Position paper on transanal irrigation in chronic non-organic constipation

The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.

Effect of a new synbiotic supplement on symptoms, stool consistency, intestinal transit time and gut microbiota in patients with severe functional constipation: a pilot randomized double-blind, controlled trial

BACKGROUND

Data on the benefits of synbiotics in functional constipation are conflicting. The aim of this study was to assess whether the administration of the synbiotic supplement Psyllogel Megafermenti(®) normalized stool consistency and decreased intestinal transit time (ITT) in patients with severe functional constipation, based on its ability to impact on the gut microbiota.

METHODS

We conducted a pilot randomized, double-blind, controlled trial. After a 2-week run-in period, patients from a tertiary care setting with severe functional constipation fulfilling the Rome III Diagnostic Criteria in the past year were randomly assigned to receive by mouth 2 bags/day of Psyllogel Megafermenti(®) (Group A) or 2.8 g of maltodextrin twice daily (Group B) for 8 weeks. Primary endpoints were increase of bowel evacuations with normal stool consistency and volume, and ITT reduction. Secondary endpoints included symptom improvement according to the Rome III Diagnostic Criteria, reduction of the Agachan-Wexner score and changes in gut microbiota composition.

RESULTS

Twenty-nine patients completed the study: 17 were allocated to Group A and 12 to Group B. A statistically significant increase in stools with normal consistency was observed only in Group A (p = 0.001), even when considering patients with normal stools ≤50 % of time at baseline. In Group A, a significant reduction in ITT was also found (p = 0.022). According to polymerase chain reaction-denaturing gradient gel electrophoresis profiling of stool samples, 50 % of the patients treated with synbiotics harbored all the probiotic species of the study product.

CONCLUSIONS

An 8-week treatment with Psyllogel Megafermenti(®) improved the main clinical parameters of functional constipation in patients extremely homogeneous for disorder severity and underlying pathophysiology ( Eudract.ema.europa.eu , No. 2008-000913-30).

Reliability of the international spinal cord injury bowel function basic and extended data sets

STUDY DESIGN

This study was designed as an international validation study.

OBJECTIVE

The objective of this study was to assess the inter-rater reliability of the International Spinal Cord Injury Bowel Function Basic and Extended Data Sets.

SETTING

Three European spinal cord injury centers.

METHODS

In total, 73 subjects with spinal cord injury and a history of bowel dysfunction, out of which 77% were men and median age of the subjects was 49 years (range 20-81), were studied. The inter-rater reliability was estimated by having two raters complete both data sets on the same subject. First and second tests were separated by 14 days. Cohen's kappa was computed as a measure of agreement between raters.

RESULTS

Inter-rater reliability assessed by kappa statistics was very good (≥0.81) in 5 items, good (0.61-0.80) in 11 items, moderate (0.41-0.60) in 20 items, fair (0.21-0.40) in 11 and poor (<0.20) in 5 items.

CONCLUSION

Most items within the International Spinal Cord Injury Bowel Function Data sets have acceptable inter-rater reliability and are useful tools for data collection in international clinical practice and research. However, minor adjustments are recommended.

Cryptogenic stroke in hanging. A case report

This paper reports the unique neuroimaging findings of a 37-year-old woman who attempted suicide by hanging. To our knowledge, this is the first reported case describing neuroimaging findings of unilateral lesions instead of the well-documented bilateral lesions after a hanging event. Computed tomography demonstrated a low density area in the right thalamus and no hemorrhage. 3.0 T Magnetic resonance revealed a hyperintense area on both T2-weighted and FLAIR images on the right thalamus. Diffusion weighted images demonstrated no area of diffusivity restriction. Another smaller lesion with the same signal characteristics was found in the left cerebellum. A second relevant point of this report is the observation that the most probable cause of the documented unilateral lesions was an ischemic-arterial event.

Molecular Imaging and Magnetic Resonance Imaging in Early Diagnosis of Alzheimer's Disease

Alzheimer's disease (AD), a progressive neurodegenerative disorder, is the most common cause of dementia in the elderly. Magnetic resonance (MR) or computed tomography (CT) imaging is recommended for routine evaluation of dementias. The development of molecular imaging agents and the new techniques of MR for AD are critically important for early diagnosis, neuropathogenesis studies and assessing treatment efficacy in AD. Neuroimaging using nuclear medicine techniques such as SPECT, PET and MR spectroscopy has the potential to characterize the biomarkers for Alzheimer's disease. The present review summarizes the results of radionuclide imaging and MR imaging in AD.

Evaluation of an occupational therapy program for patients with spinal cord injury

STUDY DESIGN

Clinical controlled trial.

OBJECTIVES

To evaluate the effectiveness of an occupational therapy (OT) program combined with neuromotor rehabilitation, by assessing the degree of functional independence reached by patients with spinal cord injuries at first hospitalization.

SETTINGS

Subjects selected from the Spinal Cord Unit of the Rehabilitation Institute of Montecatone (Imola, Italy).

PARTICIPANTS

Thirty-six male patients below age 60, with complete paraplegia (ASIA-A) in thoracic-lumbar level, at first hospitalization.

METHODS

Patients were divided into experimental and control groups. Subjects in the experimental group underwent neuromotor rehabilitation coupled with an OT program, whereas those in the control group followed neuromotor rehabilitation only. Increase in functional independence at discharge was evaluated by the Valutazione Funzionale Mielolesi (VFM) assessment scale.

RESULTS

Patients in the experimental group showed a significant increase in the total VFM score, and in domains concerning transfers and wheelchair use. A significant improvement was observed in unmarried patients as compared to married ones.

CONCLUSION

An OT service within a Spinal Cord Unit allows us to achieve a higher level of functional independence.

Study of the effectiveness of bronchial clearance in subjects with upper spinal cord injuries: examination of a rehabilitation programme involving mechanical insufflation and exsufflation

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

To establish whether the use of mechanical insufflation/exsufflation leads to a significant improve in tracheostomy subjects with upper spinal cord injuries (C1-C7), ASIA classification grade A and bronchial hyper secretion the following parameters: forced vital capacity (FVC), forced exspiratory volume on the first second (FEV1), FEV1/FVC, peak exspiratory flow (PEF), arterious pressure of O(2) (Pa O(2)), arterious pressure of CO(2) (Pa CO(2)), pH, saturation of O(2) (Sa O(2)).

SETTING

Spinal Cord Unit, Montecatone Rehabilitation Institute, Imola, Italy.

METHODS

The patients were split into two groups: the experimental group (EG) and the control group (CG). Each patient was given 10 treatments: the EG was given manual respiratory kinesitherapy associated with mechanical insufflation/exsufflation with inhale and exhale pressure between 15 cm H(2)O and 45 cm H(2)O, while the CG was only given manual kinesitherapy. The treatment sessions covered the necessary amount of time in order to achieve sufficient clearance. The study has been approved by the local ethic committee. The patients were informed before being enrolled in that study and gave their written consent.

RESULTS

At the end of the treatment associated with the mechanical insufflation/exsufflation, the EG showed a significant increase in FVC, FEV1 and PEF, although it was not possible to compare the latter with the CG. The other parameters were also subject to variations, although not statistically significant. The CG did not show signs of any significant change.

CONCLUSION

The use of mechanical insufflation/exsufflation in subjects with the aforementioned characteristics is shown to be an effective adjunct to manual respiratory kinesitherapy, since it makes it possible to achieve adequate bronco-pulmonary clearance, even removing thick, deep secretions and making it possible to insufflate any areas affected by atelectasis.

Intestinal microflora and oral bacteriotherapy in irritable bowel syndrome

On the basis of many clinical and experimental observations, it would appear feasible to hold that the characteristics of the luminal milieu, the relationship, the balance between luminal prokaryotic cells and mucosal eukaryotic cells and the consequent immunological and humoral local and systemic responses take part in the pathophysiology of several diseases and, consequently bacteriotherapy can play a relevant role in the treatment and prevention of irritable bowel syndrome and more in general, of the intestinal functional disorders. The irritable bowel syndrome is characterised by sudden and unforeseeable changes in the two main symptoms, constipation and diarrhoea, even within a few days. The amount and composition of proximal colon microflora, increasing with regard to the above-mentioned factors, and the time in which this development occurs, are, in our opinion, elements taking part, together with colon dysmotility and alterations of visceral perception, in the onset of the variability in stool frequency, typical of these patients. The present open noncontrolled trial is the first observation showing a clinical improvement related to changes in the composition of the faecal bacterial flora and in faecal biochemistry and, remarkably, in the colonic motility pattern, all of which induced by administration of probiotics, in patients with functional diarrhoea.

Effects of probiotic administration upon the composition and enzymatic activity of human fecal microbiota in patients with irritable bowel syndrome or functional diarrhea

In a clinical trial, 10 patients suffering from irritable bowel syndrome or functional diarrhea were administered the probiotic preparation VSL-3. Preliminary results indicated that administration of VSL-3 improved the clinical picture and changed the composition and biochemistry of fecal microbiota. Titer variations of intestinal bacterial groups were evaluated by culture and PCR techniques. A significant increase in lactobacilli, bifidobacteria and Streptococcus thermophilus was observed as a consequence of probiotic treatment, while enterococci, coliforms, Bacteroides and Clostridium perfringens did not change significantly. The strains Bifidobacterium infantis Y1 and Bifidobacterium breve Y8, included in VSL-3, were specifically detected in feces of patients treated with the probiotic by using strain-specific PCR primers. In addition, fecal beta-galactosidase increased and urease activities decreased as a result of changes in the intestinal microbiota induced by VSL-3 administration.

Immune-endocrine status and coeliac disease in children with Down's syndrome: relationships with zinc and cognitive efficiency

Immune defects, thyroid abnormalities, plasma zinc levels, and the presence of gastrointestinal disease were investigated in 43 children with Down's syndrome (DS). Peripheral T lymphocytes with the phenotype of helper cells or cluster of differentiation 4 (CD4) were decreased. Circulating activated T cells (CD3/HLA-DR-positive cells) and large granular lymphocytes (CD16/CD56 positive cells) were increased. Plasma levels of interleukin-6 were higher in DS children than in controls. Serum levels of thyroid-stimulating hormone were increased in DS. Coeliac disease was over-represented in the group of DS children and many of these children also showed increased serum levels of immunoglobulin-G (IgG) specific for gliadin antigen. The increment of serum interleukin-6 was age-related and correlated with anti-gliadin IgG levels in DS. Plasma zinc levels were lower in DS children with coeliac disease and in those with anti-gliadin IgG than in DS without detectable anti-gliadin IgG. Dietary antigens may represent a continuous stimulus for the immune system in this syndrome and interfere with normal immune responses. Altered intestinal absorption of nutrients may in turn affect endocrine functions, brain development, and cognitive performances.

Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial

BACKGROUND & AIMS

Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Most patients have relapsing disease, and no maintenance treatment study has been performed. We evaluated the efficacy of a probiotic preparation (VSL#3) containing 5 x 10(11) per gram of viable lyophilized bacteria of 4 strains of lactobacilli, 3 strains of bifidobacteria, and 1 strain of Streptococcus salivarius subsp. thermophilus compared with placebo in maintenance of remission of chronic pouchitis.

METHODS

Forty patients in clinical and endoscopic remission were randomized to receive either VSL#3, 6 g/day, or an identical placebo for 9 months. Patients were assessed clinically every month and endoscopically and histologically every 2 months or in the case of a relapse. Fecal samples were collected for stool culture before and after antibiotic treatment and each month during maintenance treatment.

RESULTS

Three patients (15%) in the VSL#3 group had relapses within the 9-month follow-up period, compared with 20 (100%) in the placebo group (P < 0.001). Fecal concentration of lactobacilli, bifidobacteria, and S. thermophilus increased significantly from baseline levels only in the VSL#3-treated group (P < 0.01).

CONCLUSIONS

These results suggest that oral administration of this new probiotic preparation is effective in preventing flare-ups of chronic pouchitis.

Long term efficacy, safety, and tolerabilitity of low daily doses of isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in the treatment of functional chronic constipation

AIMS

To assess the long term therapeutic effectiveness, safety, and tolerability of low daily doses of isosmotic PEG electrolyte solutions (PMF-100) administered for a six month period for the treatment of functional constipation, in a double blind, placebo controlled, parallel group study.

METHODS

After an initial four week run in period with PMF-100 (250 ml twice daily; PEG 14.6 g twice daily), 70 patients suffering from chronic constipation (58 females, aged 42 (15) years) with normalised bowel frequency (>3 bowel movements (bm)/week) were randomly allocated to receive either PMF-100 or placebo, contained in sachets (one sachet in 250 ml of water twice daily) for 20 weeks. Patients were assessed at four week intervals, and reported frequency and modality of evacuation, laxative use, and relevant symptoms on a diary card. At weeks 1, 12, and 24, a physical examination and laboratory tests were performed.

RESULTS

Complete remission of constipation was reported by a significantly (p<0.01) higher number of patients treated with PMF-100 compared with placebo at each four week visit. At the end of the study, 77% of the PMF-100 group and 20% of the placebo group were asymptomatic. Compared with placebo, patients treated with PMF-100 reported hard/pellety stools and straining at defecation less frequently, a significantly higher bowel frequency (week 12: 7. 4 (3.1) v 4.3 (2.5) bm/week, 95% CI 1.64, 4.42; week 24: 7.4 (3.2) v 5.4 (2.1) bm/week, 95% CI 0.13,3.93), reduced consumption of laxative/four weeks (week 12: 0.7 (2.7) v 2.2 (3.3), 95% CI -2.29, 0. 03; week 24: 0.2 (0.8) v 1.4 (2), 95% CI -2.07, -0.023), reduced mean number of sachets used (week 12: 33 (13) v 43 (12), 95% CI -17. 24, 4.56; week 24: 33 (13) v 44 (12), 95% CI -19.68, -2.24), and reduced number of drop outs for therapy failure (16 v 3; p<0.005). Adverse events, physical findings, laboratory values, palatability, and overall tolerance of the solutions did not differ between groups.

CONCLUSIONS

Administration of small daily doses of isosmotic PEG electrolyte balanced solutions was effective over a six month period for the treatment of functional constipation. A mean daily dose of approximately 300 ml of PEG solution (PEG 17.52 g) appeared to be safe, well tolerated, and devoid of significant side effects.

Polyethylene glycol solution in subgroups of chronic constipation patients: experience in obstructed defaecation

Low doses of polyethylene glycol solutions were administered in patients with long-standing constipation and in a subgroup with severe symptoms of obstructed defaecation and in whom anorectal surgery was considered. During treatment all patients with constipation improved and nineteen of the twenty-one patients with dyschezia became asymptomatic. Only two patients were submitted to surgery.

Illness behavior, affective disturbance and intestinal transit time in idiopathic constipation

Patients with constipation differ not only from healthy subjects but can also be categorized into two groups: slow transit constipation (STC) and normal transit constipation (NTC) using measures of total intestinal transit time (TITT). We investigated the role of illness behavior and affective state in 45 NTC and 29 STC patients as compared with 20 healthy subjects. All subjects completed the Illness Behavior Questionnaire (IBQ), the Symptom Questionnaire (SQ), and the CES-D to assess illness behavior, psychological distress, and depression. The constipated patients reported more psychological distress than healthy subjects. Within the constipated group, the NTC subjects had significantly higher scores on the IBQ dimensions of hypochondriasis and disease affirmation. Our results suggest that even among constipated patients psychological distress is prominent and that measures of illness behavior help to discriminate among different pathophysiological groups.

Acute pancreatitis after azathioprine treatment for ulcerative colitis

Inflammatory bowel disease, in addition to intestinal involvement, may be complicated also by other extra-intestinal manifestations. Moreover, drugs commonly employed in the treatment of ulcerative colitis and Crohn's disease may induce iatrogenic pancreatitis. Acute pancreatitis is described in two ulcerative colitis patients following azathioprine treatment.

Dietary habits as risk factors for inflammatory bowel disease

OBJECTIVE

To examine the influence of dietary factors in Italian patients with ulcerative colitis and Crohn's disease.

DESIGN

We studied dietary habits immediately prior to the onset of disease in 104 patients enrolled in a prospective, epidemiological study of the incidence of inflammatory bowel disease in Italy.

METHODS

Each patient was interviewed using a recall questionnaire to provide information on the daily intake of nutrients. The differences in diet between patients and healthy subjects matched for age, sex and city of residence were determined.

RESULTS

Our data confirm that patients with Crohn's disease and ulcerative colitis have a high intake of total carbohydrate, starch and refined sugar. This resulted in a significantly higher relative risk (P < 0.001) in both ulcerative colitis and Crohn's disease patients. Total protein intake was significantly higher in ulcerative colitis, but not in Crohn's disease patients, than in controls. Fibre consumption did not differ between patients and controls.

CONCLUSIONS

Our results confirm that carbohydrate consumption is significantly higher in IBD patients than in healthy controls. Ulcerative colitis patients also consumed more total protein than controls. The pathogenetic significance of these findings, however, remains unclear.

Electromechanical activities of human uteri during extra-corporeal perfusion with ovarian steroids

A new experimental system was designed to study human uterine activities based on the extra-corporeal perfusion of isolated human uteri. Electromechanical activities in the uterine wall were recorded using bipolar silver-silver electrodes, endoluminal pressure catheters and a dedicated acquisition, storage and analytical system. The electrical signals recorded were isolated spikes and rhythmic activities; the last being primarily associated with organized mechanical events. Perfusion media containing 17 beta-oestradiol alone or with progesterone were used for those uteri obtained during proliferative (n = 5) or secretory (n = 5) phases of the menstrual cycle, respectively. Progesterone caused a reduction of frequency (P < 0.001) and duration (P < 0.001) of the rhythmic electrical activity, and decreased the endoluminal pressure at both detection sites (P < 0.01). 17 beta-Oestradiol increased both frequency (P < 0.001) and duration (P < 0.001) of the rhythmic electrical activity as well as the endoluminal pressure at two different detection sites (3 and 5 cm from the fundus) (P < 0.05). Significant differences between the fundus and cervix sites in the uterine wall were detected. In conclusion, uterine perfusion would be useful to examine the effects of uterotonic and tocolytic drugs before administration to humans, at no risk to the patients. Oestrogens increase and progesterone decreases both electrical and mechanical uterine activities.

Colonic manometry in children with chronic intestinal pseudo-obstruction

Pressure changes were evaluated in the transverse, descending, and rectosigmoid colon of 30 children with chronic intestinal pseudo-obstruction. Twenty two had severe lifelong constipation and eight had symptoms suggesting a motility disorder exclusively of the upper gastrointestinal tract. Based on prior antroduodenal manometry, 24 children were diagnosed as having a neuropathic and six a myopathic form of intestinal pseudo-obstruction. On the day of study, endoscopy was used to place a manometry catheter into the transverse colon and intraluminal pressure was recorded for more than four hours. After a baseline recording, we gave a meal to assess the gastrocolonic response. Colonic contractions were noted in 24 children. The six children with no colonic contractions had a hollow visceral myopathy and constipation. In the children with colonic contractions, fasting motility did not differentiate children with and without constipation. After the meal, in all eight children without constipation there was (1) an increase in motility index (3.2 (SEM 0.3) mm Hg/min basal v 8.4 (SEM 1.1) mm Hg/min postprandial; p < 0.001), and (2) at least one high amplitude propagated contraction (HAPC). In the 16 constipated children with colonic contractions the motility index did not significantly increase after the meal (2.1 (SEM 0.3) mm Hg/min basal v 3.1 (SEM 0.4) mm Hg/min postprandial) and 12 of them had no HAPCs (p < 0.01 v group without constipation). In summary, in children with a clinical diagnosis of chronic intestinal pseudo-obstruction, constipation is associated with absence of HAPCs, and the gastrocolonic response or with total absence of colonic contractions. It is concluded that studies of colonic manometry are feasible in children and may document discrete abnormalities in those with intestinal pseudo-obstruction with colonic involvement.

Epidemiological characteristics of inflammatory bowel disease in Bologna, Italy--incidence and risk factors

Recently, in Bologna, an inflammatory bowel disease incidence of 7.7/10(5)/year has been calculated, about one third of that reported in Northern Europe, confirming the existence of a 'North-South gradient'. A first peak of incidence was observed at 20-29 years of age and a second peak at 60-69 years of age for ulcerative colitis (UC) alone. A prevalence of UC males, mainly after the 7th decade, and of Crohn's disease (CD) females in the first peak was found. A greater frequency of ex-smokers in UC, with a relative risk (RR) significantly higher in males for all age groups (RR = 6.1; p < 0.01) and of smokers in CD with a RR significantly higher in 20- to 29-year-old females (RR = 11.6; p < 0.05) was observed. A different pattern for the two diseases exists: male ex-smokers and young female smokers are at risk of developing UC and CD, respectively.

A method for evaluating human tubal motility in vivo: a new approach for infertility investigation

The motility of the Fallopian tube plays an important role in the gametes and embryo transport. Disorders of the tubal motor function may be involved in a great number of patients with unexplained infertility. The aim of this study was to develop a method to measure the tubal motility by means of an hysteroscopic approach in humans. The following motor parameters were evaluated: 1) the basal pressure of each 1 cm tract of the tube; 2) amplitude and frequency of the tubal contractions; 3) the uterine intraluminal pressure eight patients in the follicular phase (FP group) and 8 in the luteal phase (LP group) of the menstrual cycle, were studied. The duration of the motility recording session was 12 +/- 3 minutes (range 7-19 minutes). No significant differences were shown between the two groups of patients, and no differences were found between the recordings obtained from the right and the left tubes.

Colonic motility and transit in health and ulcerative colitis

Preprandial and postprandial colonic motility and transit (scintigraphy), with respect to the splenic flexure, were studied in 10 patients with ulcerative colitis and in 9 healthy subjects. The healthy subjects had a postprandial increase in intraluminal pressure that was significantly (P less than 0.03) greater in the descending colon than in other regions of the colon. In ulcerative colitis, the pressure was decreased in all regions compared with healthy subjects, with no significant pressure gradient among different regions. In normal subjects, transit was quiescent during fasting; eating stimulated both antegrade and retrograde transit. In ulcerative colitis, transit was variable before as well as after the meal. Both healthy subjects and patients with ulcerative colitis had more rapid emptying from the splenic flexure into the sigmoid than into the transverse colon. More frequent, low-amplitude, postprandial propagating contractions occurred in ulcerative colitis (P less than 0.05) than in healthy subjects. Propagating contractions were always antegrade and caused a rapid movement of the tracer into the sigmoid. In conclusion, ulcerative colitis is characterized by (a) decreased contractility, (b) increased low-amplitude propagating contractions, and (c) variable transit. These disturbances may accentuate the diarrhea in ulcerative colitis.

Effect of eating on colonic motility and transit in patients with functional diarrhea. Simultaneous scintigraphic and manometric evaluations

The aim of this study was to correlate colonic motility with transit in 8 patients with functional diarrhea compared to 12 healthy subjects. Intraluminal pressure was measured with perfused catheter ports in the transverse colon, splenic flexure, and descending and sigmoid colons. Transit of the luminal contents was measured by following the movement of 99mTC-diethylenetriaminepentaacetic acid instilled as a bolus in the splenic flexure. In patients with diarrhea, the intraluminal marker moved in and out of the transverse and sigmoid colon regions of interest during fasting, unlike healthy subjects, in whom the marker remained in the splenic flexure. After eating, radioactivity immediately increased in both the transverse and sigmoid colons in healthy subjects. In the patients with diarrhea, eating did not alter the marker movement into the different regions of the colon compared with fasting. Within 100 minutes of eating, the intraluminal marker almost disappeared from the regions of interest in patients with diarrhea. Postprandial colonic nonpropagating contractions increased in each region of the colon in healthy subjects; there was only a small postprandial increase in colonic motility in patients with diarrhea. However, the numbers of fasting and postprandial propagating contractions were increased in patients with diarrhea compared with healthy subjects (P less than 0.02). Each propagating contraction moved more tracer in patients with diarrhea than in healthy subjects (P less than 0.05). These studies suggest that (a) in patients with diarrhea, the fluctuation of marker in both transverse and sigmoid colons during the fasting and postprandial periods is associated with decreased nonsegmenting contractions and frequent propagating contractions; and (b) in healthy subjects, the intraluminal marker moved after eating because of a pressure gradient caused by nonpropagating contractions.

[Methods of analyzing gastrointestinal motor activity]

In an attempt to computerize the measurements of various analytical features of gastrointestinal motility signals, a brief description of these signals, particularly for myoelectric and contractile activities, is given. The study of myoelectrical activity includes frequency and coupling based on period (1/T) and Fast Fourier Transform (FFT) based correlation and spectral analysis techniques. The contractile signals are studied for motility index as an indication of the amount of activity, waveform features, propagational characteristics, and the frequency of contractions. To deal with situations where only electrical activities are recorded, a methodology for the analysis of spike bursts as per contractile activities is given.

Centred radio-frequency hyperthermia in solid tumours

After some notions on the mechanisms of action of radio-waves on solid tumours, the treatise illustrates the results achieved in the first 125 cases of malignant tumours treated with this method, its results are definitely encouraging, even in cases apparently with no hope. It also describes briefly the histologic modifications induced by this therapeutic method on neoplastic masses and discusses the criteria of the directions of thermotherapy, alone or combined, which is obviously the fifth weapon against tumours.

Association between postprandial changes in colonic intraluminal pressure and transit

The aim of this study was to correlate the movement of colonic luminal contents with the changes in intraluminal pressure. Studies were performed in 9 healthy volunteers. Intraluminal pressure was measured with perfused catheter ports in the transverse, splenic flexure, descending, and sigmoid colon. Movement of the luminal contents was measured by following the movement of technetium 99m-ethylenetriamine-pentaacetic acid that was instilled as a bolus in the splenic flexure. During fasting there was very little change in pressure or in the movement of intraluminal contents. After eating a 1000-kcal meal, the tracer moved from the splenic flexure into the transverse colon and the sigmoid colon. Nonpropagating colonic motor activity increased in all colonic segments immediately after eating the meal (p less than 0.05). The increase in motility was significantly greater in the descending colon than in the transverse and sigmoid colon (p less than 0.05). In one-half of the subjects propagating contractions occurred postprandially. The movement of the intraluminal tracer occurred during both types of motility. The nonpropagating contractions were associated with a gradual movement of the luminal contents. The direction of the movement of the contents was determined by the differences in pressure in the different segments of the colon. The propagating contractions were associated with a rapid movement of intraluminal contents. These studies suggest that (a) colonic motility and transit are quiescent during fasting and (b) the transverse colon acts as a mixing and storage area, as retrograde transit into the transverse colon is the characteristic postprandial pattern.

Reduction by cimetropium bromide of the colonic motor response to eating in patients with the irritable bowel syndrome

Cimetropium bromide is an antimuscarinic compound with antispasmodic properties. Its effect on meal-stimulated sigmoid motor activity in 30 patients with the irritable bowel syndrome, mainly with pain and constipation, has been evaluated. The mechanical activity of the sigmoid colon was recorded with a probe with three open-tipped tubes ending 45, 30, and 15 cm from the anal margin. After a recording period of 60 min, 5 mg cimetropium bromide or saline was given i.v., according to a randomized, double-blind design 5 min before a 1000 calorie meal, and motility was then recorded for 2 h. The meal caused a significant increase in motor activity for 90 min in the saline-treated group. Cimetropium bromide abolished the peak of motor activity 10-20 min after the meal and significantly inhibited postprandial colonic motility for at least 2 h (p less than 0.01). This effect provides a rationale for the use of cimetropium bromide in treatment of the irritable bowel syndrome.

Efficacy of 5-aminosalicylic acid enemas versus hydrocortisone enemas in ulcerative colitis

A controlled trial has been carried out in order to compare the efficacy of enemas containing a high dosage of 5-ASA (4 g) versus enemas containing hydrocortisone 100 mg. The trial was conducted on 86 patients, 44 of whom received 5-ASA and 42 received hydrocortisone. The results were favorable in terms of clinical, sigmoidoscopic, and histologic criteria for 5-ASA treatment. Other aspects have been investigated, such as retrograde spread of enemas which have been shown to reach the left colon. No nephrotoxicity was detected. The long term experience confirmed the preliminary positive results.

Clinical course of Crohn's disease in Italy

The clinical course of Crohn's disease in 131 patients was studied for a mean period of 4.2 +/- 3.2 years. The clinical activity of the disease, expressed as percentage of patients per year in an active phase, is high in the first year (70.2 percent) and progressively decreases during subsequent years (25 percent after seven years). The percentage of patients who needed steroid treatment is high during the first year (68 percent) and falls to 19 percent after seven years. An operative risk rate of 54 percent was registered, with a probability of reoperation equal to 34 percent. Clinical relapse after the first surgery occurred in 70 percent of cases. The registered mortality was 6.9 percent, with a ratio of 6 to 1 between observed and expected mortality. In conclusion, the disease, while showing a tendency to reduce its activity over the years, is burdened by a risk of surgery and mortality which progressively increases with time.

A laboratory index for predicting relapse in asymptomatic patients with Crohn's disease

Currently there are no completely reliable methods for predicting an impending relapse in Crohn's disease. As approximately 50% of patients in remission [Crohn's disease activity index (CDAI) less than 150] show some laboratory abnormalities, we inquired whether these alterations might be of value for predicting relapse. We prospectively studied 41 patients with Crohn's disease who had been showing CDAI less than 150 for at least 6 mo before entering the study and who were not receiving any long-term treatment. The 41 patients were studied at the ninth and at the 18th month after inclusion in the study. Disease activity was monitored by CDAI calculation and by measurement of erythrocyte sedimentation rate, white blood cell count, hemoglobin, albumin, alpha 2-globulin, serum iron, C-reactive protein, alpha 1-glycoprotein, and alpha 2-antitrypsin. Seventeen of the 41 patients had a clinical relapse during follow-up. At the beginning of the study the patients who later relapsed showed a remarkable alteration of acid alpha 1-glycoprotein (p less than 0.0001), alpha 2-globulin (p less than 0.0003), and erythrocyte sedimentation rate (p less than 0.0006), in comparison with the patients who remained in remission. by discriminant analysis a prognostic index with these laboratory investigations provided a high percentage (88%) of accuracy according to the outcome at the 18th month.

Dietary allergy evaluated by PRIST and RAST in inflammatory bowel disease

The role of allergic responses to dietary antigens in the pathogenesis of inflammatory Bowel Disease (IBD) remains speculative. We studied 50 patients with Ulcerative Colitis (UC), 50 patients with Crohn's Disease (CD) and 100 healthy controls (HC) matched for sex and age. In these patients total serum IgE and specific IgE to ten selected foods were estimated using Phadebas PRIST and RAST. There was no significant difference in the total serum IgE level between UC, CD and HC. The percentage of positive reaction to specific IgE was significantly lower in HC (score 1-2: 7%; score 2: 3%) compared with UC (score 1-2: 24%, p less than 0.004; score 2: 8%, n.s.) and CD (score 1-2: 16%, n.s.; score 2: 12%, p less than 0.03). In CD with colic or ileocolic involvement, the percentage of patients with a positive response to RAST was significantly greater (score 1-2: 26%; score 2: 21%) than in CD with ileal involvement. The considerable increase in positive results to RAST in IBD may be due to a greater absorption of antigens through the diseased wall.

Importance of laboratory parameters in the evaluation of Crohn's disease activity

Some laboratory investigations are abnormal during the course of Crohn's disease (CD). We investigated the trend of some of these laboratory tests in a group of patients with CD to study the relationships between an activity index made up of such laboratory parameters only (LCDAI) and the usual Crohn's disease activity index (CDAI). One hundred thirty-one examinations of 63 patients were evaluated. At each investigation, besides calculation of the CDAI, 10 laboratory investigations were carried out. Three gastroenterologists independently gave an overall evaluation of the laboratory activity for each of the 131 examinations on the basis of the results of the blood tests alone. The sum of the evaluations was used as an independent variable on which a laboratory index was developed by multiple regression analysis. C reactive protein, red cell sedimentation rate, acid alpha 1-glycoprotein, alpha 1-antitrypsin, and white blood cells had an important share in the development of this laboratory index. The evaluation of the relationships existing between LCDAI and CDAI showed that in patients with moderate to severe clinical disease activity, LCDAI was constantly altered. The same happened in 55% of cases in clinical remission, which suggests an inflammatory activity that is not clinically evident. These results point to the advisability of supplementing a predominantly clinical index, such as CDAI, with a laboratory index such as LCDAI in the evaluation of CD.

Retrograde spread of 5-aminosalicylic acid enemas in patients with active ulcerative colitis

In an attempt to know the exact retrograde spread of high-dosage 5-aminosalicylic acid enemas, we have studied eight patients with active left-sided colitis, by adding a small amount of barium sulfate to the enemas and by checking the spread radiologically after 15 minutes, 1 hour, and 6 hours. Four grams of 5-aminosalicylic acid in 100-ml enemas and 4 gm in 200-ml enemas were used. The same experiment was repeated in a subsequent attack, with enemas labeled with technetium-99m and checked by scintiscans in five of these patients. We always have observed a volume-dependent spread of enemas but, interestingly, in the patients studied with technetium-99m there was always a wider spread than that which was detected with barium enemas. In all five patients, 100-ml enemas reached the splenic flexure. In two patients with total colitis, a progression of 100-ml technetium-99m enemas was performed in the transverse colon, but the maximum opacity remained in the left side. We can conclude that 4 gm of 5-aminosalicylic acid in 100-ml enemas can be suitable for treating patients with left-sided colitis, and will represent a valid addition for patients with more extensive colitis.

Anorectal motility and rectal sensitivity in chronic idiopathic constipation: effect of high-fiber diet

The rectoanal inhibitory reflex and rectal sensitivity were evaluated in 13 patients with idiopathic chronic constipation and in 13 control subjects. A double balloon probe was used to stimulate and record the rectoanal inhibitory reflex and rectal sensitivity. The results showed a linear relationship between relaxation amplitude and the logarithm of rectal distending volume, and between relaxation duration and the logarithm of rectal distending volume, with a significant reduction of relaxation amplitude in the patient group. The rectal sensitivity thresholds were significantly increased in patients compared with controls. In 10 additional patients with chronic constipation, motility and sensitivity parameters were evaluated before and after 28 days of high-fiber diet. After diet, the values of relaxation amplitude were significantly increased, returning within normal range, but sensitivity parameters did not change. In conclusion, it appears that in adult chronic idiopathic constipation, anorectal motility and rectal sensitivity are altered, and that only motor abnormalities are corrected by a high-fiber diet.

Topical administration of 5-aminosalicylic acid enemas in patients with ulcerative colitis. Studies on rectal absorption and excretion

5-aminosalicylic acid (5-ASA) is a new treatment for patients suffering from ulcerative colitis but only limited information is available about its rectal absorption. We therefore studied seven patients with ulcerative colitis in remission, and five with active disease to determine acetylated and free 5-ASA plasma concentrations and urinary acetyl 5-ASA after the administration of three different types of enemas: (2 g 5-ASA/100 ml, 4 g/100 ml, and 200 ml). In patients in remission urinary acetyl 5-ASA excretion was dose and volume dependent (p less than 0.01; p less than 0.05) but this correlation was absent in active disease. Because aminosalicylates are usually eliminated through the kidney, these low values (10% in active disease and 19% in those in remission) suggest that the beneficial action may be local. Urinary recovery was significantly lower in patients with active disease (p less than 0.01; p less than 0.02). No accumulation of 5-ASA was found in plasma after repeated daily administration.

Effect of domperidone and dopamine on colonic motor activity in patients with the irritable bowel syndrome

The effect of domperidone, a peripheral antidopaminergic drug, on sigmoid motor activity in the irritable bowel syndrome, has been evaluated by measuring pressures in 3 opentipped tubes perfused with distilled water at a constant flow rate of 0.636 ml/min and inserted into the sigmoid colon. Domperidone 20 mg i.v. in 10 patients, did not induce any significant change in basal motility, but prevented the increase in motor activity produced by the infusion of dopamine 5 micrograms/kg/min for 10 min. It appears that domperidone had no effect on sigmoid motor activity, although the inhibition of dopamine-induced motility confirms the presence of specific dopaminergic receptors in the colon and the antidopaminergic action of domperidone.

Different patterns of intestinal transit time and anorectal motility in painful and painless chronic constipation

Anorectal motility and gastrointestinal transit time were studied in 25 patients complaining of non-organic constipation. Colonic pain was reported by 14 patients, it was absent in the remaining 11. The group with painful constipation was composed of four men and 10 women and age onset of the symptom was 22.1 +/- 5.1 years. The other group was composed only of women and painless constipation was reported to have begun at 7.9 +/- 2.2 years previously. In the group presenting painful constipation higher values of the anal maximum resting pressure, of the amplitude of the rectoanal inhibitory reflex, lower values of sensation threshold, need to evacuate, maximum tolerable volume were recorded, in comparison with those registered in the painless constipation group. All these differences were significant. In the latter group the total transit time was always very slow (186.0 +/- 4.7 h), while it was quite variable in the other group, so that the mean was in the normal range (79.0 +/- 10.0 h). The data show that two different patterns of motor abnormalities can be recognised in constipated patients. The presence of colonic pain can suggest the characteristics of the underlying motor abnormality.

Assessment of nutritional status in Crohn's disease in remission or low activity

Malnutrition is frequently reported in chronic diseases with involvement of gastrointestinal tract, such as Crohn's disease; however, information about this problem is scarce, and available only for hospitalized patients with severe disease. The aim of this study was to evaluate the nutritional status of 44 consecutive outpatients with Crohn's disease in remission or in a stage of low activity (CDAI less than 250). Eighteen of the patients weighed less than 90% of ideal weight and 5 of these weighed less than 80%. Triceps skinfold, a measure of fat store, was less than or equal to 15th percentile in 30%; arm muscle circumference, indicative of muscle mass, was less than or equal to 15th percentile in 59%. The alteration of weight and arm muscle circumference was greater in patients with midly active disease (p less than 0.005) and in those with ileal and ileocolic involvement. Caloric intake, assessed by a seven day questionnaire, was generally good (35.9 +/- 11 Kcal/kg ideal weight/day) and sufficient to maintain weight. Creatinine height index was elevated in 55% of the whole group. Serum albumin was decreased in only 2 cases, and haemoglobin in only 4. Our results show that malnutrition is a serious problem also in outpatients with Crohn's disease. Anthropometric parameters are more sensitive indicators than conventional laboratory studies.

Anorectal manometry in the diagnosis of Hirschsprung's disease--comparison with clinical and radiological criteria

In 34 consecutive patients in whom the diagnosis of Hirschsprung's disease (HD) was suspected, the reliability of clinical symptoms, radiological parameters, and anorectal manometry was retrospectively and blindly evaluated by three independent investigators. In 19 patients the diagnosis of HD was histologically proved, while in the remaining 15 cases the diagnosis of idiopathic constipation was justified by persistent success of medical treatment at regular follow-up. Anorectal manometry was correctly diagnostic in all the patients who were examined. The recto and inhibitory reflex, recorded in all the patients with idiopathic constipation was absent in patients suffering from HD. Moreover, other manometric parameters, peculiar to HD were found: a significant lower anal resting pressure and pain threshold, as well as a decreased frequency of spontaneous rhythmic oscillations. The reliability of radiological and clinical data for these diagnoses appeared to be inadequate. Therefore, the diagnosis of HD can be confidently stated only on the basis of manometric investigations.

A double-blind clinical trial to compare the effects of 4-aminosalicylic acid to 5-aminosalicylic acid in topical treatment of ulcerative colitis

5-Aminosalicylic acid (5-ASA) is the active component of Salazopyrin and induces a prompt and excellent improvement, when administered as high dosage enema, in patients suffering from active ulcerative colitis. However, the high instability of this metabolite makes its large use difficult. We aimed at finding a more stable preparation and therefore wondered whether another similar molecule, i.e. 4-aminosalicylic acid (4-ASA, generally known as p-aminosalicylic acid, PAS), which differs from 5-ASA only for the position of the amino group, might be a valid alternative. Therefore, 4-ASA at 2 g dosage, administered as rectal enema, was compared to an equivalent preparation of 5-ASA. We carried out a double-blind therapeutical trial, in which 63 patients, similarly matched for age, sex and extent of disease, took part. The analysis of the final results showed that in the 5-ASA group, 26 (81%) out of 32 patients improved clinically, 25 (78%) sigmoidoscopically and 15 (46%) histologically. In the group of the 31 patients treated with 4-ASA, 24 (77%) improved clinically, 24 (77%) sigmoidoscopically and 13 (41%) histologically. Since no difference was registered between the two types of treatment (p = 0.141, X2 test), 4-ASA could be a possible form of treatment for active ulcerative colitis.

Inhibition of postprandial colonic motility by sulpiride in patients with irritable colon

Sulpiride, a benzamide derivative, selectively antagonizes dopaminergic receptors within and outside the central nervous system. Dopamine has previously been shown to increase colonic motility. In the present investigation the motor response of the pelvic colon to a standard 1000 calorie meal was studied in 12 patients with the irritable bowel syndrome. The meal induced a significant increase in motor activity, lasting for 1 h and greatest in the first 30 min. In 6 cases the administration of sulpiride 100 mg i.m. significantly reduced the postprandial increase in colonic motor activity. Thus dopaminergic receptors may be involved in the colonic motor response to food.

Clinical course of ulcerative colitis in Italy

The prognosis of ulcerative colitis has been studied in 122 patients with this disease who had been referred to Bolgna from various parts of Italy and were then followed up. The overall mortality rate was 4.9% and the percentage of patients who were treated by total colectomy was 15.5%. Postoperative mortality was 10.5%, and the percentage of patients who developed carcinoma of the colon was 0.8%. All these figures fall within the range of values for the relevant variables quoted by previous authors from different countries. It is concluded that the prognosis of ulcerative colitis in the 122 Italian patients in the present study was similar to that reported previously in patients of other nationalities.