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Biomedical subjects

R J Nicholls

Publications and source records attributed to R J Nicholls.

At least 19 recordsLinked to original sources
PubMed1992

Ileoanal pouch compliance and motor function.

Measurement of intrapouch pressure during continuous distension with water (pouchmetrography) was performed in ten patients with good pouch function after restorative proctocolectomy and a 'normal' baseline pressure curve was constructed from the mean pressures at 50-ml intervals. Eight other patients with poor pouch function were studied and the two groups were compared. Patients with poor function had significantly lower maximum tolerated volumes (297.5 versus 565 ml, P less than 0.02) and volumes which caused urgency (135 versus 265 ml, P less than 0.02). Baseline pressure curves were above the upper limit of the normal range (mean plus two standard deviations) for a substantial proportion of the recording in six of the patients with poor function. Large, isolated contraction waves were recorded in six of ten patients with good function and in three of those with poor function. Rhythmic waves were frequently seen in both groups but were more prominent in patients with poor function. Pouchmetrography is a provocative test of pouch motor function which may unmask abnormal muscle activity resulting from reduced compliance or a primary motility disorder.

Adult↗
PubMed1992

Anal fistula.

Anal fistula is a common cause of chronic irritation to both patients and surgeons. Treatment failure rates may be decreased by a good appreciation of normal anorectal anatomy and fistula pathoanatomy, as well as a wide and practical knowledge of the possible treatment regimens. The various treatment options available for acute abscesses as well as simple and complex anal fistulae are presented and discussed. Identification of the patient at risk of postoperative anal incontinence or of the difficult or high fistula may allow treatment in a specialized proctology unit.

Abscess↗
PubMed1992

Decreased sensitivity of muscarinic but not 5-hydroxytryptamine receptors of the internal anal sphincter in neurogenic faecal incontinence.

Previous studies of the internal anal sphincter in patients with neurogenic faecal incontinence have indicated an abnormality of the adrenergic innervation, but little is known about the responsiveness of other receptors in the internal and sphincter in this condition. In this study the in vitro sensitivity to carbachol and 5-hydroxytryptamine (5-HT) of muscle strips from patients with neurogenic incontinence (n = 6 and n = 7) and from control patients (n = 9 and n = 10) was examined. Preparations of internal and sphincter from patients with incontinence were less sensitive to the relaxant actions of carbachol than preparations from the control group. The pD2 value for carbachol (i.e. the negative logarithm of the concentration for half-maximal response) was significantly greater in the controls than in the incontinent group (mean(s.e.m.) 6.03(0.15) versus 5.43(0.24), P < 0.05). There was no significant difference in the contractile responses to 5-HT, which had pD2 values of 6.93(0.13) and 6.63(0.27) for the control and incontinent groups respectively. The unaffected state of the 5-HT receptor and the subsensitivity of the muscarinic receptor are discussed in relation to intrinsic neural control of the internal and sphincter in neurogenic faecal incontinence.

Adult↗
PubMed1992

Abdominal rectopexy for complete prolapse: prospective study evaluating changes in symptoms and anorectal function.

The effect of abdominal rectopexy on bowel function is difficult to assess in retrospective studies because preoperative bowel habit cannot be determined accurately. This study examined bowel symptoms and physiologic tests of anorectal function prospectively in 23 patients before and at three months after rectopexy. Rectopexy eliminated complete prolapse in all and stopped bleeding in 16 of 18 patients. Incontinence improved significantly. Constipation (less than 3 bowel actions per week or straining for more than 25 percent of defecation time) was relieved in 4 of 11 affected patients but developed in 5 of the 12 who were not constipated preoperatively. Since the median bowel frequency was 21 motions per week before surgery and 17 afterward, the main determinant of constipation was straining. Abdominal pain was relieved after rectopexy in 6 of 12 patients but developed in 3 of 13 who were pain-free before surgery. Three patients (13 percent) had a first-degree relative with rectal prolapse. Perineal descent decreased significantly. Maximal anal resting pressure increased significantly, but this did not correlate significantly with improved continence. Twenty-one patients (91 percent) could expel a 50-ml balloon preoperatively; 18 of those 21 could still do so postoperatively. The two patients who could not expel the balloon preoperatively were able to do so postoperative. This study shows that rectal prolapse is associated with profoundly abnormal defecation and abdominal pain. While abdominal rectopexy improved continence, it may improve or worsen other bowel symptoms, including constipation.

Abdominal Pain↗
PubMed1992

Restorative proctocolectomy in patients after previous intestinal or anal surgery.

Restorative proctocolectomy is now established as the procedure of choice in many patients with ulcerative colitis or familial polyposis coli as well as in some patients with multiple colorectal tumors, ischemia, trauma, or congenital abnormalities. Some patients, however, may have had previous pelvic, abdominal, or perineal surgery, which might be considered a contraindication to restorative proctocolectomy. In a consecutive series of 73 private patients undergoing restorative proctocolectomy under one surgeon, we have reviewed in detail 13 who had had previous "significant" abdominal, pelvic, or anal surgery. Eight patients had previously had surgery for fistula-in-ano or fissure-in-ano, two had had an anal sphincter repair, and three had undergone possibly compromising abdominal or pelvic surgery prior to restorative proctocolectomy. Twelve of the 13 made an uncomplicated recovery from restorative proctocolectomy, although one has since died from carcinomatosis. One patient died after closure of an ileostomy from a combination of enterocutaneous fistula, infection, bleeding, and a perforated duodenal ulcer. One patient developed sepsis, necessitating removal of the pouch, and is classified as a failure. Two of the remaining 11 have had minor long-term functional problems with nocturnal fecal incontinence, and one patient needs to catheterize the pouch to evacuate, but all three patients prefer a pouch to an ileostomy. Restorative proctocolectomy can be performed successfully even after previous pelvic, abdominal, or anal surgery with an acceptable complication rate when compared with pouch surgery in the uncompromised patient.

Anal Canal↗
PubMed1992

Intestinal pseudo-obstruction with deficient smooth muscle alpha-actin.

We describe a 48-year-old woman with chronic constipation since early childhood who has an intestinal myopathy associated with a hitherto undescribed absence by immunostaining of smooth muscle alpha-actin confined to the intestinal circular muscle. There were no abnormalities in other contractile proteins (myosin, tropomyosin, filamin, caldesmon or desmin) and despite the abnormality of a contractile protein isoform in the circular muscle, no significant morphological changes were identified by light microscopy or ultrastructural examination. A possible developmental mechanism for the observed change is proposed. The use of specific antibodies to isoforms of contractile proteins may have potential value in the study of intestinal myopathies.

Actins↗
PubMed1992

Portal vein thrombosis in a complicated case of Crohn's disease.

Portal vein thrombosis is a rare complication of ulcerative colitis and is invariably fatal. This report describes a patient with severe Crohn's disease who underwent elective surgery complicated by an anastomotic disruption with faecal peritonitis. Following emergency laparotomy he developed left hypochondrial pain which was a manifestation of splenomegaly consequent upon portal vein thrombosis. Anticoagulation was successful in preventing further spread of the thrombosis as monitored by colour Doppler ultrasound. Severe active disease, surgery and sepsis have been recognized as predisposing factors for thromboembolic complications in inflammatory bowel disease and this patient was exposed to all three. It is conceivable that portal vein thromboses occur more commonly than suspected and ultrasound scanning could ascertain the prevalence if performed prospectively.

Adult↗
PubMed1991

Natural history of indeterminate colitis.

The long-term outcome of patients with a pathological diagnosis of indeterminate colitis on a colectomy specimen was investigated. The case records of 46 such patients operated on for inflammatory bowel disease between 1960 and 1983 were reviewed. Using the preoperative clinical information, pathological and radiological reports, it was possible to divide the patients into three groups: group 1, probable Crohn's disease (19 cases); group 2, probable ulcerative colitis (11 cases); and group 3, indeterminate colitis (16 cases). The patients were followed for a minimum of 2.5 years (median 10, range 2.5-28 years). During this period the probable diagnosis changed in five cases only. One patient in group 1 (Crohn's disease) was subsequently considered to have ulcerative colitis (group 2). The other four patients were all in group 3. Three were reclassified as ulcerative colitis and the fourth as Crohn's disease on the finding of a single granuloma in a rectal biopsy. No case in group 3 required subsequent small bowel surgery. These data suggest that patients continuing with a diagnosis of indeterminate colitis in spite of careful preoperative and postoperative assessment are unlikely to show features of Crohn's disease in the long term. This may be important when considering a subsequent restorative proctectomy.

Adolescent↗
PubMed1991

Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy.

A prospective randomized trial was performed to compare complications and function after hand sewn ileoanal anastomosis with mucosectomy (group A) with stapled ileoanal anastomosis without mucosectomy (group B) during restorative proctocolectomy. Thirty-two age- and sex-matched consecutive patients under the care of one surgeon were randomized. The median duration of anal dilatation while making the anastomosis was 19 min (range 14-33 min) and 1 min (range 0-39 min) in groups A and B respectively (P less than 0.005). The median level of the anastomosis was at the dentate line (range 0-0.5 cm) in group A and 2 cm above the dentate line (range 0.2-4.0 cm) in group B (P less than 0.005). Seven patients in group A and 11 in group B had at least one postoperative complication (n.s.). One patient in group A and four in group B developed an anastomotic stricture requiring dilatation (n.s.). One patient in group B had the reservoir removed. Function was assessed at a median of 11 months (range 7-15 months) after ileostomy closure in 14 patients in group A, and at a median of 12 months (range 5-17 months) in 14 patients in group B. Median frequency of defaecation per 24 h was 4 in both groups (group A, range 2-7; group B, range 2-10). Night evacuation (greater than once per week) occurred in seven patients in each group. All patients in both groups could delay the desire to defaecate by more than 30 min. Eleven patients in group A and 12 in group B had normal continence. Evidence to date favours a full mucosectomy. Function is not vitiated by this technique and surgical removal of the disease is more complete.

Adult↗
PubMed1991

Comparison between anal endosonography and digital examination in the evaluation of anal fistulae.

A prospective trial was performed comparing the accuracy of digital examination and anal endosonography in defining the anatomy of anal fistulae. Before operation 38 consecutive patients were assessed by the consultant in charge of the case, by a research fellow and by anal endosonography involving two radiologists. These findings were compared with the operative findings. Consultants correctly identified 26 of 33 internal openings, 29 of 34 primary tracks and 15 of 21 secondary tracks. The research fellow correctly identified 26 internal openings, 24 primary tracks and 10 secondary tracks. There was no significant difference between the accuracy of consultants and the research fellow. Anal endosonography identified 10 internal openings based on initial criteria. This rose to 24 when revised ultrasonographic criteria were applied. There was no statistical difference between consultant assessment and anal ultrasonography in correctly identifying intersphincteric and transphincteric tracks. Ultrasonography is unable to assess primary superficial, suprasphincteric and extrasphincteric tracks or secondary supralevator and infralevator tracks. Consultant assessment of secondary supralevator and infralevator tracks was correct in 78 per cent of cases.

Humans↗
PubMed1991

Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis.

Restorative proctocolectomy with an ileal reservoir (RPC) should prevent colorectal cancer in patients with familial adenomatous polyposis. Until this is confirmed its role compared with total colectomy and ileorectal anastomosis (IRA) will depend on the relative morbidity and postoperative bowel function after the two procedures. This was analysed in 99 patients (37 RPC, 62 IRA) operated on between 1977 and 1989. Morbidity was greater after RPC with subsequent ileostomy closure (median hospital stay, 24 versus 11 days; complications, 60 versus 21 per cent; reoperation, 29 versus 3 per cent; return to normal activity; 31 versus 14 weeks). There was little difference in bowel function; after IRA median frequency was 3/24 h and urgency (unable to wait 15 min) occurred in 50 per cent, compared with 4.5/24h and 17 per cent after RPC. Night evacuation occurred in 10 and 43 per cent respectively. IRA was performed in younger patients (median 19 versus 31 years) who had fewer bowel motions before operation (2 versus 5/24 h). The greater morbidity of RPC suggests that it should be restricted to patients at higher risk of developing later rectal cancer, including those unavailable for follow-up and those with large or confluent rectal polyps or with curable colon cancer at the initial colectomy.

Adenomatous Polyposis Coli↗
PubMed1991

Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study.

Denervation of the rectum during rectopexy has been suggested as a reason for postoperative constipation. Bowel symptoms and anorectal function have been examined in a prospective randomized study of rectopexy with (n = 14) or without (n = 12) division of the lateral ligaments. Incontinence improved in both groups of patients. Division of the lateral ligaments increased the number of patients with constipation (three before operation, ten after operation, P less than 0.01). Mean and canal pressures were higher after operation in all patients. Rectal electrical sensory threshold increased significantly in those in whom the ligaments had been divided (preoperative 27.6 mA versus postoperative 56.7 mA; P less than 0.01) but not in those in whom they were preserved (39.0 versus 34.9 mA; P greater than 0.05). Prolapse recurred in six patients who did not undergo division of the lateral ligaments, but in none of the group in whom the ligaments were divided.

Adult↗
PubMed1991

Pouch dynamics--a simple test of ileo-anal pouch evacuation.

A simple technique for quantifying ileo-anal pouch evacuation has been used to compare patients with good pouch function and fully spontaneous defaecation (n = 10) to patients with a symptomatic disorder of pouch evacuation (n = 10), usually due to a pouch-anal stricture (n = 7). Pouch emptying was significantly less efficient in those with disordered evacuation (median 54% evacuated) than in those with good function (median 98% evacuated, p = 0.02) and significantly slower (median 22.4 sec vs 5.2 sec to evacuate 75% of instilled barium, p less than 0.02) even when of comparable efficiency. Testing of four further patients with high stool frequency but neither stenosis nor symptomatic difficulty with evacuation excluded a significant disorder of evacuation in three but identified inefficient emptying in the fourth. This test may prove useful in the investigation of patients with poor pouch function of uncertain origin.

Adult↗