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Klinge MW, Borghammer P, Lund S, Fedorova T, Knudsen K, Haase AM, Christiansen JJ, Krogh K. Enteric cholinergic neuropathy in patients with diabetes: Non-invasive assessment with positron emission tomography. Neurogastroenterol Motil 2020; 32:e13731. [PMID: 31595630 DOI: 10.1111/nmo.13731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND 11 C-Donepezil positron emission tomography (PET) allows non-invasive assessment of cholinergic innervation of visceral organs. We aimed to compare cholinergic innervation in the gut in patients with diabetes mellitus (DM) and in healthy controls (HC). METHODS 11 C-Donepezil PET and computed tomography (CT) were performed in 19 patients with type 1 DM and gastrointestinal symptoms and in 19 age- and sex-matched HC in a cross-sectional design. KEY RESULTS All patients had severe gastrointestinal symptoms when assessed by standard questionnaires. DM patients had significantly increased volume of the small intestinal wall (DM: median 557 cm3 [interquartile range [IQR] 446-697] vs HC median: 448 cm3 [IQR; 341-518; P < .01]), and the 11 C Donepezil PET uptake was reduced in patients (DM: median 7.08 standardized uptake value [SUV] [IQR; 5.94-8.43] vs HC: median 9.18 SUV [IQR; 8.57-10.11; P < .01]). A similar pattern was found in colon (DM: median volume 1064 cm3 [IQR; 882-1312] vs HC: median 939 cm3 [IQR; 785-1081; P = .13] and DM: median 1.22 SUV (IQR; 1.08-1.36) vs HC: median 1.42 SUV (IQR; 1.32-1.53; P = .03). Furthermore, patients had significantly reduced pancreatic volume (DM: median 53 cm3 [IQR; 41-69] vs HC: median 98 cm3 [IQR;82-110; P < .01]) and reduced PET uptake of the pancreas (DM: median 13.14 SUV [IQR;9.58-15.82] vs HC: median 21.46 SUV [IQR;18.97-24.06; P < .01]) as well as the adrenal gland (DM: median 7.62 SUV [IQR;7.61;15.82] vs HC: median 15.51 SUV [IQR;12.22;19.49; P = .03]). CONCLUSION AND INFERENCES Assessed with 11 C-Donepezil PET/CT, patients with DM and severe bowel symptoms have reduced cholinergic innervation of the gut indicative of parasympathetic denervation.
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Affiliation(s)
- Mette W Klinge
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Borghammer
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Sten Lund
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark.,Steno Diabetes Center, Aarhus, Denmark
| | - Tatyana Fedorova
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Karoline Knudsen
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Haase
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Juel Christiansen
- Department of Internal Medicine and Endocrinology, Herning Regional Hospital, Herning, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Steno Diabetes Center, Aarhus, Denmark
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Hod K, Sperber AD, Maharshak N, Ron Y, Shapira I, David Z, Rogowski O, Berliner S, Shenhar-Tsarfaty S, Dekel R. Serum cholinesterase activity is elevated in female diarrhea-predominant irritable bowel syndrome patients compared to matched controls. Neurogastroenterol Motil 2018; 30:e13464. [PMID: 30240124 DOI: 10.1111/nmo.13464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Micro-inflammation is involved in the pathogenesis of irritable bowel syndrome (IBS). The parasympathetic nervous system, via acetylcholine (ACh), and its hydrolytic enzymes, plays a role in regulating inflammation. Increased serum cholinesterase activity, named cholinergic Status (CS), is associated with decreased inflammatory inhibition (ie, pro-inflammation). We assessed the association between IBS diarrhea-predominant (IBS-D) symptoms, CS, and inflammatory biomarkers. METHODS Women with IBS-D were prospectively recruited. Serum acetylcholinesterase (AChE), CS, and high-sensitivity C-reactive protein (hs-CRP) levels were analyzed and fecal calprotectin (FC) in a subgroup of patients. The control group included women attending routine health checkups (matched by age and BMI). KEY RESULTS Ninety-four women with IBS-D were compared to matched controls (1:1). Serum CS, AChE, and the AChE/butyrylcholinesterase (BChE) ratios were significantly increased in the IBS-D group compared to matched controls (P = 0.018, P = 0.001, and P = 0.004, respectively). Using a multiple logistic regression model, IBS-D was almost twice as likely in women with high CS compared to women with low CS (adjusted OR=1.84 (95% CI: 1.01-3.33), P = 0.045). Furthermore, IBS-D patients with higher hs-CRP levels demonstrated lower CS and BChE activity and elevated AChE and AChE/BChE ratios compared to patients with lower hs-CRP levels (P = 0.026, P = 0.036, P = 0.002; and P = 0.0007, respectively). CS was not correlated with the IBS symptoms score. CONCLUSIONS AND INFERENCES This is the first study to explore the potential role of serum CS in IBS-D. The findings emphasize the possible role of the autonomic nervous system and its anti-inflammatory properties in IBS.
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Affiliation(s)
- Keren Hod
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Research Division, Epidemiology Service, Assuta Medical Centers, Tel Aviv, Israel
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Yishay Ron
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Izthak Shapira
- Internal Medicine "C", "D" and "E", the Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Zeltser David
- Internal Medicine "C", "D" and "E", the Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ori Rogowski
- Internal Medicine "C", "D" and "E", the Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Shlomo Berliner
- Internal Medicine "C", "D" and "E", the Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Shani Shenhar-Tsarfaty
- Internal Medicine "C", "D" and "E", the Tel Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Roy Dekel
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv, Israel
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Effects of Calcitonin Gene-Related Peptide on Colonic Motility and Defecation in Conscious Dogs. J Gastrointest Surg 2018; 22:2097-2103. [PMID: 29980973 DOI: 10.1007/s11605-018-3858-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/20/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although intra-arterial infusion of calcitonin gene-related peptide (CGRP) reportedly stimulates giant migrating contractions (GMCs) of the small intestine in conscious dogs, the effect of intravenous CGRP administration on colonic motility remains unclear. In the present study, we investigated the effects of intravenous CGRP on colonic motility and defecation and determined the underlying mechanism of action in conscious dogs. METHODS Sixteen Beagle dogs weighing 11-13 kg were included. The effects of intravenous CGRP at doses of 3.33 (with various antagonists), 0.83, and 1.67 μg/kg on colonic motility and defecation were evaluated in neurally intact dogs (n = 6). For comparison, dogs with transection/re-anastomosis (T/R) between the proximal and middle segments of the colon (n = 5) and dogs with extrinsic denervation of the ileocolonic segments (n = 5) also received intravenous CGRP at 3.33 μg/kg. All dogs were equipped with strain gauge force transducers on the ileocolon for measurement of the colonic contractile activity. RESULTS Intravenous CGRP evoked GMCs and defecation in the neurally intact group; these stimulatory effects were inhibited by atropine and hexamethonium. Compared with the neurally intact group, the T/R group exhibited similar proximal colonic motility and decreased distal colonic motility after intravenous CGRP administration, whereas the extrinsic denervation group exhibited increased colonic motility overall. CONCLUSIONS Intravenous CGRP induces colonic motility and defecation through acetylcholine release in conscious dogs. The continuity of the enteric nerves plays an important role in CGRP-induced colonic contractions and defecation, while the extrinsic nerves suppress CGRP-induced colonic motility.
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Wells CI, O’Grady G, Bissett IP. Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms. World J Gastroenterol 2017; 23:5634-5644. [PMID: 28852322 PMCID: PMC5558126 DOI: 10.3748/wjg.v23.i30.5634] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/29/2017] [Accepted: 07/22/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO). METHODS A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken. RESULTS No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors. CONCLUSION Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.
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Mosińska P, Zatorski H, Storr M, Fichna J. Future Treatment of Constipation-associated Disorders: Role of Relamorelin and Other Ghrelin Receptor Agonists. J Neurogastroenterol Motil 2017; 23:171-179. [PMID: 28238253 PMCID: PMC5383112 DOI: 10.5056/jnm16183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/19/2016] [Accepted: 01/08/2017] [Indexed: 12/22/2022] Open
Abstract
There is an unmet need for effective pharmacological therapies for constipation, a symptom that significantly deteriorates patients’ quality of life and impacts health care. Ghrelin is an endogenous ligand for the growth hormone secretagogue receptor and has been shown to exert prokinetic effects on gastrointestinal (GI) motility via the vagus and pelvic nerves. The pharmacological potential of ghrelin is hampered by its short half-life. Ghrelin receptor (GRLN-R) agonists with enhanced pharmacokinetics were thus developed. Centrally penetrant GRLN-R agonists stimulate defecation and improve impaired lower GI transit in animals and humans. This review summarizes the current knowledge on relamorelin, a potent ghrelin mimetic, and other GRLN-R analogs which are in preclinical or clinical stages of development for the management of disorders with underlying GI hypomotility, like constipation.
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Affiliation(s)
- Paula Mosińska
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | - Hubert Zatorski
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | - Martin Storr
- Center of Endoscopy, Starnberg, Germany and Walter-Brendel-Centre, Ludwig-Maximilians University Munich, Munich, Germany
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
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Dinning PG, Sia TC, Kumar R, Mohd Rosli R, Kyloh M, Wattchow DA, Wiklendt L, Brookes SJH, Costa M, Spencer NJ. High-resolution colonic motility recordings in vivo compared with ex vivo recordings after colectomy, in patients with slow transit constipation. Neurogastroenterol Motil 2016; 28:1824-1835. [PMID: 27282132 DOI: 10.1111/nmo.12884] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/11/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The pathogenesis of slow transit constipation (STC) remains poorly understood, with intrinsic and extrinsic abnormalities implicated. Here, we present high-resolution colonic manometry recordings from four STC patients recorded before total colectomy, and subsequently, ex vivo, after excision. METHODS In four female, treatment-resistant STC patients (median age 35.5 years), a fiber-optic manometry catheter (72 sensors spaced at 1 cm intervals) was placed with the aid of a colonoscope, to the mid-transverse colon. Colonic manometry was recorded 2 h before and after a meal. After the colectomy, ex vivo colonic manometry was recorded in an organ bath. Ex vivo recordings were also made from colons from 4 patients (2 male; median age 67.5 years) undergoing anterior resection for nonobstructive carcinoma ('control' tissue). KEY RESULTS A large increase in 'short single propagating contractions' was recorded in STC colon ex vivo compared to in vivo (ex vivo 61.3 ± 32.7 vs in vivo 2.5 ± 5/h). In STC patients, in vivo, the dominant frequency of contractile activity was 2-3 cycle per minute (cpm), whereas 1-cpm short-single propagating contractions dominated ex vivo. This same 1-cpm frequency was also dominant in control colons ex vivo. CONCLUSIONS & INFERENCES In comparison to control adults, the colon of STC patients demonstrates significantly less propagating motor activity. However, once the STC colon is excised from the body it demonstrates a regular and similar frequency of propagating activity to control tissue. This paper provides interesting insights into the control of colonic motor patterns.
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Affiliation(s)
- P G Dinning
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
| | - T C Sia
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
| | - R Kumar
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
| | - R Mohd Rosli
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
| | - M Kyloh
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia
| | - D A Wattchow
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Bedford Park, SA, Australia
| | - L Wiklendt
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia
| | - S J H Brookes
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia
| | - M Costa
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia
| | - N J Spencer
- Disciplines of Human Physiology, Flinders University, Bedford Park, SA, Australia
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7
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Short-Term Effects of Relamorelin on Descending Colon Motility in Chronic Constipation: A Randomized, Controlled Trial. Dig Dis Sci 2016; 61:852-60. [PMID: 26467700 DOI: 10.1007/s10620-015-3876-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 09/04/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The pentapeptide ghrelin agonist, relamorelin, accelerates colonic transit in patients with chronic constipation (CC). In a murine model, relamorelin decreased excitability of colonic circular smooth muscle cells and colonic intraluminal pressure. AIM To determine short-term effects of relamorelin on colonic motility measured by barostat and multilumen manometry in CC. METHODS In a placebo-controlled, single-dose, double-blind, randomized study in patients with CC, we investigated the motor effects of relamorelin, 100 μg, SQ (12 patients) compared to placebo SQ (six patients). A motility-barostat balloon assembly was used to measure colonic compliance; tone and phasic pressure activity were measured before and after a 1000-kcal milkshake meal (administered ~60 min post-medication). Overall "background" phasic pressure activity was assessed by: average amplitude and motility index (MI = ln[sum amplitudes × #contractions + 1]) over defined periods. High-amplitude propagating contractions (HAPCs) were characterized by amplitude >75 mmHg and propagating contractions >50 mmHg; both were propagated over at least 10 cm. Postprandial HAPCs were the primary end point. The study sample had 80% power to detect an increase of 3.3 HAPCs in the hour post-meal. RESULTS Relamorelin, 100 μg, significantly induced more pre-meal propagated contractions [PCs of either >50 or >75 mmHg] compared to placebo (p < 0.05). Relamorelin also induced more post-meal PCs >50 or >75 mmHg than placebo. Relamorelin did not significantly alter colonic compliance, fasting or postprandial phasic pressure activity (20 min pre-meal fasting MI) or tone, and 60 min postprandial phasic pressure amplitude or MI, or tone. CONCLUSIONS Relamorelin stimulates propagated colonic contractions without alteration of background irregular contractions in CC. ClinicalTrial.Gov registration number: NCT 01781104.
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Parthasarathy G, Ravi K, Camilleri M, Andrews C, Szarka LA, Low PA, Zinsmeister AR, Bharucha AE. Effect of neostigmine on gastroduodenal motility in patients with suspected gastrointestinal motility disorders. Neurogastroenterol Motil 2015; 27:1736-46. [PMID: 26387781 PMCID: PMC4659742 DOI: 10.1111/nmo.12669] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/11/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acetylcholinesterase inhibitors (ACIs), e.g., neostigmine, are known to increase upper and lower gastrointestinal (GI) motility and are used to treat acute colonic pseudoobstruction. However, their effects on gastroduodenal motility in humans are poorly understood. Our hypotheses were that, in patients with suspected GI motility disorders, neostigmine increases gastric and small intestinal motor activity, and these effects are greater in patients with cardiovagal neuropathy, reflecting denervation sensitivity. METHODS In this open label study, the effects of neostigmine (1 mg intravenously) on gastroduodenal motor activity recorded with manometry were assessed in 28 patients with a suspected GI motility disorder. Cardiovagal function was assessed with the heart rate response to deep breathing and GI transit by scintigraphy. KEY RESULTS The final diagnoses were gastroparesis (6 patients), gastroparesis with intestinal neuropathy (3 patients), intestinal neuropathy or pseudoobstruction (5 patients), functional dyspepsia (6 patients), chronic abdominal pain (3 patients), mechanical small intestinal obstruction (3 patients), and pelvic floor dysfunction (2 patients). Neostigmine increased both antral and intestinal phasic pressure activity (p < 0.001). Neostigmine increased antral and intestinal pressure activity in 81% and 50% of patients with reduced postprandial antral and intestinal contractile responses to meal, respectively. The antroduodenal pressure response to neostigmine was not higher in patients with cardiovagal dysfunction. CONCLUSIONS & INFERENCES Neostigmine increased antral and intestinal motor activity in patients with hypomotility, including intestinal dysmotility. These responses to neostigmine were not greater in patients with cardiovagal dysfunction. The use of longer-acting ACIs for treating antroduodenal dysmotility warrant further study.
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Affiliation(s)
- Gopanandan Parthasarathy
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | | | - Lawrence A. Szarka
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Phillip A. Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Alan R Zinsmeister
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E. Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
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Smith TK, Park KJ, Hennig GW. Colonic migrating motor complexes, high amplitude propagating contractions, neural reflexes and the importance of neuronal and mucosal serotonin. J Neurogastroenterol Motil 2014; 20:423-46. [PMID: 25273115 PMCID: PMC4204412 DOI: 10.5056/jnm14092] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/05/2014] [Accepted: 09/08/2014] [Indexed: 12/15/2022] Open
Abstract
The colonic migrating motor complex (CMMC) is a critical neurally mediated rhythmic propulsive contraction observed in the large intestine of many mammals. It seems to be equivalent to the high amplitude propagating contractions (HAPCs) in humans. This review focuses on the probable neural mechanisms involved in producing the CMMC or HAPC, their likely dependence on mucosal and neuronal serotonin and pacemaker insterstitial cells of Cajal networks and how intrinsic neural reflexes affect them. Discussed is the possibility that myenteric 5-hydroxytryptamine (5-HT) neurons are not only involved in tonic inhibition of the colon, but are also involved in generating the CMMC and modulation of the entire enteric nervous system, including coupling motility to secretion and blood flow. Mucosal 5-HT appears to be important for the initiation and effective propagation of CMMCs, although this mechanism is a longstanding controversy since the 1950s, which we will address. We argue that the slow apparent propagation of the CMMC/HAPC down the colon is unlikely to result from a slowly conducting wave front of neural activity, but more likely because of an interaction between ascending excitatory and descending (serotonergic) inhibitory neural pathways interacting both within the myenteric plexus and at the level of the muscle. That is, CMMC/HAPC propagation appears to be similar to esophageal peristalsis. The suppression of inhibitory (neuronal nitric oxide synthase) motor neurons and mucosal 5-HT release by an upregulation of prostaglandins has important implications in a number of gastrointestinal disorders, especially slow transit constipation.
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Affiliation(s)
- Terence K Smith
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, Nevada, USA
| | - Kyu Joo Park
- Department of Surgery, School of Medicine, Seoul National University, Seoul Korea
| | - Grant W Hennig
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, Nevada, USA
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Abstract
While most colonic motor activity is segmental and non-propulsive, colonic high amplitude propagated contractions (HAPC) can transfer colonic contents over long distances and often precede defecation. High amplitude propagated contractions occur spontaneously, in response to pharmacological agents or colonic distention. A subset of patients with slow transit constipation have fewer HAPC. In this issue of Neurogastroenterology and Motility, Rodriguez et al. report that anal relaxation during spontaneous and bisacodyl-induced HAPC exceeds anal relaxation during rectal distention in constipated children undergoing colonic manometry. Moreover, and consistent with a neural mechanism, anal relaxation often precedes arrival of HAPC in the left colon. High amplitude propagated contractions are also used to evaluate the motor response to a meal and pharmacological stimuli (e.g., bisacodyl, neostigmine) and to identify colonic inertia during colonic motility testing in chronic constipation. This editorial comprehensively reviews the characteristics, physiology and pharmacology of HAPC, their assessment by manometry, and relevance to constipation and diarrhea.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN
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11
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Effect of meal ingestion on ileocolonic and colonic transit in health and irritable bowel syndrome. Dig Dis Sci 2010; 55:384-91. [PMID: 19949866 PMCID: PMC2900583 DOI: 10.1007/s10620-009-1041-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 10/26/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postprandial symptoms in irritable bowel syndrome (IBS) have been associated with increased bowel contractility. AIM To compare ileocolonic and colonic responses to feeding in health and IBS. METHODS We prospectively analyzed data from separate research trials in 122 IBS patients and 41 healthy volunteers. Ileocolonic transit (ICT) was evaluated before (colonic filling [CF]3h) and immediately after (CF4 h) a standard lunch at 3 h 45 min, and 2 h thereafter. The colonic geometric center (GC) was calculated 2 h (GC6 h) after lunch ingested at 4 h (GC4 h) and directly after (GC8 h) a standard dinner ingested at 7 h 45 min. RESULTS ICT immediately after eating was higher in IBS diarrhea predominant (IBS-D) patients than in the healthy cohort (23.1 +/- 2.4 vs. 17.5 +/- 2.8%, P = 0.059). ICT 2 h after lunch was similar between groups (P = 0.55). There was significant overall group differences in colonic transit 2 h post-lunch (P = 0.045), particularly in the IBS constipation predominant (IBS-C; GC6-GC4, delta 0.29 +/- 0.08) patients versus healthy volunteers (delta 0.56 +/- 0.12 GC units). CONCLUSIONS After feeding, ICT is increased in IBS-D, whereas colonic transit is blunted in IBS-C.
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12
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Bharucha AE, Camilleri M, Burton D. Pilot study of pyridostigmine in constipated patients with autonomic neuropathy. Clin Auton Res 2008; 18:194-202. [PMID: 18622640 PMCID: PMC2536749 DOI: 10.1007/s10286-008-0476-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 05/02/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effects of cholinesterase inhibitors, which increase colonic motility in health, on chronic constipation are unknown. Our aims were to evaluate the efficacy of cholinesterase inhibitors for dysautonomia and chronic constipation and to assess whether acute effects could predict the long term response. METHODS In this single-blind study, 10 patients with autonomic neuropathy and constipation were treated with placebo (2 weeks), followed by an escalating dose of pyridostigmine to the maximum tolerated dose (i.e., 180-540 mg daily) for 6 weeks. Symptoms and gastrointestinal transit were assessed at 2 and 8 weeks. The acute effects of neostigmine on colonic transit and motility were also assessed. RESULTS At baseline, 4, 6, and 3 patients had delayed gastric, small intestinal, and colonic transit respectively. Pyridostigmine was well tolerated in most patients, improved symptoms in 4 patients, and accelerated the geometric center for colonic transit at 24 h by > or =0.7 unit in 3 patients. The effects of i.v. neostigmine on colonic transit and compliance predicted (P < 0.05) the effects of pyridostigmine on colonic transit. CONCLUSIONS Pyridostigmine improves colonic transit and symptoms in some patients with autonomic neuropathy and constipation. The motor response to neostigmine predicted the response to oral pyridostigmine.
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Affiliation(s)
- Adil E. Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.) Mayo Clinic 200 First St. S.W. Rochester (MN) 55905, USA Tel.: +1-507/538-5854 Fax: +1-507/538-5820 E-Mail:
| | - Michael Camilleri
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.) Mayo Clinic 200 First St. S.W. Rochester (MN) 55905, USA Tel.: +1-507/538-5854 Fax: +1-507/538-5820 E-Mail:
| | - Duane Burton
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.) Mayo Clinic 200 First St. S.W. Rochester (MN) 55905, USA Tel.: +1-507/538-5854 Fax: +1-507/538-5820 E-Mail:
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13
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Abstract
The human ileocolonic sphincter (ICS) develops a sustained tone mainly due to propagated and not propagated phasic motor activity. The ileocaecocolonic segment is also able to behave, yet uncommonly, as a synchronized segment involving propagated contractions originating from the ileum and migrating to the proximal colon. The ICS motor activity alone has a limited role towards forward flow. On the contrary, the functional entity corresponding to the distal ileum and the ICS provides a clearance mechanism for reflux of colonic contents into the small intestine. The presence of short chain fatty acids (SCFA) in the distal ileum, sensed either by endocrine cells or chemo-sensitive vagal afferents, is an important actor in triggering this clearance mechanism. The ICS tone is in part myogenic but a neuronal nitrergic component is also involved. Reflex excitatory and inhibitory responses of the ICS originating from ileal or colonic distension involve primarily spinal nitrergic and adrenergic pathways.
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14
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Abstract
PURPOSE OF REVIEW In the past year, many studies were published in which new and relevant information on small intestinal motility in humans and laboratory animals was obtained. RECENT FINDINGS Although the reported findings are heterogeneous, some themes appear to be particularly interesting and novel. Among these is the association between disordered small intestinal motility and bacterial overgrowth of the small intestine. Studies in patients with portal hypertension, in patients with chronic renal failure, and in a rat model of experimental acute pancreatitis all point in the same direction. Another topic of particular interest is the relation between duodenal motility and glucose absorption; propagated duodenal pressure wave sequences are positively related to glucose absorption. Finally, many studies addressed the mechanisms involved in the regulation of interdigestive and postprandial small intestinal motility. These confirmed the key role of cholecystokinin and provided new information on the role of orexin A and leptin. SUMMARY The new information on intestinal motility gathered in the past year provides a greater insight in the pathophysiology of a number of diseases and will stimulate further studies in laboratory animals and in human subjects.
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Affiliation(s)
- André J P M Smout
- Department of Gastroenterology, University Medical Center, Ulrecht, The Netherlands.
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