Motility of the jejunum after proctocolectomy and ileal pouch anastomosis

Clinical significance of small bowel manometry patterns suggestive of intestinal obstruction

INTRODUCTION

Minute rhythm and prolonged simultaneous contractions are patterns of postprandial small bowel contractile activity that historically have been considered as suggestive of mechanical intestinal obstruction; however, these patterns have been also encountered in patients with motility-like symptoms in the absence of bowel obstruction. The objective of this study was to determine the current diagnostic outcome of patients with these intestinal manometry patterns.

METHODS

Retrospective study of patients with chronic digestive symptoms evaluated by intestinal manometry at our center between 2010 and 2018.

RESULTS

The minute rhythm (MRP) or prolonged simultaneous contractions (PSC) postprandial patterns were detected in 61 of 488 patients (55 MRP and 6 PSC). Clinical work-up detected a previously non-diagnosed partial mechanical obstruction of the distal intestine in 10 (16%) and a systemic disorder causing intestinal neuropathy in 32 (53%). In the remaining 19 patients (31%, all with MRP), the origin of the contractile pattern was undetermined, but in 16, substantial fecal retention was detected within 7 days of the manometric procedure by abdominal imaging, and in 6 of them colonic cleansing completely normalized intestinal motility on a second manometry performed within 39 ± 30 days.

CONCLUSION AND INFERENCE

Currently, the most frequent origin of MRP and PSC encountered on small bowel manometry is intestinal neuropathy, while a previously undetected mechanical obstruction is rare. Still, in a substantial proportion of patients, no underlying disease can be identified, and in them, colonic fecal retention might play a role, because in a subgroup of these patients, manometry normalized after colonic cleansing. Hence, colonic preparation may be considered prior to intestinal manometry.

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.

Volvulus of the ileal pouch-anal anastomosis: a meta-narrative systematic review of frequency, diagnosis, and treatment outcomes

Background

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA.

Methods

A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018.

Results

The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%).

Conclusion

Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

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.

Motility of the oesophagus and small bowel in adults treated for Hirschsprung's disease during early childhood

BACKGROUND

Dysmotility of the upper gastrointestinal (GI) tract has been reported in children with Hirschsprung's disease (HD). In the present study, motility of the oesophagus and the small bowel was studied in adults treated for HD during early childhood to elucidate whether there are alterations in motility of the upper GI tract in this patient group. [Correction added after online publication 15 Sep: The preceding sentence has been rephrased for better clarity.]

METHODS

Ambulatory small bowel manometry with recording sites in duodenum/jejunum was performed in 16 adult patients with surgically treated HD and 17 healthy controls. In addition, oesophageal manometry was performed with station pull-through technique.

KEY RESULTS

The essential patterns of small bowel motility were recognized in all patients and controls. During fasting, phase III of the migrating motor complex (MMC) was more prominent in patients with HD than in controls when accounting for duration and propagation velocity (P = 0.006). Phase I of the MMC was of shorter duration (P = 0.008), and phase II tended to be of longer duration (P = 0.05) in the patients. During daytime fasting, propagated clustered contractions (PCCs) were more frequent in the patients (P = 0.01). Postprandially, the patients demonstrated a higher contractile frequency (P = 0.02), a shorter duration of contractions (P = 0.008) and more frequent PCCs (P < 0.001). The patients had normal oesophageal motility.

CONCLUSIONS & INFERENCES

This study demonstrates that adult patients with HD have preserved essential patterns of oesophageal and small bowel motility. However, abnormalities mainly characterized by increased contractile activity of the small bowel during fasting and postprandially are evident. These findings indicate alterations in neuronal control of motility and persistent involvement of the upper GI tract in this disease.

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.

Ileo-anal pouch necrosis secondary to small bowel volvulus: A case report

INTRODUCTION

Small bowel volvulus is a rare occurrence in the Western world and its occurrence after ileo-anal ouch formation is even rarer.

CASE PRESENTATION

We report a case of a 26 year old lady who presented with small bowel volvulus and subsequent ischaemia and necrosis of her ileo-anal pouch created 5 years previously.

CONCLUSION

This case illustrates a rare but potentially devastating complication of ileo-anal pouch formation and as such the diagnosis should be borne in mind when a patient with a pouch presents with an acute abdomen.

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.

Analysis of fasting antroduodenal manometry in children

Antroduodenal manometry has been used to determine the pathophysiology associated with signs and symptoms of gastrointestinal motility disorders. The diagnostic value of antroduodenal manomentry has been limited by the paucity of data from normal children. In this study, we compared antroduodenal manometry findings from 95 patients with symptoms suggesting a gastrointestinal motility disorder to 20 control children. Phase III of the migrating motor complex (MMC) was less frequent in patients (P < 0.05), especially in those who required total parenteral nutrition (P < 0.001), than in controls. Abnormal migration of phase III and short intervals between phase IIIs were more frequent in patients than in controls (P < 0.01 and P < 0.05, respectively). During phase II, persistent low-amplitude contractions and sustained tonic-phasic contraction were found only in parenteral-nutrition-dependent children. Short or prolonged duration of phase III, absence of phase I following phase III, tonic contractions during phase III, low amplitude of phase III contractions in a single recording site and clusters of contractions or prolonged propagating contractions during phase II were not more frequent in patients than in controls. We conclude that there are five manometric features having a clear association with pediatric gastrointestinal motility disorders: (1) absence of phase III of the MMC, (2) abnormal migration of phase III, (3) short intervals between phase III episodes, (4) persistent low-amplitude contractions, and (5) sustained tonic-phasic contractions.

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.

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 results of pouch surgery after ileo-anal anastomosis for inflammatory bowel disease: the manometric assessment of pouch continence and its reservoir function

Anal sphincter function after restorative proctocolectomy has mainly been investigated by anal manometry. A significant decrease of basal pressure up to 45%, has been recorded postoperatively, possibly due to sphincter stretch during endoanal mucosectomy. Both abdominal mucosectomy and anastomosis at the level of the anorectal ring have been reported to prevent anal sphincter damage and lead to better continence. The striated sphincter is not significantly affected by the surgical procedure. Pouch-anal inhibitory reflex is partly maintained in the presence of a rectal cuff which leaves the ganglionic plexus unaltered; a satisfactory continence is also retained in the absence of the reflex when the rectum is totally excised. Pouch capacity, compliance and motility have been investigated by endoluminal balloon and probes. Pouch emptying has been studied by a "porridge" test, by a semi-solid medium labelled with technetium-99, and by other methods. A more effective storage function is achieved by large capacity reservoirs which lower the bowel frequency. The motor response to pouch distension, to a meal, and to pharmacological stimuli is usually counteracted by sphincter contraction. Ileal hypermotility may lead to fecal leakage mainly in the presence of weak sphincters. Poor pouch emptying may be related to an anal stricture.

Clinical and physiological study of anal sphincter and ileal J pouch before preileostomy closure and 6 and 12 months after closure of loop ileostomy

Spontaneous evolution of pouch and anal function, and absorption features has been assessed in 15 patients who underwent proctocolectomy with J ileal pouch anastomosis without conservation of a rectal muscular cuff. All the patients were studied before preileostomy closure and six and 12 months after the closure of the protection loop ileostomy. Stool frequency was identical at six and 12 months (mean +/- SEM: 5.0 +/- 0.4 and 5.3 +/- 0.5/day, respectively). Sixty-six percent of patients at six months and 40% of patients at 12 months need to defecate at least one time during night. Stool weight as well as steatorrhea decreased significantly six months after the closure of loop ileostomy (P less than 0.05). Mean resting anal pressure remained unchanged six and 12 months after closure of the loop ileostomy (41 +/- 6 and 45 +/- 5 cm H2O, respectively). Maximum squeeze anal pressures increased significantly at six (P less than 0.05) and 12 months (P less than 0.05). The rectoanal inhibitory reflex was always absent at the same period. The maximum pouch capacity increased significantly during the first six months (P less than 0.01) from 142 +/- 17 to 279 +/- 27 ml. The maximum infused volume during a saline continence test was not significantly different at six and 12 months; the percentage of evacuation of the reservoir and the volume at which the first ileal contraction appeared in the reservoir increased significantly (P less than 0.05) at six and 12 months. In conclusion, in patients with ileoanal anastomosis and pouch reservoir, the closure of the loop ileostomy is associated with spontaneous modifications of the anal and pouch parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe short bowel syndrome with a surgically reversed small bowel segment

We report a case of short bowel syndrome (60 cm of jejunum anastomosed to the left colon) with reversal of the distal 15 cm of jejunum in a 21-year-old man. The nutritional absorptive capacity and digestive motility was studied for 18 months postoperatively. His absorptive capacity reached subnormal values allowing him oral nutritive autonomy and normal social life. The results of the manometric study suggested that the reversed segment delayed intestinal transit time. The prolonged contact of the chyme with the intestinal absorptive mucosa possibly increased its absorptive capacity. Our data and the literature reports suggest that reversal of a bowel loop could help wean patients from their dependence on parenteral nutrition.