The effects of alcohol on gastrointestinal tract, liver and pancreas: evidence-based suggestions for clinical management

Alcohol has a direct impact on the digestive system due to its contact with mucosal lining and interference with digestive functions. Various diseases of the gastrointestinal tract, including tumors, may be related to an excess of alcohol intake and the relationship between alcohol abuse and hepatic and pancreatic damage is well established. According to WHO, alcohol and alcohol-related diseases represent a major health problem and will probably continue to do so in the foreseeable future. In this review, we summarize the present knowledge on clinically relevant alcohol-related problems in order to provide practicing physicians with evidence-based general suggestions which might help in the management of alcohol-related gastrointestinal disorders. A thorough clinical history together with a number of questionnaires are essential for detecting alcohol dependence or abuse. Biochemical tests (nonspecific and specific) have been considered to be less sensitive than questionnaires in screening for alcohol abuse, but they may be useful in identifying relapses. Protracted behavior modification, cognitive behavioral therapy, psychological counseling, and mutual support groups have been considered the most effective long-term treatments. Several drugs have been developed that are able to interfere with the neurotransmitters involved in craving mechanisms, and we summarize the evidence of their efficacy to increase abstinence and to prevent relapse.

Validation of the balloon evacuation test: reproducibility and agreement with findings from anorectal manometry and electromyography

BACKGROUND & AIMS

The balloon evacuation test (BET) measures the time required to evacuate a balloon filled with 50 mL water; it has been incorporated into many algorithms for diagnosis of pelvic floor dyssynergia. We aimed to assess the reproducibility of the BET, determine the upper limit of normal, and assess its concordance with evaluation of pelvic floor dyssynergia by anorectal manometry (ARM) and pelvic floor surface electromyography (EMG).

METHODS

The BET was tested in 286 consecutive patients with chronic constipation (mean age, 44 years; 91% female) before and after 30 days of conservative treatment at a tertiary gastroenterology clinic in Italy from March 2010 through May 2012. The BET was tested twice, 7 days apart, in 40 healthy individuals (controls: mean age, 38 years; 92% female). The 238 constipated patients who responded incompletely to conservative therapy were examined by ARM, EMG, and digital rectal examination. Forty-seven patients with conflicting ARM and BET results underwent defecography.

RESULTS

The balloon was evacuated within 1 minute by 37 controls (93%; 3 individuals required 1-2 minutes). Among patients with constipation, 148 (52%) passed the balloon within 5 minutes (110 passed the balloon in 1 minute, 35 passed it in 1-2 minutes, and 3 passed it in 2-5 minutes). The BET showed perfect reproducibility in 280 of the patients with constipation (98%) when a time less than 2 minutes was set as abnormal. The level of agreement between BET and ARM for dyssynergia was 78%, and between BET and EMG it was 83%. Thirty-two patients had abnormal results from the BET but normal results from ARM; 31 cases had inadequate straining (n = 11) or anatomic defects (n = 20), which could account for the abnormal findings from BET.

CONCLUSIONS

The BET is reliable for analysis of pelvic floor dyssynergia; the optimal upper limit of normal is 2 minutes. Findings from the BET have a high level of agreement with those from ARM and EMG.

Application of international consensus diagnostic criteria to an Italian series of autoimmune pancreatitis

BACKGROUND

International consensus diagnostic criteria (ICDC) have been proposed to classify autoimmune pancreatitis (AIP) in type 1, type 2, or not otherwise specified.

OBJECTIVE

Aim was to apply the ICDC to an Italian series of patients to evaluate the incidence and clinical profiles among different subtypes of AIP.

METHODS

we re-evaluated and classified 92 patients diagnosed by Verona criteria, according to the ICDC.

RESULTS

Out of 92 patients, 59 (64%) were diagnosed as type 1, 17 (18%) as type 2, and 15 (16%) as not otherwise specified according to the ICDC. A significant difference between type 1 and type 2 were found for age (54.5 ± 14.5 vs. 34.4 ± 13.9 respectively; p < 0.0001), male sex (76 vs. 47%; p = 0.007), jaundice (66 vs. 18%; p = 0.002) and acute pancreatitis (9 vs. 47%; p < 0.0001), elevated serum IgG4 levels (85 vs. 7%; p < 0.0001), inflammatory bowel disease (8 vs. 82%; < 0.0001), and relapse of the disease (34 vs. 6%; p = 0.058). Imaging and response to steroids in the not-otherwise-specified group were similar to type 1 and 2.

CONCLUSIONS

Type 1 has a different clinical profile from type 2 autoimmune pancreatitis. The not-otherwise-specified group has peculiar clinical features which are shared both with type 1 or type 2 groups.

Fecal elastase-1 is useful in the detection of steatorrhea in patients with pancreatic diseases but not after pancreatic resection

BACKGROUND

Fecal elastase-1(FE-1) has been suggested as an alternative to steatorrhea quantification to evaluate pancreatic insufficiency, but its diagnostic performance has not been compared with steatorrhea in chronic pancreatitis or after pancreatic resection.

METHODS

The relationship between steatorrhea and FE-1 was studied in patients with chronic pancreatic disorders or pancreatic resection. Student's t test and ANOVA were used for statistical analysis, accepting 0.05 as limit for significance.

RESULTS

Eighty-two patients were studied (42 non-operated; 40 previously submitted to pancreatic resection). Fat output was higher in operated than non-operated patients (29.2 ± 3.1 vs 9.9 ± 2.2 g/day, p < 0.001) FE-1 was more severely reduced in operated patients (202 ± 32.3 μg/g in non operated vs 68.6 ± 18.2 in operated patients; p < 0.001). Steatorrhea was significantly more severe in operated patients across different levels of FE-1. The relationship between FE-1 and steatorrhea was described by a power regression model, with a regression line significantly different in operated and non-operated patients (p < 0.001). A steatorrhea of 7 g (upper limit of normal range) was calculated by this regression line when FE-1 is 15 μg/g in non-operated, but as high as 225 μg/g in operated patients.

CONCLUSION

FE-1 is useful to identify pancreatic insufficiency. Steatorrhea is anticipated in non-operated patients only when FE-1 is below the limit for a confident measurement of our assay. In operated patients, steatorrhea may be present even if FE-1 is only slightly reduced, that suggests a role for non pancreatic factors. FE1 is not useful to identify operated patients at risk of malabsorption.

A practical approach to the diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis is a disease characterized by specific pathological features, different from those of other forms of pancreatitis, that responds dramatically to steroid therapy. The pancreatic parenchyma may be diffusely or focally involved with the possibility of a low-density mass being present at imaging, mimicking pancreatic cancer. Clinically, the most relevant problems lie in the diagnosis of autoimmune pancreatitis and in distinguishing autoimmune pancreatitis from pancreatic cancer. Since in the presence of a pancreatic mass the probability of tumour is much higher than that of pancreatitis, the physician should be aware that in focal autoimmune pancreatitis the first step before using steroids is to exclude pancreatic adenocarcinoma. In this review, we briefly analyse the strategies to be followed for a correct diagnosis of autoimmune pancreatitis.

Esophageal motility and symptoms in restricting and binge-eating/purging anorexia

BACKGROUND

Esophageal symptoms are common in anorexia nervosa, but it is not known whether they are associated with motility disorders, with different forms of the disease, and whether they respond to nutritional rehabilitation.

METHODS

To clarify these points, 23 patients with anorexia nervosa (12 binge-eating/purging, "purgers"; 11 restricting type, "restricters") were studied by esophageal manometry before and after 22 weeks rehabilitation. Manometric parameters of 35 age and sex-matched patients were used as controls. Patients with anorexia also filled questionnaires on eating disorder psychopathology, psychopathological distress and esophageal, gastric and colonic symptoms before and after 4 and 22 weeks of a rehabilitation program.

RESULTS

Symptoms were more severe in patients than in controls. Gastric and colonic, but not esophageal symptoms improved with treatment. LES basal pressure was higher in restricters (restricters 32.1±4.6; purgers 14.9±2.2; controls 17.1±1.1 mmHg, p<0.005), but still within normal range; this difference disappeared after treatment. Postdeglutitive body waves were normally propagated. Their amplitude was significantly higher in anorexia than in controls. No correlation was found between results of psychopathological tests (improved after treatment), esophageal symptoms and manometry.

CONCLUSIONS

In anorexia, esophageal symptoms are frequent and severe. They are not adequately explained by psychological or manometric derangements.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Exocrine and endocrine pancreatic function in 21 patients suffering from autoimmune pancreatitis before and after steroid treatment

BACKGROUND/AIM

Autoimmune pancreatitis (AIP) responds rapidly and dramatically to steroid therapy. The aim of this study was to evaluate pancreatic exocrine and endocrine function in patients suffering from AIP both before and after steroid therapy.

PATIENTS AND METHODS

Fecal elastase 1 and diabetes were evaluated before steroid therapy and within 1 month of its suspension in 21 patients (13 males and 8 females, mean age 43 +/- 16.5 years) diagnosed as having AIP between 2006 and 2008.

RESULTS

At clinical onset, fecal elastase 1 was 107 +/- 126 microg/g stool. Thirteen patients (62%) showed severe pancreatic insufficiency (<100 microg/g stool), 4 (19%) had mild insufficiency (100-200 microg/g stool), while 4 (19%) had normal pancreatic function (>200 microg/g stool). Before steroids, diabetes was diagnosed in 5 patients (24%), all of whom had very low levels of fecal elastase 1 (<19 microg/g stool). Following steroids, fecal elastase 1 increased in all patients (237 +/- 193 microg/g stool) and observed levels were significantly higher than those seen before steroids (p = 0.001).

CONCLUSIONS

Patients suffering from AIP display exocrine and/or endocrine pancreatic insufficiency at clinical onset. These insufficiencies improve after steroid therapy.

Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome

BACKGROUND & AIMS

Levator ani syndrome (LAS) might be treated using biofeedback to teach pelvic floor relaxation, electrogalvanic stimulation (EGS), or massage of levator muscles. We performed a prospective, randomized controlled trial to compare the effectiveness of these techniques and assess physiologic mechanisms for treatment.

METHODS

Inclusion criteria were Rome II symptoms plus weekly pain. Patients were categorized as "highly likely" to have LAS if they reported tenderness with traction on the levator muscles or as "possible" LAS if they did not. All 157 patients received 9 sessions including psychologic counseling plus biofeedback, EGS, or massage. Outcomes were reassessed at 1, 3, 6, and 12 months.

RESULTS

Among patients with "highly likely" LAS, adequate relief was reported by 87% for biofeedback, 45% for EGS, and 22% for massage. Pain days per month decreased from 14.7 at baseline to 3.3 after biofeedback, 8.9 after EGS, and 13.3 after massage. Pain intensity decreased from 6.8 (0-10 scale) at baseline to 1.8 after biofeedback, 4.7 after EGS, and 6.0 after massage. Improvements were maintained for 12 months. Patients with only a "possible" diagnosis of LAS did not benefit from any treatment. Biofeedback and EGS improved LAS by increasing the ability to relax pelvic floor muscles and evacuate a water-filled balloon and by reducing the urge and pain thresholds.

CONCLUSIONS

Biofeedback is the most effective of these treatments, and EGS is somewhat effective. Only patients with tenderness on rectal examination benefit. The pathophysiology of LAS is similar to that of dyssynergic defecation.

Identification of a novel antibody associated with autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis is characterized by an inflammatory process that leads to organ dysfunction. The cause of the disease is unknown. Its autoimmune origin has been suggested but never proved, and little is known about the pathogenesis of this condition.

METHODS

To identify pathogenetically relevant autoantigen targets, we screened a random peptide library with pooled IgG obtained from 20 patients with autoimmune pancreatitis. Peptide-specific antibodies were detected in serum specimens obtained from the patients.

RESULTS

Among the detected peptides, peptide AIP(1-7) was recognized by the serum specimens from 18 of 20 patients with autoimmune pancreatitis and by serum specimens from 4 of 40 patients with pancreatic cancer, but not by serum specimens from healthy controls. The peptide showed homology with an amino acid sequence of plasminogen-binding protein (PBP) of Helicobacter pylori and with ubiquitin-protein ligase E3 component n-recognin 2 (UBR2), an enzyme highly expressed in acinar cells of the pancreas. Antibodies against the PBP peptide were detected in 19 of 20 patients with autoimmune pancreatitis (95%) and in 4 of 40 patients with pancreatic cancer (10%). Such reactivity was not detected in patients with alcohol-induced chronic pancreatitis or intraductal papillary mucinous neoplasm. The results were validated in another series of patients with autoimmune pancreatitis or pancreatic cancer: 14 of 15 patients with autoimmune pancreatitis (93%) and 1 of 70 patients with pancreatic cancer (1%) had a positive test for anti-PBP peptide antibodies. When the training and validation groups were combined, the test was positive in 33 of 35 patients with autoimmune pancreatitis (94%) and in 5 of 110 patients with pancreatic cancer (5%).

CONCLUSIONS

The antibody that we identified was detected in most patients with autoimmune pancreatitis but also in some patients with pancreatic cancer, making it an imperfect test to distinguish between these two conditions.

Reduced serum hepcidin levels in patients with chronic hepatitis C

BACKGROUND/AIMS

Patients with chronic hepatitis C (CHC) often have increased liver iron, a condition associated with reduced sustained response to antiviral therapy, more rapid progression to cirrhosis, and development of hepatocellular carcinoma. The hepatic hormone hepcidin is the major regulator of iron metabolism and inhibits iron absorption and recycling from erythrophagocytosis. Hepcidin decrease is a possible pathophysiological mechanism of iron overload in CHC, but studies in humans have been hampered so far by the lack of reliable quantitative assays for the 25-amino acid bioactive peptide in serum (s-hepcidin).

METHODS

Using a recently validated immunoassay, we measured s-hepcidin levels in 81 untreated CHC patients and 57 controls with rigorous definition of normal iron status. All CHC patients underwent liver biopsy with histological iron score.

RESULTS

s-hepcidin was significantly lower in CHC patients than in controls (geometric means with 95% confidence intervals: 33.7, 21.5-52.9 versus 90.9, 76.1-108.4 ng/mL, respectively; p<0.001). In CHC patients, s-hepcidin significantly correlated with serum ferritin and histological total iron score, but not with s-interleukin-6. After stratification for ferritin quartiles, s-hepcidin increased significantly across quartiles in both controls and CHC patients (chi for trend, p<0.001). However, in CHC patients, s-hepcidin was significantly lower than in controls for each corresponding quartile (analysis of variance, p<0.001).

CONCLUSIONS

These results, together with very recent studies in animal and cellular models, indicate that although hepcidin regulation by iron stores is maintained in CHC, the suppression of this hormone by hepatitis C virus is likely an important factor in liver iron accumulation in this condition.

Models of learning, training and progress evaluation of medical students

Medical education has changed during the last century. Teachercentred medical education has been replaced by a studentcentred one. Some general educational principles have been adopted in medicine faculties, leading to more active students involved in learning, and interactive methods have been introduced, and the role of experience has been focused. Disciplinebased medical education is inadequate for developing comprehensive competence and doctoring. Integrated multidisciplinary learning, together with new clerkship approaches and organization, represent the future of medical education. Continuing, comprehensive, assessment can measure progression in knowledge, skills, attitudes and values. Progress test have recently been introduced in some medical school as a reliable tool for assessing the progressive performance of students in time and monitoring the entire learning process.

Omeprazole reduces the response to capsaicin but not to methacholine in asthmatic patients with proximal reflux

OBJECTIVE

To study the relationships between airway responsiveness to methacholine and capsaicin, proximal or distal reflux and the effects of short-term acid inhibition.

MATERIAL AND METHODS

Twenty-nine asthmatics, not taking steroids regularly, underwent respiratory symptom measurements, 24-h dual-probe pH monitoring, and challenges with methacholine and capsaicin. Challenges and symptom measurements were repeated after 12 days' omeprazole treatment (20 mg b.i.d.). The results (median and range) were expressed as PD20 methacholine (mg) and PD5 capsaicin (dose causing five coughs, nmol).

RESULTS

Seventeen patients presented pathological reflux in the distal esophagus, and 17 in the proximal esophagus. At baseline no correlation was found between PD20 or PD5 and reflux. Treatment with omeprazole did not change bronchial responsiveness to methacholine (basal: 0.16 mg, 0.02-1.27; omeprazole: 0.15 mg, 0.02-1.60); omeprazole decreased the tussive response to capsaicin (basal: 0.08 nmol, 0.08-2.46; omeprazole: 0.61 nmol, 0.08-9.84, p<0.001) only in patients with pathological reflux. The decrease was positively correlated with proximal acid exposure (r2=0.70, p<0.001). Omeprazole reduced asthma symptoms in patients with proximal reflux, cough in those with proximal or distal reflux.

CONCLUSIONS

In asthmatics, inhibition of gastric acid secretion does not influence bronchial hyperresponsiveness but decreases tussive sensitivity and this effect is related to proximal reflux.

Intraductal papillary mucinous neoplasms and chronic pancreatitis

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) may present with clinical and radiological pictures resembling those of chronic pancreatitis (CP).

AIMS

To compare the clinical and epidemiological characteristics of patients suffering from CP with those of patients suffering from IPMN. To assess whether CP is associated with an increased risk of developing IPMN.

METHODS

In our departments, from 1981 to 1998, we prospectively followed 473 patients suffering from CP, including 93 cases of chronic obstructive pancreatitis (COP), and 45 patients with a histologically confirmed diagnosis of IPMN. Another 6 patients had an initial diagnosis of CP and a subsequent diagnosis of IPMN.

RESULTS

Patients with IPMN were more often female (females 53 vs. 15%; p < 0.001), were older (mean age 63.1 vs. 42.8 years; p < 0.001), drank less alcohol (19 vs. 107 g/day; p < 0.001) and smoked fewer cigarettes (mean 8 vs. 21 cigarettes/day) than CP patients. These results were also confirmed when considering only patients with COP. The 6 patients with a subsequent diagnosis of IPMN were males (p n.s.) with a mean age of 51.4 years (p < 0.05). Only 1 patient was a drinker (p < 0.05) and 4 were smokers (p n.s.). Comparing CP and IPMN, logistic regression analysis selected sex, age, alcohol and smoking, whereas only sex and age were selected when comparing COP vs. IPMN.

CONCLUSIONS

In general patients with IPMN present different epidemiological characteristics than those with CP and the subgroup with COP. The clinical and pathological features suggest that in most cases IPMN is the cause of CP and not vice versa.

Prokinetic effect of gut-oriented hypnosis on gastric emptying

BACKGROUND

No data are available on the effect of hypnosis on gastric emptying.

AIM

To determine the effect of a hypnosis session on gastric emptying and dyspeptic symptoms.

METHODS

We studied emptying by ultrasonography and epigastric sensations in 11 healthy subjects and in 15 patients affected by functional dyspepsia under three conditions according to a fixed schedule: (a) basal, (b) after cisapride and (c) during a 90 min hypnotic trance. Eight healthy subjects repeated an emptying study listening to relaxing music. Statistical analysis was performed using the Friedman test or RM-ANOVA.

RESULTS

In dyspeptics, the postprandial increase in the antral area was significantly smaller during the hypnosis trance than under the basal and the cisapride conditions. For the patients gastric emptying was significantly shortened by cisapride, and even more by hypnosis (basal 274 +/- 16.8 min; cisapride 227 +/- 13.2; hypnosis 150 +/- 9.7) whereas for healthy subjects it was shortened only by hypnosis. The repeated study in healthy subjects listening to relaxing music showed no significant difference compared with the basal. Epigastric sensations were improved in dyspeptics by hypnosis, but not by cisapride.

CONCLUSIONS

Gut-oriented hypnosis is effective in shortening gastric emptying both in dyspeptic and in healthy subjects.

Colonic fermentation of indigestible carbohydrates contributes to the second-meal effect

BACKGROUND

Low postprandial blood glucose is associated with low risk of metabolic diseases. A meal's ability to diminish the glucose response to carbohydrates eaten during the following meal is known as the "second-meal effect" (SME). The reduced glycemia elicited by low-glycemic-index (LGI) foods consumed during the first meal has been suggested as the main mechanism for SME. However, LGI foods often increase colonic fermentation because of the presence of fiber and resistant starch.

OBJECTIVE

The objective was to study the SME of greater fermentation of high-glycemic-index (HGI) and LGI carbohydrates eaten during a previous meal.

DESIGN

Ten healthy volunteers ate 3 breakfast test meals consisting of sponge cakes made with rapidly digestible, nonfermentable amylopectin starch plus cellulose (HGI meal), amylopectin starch plus the fermentable disaccharide lactulose (HGI-Lac meal), or slowly digestible, partly fermentable amylose starch plus cellulose (LGI meal). Five hours later, subjects were fed the same standard lunch containing 93 g available carbohydrates. Blood was collected for measurement of glucose, insulin, and nonesterified fatty acids (NEFAs). Breath hydrogen was measured as a marker of colonic fermentation. Postlunch gastric emptying was measured by using ultrasonography.

RESULTS

Both the HGI-Lac and LGI meals improved glucose tolerance at lunch. In the case of the HGI-Lac meal, this effect was concomitant with low NEFA concentrations and delayed gastric emptying.

CONCLUSION

Fermentable carbohydrates, independent of their effect on a food's glycemic index, have the potential to regulate postprandial responses to a second meal by reducing NEFA competition for glucose disposal and, to a minor extent, by affecting intestinal motility.

Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa

OBJECTIVES

Gastrointestinal symptoms are common in anorexia and in bulimia nervosa, but their relationship with gastric dysmotility and their possible improvement with refeeding are still debated.

METHODS

Twenty-three anorexic patients (12 with the binge/purging and 11 with the restricting subtypes) were studied using an ultrasonographic gastric-emptying test, psychopathological questionnaires, and bowel symptom questionnaires, before and after 4 and 22 wk rehabilitation.

RESULTS

Gastric symptom scores were markedly higher in patients than in controls and improved significantly with treatment. On entry, compared to controls, gastric emptying was significantly delayed in restricters and purgers (357 +/- 25.3 and 360 +/- 13.0 min, respectively, mean +/- SEM; controls 207 +/- 9.1). After 4 and 22 wk of treatment, it improved in restricters (315 +/- 20.1 and 296 +/- 17.2 min, respectively), but not in purgers (337 +/- 14.3 and 335 +/- 15.9 min). No relationship was found between entry values of symptoms of gastric emptying and of psychopathological tests or between their variations over time.

CONCLUSIONS

Gastric emptying derangement and dyspeptic symptoms are present in both subtypes of anorexia nervosa patients. Long-term rehabilitation improves gastrointestinal symptoms, gastric emptying, and psychopathological distress in an independent manner, whereas short-term refeeding does not.

One-year follow-up study on the effects of electrogalvanic stimulation in chronic idiopathic constipation with pelvic floor dyssynergia

BACKGROUND

Constipation is a commonly reported symptom, and pelvic floor dyssynergia is frequently documented in constipated patients. The standard therapeutic approach for pelvic floor dyssynergia is biofeedback training, but long-term studies show that a significant percentage of patients remain symptomatic. Alternative or adjunctive therapeutic options are needed.

AIMS

The purpose of this study was to evaluate the long-term effects of electrogalvanic stimulation in patients with pelvic floor dyssynergia and severe constipation, to see whether this treatment may be of some benefit.

PATIENTS AND METHODS

Thirty consecutive constipated patients with clinical and instrumental evidence of pelvic floor dyssynergia entered the study and were treated with a standard high-frequency galvanic electrostimulation protocol. Clinical and instrumental (colon transit time, anorectal manometry, defecography, rectal balloon expulsion) assessment evaluations were performed basally and one year after the treatment.

RESULTS

Overall, approximately 50 percent of patients showed significant improvement after electrogalvanic treatment, from both a clinical and an instrumental point of view, as shown by the objective measurements obtained through manometry, defecography, and the balloon expulsion test. The benefit was limited to normal transit constipation patients.

CONCLUSIONS

Because of the relatively simple, painless and effective nature of electrogalvanic stimulation, we concluded that it may represent a useful adjunct to the therapeutic armamentarium for pelvic floor dyssynergia in normal transit constipation.

Survival rate and prognostic factors in patients with intestinal failure

BACKGROUND

Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients.

AIMS

This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency.

PATIENTS

Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others).

METHODS

Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model.

RESULTS

At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance.

CONCLUSIONS

Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.

Nonresponse to interferon monotherapy in HCV-related chronic hepatitis: results of retreatment and prognostic factors

At present two of the most relevant problems of the therapy of HCV-related chronic active hepatitis are the retreatment of nonresponders to interferon-alpha (IFN-alpha) and the definition of a prognostic index of response. We treated 44 patients who previously were nonresponders to IFN-alpha alone with IFN-alpha plus ribavirin for 12 months. Among the tests performed, we included the serum level of soluble intercellular adhesion molecule-1 (sICAM-1) at the beginning of the trial and at 3 months thereafter. We obtained 56.81% end of treatment responses and 47.72% sustained responses. A decrease of at least 10% of the sICAM-1 serum level during the first 3 months of treatment strongly correlated to the results of therapy while the usual important prognostic factors (HCV genotype and viral load) did not show this relation.

[Current trends of artificial enteral nutrition in acute pancreatitis]

During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. Enteral nutrition with its known potential for reducing this type of infection constitutes an attempt to prevent it by preserving the enteric mucosal barrier. Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.

Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence

OBJECTIVES

Biofeedback is a nonsurgical treatment that reportedly produces good results in 65-75% of fecally incontinent patients. However, previous studies have not ruled out nonspecific treatment effects. It is also unknown whether biofeedback works primarily by improving the strength of the striated pelvic floor muscles or by improving the rectal perception. We aimed to 1) evaluate the efficacy of biofeedback in formed-stool fecal incontinence, 2) assess the relative contribution of sensory and strength retraining to biofeedback outcomes, and 3) identify patient characteristics that predict a good response to treatment.

METHODS

Twenty-four patients with frequent (at least once a week) solid-stool incontinence were provided with three to four biofeedback sessions. They were taught to squeeze in response to progressively weaker rectal distentions. Patients were re-evaluated by anorectal manometry and symptom diary 3 months after completing training and by diary and interview 6-12 months after training.

RESULTS

Seventeen (71%) were classified responders; 13 became continent and four reduced incontinence frequency by at least 75%. Clinical improvements were maintained at 12-month follow-up. At 3-month follow-up, responders had significantly lower thresholds for perception of rectal distention and for sphincter contraction, but squeeze pressures did not significantly differ from those of nonresponders. Baseline measures that predicted a favorable response were sensory threshold (50 ml or less), urge threshold (100 ml or less), lower threshold for sphincter contraction, and lower threshold for the rectoanal inhibitory reflex; neither anal squeeze pressure nor severity of incontinence predicted treatment outcome.

CONCLUSIONS

In solid-stool fecal incontinence biofeedback training effects are robust and seem not to be explained by expectancy or nonspecific treatment effect. Sensory retraining appears to be more relevant than strength training to the success of biofeedback.

Gastric emptying of realistic meals with and without gluten in patients with coeliac disease. Effect of jejunal mucosal recovery

BACKGROUND

Few data are available on disturbed gastric emptying in patients with coeliac disease. The aims of the study were to investigate (a) the presence of delayed gastric emptying: (b) the acute effect on gastric emptying of gliadin; and (c) the effect of jejunal recovery on gastric emptying of meals with or without gluten in such patients.

METHODS

We measured gastric emptying of two meals in 16 patients with coeliac disease; one meal contained gliadin. Results were compared with those obtained in 24 controls. In 12 patients, both measurements were repeated after mucosal recovery. Statistical analysis was performed using the analysis of variance for repeated measurements and Student's t test. Mean +/- 1 s(mean) (standard error of the mean) are shown.

RESULTS

No difference was found in fasting and in maximal antral sections after the two meals. On entry, gastric emptying was significantly (P < 0.001) delayed compared to controls both after the meal containing gluten (326.9 +/- 12.4 min versus controls 213.5 +/- 11.5) and after the gluten-free meal (315.3 +/- 16.7 min). After jejunal recovery, emptying of the meal containing gluten remained unchanged (337 +/- 18.9 min), whereas emptying of the gluten-free meal was significantly shortened (280.6 +/- 10.5 min; P < 0.001).

CONCLUSIONS

In coeliac disease there is an impairment of gastric emptying which is at least partially reversible. This suggests either an immunological disorder or that unabsorbed meal constituents are responsible for an ileal-brake effect.

Alcohol intake, cigarette smoking, and body mass index in patients with alcohol-associated pancreatitis

The differential diagnosis between acute and chronic alcohol-associated pancreatitis is often difficult or impossible at onset of the disease. A study was conducted to determine possible relationships between patients suffering from a first episode of acute alcoholic pancreatitis and patients with unequivocal chronic alcoholic pancreatitis, comparing age, drinking and smoking habits, and body mass index (BMI). Two groups of men were considered. The first group consisted of 67 patients with a diagnosis of acute alcohol-associated pancreatitis in the absence of other potential pathogenic factors; in this group, 48 of the 56 patients surviving the acute attack were submitted to imaging studies for a median period of 9 years. The second group consisted of 396 patients with chronic alcoholic pancreatitis with a median follow-up period of 12 years. The variables that differed significantly in the two groups were BMI (p < 0.009) and number of smokers (p < 0.001). Logistic regression analysis selected only BMI with an odds ratio of 1.19 (95% CI, 1.07-1.33; p < 0.00015) in favor of acute alcoholic pancreatitis. In male patients, from an epidemiologic standpoint, only smoking habits and BMI are significant differences at clinical onset between the two types of pancreatitis.

Anorectal dysfunction in constipated women with anorexia nervosa

OBJECTIVE

To evaluate anorectal and colonic function in a group of patients with anorexia nervosa complaining of chronic constipation.

PATIENTS AND METHODS

Twelve women (age range, 19-29 years) meeting the criteria for anorexia nervosa and complaining of chronic constipation were recruited for the study. A group of 12 healthy women served as controls. Colonic transit time was measured by a radiopaque marker technique. Anorectal manometry and a test of rectal sensation were carried out with use of standard techniques to measure pelvic floor dysfunction. A subgroup of 8 patients was retested after an adequate refeeding program was completed.

RESULTS

Eight (66.7%) of 12 patients with anorexia nervosa had slow colonic transit times, while 5 (41.7%) had pelvic floor dysfunction. Colonic transit time normalized in the 8 patients who completed the 4-week refeeding program. However, pelvic floor dysfunction did not normalize in these patients.

CONCLUSIONS

Patients with anorexia nervosa who complain of constipation have anorectal motor abnormalities. Delayed colonic transit time is probably due to abnormal eating behavior.

Cough threshold in reflux oesophagitis: influence of acid and of laryngeal and oesophageal damage

BACKGROUND

Gastro-oesophageal reflux is often associated with cough. Patients with reflux show an enhanced tussive response to bronchial irritants, even in the absence of respiratory symptoms.

AIM

To investigate the effect of mucosal damage (either oesophageal or laryngeal) and of oesophageal acid flooding on cough threshold in reflux patients.

PATIENTS

We studied 21 patients with reflux oesophagitis and digestive symptoms. Respiratory diseases, smoking, and use of drugs influencing cough were considered exclusion criteria.

METHODS

Patients underwent pH monitoring, manometry, digestive endoscopy, laryngoscopy, and methacholine challenge. We evaluated the cough response to inhaled capsaicin (expressed as PD5, the dose producing five coughs) before therapy, after five days of omeprazole therapy, and when oesophageal and laryngeal damage had healed.

RESULTS

In all patients spirometry and methacholine challenge were normal. Thirteen patients had posterior laryngitis and eight complained of coughing. Twenty patients showed an enhanced cough response (basal PD5 0.92 (0.47) nM; mean (SEM)) which improved after five and 60 days (2.87 (0.82) and 5.88 (0.85) nM; p<0.0001). The severity of oesophagitis did not influence PD5 variation. On the contrary, the response to treatment was significantly different in patients with and without laryngitis (p = 0.038). In patients with no laryngitis, the cough threshold improved after five days with no further change thereafter. In patients with laryngitis, the cough threshold improved after five days and improved further after 60 days. Proximal and distal oesophageal acid exposure did not influence PD5. Heartburn disappeared during the first five days but the decrease in cough and throat clearing were slower.

CONCLUSIONS

Patients with reflux oesophagitis have a decreased cough threshold. This is related to both laryngeal inflammation and acid flooding of the oesophagus but not to the severity of oesophagitis. Omeprazole improves not only respiratory and gastro-oesophageal symptoms but also the cough threshold.

Simultaneous measurement of gastric emptying of a solid meal by ultrasound and by scintigraphy

OBJECTIVE

Although ultrasonic imaging may represent a valid alternative to scintigraphy for measurement of gastric emptying, most studies comparing the two methods have been carried out with liquid meals. The aim of this study was to compare scintigraphic and ultrasonographic measurements of gastric emptying of a solid meal in healthy subjects and in patients with possible delay in emptying.

METHODS

Nineteen subjects were studied: five controls, six patients with gastroesophageal reflux, and eight patients with dysmotility-like dyspepsia. Gastric emptying was measured by both scintigraphy and ultrasonography after ingestion of an 800-calorie solid, realistic meal containing 99mTc-labeled chicken liver. Scintigraphic measurements were made every 15 min for 6 h, and ultrasonic imaging of antral sections was undertaken every 15 min for the first 1 h and every 30 min thereafter. Total emptying times were calculated independently using the two methods, and the emptying patterns recorded by the two methods were compared.

RESULTS

Maximal antral dilation occurred 30 min (range 0-90 min) after the end of the meal and persisted until 96 +/- 42 min, by which time gastric radioactivity had decreased from its maximum by 43% +/- 23%. From this time on, the antral cross-sectional area returned toward the basal value, declining faster than the gastric counts recorded by scintigraphy. Total emptying times measured by ultrasound and by scintigraphy were in good agreement in all subjects, with a mean difference of only 4.5 min (limits of agreement, -17.1 to 21.6 min).

CONCLUSIONS

Ultrasonographic measurement of antral cross-sectional area provides a valid alternative to scintigraphy for the measurement of total gastric emptying of a solid meal. It is less reliable if other parameters of gastric emptying such as T(1/2) are required.

Alcohol and smoking as risk factors in chronic pancreatitis and pancreatic cancer

The aim of this study was to compare alcohol and smoking as risk factors in the development of chronic pancreatitis and pancreatic cancer. We considered only male subjects: (1) 630 patients with chronic pancreatitis who developed 12 pancreatic and 47 extrapancreatic cancers; (2) 69 patients with histologically well documented pancreatic cancer and no clinical history of chronic pancreatitis; and (3) 700 random controls taken from the Verona polling list and submitted to a complete medical check-up. Chronic pancreatitis subjects drink more than control subjects and more than subjects with pancreatic cancer without chronic pancreatitis (P<0.001). The percentage of smokers in the group with chronic pancreatitis is significantly higher than that in the control group [odds ratio (OR) 17.3; 95% CI 12.6-23.8; P<0.001] and in the group with pancreatic carcinomas but with no history of chronic pancreatitis (OR 5.3; 95% CI 3.0-9.4; P<0.001). In conclusion, our study shows that: (1) the risk of chronic pancreatitis correlates both with alcohol intake and with cigarette smoking with a trend indicating that the risk increases with increased alcohol intake and cigarette consumption; (2) alcohol and smoking are statistically independent risk factors for chronic pancreatitis; and (3) the risk of pancreatic cancer correlates positively with cigarette smoking but not with drinking.

Alcohol and smoking as risk factors in chronic pancreatitis and pancreatic cancer

The aim of this study was to compare alcohol and smoking as risk factors in the development of chronic pancreatitis and pancreatic cancer. We considered only male subjects: (1) 630 patients with chronic pancreatitis who developed 12 pancreatic and 47 extrapancreatic cancers; (2) 69 patients with histologically well documented pancreatic cancer and no clinical history of chronic pancreatitis; and (3) 700 random controls taken from the Verona polling list and submitted to a complete medical check-up. Chronic pancreatitis subjects drink more than control subjects and more than subjects with pancreatic cancer without chronic pancreatitis (P<0.001). The percentage of smokers in the group with chronic pancreatitis is significantly higher than that in the control group [odds ratio (OR) 17.3; 95% CI 12.6-23.8; P<0.001] and in the group with pancreatic carcinomas but with no history of chronic pancreatitis (OR 5.3; 95% CI 3.0-9.4; P<0.001). In conclusion, our study shows that: (1) the risk of chronic pancreatitis correlates both with alcohol intake and with cigarette smoking with a trend indicating that the risk increases with increased alcohol intake and cigarette consumption; (2) alcohol and smoking are statistically independent risk factors for chronic pancreatitis; and (3) the risk of pancreatic cancer correlates positively with cigarette smoking but not with drinking.

Incidence of cancer in the course of chronic pancreatitis

OBJECTIVE

Chronic pancreatitis patients appear to present an increased incidence of pancreatic cancer. The aim of the study was to compare the incidence of cancer, whether pancreatic or extrapancreatic, in our chronic pancreatitis cases with that in the population of our region.

METHODS

We analyzed 715 cases of chronic pancreatitis with a median follow-up of 10 yr (7287 person-years); during this observation period they developed 61 neoplasms, 14 of which were pancreatic cancers. The cancer incidence rates were compared, after correction for age and gender, with those of a tumour registry.

RESULTS

We documented a significant increase in incidence of both extrapancreatic (Standardized Incidence Ratio [SIR], 1.5; 95% confidence interval [CI], 1.1-2.0; p <0.003) and pancreatic cancer (SIR, 18.5; 95% CI, 10-30; p <0.0001) in chronic pancreatitis patients. Even when excluding from the analysis the four cases of pancreatic cancer that occurred within 4 yr of clinical onset of chronic pancreatitis, the SIR is 13.3 (95% CI, 6.4-24.5; p <0.0001). If we exclude these early-onset cancers, there would appear to be no increased risk of pancreatic cancer in nonsmokers, whereas in smokers this risk increases 15.6-fold.

CONCLUSIONS

The risks of pancreatic and nonpancreatic cancers are increased in the course of chronic pancreatitis, the former being significantly higher than the latter. The very high incidence of pancreatic cancer in smokers probably suggests that, in addition to cigarette smoking, some other factor linked to chronic inflammation of the pancreas may be responsible for the increased risk.

Endoluminal instillation of bisacodyl in patients with severe (slow transit type) constipation is useful to test residual colonic propulsive activity

BACKGROUND

Chronic constipation is a frequent symptom among the general population, and a minority of cases do not respond to any therapeutic measures, except surgery. The purpose of this study was to test the residual colonic motor propulsive activity with a pharmacologic stimulus in a series of patients referred for severe constipation.

PATIENTS

Twenty-five chronically constipated patients, slow transit type, age range 16-71 years, unresponsive to conventional medical treatment and referred for functional evaluation, entered the study.

METHODS

Colonic manometry by means of an endoscopically positioned probe was carried out in all patients. Following a basal recording period, a placebo solution followed by 10 mg bisacodyl solution was infused into the colon through the more proximal recording port.

RESULTS

After bisacodyl infusion, about 90% of patients showed a motor response characterized by the appearance (within on average 13 +/- 3 min) of one or more high-amplitude propagated contractions, the manometric equivalent of mass movements, and about 75% of these were followed (mean 18.5 +/- 4 min) by defecation.

CONCLUSIONS

Physiological and pharmacological testing of colonic motor activity may be important in severely constipated patients, especially in those labeled as 'intractable', in whom more in depth investigation planning may encourage further therapeutic efforts.

Effect of different doses of erythromycin on colonic motility in patients with slow transit constipation

BACKGROUND

Erythromycin has been proposed as a therapeutic agent for the treatment of functional motor disorders of the upper gastrointestinal tract. Moreover, some data exist showing a potential effect on colonic motility.

AIMS

Since no data are available concerning erythromycin effects in chronically constipated patients, we investigated the effects of three different doses of the drug (50, 200, and 500 mg i. v.) on colonic intraluminal pressures in such patients.

PATIENTS AND METHODS

18 severely constipated women were studied by a colonoscopically-positioned manometric probe, and were randomized to receive one of three doses of erythromycin. Proximal and distal colonic motility was recorded basally, then during placebo infusion for 60 min and for a further 60 min after the drug had been infused.

RESULTS

Analysis of the tracings showed that, except for the lowest dose in the distal colon, erythromycin failed to stimulate colonic motility in constipated patients.

CONCLUSIONS

It is concluded that erythromycin cannot be considered a colokinetic agent, at least at doses commonly employed in the upper gut.

Gluten-free diet normalizes mouth-to-cecum transit of a caloric meal in adult patients with celiac disease

The mechanisms responsible for bowel disturbances in celiac disease are still relatively unknown. Recent reports suggested that small bowel motor abnormalities may be involved in this pathological condition; however, there are no studies addressing small bowel transit in celiac disease before and after a gluten-free diet. We studied the mouth-to-cecum transit time of a caloric liquid meal in a homogeneous group of celiac patients presenting with clinical and biochemical evidence of malabsorption and complaining of diarrhea. Sixteen patients were recruited and investigated by means of hydrogen breath test through ingestion of 20 g lactulose together with an enteral gluten-free diet formula. A urinary D-xylose test was also done in each patient. Both breath tests and D-xylose tests were carried out basally and after a period of gluten-free diet. Twenty healthy volunteers were recruited as a control group and underwent the same breath testing. At the time of the diagnosis, mouth-to-cecum transit time was significantly prolonged in celiacs with respect to controls (243 +/- 10 vs 117 +/- 6 min, P = 0.0001). The D-xylose test was also abnormal (average urinary concentration 2.8 +/- 0.25 g, normal values >4.5). No correlation was found in patients between mouth-to-cecum transit time and urinary D-xylose output (r = 0.22). After the gluten-free diet period, mouth-to-cecum transit time in celiacs was significantly reduced compared to prediet transit (134 +/- 8 vs 243 +/- 10 min, P = 0.0001) and did not show statistical difference when compared to that found in controls (P = 0.1). The D-xylose test reverted to normal in all but two subjects, who were found to be noncompliant with the diet. Mouth-to-cecum transit time is significantly prolonged in patients affected by untreated celiac disease when compared to healthy controls. This alteration might not be correlated to intestinal malabsorption, and the prolonged orocecal transit could be due to impaired small bowel function (deranged motility?). Since intestinal transit returned to normal values after an adequate gluten-free period, a link with severe active mucosal lesions is suggestive.

Upper gastrointestinal motor activity in patients with slow-transit constipation. Further evidence for an enteric neuropathy

Recent evidence indicates that patients complaining of severe chronic idiopathic constipation may have motor abnormalities not limited to the colon. We studied by manometric means gastric and small bowel motility in a homogeneous group of patients with chronic idiopathic constipation, ie, the slow transit type. Twenty-one patients were recruited for the study and compared to 33 healthy subjects. Manometric examination was carried out for about 5 hr fasting and 1 hr after a standard meal. Analysis of the manometric tracings revealed during fasting no abnormalities in number and configuration of migrating motor complex with respect to controls. However, in 70% of patients motor abnormalities were detected, represented by bursts of nonpropagated contractions and discrete clustered contractions. After feeding, the patient group displayed a significantly shorter antral motor response to the meal with respect to controls; moreover, intestinal bursts of nonpropagated contractions were found in 19% of patients, and 14% of them had an early return of the activity fronts. We conclude that patients with slow transit constipation frequently display motor abnormalities of the upper gut. These findings further strengthen the concept that this condition may represent a panenteric disorder.

Fecal fat measurement in the presence of long- and medium-chain triglycerides and fatty acids. Comparison of three methods

BACKGROUND

It has been suggested that some of the limitations of the Van de Kamer method for fecal fat measurement could be overcome with the Jeejeebhoy method or the near-infrared reflectance assay.

METHODS

To test this hypothesis, a fecal fat test was carried out with the three methods, adding butter or MCT oil to the diet of four steatorrhoic patients. An in vitro recovery study of long- and medium-chain triglycerides was also performed.

RESULTS

The Jeejeebhoy method measured long- and medium-chain fats more accurately than the Van de Kamer method. It found consistently higher steatorrhea values. Mean results of the near-infrared reflectance analysis resembled those of the Van de Kamer method, but with wide discordance of individual data.

CONCLUSION

The Jeejeebhoy method is more accurate than the Van de Kamer method for fecal fat measurement. The difference may be clinically relevant when most fecal fatty acids derive from medium-chain triglycerides. Near-infrared reflectance may be a viable proposition only when a greater degree of approximation is acceptable.

Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation

The present multicenter double-blind placebo-controlled trial evaluates the therapeutic effectiveness of small-volume daily doses of an isosmotic polyethylene glycol (PEG) electrolyte solution in the treatment of chronic nonorganic constipation. After a complete diagnostic investigation, patients still constipated at the end of a four-week placebo-treatment run-in period were enrolled and randomized to receive either placebo or PEG solution 250 ml twice a day for the following eight weeks. Patients were assessed at four and eight weeks of treatment, and they reported frequency and modality of evacuation, use of laxatives, and relevant symptoms daily on a diary card. Oroanal and segmental large-bowel transit times were assessed with radiopaque markers during the fourth week of the run-in period and the last week of the treatment period. During the study period, dietary fiber and liquids were standardized and laxatives were allowed only after five consecutive days without a bowel movement. Of the 55 patients enrolled, five dropped out, three because of adverse events and two for reasons unrelated to therapy; another two were excluded from the efficacy analysis because of protocol violation. Of the remaining 48 patients (37 women, age 42 +/- 15 years, mean +/- SD), 23 were assigned to placebo and 25 to PEG treatment. In comparison to placebo, PEG solution induced a statistically significant increase in weekly bowel frequency at four weeks and at the end of the study (PEG: 4.8 +/- 2.3 vs placebo: 2.8 +/- 1.6; P < 0.002) and a significant decrease in straining at defecation (P < 0.01), stool consistency (P < 0.02), and use of laxatives (P < 0.03). Oroanal, left colon, and rectal transit times were significantly shortened by PEG treatment. There was no difference between controls and PEG-treated patients as far as abdominal symptoms and side effects were concerned. In conclusion, PEG solution at 250 ml twice a day is effective in increasing bowel frequency, accelerating colorectal transit times, and improving difficult evacuation in patients with chronic nonorganic constipation and is devoid of significant side effects.

Gastric emptying and dyspeptic symptoms in patients with gastroesophageal reflux

OBJECTIVES

To clarify 1) whether gastric emptying of a mixed meal is delayed in patients with gastroesophageal reflux and 2) the relationship between dyspeptic symptoms and delayed gastric emptying in refluxers.

METHODS

Gastric emptying of a solid meal was studied by ultrasound in 25 patients with pathological esophageal acid exposure. Gastric emptying was then assessed in relation to upper digestive endoscopy, esophageal manometry, 24-h pH monitoring and quantification of symptoms of reflux- and dysmotility-like dyspepsia.

RESULTS

Fifteen of 25 refluxers had esophagitis, and 15 were "dyspeptic". Refluxers exhibited a significant delay in gastric emptying compared with controls [307.6 (21.0) vs. 209 (10.4) min, p < 0.001). Patients with delayed emptying had low LES pressure [11.9 (2.1) vs. 18.6 (2.1) mm Hg, p < 0.05]. There was no correlation between delayed emptying and either pH monitoring or presence of esophagitis. There were no differences in any of the pH monitoring parameters between refluxers with and without coexisting dysmotility-like symptoms.

CONCLUSIONS

Gastric emptying of a solid meal is markedly delayed in patients with gastroesophageal reflux. However, no direct causal link was found between delayed emptying and reflux. Our data suggest the presence of a motility disorder in gastroesophageal reflux which is not confined to the esophagogastric junction.

Pain relapses in the first 10 years of chronic pancreatitis

PURPOSE

To evaluate whether the annual number of pain relapses of chronic pancreatitis correlated with sex, type of pancreatitis, drinking and smoking, presence of intraductal calcifications, pancreaticojejunostomy, and length of follow-up in the first 10 years of follow-up.

METHODS

The authors analyzed 205 nonobstructive chronic pancreatitis cases with at least a 10 year follow-up, for a total of 2,034 person/year observations. Data were recorded on the daily number of cigarettes smoked and grams of alcohol drunk, as well as the presence of intraductal calcifications, and performance of pancreaticojejunostomy.

RESULTS

The model for multivariate autoregressive repeated measures analysis indicated that drinking (P < 0.0001), smoking (P < 0.0001), calcifications (P < 0.0001), pancreaticojejunostomy (P < 0.0011), and length of follow-up (P < 0.0001) all correlated significantly with annual number of pain relapses. Pancreaticojejunostomy is probably very effective in reducing pain both physically, by removing the largest intraductal calcifications and obstructions through drainage of Wirsung's duct, and psychologically, by inducing patients to cut down their postsurgical alcohol intake.

CONCLUSIONS

Regardless of surgical treatment, patients should be advised to reduce both their alcohol intake and cigarette smoking.

Achalasia. A possible late cause of postpolio dysphagia

The aim of this paper is to describe a patient with severe postpolio problems who developed achalasia. A 66-year-old patient came to our observation for severe dysphagia. He had suffered from paralytic poliomyelitis at the age of 7 months and had severe residual deficits. At the age of 62 he presented with sudden pain localized in the distribution of the C4 and C5 dermatomes and an inability to abduct the left arm. At the time, he experienced only occasional and mild dysphagia; his esophagus was not dilated and emptied normally. Over the following months his muscular function improved, but dysphagia worsened. We found a megaesophagus with a sigmoid appearance and the manometric features of achalasia. Pneumatic dilatation produced good resolution of dysphagia. A year later manometry showed the reappearance of peristalsis after all wet swallows. In patients with postpolio dysphagia, the possible presence of achalasia must be considered.

Cigarette smoking: an independent risk factor in alcoholic pancreatitis

It is not known whether cigarette smoking plays a role as a risk factor in alcoholic pancreatitis. The aim of this study was to compare drinking and smoking habits in three groups of male subjects with an alcohol intake in excess of 40 g/day: (i) 67 patients with acute alcoholic pancreatitis, without other known potential causative agents; (ii) 396 patients with chronic alcoholic pancreatitis; and (iii) 265 control subjects randomly selected from the Verona polling lists and submitted to a complete medical checkup. The variables considered were age at onset of disease, years of drinking and smoking, daily alcohol intake in grams, number of cigarettes smoked daily, and body mass index (BMI). Cases differed from controls in daily grams of alcohol, number of cigarettes smoked and BMI (Mann-Whitney U test, p < 0.00001 for each comparison). Multivariate logistic regression analysis, comparing acute and chronic cases, respectively, versus controls, revealed an increased relative risk of pancreatitis in the two comparisons, associated in both cases with a higher alcohol intake (p < 0.00001) and cigarette smoking (p < 0.00001). No significant interaction between alcohol and smoking was noted, indicating that the two risks are independent. In conclusion, in males a higher number of cigarettes smoked daily seems to be a distinct risk factor in acute and chronic alcoholic pancreatitis.

Omeprazole causes delay in gastric emptying of digestible meals

We have studied gastric emptying of a solid, realistic meal (800 cal, 15% protein, 45% fat, 40% carbohydrate) in 21 healthy subjects twice, with and without a four-day pretreatment with 40 mg omeprazole. The last dose of the drug was taken 24 hr before the test, to avoid hypothetical nonsecretory side effects of the drug . Gastric emptying was measured by ultrasound of antral diameters. The results show that basal and maximal postprandial antral cross-sectional areas were the same during the two tests. A greater residual distention of the antrum was present throughout the study after the omeprazole treatment, the difference being significant at time 120 and 240. Omeprazole induced a highly significant delay in gastric emptying [control 199.6 (12.6) vs omeprazole 230.9 (12.7) min, mean (1 SEM); P<0.003]. The delay was not due to a prolonged lag phase, but rather to an effect on the slope of the emptying curve. This study shows that in normal subjects omeprazole delays gastric emptying of a digestible solid meal.

Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Medium-chain triglyceride absorption in patients with pancreatic insufficiency

BACKGROUND

The role of medium-chain triglycerides (MCTs) in the management of patients with pancreatic insufficiency is controversial. The aim of the study was to evaluate the absorption of MCTs in the presence of pancreatic insufficiency and the effect of pancreatic extracts on MCT absorption so as to clarify whether the replacement of usual dietary fats with MCTs is cost-effective.

METHODS

Six patients with severe pancreatic steatorrhea were for 5 days fed a low-fat diet to which butter (long-chain triglycerides (LCTs)) or MCT oil was added, with and without pancreatic extracts, in a crossover design.

RESULTS

Fecal weight and nitrogen losses were the same during MCT and LCT intake. Steatorrhea was substantial during both periods but was significantly lower during MCT than LCT intake. Fecal weight and nitrogen and fat losses were reduced by pancreatic extracts in both diets. Steatorrhea was the same when MCTs and LCTs were consumed together with pancreatic extracts.

CONCLUSIONS

MCTs are absorbed better than LCTs in the presence of pancreatic insufficiency but require pancreatic extracts for optimal absorption. No advantage is to be expected from replacing usual dietary fats with MCTs if pancreatic supplements are used.

Idiopathic megarectum in adults. An assessment of manometric and radiologic variables

Outlet obstruction is thought to be one of the major factors responsible for idiopathic constipation. However, outlet obstruction itself may be due to several mechanisms. Among these, the presence of a megarectum is a leading one. Pathophysiological studies in adult patients with idiopathic megarectum are scarce. We studied by manometric and defecographic means 15 adult subjects with idiopathic megarectum and severe chronic constipation. Twenty-five healthy volunteers of both sexes acted as controls. Manometric variables showed significant differences between patients and controls with respect to internal anal sphincter pressure (P = 0.02), minimum relaxation volume (P < 0.001), defecatory sensory threshold (P < 0.001), mean rectal tolerable volume (P < 0.001), and rectal compliance (P < 0.001). An altered response to straining was observed in 46.6% of patients and in 12% of controls (P < 0.04); the ability to expel a 50-ml balloon per anum was 13.3% in patients and 100% in controls (P < 0.001). Although all patients opened the anorectal angle and had descent of the pelvic floor, thereby confirming an adequate expulsion effort, evacuation of contrast material appeared extremely difficult. In fact, no subject was able to expel more than 30% of the rectal contents during fluoroscopic screening. These results confirm previous hypotheses that idiopathic megarectum displays features of a neuropathic process as an underlying mechanism. Further studies are needed that also take into consideration the muscle tone component of the rectum in these patients.

No effect of long-term treatment with pancreatic extract on recurrent abdominal pain in patients with chronic pancreatitis

BACKGROUND

This study was aimed to investigate the effect of long-term treatment with high-protease pancreatic extract on the recurrent abdominal pain of patients with chronic pancreatitis.

METHODS

Twenty-six patients with a firm diagnosis of chronic pancreatitis and a pattern of recurrent pain were recruited and randomly assigned to treatment with pancreatic extract (Pancrex-Duo capsules, each containing 34,375 USP units of protease in enteric-coated microspheres) or placebo, at a dose of four capsules four times daily, for 4 months. At the end of the first period patients were switched to the other medication for the next 4 months. Four patients did not complete the study because of unbearable recurring pain or inadequate compliance with treatment. The other 22 patients daily recorded the presence, intensity, and duration of pain and the consumption of analgesics, for 8 months.

RESULTS

No difference was found when intraindividual records during placebo and extract treatment periods were compared. Conversely, in the second 4 months of follow-up, regardless of the treatment given in the first period, there was a significant reduction in the cumulative pain score (median, 95; range, 0-1005, versus 134; 0-972; p < 0.05), in the number of days (8; 0-132, versus 13; 0-126; p < 0.02) and hours (54; 0-680, versus 80; 0-602; p < 0.05) of pain, and in the analgesic consumption score (0; 0-22, versus 12; 0-44; p = 0.02).

CONCLUSIONS

Chronic supplementation with pancreatic extract is not beneficial in the management of recurrent pain in patients with chronic pancreatitis.

Tussive effect of capsaicin in patients with gastroesophageal reflux without cough

The aim of this study was to clarify the influence of gastroesophageal reflux (GER) on cough threshold in patients with digestive symptoms but free from respiratory involvement. Of 57 consecutive subjects referred for 24-h esophageal pH monitoring because of digestive reflux symptoms, 29 patients free from respiratory disorders were studied. They underwent esophageal pH monitoring and manometry, upper gastrointestinal endoscopy, pulmonary function tests, and methacholine and capsaicin challenges. The methacholine test was performed by inhalation of increasing doses of methacholine up to 4,000 micrograms; the results were expressed as the dose causing a 20% decrease in FEV1 from baseline (PD20). The capsaicin threshold was evaluated by inhalation of increasing doses of capsaicin from 0.3 up to 9.84 nmol, expressing the results as the dose of capsaicin eliciting five coughs (PD5). Fifteen patients were considered refluxers on the basis of a total esophageal acid exposure time above 4.7%. Esophagitis grade 0 was found in 15 patients, grade 1 in seven patients, grade 2 in seven patients. PD5 was significantly lower in refluxers (median 0.51 micrograms, range 0.22 to 19.8) than in nonrefluxers (19.8 micrograms, range 0.31 to 19.8) (p < 0.001); there was no difference in baseline ventilatory parameters and in airway responsiveness to methacholine between the two groups. All patients with a pathologic acid exposure time but one had a low cough threshold, irrespective of the presence or absence of esophagitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation

Idiopathic chronic constipation is a frequent and disabling symptom, but its pathophysiological grounds are still poorly understood. In particular, there is little knowledge about the relationships between distal (anorectal area) and proximal (colonic area) motor abnormalities in this condition, especially concerning high-amplitude propagated colonic activity. For this purpose, we studied 25 patients complaining of severe idiopathic constipation and categorized them as normal- or slow-transit constipation according to colonic transit time. Twenty-five age-matched controls were also studied. Investigations included standard anorectal motility testing and prolonged (24-hr) colonic motility studies. Analysis of results showed that both groups of constipated patients displayed significantly different (P < 0.05) minimum relaxation volumes of the internal anal sphincter, defecatory sensation thresholds, and maximum rectal tolerable volumes with respect to controls. Patients with normal-transit constipation also showed lower internal anal sphincter pressure with respect to slow-transit constipation and controls (P < 0.001 and P < 0.02, respectively). The daily number of high-amplitude propagated contractions (mass movements) as well as their amplitude and duration, was significantly reduced in both subgroups of constipated patients (P < 0.02 vs controls). We conclude that (1) in normal-transit constipation, motor abnormalities are not limited to the anorectal area; (2) patients with slow-transit constipation probably have a severe neuropathic rectal defect; (3) prolonged colonic motility studies may highlight further the functional abnormalities in constipated subjects; and (4) an approach taking into account proximal and distal colon motor abnormalities might be useful to understand pathophysiological grounds of chronic constipation and lead to better therapeutic approaches.