Functional MRI for the assessment of gastric motility--a better test?
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Gastric Emptying↗
Biomedical subjects
M M Schuster
Publications and source records attributed to M M Schuster.
Pain: the overlooked symptom in gastroparesis.
OBJECTIVE: Abdominal pain has not been reported generally as a significant feature of the clinical presentation of patients with gastroparesis. METHODS: Using a standardized questionnaire, we analyzed the clinical features of 28 consecutive patients referred with established or suspected gastroparesis over a 4-yr period. The diagnosis of gastroparesis was supported by abnormalities in gastric emptying studies (GES), electrogastrography (EGG), or upper endoscopy (EGD). Diagnostic tests were reviewed. RESULTS: A total of 12 male (mean age 39.5 yr) and 18 female patients (mean age 39.6 yr) were included in this study. These patients had been symptomatic for an average of 37.8 months before their referral to our center. Seven of these patients had insulin-dependent diabetes. Idiopathic gastroparesis was present in more than half of the patients. The symptom profile of the 28 patients was as follows: nausea, 92.9%; abdominal pain, 89.3%; early satiety, 85.7%; and vomiting, 67.9%. The pain was described as burning, vague, or crampy in nature. Only 36% localized to the upper abdomen. In all, 60% of patients complained of postprandial pain, whereas 80% complained of nocturnal pain that interfered with their normal sleeping pattern. In general, pain responded poorly or not at all to prokinetic agents. CONCLUSIONS: Nausea and abdominal pain are the most common complaints of patients with gastroparesis. In 80% of patients, GES and EGG correlated positively.
Abdominal Pain↗
Autonomic dysfunction in chronic intestinal pseudo-obstruction.
Fifteen tests were used to assess adrenergic, non-vagal cholinergic, and cardiovagal functions in 11 patients with chronic intestinal pseudo-obstruction (CIP). The three aims of this study were: 1) to ascertain the presence of and spectrum of autonomic involvement; 2) to assess the level of autonomic dysfunction; and 3) to compare the results of autonomic function tests with gastrointestinal motility patterns. Gastrointestinal motility displayed a neuropathic pattern in 10 patients. Adrenergic functions were abnormal in nine patients and non-vagal cholinergic functions in 10 patients. Cardiovagal functions were abnormal in only seven patients. The autonomic dysfunction was localized mostly to the postganglionic pathways. One patient, who had a myopathic pattern and muscle degeneration on small bowel biopsy, demonstrated normal responses to autonomic function tests. The patients with neuropathic CIP demonstrated widespread, mostly postganglionic autonomic dysfunction. Neuropathic CIP can occur with or without cardiovagal involvement.
Acetylcholine↗
Physiological correlates of colonic motility in patients with irritable bowel syndrome.
Irritable bowel syndrome is frequently encountered in clinical practice, and it has been repeatedly suggested that abnormal colonic motor activity is one of the major pathophysiological mechanisms responsible for the origin of symptoms in such disorder. If this statement is true, then high-amplitude propagated colonic contractions (HAPCs), i.e. the mass movements, may play an important role. To test this hypothesis, we conducted an investigation by recording colonic motility for a prolonged (24 h) period in 25 patients with irritable bowel syndrome and in 18 healthy volunteers, to compare the number of mass movements over 24 h in patients (constipation-predominant, alternating bowel habits) and controls. The overall amount of motility was also assessed in twelve patients and 13 controls. We also looked for the possible changes in mass movements and motility which may occur with defecation and after a meal. The results showed that 1) with respect to HAPCs and motility index, neither group was significantly different from controls; 2) HAPCs and the motility index were significantly reduced during sleep in all groups tested; 3) HAPCs were significantly more common before as compared to after defecation and after as compared to before meals; 4) HAPCs are not independent from the segmental contractile activity; 5) the motility index/24 h was lower in the constipation-predominant group of patients with respect to controls. We conclude that in patients with irritable bowel syndrome colonic motility per se may play a pathophysiological role in the genesis of the symptoms, although other mechanisms are likely to concur, or to be responsible for the complaints of these patients. However, colonic prolonged recordings are very useful for studying physiological and pathophysiological correlates of sleep, eating, and defecation.
Adult↗
Review and analysis of the effects of olestra, a dietary fat substitute, on gastrointestinal function and symptoms.
Olestra, a dietary fat substitute, was recently made available to consumers in savory snacks in three cities. Early reports of gastrointestinal complaints attributed to olestra attracted media coverage and fostered confusion among physicians and consumers about the nature of olestra and its effects on the digestive system. We reviewed all published studies of olestra's gastrointestinal effects and all relevant unpublished studies submitted to the Food and Drug Administration. Each study was analyzed by a group of expert gastroenterologists and epidemiologists. The symptoms reported with olestra ingestion are similar to those reported with ingestion of fiber and sorbitol, although the mechanisms involved in changing stool characteristics differ among these food additives. Olestra's effects on stool habit and characteristics are due to its presence in the stool. Large amounts are more likely to induce gastrointestinal symptoms than small amounts. There is no evidence that olestra induces pathological change in bowel function: there is no increased fluid or electrolyte nor is there altered gastrointestinal motility or microflora. Olestra and triglyceride ingestion resulted in a similar frequency of symptoms in normal adults and children and in people with chronic inflammatory bowel disease in remission. Olestra traverses the digestive tract intact to become a stool additive. Some subjects develop a change in bowel habit and stool characteristics due to the presence of more olestra in the stool. These changes resemble those associated with ingestion of sorbitol and fiber.
Controlled Clinical Trials as Topic↗
Pain from rectal distension in women with irritable bowel syndrome: relationship to sexual abuse.
The aims of this study were to determine whether increased pain sensitivity in patients with irritable bowel is due to physiological differences in perceptual sensitivity or psychological influences on perception, and whether prior sexual abuse accounts for increased pain sensitivity. Seventeen sexually abused and 15 nonabused women with irritable bowel were compared to 13 sexually abused and 14 nonabused women without irritable bowel. Among the nonabused subjects, the volume of rectal distension that produced moderate pain was lower in IBS patients than in controls, replicating earlier studies, but these thresholds were correlated with psychological measures of anxiety and somatization. The ability to discriminate between painful distensions (perceptual sensitivity) was not different between groups. Sexual abuse was not associated with lower pain thresholds. Thus, differences in pain sensitivity appear to be due to psychological influences on perception, but a history of sexual abuse does not contribute significantly to this pain sensitivity.
Colonic Diseases, Functional↗
Management of incessant ventricular tachycardia in a 39-year-old woman with cardiomyopathy.
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Adult↗
Cyclic vomiting: association with multiple homeostatic abnormalities and response to ketorolac.
Cyclic vomiting is a rare syndrome that over the years has variously been ascribed to psychogenic causes, sensory seizures, abdominal migraine, and more recently, to mechanical or electrical disturbances in gastric physiology. We describe the case of a 65-year-old white diabetic female with a 10-yr history of recurrent episodes of nausea and vomiting, occurring every 10-12 days and lasting approximately 1-3 days at a time. These episodes were accompanied by edema, mild temperature elevations, and remarkable elevations in blood pressure. In between these episodes, the patient remained asymptomatic. Initial screening tests were also negative except for moderate gastroparesis. However, antral motility was found to be normal, as was an electrogastrogram. Detailed neurological and psychiatric evaluations were negative. Trials of erythromycin, metoclopramide, naloxone, ondansetron, and amitryptiline were unsuccessful. Serial endocrinological testing revealed that an episode of vomiting was always preceded by an abnormal elevation in at least one of the following: serum adrenocorticotropic hormone, serum cortisol, or urinary cortisol. In the midst of an episode, all three values were exceedingly high (e.g., > 10-fold increases in 24-hr urinary cortisol levels). Fluctuations of a milder degree, though still abnormally high, were also noted in between cycles at times when the patient was completely asymptomatic. High-dose dexamethasone suppressed these hormonal surges completely but not the clinical symptoms, which continued undisturbed. The patient was finally given a trial of intramuscular ketorolac during one of her episodes, which produced prompt and sustained relief. During the next few weeks, she was given this drug each time her symptoms commenced, and each time it appeared that her cycle had been aborted. She has since been able to terminate her episodes promptly and completely by self-administration of ketorolac. We speculate that her syndrome is caused by a poorly characterized disorder of endogenous prostaglandin release, resulting not only in derangements in the hypothalamic pituitary system but also in nausea and vomiting.
Adrenocorticotropic Hormone↗
Mechanisms of constipation in older persons and effects of fiber compared with placebo.
OBJECTIVE: To investigate the mechanisms of constipation and the effect of fiber supplementation on physiology, mechanisms, stool parameters, and colonic transit times in a group of constipated older patients. DESIGN: Single-blind, randomized, placebo-controlled fiber intervention with crossover. SETTING: A university-based outpatient center. PATIENTS: Ten community-living older men and women, healthy except for chronic constipation. INTERVENTIONS: Patients were given either 24 g psyllium fiber or placebo fiber daily for 1 month, then crossed over to the other arm for an additional month. Structured testing, including total gut transit time and rectal and colonic manometry, was performed at the end of each intervention month. Patients recorded stool frequency, consistency, and weights daily. RESULTS: The predominant mechanism for constipation in these patients was outlet delay caused by pelvic dyssynergia. Fiber decreased total gut transit time from 53.9 hours (placebo condition) to 30.0 hours (P < .05). Stool weights and consistency were not significantly improved by fiber, though there was a trend toward an increase in stool frequency (1.3 vs 0.8 bowel movements per day.) Pelvic floor dyssynergia was not remedied by fiber, even when constipation was clinically improved. CONCLUSIONS: Fiber supplementation appeared to benefit constipated older patients clinically, and it improved colonic transit time, but it did not rectify the most frequent underlying abnormality, pelvic floor dyssynergia.
Aged↗
Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation.
OBJECTIVE: Total abdominal colectomy (TAC) for intractable constipation has a variable reported success rate that decreases to 50% beyond 2 yr. We hypothesize that this inconsistent outcome can be explained by a more extensive intestinal involvement in some patients. DESIGN: A consecutive sample of patients with intractable constipation had preoperative evaluations that included both upper and lower GI studies. Stool frequency, constipation, diarrhea, abdominal pain, and laxative or enema requirements were compared before and after operation. The study took place in an academic referral center and included 37 consecutive referred patients with severe intractable constipation and colonic dysmotility documented by radiopaque marker studies. INTERVENTIONS: TAC, with ileoproctostomy in 34 patients and ileostomy in three. MAIN OUTCOME MEASURES: Patients with motility abnormalities only of the lower GI tract were diagnosed as having colonic inertia (CI). Those with motility disorders of both the upper and the lower GI tracts were considered to have generalized intestinal dysmotility (GID) with colon predominance. RESULTS: Twenty-one patients had CI, and 16 had GID. Ninety percent of CI patients undergoing TAC had a successful outcome with a mean of 23 bowel movements (BMs)/wk at a mean follow-up of 7.5 yr. Although 88% of GID patients had initial improvement, with a mean of 19 BMs/wk at 6 months, only 13% had prolonged relief. After 2 yr, nine of the GID patients had recurrent constipation, and three had severe diarrhea. CONCLUSIONS: This study has identified two distinct types of colonic dysmotility, CI and GID. It has demonstrated the long-term success of TAC for CI and the importance of upper GI physiological studies to identify colon-predominant GID, which has a poor long-term response to TAC.
Adult↗
Congenital markers for chronic intestinal pseudoobstruction.
OBJECTIVES: Chronic intestinal pseudoobstruction (CIP) is difficult to differentiate from true mechanical obstruction, so many patients undergo multiple operations before the diagnosis is established. This is because of a lack of easily identifiable signs and symptoms that can differentiate true intestinal obstruction from pseudoobstruction. The digital arch is the least common (10%) of the three patterns of fingerprints (arches, loops, and whorls) found in primates. Digital arches have also been reported in association with mitral valve prolapse, which in turn is associated with joint laxity. Fingerprints and mitral valve prolapse are congenital features and are influenced by heredity, so we evaluated CIP patients for coexistence of these clinical markers. METHODS: Fingerprints were examined in 1566 consecutive gastrointestinal specialty referrals. In 43 patients, the initial diagnosis of CIP was confirmed by subsequent testing. Because of the clinical impression that four features were present with increased frequency in CIP patients, these signs and symptoms were recorded prospectively: 1) number of digital arches (DA); 2) presence of mitral valve prolapse (MVP), 3) presence of joint laxity (JL), and 4) onset of constipation before age 10 (C < 10). RESULTS: Forty-three CIP patients (39 female, four male, ages 18-62) were seen. Using the test for significance of differences in proportions, the presence of DA, MVP, JL, and C < 10 proved significantly higher (p < 0.001) in CIP patients than in age- and sex-matched controls and the general population. CONCLUSIONS: We conclude that: 1) CIP may be a heritable syndrome because it is associated with heritable congenital markers (DA, MVP, JL, and C < 10; 2) these markers are identified with higher frequency in CIP patients than in the general population and in age- and sex-matched patients with other gastrointestinal disorders; 3) all four markers are easily detectable, and their recognition could lead to earlier diagnosis of the disorder.
Adolescent↗
Gastrointestinal symptoms in bulimia nervosa: effects of treatment.
OBJECTIVES: The aim of this study was to characterize the frequency and severity of gastrointestinal symptoms in bulimic patients and to determine their response to treatment of the eating disorder. METHODS: Forty-three consecutive bulimic patients admitted to the inpatient Eating Disorders Unit of the Psychiatry Service were asked to fill out a gastrointestinal symptoms questionnaire, an Eating Disorders Inventory, and a Zung Depression Inventory on admission and discharge. Thirty-two age- and sex-matched healthy volunteers completed the same questionnaire. RESULTS: In bulimic patients, the most commonly reported gastrointestinal symptoms were bloating (74.4%), flatulence (74.4%), constipation (62.8%), decreased appetite (51.2%), abdominal pain (48.8%), borborygmi (48.8%), and nausea (46.5%). The average symptom score (sum of severity ratings) on the gastrointestinal symptoms questionnaire decreased from 20.6 +/- 10.8 (mean +/- SD) on admission to 13.46 +/- 10.5 (t(27) = 3.31, p < 0.01) on discharge but remained significantly higher than that of the control group (4.4 +/- 6.2, t(43) = 4.02, p < 0.001). However, the severity of reported gastrointestinal symptoms was correlated with the severity of depression (r = 0.43, p < 0.05), and when the possible mediating effects of depression on gastrointestinal symptoms were controlled statistically (analysis of covariance), the effects of treatment on gastrointestinal symptoms were not statistically significant. CONCLUSION: Gastrointestinal symptoms in bulimics are common, multiple, and often severe and they improve with treatment. However, the most important determinant of gastrointestinal symptoms appears to be depression.
Abdominal Pain↗
Functional bowel disorders in women with dysmenorrhea.
OBJECTIVES: The relationship between menstrual and bowel symptoms, the overlap between the diagnoses of dysmenorrhea (DYS) and functional bowel disorder (FBD), and markers that may be useful in discriminating functional bowel disorders from DYS were studied in 383 women (20-40 yr of age). METHODS: All women completed the NEO Personality Inventory at intake and completed the Moos' Menstrual Distress Questionnaire and a bowel symptom inventory every 3 months for 12 months. Prostaglandin levels were measured in vaginal dialysate on the first day of menses. RESULTS: DYS was diagnosed in 19.8% of the total sample. Functional bowel disorder, defined as abdominal pain with altered bowel function, was diagnosed in 61% of the DYS group compared with 20% of controls (p < 0.05). Neuroticism scores were significantly higher in subjects with functional bowel disorder with or without DYS. However, bowel symptoms were significantly correlated with menstrual symptoms even after statistically controlling for the effects of neuroticism. Painful menses and water retention distinguished the DYS group from the functional bowel disorder group. Prostaglandin levels were elevated in women with DYS, but did not consistently differentiate the diagnostic groups. CONCLUSIONS: The strong covariation of menstrual and bowel symptoms, along with the overlap in diagnoses of DYS and function bowel disorder, suggest a common physiological basis.
Adult↗
Clinical experience with a new multiprogrammable dual chamber pacemaker.
We evaluated the clinical performance of a new dual chamber pacemaker, ELA Chorus, in 35 patients. This device incorporates linear rate adaptive AV delay (AVDR), rate smoothing, fallback, impedance telemetry, pacemaker mediated tachycardia (PMT) recognition and reprogramming software, intracardiac electrogram displays, autothreshold testing, diagnostic data, battery depletion curves, and laptop computer programming. Mean patient age was 68 years; 18 patients had AV block, six had sinus node dysfunction (one with AV block), nine had carotid sinus hypersensitivity (three with AV block), and two had vagally mediated syncope. At hospital discharge, programming was DDD with a mean low rate of 60 (50-70) beats/min, mean high rate of 126 (120-154) beats/min; AVDR was ON in 21 patients, rate smoothing ON in six patients, fallback ON in six patients, and PMT reprogramming algorithm ON in 27 patients. Pacemaker follow-up involved 500 clinic visits over 14.3 months (1-36). Three patients developed atrial fibrillation, reprogrammed to DDI mode (two patients) or fallback (one patient). Fallback was used 617 times. PMT occurred 427 times in six patients; the PMT algorithm reprogrammed AV delay and postventricular atrial refractory period (PVARP) automatically, a function unique to the Chorus. Intracardiac electrograms and autothreshold testing improved follow-up efficiency. This new dual chamber pacemaker enhances programming flexibility and improves diagnostic accuracy at follow-up.
Aged↗
Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared with subjects without bowel dysfunction.
A standardised inventory of stressful life events and a bowel symptom questionnaire were administered at three month intervals for one year to 383 women who were unselected with respect to bowel symptoms. A NEO Personality Inventory was given initially to assess neuroticism. Subjects who satisfied restrictive diagnostic criteria for irritable bowel syndrome were compared with those who complained of abdominal pain plus altered bowel habits but who did not meet restrictive diagnostic criteria (functional bowel disorder) and with controls without bowel dysfunction. The irritable bowel group showed significantly higher levels of stress than the other two groups even when the confounding effects of neuroticism were statistically controlled for. Time lagged correlations showed that stress in one three month interval was significantly correlated with bowel symptoms in the subsequent three month interval for all groups. The slope of the regression line relating stress to bowel symptoms was significantly steeper for the irritable bowel group than for the other two groups at three and six months, suggesting that subjects with irritable bowel syndrome show a greater reactivity to stress. Stress scores were also significantly correlated with the number of disability days and the number of medical clinic visits for bowel symptoms.
Adult↗
Not so much what you do, but how you do it.
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Animals↗
Delayed gastrointestinal transit times in anorexia nervosa and bulimia nervosa.
Anorectic and bulimic patients frequently report symptoms of constipation, bloating, and abdominal pain suggestive of abnormal gastrointestinal motility or transit. However, except for studies of gastric emptying, gastrointestinal motility and transit in these eating disorders have not been investigated. Ten anorectic and 18 bulimic inpatients were compared with 10 healthy controls. Whole-gut transit was tested by the radiopaque marker technique, and mouth-to-cecum transit time was assessed by the lactulose breath test. All anorectics and 67% of bulimics complained of constipation. Whole-gut transit time was significantly delayed in both anorectics (66.6 +/- 29.6 hours) and bulimics (70.2 +/- 32.4 hours) compared with controls (38.0 +/- 19.6 hours). Mouth-to-cecum transit time also tended to be longer in anorectics (109.0 +/- 33.5 minutes) and bulimics (106.2 +/- 24.5 minutes) than in controls (84.0 +/- 27.7 minutes), but these differences were not statistically significant. Delayed transit could contribute to or perpetuate the eating disorders by (a) causing the patient to feel bloated, thereby exacerbating fear of fatness, or (b) causing rectal distention, which may reflexly inhibit gastric emptying.
Adolescent↗