Differential effect of long-term esophageal acid exposure on mechanosensitivity and chemosensitivity in humans

BACKGROUND & AIMS

Chronic tissue injury in the esophagus associated with gastroesophageal reflux disease may result in sensitization of afferent pathways mediating mechanosensitivity and chemosensitivity. The aim of this study was to evaluate the sensitivity to intraluminal acid and to distention of the esophagus in patients with mild-to-moderate gastroesophageal reflux disease.

METHODS

Perceptual responses to intraluminal acid perfusion and to esophageal distention and pressure volume relationships were evaluated in 10 healthy volunteers and in 11 patients. Mechanosensitivity was evaluated with a barostat using unbiased distention protocols and verbal descriptor ratings of sensations. Chemosensitivity to acid was determined at baseline and after a 1-month treatment of acid suppression.

RESULTS

Patients showed enhanced perception of acid perfusion but not of esophageal distension. Chemosensitivity but not mechanosensitivity was correlated with reflux symptoms and with the degree of endoscopically shown tissue injury at baseline. Tissue injury was not associated with altered compliance.

CONCLUSIONS

Mild-to-moderate chronic tissue injury in gastroesophageal reflux disease differentially affects mechanosensitive and chemosensitive afferent pathways. Chronic acid reflux by itself is not likely to play a role in reported esophageal hypersensitivity to distention in patients with noncardiac chest pain.

Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia

OBJECTIVE

Tricyclic antidepressants in low doses are widely used in the therapy of patients with functional gastrointestinal disorders, yet the mechanism(s) of action of these drugs in these disorders is not known. In the current study, we sought to determine in a group of patients with functional dyspepsia and associated poor sleep how amitryptiline affects digestive symptoms, perceptual responses to gastric distension, and subjective and objective measures of sleep.

METHODS

Patients were randomized to 4 wk of amitryptiline 50 mg taken at bedtime versus placebo. There was a 3-wk washout phase, followed by a cross-over to the alternate treatment. Perceptual sensitivity to gastric distention and sleep EEG were recorded at the end of each treatment period. Diaries of symptoms were maintained throughout.

RESULTS

Seven of seven patients reported significantly less severe gastrointestinal symptoms after 4 wk on amitryptiline compared to placebo. Five of seven patients had evidence for altered perception of gastric balloon distension during placebo. However, the subjective symptom improvement on amitryptiline was not associated with a normalization of the perceptual responses to gastric distension. Baseline sleep dysfunction in the form of reduced sleep efficiency, increased arousal, or abnormal amounts of REM sleep was found in all seven patients. Amitryptiline significantly reduced absolute and relative amounts of REM sleep, but had no effect on sleep parameters related to nonregenerative sleep.

CONCLUSION

The beneficial effect of low dose amitryptiline seen in functional dyspepsia is not related to changes in perception of gastric distension, or to measures of arousal from sleep. An increased tolerance to aversive visceral sensations may play a role in the therapeutic effect.

Stimulus and site specific induction of hiccups in the oesophagus of normal subjects

BACKGROUND

Hiccups that are induced by a large meal have been suggested to result from gastric overdistension. The role of the oesophagus in precipitating hiccups has never been defined.

AIMS

To determine the involvement of oesophageal mechanoreceptors in the hiccup reflex.

METHODS

Ten normal healthy subjects were prospectively evaluated at a university affiliated hospital. Controlled inflation of a polyethylene bag in the proximal and distal oesophagus was carried out using slow ramp and rapid phasic distensions, by an electronic distension device.

RESULTS

Hiccups were induced in four subjects only during rapid phasic distensions and only in the proximal oesophagus. The mean (SEM) minimal volume threshold for the hiccup reflex was 32.5 (4.8) ml, which was above the perception threshold. Hiccups appeared during inflation and resolved after deflation.

CONCLUSIONS

Sudden rapid stretch of the mechanoreceptors in the proximal oesophagus can trigger the hiccup reflex in normal subjects. Only rapid distensions above a determined volume threshold will predictably induce hiccups in a given subject. This mechanism may play a role in the physiological induction of hiccups.

Evidence for two distinct perceptual alterations in irritable bowel syndrome

BACKGROUND

Visceral hyperalgesia has been implicated as a factor contributing to symptom generation in irritable bowel syndrome (IBS). However, previous studies using intestinal balloon distension have used psychophysical procedures which do not provide adequate and unbiased measures of visceral sensitivity.

METHODS

Three psychophysical tasks were examined in 45 patients with IBS (positive Rome criteria) and 14 controls using rectal balloon distension with a computerised distension device. Discomfort threshold and tolerance were assessed during an ascending series of phasic pressure stimuli and during an interactive threshold tracking procedure. In addition, stimulus response functions were generated from intensity and unpleasantness ratings of the rectal distensions.

RESULTS

Discomfort threshold and tolerance for the ascending stimuli were significantly lower for the patients with IBS compared with the controls. In contrast, discomfort thresholds during the tracking procedure and stimulus response curves for the ascending series were not different between the groups. A factor analysis of the psychophysical data was consistent with the presence of two distinct and unrelated perceptual alterations related to rectal distension: hypervigilance for visceral stimuli, manifested as lowered response criteria for using the descriptor "discomfort"; and rectal hypersensitivity, manifested as a lower discomfort threshold and left shift of the stimulus response curves.

CONCLUSIONS

Patients with IBS as a group have a greater propensity to label visceral sensations negatively and show a lower tolerance for rectal balloon distension. A subgroup of patients also have baseline rectal hypersensitivity, assessed by unbiased measures of discomfort threshold and stimulus intensity judgements.

Relationship of esophageal anastomotic tension to the development of gastroesophageal reflux

BACKGROUND/PURPOSE

Gastroesophageal reflux (GER) is a common occurrence after repair of congenital esophageal atresia and is believed to be more frequent when the esophageal anastomosis is performed under tension. This study documents that esophageal anastomotic tension correlates directly with the severity of acid reflux into the esophagus in the rabbit model.

METHODS

Eight adult rabbits underwent complete esophageal transection with immediate reanastomosis (EA) and 12 underwent resection of a 1-cm segment of the midesophagus with reanastomosis under mild tension (EAT). Three-weeks postoperation continuous lower esophageal pH (LEpH) values were recorded for a 24-hour period for each rabbit, and compared with five normal unoperated rabbits.

RESULTS

The normal rabbit's average LEpH is 7.7. EA rabbits had LEpH values below 5.0 for a mean of 56 min/24 hr (3.8% of monitored time). EAT rabbits had LEpH values below 5.0 for a mean of 328 min/24 hr (25.5% of monitored time; P < .05). EA rabbits had a mean of 8.8 reflux episodes under 5.0/24 hr, whereas EAT rabbits had a mean of 29.6 reflux episodes under 5.0. All EAT rabbits had moderate to severe anastomotic strictures; no EA rabbits had strictures. There were no anastomotic leaks.

CONCLUSIONS

Esophageal anastomosis with mild tension in the rabbit causes severe GER with resultant anastomotic strictures in almost all rabbits, in contrast to rabbits undergoing esophageal anastomosis without tension in whom strictures did not develop and had only small reduction in esophageal pH values.

Repetitive sigmoid stimulation induces rectal hyperalgesia in patients with irritable bowel syndrome

BACKGROUND & AIMS

Only a fraction of patients with irritable bowel syndrome (IBS) show hypersensitivity to rectal distention. The current study sought to determine if repetitive high-pressure stimulation of sigmoid mechanoreceptors modulates perception of rectal pain and discomfort.

METHODS

In 14 patients with IBS and 11 healthy controls, perception thresholds for discomfort and pain during rectal sensory tracking and verbal descriptor ratings of the perceived intensity of a rectal tonic stimulus were obtained before and after repetitive high-pressure mechanical sigmoid stimulation. Gastrointestinal and psychological symptoms were assessed by questionnaires.

RESULTS

Despite heterogeneity in baseline rectal sensitivity in patients with IBS, after sigmoid stimulation, 100% of patients, regardless of baseline sensitivity, developed rectal hyperalgesia manifested by at least two of the following three criteria: lowered thresholds for pain and discomfort and increased viscerosomatic referral and lower abdominal discomfort outlasting the experimental stimulation. This pattern of responses was not observed in any of the healthy controls.

CONCLUSIONS

In patients with IBS, repetitive stimulation of sigmoid splanchnic afferents results in the development of central sensitization manifested as hyperalgesia and increased viscerosomatic referral during rectal distention and as spontaneous rectosigmoid hyperalgesia in the absence of applied stimuli. Repetitive sigmoid contractions may induce rectosigmoid hyperalgesia in patients with IBS.

Rectal afferent function in patients with inflammatory and functional intestinal disorders

Chronic symptoms of abdominal pain and discomfort are reported by patients with inflammatory bowel disease (IBD) and functional disorders of the gut, such as Irritable Bowel Syndrome (IBS). It has recently been suggested that transient inflammatory mucosal events may result in long-lasting sensitization of visceral afferent pathways. To determine the effect of recurring intestinal tissue irritation on lumbosacral afferent pathways, and to identify a plausible mechanism that could account for the overlap in symptomatology between IBD and IBS, we compared rectal afferent mechanisms in patients with Crohn's disease (inflammation limited to the ileum) with those observed in patients with diarrhea-predominant IBS. Continuous volume ramp and phasic pressure step distension of a rectal balloon were performed in 9 healthy male control subjects, 12 male patients with isolated ileal Crohn's disease and 9 male patients with diarrhea-predominant IBS using an electronic visceral stimulation device. The response of rectal afferents to distension was evaluated by measuring thresholds for the perception of physiological (stool) and aversive (discomfort) sensations, viscerosomatic referral patterns, skin conductance responses, receptive relaxation, and rectoanal reflex responses. In response to slow ramp distension, thresholds for aversive sensations were significantly higher in Crohn's disease patients, but similar between the two other groups. In response to rapid phasic distension, IBS patients reported discomfort at lower distension pressures, while all other thresholds were similar between groups. Skin conductance responses to aversive distension were greatly reduced in Crohn's disease patients while IBS patients had greater responses when compared to normals. Changes in viscerosomatic referral patterns and receptive relaxation rate were similar in Crohn's disease and IBS patients. These findings demonstrate that chronic ileal inflammation is associated with increased thresholds for discomfort and greatly diminished systemic autonomic reflex responses. In contrast, IBS patients show lowered thresholds for discomfort associated with increased autonomic responses. The findings in Crohn's patients may result from descending bulbospinal inhibition of sacral dorsal horn neurons in response to chronic intestinal tissue irritation.

Evidence for the hypersensitivity of lumbar splanchnic afferents in irritable bowel syndrome

BACKGROUND/AIMS

The pathways underlying rectal hypersensitivity to balloon distention in patients with irritable bowel syndrome (IBS) are not known. The aim of this study was to characterize the involvement of sacral and thoracolumbar afferents in the perception of rectal distention.

METHODS

Rectal balloon distention was performed in 15 normal control subjects, 6 patients with spinal cord injury, and 50 patients with IBS using a slow-volume ramp (40 mL/min) or rapid phasic step distension. Additional studies were performed in the presence of 2% intrarectal lidocaine.

RESULTS

Patients with spinal cord injury with lesions below T7 reported sensations only during phasic distention. Sixty percent of patients with IBS (n = 50) were hypersensitive for discomfort during phasic distention, whereas only 4% were hypersensitive during ramp distention. Less than 15% of patients were hypersensitive for the sensation of stool. In normal patients, lidocaine increased thresholds in response to slow ramp distention by 40%-70% but had no effect on perception in response to other types of distention. Lidocaine had no effect on (1) thresholds in response to either ramp or phasic distention in normosensitive or hypersensitive patients with IBS or (2) the rate of receptive relaxation or rectal compliance in any group.

CONCLUSIONS

Rapid phasic distention preferentially stimulates splanchnic afferents. Hypersensitivity of these afferents in patients with IBS is unaffected by mucosally applied lidocaine.

Sleep and duodenal motor activity in patients with severe non-ulcer dyspepsia

The prevalence of sleep disturbances was studied in patients with severe non-ulcer dyspepsia. It was also considered if the change in sleep pattern was associated with changes in the rhythmic fasting motor activity of the gastrointestinal tract, and if motor events correlate with the patient's symptoms. Motor activity in the duodenum was monitored over a 24 hour period under freely ambulatory conditions in 10 healthy controls and in 10 patients with severe non-ulcer dyspepsia using a transnasally placed catheter with six solid state pressure transducers connected to a digital data logging device. Symptoms and sleep disturbance were assessed by questionnaire and diary. Based on their symptoms, the patients were separated into two groups: those with dyspepsia symptoms only (non-ulcer dyspepsia; n = 5) and those with dyspepsia and additional functional symptoms thought to arise from the lower gastrointestinal tract (non-ulcer dyspepsia+irritable bowel syndrome; n = 5). When compared with either the control or the non-ulcer dyspepsia+irritable bowel syndrome group, non-ulcer dyspepsia patients had a considerably decreased number of migrating motor complexes during the nocturnal period (0.7 v 4.6), a decreased percentage of nocturnal phase I (5.2% v 78.0%), and an increased percentage of the nocturnal period in phase II (94% v 15.4%). Patients with non-ulcer dyspepsia+irritable bowel syndrome were not different from normal controls. Four of the non-ulcer dyspepsia patients and all of the non-ulcer dyspepsia+irritable bowel syndrome patients reported difficulties with sleep. Clusters of high amplitude tonic and phasic activity, not accompanied by subjective reports of discomfort were noted in several patients in both groups during the study. In eight of 10 patients, abdominal pain was reported during normal motor activity, while in one patient, pain correlated with phase III of the migrating motor complex. In contrast with previous reports in patients with irritable bowel syndrome, our findings suggest an abnormality of diurnal rhythmicity--shown in changed sleep and changed rhythmic duodenal motor activity--in patients with chronic abdominal pain thought to arise from the upper gastrointestinal tract.

Reversal of megaduodenum and duodenal dysmotility associated with improvement in nutritional status in primary anorexia nervosa

Anorexia nervosa is considered one type of eating disorder that may result in severe malnutrition. Patients with this disorder commonly complain of postprandial nausea, abdominal pain, and distension. We describe the radiologic and motility abnormalities associated with anorexia nervosa in a 21-year-old female. Barium gastrointestinal series demonstrated marked dilation of the duodenum, with prolongation of intestinal transit. A 4-hr fasting gastroduodenal motility study showed no propagating migrating motor complexes (MMC). Prolonged, but nonpropagating, bursts of high-amplitude phasic and tonic contractions were seen in the duodenum. In contrast, antral contractions were of low amplitude and esophageal motor function was normal. Metoclopramide and edrophonium caused an increase in gastroduodenal motor activity, but increased contractions were not associated with symptoms. Following a renutrition program that raised the patient's weight from 64 to 80% of her ideal body weight, the radiographic abnormalities and gastrointestinal dysmotility resolved completely. These observations suggest that anorexia-associated gastrointestinal motor dysfunctions are a consequence, not the cause of the generalized protein-calorie malnutrition associated with anorexia nervosa. The facts that motility in different parts of the gut is affected to different degrees and that gastric and duodenal muscle responds normally to exogenous stimulation argue against a generalized myogenic dysfunction and, rather, point to a reversible dysfunction of neural regulation.

VIP modulates intracellular calcium oscillations in human lymphoblasts

Vasoactive intestinal polypeptide (VIP) has been shown to stimulate adenylate cyclase in a human lymphoblast cell line (MOLT 4). In the present study, we monitored fluorescence in cell suspensions and in single fura-2 loaded MOLT 4 lymphoblasts to determine if VIP modulates intracellular calcium concentrations ([Ca2+]i), and if this modulation is mediated by adenylate cyclase. The distribution of [Ca2+]i in resting and stimulated cells was non-homogeneous, with gradients of high [Ca2+]i present in the subplasmalemmal space. In a subset of cells (10-30% of all cells studied), [Ca2+]i showed La(3+)-sensitive, temporal changes in the form of [Ca2+]i oscillations with a baseline [Ca2+]i value of 115 +/- 10 nM, an oscillation amplitude of 150 +/- 18 nM and a mean period of 9.2 +/- 2 s. The remaining non-oscillating cells showed a constant [Ca2+]i level of 75 +/- 5 nM (n = 65 cells from 4 experiments). In the subset of cells with spontaneous [Ca2+]i oscillations, VIP dose-dependently (10(-12) to 10(-8) M) increased the amplitude of oscillations but did not stimulate their frequency. The stimulatory effect of VIP was correlated with baseline [Ca2+]i in these cells, was attenuated in the presence of La3+ (25 microM), but was unaffected by cell depolarization (126 mM KCl). Dibutyryl cyclic AMP (10(-4) to 10(-3) M) and forskolin (10(-4) M) had no effect on [Ca2+]i oscillations, or on [Ca2+]i in cells without oscillations. In cell suspensions, baseline [Ca2+]i was found to be 55.1 +/- 11.2 nM (mean +/- S.E.M., n = 11); VIP, cyclic AMP analogues or forskolin had no significant effect on [Ca2+]i. These findings suggest that: a) VIP modulates the amplitude of [Ca2+]i oscillations generated by a cytosolic [Ca2+] oscillator in a subset of cells at a concentration of 10(-12) M, a thousand-fold below the KD for the VIP receptor; b) baseline [Ca2+] values may be related to both the ability of cells to generate spontaneous [Ca2+] oscillations and of oscillating cells to respond to VIP; c) due to the small number of responding cells, VIP-induced [Ca2+]i changes are not detectable when studied in cell suspensions.

Spatial and temporal patterns of intracellular calcium in colonic smooth muscle

Intracellular calcium [Ca2+]i measurements in cell suspension of gastrointestinal myocytes have suggested a single [Ca2+]i transient followed by a steady-state increase as the characteristic [Ca2+]i response of these cells. In the present study, we used digital video imaging techniques in freshly dispersed myocytes from the rabbit colon, to characterize the spatiotemporal pattern of the [Ca2+]i signal in single cells. The distribution of [Ca2+]i in resting and stimulated cells was nonhomogeneous, with gradients of high [Ca2+]i present in the subplasmalemmal space and in one cell pole. [Ca2+]i gradients within these regions were not constant but showed temporal changes in the form of [Ca2+]i oscillations and spatial changes in the form of [Ca2+]i waves. [Ca2+]i oscillations in unstimulated cells (n = 60) were independent of extracellular [Ca2+] and had a mean frequency of 12.6 +/- 1.1 oscillations per min. The baseline [Ca2+]i was 171 +/- 13 nM and the mean oscillation amplitude was 194 +/- 12 nM. Generation of [Ca2+]i waves was also independent of influx of extracellular Ca2+. [Ca2+]i waves originated in one cell pole and were visualized as propagation mostly along the subplasmalemmal space or occasionally throughout the cytoplasm. The mean velocity was 23 +/- 3 microns per sec (n = 6). Increases of [Ca2+]i induced by different agonists were encoded into changes of baseline [Ca2+]i and the amplitude of oscillations, but not into their frequency. The observed spatiotemporal pattern of [Ca2+]i regulation may be the underlying mechanism for slow wave generation and propagation in this tissue. These findings are consistent with a [Ca2+]i regulation whereby cell regulators modulate the spatiotemporal pattern of intracellularly generated [Ca2+]i oscillations.

Neurokinin receptor-mediated regulation of [Ca]i and Ca-sensitive ion channels in mammalian colonic muscle

In conclusion, these findings suggest the following: (1) NK receptor activation results in [Ca2+]i oscillations; (2) the receptor-mediated [Ca2+]i increase is partially due to influx of Ca2+ through L-type Ca2+ channels and partially to release from intracellular stores; (3) the receptor-mediated depolarization results from activation of a Cl- channel at the cell resting potential; (4) NK receptor-mediated release of [Ca2+]i may play a role in Cl- channel activation; (5) there is no evidence for multiple NK receptor types involved in cell activation.

Substance P and CGRP mediate motor response of rabbit colon to capsaicin

Primary afferent nerve terminals located in the mammalian gut wall may play a role in region-specific modulation of gastrointestinal motility. In the present study, we sought to characterize the effect of neuropeptides released from these afferents by capsaicin (CAP) on contractile activity of smooth muscle from the distal rabbit colon. CAP caused a release of acetylcholine and immunoreactivity for substance P (SP) and calcitonin gene-related peptide (CGRP) from the muscle coat. CAP caused a dose-dependent transient stimulation of longitudinal muscle contractions, followed by prolonged inhibition of spontaneous but not stimulated contractile activity. The initial stimulation was abolished by the SP antagonist spantide and by atropine. The inhibitory effect was reduced by repeated exposure of muscle to CGRP. The effect of CGRP on spontaneous contractions differed between longitudinal and circular muscle. In longitudinal muscle, a stimulation was preceded by a transient inhibition, whereas in circular muscle, only inhibition was seen. Both effects were resistant to tetrodotoxin. Repeated exposure of circular but not longitudinal muscle to CGRP resulted in a disappearance of the peptide's inhibitory effect. Exogenously applied CGRP was only a weak antagonist of contractions stimulated by SP and bethanechol. These findings suggest that in the rabbit colon at least the following two neuropeptides are released from CAP-sensitive nerve fibers: a neurokinin peptide from nerve terminals located within the myenteric plexus and CGRP from terminals probably located within the circular muscle layer.

Differential modulation of Ca2(+)-activated K+ channels by substance P

Substance P released from motoneurons or primary afferent nerves innervating the gut is an excitatory noncholinergic regulator of gastrointestinal motility and has been shown to stimulate contractions in longitudinal colonic muscle. By using the patch-clamp technique on single myocytes from the longitudinal muscle of the rabbit colon, we have studied the action of the peptide on membrane conductances. In cell-attached patches, addition of the peptide to the bath activates a large conductance Ca2(+)-activated K+ channel. At peptide concentrations (10(-12) M) that did not result in cell contraction, K+ channels were activated in a synchronized, cyclical fashion. The activation did not occur in the presence of nifedipine (10(-6) M), a blocker of dihydropyridine-sensitive Ca2+ channels. The activation was also absent when the cells were depolarized in 126 mM KCl-Ringer solution. In contrast, at a concentration of the peptide (10(-7) M) that resulted in cell contraction, there was a transient activation of K+ channels, followed by a prolonged inhibition. Nifedipine (10(-6) M) did not block the K+ channel activation by this concentration of the peptide. Removal of bath Ca2+ abolished activation of the K+ channels by both the high and low concentrations of substance P. These results indicate that substance P exerts its effect via two different membrane pathways for extracellular Ca2+.