GASTROINTESTINAL MOTILITY IN PREGNANCY

Incidence and Risk Factors of Perianal Pathology during Pregnancy and Postpartum Period: A Prospective Cohort Study

OBJECTIVE

We aimed to identify the incidence and risk factors of perianal pathology during pregnancy and the postpartum period.

METHODS

A prospective cohort study was conducted in three institutions in Lithuania. A total of 190 patients were examined and interviewed three times (<12, 18-20 weeks of gestation, and during the first 2 months after delivery). They completed a questionnaire including demographic, obstetric, coloproctological, and birth data.

RESULTS

A total of 73 (34.59%) women developed hemorrhoidal disease after delivery, and 120 (56.87%) developed perianal pathology. Multivariate analysis identified a neonatal birth weight ≥3380 g (OR 4.22; 95% CI 1.83-9.71, p < 0.001) and consumption of eggs (OR 3.10; 95% CI 1.13-8.53, p = 0.028) or cereals (OR 2.87; 95% CI 1.32-6.25, p = 0.008) several times per week as significant risk factors for hemorrhoidal disease. Neonatal birth weight ≥3380 g (OR 3.95; 95% CI 1.47-10.59, p = 0.006), maternal BMI ≥ 21.48 (OR 3.58; 95% CI 1.51-8.47, p = 0.004), the duration of the second labor period ≥38 min (OR 2.81; 95% CI 1.09-7.23, p = 0.032), and consumption of flour products several times per week (OR 2.77; 95% CI 1.10-6.98, p = 0.030) were associated with a higher risk of perianal pathology. Daily consumption of fruits and vegetables (OR 0.35; 95% CI 0.15-0.81, p = 0.014) and less frequent consumption of eggs were protective factors (OR 0.18; 95% CI 0.06-0.56, p = 0.003).

CONCLUSIONS

Perianal diseases, especially hemorrhoidal disease, are common during pregnancy and the postpartum period. A neonatal birth weight ≥ 3380 g, a maternal BMI of ≥21.48, duration of the second labor period of ≥38 min, and consumption of flour products and cereals several times a week are risk factors for developing these diseases.

Sex steroid metabolism and action in colon health and disease

The colon is the largest hormonally active tissue in the human body. It has been known for over a hundred years that various hormones and bioactive peptides play important roles in colon function. More recently there is a growing interest in the role the sex steroids, oestrogens and androgens, may play in both normal colon physiology and colon pathophysiology. In this review, we examine the potential role oestrogens and androgens play in the colon. The metabolism and subsequent action of sex steroids in colonic tissue is discussed and how these hormones impact colon motility is investigated. Furthermore, we also determine how oestrogens and androgens influence colorectal cancer incidence and development and highlight potential new therapeutic targets for this malignancy. This review also examines how sex steroids potentially impact the severity and progression of other colon disease, such as diverticulitis, irritable bowel syndrome, and polyp formation.

The Application of Engineered Nanomaterials in Perinatal Therapeutics

Pregnancy is a vulnerable life stage for the mother and developing fetus. Because of this dual concern, approved therapeutic options for pre-existing conditions or pregnancy-induced pathologies, placental deformities, or fetal concerns are extremely limited. These cases often leave patients and clinicians having to choose between maternal health and fetal development. Recent advancements in nanomedicine and nanotherapeutic devices have made the development of perinatal therapeutics an attractive objective. However, perinatal medicine requires a multifaceted approach given the interactions between maternal, placental, and fetal physiology. Maternal-fetal interactions are centralized to the placenta, a specialized transient barrier organ, to allow for nutrient and waste exchange. Perinatal nanotherapeutics must be designed for placental avoidance or uptake. In this review, pregnancy-related conditions, experimental models, and modes of drug delivery during pregnancy are discussed.

Impact of progesterone on the gastrointestinal tract: a comprehensive literature review

Women are more prone to gastrointestinal symptoms than men. A comprehensive literature search was performed to assess the impact of sex steroid hormone, especially progesterone, on the (healthy and diseased) gastrointestinal tract. Overall, 37 articles were identified. Based on these we conclude that progesterone has a dose-dependent and sex-dependent effect on gastric emptying (especially in mammals), slows down gastrointestinal motility, reduces the gallbladder's response to contractile stimulants, may support gastroesophageal reflux by reducing the esophageal sphincter pressure, may protect from Helicobacter pylori infection gastrointestinal sequelae (especially in mammals) and does not affect inflammatory bowel disease-specific symptoms. However, for several gastrointestinal symptoms and diseases no studies have yet been performed addressing the impact of sex hormone steroids.

Evidence for Implementation: Management of TB in HIV and Pregnancy

PURPOSE OF REVIEW

Pregnant people living with HIV (PLWH) are at especially high risk for progression from latent tuberculosis infection (LTBI) to active tuberculosis (TB) disease. Among pregnant PLWH, concurrent TB increases the risk of complications such as preeclampsia, intrauterine fetal-growth restriction, low birth weight, preterm-delivery, perinatal transmission of HIV, and admission to the neonatal intensive care unit. The grave impact of superimposed TB disease on maternal morbidity and mortality among PLWH necessitates clear guidelines for concomitant therapy and an understanding of the pharmacokinetics (PK) and potential drug-drug interactions (DDIs) between antitubercular (anti-TB) agents and antiretroviral therapy (ART) in pregnancy.

RECENT FINDINGS

This review discusses the currently available evidence on the use of anti-TB agents in pregnant PLWH on ART. Pharmacokinetic and safety studies of anti-TB agents during pregnancy and postpartum are limited, and available data on second-line and newer anti-TB agents used in pregnancy suggest that several research gaps exist. DDIs between ART and anti-TB agents can decrease plasma concentration of ART, with the potential for perinatal transmission of HIV. Current recommendations for the treatment of LTBI, drug-susceptible TB, and multidrug-resistant TB (MDR-TB) are derived from observational studies and case reports in pregnant PLWH. While the use of isoniazid, rifamycins, and ethambutol in pregnancy and their DDIs with various ARTs are well-characterized, there is limited data on the use of pyrazinamide and several new and second-line antitubercular drugs in pregnant PLWH. Further research into treatment outcomes, PK, and safety data for anti-TB agent use during pregnancy and postpartum is urgently needed.

An update on the physiologic changes during pregnancy and their impact on drug pharmacokinetics and pharmacogenomics

For many years, the medical community has relied in clinical practice on historic data about the physiological changes that occur during pregnancy. However, some newer studies have disputed a number of assumptions in these data for not being evidence-based or derived from large prospective cohort-studies. Accurate knowledge of these physiological changes is important for three reasons: Firstly, it facilitates correct diagnosis of diseases during pregnancy; secondly, it enables us to answer questions about the effects of medication during pregnancy and the ways in which pregnancy alters pharmacokinetic and drug-effects; and thirdly, it allows for proper modeling of physiologically-based pharmacokinetic models, which are increasingly used to predict gestation-specific changes and drug-drug interactions, as well as develop new knowledge on the mode-of-action of drugs, the mechanisms underlying their interactions, and any adverse effects following drug exposure. This paper reviews new evidence regarding the physiologic changes during pregnancy in relation to existing knowledge.

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

A Review of Pregnancy-Associated Breast Cancer: Diagnosis, Local and Systemic Treatment, and Prognosis

The incidence of pregnancy-associated breast cancer (PABC) increases as more women choose to delay childbearing and the population-based incidence of breast cancer rises. Reliably and safely staging PABC is necessary to choose between starting with local or systemic therapy. With regard to local therapy, both lumpectomy and mastectomy can be considered depending on gestational age and the stage at diagnosis. By mirroring nonpregnant treatment regimens as much as possible, chemotherapy may improve long-term oncologic outcomes while allowing for surgical downstaging during pregnancy. Delaying treatment due to misconceptions regarding risk of local and systemic therapy most certainly worsens oncologic outcomes, and most neonatal morbidity is related to gestational age at delivery and not in utero exposures. Pregnancy itself was once considered an independent risk factor for worse outcome, but the prognosis of these patients is not significantly different than nonpregnant counterparts of a similar age.

The Role of Placental Hormones in Mediating Maternal Adaptations to Support Pregnancy and Lactation

During pregnancy, the mother must adapt her body systems to support nutrient and oxygen supply for growth of the baby in utero and during the subsequent lactation. These include changes in the cardiovascular, pulmonary, immune and metabolic systems of the mother. Failure to appropriately adjust maternal physiology to the pregnant state may result in pregnancy complications, including gestational diabetes and abnormal birth weight, which can further lead to a range of medically significant complications for the mother and baby. The placenta, which forms the functional interface separating the maternal and fetal circulations, is important for mediating adaptations in maternal physiology. It secretes a plethora of hormones into the maternal circulation which modulate her physiology and transfers the oxygen and nutrients available to the fetus for growth. Among these placental hormones, the prolactin-growth hormone family, steroids and neuropeptides play critical roles in driving maternal physiological adaptations during pregnancy. This review examines the changes that occur in maternal physiology in response to pregnancy and the significance of placental hormone production in mediating such changes.

Estrogen relaxes gastric muscle cells via a nitric oxide- and cyclic guanosine monophosphate-dependent mechanism: A sex-associated differential effect

Various gastrointestinal (GI) disorders have a higher prevalence in women than in men. In addition, estrogen has been demonstrated to have an inhibitory effect on the contractility of GI smooth muscle. Although increased plasma estrogen levels have been implicated in GI disorders, the role of gastric estrogen receptor (ER) in these sex-specific differences remains to be fully elucidated. The present study was designed to investigate the sex-associated differences in the expression of the two ER isoforms, ERα and ERβ, and the effect of estrogen on gastric muscle contraction via the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) pathway. Experiments were performed on single gastric smooth muscle cells (GSMCs) isolated from male and female Sprague Dawley rats. The effect of acetylcholine (ACh), a muscarinic agonist, on the contraction of GSMCs was measured via scanning micrometry in the presence or absence of 1 µM 17β-estradiol (E2), an agonist to the majority of ERs, 1,3,5-tris(4-hydroxyphenyl)-4-propyl-1H-pyrazole (PPT), an ERα agonist, or diarylpropionitrile (DPN), an ERβ agonist. The protein expression levels of ER subtypes in GSMCs were measured using a specifically designed ELISA. GSMCs from female rats had a higher expression of ERα and ERβ protein compared with GSMCs from males. ACh induced less contraction in female that in male GSMCs. Pre-treatment of GSMCs with E2 reduced the contraction of GSMCs from both sexes, but to a greater extent in those from females. PPT and DPN inhibited ACh-induced contraction in GSMCs from females. Furthermore, E2 increased NO and cGMP levels in GSMCs from males and females; however, higher levels were measured in females. Of note, pre-incubation of female GSMCs with Nω-nitro-L-arginine, a NO synthase inhibitor, or 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one, a guanylyl cyclase inhibitor, reduced the inhibitory effect of estrogen on GSMC contraction. In conclusion, estrogen relaxes GSMCs via an NO/cGMP-dependent mechanism, and the reduced contraction in GSMCs from females by estrogen may be associated with the sex-associated increased expression of ERα and ERβ, and greater production of NO and cGMP, compared with that in GSMCs from males.

Primary Care Evaluation and Management of Gastroenterologic Issues in Women

Gastrointestinal disorders often present to the primary care setting where initial preventive, diagnostic, and treatment strategies are implemented. This article reviews the presentation and diagnosis of common gastrointestinal disorders, including colorectal cancer, irritable bowel syndrome, peptic ulcer disease, gallbladder disorders, inflammatory bowel disease, gastroesophageal reflux, and Barrett's esophagus. We focus on the evaluation and management of these diseases in women.

In vitro spontaneous contractile activity of colonic smooth muscle in naive Lewis rats: Acute effect of gonadal hormones

OBJECTIVE

Functional gastrointestinal disorders affect females more often. Changes in colonic motility may be etiological co-factors for the clinical symptoms. The aim of the present study was to analyze the influence of gonadal hormones on colonic contractile activity.

METHODS

In vitro measurements of colonic contractile activity in longitudinal smooth muscle strips of female and male Lewis rats were performed in an organ chamber experiment. After the administration of a gonadal hormone estradiol [EST], progesterone [PROG] and testosterone [TEST]) or ethanol solution as control, stimulation with acetylcholine (ACh) or inhibition with norepinephrine (NE) was performed.

RESULTS

Compared to the smooth muscle strips of male rats, significantly higher spontaneous colonic contractile activity (SCCA) was observed in female animals. Increasing doses of ACh showed the progressive stimulation of SCCA whereas rising doses of NE resulted in a stepwise inhibition of SCCA, respectively. EST superfusion displayed an inhibitory effect on SCCA in both sexes and inhibited the ACh effect in female rats. Similarly, acute superfusion with high-dose PROG inhibited SCCA in females. Acute TEST superfusion inhibited SCCA in males and led to significant higher colonic contractile activity in males following subsequent stimulation with ACh. In female rats, the inhibitory effect of NE was reduced by prior exposure to TEST.

CONCLUSION

In our in vitro study the acute exposure of colonic smooth muscle tissue to gonadal hormones led to sex-dependent changes in SCCA and translated in a modified response of smooth muscle strips to both pro-contractile and anti-contractile neurotransmitters.

Maternal creatine homeostasis is altered during gestation in the spiny mouse: is this a metabolic adaptation to pregnancy?

BACKGROUND

Pregnancy induces adaptations in maternal metabolism to meet the increased need for nutrients by the placenta and fetus. Creatine is an important intracellular metabolite obtained from the diet and also synthesised endogenously. Experimental evidence suggests that the fetus relies on a maternal supply of creatine for much of gestation. However, the impact of pregnancy on maternal creatine homeostasis is unclear. We hypothesise that alteration of maternal creatine homeostasis occurs during pregnancy to ensure adequate levels of this essential substrate are available for maternal tissues, the placenta and fetus. This study aimed to describe maternal creatine homeostasis from mid to late gestation in the precocial spiny mouse.

METHODS

Plasma creatine concentration and urinary excretion were measured from mid to late gestation in pregnant (n = 8) and age-matched virgin female spiny mice (n = 6). At term, body composition and organ weights were assessed and tissue total creatine content determined. mRNA expression of the creatine synthesising enzymes arginine:glycine amidinotransferase (AGAT) and guanidinoacetate methyltransferase (GAMT), and the creatine transporter (CrT1) were assessed by RT-qPCR. Protein expression of AGAT and GAMT was also assessed by western blot analysis.

RESULTS

Plasma creatine and renal creatine excretion decreased significantly from mid to late gestation (P < 0.001, P < 0.05, respectively). Pregnancy resulted in increased lean tissue (P < 0.01), kidney (P < 0.01), liver (P < 0.01) and heart (P < 0.05) mass at term. CrT1 expression was increased in the heart (P < 0.05) and skeletal muscle (P < 0.05) at term compared to non-pregnant tissues, and creatine content of the heart (P < 0.05) and kidney (P < 0.001) were also increased at this time. CrT1 mRNA expression was down-regulated in the liver (<0.01) and brain (<0.01) of pregnant spiny mice at term. Renal AGAT mRNA (P < 0.01) and protein (P < 0.05) expression were both significantly up-regulated at term, with decreased expression of AGAT mRNA (<0.01) and GAMT protein (<0.05) observed in the term pregnant heart. Brain AGAT (<0.01) and GAMT (<0.001) mRNA expression were also decreased at term.

CONCLUSION

Change of maternal creatine status (increased creatine synthesis and reduced creatine excretion) may be a necessary adjustment of maternal physiology to pregnancy to meet the metabolic demands of maternal tissues, the placenta and developing fetus.

Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the treatment of choice for symptomatic choledocholithiasis in pregnant patients. We aimed to present our experience with pregnant patients who underwent nonradiation ERCP and to evaluate the safety and efficacy of a new technique.

METHODS

A retrospective analysis of nonradiation ERCP in 22 pregnant patients with symptomatic choledocholithiasis between January 2002 and December 2013 was performed. The bile aspiration technique with wire-guided sphincterotome was used to confirm selective biliary cannulation. Transpapillary pancreatic septotomy was performed in cases with difficult biliary cannulation (n = 3). After endoscopic biliary sphincterotomy, endoscopic papillary balloon dilation was performed with a 6- or 8-mm dilation balloon in all patients to reduce the risk of recurrent cholangitis because of residual or additional stones. Stones were extracted by balloon sweeping after dilation. All patients were followed for 6 months after the ERCP procedure.

RESULTS

Biliary cannulation was achieved in all patients. Endoscopic papillary balloon dilation was performed with a 6-mm balloon in 17 patients and an 8-mm balloon in five patients. The stones were extracted in 18 of the 22 patients by balloon sweeping, but no stones were extracted in the remaining four patients. There were two cases of mild post-ERCP pancreatitis. All patients delivered at term, and none experienced recurrence of choledocholithiasis and/or cholangitis during the 6-month follow-up.

CONCLUSIONS

Endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation in nonradiation ERCP is a safe and effective treatment method for symptomatic choledocholithiasis during pregnancy.

Acute pancreatitis in pregnancy: a comparison of associated conditions, treatments and complications

OBJECTIVE

Acute pancreatitis is a rare condition in pregnancy. The aim of this study is to compare associated conditions, treatments and complications of pancreatitis in pregnant and age-matched non-pregnant controls.

METHODS

We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 2003 to 2010. A cohort of pregnant women with acute pancreatitis was created and compared to a created age-matched cohort of non-pregnant women with acute pancreatitis at a 1:4 ratio. Comparisons of associated conditions, treatment types, and complications were carried out using unconditional logistic regression.

RESULTS

We identified 7725 cases of acute pancreatitis in pregnancy. As compared to non-pregnant controls, pancreatitis in pregnancy was more likely to be associated with cholelithiasis and less likely with hyperlipidemia and alcohol abuse. Pancreatitis in pregnancy was more likely to be treated with parenteral nutrition and less likely to undergo endoscopic sphincterotomy. As compared to non-pregnant controls, pregnant women with pancreatitis were less likely to have pancreatic pseudocysts/hemorrhage/necrosis, generalized peritonitis, adult respiratory distress syndrome, disseminated intravascular coagulation, and death.

CONCLUSION

Pancreatitis in pregnancy is predominantly caused by cholelithiasis, and unlike in the non-pregnant state, usually has a milder course.

Non-genomic effects of progesterone on Rho kinase II in rat gastric smooth muscle cells

Various studies have shown that pregnancy is associated with gastrointestinal complaints that might result from disturbance of the normal contractile pattern of smooth muscle. Progesterone is an important steroid hormone, which plays a crucial role in female pregnancy. Progesterone affects muscle cells by genomic mechanisms, through nuclear receptors, and non-genomic mechanisms, through unidentified pathways. Non-genomic actions were defined as those occurring within 10 min of progesterone exposure. The aim of the present study was to investigate the non-genomic effect of progesterone on Rho kinase II activity in gastric smooth muscle. Single smooth muscle cells of the stomach obtained from Sprague Dawley rats were used. Dispersed gastric smooth muscle cells were treated with progesterone or acetylcholine (ACh) separately. Cells designated for progesterone treatment were incubated with 1 μM progesterone for 10 min. Rho kinase II expression and both basal and ACh-induced Rho kinase II activity were measured via specifically designed enzyme-linked immunosorbent assay (ELISA) and activity assay kits respectively in both control and progesterone-treated groups. Progesterone inhibited the ACh-induced, but not the basal, Rho kinase II activity in dispersed gastric smooth muscle cells without affecting its expression level. This study suggested that progesterone can rapidly affect the contractile activity of isolated gastric smooth muscle cells in rats via inhibition of the Rho kinase II pathway.

Imaging of pregnant and lactating patients: part 2, evidence-based review and recommendations

OBJECTIVE

The objectives of this article are to discuss the current evidence-based recommendations regarding the use of diagnostic imaging in the evaluation of pulmonary embolism, appendicitis, urolithiasis, and cholelithiasis during pregnancy.

CONCLUSION

Diagnostic imaging should be performed during pregnancy only with an understanding of the maternal and fetal risks and benefits, the comparative advantages of different modalities, and the unique anatomic and physiologic issues associated with pregnancy.

Sex differences in drug effects: interaction with sex hormones in adult life

In recent years, it has become clear that women and men may differ for drug response. Also, there is an increasing recognition on the role of sex hormones on pharmacokinetics and pharmacodynamics as mechanism accounting for sex differences in drug effects.In women, the phases of menstrual cycle, of reproductive life and fluctuations in the concentrations of sexual steroids on pharmacokinetics and pharmacodynamics must be considered. Furthermore, the use of oral contraceptives or hormonal replacement therapy, the sex hormone-related changes in total body water or in the amount of fat influence the overall effect of drugs.On the contrary, the influence of androgens on drug effects is minimal because of the even plasma levels of these hormones in adult males.Nevertheless, since women have been scarcely included in the early phases of clinical trials, the results obtained in men have been often translated to women and their exact response to drugs is still not well known.The available evidence suggests that sex hormones influence drug absorption, distribution, metabolism, pharmacodynamics, and adverse effects. For instance, many cardiovascular drugs are metabolized by enzymes of the cytochrome P450 mono-oxygenases system, which is more expressed in females than in males, showing sex differences in drug response.Upcoming pharmacological research should aim to further clarify the influence of sex hormones on drug effects and, for this purpose, to increase the number of women enrolled in all phases of clinical trials. An evidence-based pharmacotherapy in women is therefore auspicable for women's health.

Difficult intubation in pregnancy

PURPOSE OF REVIEW

This review focuses on difficult intubation in pregnant patients, particularly during the late pregnancy when physiological, patho-physiological and psychological factors may cause or aggravate difficulties with providing sufficient oxygenation and securing the airway. It is intended to highlight the methodological approach to the difficult airway in this particular patient population and to draw relevant principles in dealing with this problem.

RECENT FINDINGS

There are strong indications for improvement in the outcome of airway management in pregnant patients; however, this is obscured by the growing frequency of caesarean sections and connected to this by more tracheal intubations. Various new airway devices have been suggested as alternative techniques for laryngoscopic intubation if the latter becomes difficult or failed.

SUMMARY

A scenario-oriented approach to the problem of difficult intubation in pregnant patients leads to the recognition of the unpredicted difficult or failed intubation as the main concern. The appropriate means to cope with this rare but life-threatening complication lies in a gradual employment of principles beginning with preferential application of regional anaesthesia techniques, followed by proceeding according to locally adapted simple and comprehensive failed intubation algorithms, design of a suitable difficult airway cart that contains only a few but well chosen items and by implementation of a continuous and mandatory training program to which all personnel are subjected to participate in regular intervals.

Progesterone receptors and serotonin levels in colon epithelial cells from females with slow transit constipation

BACKGROUND

Females with slow transit constipation (STC) exhibit progesterone receptor (P4R) overexpression in colon muscle that impair their contractility. These studies examined whether these patients have an overexpression of P4R in epithelial cells and whether P4 affects the SERT-5-HT pathway.

METHODS

Tissues were obtained from surgical specimens of seven females with STC and six controls. Feasibility studies were performed in biopsies from six patients with STC and three controls. P4R, SERT and TPH-1 mRNA and protein expression and 5-HT by ELISA were determined. Contraction was studied in normal muscle cells pretreated with P4 or buffer. Progesterone effects on SERT and 5-HT levels were studied in normal human mucosa in vitro and in wild and SERT knockout mice in vivo.

KEY RESULTS

P4R was overexpressed in epithelial cells in STC compared with controls. The levels of SERT were lower and 5-HT higher in STC. In epithelial cells P4 treatment decreased SERT and increased mucosal 5-HT without affecting TPH-1. Progesterone impaired the contraction of normal muscle cells induced by Ach and 5-HT. Progesterone decreased SERT and increased 5-HT levels in the colon of wild mice in vivo but had no effect on the high basal levels of 5-HT in SERT knockout mice.

CONCLUSIONS & INFERENCES

P4R are present in colon epithelial cells and are overexpressed in females with STC. These cells have reduced SERT and high 5-HT levels and normal TPH-1. These 5-HT signaling abnormalities are related to overexpression of P4R since they are reproduced in human epithelial cells in vitro and in mice in vivo.

BILIARY AND PANCREATIC DISEASE IN PREGNANCY

Pregnancy is a physiological condition that affects all organs. Diseases unrelated to pregnancy may present coincidentally during pregnancy or may be exacerbated by pregnancy, and may increase maternal and/or fetal morbidity or mortality. Compared with many other systems, the changes within the biliary tree and pancreas are relatively minimal. However, pregnancy is associated with an increased likelihood of cholelithiasis, which can have significant implications for the parturient.

[Spontaneous acute intussusception in a pregnant woman]

Acute intussusception in adults is rare and particularly so in pregnant women (between 1 / 5000 and 1 / 68,000 deliveries). It is a life-threatening condition for both the mother and the fetus. In adults, such intussusceptions are mainly secondary to an intestinal disease and frequently a tumour. We describe here a case of spontaneous intussusception during pregnancy and surgical management of the condition. We also analyse the causes specific to pregnancy.

A Greek survey of community prevalence and characteristics of constipation

OBJECTIVES

We evaluated the prevalence and the main characteristics of constipation in the Greek general population.

METHODS

The study sample included 1000 individuals, 15-64-years-old, who were citizens of Athens, Thessaloniki, or one of 11 Greek cities with a population of greater than 10 000, and the sample was selected by a stratified, multistage, random sampling procedure. Questionnaires were completed for each individual by personal interviews.

RESULTS

The prevalence of self-reported constipation within the last year was 14%, whereas another 2% of participants had constipation according to the Rome III criteria. Constipation was significantly less frequent in males than females (11 vs. 21%, P<0.001), younger individuals (15-29-years-old: 12%, 30-59-years-old: 17%, 60-64-years-old: 25%, P = 0.006) and citizens of Athens than in citizens of other Greek cities (19 vs. 13%, P = 0.008). The mean duration of constipation was 6.3 years (females: 6.9, males: 5.1) and its mean frequency was once per 4 days. Constipation was considered to be mostly because of inappropriate diet (51%), stress (30%), and absence of physical activity (19%). Constipated patients mainly used dietary modifications (48%) and/or traditional products (40%), and/or laxatives (48%), whereas 19% of them did not try to treat constipation.

CONCLUSION

Constipation is present in approximately 15% of the Greek general population being significantly more frequent in females and older age individuals. Current dietary habits, stress, and the way of living seem to be considered as its most common causes. Although the duration is usually long, a substantial proportion of constipated patients do nothing to treat the problem, whereas the majority of them use dietary modifications and/or traditional products without satisfactory results.

The safety of histamine 2 (H2) blockers in pregnancy: a meta-analysis

Heartburn and acid reflux increase the severity of nausea and vomiting of pregnancy, and may lead to more serious medical conditions. The fetal safety of histamine 2 (H2) blockers, the most common antireflux medication, during pregnancy needs to be determined. The aim herein is to determine the fetal safety of H2 blockers during pregnancy through systematic review. All original research assessing the safety of H2 blockers in pregnancy was sought. Data included congenital malformations, spontaneous abortions, preterm delivery, and small for gestational age. A random-effects model combined results. With data from 2,398 exposed and 119,892 nonexposed to H2 blockers, overall odds ratio was 1.14 [0.89, 1.45]. Further analysis revealed no increased risks for spontaneous abortions, preterm delivery, and small for gestational age with odds ratios and 95% confidence intervals (CIs) of 0.62 [0.36-1.05], 1.17 [0.94, 1.147], and 0.28 [0.06, 1.22], respectively. H2 blockers can be used safely in pregnancy.

Acupuncture for Dyspepsia in Pregnancy: A Prospective, Randomised, Controlled Study

Objectives

This study was undertaken to describe under real-life conditions the effects of acupuncture on symptomatic dyspepsia during pregnancy and to compare this with a group of patients undergoing conventional treatment alone.

Methods

A total of 42 conventionally treated pregnant women were allocated by chance into two groups to be treated, or not, by acupuncture. They reported the severity of symptoms and the disability these were causing in daily aspects of life such as sleeping and eating, using a numerical rating scale. The study also observed the use of medications.

Results

Six women dropped out (one in the acupuncture group and five in the control group). Significant improvements in symptoms were found in the study group. This group also used less medication and had a greater improvement in their disabilities when compared with the control group.

Conclusions

This study suggests that acupuncture may alleviate dyspepsia during pregnancy.

The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis

OBJECTIVES

Heartburn and acid reflux are common medical disorders in pregnancy and can result in serious discomfort and complications. Furthermore, some pregnant women also experience more severe gastrointestinal conditions, such as Helicobacter pylori infections, peptic ulcers, and Zollinger-Ellison syndrome. To allow the use of proton pump inhibitors (PPIs) in pregnancy, the fetal safety of this drug class must be established. The aim of this study is to determine the fetal safety of PPIs during early pregnancy through systematic literature review.

METHODS

All original research assessing the safety of PPIs in pregnancy was sought from inception to July 2008. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data assessed included congenital malformations, spontaneous abortions, and preterm delivery. A random effects meta-analysis combined the results from included studies.

RESULTS

Of the 60 articles identified, 7 met our inclusion criteria. Using data from 134,940 patients, including 1,530 exposed and 133,410 not exposed to PPIs, the overall odds ratio (OR) for major malformations was 1.12 (95% confidence interval, CI: 0.86-1.45). Further analysis revealed no increased risk for spontaneous abortions (OR=1.29, 95% CI: 0.84-1.97); similarly, there was no increased risk for preterm delivery (OR=1.13, 95% CI: 0.96-1.33). In the secondary analysis of 1,341 exposed and 120,137 not exposed to omeprazole alone, the OR and 95% CI for major malformations were 1.17 and 0.90-1.53, respectively.

CONCLUSIONS

On the basis of these results, PPIs are not associated with an increased risk for major congenital birth defects, spontaneous abortions, or preterm delivery. The narrow range of 95% CIs is further reassuring, suggesting that PPIs can be safely used in pregnancy.

Oestrogen inhibits human colonic motility by a non-genomic cell membrane receptor-dependent mechanism

Background

Classical effects of oestrogen involve activation of target genes after binding nuclear receptors. Oestrogenic effects too rapid for DNA transcription (non-genomic) are known to occur. The effect of oestrogen on colonic motility is unknown despite the prevalence of gastrointestinal symptoms in pregnant and premenopausal women.

Methods

Histologically normal colon was obtained from proximal resection margins of colorectal carcinoma specimens. Circular smooth muscle strips were microdissected and suspended in organ baths under 1 g of tension. After equilibration, they were exposed to 17β-oestradiol (n = 8) or bovine serum albumin (BSA)-conjugated 17β-oestradiol (n = 8). Fulvestrant, an oestrogen receptor antagonist, was added to some baths (n = 8). Other strips were exposed to calphostin C or cycloheximide. Carbachol was added in increasing concentrations and contractile activity was recorded isometrically.

Results

Oestrogen inhibited colonic contractility (mean difference 19·7 per cent; n = 8, P &lt; 0·001). In keeping with non-genomic, rapid-onset steroid action, the effect was apparent within minutes and reversible. It was observed with both 17β-oestradiol and BSA-conjugated oestrogen, and was not altered by cycloheximide. Effects were inhibited by fulvestrant, suggesting receptor mediation.

Conclusion

Oestrogen decreases contractility in human colonic smooth muscle by a non-genomic mechanism involving cell membrane coupling.

Pregnancy-associated liver disorders

Liver disorders associated with pregnancy include hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP), and acute fatty liver of pregnancy (AFLP). These conditions are relatively common and unique to pregnancy and are more likely to occur at certain terms of gestation specific to each condition. They can be associated with significant maternal and fetal morbidity and mortality. Although managing such patients may be very challenging, spontaneous resolution of the disease occurs shortly after termination of the pregnancy, usually without hepatic sequellae. Early diagnosis and timely treatment is a key to therapeutic success. This article explores the clinical features, pathophysiology, and management of these disorders.

Overexpression of progesterone receptor B increases sensitivity of human colon muscle cells to progesterone

Colon muscle strips and cells from female patients with slow-transit constipation (STC) exhibit impaired motility, signal transduction abnormalities characterized by downregulation of Gq/11 and upregulation of Gs proteins, decreased cyclooxygenase (COX)-1 and thromboxane (Tx)B2 levels, increased COX-2 and PGE2 levels, and overexpression of progesterone receptors (PGR). Progesterone (P4) treatment of normal cells reproduced these motility and signal transduction abnormalities. The purpose of the study was to examine whether overexpression of PGR-B reproduces these abnormalities by rendering the cells more sensitive to physiological concentrations of P4. Cultured human colon muscle was transfected with a plasmid DNA expressing PGR-B. The mRNAs of PGR, COX-1, COX-2, and Gq/11 were determined by quantitative real-time PCR. Their protein expression was determined by Western blot, and prostaglandins were measured by radioimmunoassay. Cultured muscle cells maintained their phenotypic features determined with myosin light chain (MLC) and h-caldesmon antibodies. Control and transfected muscle cells responded to 10(-6) M P4. In contrast, muscle cells transfected with PGR-B responded to lower P4 concentration (10(-7) M). This P4 concentration reduced MLC phosphorylation induced by CCK-8 (10(-8) M), downregulated Gq/11, and decreased COX-1 and TxB2 levels. It upregulated Gs proteins. It also increased COX-2 and PGE2 levels. We conclude that overexpression of PGR-B renders the cells more sensitive to physiological concentrations of P4. These results are consistent with the hypothesis that overexpression of PGR-B contributes to the motility and signal transduction abnormalities observed in female patients with STC and normal serum levels of P4.

Inhibitory effects of genistein and resveratrol on guinea pig gallbladder contractility in vitro

AIM: To observe and compare the effects of phytoestrogen genistein, resveratrol and 17β-estradiol on the tonic contraction and the phasic contraction of isolated gallbladder muscle strips and to study the underlying mechanisms.

METHODS: Isolated strips of gallbladder muscle from guinea pigs were suspended in organ baths containing Kreb’s solution, and the contractilities of strips were measured before and after incubation with genistein, resveratrol and 17β-estradiol respectively.

RESULTS: Similar to 17β-estradiol, genistein and resveratrol could dose-dependently inhibit the phasic contractile activities, they decreased the mean contractile amplitude and the contractile frequencies of gallbladder muscle strips, and also produced a marked reduction in resting tone. The blocker of estrogen receptor ICI 182780 failed to alter the inhibitory effects induced by genistein and resveratrol, but potassium bisperoxo (1, 10 phenanthroline) oxovanadate bpV (phen), a potent protein tyrosine phosphatase inhibitor, markedly attenuated the inhibitory effects induced by genistein and resveratrol. In calcium-free Kreb’s solution containing 0.01 mmol/L egtazic acid (EGTA), genistein and resveratrol inhibited the first phasic contraction induced by acetylcholine (ACh), but did not affect the second contraction induced by CaCl₂. In addition, genistein, resveratrol and 17β-estradiol also could reduce the contractile responses of ACh and KCl, and shift their cumulative concentration-response curves rightward.

CONCLUSION: Phytoestrogen genistein and resveratrol can directly inhibit the contractile activity of isolated gallbladder muscle both at rest and in response to stimulation. The mechanisms responsible for the inhibitory effects probably due mainly to inhibition of tyrosine kinase, Ca²⁺ influx through potential-dependent calcium channels (PDCs) and Ca²⁺ release from sarcoplasmic reticulum (SR), but were not related to the estrogen receptors.

Coordinate regulation of gallbladder motor function in the gut-liver axis

Gallstones are one of the most common digestive diseases with an estimated prevalence of 10%-15% in adults living in the western world, where cholesterol-enriched gallstones represent 75%-80% of all gallstones. In cholesterol gallstone disease, the gallbladder becomes the target organ of a complex metabolic disease. Indeed, a fine coordinated hepatobiliary and gastrointestinal function, including gallbladder motility in the fasting and postprandial state, is of crucial importance to prevent crystallization and precipitation of excess cholesterol in gallbladder bile. Also, gallbladder itself plays a physiopathological role in biliary lipid absorption. Here, we present a comprehensive view on the regulation of gallbladder motor function by focusing on recent discoveries in animal and human studies, and we discuss the role of the gallbladder in the pathogenesis of gallstone formation.

Cumulative incidence of chronic constipation: a population-based study 1988-2003

AIM

To estimate the cumulative incidence of chronic constipation and evaluate potential risk factors.

METHODS

In previous cross-sectional studies in 1988, random samples of Olmsted County, MN residents were mailed valid gastrointestinal symptoms surveys. A similar survey was mailed in 2003 to all the remaining eligible subjects who had been mailed to previously. An incident case of chronic constipation was defined as no reported constipation or irritable bowel syndrome on their initial survey but reported constipation on the second survey.

RESULTS

In all, 5507 (79%) subjects responded to the initial survey and 2298 (55%) subjects responded to the second survey in which chronic constipation could be defined. Over 12 years, the cumulative incidence of chronic constipation was 17.4% (14.5, 20.5). Among those less than age 50 years at baseline, the incidence of chronic constipation differed by gender (9.2% in men vs. 18.3% in women). In those over 70 years, the incidence of chronic constipation was more similar for men and women (20.6% vs. 25.0%). The other risk factor associated with new onset chronic constipation was the presence of abdominal pain at baseline [OR = 2.0 (1.3, 3.0)].

CONCLUSION

The cumulative incidence of chronic constipation over more than a decade was almost one in six, and more pronounced in women and the elderly.

Epidemiology of slow and fast colonic transit using a scale of stool form in a community

BACKGROUND

Measurement of gastrointestinal transit is commonly performed in the clinic, but data on transit in the community are lacking.

AIM

To estimate the prevalence of slow and fast colonic transit using stool form, and potential risk factors.

METHODS

A validated self-reported gastrointestinal symptom questionnaire was mailed to 4196 randomly selected members of the community (response rate 54%). One question asked the subject to self-report their stool form using the Bristol Stool Scale.

RESULTS

Overall, 18%, 9% and 73% met stool form criteria for slow, fast or normal colonic transit, respectively. Increased odds for slow transit were observed with a higher Somatic Symptom Checklist score (OR = 1.6; 1.3-2.0), while a decreased odds for slow transit was observed in males relative to females (OR = 0.6; 0.5-0.8). An increased odds for fast transit was observed with higher Somatic Symptom Checklist score (OR = 2.3; 1.7-2.9) and a history of cholecystectomy (OR = 1.8; 1.2-2.8). Increasing body mass index (per 5 units) was associated with decreased odds for slow (OR = 0.85; 0.78-0.93), and an increased odds for fast (OR = 1.1; 1.04-1.24) colonic transit.

CONCLUSION

Based on stool form assessment, nearly one in five community members may have slow colonic transit and one in 12 have accelerated colonic transit.

Abnormalities of prostaglandins and cyclooxygenase enzymes in female patients with slow-transit constipation

BACKGROUND AND AIMS

Chronic constipation due to slow transit (STC) is more common in female than in male patients. We have previously shown that these gender differences may be due to over expression of progesterone (PG) receptors that alter G protein patterns. We sought to elucidate the mechanisms responsible for the impaired basal colonic motility in female patients with STC.

METHODS

Muscle tissues from females with STC and controls with adeno-carcinoma of the colon were studied. Prostaglandins were determined by immunoassay, COX enzymes by Western blot and COX enzymes and progesterone receptors mRNA by RT-PCR.

RESULTS

STC patients had impaired colonic motility index, lower TxA(2) and PGF(2) and higher PGE(2) levels than controls. STC had lower COX-1 protein and mRNA levels and higher COX-2 protein and mRNA levels than controls. These abnormalities were reproduced in normal colonic muscle cells treated with PG for 6 h. STC patients had higher PG receptor protein expression and mRNA levels than controls suggesting over expression of these receptors.

CONCLUSIONS

These findings suggest that the impaired motility index of STC is due to abnormal levels of prostaglandin and COX enzymes, probably caused by an over expression of PG receptors that make muscle cells more sensitive to circulating levels of PG.

Iron supplementation in pregnancy—does the preparation matter?

OBJECTIVE

To assess the use, side effects and discontinuation rates of iron preparations during pregnancy.

DESIGN

Six hundred and twelve randomly selected postpartum women completed a questionnaire on iron supplement use in the second and third trimesters.

RESULTS

Of the 517 women (84.5%) reported using iron supplements, 453 were eligible for the study. The most common preparation was ferrous fumarate (46.8%, P < 0.01), followed by ferrous sulfate (31.8%), ferric polymaltose (12.4%), and ferric bisglycinate (7.3%). Almost half the participants (45%) reported at least one adverse effect, especially constipation (27.4%, P < 0.01), nausea (10.8%). Multivitamin preparations and ferric bisglycinate were associated with the fewest side effects (23.7, 21.2% respectively, P < 0.01), and ferrous fumarate and immediate-release ferrous sulfate with the most (56.3, 53.7% respectively). Eighty-three women discontinued their originally prescribed iron preparation, mainly (89%) due to side effects. Discontinuation rates were lowest for the multivitamin and ferric bisglycinate (10.5, 9.1%, respectively). In most cases, the specific preparation was recommended by the women's physician (76%).

CONCLUSION

Ferrous fumarate-containing multivitamin preparations and ferric bisglycinate, although infrequently recommended as the first-line of iron supplementation, may be associated with less side effects and better compliance.

Interstitial Cajal-like cells (ICLC) as steroid hormone sensors in human myometrium: immunocytochemical approach

Expression of estrogen (ER) and progesterone (PR) receptors was investigated in cultured human normal myometrial cells (non-pregnant uterus, fertile period). The ER and PR expression was studied by immunohistochemistry and immunofluorescence on either myocytes or interstitial Cajal-like cells (ICLC). Only those cells double immunostained for c-kit and steroid receptors were considered as ICLC. ER and/or PR immunoreactivity was localized in ICLC, primarily concentrated at the nucleus level, but it was also observed in the cell body (cytoplasm) and processes. Stronger immunopositive reaction in the ICLC nucleus for PR than for ER was noted. Under our experimental conditions, a clear positive repeatable reaction for steroid receptors could not be detected in myocytes. In conclusion, these data suggest that ICLC could be true hormonal 'sensors', possibly participating in the regulation of human myometrial contractions (via gap junctions with myocytes and/or by paracrine signaling).

Risk factors associated with gallstone and biliary sludge formation during pregnancy

AIM

To define the risk factors in gallstone and sludge formation, and to investigate the incidence of gallstone and biliary sludge formation during pregnancy in a group of healthy pregnant women.

METHODS

Sixty-nine healthy pregnant women in early gestation and 28 nulliparous healthy controls were enrolled. Gallbladder volumes, gallbladder ejection fraction (GBEF), serum triglyceride and cholesterol levels were determined in both groups. In the pregnant group, repeated measurements were performed immediately after delivery and compared with initial levels. Risk factors, which are associated with gallstone and biliary sludge development during pregnancy, were determined by linear regression analysis.

RESULTS

No statistically significant difference was observed in the assessed parameters of pregnant women in early gestation and controls (both P > 0.05). In the pregnant group, gallstone and biliary sludge development during pregnancy were detected in 6.3% and 10.9% of cases, respectively. The detected parameters were significantly higher early after delivery than in early gestation, while GBEF was lower (both P < 0.001). Lower GBEF was the most significant factor (P < 0.001) associated with gallstone and sludge formation during pregnancy, while multiple childbirths was the other (P = 0.04).

CONCLUSION

Decrease in GBEF is the most significant risk factor for newly developed gallstone and sludge in pregnant women, while multiple childbirths is the other but less important risk factor.

The inhibitory effects of oxytocin on distal colonic contractile activity in rabbits are enhanced by ovarian steroids

AIMS

To study the effects of oxytocin on isolated rabbit distal colon and the regulation of ovarian steroids by its action.

METHODS

Muscle strips parallel to either the circular or the longitudinal fibres were excised and suspended in tissue chambers containing 5 mL Krebs solution (37 degrees C) and bubbled continuously with 95% O(2) and 5% CO(2). The effects of oxytocin on isometric spontaneous contractile responses were recorded. The effects of atosiban, tetrodotoxin, Mg(2+), progesterone and oestradiol on the oxytocin-induced response were also examined.

RESULTS

Oxytocin (1, 10 and 100 nmol L(-1)) dose dependently decreased the area under the contraction curve of distal colonic smooth muscle strips. The oxytocin receptor antagonist atosiban blocked the oxytocin (10 nmol L(-1))-caused responses in a dose-dependent manner. Tetrodotoxin (10 micromol L(-1)) had no effect on the oxytocin-induced response. Mg(2+)-free Krebs solution attenuated the oxytocin-induced response, but oestradiol (0.1 micromol L(-1)) or progesterone (0.1 micromol L(-1)) increased the oxytocin-induced response.

CONCLUSION

These results suggest that oxytocin inhibits the contractile motility of the distal colon, which is regulated by Mg(2+) and ovarian steroids.

Gallstone disease: Symptoms and diagnosis of gallbladder stones

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis

Acute pancreatitis is a severe complication of gallstones with considerable mortality. We sought to explore the potential risk factors for biliary pancreatitis. We compared postprandial gallbladder motility (via ultrasonography) and, after subsequent cholecystectomy, numbers, sizes, and types of gallstones; gallbladder bile composition; and cholesterol crystallization in 21 gallstone patients with previous pancreatitis and 30 patients with uncomplicated symptomatic gallstones. Gallbladder motility was stronger in pancreatitis patients than in patients with uncomplicated symptomatic gallstones (minimum postprandial gallbladder volumes: 5.8 +/- 1.0 vs. 8.1 +/- 0.7 mL; P = .005). Pancreatitis patients had more often sludge (41% vs. 13%; P = .03) and smaller and more gallstones than patients with symptomatic gallstones (smallest stone diameters: 2 +/- 1 vs. 8 +/- 2 mm; P = .001). Also, crystallization occurred much faster in the bile of pancreatitis patients (1.0 +/- 0.0 vs. 2.5 +/- 0.4 days; P < .001), possibly because of higher mucin concentrations (3.3 +/- 1.9 vs. 0.8 +/- 0.2 mg/mL; P = .04). No significant differences were found in types of gallstones, relative biliary lipid contents, cholesterol saturation indexes, bile salt species composition, phospholipid classes, total protein or immunoglobulin (G, M, and A), haptoglobin, and alpha-1 acid glycoprotein concentrations. In conclusion, patients with small gallbladder stones and/or preserved gallbladder motility are at increased risk of pancreatitis. The potential benefit of prophylactic cholecystectomy in this patient category has yet to be explored.

Role of progesterone signaling in the regulation of G-protein levels in female chronic constipation

BACKGROUND & AIMS

Chronic constipation caused by slow transit is common in women with an F/M ratio of 9:1. The cause and mechanisms responsible for this syndrome are unknown. Progesterone has been suggested as a possible contributing factor. Our aim was to investigate the site and mechanisms responsible for this colonic motility disorder.

METHODS

Seven women with intractable constipation and slow transit time underwent colectomy and 6 women who underwent a left colectomy for adenocarcinoma (controls) were studied. Dissociated colonic circular muscle cells were obtained by enzymatic digestion. Changes in G-protein levels were measured by Western blot. The messenger RNA (mRNA) expression of Galpha q and progesterone receptors was determined by reverse-transcription polymerase chain reaction and Northern blot.

RESULTS

Muscle cells from patients with chronic constipation exhibited impaired contraction in response to receptor-G-protein-dependent agonists (cholecystokinin [CCK], acetylcholine) and in response to the direct G-protein activator guanosine 5'-O-(3-thiophosphate). Contraction was normal with receptor-G-protein-independent agonists (diacylglycerol and KCl). Western blot showed down-regulation of Galpha q/11 and up-regulation of Galpha s proteins in patients with chronic constipation. The mRNA expression of Galpha q was lower and the progesterone receptors were overexpressed in patients with chronic constipation compared with controls. These abnormalities were reproduced in vitro by pretreatment of normal colonic muscle cells with progesterone for 4 hours.

CONCLUSIONS

Slow transit chronic constipation in women may be caused by down-regulation of contractile G proteins and up-regulation of inhibitory G proteins, probably caused by overexpression of progesterone receptors.

The pregnant wilderness traveler

BACKGROUND

Travel during pregnancy, especially, when it involves potentially hazardous activities in remote areas, often raises serious concerns regarding the health and safety risks involved.

METHOD

The authors have researched the available medical literature to identify these risks and present the current recommendations for their prevention and treatment.

RESULTS

Topics addressed include some political and social issues, insurance, basic comfort measures, complications of pregnancy, infectious diseases, environmental exposures, and trauma. Preventive measures include pre-travel evaluation and teaching, possible modifications of the itinerary, vaccinations and medications. Also briefly discussed are the handling of obstetrical emergencies in the field and medical evacuation of the pregnant patient.

CONCLUSIONS

The authors conclude that many trips of this nature can be made relatively safe for the pregnant traveler, but she may need to accept some precautions and modifications of the itinerary that might not otherwise be necessary.

The role of proton pump inhibitors in the treatment of heartburn during pregnancy

PURPOSE

To review the problem of heartburn in gravid women, discuss the present treatment options, and examine the use of proton pump inhibitors (PPIs) as one of the treatment options for moderate to severe heartburn.

DATA SOURCES

Extensive review of worldwide scientific literature on the use and safety of PPIs during pregnancy and heartburn during pregnancy.

CONCLUSIONS

Preliminary information indicates that use of PPIs during pregnancy is safe for both the fetus and the woman and that obstetrical practitioners are using them more frequently. Randomized controlled trials are needed to examine the efficacy of PPIs to treat heartburn during pregnancy, especially as they are compared to histamine(2) receptor antagonists.

IMPLICATIONS FOR PRACTICE

Heartburn during pregnancy is at risk for being undertreated, given that delivery is the cure. As PPIs are more widely used by women, questions will arise regarding their use in the first trimester as well as throughout pregnancy. This article brings nurse practitioners up to date on the safety of PPIs through the literature review and suggests various treatment options that can be discussed with the patient.

Liver disease in pregnancy

Liver dysfunction during pregnancy can be caused by conditions that are specific to pregnancy or by liver diseases that are not related to pregnancy itself. This review attempts to summarize the epidemiology, pathophysiology, and management of the different pregnancy-related liver diseases, and to review different liver diseases not related to pregnancy and how they may affect or be effected by pregnancy. Some of the liver diseases specific to pregnancy can cause significant morbidity and mortality both to the mother and to the fetus, while most of the liver diseases not specific to pregnancy do not have a deleterious effect on the pregnancy itself.

Effect of sex steroids on colonic distension-induced delay of gastric emptying in rats

BACKGROUND AND AIM

The objective of the present study was to examine the effect of gonadal hormones on gastric motor response to non-noxious and noxious stimuli of colonic distension.

METHODS

Male Wistar albino rats were used. Under ketamine anesthesia some rats underwent castration (n = 24), while the rest of the rats were sham-operated (n = 67) and divided into different groups (n = 7-8 per group). On the 15th day of surgery, liquid gastric emptying studies were commenced.

RESULTS

Non-noxious (P < 0.05) or noxious (P < 0.01) colonic distension inhibited gastric emptying rate. Estradiol pretreatment (20 micro g/kg per day, for 5 days, s.c.) inhibited gastric motility, while estradiol pretreatment or castration of the rats prior to noxious distension prevented the delay in gastric emptying. In contrast, blockade of testosterone receptors had no effect on the delay in gastric emptying induced by either modes of distension.

CONCLUSIONS

The results suggest that sex steroids have a modulatory role on the feedback control of gastric motility induced by noxious colonic distension.

Methods of measuring gallbladder motor functions--the need for standardization: scintigraphy

Emptying the gallbladder is part of the complex process of food digestion. The gallbladder interacts with other gastrointestinal organs and its movements are coordinated and modified by functions of the stomach, intestine and pancreas. Many factors can modify gallbladder motility, for example, sex and age of the subject, their body mass, the kinds of food ingested and stimulus used. The assumption that the gallbladder progressively empties during meals and refills during fasting is incorrect. Using a combination of ultrasonography and cholescintigraphy, it is possible to measure absolute and net gallbladder emptying. In this way we demonstrated that the gallbladder begins to refill immediately after emptying begins, and the difference between net and absolute emptying of the gallbladder indicates the refilling of bile and provides a measure of bile turnover rate, an accurate index to assess gallbladder motility.