Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett's neoplasia

BACKGROUND

Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett's neoplasia. Adequate staging is important to assure a good oncological outcome.

OBJECTIVE

The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett's oesophagus (BE) and the cardia.

METHODS

Between November 2005-May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen.

RESULTS

The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%).

CONCLUSION

The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett's dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barrett's dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.

[Laparoscopic approach in the pelvic floor surgery]

Laparoscopy offers great exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing and bowel manipulation making it an excellent modality to perform pelvic floor surgery. Laparoscopic repair of level I or apical vaginal prolapse may be challenging, due to the need for extensive dissection and advanced suturing skills. However it offers the efficacy of open abdominal sacrocolpopexy, such as lower recurrence rates and less dyspareunia than sacrospinous fixation, as well as the reduced morbidity of a laparoscopic approach.

Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy

BACKGROUND

Endoscopic dilatation of Crohn's disease-related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and concomitant medical therapy on long-term outcomes is largely unknown.

AIM AND METHODS

To study the long-term safety and efficacy of stricture dilatation in a single centre cohort.

RESULTS

Between 1995 and 2006, 237 dilatations where performed in 138 patients (mean age 50.6+/-13.4, 56% female) for a clinically obstructive stricture (<5 cm, 84% anastomotic). Immediate success of a first dilatation was 97% with a 5% serious complication rate. After a median follow-up of 5.8 years (IQR 3.0-8.4), recurrent obstructive symptoms led to a new dilatation in 46% or surgery in 24%. Niether elevated levels of C-reactive protein nor endoscopic disease activity predicted the need for new intervention. None of the concomitant therapies influenced the outcome.

CONCLUSION

This largest series ever reported confirms that long term efficacy of endoscopic dilatation of Crohn's disease outweighs the complication risk. Neither active disease at the time of dilatation nor medical therapy afterwards predict recurrent dilatation or surgery.

Outcome of surgery for rectovaginal fistula due to Crohn's disease

BACKGROUND

This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing.

METHODS

Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment.

RESULTS

Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients.

CONCLUSION

Fistula closure was achieved in most patients, but more than one operation was often required.

An evidence-based treatment algorithm for anal fissure

Guidelines for the treatment of anal fissure have been published in the USA and UK but differ. Many centers follow guidelines based on local experience. In December 2005, we met with the aim of developing an evidence-based treatment algorithm for anal fissure, applicable to both primary and secondary care. This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings.

Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature

Primary perianal actinomycosis is rare. Sporadic cases, with lesions varying in extent have been reported. The infection is caused by the bacterium Actinomyces, which often is a saprophyte. Male gender and diabetes are risk factors, but the exact pathogenic mechanism remains speculative. The diagnosis is a challenge and often delayed, with a protracted history of masses and sinuses extending into the gluteal and genital region. The treatment, a combination of surgery and antibiotics, is poorly standardized. We report three cases and compare their characteristics to those of published cases, found by a computerized literature search (1968-2002). The lesions, a simple fistula-in-ano or a mass, were diagnosed in an early stage in all three patients. The infection always spread into the scrotum. There were no risk factors other than gender, except in one patient. The diagnosis was suspected by the observation of draining sulfur granules and promptly confirmed by histology in the three cases. All patients healed with antibiotics in addition to simple surgical procedures. Treatment consisted of amoxicillin for two weeks in two cases and more extended antimicrobial treatment in the third. These findings are contrasting with the classic picture of perianal actinomycosis. It is concluded that perianal actinomycosis can occur in the absence of risk factors and that early diagnosis requires a high degree of suspicion. An infection with Actinomyces should be suspected in the presence of lesions containing watery purulent material with sulfur granules. The indication for extended antibiotherapy combined with sphincter damaging surgery may need to be revised in the presence of early detection.

Small doses of the unabsorbable substance polyethylene glycol 3350 accelerate oro-caecal transit, but slow gastric emptying in healthy subjects

BACKGROUND

Polyethylene glycol 3350 increases stool frequency and accelerates colonic transit. Used as a laxative, it proved effective in patients with normal and slow transit. Although free of severe side effects, it may cause nausea and vomiting. The effect of this substance on upper gut transit has not been studied.

AIM

To investigate the effect of polyethylene glycol 3350 on gastric emptying and oro-caecal transit in 12 healthy subjects.

METHODS

In a randomised controlled study, isosmotic polyethylene glycol 3350 electrolyte balanced solution, in the maximal recommended dose or isosmotic electrolyte solution, was administered after breakfast and lunch on separate days. Gastric half-emptying time and oro-caecal transit time were measured using [13C]-octanoate and lactose-[13C] ureide breath tests.

RESULTS

Isosmotic polyethylene glycol 3350 electrolyte solution, as compared to isosmotic electrolyte solution, decreased oro-caecal transit time from 424+/-28 to 314+/-17 min (P = 0.001). Gastric half-emptying time was significantly increased (84+/-6 min versus 127+/-14 min; P = 0.006).

CONCLUSION

Polyethylene glycol 3350 accelerate oro-caecal transit in healthy subjects, but also cause an important delay in gastric emptying. The delay in gastric emptying may be of clinical significance in patients who have associated gastroparesis.

Technologies in the evaluation of irritable bowel syndrome

During a meeting in The Hague, The Netherlands, the IBiS Club evaluated the most important techniques that can be used in the investigation of irritable bowel syndrome, either in the context of scientific research or as a clinical diagnostic tool. In each of these, the relevance of findings made in irritable bowel syndrome was balanced against the applicability of the technique. The discussion of the group is summarized in this paper.

Influence of continuous isobaric rectal distension on gastric emptying and small bowel transit in young healthy women

Patients with slow transit constipation frequently have delayed gastric emptying. In animals rectal distensions inhibit gastrointestinal motility. In healthy volunteers isovolumetric rectal distensions delay upper gut transit. The purpose of this study was to determine the effect of continuous isobaric rectal distension on gastric emptying and oro-cecal transit in young females. Using validated 13C octanoic and lactose-[13C] ureide breath tests gastric half-emptying time and oro-cecal transit time for a meal were measured in 12 volunteers. The tests were repeated in randomized order: during isobaric balloon distension and during sham distension. Isobaric rectal distension was applied using a polyethylene bag connected to a barostat. Intraballoon pressure was kept just below the threshold for the urge sensation. Mean gastric half-emptying time during rectal distension (92.3 +/-5.1 min) was significantly higher than during sham distension (78.8 +/- 4 min; P = 0.015). Mean oro-cecal transit time during rectal distension (391.3 +/-29.1 min) and sham distension (328.8 +/- 38.4 min) were not significantly different. In conclusion, these findings indicate that isobaric rectal distension inhibits gastric emptying, but not small bowel transit in young healthy women. Studies in patients with constipation are indicated.

Role of alimentation in irritable bowel syndrome

BACKGROUND

Different food items are made responsible for irritable bowel syndrome (IBS) symptoms, but the physiopathology of IBS remains unclear.

AIMS

During a meeting in Nice, France, experts of the European Working Team of the IBiS Club discussed selected data regarding the relationships between alimentation, food items (including fibers) and IBS symptoms.

METHODS/RESULTS

Food allergy remains a difficult diagnosis, but medical and general history, presence of general symptoms such as skin rash, and hypersensitivity tests may help in achieving a positive diagnosis. On the other hand, food intolerance is more confusing because of the subjectivity of the relationship between ingestion of certain foods and the appearance of clinical symptoms. Different food items which are commonly implicated in adverse reactions mimicking IBS were found to be stimulants for the gut, suggesting that patients with predominant diarrhea IBS have to be carefully questioned about consumption of different kinds of food (i.e., coffee, alcohol, chewing gum, soft drinks) and not only on lactose ingestion. Gas production is discussed on the basis of retention of intestinal gas as well as on malabsorption of fermentable substrates. The role of a large amount of this kind of substrate reaching the colon is suggested as a potential mechanism of IBS-type symptoms in overeating patients. Regarding the role of fiber in IBS, the expert group concluded that fibers are not inert substances and that they could trigger pain or bloating in some IBS patients.

CONCLUSION

Despite numerous reviews on this subject, it is very difficult to give general dietary advice to IBS patients, but dieteticians may have a positive role in managing such patients.

Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin?

OBJECTIVES

The complexity of anal fistulas is different in patients with and without Crohn's disease and in men and women. This may affect the localization of the internal orifice. We compared the characteristics of anal fistulas and the accuracy of Goodsall's rule in predicting the position of the internal orifice in male and female Crohn's and non-Crohn's patients.

METHODS

A total of 191 fistula tracks in 182 consecutive patients (110 men and 72 women) were analyzed prospectively. Of the patients, 63 were diagnosed with Crohn's disease. The positions of the orifices were recorded and the accuracy of Goodsall's rule determined.

RESULTS

The distribution of fistula subtypes among Crohn's and non-Crohn's patients differed significantly (p = 0.0471). Fistulas with an anterior external opening occurred more frequently in Crohn's patients (p = 0.0350) and in women (p = 0.0030). Fistulas with a posterior external orifice were observed more frequently in non-Crohn's patients (p = 0.0350) and in men (p = 0.0028). Overall, Goodsall's rule performed less well in women compared with men (p = 0.0633). The accuracy of Goodsall's rule overall was not affected by Crohn's disease. In female non-Crohn's patients, the positive predictive value of a posterior external orifice was lower than in men (p = 0.0406).

CONCLUSIONS

The distribution of fistula subtypes and the ratio of anterior and posterior external openings among Crohn's and non-Crohn's patients differ significantly. Many fistulas defy Goodsall's rule, particularly in women and when applied to fistulas with anterior external orifices. The popular rule, however, falls equally short in Crohn's and non-Crohn's fistulas.

Topical cidofovir (HPMPC) is an effective adjuvant to surgical treatment of anogenital condylomata acuminata

PURPOSE

Human papilloma virus infections of the anogenital region are very common and cause condylomata acuminata; cervical, penile, vulvar, or perianal intraepithelial neoplasia; and more rarely, invasive cancer. The currently available therapies often result in painful, extensive, slow-healing ulcerations and frequent early relapses. This study was aimed at determining the efficacy of topical application of the antiviral agent cidofovir at 1 percent.

METHODS

Twenty patients treated with coagulations were compared with 27 patients treated with cidofovir. Lesions refractory to cidofovir were cleared up with additional coagulations. The number of patients previously treated for condylomata did not differ between the two groups. Significantly more patients treated with cidofovir, however, had an impaired immune status (37 percent) compared with the patients treated with coagulations (5 percent).

RESULTS

Cidofovir alone cured the lesions in 32 percent of the patients and induced partial regression in 60 percent. However, in smokers, complete resolution of the condylomata occurred only in 16.6 percent compared with 66 percent of nonsmokers (P = 0.03). The number of coagulation sessions was much lower (P < 0.0005) in the cidofovir treated group (1 +/- 0.8 vs. 2.9 +/- 2). Furthermore, the relapse rate was significantly lower in the cidofovir group (3.7 vs. 55). All recurrences in the electrocoagulation group occurred within four months of confirmed lesion clearance. Topical applications of cidofovir 1 percent were well tolerated. Thirty-three percent of the patients reported only mild pain caused by erosive dermatitis. In contrast, coagulations caused painful ulcerations that necessitated the use of analgesics in all patients treated this way.

CONCLUSIONS

Topical applications of cidofovir, an antiviral compound with activity against human papilloma virus, is effective in the majority of patients with perianal condylomata and is a valuable adjuvant to surgical treatment of these lesions.

The rectum: a window to irritable bowel syndrome?

This report summarizes current concepts and information gathered to date about the rectum in the irritable bowel syndrome (IBS) that were presented at the 10th meeting of IBiS Club held in Leuven, Belgium. A working group of experts in the field of IBS discussed whether the rectum or the whole colon is the better site to test in IBS patients and provided suggestions for a number of areas where further advances are required.

Epidemiological aspects of irritable bowel syndrome in Europe and North America

The epidemiology of irritable bowel syndrome (IBS) in Europe and North America was analyzed from published material. The percentage of the population of Western civilisation with IBS symptoms is between 10 and 15% in most studies. The proportion of a Western population visiting a doctor for IBS symptoms is around 5%. The prevalence of IBS and the proportion of consulters do not seem to depend on age in an adult population. The female-to-male ratio of IBS in the population is close to 2. It is higher in IBS consulters in primary care and may be as high as 3 or 4 in tertiary referral centers. At least in patients from these centers, the number of physician visits and colonoscopies is considerable. Most of the consulters get a drug prescription.

Success and failure after repair of rectovaginal fistula in Crohn's disease: analysis of prognostic factors

OBJECTIVE

To compare the healing rate after several types of surgical repair of rectovaginal fistula (RVF) in Crohn's disease, and to identify factors predicting a successful outcome.

PATIENTS AND METHODS

A Medline review of the literature since 1980 and analysis of our results in 32 consecutive patients was done.

RESULTS

All types of repair (rectal, vaginal, anocutaneous advancement flap, or perineoproctotomy with fistula closure) seem to be equally effective. Healing after a first repair is observed in 58 (46-71)%. Healing can still be obtained at subsequent attempts in 62 (40-71)% of the patients. The reported overall healing rate is 75 (56-93)%. The need for proctectomy after an attempt to repair was 6 (0-27)% in these series. Using a tailored surgical approach, we observed primary healing in 57%, healing after one or more supplementary procedures in 71%, for a total 'definitive' closure rate of 75%. Anal continence was never compromised and all temporary stomas (12 patients) could be closed. Univariate analysis identified number of Crohn's sites, presence of extra-intestinal disease and previous Crohn's proctitis to be related with problematic healing after a surgical repair. A positive relation was found between extra-intestinal disease and the number of repairs needed to ultimately obtain healing, whereas the relation with previous right hemicolectomy was negative. Multivariate analysis revealed the number of Crohn's sites as the only factor predicting problematic healing. A defunctioning stoma was not related to the healing rate and had its intrinsic morbidity with supplementary hospitalization (9.6 days). After a median follow-up of 40.4 (range 8-87) months, we observed 4 late recurrences in 25 patients with healed RVF (16%).

CONCLUSION

Closure of a RVF in Crohn's disease should not be considered an easy undertaking, especially in patients with several Crohn's sites. In this very heterogeneous group of patients the technique is adapted to the nature and the extent of accompanying anorectal disease. Construction of a temporary stoma is not mandatory and can be limited to complex cases. Healing can be obtained in 75% of all patients, although a late recurrence might occur.

Nongastrointestinal disorders in the irritable bowel syndrome

A large proportion of irritable bowel syndrome (IBS) patients also complain of other functional disorders, such as headache, noncardiac chest pain, low back pain, and dysuria. Some of these features, particularly headache, may have a negative influence on the outcome of IBS. In a large proportion of female IBS patients, sexual intercourse triggers the symptoms, and frequently IBS symptoms exacerbate during menses. These gynecological-type symptoms often mislead the patients to the gynecological clinic, which may imply unnecessary investigations and inappropriate treatments. The diagnostic criteria of the fibromyalgia syndrome include IBS, and hence, the apparent relationship of both syndromes is difficult to analyze. On the other hand, no convincing evidence has been produced to date to sustain an association between IBS and the chronic fatigue syndrome.

Sweet's syndrome in a patient with Crohn's disease

Crohn's disease is rarely associated with Sweet's syndrome. We report a 32-year old woman who presented with diarrhea, fever and disseminated erythematous plaques on the arms and the trunk. After colonoscopy with biopsies, Crohn's disease was diagnosed. Skin biopsy showed a dense infiltration of neutrophilic polymorphonuclear leukocytes, establishing also the diagnosis of Sweet's syndrome. Crohn's disease is one of several systemic diseases that may underlie Sweet's syndrome. Treatment with methylprednisolone resulted in a rapid improvement of both gastro-intestinal symptoms and skin lesions.

Ambulatory gastrojejunal manometry in severe motility-like dyspepsia: lack of correlation between dysmotility, symptoms, and gastric emptying

BACKGROUND

Previous studies have failed to identify manometric patterns of gastrointestinal motor activity that can distinguish dyspepsia from health.

AIMS

To test the hypothesis that the combined use of prolonged, ambulatory, antrojejunal manometry and computer aided analysis in patients selected for the severity of their symptoms could reveal new insights into gastrointestinal motor activity in patients with severe motility-like dyspesia.

METHODS

Twenty four hour antrojejunal ambulatory manometry was performed in 14 patients and 10 healthy volunteers. Parameters characterising digestive and fasted motility were obtained by a validated computer program and visual analysis. Scoring systems quantified the degree of dysmotility as well as the severity of symptoms. Gastric emptying times were measured in each patient.

RESULTS

There was a high prevalence of antral and jejunal dysmotility both during the interdigestive period (71% of patients) and in the postprandial period (78%). During the interdigestive period there was a reduced incidence of antral and jejunal phases, a larger contribution of phase 2 during migrating motor complex cycles, and aberrant configuration of jejunal phase 3 in 29% of patients. Postprandially, the most frequent finding was antral (29% of patients) or jejunal (29%) hypomotility or hypermotility. Minute rhythm was present both during the postprandial (29% of patients) and the interdigestive period (21%). There was no positive correlation between symptom scores, gastric half emptying times, or motility scores.

CONCLUSION

Even with the use of prolonged recordings and advanced computer aided analysis, it is not possible to identify a specific motor pattern which can discriminate patients with severe motility-like dyspepsia from those with other diseases or even healthy individuals. Clinical symptoms or gastric half emptying times are poor predictors of gastrointestinal dysmotility in patients with functional dyspepsia.

Ambulatory small intestinal manometry. Detailed comparison of duodenal and jejunal motor activity in healthy man

The aim of this study were to provide a detailed comparison of duodenal and jejunal motor activity in healthy individuals by utilizing prolonged ambulatory manometry in combination with computer-aided analysis. Intraluminal pressure profiles were studied in the duodenum and jejunum of 18 healthy volunteers over 24 hr. The subjects ingested two meals, both of 800 kcal and of equal chemical composition, at two different times of the day. Over the whole interdigestive period, phase III motor activity started more frequently distal than proximal to the ligament of Treitz. However, an increasing time of fasting was linearly related to an increasing number of phase IIIs originating proximal to the ligament of Treitz (r = 0.95). Both meals induced a postprandial motor pattern of similar duration and contractile activity. As compared to the jejunum, individual duodenal contractions during the postprandial period and during phase II had a higher duration and amplitude. Propagated clustered contractions occurred more frequently in the duodenum than in the jejunum, both in the interdigestive and digestive state. Jejunal clusters comprised a higher number of individual contractions of lower amplitude and duration. In healthy man duodenal and jejunal motor activity are different, both in the digestive and interdigestive state. The differences include the number of activity fronts traversing these segments of the gut, the number and organization of propagated clustered contractions, and subtle changes in the amplitude, duration, and coordinated propagation of individual contractions. These changes presumably reflect a regulatory capability of the small intestine to modulate the rate of transit of intraluminal content through different segments of the gut.

Computer-supported analysis of continuous ambulatory manometric recordings in the human small bowel

An algorithm has been developed for the offline analysis of prolonged manometric recordings in the upper small intestine of humans. Sample data are acquired in the human duodenum and jejunum six solid-state strain-gauge transducers mounted on a silicon catheter that is connected to a portable digital recording device. The data are sampled at 4 Hz and filtered. For accurate calculations, the filtered signals are converted to cubic B-spline functions of order four. Based on an exponential weighted moving average, a base-line is calculated from the signal. Contractions are recognised on the basis of thresholds for minimum amplitude and duration. The developed algorithm calculates properties of these contractions, such as amplitude, duration, area and a motility index. In addition, the program automatically recognises normal motor patterns of the fasted human small intestine, such as the migrating motor complex, and aids in the identification of the postprandial motor pattern. Motor patterns are defined in terms of properties such as contraction frequency and propagation. In a validation procedure using conventional manual analysis, the program correctly identifies the number of individual contractions with a 98% confidence interval and also correctly recognises 96% of phase 3 motor activity.

A risk-benefit assessment of cisapride in the treatment of gastrointestinal disorders

Cisapride is a substituted benzamide compound that stimulates motor activity in all segments of the gastrointestinal tract by enhancing the release of acetylcholine from the enteric nervous system. Cisapride is administered orally in the treatment of gastro-oesophageal reflux disease, functional dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction syndromes and chronic constipation. In gastro-oesophageal reflux disease in both adults and children, cisapride provides symptomatic improvement and mucosal healing. Long term treatment with cisapride is effective in the prevention of relapse of oesophagitis. Cisapride improves gastric emptying rates and improves symptoms in patients with gastroparesis of various origins. Unlike domperidone and metoclopramide, long term administration of cisapride seems to result in persistently enhanced gastric emptying. Cisapride is also effective in improving symptoms in patients with functional dyspepsia. In comparative studies in patients with functional dyspepsia, cisapride was at least as effective as metoclopramide, domperidone, clebopride, ranitidine and cimetidine. Cisapride increases stool frequency and reduces laxative consumption in patients with idiopathic constipation. Severe cases of slow transit constipation seem refractory to cisapride. Clinical studies also indicate that cisapride might be effective in the treatment of chronic intestinal pseudo-obstruction, postoperative ileus, peptic ulcer and irritable bowel syndrome. Further clinical studies are warranted to define the role of cisapride in these conditions. The dosage of cisapride ranges from 5mg 3 times daily to 20mg twice daily. Cisapride is generally well tolerated, both during short and long term treatment. In children, cisapride is also well tolerated in doses of 0.2 to 0.3 mg/kg, 3 to 4 times daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis

Preliminary reports have suggested that dilatation using hydrostatic through the scope balloons may be useful for the treatment of Crohn's strictures, A prospective longterm follow up (mean (SD) 33.6 (11.2) months) was carried out in 55 Crohn's patients with 59 ileocolonic strictures submitted to 78 dilatation procedures. Hydrostatic balloons were used (Rigiflator, Microvasive) with a diameter of 18 mm on inflation. As soon as the balloons became available dilatation up to a diameter of 20 and 25 mm was attempted. The dilatations were performed under general anaesthesia using propofol (Diprivan). The patients were kept for one night in the hospital after dilatation. Seventy (90%) procedures were technically successful and passage of the stricture with a 13.6 mm diameter colonoscope was possible after 73% of the dilatations. Complications occurred in six patients (11%; 8% of procedures), including sealed perforations (n = 2), retroperitoneal perforations (n = 2), and intraperitoneal perforations (n = 2). Two of the patients were treated surgically with a one stage resection of the stricture and recovered uneventfully. Four patients were treated conservatively with intravenous fluids and antibiotics. There was no mortality. Dilatation completely relieved obstructive symptoms in 20 patients after one procedure, in another 14 patients after two (n = 13) or three (n = 1) dilatations. Total longterm success rate was 34 of 55 patients (62%). Nineteen patients (38%) were operated on because of persistent obstructive symptoms. The data show that endoscopic dilatation using the through the scope hydrostatic balloon system relieves obstructive symptoms resulting from ileocolonic Crohn's strictures. The procedure, however, carries a definite risk of perforation.

Efficacy and safety of hydrostatic balloon dilation of ileocolonic Crohn's strictures. A prospective long-term analysis

Gastro-intestinal stricture frequently is a complication in Crohn's disease and often recurs after surgical resection. Stenosis with acute inflammation can be treated by anti-inflammatory medication. A conservative approach of sclerotic strictures has been possible since the introduction of Gruentzig balloon catheters for dilating stenosis in different parts of the gastro-intestinal tract. We present a prospective follow-up study in 55 patients, on the long-term results and safety of hydrostatic balloon dilations of ileo-colonic Crohn's strictures.

5-hydroxytryptamine-3 receptors are involved in the initiation of gastric phase-3 motor activity in humans

BACKGROUND

5-hydroxytryptamine-3 (5-HT3) receptor antagonists inhibit gastric phase-3 motor activity in the dog. This study examined the role of 5-HT3 receptors in the generation of gastric phase 3 of the migrating motor complex in humans.

METHODS

Interdigestive motor activity was recorded manometrically in 16 subjects before and after administration of ondansetron, a selective 5-HT3 receptor antagonist. Plasma motilin values were also assayed in 7 individuals. The incidence of gastric activity fronts before and after ondansetron was compared with a control group that had not received ondansetron. The ability of erythromycin to induce a gastric activity front in the presence of ondansetron was also evaluated in 7 subjects.

RESULTS

The incidence of gastric activity fronts was 69% before ondansetron vs. 19% after ondansetron. In contrast, in the control group there was no significant change in the incidence of gastric activity fronts over time. Activity fronts preceding ondansetron were associated with motilin peaks while activity fronts after ondansetron were not. Despite the previous administration of ondansetron, erythromycin induced gastric activity fronts in 89% of cases.

CONCLUSIONS

Selective antagonism of 5-HT3 receptors suppresses the gastric component of phase-3 motor activity and simultaneously suppresses plasma motilin peaks. The results suggest that the suppression of gastric activity fronts is achieved via the suppression of plasma motilin peaks because in the presence of ondansetron a motilin agonist like erythromycin restores the gastric phase 3.

Endoscopic balloon dilation of colonic and ileo-colonic Crohn's strictures: long-term results

The long-term effects of endoscopic dilation of colonic or ileo-colonic Crohn's disease strictures were analyzed. In 18 patients with a Crohn's disease-related low gastrointestinal stricture, the stenosis was dilated using through-the-scope (TTS) balloon catheters. A dilation to a diameter of 18 mm was always attempted. Treatment was successfully carried out in 16 patients, and was followed by immediate symptomatic relief in 14 patients. Long-term success was observed in nine patients. There were no complications. Balloon catheter dilation of a colonic stricture or stricture of an ileo-colonic anastomosis was found to be safe and effective. This treatment modality can be an alternative to surgery in a selected group of patients.

Is the irritable bowel really irritable?

We studied 5 healthy volunteers and 9 patients with irritable bowel syndrome (IBS) during infusion of the colon with saline solution, bile acids, fatty acids and balloon distension. Our results show that the pain threshold was significantly (p less than 0.001) higher in controls than in IBS patients. Bile acids and fatty acids brought on the habitual pain in 5/7 and 7/8 patients respectively, while they did not have any effect in the control group. On the basis of our data we can conclude that the IBS patients are more sensitive to colonic distension and perfusions, thus suggesting a non-specific irritability of the colon which could be a characteristic of these patients.

Inversion of the slow-wave frequency gradient in symptomatic patients with Roux-en-Y anastomoses

Patients with Roux-en-Y anastomoses may have chronic symptoms of nausea, vomiting, epigastric fullness, and abdominal pain. To investigate the mechanism of these symptoms, the electrical activity of the Roux limb was studied in five symptomatic and four asymptomatic patients with Roux-en-Y anastomoses. Slow-wave and spike activity in the Roux limb were recorded using six bipolar suction electrodes positioned 10 cm apart. Ten healthy volunteers were studied as a control. In the control subjects, the mean slow-wave frequency decreased from 11.27 +/- 0.2 cycles/min at 30 cm below the ligament of Treitz to 10.96 +/- 0.2 cycles/min at 80 cm past Treitz. By contrast, in five patients the slow-wave frequency in the Roux limb increased from 11.12 +/- 0.2 cycles/min 10 cm below the gastrojejunal anastomosis to 11.42 +/- 0.4 cycles/min 50 cm more distally. Four of these five patients had severe symptoms. In the other four patients, of whom three were completely symptom-free, an aborally decreasing slow-wave frequency was observed. In both the controls and the patients with Roux-en-Y anastomoses, the direction of propagation of phase 3 spike bursts of the migrating motor complex was always aboral. During phase 2, most spike bursts were uncoordinated at adjacent recording sites. Propagated spike bursts, single or repetitive, were rare. The propagation direction of these spike bursts was always aboral in healthy controls. In symptomatic patients with inverted slow wave frequency gradients, however, the rare propagated spike bursts always propagated orally. The observed electrical abnormalities may in part be responsible for the symptoms of patients with the Roux-en-Y syndrome.

Interdigestive myoelectric complex in germ-free rats

The effect of intestinal bacteria on the interdigestive myoelectric complex (IDMEC) was studied by recordings of the electrical activity of the proximal and distal small bowel in fasting germ-free (n = 6), gnotobiotic (n = 7), and conventional (n = 6) rats in vivo. Germ-free and gnotobiotic rats were operated and studied in germ-free or gnotobiotic conditions. The IDMEC period (mean +/- SD) in the proximal and distal small bowel was significantly longer in germ-free rats (20 +/- 2 min and 102 +/- 14 min) as compared to conventional rats (13 +/- 1 min and 58 +/- 5 min). Association of germ-free rats with a limited flora (gnotobiotic rats) decreased the IDMEC period significantly (15 +/- 1.5 min and 75 +/- 14 min). The migration velocity of the IDMEC was inversely related to the IDMEC period. These observations confirm previous data suggesting that the interdigestive motor complex has a role in the homeostasis of the bacterial content of the small bowel.

Comparison of endoscopic polidocanol injection and YAG laser therapy for bleeding peptic ulcers

392 patients were examined by endoscopy for acute upper gastrointestinal bleeding; 140 had ulcers containing an actively bleeding visible vessel or a non-bleeding visible vessel and were enrolled in a randomised trial of three endoscopic methods of haemostasis--adrenaline (1/10(4] alone, adrenaline plus polidocanol 1%, and adrenaline followed by yttrium-aluminium-garnet (YAG) laser photocoagulation. For patients with non-bleeding visible vessels sham treatment was significantly less effective in achieving haemostasis (8 of 20 patients) than were adrenaline plus polidocanol (18 of 20; p = 0.002) and adrenaline plus laser (16 of 20; p = 0.012). All three treatments significantly reduced total transfusion needs compared with sham treatment. For the whole group of patients, adrenaline plus polidocanol was significantly more effective than adrenaline alone in achieving permanent haemostasis; adrenaline plus laser was also more effective than adrenaline alone, but not significantly so. The efficacy of the three treatments was enhanced by repeated application on recurrence of bleeding. Since injection therapy with adrenaline and polidocanol was at least as effective as adrenaline plus laser therapy, it should be preferred over laser therapy because it is cheaper, easier to use, and perhaps also safer.

Efficacy and safety of rioprostil, 300 micrograms b.d., in the treatment of duodenal ulcer: a double-blind, controlled multicentre clinical study vs. ranitidine

This study is undertaken to evaluate the efficacy and safety of rioprostil, 300 micrograms, compared with ranitidine, 150 mg, when given twice daily for 4-6 weeks to patients with active, uncomplicated duodenal ulcer. The effects of each drug on ulcer healing are evaluated by endoscopy. Of a total of 355 patients who have entered this study, 319 are statistically evaluated for efficacy; 162 receive rioprostil and 157 receive ranitidine. After 4 weeks of treatment, 63% of the patients receiving rioprostil are endoscopically healed, compared with 72% of those receiving ranitidine. After 6 weeks of treatment, the cumulative healing rates are 86% and 93.5% respectively; this difference is statistically significant. Diarrhoea is the main adverse event, but is generally mild and self-limiting. These results indicate that rioprostil, 300 micrograms b.d., is a safe and effective treatment for duodenal ulcer, but is slightly less effective than ranitidine, 150 mg b.d.

Risk factors which determine the long term outcome of Neodymium-YAG laser palliation of colorectal carcinoma

We have analysed the long term results of YAG laser palliation for incurable colorectal carcinoma in 88 patients. Although initial palliation was achieved in 82%, good palliation could only be maintained in 51% and 41% of patients surviving 6 months and 12 months respectively. The relative inefficacy of YAG laser therapy for palliation of rectal cancer is due to the failure to control extraluminal tumour growth, complications of YAG laser therapy and the poor general condition of these elderly patients. Factors influencing the efficacy of palliation, besides life expectancy, included T classification, and length of the neoplastic stricture. Treatment-related mortality due to perforation was 2.3%. YAG laser therapy, applied as the sole therapeutic modality, is effective for short term palliation of incurable colorectal carcinoma, but is not adequate for long term palliation in most patients. Trials should be conducted to study the effect of combined treatment (e.g. laser + radiotherapy) on palliation.

Cisapride stimulates propulsive motility patterns in human jejunum

The effects of cisapride on upper gut motility were studied in seven healthy volunteers by means of a novel intraluminal electromyographic technique in a placebo-controlled study. In the interdigestive state, cisapride (10 mg intravenous bolus injection) markedly increased the number of spike bursts. The most obvious effect was observed during the first 5-min period when a nonmigrating phase-3-like activity (stationary phase 3) occurred, which lasted for 2.6 +/- 0.4 min. This initial pattern was followed by an intense phase 2 activity, characterized by a 10-fold increase in the number of groups of repetitive spike bursts and a sixfold increase in the number of ultrarapid single propagated spike bursts (ultrarapid peristaltic rushes). Cisapride induces in the human upper gut a remarkable pattern of aborally propagated (peristaltic) contractions, which are very likely responsible for the active propulsion of intestinal contents in the interdigestive state.

Palliative Nd:YAG laser therapy for cancer of the esophagus and gastroesophageal junction: impact on the quality of remaining life

Endoscopic laser therapy (ELT) for palliation of cancer of the esophagus and the gastroesophageal junction was evaluated in 31 patients with far advanced disease. Initial technical success (94%) and initial improvement of symptoms (81%) were comparable to data reported previously. Complications were bleeding (6%), sepsis (6%), and tracheoesophageal fistula (6%). This analysis, however, addressed the impact of ELT on the remaining life of the patients. In 9 patients (29%) ELT was the only palliative alternative, and in 7 of these patients a fair functional success was achieved. In 13/21 (63%) of the patients with good initial functional result palliation could be preserved by repeated ELT until death from cachexia. Eight patients, however, were intubated in the follow-up period because of failure to keep the esophagus open. The dysphagia-free interval was only 4 weeks, and repeated ELT became progressively more difficult because of increased tumor load and increasing debility of the patient. 32% of the patients experienced ELT as more difficult than repeated dilations. Our data also suggest that duration of palliation after ELT alone lasts longer than palliation after dilation followed by ELT. Results of ELT were best in patients with recurrent cancer at the esophagogastric or esophagojejunal anastomosis.

Neodymium-YAG laser photocoagulation versus multipolar electrocoagulation for the treatment of severely bleeding ulcers: a randomized comparison

A randomized trial comparing the efficacy of BICAP electrocoagulation and YAG laser photocoagulation was carried out in 100 patients presenting at endoscopy with peptic ulcer and a spurting or oozing vessel or a nonbleeding vessel. Fifty patients were enrolled in each treatment group. All lesions were pretreated with injection of epinephrine 1:10,000. Subsequently, 1-sec pulses of 80 watt YAG laser power were applied to the vessel or 1- to 2-sec pulses of electrocoagulation of 25 watt BICAP at a setting of 10. The 10 F BICAP probe was always used. Definitive hemostasis after one treatment amounted to 72% in both the laser and in the BICAP group. After two sessions the cumulative success rate was 88% in the laser group and 86% in the BICAP group. Emergency surgery and mortality were also comparable. One perforation occurred in each treatment group and both patients were operated upon without complications. It is concluded that both YAG laser and BICAP are highly and equally effective in the treatment of severe bleeding from peptic ulcers. This study stresses the importance of repeated treatment sessions in order to obtain optimal results.

Migrating action potential complexes in a patient with secretory diarrhea

A 70-year-old woman with secretory diarrhea was studied with a novel technique of recording small intestinal myoelectrical activity which allowed us to obtain long, uninterrupted records of slow waves and spikes at eight or more different intestinal levels simultaneously. Typical migrating action potential complexes (MAPCs) were observed, consisting of spike bursts that extended over more than one slow wave and migrated distally at the same propagation velocity as the slow waves. This motility pattern occurred frequently during the period the patient presented with secretory diarrhea and disappeared with the disappearance of the diarrhea. It was observed only once in a series of 10 normal control subjects. This is the first report on MAPC activity in man and on the association of this myoelectrical pattern with secretory diarrhea in man.

Gastrointestinal motility disorders

A classification of gastrointestinal motility disorders is offered based upon the type of disorder in transit (delay or acceleration), and the region of the gastrointestinal tract affected. Specific abnormalities of myoelectrical patterns are identified when possible and related to disturbances in transit in the stomach and small bowel.

Long term results of treatment of vascular malformations of the gastrointestinal tract by neodymium Yag laser photocoagulation

The effect of Yag laser photocoagulation on the course of bleeding of gastrointestinal vascular malformations was studied in 59 patients, with a total of 482 lesions. The lesions were located in the upper gastrointestinal tract alone in 25 patients, in the lower tract alone in 31 patients and in both the lower and the upper gastrointestinal tract in three patients. In the month before laser therapy the number of bleeding episodes averaged 1.09 +/- 0.6 (SD) per patient (n = 57) and the transfusion requirements 2.4 +/- 2.6 red blood cells units per patient, while in the month after treatment the bleeding incidence averaged 0.16 +/- 0.5 and the transfusion requirements 0.21 +/- 0.8 (both p less than 0.001). Long term results were analysed considering for each patient an equally long pretreatment and follow up period. After a mean follow up period of 11.5 months (1-48 months), 17 of the 57 patients available for follow up rebled. The reduction of the bleeding rate was statistically significant at one, six, 12, and 18 months of follow up, while transfusion rate was significantly decreased at one, six, and 12 months. The results were disappointing in patients with Osler-Weber-Rendu (n = 4) and in patients with angiomas associated with Von Willebrand's disease (n = 3), who all rebled. In angiodysplasia the treatment was successful in 82% of the 49 patients. The more numerous the lesions, the less effective the reduction in bleeding rate by laser treatment was. Histological studies showed that the haemostatic effect of Yag laser photocoagulation was obtained by destruction of the lesion. Rebleeding was due to lesions missed at the first treatment, incompletely treated lesions and recurrence of new lesions. In two patients a free caecal perforation necessitated a right hemicolectomy. In both patients numerous or very large lesions had been treated in the caecum.

Gastrointestinal transit time and anorectal manometry in children with fecal soiling

Fifty-three children with chronic idiopathic constipation, 32 with fecal soiling and 21 without soiling, were investigated by total gastrointestinal transit time (TGITT) and anorectal manometry (ARM). TGITT and ARM were also performed, respectively, in 46 and 32 healthy subjects. Twenty-two of the 32 children with soiling were successfully managed by medical treatment and toilet training. TGITT was significantly longer in all constipated children than in normal children. Furthermore, some parameters of anorectal motility (threshold volume, amplitude of threshold inhibitory anal reflex) of the patients differed markedly from those measured in controls. Rectal compliance was significantly higher in children with fecal soiling than in children with constipation without soiling and healthy controls. In the successfully treated children, soiling disappeared, TGITT normalized, and anorectal variables changed significantly. It is concluded that TGITT is useful in assessing the degree of constipation. Electromanometry of the anorectum is of great help in the diagnosis of functional constipation by excluding aganglionosis; furthermore, it provides additional information allowing better understanding of the mechanisms involved in functional constipation in children.