Impaired anal sphincter function in professional cyclists

BACKGROUND

The purpose of our study was to assess anal function in professional mountain bikers, as an increasing number of cycling enthusiasts report functional and morphological problems in the anal region. We tried to find out if constant saddle vibration suffered by professional cyclists could lead to defecation disorders.

METHODS

19 professional male mountain bikers took part in this study. The findings were compared with those of a control group (CG) of healthy volunteers who rode bikes less frequently. Both groups underwent rectal examination and anorectal manometry. Rectal sensation, rectal compliance and the anorectal inhibitory reflex were also assessed. Information on anal pain, blood on the toilet tissue, history of hemorrhoids, anal fissure, abscess formation and problems with defecation was collected by questionnaire and local examination was carried out.

RESULTS

Sphincter resting pressures (89 +/- 27 mmHg vs CG: 69 +/- 16 mmHg), squeeze pressures (137 +/- 36 mmHg vs CG: 96 +/- 19 mmHg) and sphincter volumes (resting vector volume: 513 +/- 277 cc vs CG 273 +/- 170 cc, squeeze vector volume: 1389 +/- 867 cc vs CG: 490 +/- 219 cc) were significantly higher in the professional mountain bikers. Values reflecting rectal sensation (sensory threshold: 51 +/- 32 ml vs CG: 46 +/- 12 ml) were not significantly different between the groups.

CONCLUSION

Proctological problems are very common in professional mountain bikers. Permanent microtrauma through constant saddle vibration may lead to chronic inflammation and anal fissure resulting in anal pain and therefore high sphincter pressure. Muscle hypertrophy as a consequence may lead to defecation disorders.

Clinical correlates of rectal gonococcal and chlamydial infections

As few studies have compared the clinical features of rectal gonorrhoea in men who have sex with men with or without concurrent chlamydial infection, this longitudinal study was undertaken to address this issue. The cohort consisted of 129 men with rectal gonorrhoea, 34 of whom had concurrent chlamydiae. Symptoms of proctitis in men with rectal gonorrhoea with or without concurrent chlamydial infection were significantly higher than in men with isolated chlamydial infection (27% versus 10% [chi2=17.55; P<0.0001]). There was, however, no significant difference in the prevalence of symptoms between those with rectal gonorrhoea only (28%) and those with concurrent chlamydiae (23%); chi2=0.11; P>0.05). The median prepatent period or rectal gonorrhoea (21 men) was 5.0 days (interquartile range 11.0 days).

Colorectal motor and sensitivity features in patients affected by ulcerative proctitis with constipation: a radiological and manometric controlled study

BACKGROUND AND AIM

Constipation may be present in ulcerative proctitis (UP), but its pathogenesis has not yet been evaluated. The aim of this article is to investigate functional and morphologic features of the anorectal region in patients with UP and constipation.

MATERIALS AND METHODS

Eleven patients with quiescent clinical, endoscopic, and histological UP and constipation and 10 patients with functional constipation (FC) underwent radiologic evaluation of intestinal transit time, anorectal manometry, and defecography. Transit time was measured with radiograms at 72 h after ingestion of radiopaque markers. Manometry was carried out using a continuous perfused catheter and a balloon inflated with increasing volumes of air. Defecography was performed after the injection of a barium-sulfate solution in the rectum, with the registration of videotapes during straining, squeezing, and evacuation.

RESULTS

Manometry showed in UP significantly lower values of rectal compliance than those in FC (3.10 and 5 mL/mmHg, respectively) (P = 0.03). Rectal sensitivity threshold was increased but without significant differences in UP and FC (30 and 50 mL air, respectively). At defecography, the median value of rectosacral space was increased in UP in comparison with FC (1.30 vs 0.8; P = 0.002). Lateral rectal diameter in UP was lower than in FC (6 and 8.8 cm, respectively; P = 0.016). Nonsymptomatic rectocele, mucosal prolapse, descending perineum, and abdominopelvic dyssynergy were equally present in UP and FC. The majority of UP patients showed a prolonged intestinal transit time similar to FC patients, and, more frequently, they showed low transit in the left colon in comparison with the right colon in comparison with FC patients.

CONCLUSIONS

This study suggests that constipation in UP may be correlated with rectal fibrosis, which reduces the transit of stools from the left colon. The concomitance of asymptomatic anorectal organic or functional alteration may contribute to worsen constipation.

Lymphogranuloma venereum proctitis: An emerging sexually transmitted disease in HIV-positive men in the Netherlands

A recent outbreak of lymphogranuloma venereum (LVG) proctitis caused by Chlamydia trachomatis serovar L2 has been detected in HIV-positive men in the Netherlands and Belgium. This sexually transmitted disease (STD), which is well known and frequently occurring in tropical countries, was quite unusual in Europe until 2003. STDs with ulcerative lesions, such as LGV, facilitate transmission of other microorganisms, including HIV and hepatitis C. This in combination with risky sexual behavior, such as unprotected anal sexual intercourse or use of sex toys, increases the risk of blood-blood contact and hence the risk of contracting multiple STDs. Two cases of patients who in a short time period contracted multiple STDs, including LGV proctitis, is presented.

Rectal function following permanent prostate brachytherapy

The purpose of this study was to review the clinical presentation, dosimetry, quality of life assessment, and management of proctitis following permanent prostate brachytherapy. The permanent prostate brachytherapy literature was reviewed using MEDLINE searches to ensure completeness. Rectal complications primarily consist of mild, self-limited proctitis. Rectal bleeding has been correlated with rectal dose. Dose response analysis has demonstrated that the risk of proctitis strongly correlates with the volume of rectal tissue exposed to a given dose. The reported incidence of rectal ulceration/fistula formation is < or = 1%. Constipation significantly increases the radiation dose to the rectum and potentially may contribute to brachytherapy-related morbidity. Quality of life assessments obtained via patient-administered instruments and by physician interview have illustrated that long-term bowel dysfunction is relatively uncommon. Significant bowel dysfunction following prostate brachytherapy is relatively rare, but rectal bleeding has been correlated with radiation dose. Routine post-brachytherapy biopsies of the anterior rectal wall are strongly contraindicated. The continued elucidation of the etiology of bowel dysfunction should result in refinements in implant technique and decreased brachytherapy-related morbidity.

Physiologic changes of the anorectum after pelvic radiotherapy for the treatment of prostate and bladder cancer

INTRODUCTION

The effect of pelvic radiotherapy on anorectal function is not clearly documented and is investigated in this prospective study.

METHODS

Thirty-one males (median age, 70 years) with carcinoma of the prostate (n = 28) and bladder (n = 3) completed proctitis/incontinence symptom score questionnaires and anorectal physiology studies before and six weeks after pelvic radiotherapy. At six months after completion of radiotherapy, 25 of these patients were studied again. The results were expressed as medians and ranges and compared by the Mann-Whitney U test (2-tailed).

RESULTS

Six weeks and six months after treatment, respectively, the proctitis symptom scores (0 (0-4) vs. 2 (0-7) (P < 0.001) vs. 2 (0-5) (P < 0.001)) and the incontinence symptom scores (0 (0-5) vs. 4 (0-11) (P < 0.001) vs. 3 (0-14) (P < 0.001)) increased. Urgency, frequency of defecation, anorectal pain, incontinence to liquid stool and to flatus, and alteration in lifestyle were significant symptoms after treatment. The following measurements decreased: anal canal resting pressure (83 (35-137) vs. 79 (26-152) (P = NS) vs. 71 (29-97) (P < 0.01) cm H2O), the squeeze increment (152 (51-135) vs. 162 (63-321) (P = NS) vs. 108 (45-296) (P < 0.042) cm H2O), and the maximum tolerated rectal volume (245 (115-450) vs. 194 (112-344) (P < 0.05) vs. 200 (109-350) (P < 0.138) ml). The rectal electrosensory threshold increased (20 (5.4-44) vs. 22 (9-50.5) (P < 0.134) vs. 31.5 (13.6-76) (P < 0.001) mA).

CONCLUSIONS

Anorectal symptoms at six weeks after pelvic radiotherapy are related to reduced rectal capacity and compounded at six months by diminished internal and external sphincter function and rectal mucosal sensitivity.

Rectal function following brachytherapy with or without supplemental external beam radiation: Results of two prospective randomized trials

PURPOSE

To evaluate the effect of isotope and supplemental external beam radiation therapy (XRT) on brachytherapy-related rectal morbidity, using prospective, patient-administered quality of life (QOL) assessments.

METHODS AND MATERIALS

Two hundred thirteen consecutive patients (median follow-up 22 months) were implanted on 2 prospective randomized brachytherapy trials evaluating the effect of isotope for low-risk patients and different doses of supplemental XRT for patients with higher risk features. Treatment-related rectal morbidity was evaluated by modified Radiation Therapy Oncology Group (RTOG) criteria and the multifactorial Rectal Function Assessment Score (R-FAS). Clinical, treatment and dosimetric parameters evaluated included patient age, diabetes, hypertension, tobacco consumption, clinical stage, prostate ultrasound volume, elapsed time since implant, hormonal manipulation, supplemental XRT, isotope, treatment planning volume, and values of the minimum dose received by 90% of the prostate gland (D90), the percent prostate volume receiving 100%, 150%, and 200% of the minimum peripheral dose (V(100/150/200)), rectal implant doses (V(75/100/125/150) and D(5/10/25/50)) and rectal XRT doses (D(5/10/25/50/75)).

RESULTS

Using the RTOG instrument, rectal morbidity peaked at 1 month. The pre- and most recent postimplant median RTOG scores were 0 and 0, respectively. The pre- and postimplant R-FAS scores were 2.41 and 3.83, respectively. With time, the rectal scores for both instruments improved and approached baseline. In multivariate analysis, only the rectal dosimetry variable D5 predicted for bowel function when using the R-FAS instrument. No clinical, treatment, or dosimetric parameters predicted for bowel function when using the RTOG survey. No patient required surgical intervention for rectal complications.

CONCLUSIONS

The multifactorial R-FAS elucidated fine gradations in bowel function of a severity less than RTOG Grade 3 morbidity. Of multiple clinical, treatment, and dosimetric parameters evaluated, only the minimum dose received by 5% of the rectum (D5) correlated with rectal dysfunction via the R-FAS instrument, while none of the evaluated parameters predicted for bowel dysfunction using the RTOG survey. Following permanent prostate brachytherapy, the ability to discern subtle changes in rectal function is dependent on the sensitivity of the survey instrument.

Pharmacotherapy for chronic hemorrhagic radiation proctitis

Endoscopic thermal therapy and formalin are being increasingly recommended for the treatment of chronic hemorrhagic radiation proctitis. It may be too early, however, to discard pharmacologic agents from the management process, especially in medical institutions where specialized equipment is unavailable. We prospectively assessed the effectiveness of medical therapy in 14 consecutive patients with chronic hemorrhagic radiation proctitis from July 1999 to June 2001. All 14 subjects were women (mean age 56 years), 13 of whom had had radiotherapy for cancer of the cervix. The median time to onset of symptoms following irradiation was 16 months. Six patients had a hemoglobin level of < 8 g/dl, and blood transfusion was required in 11 patients. In five patients (36%) initially treated with hydrocortisone enemas prior to referral, this treatment continued; and the remaining nine patients were commenced on sucralfate enemas. Two patients given rectal hydrocortisone continued to bleed and were treated with sucralfate enemas and topical formalin, respectively. Rectal sucralfate suspension effectively procured symptomatic alleviation in all 11 patients. Rectal bleeding recurred in two patients who had been managed exclusively with hydrocortisone and sucralfate enemas, respectively, over a mean follow-up of 6 months. Both patients were managed with topical formalin, which controlled their symptoms. Even though the number of subjects in this study is small, sucralfate enema can be recommended as an effective first-line agent for managing patients with chronic hemorrhagic radiation proctitis. The use of more specialized therapy can therefore be reserved for cases where primary treatment failure occurs with sucralfate therapy.

Inflammation enhances reflex and spinal neuron responses to noxious visceral stimulation in rats

To improve understanding of sensory processes related to visceral inflammation, the effect of turpentine-induced inflammation on reflex (cardiovascular/visceromotor) and extracellularly recorded lumbosacral dorsal horn neuron responses to colorectal distension (CRD) was investigated. A 25% solution of turpentine, applied to the colorectal mucosa, produced inflammation, decreased compliance of the colonic wall, and enhanced reflex responses in unanesthetized rats within 2-6 h. At 24 h posttreatment, pressor responses to CRD (80 mmHg, 20 s) were 20% greater, and intraluminal pressures needed to evoke visceromotor reflexes were 30% lower than controls. Parallel electrophysiological experiments in spinal cord-transected, decerebrate rats demonstrated that two neuronal subgroups excited by CRD were differentially affected by turpentine administered 24 h before testing. During CRD, abrupt neurons were 70% less active and sustained neurons were 25% more active than similar neurons in controls. In summary, reflex and neuronal subgroup (sustained neurons) responses to CRD were both potentiated by chemical inflammation. This suggests that the neurophysiological basis for inflammation-induced increases in reflex responses to CRD is increased activity of this neuronal subgroup.

A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients

OBJECTIVE

Radiation proctitis is a known complication of radiation therapy for prostate cancer. Available medical treatment is usually ineffective and has focused on relieving symptoms after damage has occurred. Our study aimed at evaluating the use of misoprostol rectal suppositories in the prevention of acute as well as chronic radiation proctitis symptoms.

METHODS

A prospective, randomized, placebo-controlled, double-blinded trial was conducted in patients with recently diagnosed stages B and C prostate cancer who underwent external beam irradiation. Patients received either a misoprostol or a placebo suppository 1 h before each radiation session. Misoprostol suppositories were made from two 200-microg tablets (Cytotec, Searle Pharmaceuticals, Skokie, IL), whereas the placebo was made from cocoa butter. A 12-point radiation proctitis symptom score was obtained from each patient at 4, 8, 12, and 36 wk after radiation therapy.

RESULTS

A total of 16 patients were enrolled. Seven patients received placebo, and nine patients received misoprostol. Mean radiation proctitis symptom scores in the placebo group were 4.86, 5.86, 5.71, and 3.83 at 4, 8, 12, and 36 wk, respectively. The mean scores in the misoprostol group were 0.78, 0.67, 0.33, and 0.37 at 4, 8, 12, and 36 wk, respectively. The difference between the two groups was statistically significant (p < 0.05) at 4, 8, 12, and 36 wk.

CONCLUSION

Misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.

Colonic J pouch reconstruction of the radiation-damaged neorectum

BACKGROUND

Postoperative radiotherapy after restorative resection for rectal carcinoma can cause fibrosis, stricture and proctitis. There are few accounts in the literature of the surgical approach to the radiation-damaged neorectum.

METHODS

Reported are four patients who underwent resection of the radiation-damaged neorectum with colonic J pouch reconstruction between September 1996 and July 1997. The operative and postoperative course is described. Parameters of bowel function were assessed by standardized interview 6 months after ileostomy reversal. Ongoing follow up has occurred to the present time.

RESULTS

There was no mortality. Complications were splenic injury requiring splenectomy and a pelvic collection requiring percutaneous drainage. At 6 months after ileostomy reversal all patients had ongoing disturbance of bowel function, and two patients described some degree of incontinence. The mean frequency of bowel actions was four per day. Two patients have subsequently undergone further resection and formation of an end stoma.

CONCLUSIONS

Resection of the radiation-damaged neorectum with colonic J pouch reconstruction is technically feasible. Functional results in the present series were disappointing and half the patients went on to formation of a permanent stoma.

A review of radiation proctitis in the treatment of prostate cancer

Pelvic radiation is a common therapy for the treatment of prostate cancer. A complication of this therapy, radiation proctitis, may be limited to the direct posttreatment period or it may appear as serious complications that occur months to years after therapy has been completed. Mucosal damage, present with both acute and chronic radiation proctitis, produces a variety of symptoms including mucoid diarrhea, pain upon defecation, serious rectal bleeding, stenosis, and fistula formation. The treatment of radiation proctitis is symptom related, and the goals of therapy include the prevention or correction of mucosal changes and eradication of rectal bleeding. This article will review the pathophysiology of radiation proctitis and its treatment.

The natural history of ulcerative proctitis: a multicenter, retrospective study. Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII)

OBJECTIVE

The aim of this study was to evaluate the clinical features and the long term evolution of patients with a well defined initial diagnosis of ulcerative proctitis.

METHODS

Patients with an original diagnosis of ulcerative proctitis who had been seen at any of 13 institutions from 1989 to 1994 were identified. Data on disease onset and subsequent evolution were recorded. In addition, 575 patients with more extensive disease, treated in the same centers, were used as controls.

RESULTS

A total of 341 patients satisfied the inclusion criteria. The percentage of smokers in these patients was slightly lower than in controls; no differences were found in the other clinical/demographic variables evaluated. A total of 273 patients entered long term follow-up (mean, 52 months). Proximal extension of the disease occurred in 74 of them (27.1%). The cumulative rate of proximal extension and of extension beyond the splenic flexure was 20% and 4% at 5 yr and 54% and 10% at 10 yr, respectively. The risk of proximal extension was higher in nonsmokers, in patients with >3 relapses/yr, and in patients needing systemic steroid or immunosuppressive treatment. Refractory disease was confirmed as an independent prognostic factor at multivariate analysis.

CONCLUSIONS

Proximal extension of ulcerative proctitis is frequent and may occur even late after the original diagnosis. However, the risk of extension beyond the splenic flexure appears to be quite low. Smoking seems to be a protective factor against proximal extension, whereas refractoriness is a risk factor for proximal extension of the disease.

Radiation proctitis. Clinical and pathological manifestations, therapy and prophylaxis of acute and late injurious effects of radiation on the rectal mucosa

BACKGROUND

Often the rectum is the dose-limiting organ in curative radiation therapy of pelvic malignancies. It reacts with serous, mucoid, or more rarely bloody diarrhea.

METHODS

A research for reports on prophylactic and supportive therapies of radiation-induced proctitis was performed (Medline, Cancerlit, and others).

RESULTS

No proven effective prophylactic local or systemic therapies of radiation proctitis exist. Also, no reasonable causal medication is known. In the treatment of late radiation sequelae no clinically tested certain effective therapy exists, too. Antiinflammatory, steroidal or non-steroidal therapeutics as well as sucralfate can be used as topical measures. They will be successful in some patients. Side effects are rare and the therapy is cost-effective. Treatment failures can be treated by hyperbaric oxygen. This will achieve good clinical results in about 50% of the cases. Single or few mucosal telangiectasias with rectal bleeding can be treated sufficiently by endoscopic catheterization.

CONCLUSION

Besides clinical studies acute proctitis should be treated just symptomatically. Radical surgery should be performed only when all conventional treatments have been uneffective, although no certain effective therapies of radiation-induced late proctitis exist.

Influence of trimebutine on inflammation- and stress-induced hyperalgesia to rectal distension in rats

The effects of trimebutine and its major metabolite, N-desmethyltrimebutine on inflammation- and stress-induced rectal hyperalgesia have been evaluated in rats fitted with electrodes implanted in the longitudinal striated muscle of the abdomen. Intermittent rectal distension was performed before and 3 days after induction of rectal inflammation by local infusion of trinitrobenzenesulphonic acid (in ethanol). Stress consisted of 2h partial restraint and rectal distension was performed before and 30min after the end of the partial restraint session. The animals were treated intraperitoneally with trimebutine or desmethyltrimebutine (5, 10 or 20mgkg(-1)) or vehicle 15min before rectal distension. Naloxone (1mgkg(-1)) or saline was injected subcutaneously before trimebutine and desmethyltrimebutine. Before treatment trimebutine at the highest dose (20mgkg(-1)) reduced the abdominal response to rectal distension for the highest volume of distension (1.6mL) whereas desmethyltrimebutine was inactive. After rectocolitis the abdominal response to rectal distension was enhanced and trimebutine at 5mgkg(-1) reduced and at 10 mgkg(-1) suppressed inflammation-induced hyperalgesia, an effect reversed by naloxone. Desmethyltrimebutine was inactive. Stress-induced hypersensitivity was attenuated or suppressed, or both, by trimebutine and desmethyltrimebutine at doses of 5, 10 or 20mgkg(-l); greater efficacy was observed for desmethyltrimebutine and the effects were not reversed by naloxone. It was concluded that trimebutine and desmethyltrimebutine are active against inflammation- and stress-induced rectal hyperalgesia but act differently. The effect of trimebutine on inflammation-induced hyperalgesia is mediated through opioid receptors.

Sensory and motor dysfunction assessed by anorectal manometry in uterine cervical carcinoma patients with radiation-induced late rectal complication

PURPOSE

To investigate the effects of radiation on anorectal function in patients with carcinoma of the uterine cervix.

METHODS AND MATERIALS

Anorectal manometry was carried out on 24 patients (complication group) with late radiation proctitis. All of the manometric data from these patients were compared with those from 24 age-matched female volunteers (control group), in whom radiation treatment had not yet been performed.

RESULTS

Regardless of the severity of proctitis symptoms, 25% of patients demonstrated all their manometric data within the normal range, but 75% of patients exhibited one or more abnormal manometric parameters for sensory or motor functions. Six patients (25%) had an isolated sensory dysfunction, eight patients (33.3%) had an isolated motor dysfunction, and four patients (16.7%) had combined disturbances of both sensory and motor functions. The maximum tolerable volume, the minimal threshold volume, and the urgent volume in the complication group were significantly reduced compared with those in the control group. The mean squeeze pressure in the complication group was significantly reduced, whereas the mean resting pressure and anal sphincter length were unchanged.

CONCLUSIONS

Physiologic changes of the anorectum in patients with late radiation proctitis seem to be caused by a variety of sensory and/or motor dysfunctions in which many different mechanisms are working together. The reduced rectal reservoir capacity and impaired sensory functions were crucial factors for functional disorder in such patients. In addition, radiation damage to the external anal sphincter muscle was considered to be an important cause of motor dysfunction.

Anal sensitivity test: what does it measure and do we need it? Cause or derivative of anorectal complaints

PURPOSE

This study was undertaken to determine the anal sensitivity in controls and in different patient groups and to establish factors that determine anal sensitivity.

METHODS

Anorectal function tests were performed in 387 patients with different anorectal diseases. Anal sensitivity was measured in 36 controls. Anal sensitivity was measured by means of mucosal electrosensitivity (MES) using a catheter with two electrodes placed in the anal canal. A constant current (square wave stimuli 100 microsec, pulses per second) was increased stepwise from 1 to 20 mAmp until the threshold sensation was reached. Other tests used were anal manometry (maximum basal pressure, maximum squeeze pressure, rectal compliance (maximum rectal volume and pressure), endosonography (submucosal thickness), defects and thickness of internal and external sphincter), electromyography (maximum contraction pattern, Grade 1 (solitary contractions) to Grade 4 (interference pattern)), and pudendal nerve terminal motor latency. Multiple regression analysis was performed. It was postulated that age, local conditions (anal scars, anal fissures, hemorrhoids, mucosal prolapse, proctitis, sphincter thickness and defects, and submucosal thickness), and neurologic factors could influence anal sensitivity.

RESULTS

Controls had an MES of 3.4 +/- 1.7. MES was significantly increased compared with controls in patients with fecal incontinence, soiling, hemorrhoids, mucosal prolapse, constipation, anal scars, anal surgery, and sphincter defects; patients with fecal incontinence had the highest MES (6.7 +/- 4.3; P < 0.0001). Patients with anal fissures and proctitis showed no differences compared with controls. MES correlated significantly with age (R = 0.29), maximum basal pressure (R = -0.29), maximum squeeze pressure (R = -0.32), submucosal thickness (R = 0.19), maximum contraction pattern (R = -0.39), single-fiber electromyography (R = 0.39), and maximum rectal volume and pressure (0.14). Multiple regression analysis showed that age, internal sphincter defects, and submucosal thickness significantly influenced anal sensitivity, but explained only 10 percent of the variance.

CONCLUSION

Anal sensitivity is diminished in all patients with anorectal diseases except for anal fissures and proctitis. There are correlations with other anorectal function tests. Anal sensitivity is determined for 10 percent by age, internal sphincter defects, and thickness of the submucosa. Anal sensitivity measurement, therefore, has limited clinical value and should be used in conjunction with other tests in a research setting.

[Non-gastroduodenal digestive toxicity of non-steroidal anti-inflammatory agents]

Recent data have confirmed that non-steroidal anti-inflammatory drugs can cause serious damage to the gastrointestinal tract involving localizations other than the well-known gastroduodenal complications. Perforation and hemorrhage of the small bowel have been reported as well as ulcerations, stenoses and diaphragm disease. The same type of lesions can occur in the large bowel in addition to ischemia and collagen colitis. Diverticular diseases of the colon can be complicated by use of non-steroidal anti-inflammatory drugs which may also trigger flare-ups of inflammatory diseases. Use in suppository form can complicate rectitis and rectal stenosis. Non-steroidal anti-inflammatory drugs apparently increase intestinal permeability by inhibiting the cyto-protective effect of prostaglandins. The exact frequency of such complications remains to be determined, but prolonged treatment in elderly subjects appears to increase risk. Current data have not shown greater or lesser toxicity for any specific drug. Non-steroidal anti-inflammatory drugs should be entertained as the cause of intestinal disorders in patients under long-term treatment.

The ileocecal reservoir for rectal replacement in complicated radiation proctitis

BACKGROUND/AIMS

Total rectal resection is the radical treatment method for radiation proctitis complications. Park's straight colo-anal reconstruction to replace the rectum often impairs anal continence, increases stool frequency, and causes imperative urgency. We developed and assessed a colo-anal reconstruction (ileocecal reservoir) after resection of radiation-damaged rectum.

METHODS

An ileocecal segment was isolated on its lymphovascular pedicel, rotated counterclockwise, and reanastomosed at the dentate line. This provided a neorectal segment with intact intrinsic and extrinsic nerve and lymphovascular supply. We evaluated the safety, defecation quality, and anorectal function of this neorectum in two radiation-injured patients when compared with 15 patients after total mesorectal excision without radiation damage.

RESULTS

No perioperative morbidity related to this technique was observed. Neorectal patients showed good defecation quality with maximal tolerable volumes, compliances, and anal manometry comparable with patients without radiation injury.

CONCLUSIONS

This rectal replacement technique permits good defecation quality and excellent anorectal function.

Beclomethasone dipropionate (3 mg) versus 5-aminosalicylic acid (2 g) versus the combination of both (3 mg/2 g) as retention enemas in active ulcerative proctitis

Sixty patients with active distal ulcerative colitis participated in a multicentre randomized double-blind trial to compare the effect of a beclomethasone dipropionate (BDP) enema (3 mg/100 ml) with 5-aminosalicylic acid (5-ASA) enemas (2 g/ 100 ml) and enemas with a combination of BDP/5-ASA (3 mg/2 g/100 ml). The patients were treated for 4 weeks and the efficacy of the drugs was evaluated by sigmoidoscopy, histology and subjective symptoms after that time. The overall results after 28 days of treatment were: clinical improvement 100% (BDP/5-ASA) vs. 70% (BDP) and 76% (5-ASA); endoscopic improvement 100% (BDP/5-ASA) vs. 75% (BDP) and 71% (5-ASA); histological improvement 95% (BDP/5-ASA) vs. 50% (BDP) and 48% (5-ASA). After 4 weeks of treatment seven of 19 patients (37%) receiving BDP/5-ASA had healed endoscopically, compared with six of 20 receiving BDP (30%) and two of 21 receiving 5-ASA (10%). Two patients on 5-ASA and three on BDP had a marked deterioration during treatment. The combination of BDP and 5-ASA was significantly superior to single-agent therapy in terms of both improved sigmoidoscopic and improved histological score. No differences in improvement between the 5-ASA vs. BDP-treated patients were noticed. No side effects were seen. The results of the study show that topical treatment of active distal ulcerative colitis with either 5-ASA or BDP is equally efficacious. So far, no data on topical combination therapy have been described. However, combination therapy with BDP/5-ASA seems superior to single-agent therapy and causes no adverse reactions.

Influence of bradykinin in gastrointestinal disorders and visceral pain induced by acute or chronic inflammation in rats

This work investigated the role of bradykinin in viscerosensitivity before and during inflammation in two models of visceral pain induced by rectal distension (RD) or "abdominal distension" (AD) in rats. RD induced both inhibition of colonic motility and an increase of abdominal spike bursts. Bradykinin receptor antagonist, Hoe 140 did not affect any of the RD-induced responses. After TNB-induced rectal inflammation, colonic inhibition and the number of abdominal contractions were enhanced. Hoe 140 selectively reduced the abdominal response to the highest distension volume, without affecting the colonic response. In AD group, acetic acid inhibited gastric emptying and increased the number of abdominal contractions, whereas the same volume of saline did not affect any of the responses. Before inflammation, Hoe 140 (1-5 mg/kg, intraperitoneally) did not affect per se abdominal and gastric emptying responses; in contrast, at 5 mg/kg, intraperitoneally, it reduced significantly (P < 0.05) both acetic acid-induced responses. We conclude that bradykinin is involved in viscerosensitivity changes related to abdominal and rectal distension in inflammatory conditions.

Transanal mucosectomy. Ileal pouch advancement for anorectal dysplasia or inflammation after restorative proctocolectomy

PURPOSE

Restorative proctocolectomy has gained increasing popularity in the surgical treatment of ulcerative colitis. However, symptomatic proctitis in an excessively long anorectal stump or high-grade dysplasia within the retained anorectal mucosa can pose challenging problems. A corrective operation for these problems is described.

METHODS

A sphincter-preserving perineal approach to mobilize the pouch was described. It allows excision of the inflamed or dysplastic-retained anorectal mucosa, followed by pouch advancement and a neoileoanal anastomosis.

RESULTS

The technique was successfully performed in two patients, one with symptomatic "proctitis" and another with high-grade dysplasia in the anorectal mucosa after a previously stapled ileoanal (distal rectal) anastomosis.

CONCLUSIONS

This report illustrates the relative ease and safety of delayed mucosectomy via a perineal approach, provided that the initially stapled anastomosis is within 3 cm to 4 cm of the dentate line. This technique also obviates the need for complex abdominopelvic surgery after previous restorative proctocolectomy.

Electrorectography in chronic proctitis

Rectal electrical activity, measured by electrorectography (ERG), was studied in 18 patients with chronic proctitis (11 ulcerative and 7 bilharzial proctitis). Mean age was 36.6 +/- 9.4 (SD) years. Eight healthy volunteers were included as controls. Monopolar recordings were made from silver-silver chloride electrodes situated 1 cm from the tip of the catheter, which was applied to the rectal mucosa. Signals from the electrode were displayed on a U-V recorder. Rectal neck and rectal pressures were recorded simultaneously. Pacesetter potentials (PP) were also recorded from all subjects. The healthy volunteers had a mean frequency of 2.6 +/- 0.6 cycles per minute (cpm), an amplitude of 2.4 +/- 0.5 mV, and a velocity of 4.3 +/- 0.5 cm/sec. The potentials had the same frequency and regular rhythm when the test was repeated and were followed randomly by bursts of action potentials (AP). The rectal pressure increased simultaneously with the AP. In the proctitis patients the PP frequency was higher than normal (mean 8.2 +/- 1.6 cpm in patients with bilharziasis and 8.9 +/- 2.1 cpm in those with ulcerative proctitis) (p < 0.001), whereas the amplitude and velocity were lower than normal (p < 0.05 and p < 0.01, respectively). APs had higher frequency and amplitude and were accompanied by higher rectal pressure than in the normal volunteers. The increased PP, or tachyrectia, may be due to rectal wall or rectosigmoid pacemaker irritation caused by proctitis, whereas the diminished amplitude and velocity may be caused by a diseased rectal wall. The increased AP frequency and amplitude seem to cause increased rectal contractile activity with a resulting tenesmus.(ABSTRACT TRUNCATED AT 250 WORDS)

A pathophysiologic study of diversion proctitis

Diversion proctitis occurs with variable frequency after exclusion of the fecal stream. Its importance lies in the inability to differentiate it from other types of proctitis that may result in inappropriate therapy and a reluctance to recommend stoma closure. The effect of fecal diversion (n = 18) and restoration of intestinal continuity (n = 10) on human rectal mucosa in patients without inflammatory intestinal disease has been prospectively evaluated. Fecal diversion was associated with macroscopic inflammation in 55 percent of the patients and histologic inflammation in 72 percent, with a variable incidence of aphthoid ulceration, crypt abscess formation and submucosal nodularity. Restoration of continuity was associated with improvement in histologic features in all patients, but the mucosa returned to normal in only 50 percent of the patients. Onset or resolution of diversion proctitis was not associated with any significant changes in colonic cellular proliferation, glycoprotein synthesis or mucosa-associated or luminal flora. The only diagnostic feature of defunctioned proctitis remains its resolution on reintroducing the fecal stream.

Laser Doppler assessment of human colonic blood flow

We have used laser Doppler flowmetry to assess human colonic blood flow in patients with healthy mucosa and in those with active proctitis. We report a significant correlation between colonic serosal laser Doppler flux readings and serosal tissue oxygen tension (n = 45: r = 0.671: p = 0.001). Mucosal blood flow was measured using the PF309 probe of a Perimed Pf2b set on 12 kHz frequency shift. There was no significant difference throughout the colon in healthy patients. The flow in rectal mucosa was significantly higher in patients with proctocolitis than in normal mucosa.

A controlled study of faecal distribution in ulcerative colitis and proctitis

The object of this study was to assess faecal distribution and faecal stasis in patients with ulcerative colitis and healthy control subjects and to relate the findings to the activity and extent of the disease. Each subject ingested 10 radiopaque markers daily for 13 days and attended for a plain abdominal roentgenogram on the 14th day. Patients with active ulcerative proctocolitis retained significantly fewer markers in the whole colon (median values, 11 versus 24 markers) due to a decrease of markers in the left colon (median values, 3 versus 13 markers) compared with the control group (p less than 0.05). Patients with either proctitis or colitis in remission and control subjects retained similar numbers of markers. The results of this study suggest that, as a group, patients with proctocolitis do not have proximal faecal stasis.

Transit time in ulcerative proctitis

Whole-gut transit time was measured by the time taken for an orally administered dose of brilliant blue dye to disappear from the stool in 20 patients with ulcerative proctitis and in 20 age- and sex-matched controls. Ten of the patients had active, and 10 inactive disease. The dye usually appeared in the stool with the next bowel movement after ingestion in both patients and controls; however, the time at which the dye disappeared from the stool (transit time) was prolonged to 76.1 h in the patients, compared with 50.2 h in the controls (p less than 0.01). This delay occurred both in patients with active disease at 70.5 h (p less than 0.05) and in those with inactive disease at 81.8 h (p less than 0.05). This prolongation of transit time may be relevant to both the pathogenesis and treatment of ulcerative proctitis.

Mucosal surface pH of the large intestine of the rat and of normal and inflamed large intestine in man

The surface pH of rat distal colonic mucosa and human rectal mucosa was measured in vitro using first a small pH electrode with a flattened tip. In buffer with pH 7.56 the mean rat colonic surface pH was 6.72. Lowering the buffer pH in steps resulted in a small fall in surface pH, the values being buffer pH 7.06 surface pH 6.64, buffer pH 6.58 surface pH 6.61 and finally buffer pH 6.09 surface pH 6.39. Similar results were obtained with a buffer where butyrate, 30 mmol/l replaced chloride and when a CO2/bicarbonate buffer was used. During the time taken for the study transmural potential difference only changed by 1-2 mV. Serosal surface pH changed with buffer pH, suggesting that the maintained surface pH is a property of the mucosal surface only. The surface pH of human rectal mucosa was similar to that of rat distal colonic mucosa. As buffer pH fell from pH 7.51 to 5.96 mucosal surface pH only fell from pH 6.80 to 6.26. The values obtained in ulcerative proctitis did not differ from normal mucosa. Secondly pH microelectrodes were used to measure the juxta mucosal pH and the pH-microclimate thickness when luminal pH was controlled. The microclimate had a pH 6.63 adjacent to the mucosa with a thickness of 840 micron. The importance of mucus in maintaining the microclimate was shown by n-acetyl cysteine thinning and prostaglandin E2 thickening the layer. These results describe a surface microclimate in the large intestine of appreciable thickness and a constant juxta mucosal pH. Luminal pH changes produce only a small change in microclimate pH.

Conditions that mimic inflammatory bowel disease. Diagnostic clues and potential pitfalls

Many of the features that identify idiopathic inflammatory bowel disease are also found with other colorectal conditions that are often encountered by the primary care physician. Although, initially, symptoms of these disorders may appear to be caused by ulcerative colitis or Crohn's disease, the cause could be bacterial, viral, parasitic, or fungal infection. Ischemic colitis and radiation colitis are other conditions that are similar in presentation to ulcerative colitis. In most cases, the physician should be able to make a differential diagnosis from a thorough history and physical examination, anoscopy or sigmoidoscopy, rectal biopsy, stool examination, and serology. An occasional patient, in whom diagnosis is not made by these methods, may require a barium enema study, colonoscopy, or referral to a gastroenterologist.

Significance of gastrointestinal cytomegalovirus infection in homosexual males

Gastrointestinal cytomegalovirus (CMV) infection usually occurs in immunosuppressed patients and has recently been reported in patients with the acquired immune deficiency syndrome (AIDS). Serological evidence of CMV infection and a variety of traumatic and infectious gastrointestinal disorders are known to occur in nonimmunosuppressed homosexual males. However, the significance of gastrointestinal CMV infection in nonimmunosuppressed homosexual males is not well known. Three unusual cases of gastrointestinal CMV infection in homosexual males are presented. Infection of a Kock pouch in one patient and an anal ulcer in another, occurred as part of a CMV mononucleosis syndrome. In the third patient, CMV was found in an acutely inflamed appendix. Although gastrointestinal CMV infection has been reported frequently in patients with AIDS, our patients showed no evidence of immunosuppression or AIDS 6 wk to 1 year later. Gastrointestinal CMV infection in homosexual males with gastrointestinal disease should not be considered indicative of AIDS.

Inflammatory bowel disease in the older patient

This paper presents a review of 64 patients in whom the first symptoms of inflammatory bowel disease occurred after the age of 60 years. Inflammatory bowel disease in older patients affects the large bowel much more commonly than the small bowel. The commonest variant is disease localized in the rectum and distal colon, and many of these patients have Crohn's disease (14 out of 28 patients). In 19 patients with localized left-sided colitis it was difficult to distinguish ischaemic colitis, acute diverticulitis and Crohn's disease. Patients with left-sided colitis or total colitis (15 patients) had a high incidence of acute complications, particularly colonic perforation. There should be an awareness of the risks associated with all types of colitis in the older patient.

[Clinical picture and therapy of nonspecific ulcerative proctitis (author's transl)]

Nonspecific ulcerative proctitis is a variant of diffuse ulcerative colitis with a markedly different clinical course and prognosis. Therapy of choice today consists in salicylazosulphapyridin enemas. Preparation and application as well as results of treatment are discussed.

Morphological and mucus secretion criteria for differential diagnosis of solitary ulcer syndrome and non-specific proctitis

Over a four-year period 21 cases of solitary ulcer syndrome (SUS) were studied for their clinical, histological, and mucus secretion patterns and compared with histological and mucus secretion patterns of 78 cases of non-specific proctitis collected over the same period. Normal mucus composition was found in non-specific proctitis while abnormalities of mucins with predominance of sialomucins were associated with SUS. Although histology remains the most important investigation in the diagnosis of SUS, mucin changes provide valuable additional evidence.

Pathogenesis of urgency in defaecation in Crohn's disease

In 39 patients with Crohn's disease with 20 suffering from urgency in defaecation, the degree of proctitis, anal basal and squeeze pressures and anal sphincter responses to passive rapid or slow rectal filling were not correlated to the presence or absence of urgency or its severity. However, there was a positive correlation between urgency and both defaecation frequency and looseness of stools as well as extent of disease, with invariable involvement of the small intestine in urgency patients. Disease confined to the colon was found only in non-urgency cases. It was proposed that extensive disease involving both the small and large intestine could elicit abnormal bowel motility, and lead to unusually rapid rectal filling, inevitably followed by rapid reflex relaxation of the anal sphincter, manifesting itself as urgency. This hypothesis would be consistent with the observation that operative removal of diseased bowel with ileorectal anastomosis may abolish urgency.

Relationship of proctitis and rectal capacity in Crohn's disease

In patients with Crohn's disease involving the rectum (n=25), there was an inverse relationship between rectal capacity and the degree of proctitis. However, in patients with Crohn's disease not involving the rectum (n=22) the rectal capacity was similar to that of normal controls (n=20). The frequency of defaecation was not related to the degree of proctitis or to the pressure of a colectomy and ileorectal anastomosis. Control subjects had a significantly lower frequency of defaecation than patients with Crohn's disease irrespective of involvement of the rectum.

The effect of wheat bran on intestinal transit

In 18 students and two members of staff at a boys' boarding school, the time taken to pass 20 out of 25 radiopaque pellets varied from one to seven days while the subjects were eating a normal English diet. After the additon of bran, about 20 g daily, to this diet transit time fell from 2-75 plus or minus 1-6 to 2-0 plus or minus 0-9 days (P smaller than 0-025). Transit became faster in all nine subjects who had an initial time of three days or more, and in three of seven with an initial time of two days, but became slower in all four boys with an initial one-day transit. Frequency of defaecation correlated poorly with transit time (a once daily bowel action being found with transit times ranging from one to four days), and did not increase significantly with bran. In 10 additional adults with slow initial transit (three or four days) the effect of bran was compared with that of an equal volume of ground oatflakes in a double-blind crossover trial. Bran caused a significant acceleration of transit, wherease oatmeal had no effect. These studies confirm that bran accelerates slow intestinal transit and show that this is not simply a psychological effect. Bran may also slow down fast transit.