Viscerosomatic convergence onto feline spinal neurons from esophagus, heart and somatic fields: effects of inflammation

Electrophysiological recording from neurons controlling sensory and motor functions of the esophagus

Much work has been done in recent years to understand the functional roles of sensory neurons that regulate reflexes and sensations. Information about the response patterns of spinal dorsal horn and brain stem neurons associated with esophageal functions has become available by using electrophysiological techniques. These techniques allow understanding of response characteristics of neurons to various types of stimuli, neurotransmitters involved in excitation or inhibition of neurons, changes in response characteristics of neurons under pathological conditions, and the shape and size of a particular neuron in the central nervous system, as well as its projection to other areas of the brain. Response properties of primary afferent fibers in the vagus and thoracic sympathetic nerves have been studied in intact animal models by using single-fiber or extracellular microelectrode recording techniques. Recently, the single-fiber recording technique has been used in vitro in isolated esophagus-vagus nerve preparations. Recordings from the brain stem nuclei and thoracic spinal dorsal horn neurons also have examined the response characteristics of second-order neurons receiving afferent input from the esophagus. In the spinal cord, dorsal horn neurons responsive to esophageal distension also receive ipsilateral somatic input (ie, viscero-somatic convergence) from the upper thoracic area. These neurons exhibit sensitization of response after repeated noxious distension of the esophagus or instillation of irritant substances in the esophagus. In the nucleus ambiguus, neurons receiving input from the distal esophagus exhibit excitation to distension of the distal esophagus but undergo inhibition to midthoracic esophageal distension or to swallow. Neurons in the nucleus tractus solitarius receiving input from the distal esophagus exhibit 2 types of responses to proximal and distal esophageal distension. One type of response is a rhythmic firing synchronized with peristaltic contractions of the distal esophagus. This response undergoes inhibition in response to proximal distension. In addition, there is a second, nonrhythmic firing response that occurs both proximal and distal esophageal distension. This observation suggests that swallow-induced inhibition of the distal esophagus is controlled by the preganglionic motor neurons in the brain stem. Electrophysiological studies allow direct understanding of neuronal activities regulating esophageal functions. In vivo recording has an advantage for studying functional roles of the neurons in regulatory reflexes, whereas in vitro recording is useful for more accurate study of receptor pharmacology. Recordings from the central nervous system allow study of the neurotransmitters involved in neuronal function and the circuitry of different reflex mechanisms.

Central neural mechanisms mediating human visceral hypersensitivity

Although visceral hypersensitivity is thought to be important in generating symptoms in functional gastrointestinal disorders, the neural mechanisms involved are poorly understood. We recently showed that central sensitization (hyperexcitability of spinal cord sensory neurones) may play an important role. In this study, we demonstrate that after a 30-min infusion of 0.15 M HCl acid into the healthy human distal esophagus, we see a reduction in the pain threshold to electrical stimulation of the non-acid-exposed proximal esophagus (9.6 +/- 2.4 mA) and a concurrent reduction in the latency of the N1 and P2 components of the esophageal evoked potentials (EEP) from this region (10.4 +/- 2.3 and 15.8 +/- 5.3 ms, respectively). This reduced EEP latency indicates a central increase in afferent pathway velocity and therefore suggests that hyperexcitability within the central visceral pain pathway contributes to the hypersensitivity within the proximal, non-acid-exposed esophagus (secondary hyperalgesia/allodynia). These findings provide the first electrophysiological evidence that central sensitization contributes to human visceral hypersensitivity.

Inflammation enhances reflex and spinal neuron responses to noxious visceral stimulation in rats

To improve understanding of sensory processes related to visceral inflammation, the effect of turpentine-induced inflammation on reflex (cardiovascular/visceromotor) and extracellularly recorded lumbosacral dorsal horn neuron responses to colorectal distension (CRD) was investigated. A 25% solution of turpentine, applied to the colorectal mucosa, produced inflammation, decreased compliance of the colonic wall, and enhanced reflex responses in unanesthetized rats within 2-6 h. At 24 h posttreatment, pressor responses to CRD (80 mmHg, 20 s) were 20% greater, and intraluminal pressures needed to evoke visceromotor reflexes were 30% lower than controls. Parallel electrophysiological experiments in spinal cord-transected, decerebrate rats demonstrated that two neuronal subgroups excited by CRD were differentially affected by turpentine administered 24 h before testing. During CRD, abrupt neurons were 70% less active and sustained neurons were 25% more active than similar neurons in controls. In summary, reflex and neuronal subgroup (sustained neurons) responses to CRD were both potentiated by chemical inflammation. This suggests that the neurophysiological basis for inflammation-induced increases in reflex responses to CRD is increased activity of this neuronal subgroup.

Contribution of central sensitisation to the development of non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain mimics angina pectoris but generally originates from the oesophagus. Visceral hypersensitivity may contribute, but its neurophysiological basis is unclear. We investigated whether central sensitisation, an activity-dependent amplification of sensory transfer in the central nervous system, underlies visceral pain hypersensitivity and non-cardiac chest pain.

METHODS

We studied 19 healthy volunteers and seven patients with non-cardiac chest pain. Acid was infused into the lower oesophagus. Sensory responses to electrical stimulation were monitored within the acid-exposed lower oesophagus, the non-exposed upper oesophagus, and the cutaneous area of pain referral, before and after the infusion.

FINDINGS

In healthy volunteers, acid infusion into the lower oesophagus lowered the pain threshold in the upper oesophagus (mean decrease 18.2% [95% CI 10.4 to 26.0]; p=0.01) and on the chest wall (24.5% [10.2 to 38.7]; p=0.01). Patients with non-cardiac chest pain had a lower resting oesophageal pain threshold than healthy controls (45 [30 to 58] vs 64 [49 to 81] mA; p=0.04). In response to acid infusion, their pain threshold in the upper oesophagus fell further and for longer (mean fall in area under threshold/time curve 26.7 [11.0 to 42.3] vs 5.8 [2.8 to 8.8] units; p=0.04).

INTERPRETATION

The finding of secondary viscerovisceral and viscerosomatic pain hypersensitivity suggests that central sensitisation may contribute to visceral pain disorders. The prolonged visceral pain hypersensitivity in patients with non-cardiac chest pain suggests a central enhancement of sensory transfer. New therapeutic opportunities are therefore possible.

Responses of rat spinal neurones to natural and electrical stimulation of colonic afferents: effect of inflammation

Single unit electrical activity has been recorded from 107 neurones excited by electrical stimulation of the pelvic nerve in or around lamina X of the L6-S1 spinal cord in anaesthetised rats. Responses to colorectal distension (CRD; 30 s, 5-80 mmHg) and to somatic electrical and mechanical stimulation were characterised. Of 107 neurones excited by pelvic nerve stimulation, 58 (54%) were affected by CRD: 46 neurones were excited (39 with a sustained response and 7 with an on-off response) and 12 neurones were inhibited. The vast majority of the neurones affected by CRD (54/58) had nociceptive somatic receptive fields. Neurones excited by CRD showed graded stimulus response functions in the noxious range (20-80 mmHg), except for two neurones which only encoded stimulus intensity below 20 mmHg. Neurones inhibited by CRD had significantly larger somatic receptive fields, and more superficial recording sites than those excited by CRD. A group of 12 neurones with sustained excitatory responses to CRD were characterised before and 45 min after intracolonic instillation of 1 ml 0.6% acetic acid. Colon inflammation provoked a significant increase in responses to CRD and to pelvic nerve stimulation (n=12), but no significant change in responses to pinch of their somatic receptive field (n=10). We conclude that of these neurones, the population with excitatory sustained responses to CRD are those likely responsible for processing information leading to acute pain sensations from the colon, and also show central sensitisation after colon inflammation, suggesting they play an important role in development of colonic hyperalgesia.

An overview of esophageal sensory receptors

The neurophysiological basis of esophageal pain and discomfort is not well known. Functional disorder, such as noncardiac chest pain, is thought to be associated with hypersensitivity of primary afferents innervating the esophagus and/or sensitization of spinal dorsal horn cells receiving input from the organ. Although we have accumulated a large body of information about the morphologic structure and neuropeptide contents of the extrinsic primary afferents, we lack a full understanding of its integrative function in esophageal pain. The esophagus is innervated dually by vagus and spinal nerves. The majority of sensory afferents in the vagal and spinal pathway are pseudounipolar cells, with their cell bodies (soma) located in the nodose and dorsal root ganglia, respectively. These afferent fibers innervate serosa (adventitia), longitudinal and circular muscles, and mucosa of the esophagus. Afferents innervating the muscle are sensitive to intraluminal distension. In the vagus, these afferents exhibit low threshold for response, whereas the spinal afferents, including the splanchnic nerve afferents, have either low or high thresholds for response. In addition, these afferents are chemosensitive. Both vagal and spinal afferents also innervate the mucosa of the esophagus. These fibers are exquisitely sensitive to light touch of the mucosa and are sensitive to pH and chemicals. The spinal afferents, including splanchnic nerve afferents, project to the spinal cord, spanning from upper cervical (C1) to upper lumbar (L2) segments. A majority of the spinal dorsal horn neurons receiving input from the esophageal spinal afferents also receives somatic converging input. The somatic receptive fields are distributed mainly ipsilaterally over the chest and forearm area. These spinal dorsal horn neurons exhibit either excitatory, inhibitory, or biphasic (i.e., excitation followed by inhibition) responses to esophageal distension.

Intramuscular and intradermal injection of capsaicin: a comparison of local and referred pain

The present study compared capsaicin-induced muscle and skin pain in humans. Twelve healthy subjects received, in a randomised, balanced order, 3 intramuscular (i.m.) injections into the brachioradial muscle: capsaicin 100 microg/1 ml, capsaicin 100 microg/20 microl or 1 ml solvent (Tween 80), and one intradermal injection (i.d.): capsaicin 100 microg/20 microl. Local and referred pain intensities and areas were assessed from 0 to 60 min after injection. Intradermal capsaicin produced more intense local pain than i.m. capsaicin in the first min (skin: 68+/-6, muscle: 51+/-6 mm VASxmin, P<0.05). In contrast, the local pain offset was later (muscle: 38+/-5, skin: 23+/-5 min, P<0.05) and referred pain was more frequent (muscle: 9/12, skin: 1/12 subjects, P<0.01) following i.m. capsaicin compared with i.d. capsaicin. Capsaicin (1 ml) produced significantly more pain than 20 microl i.m. (pain in the first min: 1 ml: 71+/-6, 20 microl: 51+/-6 VASxmin, P<0.05, offset: 1 ml: 50+/-4, 20 microl: 38+/-5 min, P<0.05). The different local and referred pain following identical noxious stimulation of muscle and skin indicates that the neurophysiological mechanisms underlying skin and muscle pain differs. The model with identical noxious stimulation of muscle and skin may be suitable for the study of differences in deep and superficial pain as seen in the clinic.

Responses of neurons in the lateral thalamus of the cat to stimulation of urinary bladder, colon, esophagus, and skin

In seven female alpha-chloralose-anesthetized cats, 52 lateral thalamic neurons were tested with noxious distension of the urinary bladder, the distal colon and the lower esophagus. In addition, the neurons were characterized with innocuous and noxious mechanical stimulation of the skin and deep structures. Of the 52 neurons tested, 32 (62%) were visceroceptive. Of these visceroceptive neurons, 20 (63%) were located in the periphery of the ventral posterolateral nucleus (VPLp), 10 (31%) in the adjacent posterior complex (PO), and two (6%) in the ventrolateral nucleus (VL). No differences were found with respect to location between neurons responsive or unresponsive to visceral stimulation. Ten neurons (31%) received input from more than one viscus and, therefore, showed viscerovisceral convergence. Excitatory or "inhibitory" responses were elicited by stimulation of the esophagus in 21 neurons, of the colon in 13, and of the urinary bladder in 11 neurons. No indications were found for a segregation of neurons responsive to a certain viscus and their location in VPLp or PO. Of 51 neurons, for which a somatic receptive field was determined, 44 (86%) exhibited low threshold type (LT), and seven (14%) wide dynamic range type (WDR) responses. The data indicate that there might exist a somatovisceral coregistration, because many neurons (69%) had homosegmental receptive fields, and bladder stimulation was the most successful stimulus. It is concluded that VPLp and the adjacent PO in the cat play a role in the perception and localization of painful events originating from thoracic and pelvic organs.

Effects of electrical stimulation of thalamic nucleus submedius and periaqueductal gray on the visceral nociceptive responses of spinal dorsal horn neurons in the rat

Electrical stimulation of the nucleus submedius (Sm) has been shown to suppress the viscerosomatic reflex (VSR), which is evoked by colorectal distension (CRD). We have examined the effects of focal electrical stimulation (0.3 ms, 50 Hz, 100 microA, 10 s) of the Sm and the periaqueductal gray (PAG) on the excitatory responses evoked by CRD in spinal dorsal horn neurons within the L6-S1 region in the urethane-anesthetized Wistar rats. Extracellular recordings were made from 32 spinal excitatory CRD responses. All of these neurons were convergent neurons with cutaneous receptive fields. The majority of the neurons (27/32) were wide dynamic range (WDR) neurons (responding to noxious and non-noxious cutaneous stimuli) while the remaining five neurons were nociceptive specific (NS) neurons (responding only to noxious cutaneous stimuli). The effects of electrical stimulation applied to 28 sites within the Sm were assessed for spinal neurons. Electrical stimulation in seven sites within the Sm (25%) inhibited the CRD excitatory response of dorsal horn neurons, while in two sites (7%) the same stimulation yielded facilitation. Electrical stimulation in the majority of the sites in the Sm (19/28, 68%) did not affect spinal excitatory CRD responses. On the other hand, electrical stimulation of the PAG clearly inhibited 20 of 22 (90%) CRD excitatory responses. These results suggest that the majority of Sm neurons may suppress VSR activity at a supraspinal reflex center rather than via a descending inhibition of spinal visceral nociceptive transmission, as is the case for the PAG.

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.

Spinal mechanisms underlying persistent pain and referred hyperalgesia in rats with an experimental ureteric stone

Spinal neurons processing information from the ureter have been characterized in rats 1-4 days after the implantation of an experimental ureteric stone and compared with those of normal rats. The effects of a conditioning noxious stimulation of the ureter in the presence of the hyperalgesia evoked by the calculosis also were examined. Extracellular recordings were performed at the T12-L1 segments of the spinal cord. In rats with calculosis, more neurons expressed a ureter input (53 vs. 42% in normal rats); such cells being more likely to show background activity, at a higher rate than normals (6.6 +/- 1.2 vs. 3.2 +/- 0.9 spikes/s; mean +/- SE) and increasing with the continuing presence of the stone. The threshold pressure for a ureteric response was higher than in normal rats (79 +/- 5 vs. 54 +/- 4 mmHg) but the neurons failed to encode increasing intensities of stimulation. Thirty-five percent of the neurons with exclusively innocuous somatic receptive fields had a ureter input in rats with calculosis, whereas none were seen in normal rats. A noxious ureteric distention applied to neurons with ureter input evoked a complex mixture of increases and decreases in somatic receptive field size and/or somatic input properties markedly different from the generalized increases in excitability seen when such a stimulus was applied to normal animals. We conclude that the presence of a ureteric stone evokes excitability changes of spinal neurons (enhanced background activity, greater number of ureter-driven cells, decreased threshold of convergent somatic receptive fields), which likely account for the referred hyperalgesia seen in rats with calculosis. However, further noxious visceral input occurring in the presence of persistent hyperalgesia produces selective changes that cannot be explained by a generalized excitability increase and suggest that the mechanisms underlying maintenance of hyperalgesia include alteration of both central inhibitory and excitatory systems.

Classification of dorsal horn neurons based on somatic receptive fields in cats with intact and transected spinal cords: neural plasticity

Classification of dorsal horn neurons based on cell activity responses to somatic receptive fields stimulation, was compared between anesthetized cats with transected or intact cords. Results showed a significant (P < or = 0.001) difference. In animals with transected cords, dorsal horn neurons responded with less specificity to noxious and innocuous stimulation. The results are consistent with the proposition that loss of supraspinal influences plays a significant role in determining response characteristics of dorsal horn neurons.

The effect of topical turpentine on the functional properties of cutaneous afferents in the anaesthetized rat

Turpentine was applied to the rat dorsal hindpaw over 1.5-3.5 h and afferent activity was recorded for 1.5-7 h after its removal. Increased spontaneous activity from both A- and C-fibres was observed. There was an increase in units with no response to natural stimuli and a reduction in the numbers of all types of afferent unit, with some recovery of the C- and A delta-classes during the recording period. Surviving C-polymodal nociceptor units had normal sensitivity to noxious heat, but higher mechanical thresholds. Thus turpentine application caused no nociceptor sensitization. Instead, the many insensitive units plus the generalized spontaneous firing may be signs of non-specific axonal damage. A general division of irritant chemicals into those that are predominately damaging, like turpentine, and those that generate specific nociceptor firing or sensitization, is proposed.

The effects of an intrathecal NMDA antagonist (AP5) on the behavioral changes induced by colorectal inflammation with turpentine in rats

Visceral pain, especially that associated with inflammation of visceral organs, is poorly understood and difficult to treat clinically. The purpose of this study was to investigate the effects of intrathecal 2-amino-5-phosphonovaleric acid (AP5, a competitive NMDA antagonist) upon a visceromotor response to distension of colonic tissue inflamed by exposure to turpentine. All experiments were conducted under pentobarbital anesthesia. Animals were prepared with a laminectomy from T12 to L1 to facilitate intrathecal drug administration. Colonic distension thresholds for a visceromotor response were determined in the presence and absence of AP5. Animals were divided into two groups. The NS group received 50 microl of saline intrathecally and the AP5 group 10 mM of AP5 in 50 microl saline. After baseline measurements, intrathecal drugs were administered. Five minutes later, the effects of intrathecal drugs were measured, then 1 ml of 25% turpentine was administered anorectally. Subsequent measurements were made every 5 minutes for the next 90 minutes. Visceromotor thresholds to colorectal distension (CRD) were significantly decreased 50 min after turpentine administration in the NS group. There was no threshold change in the AP5 group. This study suggests that the administration of the competitive NMDA receptor antagonist AP5 in this model blocks the effect of turpentine sensitization on visceromotor response to CRD. The absence of AP5 effects in animals not sensitized by turpentine suggests that NMDA systems may be involved in the sensitization.

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.

Cardioesophageal reflex: a mechanism for "linked angina" in patients with angiographically proven coronary artery disease

OBJECTIVES

The purpose of this study was to investigate the presence of a cardioesophageal reflex in patients with coronary artery disease that may explain the mechanism of "linked angina."

BACKGROUND

It has been previously shown that esophageal acid stimulation can reduce coronary blood flow in patients with syndrome X, suggesting the presence of a cardioesophageal reflex in humans.

METHODS

We studied the effect of esophageal acid stimulation on coronary blood flow in 14 patients with angiographically documented significant coronary artery disease and in 18 heart transplant recipients. Hydrochloric acid (0.1 mol/liter) and 0.9% saline solution were infused in random, double-blind manner (60 ml over 5 min) through a fine-bore tube positioned in the patient's distal esophagus, and coronary blood flow measurements were obtained after each infusion by use of a 3.6F intracoronary Doppler catheter positioned in the proximal left anterior descending coronary artery.

RESULTS

Coronary blood flow was reduced significantly by esophageal acid stimulation in the coronary artery disease group (before acid 70.4 +/- 14.3 ml/min, after acid stimulation 46.4 +/- 19.1 ml/min [mean +/- SD], p < 0.01). However, there was no significant difference in coronary blood flow during saline infusion (73.5 +/- 15.3 vs. 72.5 +/- 14 ml/min). Coronary blood flow in the heart transplant group was not affected by acid or saline infusion.

CONCLUSIONS

Esophageal acid stimulation can cause animal attacks and significantly reduce coronary blood flow in patients with coronary artery disease. The lack of any significant effect in heart transplant recipients with heart denervation suggests a neural reflex.

Pain perception and brain evoked potentials in patients with angina despite normal coronary angiograms

OBJECTIVE

To evaluate the role of nociception in patients with angina despite normal coronary angiograms and to investigate whether any abnormality is confined to visceral or somatosensory perception.

METHODS

Perception, pain threshold, and brain evoked potentials to nociceptive electrical stimuli of the oesophageal mucosa and the sternal skin were investigated in 10 patients who had angina but normal coronary angiograms, no other signs of cardiac disease, and normal upper endoscopy. Controls were 10 healthy volunteers. The peaks of the evoked potential signal were designated N for negative deflections and P for positive. Numbers were given to the peaks in order of appearance after the stimulus. The peak to peak amplitudes (P1/N1, N1/P2) were measured in microV.

RESULTS

(1) Angina pectoris was provoked in seven patients following continuous oesophageal stimulation. (2) Distant projection of pain occurred after continuous electrical stimulation of the oesophagus in four patients and in no controls. (3) Patients had higher oesophageal pain thresholds (median 16.3 mA v 7.3 mA, P = 0.02) to repeated stimuli than controls, whereas the values did not differ with respect to the skin. There were no intergroup differences in thresholds to single stimuli. (4) Patients had substantially reduced brain evoked potential amplitudes after both single oesophageal (P1/N1, median values: 7.2 microV, controls: 29.0 microV; N1/P2: 16.5 microV, controls: 66.0 microV; P < 0.001 for both) and skin (N1/P2: 13.5 microV; controls: 76.0 microV; P < 0.001) stimuli despite the similar pain thresholds.

CONCLUSION

Central nervous system responses to visceral and somatosensory nociceptive input are altered in patients who have angina despite normal coronary angiograms.

Increasing pain sensation to repeated esophageal balloon distension in patients with chest pain of undetermined etiology

Previous studies have demonstrated lowered sensory thresholds to esophageal balloon distension in patients with chest pain of undetermined etiology. Whether this finding is specific to patients with chest pain or is simply related to an underlying esophageal motility disorder is unclear. In the present study, distension-induced pain-sensation scores and the effect of repeated balloon distension were compared in patients with chest pain, dysphagia secondary to esophageal dysmotility, and healthy controls. All subjects underwent standard esophageal manometry followed by mid-esophageal balloon distension. Volumes 2.5, 5, 7.5, and 10 ml (each volume repeated three times) were applied in random order in a single-blind fashion, and the pain-sensation score was recorded after each distension. Pain-sensation scores varied directly with balloon volume. Mean pain scores were significantly higher (P < 0.001) in the chest pain group than in either the controls or dysphagia group. There was no significant difference between controls and the dysphagia group, and the motor response to distension was no different between groups. In the controls and dysphagia groups, pain-sensation score was not significantly different between the first, second, or third distension at a given volume. However, in the chest pain group, pain-sensation scores increased significantly with the second (P = 0.004) or third (P = 0.002) distension using the same balloon volume. These studies suggest that abnormal esophageal nociception in patients with chest pain of undetermined etiology is not simply related to underlying esophageal motor dysfunction. In addition, chest pain patients display a conditioning phenomenon, further supporting the presence of a visceral sensory abnormality.

Artificial ureteral calculosis in rats: behavioural characterization of visceral pain episodes and their relationship with referred lumbar muscle hyperalgesia

In a rat model of artificial ureteral calculosis, the aim of the study was to characterize the behavioural manifestations of direct visceral pain and to evaluate the relationship between number, duration and complexity of the visceral episodes and the extent of referred lumbar muscular hyperalgesia. As evidenced by non-stop video-tape recordings over 4-14 days, almost 98% of stone-implanted rats showed episodes similar to the writhing behaviour characteristic of noxious visceral stimulation in animals. From one rat to another, these episodes varied from very few (1-3) to a very high number (+/- 60), lasted a few minutes to over 45 min and were of variable complexity, as evaluated via an arbitrary scale on the basis of the combination of movements. Their number and duration decreased significantly, in a linear fashion, as time passed after the operation, so that they were mostly concentrated during the first 3 days. Number, duration and complexity of episodes were reduced by chronic treatment with morphine in a dose-dependent fashion. Stone-implanted rats displaying visceral episodes also showed hyperalgesia of the ipsilateral oblique musculature, as evidenced by a decrease in the vocalization threshold to electrical muscle stimulation, which was maximum on the first 3-4 days after implantation but lasted up to 10 days. The visceral episodes and the muscle hyperalgesia showed a strict relationship of interdependence: a significant, direct linear correlation was found between number and duration of episodes and tendency to also develop a contralateral muscle hyperalgesia. By applying the results of the study to the interpretation of human pathology, referred lumbar muscle hyperalgesia from ureteral calculosis would appear to be a strict function of the colic pain experienced.

Review article: the hypersensitive gut--peripheral kappa agonists as a new pharmacological approach

Hypersensitivity to pain is a common component of functional bowel disorders. Hyperalgesia may be induced by various stimuli which produce a cocktail of inflammatory mediators that decrease the pain threshold. Drugs able to block these peripheral events within the gut may offer a new pharmacological approach for treating functional bowel disorders. Kappa opioids have been shown to inhibit somatic pain through a peripheral mechanism of action, acting directly on receptors located on peripheral sensory endings. They can block both the nociceptive messages as well as the release of sensory peptides. This paper reviews the effects of opioid agonists on gut visceral pain and motility anomalies induced by visceral pain. Kappa opioids have strong effects on all models tested, with a peripheral mechanism of action allowing the design of drugs acting only in the periphery and having no central nervous system side-effects. This contrasts with mu agonists which are centrally active on pain and worsen the subsequent transit and motility anomalies.

Decreased activity of spontaneous and noxiously evoked dorsal horn cells during transcutaneous electrical nerve stimulation (TENS)

The purpose of this study was to examine the effects of TENS application to somatic receptive fields on spontaneous and noxiously evoked dorsal horn cell activity in alpha-chloralose-anesthetized cat. Carbon-filament microelectrodes were used to record extracellular action potentials from 83 spontaneously discharging cells. Using a commercial TENS unit (Medtronic Eclipse Model 7723), spontaneous cell activity was decreased in 54% (65%) of the cells. Twenty-five (30%) did not respond and 4 (5%) increased activity. It was also shown that for 36 cells which were evoked with either manual pinch (19 cells) or manual clamp (17 cells), cell activity decreased during TENS application. This study shows that dorsal horn neurons which can potentially transmit noxious information to supraspinal levels, can have their cell activity decreased during TENS application to somatic receptive fields. This is consistent with the concept of the 'gate control theory of pain' in that less noxious information would be involved in the pain perception process.

Basic and clinical aspects of visceral hyperalgesia

Although physiological stimuli in the healthy gastrointestinal tract are generally not associated with conscious perception, chronic abdominal discomfort and pain are the most common symptoms resulting in patient visits with gastroenterologists. Symptoms may be associated with inflammatory conditions of the gut or occur in the form of so-called functional disorders. The majority of patients with functional disorders appear to primarily have inappropriate perception of physiological events and altered reflex responses in different gut regions. Recent breakthroughs in the neurophysiology of somatic and visceral sensation are providing a series of plausible mechanisms to explain the development of chronic hyperalgesia within the human gastrointestinal tract. A central concept to all these mechanisms is the development of hyperexcitability of neurons in the dorsal horn, which can develop either in response to peripheral tissue irritation or in response to descending influences originating in the brainstem. Taking clinical characteristics and the concept of central hyperexcitability into account, a model is proposed by which abdominal pain from chronic inflammatory conditions of the gut and functional bowel disorders such as noncardiac chest pain, nonulcer dyspepsia, and irritable bowel syndrome could develop by multiple mechanisms either alone or in combination.

A model of cardiac nociception in chronically instrumented rats: behavioral and electrophysiological effects of pericardial administration of algogenic substances

This report presents evidence that pericardial administration of a mixture of algogenic substances is a potentially useful model of cardiac nociception. In awake rats in which a looped silicone catheter had been placed in the pericardial sac at least 5 days previous, administration of a mixture containing equal concentrations of bradykinin (BK), acetylcholine (ACh), adenosine (ADEN), histamine (HIST), serotonin (5-HT) and prostaglandin E2 (PGE2) (total 25 nmol in 25 microliters) led to rapid acquisition of a passive avoidance behavior. In contrast, neither BK alone (5-25 nmol) nor the same mixture of ACh, ADEN, HIST, 5-HT and PGE2 without BK led to acquisition of the behavior or produced effects significantly different than produced by saline given into the pericardial sac in the same volume (25 microliters). Both BK and the mixture containing BK produced dose-dependent cardiovascular responses (pressor response and tachycardia) of similar magnitude. Neither saline nor the mixture without BK produced significant changes in mean arterial blood pressure or heart rate. In electrophysiological experiments in the same rats, thoracic spinal cord neurons responded dose-dependently to the mixture and, except for one neuron, responded also to BK in a dose-dependent manner. However, responses to BK, when compared to a similar dosage of BK contained in the mixture, were significantly less in magnitude and duration. All units received convergent somatic input from the thorax and all neurons also received convergent input from the esophagus. Balloon distension of the esophagus excited all units. Results of the behavioral characterization of algogenic substances administered into the pericardial sac of awake rats gave evidence of differences between the effects of BK and a mixture of six substances, including BK. BK in either of two dosages tested produced effects not different than saline while the mixture containing BK was aversive. In complementary electrophysiological studies, both BK and the mixture containing BK excited thoracic spinal cord neurons, suggesting that neuron responses to putative algogenic substances are not necessarily reliable measures of cardiac nociception.

Experimental colitis alters visceromotor response to colorectal distension in awake rats

The influence of intermittent colorectal distension (CRD) on proximal colonic motility and abdominal pain perception was investigated in awake rats equipped with intraparietal electrodes on the cecum, proximal colon, and abdomen, before and three days after rectocolitis induction by trinitrobenzene sulfonic acid (TNB)/ethanol. The normal myoelectrical activities of cecum and proximal colon [5.2 +/- 0.5 and 9.7 +/- 0.7 long spike bursts (LSB) per 5 min, respectively] were significantly (P < 0.05) and gradually decreased by control CRD, at diameters above 9 mm. At the maximum CRD diameter (13.7 mm), 1.6 +/- 0.6 cecal and 3.9 +/- 0.8 colonic spike bursts occurred per 5 min (respectively, 69 and 60% decreases). This upstream inhibition was accompanied by a significant (P < 0.05) and gradual increase in abdominal contractions (0.4 +/- 0.4 per 5 min in control vs 23.4 +/- 1.9 in response to 13.7 mm in diameter). Three days after TNB/ethanol, visceromotor and abdominal responses were significantly (P < 0.05) enhanced at the least CRD diameter of 9 mm (cecum: 3.1 +/- 0.4 after TNB vs 5.0 +/- 0.7 in control; proximal colon: 5.1 +/- 0.9 vs 9.3 +/- 2.2; abdomen: 7.7 +/- 1.5 vs 0.5 +/- 0.4). We conclude that in awake rats, CRD evokes both abdominal contractions in response to pain and inhibition of cecal and proximal colonic motility, which thresholds are both lowered by TNB-induced rectocolitis.

Ipsilateral referral of pain following cordotomy

We report a patient who developed ipsilateral referred pain following unilateral percutaneous cervical cordotomy (PCC). A right-sided PCC was performed on a 44-year-old woman who had been suffering from left groin and thigh pain caused by a fibrosarcoma. PCC produced analgesia below T7 on the left side, and the pain disappeared. A novel spontaneous pain with prominent allodynia occurred postoperatively in the right infraclavicular region (C3-C4). Strong pressure on the left groin where severe spontaneous pain and tenderness had been before PCC increased the new pain, and an epidural block which produced analgesia below T10 relieved the new pain. These facts indicate that the new pain was induced by afferent inputs from the originally painful region.

Spinal termination patterns of canine identified A-delta and C spermatic polymodal receptors traced by intracellular labeling with Phaseolus vulgaris-leucoagglutinin

The spinal projection patterns of spermatic polymodal receptors were studied by intracellular labeling of functionally identified canine dorsal root ganglion (DRG) neurons with Phaseolus vulgaris-leucoagglutinin (PHA-L). The processes of 2 C-fiber and 1 A-delta-fiber spermatic polymodal receptor neurons were labeled well enough to trace their central terminations. The labeled C-fiber DRG neurons were of medium size (mean diameter 36.8 and 40.7 microns). On entering the spinal cord, axons of the C-polyclonal receptors divided into rostral and caudal main branches that extended over 3 spinal segments (20 and 25 mm, respectively), and issued a total of 16 and 15 collaterals, respectively. The majority of collaterals ran in or along the lateral surface, but both neurons had 1 or 2 collaterals or terminal branches running through the middle, or along the medial surface of the dorsal horn. Terminal swellings and en passant enlargements were observed mainly in laminae I, V, and VII. Some C-fiber terminations appeared in lamina II and the adjacent lateral column. The A-delta polymodal receptor had a termination pattern similar to that of the C-fiber units with the exception of a shorter distance over which its 13 identified collaterals were issued (10 mm), and continuation of the rostral main branch into Lissauer's tract (traced for 3.6 mm) after all branches appeared. Two terminal branches were found running just above the central canal in another A-delta neuron in which termination could be only partially traced.(ABSTRACT TRUNCATED AT 250 WORDS)

Responses of neurons in thalamic ventrobasal complex of rats to graded distension of uterus and vagina and to uterine suprafusion with bradykinin and prostaglandin F2 alpha

This study examined the responses of somatic-responsive neurons in and near the ventrobasal complex (VB) of halothane/nitrous oxide-anesthetized and paralyzed estrous virgin rats to increasing levels of distension of the uterine horn and vaginal canal and to uterine suprafusion with PGF2 alpha and bradykinin (BK). While individual responses of single neurons to uterine and vaginal distensions were idiosyncratic, as a group the neurons responded in a graded fashion to graded distensions, producing stimulus-responses functions nearly identical to those produced by conscious rats making escape responses to the same stimuli [Berkley and Wood, Soc. Neurosci, Abstr., 15 (1989) 979; Berkley et al., Soc. Neurosci. Abstr., 16 (1990) 416]. In addition, most neurons responded vigorously to PGF2 alpha and BK, with responses to BK but not PGF2 alpha, reliably preceding the 'giant' uterine contractions that were also produced by these algogenic agents. These results indicate that certain neurons in and near VB may as a group be involved in some aspect of pain arising from female reproductive organs. The responses of these neurons to somatic and possibly other visceral stimuli, however, point to their potential additional involvement in other aspects of visceral and somatic nociception.