Motility of the small intestine after proctocolectomy and ileal pouch-anal anastomosis

Manometry of the Human Ileum and Ileocaecal Junction in Health, Disease and Surgery: A Systematic Review

Background: The terminal ileum and ileocaecal junction form a transition zone in a relatively inaccessible portion of the gastrointestinal tract. Little is known about the motility of this region with few detailed studies, indicating the need for a robust synthesis of current knowledge. This review aimed to evaluate the quantitative and qualitative data on the manometry findings of the terminal ileum and ileocaecal junction during the fasting and post-prandial periods in healthy individuals and patients with motility disorders or patients after bowel surgery.

Methods: A systematic search of five databases (Medline, Pubmed, Embase, Scopus, and Cochrane Library) was performed. Studies that presented manometry data from the human ileum or ileocaecal junction were included.

Results: Forty-two studies met the inclusion criteria. The main motility patterns reported in the terminal ileum during fasting were the migrating motor complex, discrete clustered contractions, prolonged propagated contractions and phasic contractions. Post-prandial motility featured irregular, intense contractions. Some studies found a region of sustained increased pressure at the ileocaecal junction while others did not. Patients with motility disorders showed differences in manometry including retrograde propagation of phase III. Patients post-bowel surgery showed differences including higher incidence of phase III.

Conclusion: Motility patterns of the terminal ileum differ between fasting and fed states. Large variability existed in manometry recordings of the terminal ileum. Technical challenges and lack of standardized definitions may reduce accuracy of manometry assessment. Further research is needed to understand how this key portion of the gut physiologically functions.

Abnormal gut motility in inflammatory bowel disease: an update

BACKGROUND

There is substantial evidence linking disturbed gastrointestinal motility to inflammation. Thus, it is not surprising that abnormalities of gastrointestinal motility play a role in inflammatory bowel disease (IBD), affecting patient outcomes. We performed a review of the literature to investigate the relationship between abnormal gut motility and IBD.

METHODS

With an extensive literature search, we retrieved the pertinent articles linking disturbed gut motility to IBD in various anatomical districts.

RESULTS

The evidence in the literature suggests that abnormal gastrointestinal motility plays a role in the clinical setting of IBD and may confuse the clinical picture.

CONCLUSIONS

Abnormal gut motility may be important in the clinical setting of IBD. However, additional data obtained with modern techniques (e.g., magnetic resonance imaging) are needed to individuate in a more precise manner gastrointestinal motor dysfunctions, to understand the nature of clinical manifestations and properly tailor the treatment of patients.

Acupuncture in Inflammatory Bowel Disease

Scientific research into the effects and mechanisms of acupuncture for gastrointestinal diseases including inflammatory bowel disease has been rapidly growing in the past several decades. In this review, we discuss the history, theory, and methodology of acupuncture and review potentially beneficial mechanisms of action of acupuncture for managing inflammatory bowel disease. Acupuncture has been shown to decrease disease activity and inflammation via increase of vagal activity in inflammatory bowel disease. Acupuncture has demonstrated beneficial roles in the regulation of gut dysbiosis, intestinal barrier function, visceral hypersensitivity, gut motor dysfunction, depression/anxiety, and pain, all of which are factors that can significantly impact quality of life in patients with inflammatory bowel disease. A number of clinical trials have been performed to investigate the therapeutic effects of acupuncture in ulcerative colitis and Crohn's disease. Although the data from these trials are promising, more studies are needed given the heterogeneous and multifactorial aspects of inflammatory bowel disease. There is also an important need to standardize acupuncture methodology, study designs, and outcome measurements.

Laboratory tests for patients with ileal pouch-anal anastomosis: clinical utility in predicting, diagnosing, and monitoring pouch disorders

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC-associated dysplasia, and for the majority of patients with familial adenomatous polyposis. Pouchitis and other complications of IPAA are common. There are scant data on laboratory markers for the evaluation and diagnosis of pouch disorders. The presence of immunogenotypic markers such as genetic polymorphisms of interleukin-1 (IL-1) receptor antagonist, NOD2/CARD15, Toll-like receptor, and tumor necrosis factor-alpha has been reported to be associated with pouchitis. Immunophenotypic/serologic markers such as perinuclear antineutrophil cytoplasmic antibody and anti-CBir1 have been investigated as possible markers for predicting and diagnosing pouchitis. Fecal markers including lactoferrin and calprotectin seem to be useful in distinguishing inflammatory from noninflammatory pouch disorders. In our practice, we have encountered a large number of pouch patients with Clostridium difficile infection. Laboratory evaluation provides information on the etiology and pathogenesis of pouchitis, and it also helps practicing clinicians with accurate diagnosis, differential diagnosis, disease stratification, and management of ileal pouch disorders.

Chronic pouchitis is not related to small intestine bacterial overgrowth

BACKGROUND

Restorative ileal pouch-anal anastomosis (IPAA) potentially may lead to upper gastrointestinal tract motility disturbances. In addition, a bacterial etiology of IPAA complication-pouchitis-has been suggested. The oro-anal transit time is significantly reduced in this patient group. Therefore, we investigated the hypothesis if IPAA constitutes a significant risk for small intestine bacterial overgrowth (SIBO).

METHODS

Twenty-eight patients age 23-71 years with IPAA operated due to ulcerative colitis without subjective symptoms of pouchitis were evaluated as outpatients according to the prescheduled follow-up after operation and included in the study. The modified Pouchitis Disease Activity Index (PDAI) was determined in all IPAA patients, including clinical, endoscopic, and histopathological (Moskowitz criteria) parameters. In addition, anorectal manometry was performed. The presence of SIBO was determined with the use of a glucose breath test (GBT).

RESULTS

In 1 subject (3.6%) an abnormal GBT result was recorded consistent with SIBO. In addition, 2 borderline values (7.1%) were documented. Both patients with SIBO as subjects with borderline values presented with low PDAI values. All patients with PDAI >7 had normal GBT results. In patients with SIBO the maximal tolerated rectal volume was significantly higher than in subjects without SIBO (P < 0.007). Similarly, the PDAI value was significantly lower (P < 0.014).

CONCLUSIONS

Asymptomatic chronic pouchitis is not related to SIBO. However, excessive colonization of the small intestine does occur in some IPAA patients and needs to be kept in the differential diagnosis.

Gastric emptying function after ileal J pouch-anal anastomosis for ulcerative colitis

BACKGROUND

Little is known of the effects on gastric function after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis. This study aimed to determine whether patients with postoperative high stool frequency after IPAA exhibit impaired gastric function.

METHODS

Gastric emptying time (GET) for a solid diet (rice gruel) with the use of a radioisotope method and for a liquid diet (orange juice) with the use of an acetaminophen method were assessed in 36 patients with ulcerative colitis more than 30 months after closure of protective ileostomy. Patients were divided into 2 groups: 18 patients with stool frequency less than 6 per day (group A) and 18 patients with stool frequency more than 7 per day (group B). GET for solid and liquid diets in groups A and B were compared with those in 18 healthy volunteers (group C). We correlated the time of peak blood concentration of acetaminophen (TPBCA) and both individual stool frequency per day and the length of distal ileum removed.

RESULTS

GET for the solid diet in groups A and B was not altered by IPAA compared with group C. GET for the liquid diet in groups A and B was slower than in group C (P<.0001). GETs for the liquid diet at 60 minutes or more in group A were slower than in group B (P<.0001); TPBCA was longer in group A than in groups B or C (P<.01). There were inverse correlations between TPBCA and individual stool frequency per day and between TPBCA and length of distal ileum removed (P<.001).

CONCLUSIONS

Rapid transit from the stomach of the liquid diet in group B compared with group A may influence high stool frequency after IPAA. Our results suggested that, to obtain an adequate stool frequency after IPAA, the length of distal ileum removal should be less than 15 cm.

Relationship between gastrointestinal transit time and daily stool frequency in patients after Ileal J pouch-anal anastomosis for ulcerative colitis

BACKGROUND

To investigate how the gastrointestinal transit function changes after ileal J pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and to study whether gastrointestinal transit time (GTT) has an influence on daily stool frequency, we investigated the relationship between GTT and stool frequency per day.

METHODS

Forty patients with UC who had undergone restorative proctocolectomy, with ileostomy closure at least 48 to 120 months (mean 96.3) previously, and who had no preoperative and postoperative complications were recruited. They were divided into two groups on the basis of their stool frequency: 26 patients had a stool frequency of less than 6 times per day (group A: 16 men, 10 women; aged 15 to 59 years old, average 36.6) and 14 patients had a stool frequency of 7 or more times per day (group B: 10 men, 4 women; 24 to 56 years old, average 40.9). The GTTs using a radiopaque marker were studied. Interviews concerning the defecation states were performed at the examination.

RESULTS

High nocturnal stool frequency was significantly noted more in group B than in group A (P <0.001). All cases in group A and 12 cases in group B could discriminate flatus from feces, and there were significant differences between groups A and B (P <0.05). Feeling of stool remaining was significantly noted more in group B than in group A (P <0.01). Stool consistency in group A was harder than that in group B (P <0.001). Patients with soiling were significantly noted more in group B compared with those in group A (P <0.001). Incontinence was detected in only 2 cases in group B. Group A showed a better defecation state than group B. In the GTT study, the GTT was almost the same in groups A and B. The small bowel transit, pouch transit, and whole gut transit times in group B were faster than those of group A (P <0.001). Removal length of the terminal ileum in patients after IPAA: patients in group B (13.8 +/- 3.9 cm) had significantly more ileum removed compared with patients in group A (6.3 +/- 2.4 cm; P <0.001). Regression lines in the relationship between removal length of the terminal ileum and individual stool frequency showed there was a correlation between removal length of the terminal ileum and individual stool frequency per day in direct proportion (r = 0.79, P <0.001). A resection of more ileum, up to 15 cm, plays a role in increased stool frequency.

CONCLUSIONS

The present results suggested that rapid transit of both the small bowel and pouch may lead to a high stool frequency of 7 or more times per day with a poor defecation state after IPAA. It was also pointed out in this study that an important point is a resection of more ileum, up to 15 cm, plays a role in increased stool frequency.

Ileal manometry in children following ileostomies and pull-through operations

Our aim was to analyse the patterns of ileal contractions in children. We reviewed the charts of 23 children who had ileal manometry studies (16 males), mean age 7 years (range 2 months to 17 years). We positioned the manometry catheters with 4-8 recording sites, 5 or 15 cm apart, through ileostomies fashioned for clinically indicated reasons. We studied six additional children with persistent faecal soiling following endorectal pull through for Hirschsprung's disease; the catheters were positioned through the anus and colon into the ileum. We recorded phasic and tonic intermittent contractions in all the subjects, clustered contractions (rate 5-9 min-1, duration 20-120 s) in 19 subjects with ileostomies and four with endorectal pull throughs. In 13 children there were prolonged propagated contractions, > 60 mmHg in amplitude, > 15 s in duration, propagating at rates of 2-6 cm s-1 over at least 20 cm. The migrating motor complex was rare; in 55 h of fasting recording there were two phase III sequences. There are four distinctive features of ileal manometry recordings in children: random intermittent contractions, clustered contractions, prolonged propagated contractions and tonic contractions. The features of ileal motility differ from motility in the proximal small bowel.

Small intestinal transections decrease the occurrence of tapeworm-induced myoelectric patterns in the rat

Abstract Luminal infection by the noninvasive tapeworm, H. diminuta, alters rat small intestinal myoelectric activity. The significance of continuity between small intestinal enteric nervous system (ENS) and that of both the stomach/pylorus and colon/caecum regarding the induction of tapeworm-altered myoelectric patterns was evaluated. A total of 32 rats were implanted with four serosal electrodes placed at sites in the duodenum through the mid-jejunum. Sixteen of the 32 rats underwent intestinal transections and anastomoses at both the duodenum and ileum. After recording myoelectrical activity of both normal and transected intestines, eight rats from each group (normal and transected) were infected with H.diminuta. Phase III frequency, duration of the migrating myoelectric complex (MMC), slow wave frequency, percentage of slow waves associated with spike potentials and the occurrence of the the two tapeworm-initiated myoelectric patterns, repetitive bursts of action potentials (RBAP) and sustained spike potentials (SSP), were measured. In infected rats, the frequency of the RBAP and SSP electric patterns were significantly reduced by the double transection. Intestinal transection did not affect the other changes caused by infection, such as decreased MMC phase III frequency and percentage of slow waves associated with spike potentials. In conclusion, a small intestinal ENS in continuity with other segments of the GI tract is required to generate maximal numbers of tapeworm-induced SSP and RBAP myoelectric activity in the small intestine of the rat.

A comparison of the effect of loperamide in oral or suppository form vs placebo in patients with ileo-anal pouches

OBJECTIVE

The effect of the anti-diarrhoeal drug, loperamide hydrochloride, on bowel function in patients with an ileo-anal pouch was studied by means of a blinded, three-tailed, case-controlled and randomized crossover trial, using a daily dose of 12 mg in either oral (4 mg t.d.s.) or suppository (6 mg b.d.) form.

PATIENTS AND METHODS

Daily stool frequency was recorded in a diary and an objective measure of pouch motor function was obtained at the end of each treatment phase. Ten subjects (seven males, three females) aged 23-50 years (median 38 years) were studied 9-48 months (median 27 months) after ileostomy closure. Eight pouches had been constructed for ulcerative colitis and two for familial adenomatous polyposis (9J, 1W).

RESULTS

Mean daily stool frequency during the oral loperamide phase was lower than during both the placebo (P=0.05) and suppository (P < 0.02) phases. Stool frequency did not differ significantly between placebo and suppository phases. There was a strong inverse correlation between mean daily stool frequency and pouch capacity (r=-0.82 after both oral and suppository phases). Large isolated pouch contractions were evident in five of eight subjects studied; suppression was observed in two of the five after oral loperamide and in three of the five after loperamide suppositories. Rhythmic pouch contractions were seen in four subjects and suppression was evident after loperamide suppositories (but not after oral loperamide) in three. A daily oral dose of 12 mg loperamide significantly lowered stool frequency in pouch patients and modified some aspects of pouch contraction. Loperamide suppositories produced more prominent suppression of pouch contractions but did not lower stool frequency.

CONCLUSION

This suggests that the beneficial effect of oral loperamide is primarily due to its action on intestine proximal to the pouch itself.

Myoelectric and motor activity after proctocolectomy and ileal pouch-anal anastomosis in dogs

BACKGROUND

The aim of this study was to investigate the motor function of the ileoanal pouch and to evaluate its coordination with proximal small-intestine motility.

METHODS

Proctocolectomy and ileal J pouch-anal anastomosis were performed in 12 dogs. Motility was recorded by serosal electrodes and strain gauge transducers.

RESULTS

Transmission of the migrating motor complex (MMC) on the pouch appeared in only 37 of 109 measurements. On the ascending limb there was a constant irregular activity with no MMC detectable. Motility pattern of the pouch did not change postprandially. Spontaneous defecation always appeared independently from MMC transmission without an increase of electrical or mechanical activity or endoluminal pouch pressure.

CONCLUSIONS

Ileal pouch motility is independent from motility patterns of the proximal intestine. Its random contractile activity might provide storage function and make the pouch act as a functional reservoir. Intrinsic pouch motility is not responsible for pouch evacuation under physiologic conditions.

The physiology of ileo-anal pouch function

Even excellent clinical function after ileo-anal pouch construction is associated with a variety of physiological abnormalities. Small bowel intestinal motility is essentially normal but the ileal reservoir serves to markedly suppress the ileal motor response both to progressive distension by intestinal contents and to transmitted myoelectrical complexes. As a result, the healthy pouch can accommodate a large volume of intestinal content before the rising baseline pressure and the appearance of large isolated contraction waves produce an urge to defecate. Evacuation in the normal pouch patient is rapid and highly efficient and is achieved by means of the Valsalva maneuver without any evidence of significant intestinal propulsion. External anal sphincter function is fully preserved but internal anal sphincter function is significantly impaired in the immediate postoperative period. Recovery occurs over the next 6 to 12 months but is often incomplete. Bacterial overgrowth in the pouch and prepouch ileum is almost universal and results in the premature deconjugation of primary bile salts and accumulation of secondary bile salts within the pouch. These produce morphologic changes in the ileal mucosa, and their excretion in pouch effluent gradually depletes the bile salt pool. Anerobic organisms also bind with vitamin B12 and the vitamin B12-intrinsic factor complex, resulting in subtle but measurable reductions in vitamin B12 levels in pouch patients. Finally, anerobic fermentation of mucus and undigested carbohydrate results in excessive quantities of short chain fatty acids within the pouch lumen. The clinical significance of these substances is unclear, but they may have an adverse action on both ileal mucosal and smooth muscle function. In essence, however, the pouch surgeon can maximize the likelihood of good clinical function by constructing a large capacity pouch, by avoiding surgery in patients with clearly deficient anal sphincter mechanisms, and by careful attention to pouch-anal anastomotic technique.

Substance P- and vasoactive intestinal polypeptide-immunoreactive innervation in normal and inflamed pouches after restorative proctocolectomy for ulcerative colitis

Recent studies suggest that the intestinal polypeptides substance P (SP) and vasoactive intestinal polypeptide (VIP) play a role in the bowel inflammatory processes. The aim of this study was to evaluate the distribution of SP and VIP immunoreactivities in the ileal pouch of the patients with ulcerative colitis (UC). Thirty-six patients underwent clinical evaluation, endoscopy, and histological examinations. Samples were taken from normal ileum (N = 9), ileum of UC patients (N = 9), normal ileal pouch (N = 9) and pouchitis (N = 9). SP- and VIP-containing nerve fibers were visualized in sections processed for immunofluorescence microscopy. The number and intensity of SP and VIP immunoreactivities were subjected to quantitative scoring. On samples from all groups lamina propria contained fibers showing bright immunofluorescence for SP and VIP. The number and intensity of SP immunoreactive nerve fibers were markedly increased in pouchitis as compared to normal pouch (P < 0.005), to ileum of UC patients (P < 0.001), and to normal ileum (P < 0.05). The number and intensity of VIP-immunoreactive nerve fibers in the lamina propria were markedly increased in pouchitis patients and in those having a normal pouch as compared to pooled values of ileum of UC patients and normal ileum (P < 0.05). The results suggest that SP, which may play a role in mediating inflammatory processes, is increased in pouchitis and that VIP, which may contribute to the regulation of intestinal motility, is increased in the pouch.

Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis

AIMS

A prospective randomised controlled trial was conducted to find out what influence the design of the pelvic reservoir had on the functional outcome.

PATIENTS AND METHODS

Sixty patients received either a duplicated (J) or a quadruplicated (W) reservoir, constructed with either 30 or 40 cm of ileum. Each patient underwent laboratory tests of anorectal function before and one year after operation.

RESULTS

One year after operation, 57 patients were available for assessment: each had good anal continence, though eight experienced minor leakage of mucus, and all were able to defer defecation for more than 15 minutes. Median bowel frequency in 24 hours (IQR) in patients with J reservoirs (5 (4-7)) did not differ significantly from that of patients with W reservoirs (5 (4-6)). Likewise, bowel frequency in patients with the smaller (30 cm) reservoirs did not differ significantly from bowel frequency in patients with the larger (40 cm) reservoirs. However, patients with large W40 reservoirs had the lowest bowel frequency of the four groups (median 4 per 24 hours, p = NS). The capacity and compliance of the W40 reservoirs were greater than those of the other types of reservoir, but the differences were not statistically significant.

CONCLUSIONS

These findings provide support for the use of a relatively small (30 cm), duplicated (J) ileal reservoir, which is simple to construct with linear stapling instruments.

Simple radiographic evaluation of ileoanal pouch volume

PURPOSE

Total colectomy and mucosal protectomy with ileal reservoir and anal pull-through is used in the treatment of ulcerative colitis or familial polyposis, with one complication being frequent bowel movements. A simple radiographic test to predict frequency of bowel movements and measure spasticity was evaluated.

METHODS

Fourteen patients underwent evaluation after ileal reservoir and anal pull-through J-pouch construction. Barium sulfate suspension was instilled into the pouch via the anus in the standing position until reflux flowed into the small intestine proximal to the pouch and patients felt the urge to defecate. Total volume infused (VOLtot), volume to reflux (VOLrflx), and volume voided (VOLvoid) were measured.

RESULTS

VOLvoid and the "voiding efficiency" (VOLvoid/VOLtot) correlated significantly with stool frequency (R=-0.744, P<0.002 and R=-0.754, P<0.002, respectively). Time from operation was correlated with VOLvoid and stool frequency (R=-0.723, P<0.003 and RO.573, P<0.032, respectively).

CONCLUSIONS

The addition of quantitative measurements to this radiographic test gives useful information about pouch performance. Furthermore, the data imply that spasticity, as measured by voiding quantum and efficiency, rather than actual pouch volume is a major determinant of bowel movement frequency.

Endosonography of the anal sphincter after ileal pouch-anal anastomosis. Relation with anal manometry and fecal continence

PURPOSE

The aim of the present study was to visualize supposed defects of the internal anal sphincter after ileal pouch-anal anastomosis (IPAA) by anal endosonography and to relate these findings with anal manometry and fecal continence.

METHODS

We investigated 23 patients, visualized the sphincter complex by anal endosonography, and quantified the anatomic changes of the sphincter. Anal resting and squeezing pressures as well as length of the anal canal were determined by anal manometry. Continence was objectively scored by an observer not involved in treatment of patients and subjectively by patients themselves.

RESULTS

At anal endosonography, the mean thickness of the internal anal sphincter was 1.16 mm (95 percent confidence interval, 0.98-1.33), which is significantly less than in normal volunteers. Tapering of the internal anal sphincter only occurred in six patients (of whom two had a gap in the internal sphincter). In 17 patients endosonography showed a thin internal anal sphincter without essential variation in thickness over the complete circumference. Approximately eight weeks after ileostomy closure following IPAA, maximum resting pressure (MRP) and length of the anal canal appeared to be significantly decreased compared with values before IPAA (P = 0.001 and 0.002, respectively). These differences were less striking (P = 0.05 and 0.04, respectively) when measured six or more months after ileostomy closure. The extent of reduction of the MRP and thickness of the internal anal sphincter were not correlated with grade of continence or with subjectively scored continence.

CONCLUSIONS

IPAA leads to a reduction of thickness of the internal anal sphincter and reduction of the MRP. Tapering or gaps in the internal anal sphincter are probably caused by direct trauma to this sphincter because of mucosectomy, whereas in cases of circular reduction of thickness of the internal anal sphincter without tapering or gaps, direct trauma is an unlikely explanation; this reduction is probably caused by denervation. IPAA compromises continence to a variable degree in 18 of 23 patients. No correlations were found between the extent of reduction of the MRP and the extent of reduction in internal anal sphincter thickness or between these two parameters and objectively or subjectively scored continence. Difficulties in obtaining reliable information on continence may be a causal factor. A striking discrepancy was noticed among objective, scored disturbances in continence, and overall satisfaction concerning level of continence by patients themselves.

Ambulatory pouch and anal motility in patients with ileo-anal reservoirs

Twelve patients were studied for a median of 18 hours (range 8.5-21.5 hr) by continuous, ambulatory, simultaneous pouch and anal manometry 10-85 months after restorative proctocolectomy. Two main patterns of motility were observed: (1) Large isolated contractions up to 68 cm H2O in amplitude and up to 67 seconds in duration were present in ten patients. These were often associated with the urge to defaecate and were more frequent before defaecation than after but did not appear to be associated with expulsion of faeces from the pouch. In two patients atypical large isolated contractions up to 378 cm H2O in amplitude were observed. (2) Rhythmic contractions at a frequency of 7-11 per minute and amplitude of 24-330 cm H2O, occurred for a duration of 18 seconds to 18 minutes in six patients. In the other six patients this motility pattern was not seen. Of the 12 patients nine were considered to have good function (five or less bowel actions per 24 hours) and three poor function (ten or more bowel actions per 24 hours). Rhythmic activity was the predominant motility pattern in all three with poor function whereas large isolated contractions predominated in those with good function, although there was considerable overlap in the types of motility observed between patients with good and poor function. Mean pouch pressure tended to be higher in patients with poor function than in those with good function both throughout the entire recording and during sleep. In a number of patients simultaneous anal recordings revealed the presence of slow waves and falls in pressure, some of which were associated with a simultaneous rise in pouch pressure.

Relationship of small bowel motility to ileoanal reservoir function

Some patients with an ileoanal reservoir have a high defecation frequency, despite a good anatomical result and the absence of pouchitis. This study aimed to determine whether variation in function is related to a difference in small bowel motility proximal to the reservoir and if small bowel motility is propagated into the reservoir. Ambulatory small bowel and reservoir motility was studied for 24 hours in five patients with good function (median bowel frequency 4 per day, range 3-6) and seven subjects with poor function (median bowel frequency 12 per day, range 10-20). Five solid state pressure sensors were positioned in the small bowel and one in the reservoir. During the fasting nocturnal period (2300-0800 h), patients with poor function had a median of 10 (range 5-13) migrating motor complexes (MMC), significantly greater (p = 0.03) than the corresponding median number of 3 (range 2-7) in patients with good function. A total of 120 MMCs were observed in the whole series of 12 patients. Of these only two were propagated from the small bowel into the reservoir. Discrete clustered contractions were not propagated into the reservoir, although prolonged propagated contractions did pass into the reservoir in one patient. Patients with poor function had similar 24 hour stool output and radiological reservoir size to those with good function, but the median maximum tolerated volume on reservoir distension was 290 ml (range 160-450) for patients with poor function compared with 475 ml (range 460-550) for patients with good function (p = 0.005). Small bowel motility proximal to the reservoir bears an important relationship to pouch function and defecation frequency. Propagation of coordinated proximal small intestinal motility into the reservoir is rare.

The ileal pouch operation for ulcerative colitis

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Human gastric and jejunal transit and motility after Roux gastrojejunostomy

Upper gut transit and motility among 10 symptomatic and 9 asymptomatic patients with Roux gastrectomy were compared with those among 10 healthy, unoperated controls. Gastric emptying of solids and Roux limb and small intestinal transit of liquids were assessed scintigraphically. Motor patterns in the Roux limb or healthy jejunum were recorded manometrically. Whereas gastric emptying was sometimes faster and sometimes unchanged after Roux gastrectomy compared with controls, Roux limb transit in patients was consistently slower than jejunal transit in controls. Postprandially, the Roux limb showed decreased overall motility, fewer clustered waves, and less aboral migration of clustered waves than the healthy jejunum. Symptomatic Roux patients had jejunal transit and motor patterns similar to those of asymptomatic patients. Nonetheless, reflux from Roux limb to gastric remnant occurred in 4 of 10 symptomatic patients but in none of the asymptomatic patients. In conclusion, stasis and dysmotility are present in the Roux limb after Roux gastrectomy and Roux-gastric reflux can occur. Other factors, however, must have a role in determining whether symptoms appear.

Persistent gastrointestinal symptoms after correction of malrotation

Persistent vomiting, diarrhoea, or intolerance of feeding, are well recognised problems in children after surgical correction of intestinal malrotation. Conversely, intestinal malrotation is a common accompaniment of chronic idiopathic intestinal pseudo-obstruction. We investigated motor activity of the small intestine during fasting in eight children who had persistent vomiting, intolerance of full enteral feeding, or severe diarrhoea after surgical correction of intestinal malrotation. Abnormality of motor function similar to that found in neuropathic pseudo-obstruction was found in seven of the eight patients. Persistence of symptoms after surgical correction of a malrotation is associated with a motility disturbance which seems to be due to a defect of intrinsic enteric innervation. Such a defect may be important in the aetiology of the malrotation.

Small intestinal motility and transit in disease

Disorders of small intestinal motility and transit are becoming increasingly recognized partly as a result of a greater awareness of their existence and partly because suitable diagnostic methods are more widely available. Usually, the neuropathic and myopathic forms can be separated, and gut disease secondary to a generalized neuromuscular disorder can be identified by the clinician. The availability of better non-invasive methods for the diagnosis of disorders of motility and transit would greatly facilitate their management. Treatment must include the restoration and maintenance of nutrition, attempts to improve intestinal motor function and resection of any segments of localized disease. Regrettably, all such measures are ineffective in the severest cases. In the future, a greater understanding of the enteric neural control of the smooth muscle and an ability to manipulate it with novel, specific drugs or peptidergic receptor agonists and antagonists, or electrical pacing, may lead to more effective therapies.

Myectomy reduces ileal motility after ileoanal anastomosis

The hypothesis tested was that myectomy of the distal ileum would produce a long-lasting decrease in ileal motility, and so render single-lumen ileum more suitable for use as a rectal substitute in the course of restorative proctocolectomy, without the need for a pelvic ileal reservoir. Ileal motility, both spontaneous and in response to intraluminal volatile fatty acids (VFA), was studied after proctocolectomy in 25 female adult beagles, at least 6 months after ileoanal anastomosis alone (IAA, n = 6), IAA with myectomy (n = 8), IAA with myectomy and an ileal valve (n = 5) or IAA with a duplicated (J) ileal reservoir (n = 6). VFA were found to stimulate ileal motility significantly in each group. Myectomy significantly reduced the number of ileal contractions (P less than 0.01), the mean amplitude of contractions (P less than 0.05) and the motility index (P less than 0.01). The addition of the valve to myectomy made no significant difference.

Absorption and motility of the bypassed human ileum

The authors assessed absorption and motility of the human ileum after a prolonged period of disuse. In eight patients with ulcerative colitis, a manometric-catheter assembly was placed via the ileostomy into the unused portion of distal ileum two months after ileal pouch-anal anastomosis and temporary diverting loop ileostomy. The distal ileum was perfused at 5 ml/min with an isosmotic solution of either sodium chloride or ileal chyme diluted with sodium chloride for three hours before and three hours after a meal on two consecutive days. Absorption was measured, single and clustered pressure waves were identified and quantitated with the aid of a computer program, and a motility index was calculated. Mean absorption +/- S.E.M. of both perfusates was poor on day 1 (-10 +/- 2 ml/25 cm x 30 min), and the meal induced no ileal motor response. By day 2, however, absorption of both perfusates was much improved (-1 +/- 2 ml/25 cm x 30 min; P less than 0.05), and the number of discrete clustered contractions and the motility index now clearly increased after the meal (2.6 +/- 0.6 vs. 7.2 +/- 1.0 clustered waves/hr; 7.5 +/- 0.5 vs. 9.7 +/- 0.2 motility units/30 min; P less than 0.05). The conclusion was that absorption and motility of the human ileum were impaired after two months of disuse, but that ileal absorption and motility improved one day after the introduction of isosmotic ileal perfusates.

Motility disorders and stress

The association between emotion and gastrointestinal dysfunction has been postulated for centuries, and all practicing clinicians have anecdotal experience of the association between stress and irritable bowel syndrome (IBS). However, definite proof of an etiologic link between stress and gut motor dysfunction remains elusive, despite the large number of publications on this topic. A critical appraisal of methodology, use of controls, data interpretation, and significance of findings in the published literature is necessary to assess the present state of knowledge and to develop more meaningful studies in the future. This review attempts to summarize these perspectives.

Jejunal manometry in distal subacute mechanical obstruction: significance of prolonged simultaneous contractions

The aim of this study is to assess the value of jejunal manometry in the diagnosis of subacute mechanical obstruction distal to the proximal small bowel. In a retrospective review of 850 manometric tracings carried out in patients with unexplained nausea, vomiting, abdominal pain or altered bowel movements, 16 tracings were identified with features suggestive of mechanical obstruction: prolonged simultaneous contractions (PC) and postprandial clustered contractions (CC). Three patients had CC lasting less than 20 minutes: none proved to have mechanical obstruction. Among seven patients with CC lasting more than 30 minutes, three had proven mechanical obstruction, one probable adhesion obstruction, and in three no obstruction was found. All three patients with PC and three with mixed PC and CC had mechanical obstruction. The obstructed intestine manifests a variety of pressure profiles in the proximal jejunum: PC, CC, or mixed patterns. Prolonged simultaneous contractions are suggestive of distal subacute bowel obstruction; CC lasting over 30 minutes are less specific, whereas CC lasting less than 20 minutes are not associated with obstruction.

Motility of the jejunum after proctocolectomy and ileal pouch anastomosis

Proctocolectomy with ileal pouch anastomosis could modify motility of the small intestine through two mechanisms: obstruction or bacterial overgrowth. Motility of the jejunum was measured in 11 patients with ileoanal anastomosis six (n = 6), or 12 (n = 5) months after closure of the loop ileostomy. Manometric recording from the jejunum were made during fasting (four hours) and after a liquid meal (one hour). These findings were compared with those of six healthy volunteers. Motor events were classified as follows: migrating motor complex (MMC), propagated contractions, or discrete clustered contractions. All patients were investigated for bacterial overgrowth (D-glucose breath test). Only two patients had bacterial overgrowth. The frequency of MMC remained unchanged after ileo-anal anastomosis (2.83 (0.37)/four hours) compared with normal volunteers (2.81 (0.29)/four hours). During fasting, four patients had numerous propagated contractions in the jejunum. This condition was associated in two with bacterial overgrowth and in two with intubation of the reservoir. Discrete clustered contractions were found in the seven patients studied postprandially (7.6 (2.5)/h), but not in volunteers. These seven patients emptied their pouch spontaneously and bacterial overgrowth was found in only one. As this motility pattern was previously described in partial small intestinal obstruction, it is postulated that discrete clustered contractions could be the consequence of a functional obstruction as a result of anastomosis of the small intestine to the high pressure zone of the anal sphincters.

Physiological parameters influencing function in restorative proctocolectomy and ileo-pouch-anal anastomosis

Ileo-pouch-anal function has been assessed in 30 patients after restorative proctocolectomy and compared with age- and sex-matched controls. Median resting anal canal pressure was only 42 cmH2O (7-113 cmH2O) compared with 100 cmH2O (46-114 cmH2O) in controls (P less than 0.005). Maximum squeeze anal pressures were also significantly lower in pouch patients: 87 cmH2O (25-180 cmH2O) than controls: 143 cmH2O (114-171 cmH2O) (P less than 0.01). The recto-anal inhibitory reflex was absent in all pouch patients but was present in all controls. Maximum pouch or ileal pressures exceeded resting anal canal pressures in three patients. Median volume at first leak during saline infusion was 320 ml (60 ml-no leak) in pouch patients whereas the majority of controls had no leakage (median, none; 450 ml-no leak; P less than 0.05). Threshold pouch sensation (median, 50 ml (0-250 ml] did not differ from rectal sensation in controls (50 ml (0-180 ml] but pouches were less compliant than a normal rectum, median 6.8 ml/cmH2O (2.1-17 ml/cmH2O) and 11.6 ml/cmH2O (4.7-16.2 ml/cmH2O) respectively (P less than 0.05). In patients who had an episode of pelvic sepsis (n = 8) the average number of abnormal physiological indices per patient was 3.8, compared with 1.3 in those with no sepsis (P less than 0.05). There was no difference in the number of abnormalities per patient with a J pouch (2.0; n = 19) or a W pouch (1.9; n = 11).

Operative treatment of ulcerative colitis: conventional proctectomy with Brooke ileostomy versus mucosal proctectomy with ileoanal anastomosis

Fifty-four patients with ulcerative colitis were operated on during a 3-year period; 35 had conventional proctectomy and Brooke ileostomy, and 19 had mucosal proctectomy, performed from the abdominal side, leaving 1-2 cm of the distal anal mucosa, and a straight ileoanal anastomosis (IAA) without diverting ileostomy. There were no operative deaths. In the ileostomy group 19 (54%) of the patients had a total of 38 reoperations: 10 laparotomies and 28 revisions of a perineal sinus. Three (16%) of the IAA patients had a total of five reoperations: four laparotomies and one closure of a loop ileostomy. All IAA patients had perfect continence day and night and a median stool frequency of 7.5/24 h 1 year after the operation. Ileostomy patients had significantly longer time out of work, and more urinary, sexual, and social dysfunctions than the IAA patients. After 2-3 years' follow-up study, all differences in results are greatly in favour of the ileoanal procedure.

[Physiologic aspects of postoperative continence following ileoanal anastomosis with and without intrapelvic reservoir]

Clinical and electro-manometric investigations were performed in six patients with ileoanal anastomoses. The results were compared with electromyographic and electrophysiological observations in the literature. It can be shown that decreasing motility, increasing compliance and a normalisation of the frequency of stools is possible after ileoanal as well as after ileo-pouch-anal anastomoses. Following both procedures high amplitude phase waves may persist in the distal and even in the proximal ileum. These waves can be stopped by voluntary contractions of the striated sphincter muscles if the patient becomes aware of them. During the night, however, uncontrolled defecations may occur. Un-isoperistaltic bowel segments will become isoperistaltic a few weeks or months after the operation. However, pouch-anal anastomoses show a better compliance and lower amplitude segmental or peristaltic waves than ileoanal anastomoses.

S-pouches vs. J-pouches. A comparison of functional outcomes

Subjects undergoing proctocolectomy with ileoanal anastomosis of either a J-shaped or an S-shaped ileal reservoir were studied with respect to functional status. Both subjective and objective measures were used. The S-pouch subjects appeared to have better early functional results, but no differences were found between groups evaluated at least one year from ileostomy closure. While virtually all subjects preferred restorative proctocolectomy to their previous loop ileostomy, there was a relatively high frequency of bowel-related symptoms, worries about bowel activity, and associated behavioral changes. The actual significance of these symptoms is difficult to determine at present. Further assessment of the quality of life in individuals with restorative proctocolectomy in comparison with subjects undergoing alternative surgical treatments is recommended.

Coating of oral beclomethasone dipropionate capsules with cellulose acetate phthalate enhances delivery of topically active antiinflammatory drug to the terminal ileum

Selective delivery of orally administered topically active antiinflammatory drugs to the terminal ileum and ascending colon could be potentially useful for patients with inflammatory bowel disease involving these sites. Because topical beclomethasone dipropionate (BDP) enemas have been used successfully in the treatment of distal idiopathic colitis, oral formulations of this drug were studied. Enteric-coated or uncoated capsules containing BDP were administered in a single-dose protocol on separate days to 6 healthy volunteers with postcolectomy ileostomies. Ileostomy effluent was collected for a minimum of 8 h and analyzed by high-performance liquid chromatography for BDP, its pharmacologically active derivative beclomethasone monopropionate (BMP), and inactive beclomethasone alcohol. Cellulose acetate phthalate coating of oral BDP capsules significantly increased the mean percentage recovery of BDP + BMP in ileal effluent (43.0% +/- 24.1%) compared to uncoated BDP capsules (13.5% +/- 8.5%, p less than 0.05, Student's paired t-test). We conclude that oral cellulose acetate phthalate-coated BDP capsules may merit clinical trial in Crohn's ileitis and ileocolitis or in conjunction with BDP enemas for topical treatment of ulcerative colitis involving the whole colon.

Achieving enteric continence: principles and applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Comparison of the myoelectrical activity of the lateral and J-shaped ileal reservoirs

Ileal myoelectrical activity was studied in ten 10-cm J-shaped and ten lateral ileal reservoirs (IR) in rabbits. Electrodes and a strain gauge were placed on both ileal segments of the reservoirs as well as the proximal and distal ileum entering and leaving the reservoirs. In three additional rabbits without reservoirs (controls), electrodes and a strain gauge were sutured to the distal ileum in a similar manner. Myoelectrical activity was recorded as (1) short spike burst complexes (SSBC) lasting greater than 25 seconds but less than three minutes, and (2) long spike burst complexes (LSBC) lasting more than three minutes. SSBC propagated through the lateral IR two weeks after its construction and were synchronous with intestinal contraction. In contrast, SSBC did not become organized or propagate distally through the J-shaped IR until eight weeks after reservoir construction. LSBC occurred infrequently in control rabbits and in those after construction of the J-shaped and lateral IRs. Propagation of LSBC in control rabbits was synchronous with prolonged propulsive intestinal contraction. In both the J-shaped and lateral reservoirs, LSBC occurred randomly and did not propagate from proximal to distal ileum through the IR until three months after reservoir construction. The frequency and duration of LSBC remained diminished for the J-shaped IR at three months when compared with the lateral IR. It is concluded that the return of normal propulsive activity occurs earlier in the lateral iso-peristaltic IR than in the J-shaped IR but that both are effective at three months.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications

The function and complications associated with temporary ileostomies were reviewed in patients undergoing ileal pouch-anal anastomosis. A series of 180 patients had temporary ileostomies established (157 loop, 23 Brooke). Patients with incomplete fecal diversion had a significantly higher incidence of pouch-anal anastomotic complications (44 percent) than did those with complete diversion (14 percent). Patients with loop ileostomies were more likely than patients with Brooke ileostomies to develop technique-related complications (18 percent vs. 13 percent) and peristomal irritation (54 percent vs. 26 percent). The most frequent complications after take-down of the ileostomy were transient bowel obstruction (13 percent) and peritonitis (7 percent). These complications could not be related to the type of stoma used or the interval to closure. Temporary diversion of a pouch-anal anastomosis decreased the incidence of anastomotic complications. These ileostomies, however, are associated with a significant risk of complications, which can be minimized by meticulous surgical technique.

Anal and neorectal function after ileal pouch-anal anastomosis

Bowel function varies markedly among patients with colectomy and ileal pouch-anal anastomosis. Little is known of the mechanisms controlling fecal continence and frequency of defecation after operation. The aim of this study was to determine which features of the anal sphincter and neorectum accounted for the variation in clinical outcome. Twenty patients were studied 4 to 35 months after operation and compared to 12 healthy volunteers. Despite several patients exhibiting impaired fecal continence, anal sphincteric length and pressures and ileal pouch capacity and distensibility were similar in patients and controls. Patients with poor results, however, had rapid filling of their ileal pouch, which resulted in early onset of high amplitude propulsive pressure waves in the pouch. As these waves became more frequent, defecation resulted. Patients with poor results also were not able to empty adequately their pouch. The poorer the completeness of evacuation, the more frequent the defecation (r = 0.62, p less than 0.01). The authors conclude that rapid pouch filling and impaired pouch evacuation can lead to increased stool frequency in patients after ileal pouch-anal anastomosis.