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Kudrow D, Nguyen L, Semler J, Stroud C, Samaan K, Hoban DB, Wietecha L, Hsu H, Pearlman E. A phase IV clinical trial of gastrointestinal motility in adult patients with migraine before and after initiation of a calcitonin gene-related peptide ligand (galcanezumab) or receptor (erenumab) antagonist. Headache 2022; 62:1164-1176. [PMID: 36111429 PMCID: PMC9826055 DOI: 10.1111/head.14390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/06/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To compare effects of an initial dose of calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) antagonists on gastrointestinal (GI) motility in patients with migraine and to explore if the mechanistic difference contributes to GI adverse events (AEs). BACKGROUND Different frequencies of constipation have been observed between CGRP mAbs that target the ligand (galcanezumab [GMB]) or receptor (erenumab [ERE]). METHODS Patients (n = 65) with migraine without significant GI symptoms were enrolled in a multi-center, single-blind phase IV clinical trial (NCT04294147) and randomized 1:1 to receive GMB (240 mg; n = 33) or ERE (140 mg; n = 32). GI whole and regional transit times were assessed using a wireless motility capsule 1 week before and 2 weeks after mAb administration. The primary endpoint was change from baseline in colonic transit time (CTT) within each treatment group. Other measures included GI Symptom Rating Scale (GSRS), Bristol Stool Form Scale (BSFS), and spontaneous bowel movement (SBM) evaluation. AEs were monitored throughout the study. RESULTS Baseline characteristics indicated significant GI transit time variability with minimal GI reported symptoms. While not statistically significant, a numerical mean increase in CTT was observed in ERE patients (n = 28, mean [SD] at baseline: 33.8 [29.4] h; least square [LS] mean [SE] change: 5.8 [5.7] h, 95% confidence interval [CI] -5.7 to 17.2, p = 0.320), while GMB decreased CTT (n = 31, mean [SD] at baseline: 29.3 [24.5] h; LS mean [SE] change: -5.4 [5.4] h, 95% CI -16.2 to 5.5, p = 0.328) compared to baseline. No meaningful changes were observed in other regional transit times. ERE significantly reduced BSFS (LS mean [SE] score -0.5 [0.2], p = 0.004) and SBM (LS mean [SE] -1.2 [0.5], p = 0.0120), and increased GSRS-constipation compared to baseline (LS mean [SE] score 0.3 [0.1], p = 0.016). GMB increased GSRS-constipation (LS mean [SE] score 0.4 [0.1], p = 0.002). There were no discontinuations due to or serious AEs. A higher percentage of treatment-emergent AEs were reported with ERE than GMB (ERE: nine of 32 [28.1%] versus GMB: three of 33 [9.1%]), with constipation the most frequently reported (ERE: five of 32 [15.6%] versus GMB one of 33 [3.0%]). CONCLUSION While the primary endpoint of this study was not met, secondary and tertiary endpoints support a within- and between-treatment change in GI effects suggesting possible mechanistic differences between ligand (GMB) and receptor (ERE) antagonism.
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Affiliation(s)
- David Kudrow
- California Medical Clinic for HeadacheSanta MonicaCaliforniaUSA
| | - Linda Nguyen
- Division of GastroenterologyStanford UniversityPalo AltoCaliforniaUSA
| | | | | | | | | | | | - Hai‐An Hsu
- Eli Lilly and CompanyIndianapolisIndianaUSA
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Clinical Impact of Rectal Hyposensitivity: A Cross-Sectional Study of 2,876 Patients With Refractory Functional Constipation. Am J Gastroenterol 2021; 116:758-768. [PMID: 33982946 DOI: 10.14309/ajg.0000000000001039] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Normal bowel function requires intact sensory pathways. Diminished rectal sensation (rectal hyposensitivity [RH]) is associated with constipation, although its clinical importance remains unclear. METHODS Consecutive patients (aged 18-80) attending a tertiary center (2004-2016) for investigation of refractory functional constipation (Rome IV core criteria defined, applied post hoc) were included. Patients completed a clinical symptom questionnaire and underwent anorectal physiologic investigations, including rectal sensory testing (balloon distension) to determine 3 well-established sensory thresholds. Multivariate regression analyses were performed to evaluate associations between RH, symptomology, and allied physiologic investigations. RESULTS Of 2,876 patients meeting inclusion criteria, 722 (25%) had RH based on ≥1 elevated sensory thresholds (0: n = 2,154 [74.9%]; 1: n = 327 [11.4%]; 2: n = 209 [7.3%]; and 3: n = 186 [6.5%]). A linear relationship existed between increasing number of elevated sensory thresholds and constipation severity (Cleveland Clinic constipation score: mean difference per threshold [95% confidence interval] 0.69 [0.48-0.90]; P < 0.001). Several symptoms were significantly (P < 0.05) associated with RH including: infrequent defecation (odds ratio 1.29 [1.17-1.42]), painful evacuation (1.15 [1.05-1.27]), prolonged toileting (1.14 [1.05-1.24]), and digitation or enema use (1.18 [1.08-1.30]). On defecography, a "functional" evacuation disorder was also associated with RH (1.37 [1.25-1.50], P < 0.001), as was megarectum (2.52 [2.08-3.05], P < 0.001). DISCUSSION RH occurs in 25% of patients with refractory functional constipation. Increased number of elevated sensory thresholds is associated with more severe constipation phenotype. These data, in the largest study to date, provide for the first time evidence to show that RH is a major pathophysiologic mechanism in constipation, with recognized clinical impact (http://links.lww.com/AJG/B765).(Equation is included in full-text article.).
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Li C, Shuai Y, Zhou X, Chen H. Association between Helicobacter pylori infection and irritable bowel syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22975. [PMID: 33327230 PMCID: PMC7738067 DOI: 10.1097/md.0000000000022975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In recent years, the incidence of IBS has gradually increased, and it is considered as one of the most common functional gastrointestinal diseases. However, the etiology of IBS is still unclear, and expectations are rising for more targeted treatments. Many clinical trials have explored the link between Helicobacter pylori (H pylori) and IBS, with different conclusions. Therefore, we conducted a meta-analysis to explore whether there is an association between H pylori and IBS, which is of great significance for targeted treatment of IBS. METHODS We performed a systematic review and meta-analysis of the association between H pylori and IBS. We searched PubMed, EMBASE, Medline and the Cochrane Library to collect related studies. OR was used to describe the ratio of the probability of the H pylori infection occurring in IBS patients versus the controls. Heterogeneity was assessed by subgroup and meta-regression analysis. RESULTS Eight studies, including 1861 patients, assessed the association between H pylori infection and IBS. The OR of H pylori in IBS patients compared to controls was 1.32 (95% CI: 0.94-1.87; P = 0.11). Subgroup analyses showed a difference between IBS patients diagnosed with Roman III criteria and those diagnosed with non-Roman III criteria. CONCLUSIONS Our study suggests that H pylori may have a positive effect on the development of IBS. Although the differences were not statistically significant, there were significant differences among subgroups of patients. Considering the limitations and heterogeneity, high quality studies are needed to further explore the effect of H pylori on the development of IBS.
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Affiliation(s)
- Chenyu Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, Jiangxi Province
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yujun Shuai
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, Jiangxi Province
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Xiaodong Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, Jiangxi Province
| | - Hongxia Chen
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Nanchang University
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Wen Y, Li J, Long Q, Yue CC, He B, Tang XG. The efficacy and safety of probiotics for patients with constipation-predominant irritable bowel syndrome: A systematic review and meta-analysis based on seventeen randomized controlled trials. Int J Surg 2020; 79:111-119. [DOI: 10.1016/j.ijsu.2020.04.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
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The efficacy and safety of probiotics in patients with irritable bowel syndrome: Evidence based on 35 randomized controlled trials. Int J Surg 2020; 75:116-127. [DOI: 10.1016/j.ijsu.2020.01.142] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/11/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
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Marola S, Ferrarese A, Gibin E, Capobianco M, Bertolotto A, Enrico S, Solej M, Martino V, Destefano I, Nano M. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study. Open Med (Wars) 2016; 11:509-517. [PMID: 28352843 PMCID: PMC5329875 DOI: 10.1515/med-2016-0088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 11/15/2022] Open
Abstract
Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient. RESULTS Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively). CONCLUSIONS The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.
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Affiliation(s)
- Silvia Marola
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Alessia Ferrarese
- University of Turin, Section of General Surgery, San Luigi Gonzaga Teaching Hospital, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Enrico Gibin
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Marco Capobianco
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Antonio Bertolotto
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Stefano Enrico
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Mario Solej
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Valter Martino
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Ines Destefano
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
| | - Mario Nano
- University of Turin, Department of Oncology, School of Medicine, Teaching Hospital “San Luigi Gonzaga”, Section of General Surgery, Orbassano, Turin, Italy
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Glickman-Simon R, Wallace J. Acupuncture for Knee Osteoarthritis, Chasteberry for Premenstrual Syndrome, Probiotics for Irritable Bowel Syndrome, Yoga for Hypertension, and Trigger Point Dry Needling for Plantar Fasciitis. Explore (NY) 2015; 11:157-61. [DOI: 10.1016/j.explore.2014.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ford AC, Quigley EMM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, Soffer EE, Spiegel BMR, Moayyedi P. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. Am J Gastroenterol 2014; 109:1547-61; quiz 1546, 1562. [PMID: 25070051 DOI: 10.1038/ajg.2014.202] [Citation(s) in RCA: 447] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 04/30/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) are functional bowel disorders. Evidence suggests that disturbance in the gastrointestinal microbiota may be implicated in both conditions. We performed a systematic review and meta-analysis to examine the efficacy of prebiotics, probiotics, and synbiotics in IBS and CIC. METHODS MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Randomized controlled trials (RCTs) recruiting adults with IBS or CIC, which compared prebiotics, probiotics, or synbiotics with placebo or no therapy, were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). Continuous data were pooled using a standardized or weighted mean difference with a 95% CI. RESULTS The search strategy identified 3,216 citations. Forty-three RCTs were eligible for inclusion. The RR of IBS symptoms persisting with probiotics vs. placebo was 0.79 (95% CI 0.70-0.89). Probiotics had beneficial effects on global IBS, abdominal pain, bloating, and flatulence scores. Data for prebiotics and synbiotics in IBS were sparse. Probiotics appeared to have beneficial effects in CIC (mean increase in number of stools per week=1.49; 95% CI=1.02-1.96), but there were only two RCTs. Synbiotics also appeared beneficial (RR of failure to respond to therapy=0.78; 95% CI 0.67-0.92). Again, trials for prebiotics were few in number, and no definite conclusions could be drawn. CONCLUSIONS Probiotics are effective treatments for IBS, although which individual species and strains are the most beneficial remains unclear. Further evidence is required before the role of prebiotics or synbiotics in IBS is known. The efficacy of all three therapies in CIC is also uncertain.
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Affiliation(s)
- Alexander C Ford
- 1] Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK [2] Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - Brian E Lacy
- Dartmouth-Hitchcock Medical Center, Gastroenterology, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Anthony J Lembo
- The Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yuri A Saito
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence R Schiller
- Digestive Health Associates of Texas, Baylor University Medical Center, Dallas, Texas, USA
| | - Edy E Soffer
- Division of Gastroenterology at Cedars-Sinai, University of Southern California, Los Angeles, California, USA
| | - Brennan M R Spiegel
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Paul Moayyedi
- Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, Ontario, Canada
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Abstract
Intestinal motor and sensory dysfunctions in traumatic complete or incomplete spinal cord injury (SCI) are frequent and result in altered mechanisms of defecation. The aim of this study is to investigate sigmoid compliance and perception in chronic SCI patients. Sigmoid responses to fixed-tension distentions were assessed using a tensostat in six patients (six men, 42 ± 4 years) with chronic complete transection of the spinal cord (high-SCI; five tetraplegic C5-C7 and one paraplegic T4-T6) and impaired evacuation (i.e. constipation). A group of 10 healthy individuals (six men, 25 ± 1 years) served as controls. SCI patients had higher sigmoid compliance at the highest distention level than the controls (10.3 ± 2.4 vs. 5.1 ± 0.8 ml/mmHg; P<0.05). Perception scores at first sensation were higher in SCI patients (2.3 ± 0.7 vs. 1.1 ± 0.1; P<0.05), but were not different at the highest distention levels (3.7 ± 0.8 vs. 3 ± 1; NS). The most commonly reported sensation by patients was distention/bloating and was referred less commonly to the hypogastrium compared with distention/bloating in controls. An increased sigmoid compliance can be detected in constipated SCI patients. The preservation of some degree of visceral sensations, although abnormally referred, could imply the occurrence of sensory input remodeling at the spinal level.
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Bassotti G, Villanacci V, Bellomi A, Fante R, Cadei M, Vicenzi L, Tonelli F, Nesi G, Asteria CR. An assessment of enteric nervous system and estroprogestinic receptors in obstructed defecation associated with rectal intussusception. Neurogastroenterol Motil 2012; 24:e155-61. [PMID: 22188470 DOI: 10.1111/j.1365-2982.2011.01850.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The pathophysiological basis of obstructed defecation (OD) is still incompletely understood. In particular, few or no data are available concerning the enteric nervous system (ENS) in this condition. We investigated ENS abnormalities in patients with OD, undergoing surgery, together with the presence of estrogen (α and β) and progesterone receptors, and compare the results with those obtained in controls. METHODS Full-thickness rectal samples were obtained from 17 patients undergoing stapled transanal rectal resection for OD associated with rectal intussusception. Samples were analyzed by immunohistochemistry for enteric neurons, enteric glial cells, interstitial cells of Cajal (ICC), and for estrogen and progesterone receptors. Data were compared with those obtained in 10 controls. KEY RESULTS No differences between patients and controls were found for enteric neurons, whereas (compared with controls) OD patients displayed a significant decrease of enteric glial cells in both the submucous (P = 0.0006) and the myenteric (P < 0.0001) plexus. ICC were significantly increased in patients in the submucosal surface (P < 0.0001) and the myenteric area (P < 0.0001). Concerning estroprogestinic receptors, both were present on ICC in patients and controls. Estrogen receptors α and progesterone receptors were absent on enteric neurons and enteric glial cells in patients and controls, whereas estrogen receptors β were present in all controls and in 69% of patients' enteric neurons (P = 0.18) and in 12% of patients' glial cells (P = 0.0001). CONCLUSIONS & INFERENCES Patients with OD associated to rectal intussusception display abnormalities of the ENS and of estrogen receptors β.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
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Morphological alterations of the enteric nervous system in young male patients with rectal prolapse. Int J Colorectal Dis 2011; 26:1483-91. [PMID: 21800050 DOI: 10.1007/s00384-011-1282-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2011] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The pathogenesis of rectal prolapse (RP) defined by a circumferential, full-thickness invagination of the rectal wall into the anal canal is controversial. RP is normally encountered in elderly women and attributed to several etiological factors (e.g., advanced age, pudendal nerve injury, laxity of supporting ligaments). RP affecting young male patients is unlikely to be explained by these factors and may be due to a rectal motility disorder. Therefore, the enteric nervous system (ENS) as key regulator of intestinal motility was evaluated by a systematic morphometric analysis. PATIENTS AND METHODS Full-thickness rectosigmoid specimens obtained from young male patients with symptomatic RP (n = 5) and male controls (n = 15) were processed for conventional histology and immunohistochemistry using anti-HuC/D as pan-neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric (MP) and submucosal plexus (SMP). RESULTS Compared to controls, patients with RP showed significantly (p < 0.05) increased mean ganglionic area both in MP and SMP, increased mean neuronal content of submucosal ganglia, and nearly threefold higher frequency of submucosal ganglia containing ≥7 neurons. CONCLUSION The morphometric analysis reveals distinct quantitative alterations of the ENS in young male patients with RP mainly characterized by submucosal hyperganglionosis similar to histopathological features described in intestinal neuronal dysplasia. The data give evidence that RP in this unusual subgroup is associated with morphological changes of enteric ganglia which may contribute to the development of RP and complement established etiological concepts.
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Scott SM, van den Berg MM, Benninga MA. Rectal sensorimotor dysfunction in constipation. Best Pract Res Clin Gastroenterol 2011; 25:103-18. [PMID: 21382582 DOI: 10.1016/j.bpg.2011.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 01/03/2011] [Indexed: 01/31/2023]
Abstract
The pathophysiological mechanisms underlying chronic constipation in both adults and children remain to be unravelled. This is a not inconsiderable challenge, but is fundamental to improving management of such patients. Rectal sensorimotor function, which encompasses both sensation and motility, as well as biomechanical components (compliance, capacity), is now strongly implicated in the pathogenesis of constipation. Rectal hyposensitivity, rectal hypercompliance, increased rectal capacity, rectal motor dysfunction (phasic contractility and tone), and altered rectoanal reflex activity are all found in constipated patients, particularly in association with 'functional' disorders of defaecation (i.e. pelvic floor dyssynergia). This review covers contemporary understanding of how components of rectal sensorimotor function may contribute to symptom development in both adult and paediatric populations. The complex interaction between sensory/motor/biomechanical domains, and how best to measure these functions are addressed, and where data exist, the impact of sensorimotor dysfunction on therapeutic outcomes is highlighted.
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Affiliation(s)
- S M Scott
- Academic Surgical Unit & Neurogastroenterology Group, Barts and The London School of Medicine and Dentistry, Queen Mary University London, United Kingdom.
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Bassotti G, Villanacci V. Can "functional" constipation be considered as a form of enteric neuro-gliopathy? Glia 2010; 59:345-50. [PMID: 21264943 DOI: 10.1002/glia.21115] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 11/03/2010] [Indexed: 12/12/2022]
Abstract
Constipation has been traditionally viewed and classified as a functional or idiopathic disorder. However, evidence has been accumulating that suggests how constipation might be considered as due to abnormalities of the enteric nervous system, since alterations of this system, not evident in conventional histological examination, may be present in these patients. These abnormalities often consist in decrease or loss of the enteric glial cells, a pathological finding present in most types of constipation so far investigated. In this article we will discuss these evidences, and will try to consider constipation no more as a simple functional or idiopathic disorder but as a form of enteric neuro-gliopathy.
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Affiliation(s)
- Gabrio Bassotti
- Department of Clinical and Experimental Medicine, Gastroenterology and Hepatology Section, University of Perugia, Italy.
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Compliance and capacity of the normal human rectum--physical considerations and measurement pitfalls. ACTA ACUST UNITED AC 2008; 54:49-57. [PMID: 18044316 DOI: 10.2298/aci0702049z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The assessment of parameters which adequately represent rectal and neorectal compliance is complex. Biological properties of the rectum during distension and relaxation show significant departures from in vitro physical compliance measurements; as much dependent upon the viscoelastic charateristics of hollow organ deformation as upon the technique of compliance calculation. This review discusses the pressure/volume characteristics of importance in the rectum during distension from a bioengineering perspective and outlines the disparities of such measurements in living biological systems. Techniques and pitfalls of newer methods to assess rectal wall stiffness (impedance planimetry and barostat measurement) are discussed.
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Bassotti G, Villanacci V, Nascimbeni R, Asteria CR, Fisogni S, Nesi G, Legrenzi L, Mariano M, Tonelli F, Morelli A, Salerni B. Colonic neuropathological aspects in patients with intractable constipation due to obstructed defecation. Mod Pathol 2007; 20:367-74. [PMID: 17277762 DOI: 10.1038/modpathol.3800748] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
One of the most frequent subtypes of constipation is represented by obstructed defecation, and it has recently been reported that these patients may have colonic motor abnormalities in addition to alterations of the anorectal area. However, it is unknown whether these patients display abnormalities of the enteric nervous system, as reported in other groups of constipated subjects. For this reason, we evaluated the neuropathologic aspects of the enteric nervous system in a homogeneous group of patients with obstructed defecation. Colonic specimens from 11 patients (nine women, age range 39-66 years) undergoing surgery for symptoms refractory to any therapeutic measure, including biofeedback training, were obtained and examined by means of conventional histological methods and immunohistochemistry (NSE, S100, c-Kit, formamide-mAb, Bcl-2, CD34, alfa-actin). Analysis of the specimens showed that the enteric neurons were significantly decreased only in the submucosal plexus of patients (P<0.0001 vs controls), whereas the enteric glial cells of constipated patients were reduced in both the myenteric (P=0.018 vs controls) and the submucosal plexus (P=0.004 vs controls). No difference between patients and controls were found concerning c-Kit and CD34 expression, and the number of apoptotic neurons. These findings support the concept that at least a subgroup of patients with obstructed defecation and severe, intractable symptoms display abnormalities of the enteric nervous system, mostly related to the enteric glial cells. These findings might explain some of the pathophysiological abnormalities, and help to better understand this condition.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
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Awad RA, Camacho S, Martín J, Ríos N. Rectal sensation, pelvic floor function and symptom severity in Hispanic population with irritable bowel syndrome with constipation. Colorectal Dis 2006; 8:488-93. [PMID: 16784468 DOI: 10.1111/j.1463-1318.2006.01038.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In patients with irritable bowel syndrome with constipation (IBS-C, Rome II) we determined if pelvic floor function correlates with rectal sensitivity and tone, and if the pelvic and rectal measurements correlate with symptoms. PATIENTS AND METHODS Sensory thresholds and tone in fasting and postprandial states were evaluated with an electronic barostat in 34 patients and 10 normal controls. The pelvic floor was assessed by defaecography. RESULTS Pain threshold to rectal distension was lower in IBS-C patients (P = 0.007). Postprandially, IBS-C patients showed lower values for sensation of gas, perception of urge, and pain threshold compared with controls. In IBS-C the anorectal angle widened less and showed less perineal mobility during defecation; the rectal tone in fasting IBS-C patients correlated with the angle at rest (P = 0.04) and with the perineal descent at rest (P = 0.01). The severity of abdominal discomfort or pain, and abdominal fullness correlated with the anorectal angle. The duration of symptoms and frequency of bowel movements correlated with perineal descent. Straining, mucus expulsion, and the feeling of incomplete evacuation correlated with rectal sensitivity variables. CONCLUSION Patients with IBS-C have lowered sensory thresholds for noxious and non-noxious stimuli, increased visceral sensitivity after food, less perineal mobility during defecation, and symptoms that correlate with rectal sensitivity and pelvic floor parameters.
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Affiliation(s)
- R A Awad
- Colon and Rectum Physiological Section, Experimental Medicine and Motility Unit, Gastroenterology Service, Mexico City General Hospital, Mexico City, Mexico.
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17
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Quigley EMM, Wald A, Fidelholtz J, Boivin M, Pecher E, Earnest D. Safety and tolerability of tegaserod in patients with chronic constipation: pooled data from two phase III studies. Clin Gastroenterol Hepatol 2006; 4:605-13. [PMID: 16678076 DOI: 10.1016/j.cgh.2006.02.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Studies show that tegaserod effectively relieves the symptoms of chronic constipation/idiopathic constipation (CC). This pooled analysis assessed the safety and tolerability of tegaserod in a large dataset of CC patients. METHODS Adverse event (AE) data were pooled from 2 double-blind, placebo-controlled phase III trials of 12 weeks' duration. Post hoc analysis was conducted for the most frequent AEs (incidence, >or=3%). RESULTS Eight hundred eighty-one, 861, and 861 patients received tegaserod 6 mg twice a day, 2 mg twice a day, or placebo, respectively. Most AEs were mild/moderately severe. AE incidence was similar for the tegaserod 6 mg and 2 mg twice a day (57.1% and 56.3%, respectively) and placebo groups (59.6%) and most frequent in the gastrointestinal system (tegaserod 6 mg twice a day, 25.8%; 2 mg twice a day, 22.5%; placebo, 24.6%). Headache, the most common AE, was slightly more frequent in the placebo group (tegaserod 6 mg twice a day, 11.0%; 2 mg twice a day, 10.1%; placebo, 13.2%). Diarrhea (generally transient and resolved with continued treatment) was the only AE with a statistically significant difference between groups (tegaserod 6 mg twice a day 6.6% vs placebo 3.0%, P=.0005). Serious AE incidence (1.4% overall) was comparable across treatment groups, although abdominal surgery was less common in the combined tegaserod (0.5%) than the placebo group (1.0%). Discontinuation as a result of AEs was slightly higher in tegaserod 6 mg twice a day patients (5.7%; 2 mg twice a day, 3.3%; placebo, 3.7%), mainly because of diarrhea. Laboratory and electrocardiogram parameters were comparable across groups. CONCLUSIONS Tegaserod is well tolerated by patients with CC during 12 weeks of treatment.
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Affiliation(s)
- Eamonn M M Quigley
- Alimentary Pharmabiotic Centre, Department of Medicine, Cork University Hospital, Wilton, Cork, Ireland.
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18
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Gladman MA, Dvorkin LS, Lunniss PJ, Williams NS, Scott SM. Rectal hyposensitivity: a disorder of the rectal wall or the afferent pathway? An assessment using the barostat. Am J Gastroenterol 2005; 100:106-14. [PMID: 15654789 DOI: 10.1111/j.1572-0241.2005.40021.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension. Diagnosis on the basis of abnormal threshold volumes on balloon distension alone may be inaccurate due to the influence of differing rectal wall properties. The aim of this study was to investigate whether RH was actually due to impaired afferent nerve function or whether it could be secondary to abnormalities of the rectal wall. METHODS A total of 50 patients were referred consecutively to a tertiary referral unit for physiologic assessment of constipation (Rome II criteria), 25 of whom had associated fecal incontinence. Thirty patients had RH (elevated threshold volumes on latex balloon distension), and 20 patients had normal rectal sensation (NS). Results were compared with those obtained in 20 healthy volunteers (HV). All subjects underwent standard anorectal physiologic investigation, and assessment of rectal compliance, adaptive response to isobaric distension at urge threshold, and postprandial rectal response, using an electromechanical barostat. RESULTS Mean rectal compliance was significantly elevated in patients with RH compared to NS and HV (p < 0.001). However, 16 patients with RH (53%) had normal compliance. Intensity of the urge to defecate during random phasic isobaric distensions was significantly reduced in patients with RH compared to NS and HV (p < 0.001). The adaptive response at urge threshold was reduced in patients with RH compared to NS and HV (p < 0.001), although spontaneous adaptation at operating pressure was similar in all three groups studied (p= 0.3). Postprandially, responses were similar between groups. CONCLUSIONS In patients found to have RH on simple balloon distension, impaired perception of rectal distension may be partly explained in one subgroup by abnormal rectal compliance. However, a second subgroup exists with normal rectal wall properties, suggestive of a true impairment of the afferent pathway. The barostat has an important role in the identification of these subgroups of patients.
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Affiliation(s)
- Marc A Gladman
- Centre for Academic Surgery (Gastrointestinal Physiology Unit), Barts and The London, Queen Mary's School of Medicine & Dentistry, Whitechapel, London E1 1BB, United Kingdom
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