermal stimulation

To obtain clear evidence of the rectoanal reflex, cold water was injected into the rectum. All patients with a normal reflex had a rectoanal reflex when the water was either 4 degrees C or 17 degrees C. The same reflex was seen when a balloon was used for distention. No reflex was evident when the water was 37 degrees C. At 27 degrees C or 45 degrees C, the reflex was evident occasionally. In patients with Hirschsprung's disease, the rectoanal reflex was absent with balloon distention, and when water at any temperature was injected. As cold water will induce the rectoanal reflex safely and without rectal distention, measurement of the reflex using cold water is useful when the presence or absence of the reflex is doubtful. The authors' results suggest that the receptor related to the reflex is neuronal in origin and not muscular, and that the receptor locates near the mucosa.

Diagnosis of Hirschsprung's disease by anorectal manometry

Anorectal manometry was performed in 48 Japanese children with Hirschsprung's disease and 61 normal children. The resting pressure of the rectum and anal canal was not significantly different between these groups of subjects. The frequency of rhythmical contractions of the anal canal of patients was significantly lower than for the normal subjects, but the frequencies overlapped considerably. Therefore, the frequency is an inadequate indicator for identifying these patients. Conventional manometry elicited a distinct rectoanal relaxation reflex from 90% of the normal children, and the rate increased to 98% when indistinct reflexes were regarded as positive. Indistinct reflexes often occur in neonates, possibly because the constriction of the anal canal is weak. However, when prostaglandin F2 alpha was intravenously administered during the examination, all ambiguous reflexes became distinct. Of patients with Hirschsprung's disease, 4% had a distinct reflex and 19% an atypical one. Most of the atypical reflexes were regarded as being artifacts and were mostly attributed to distension by a balloon. In these patients, the reflex was abolished in case of examination with electric stimulation or stimulation with cold water, procedures which do not dilate the rectum. Moreover these atypical reflexes did not fit the criteria for the normal rectoanal relaxation reflex prepared by the Japan Study Group of Pediatric Intestinal Manometry. The use of electric stimulation, cold water, or intravenously administered prostaglandin F2 alpha improves reliability of the conventional anorectal manometry. A clear and accurate definition of the normal reflex should aid in excluding the atypical reflex.