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Current ideas on the etiology and pathogenesis of functional disorders of the large intestine are discussed. Their classification, clinical picture, principles of diagnosis and differential diagnosis are outlined with emphasis of the most spread functional diseases of the large intestine: functional (common) obstipation, irritation of the large intestine pruritus ani, insufficiency of anal sphincters, proctalgia. Special attention is paid to treatment (diet, drugs, physiotherapy, spa).
Functional bowel disorders are characterized by the presence of a visceral hyperalgesia in most patients. This visceral hyperalgesia is related to an enhanced perception of sensations originating from the gut. Stressful events can dramatically influence the course of functional bowel disorders, and patients suffering from these syndromes appear to be more susceptible to the stressful events of daily life. However, until now, few studies have evaluated the relationship between stress and visceral perception. Some studies of healthy volunteers indicated contradictory results, but the studies used different methodologies. During stress conditions, either physical or mental, thresholds of perception of rectal distension were increased, suggesting a 'distraction effect', or were decreased, supporting a sensitizing effect of stress. In most studies, rectal compliance was not affected, but stress has been shown to alter the rectal tone, as measured by a barostat. One study comparing irritable bowel syndrome patients with controls demonstrated the importance of cognitive processes in the modulation of visceral perception by stress. Animal studies have also demonstrated the sensitizing effect of stress on the perception of rectal distension. Mediators involved may be numerous, but corticotropin-releasing factor has been demonstrated to play a major role at the central level. Mast cells and histamine release may play a role at the peripheral level. Stress can thus be included in an integrative model explaining the pathophysiology of functional bowel disorders. Advances in the understanding of the relationship between stress and visceral perception may constitute a basis for a therapeutic approach of functional bowel disorders targeted on the central nervous system.
For normal individuals and probably for persons with diverticular disease, dietary fiber affects stool bulk and decreases transit time. The unproven rationale for the use of fiber in irritable colon and diverticular disease assumes that these diseases are the result of increased intraluminal pressure caused by excessive segmentation over a period of years. In short-term experiments, certain fibrous materials do decrease intraluminal pressures, usually in response to a stimulus such as food but sometimes under resting conditions as well. It seems likely that the physical and probably chemical characteristics of fiber influence the motor responses of the alimentary tract. Anecdotal testimonials to the merits of fiber abound, but firm evidence that even wheat bran, the most commonly studied fiber, is effective is difficult to obtain. Controlled clinical trials have been attempted and to date have given conflicting results. Careful studies using a number of well-defined fibrous materials are urgently required to determine the physiological mechanisms of action of different fibers on gastrointestinal motor activity.
In irritable bowel syndrome (IBS), abnormalities of motility have been observed in the esophagus and small bowel, as well as in the colon. In order to investigate gastric function, gastric emptying has been measured in 25 patients with strictly defined IBS and compared with 25 age- and sex-matched controls. A standard radioisotope method for measuring gastric emptying has been employed. There was no significant difference between the two groups (T1/2 gastric emptying, IBS subjects 99.3 +/- 9.4 min, control subjects 104.0 +/- 11.9 min, mean +/- SEM), nor was there any major correlation between different symptom patterns and altered gastric emptying times. The results of the present investigation suggest that future studies on abnormalities in IBS should investigate other aspects of gastric motor function.
Computerized auscultation of the abdomen provides a noninvasive and quantitative method to investigate gastrointestinal function. Two-dimensional mapping of bowel sound sites of origin, to the surface of the abdomen, was accomplished through simultaneous recording with three electronic stethoscopes. Control, irritable bowel syndrome, and nonulcer dyspepsia groups were studied. The predominant site of fasting sound production was the right lower quadrant in all except a subgroup of nonucler dyspepsia patients. The second most common site mapped to the area of the stomach. The region mapping to the small intestine was largely devoid of sound. The control group had a higher percentage of sounds in the 184- to 248-Hz range than the functional bowel patients (P < 0.001) for sounds mapping to the stomach region. We conclude that two-dimensional mapping may have the potential to allow for the meaningful and objective categorization of groups of functional bowel patients.
Nurses are often involved in helping patients alleviate chronic distressing gastrointestinal symptoms such as those associated with irritable bowel syndrome or functional bowel disorder. One therapeutic strategy is to increase dietary fiber intake and to eliminate gastrointestinal (GI) irritants such as caffeine, alcohol, and tobacco smoking. However, little work has been done to establish a relationship between dietary factors and chronic GI symptoms. In this article, the authors: (a) describe and compare caloric and dietary constituent intake in symptomatic (n = 18) and asymptomatic (n = 37) women, and (b) examine the relationships among diet, GI symptoms, and stool characteristics in the two groups. In particular, total calories, fiber, fat, protein, and carbohydrates as well as alcohol and caffeine intakes were compared in women who do not smoke. Because menstrual cycle phase modulates both symptoms and appetite, women were studied during the follicular phase. Groups had similar caloric, fat, and protein intakes. Fiber intakes were similar and similar to national norms in both groups. When compared with asymptomatic women, the symptomatic women consumed more refined carbohydrates. Relationships were observed among dietary intake of refined carbohydrates, fiber, GI symptoms, and stool characteristics in women with functional bowel disorder.
Abnormalities of the autonomic nervous system function and cholecystokinin release have been described in patients with irritable bowel syndrome. Because the autonomic nervous system and cholecystokinin have an important role in the normal functioning of the gallbladder, we studied gallbladder contraction in response to a meal, using real time ultrasonography in irritable bowel syndrome patients (n = 20) and healthy controls (n = 15). The following parameters were studied: 1) fasting gallbladder volume, 2) residual volume after maximal contraction and at the end of 2 h, 3) maximum percent of gallbladder emptied, and 4) the time taken for maximal contraction. Fasting gallbladder volume (26.21 +/- 1.81 ml vs 15.21 +/- 1.63 ml, p < 0.001), and residual volume after maximal contraction (14.2 +/- 1.69 ml vs. 5.86 +/- 0.98 ml, p < 0.001) and at the end of 2 h (18.81 +/- 1.73 ml vs. 11.65 +/- 1.45 ml, p < 0.01) were significantly higher in the patient group, compared with controls. The maximum emptying was less (49.55 +/- 2.75% vs. 63.98 +/- 4.55%, p < 0.01) and the time taken for maximal contraction (59.25 +/- 3.8 min vs. 42.33 +/- 2.04 min, p < 0.001) was longer in the patient group than in the controls. Based on these observations, we conclude that patients with irritable bowel syndrome have significant abnormalities of gallbladder motor function.
Patients with functional disorders of the gastrointestinal tract often respond poorly to standard therapeutic regimes. Therefore, "alternative" forms of treatment (e.g. homocopathy, acupuncture, phytotherapy, diet modifications, psychotherapy, hypnosis) often come into play. Critical assessment of these forms of therapy is difficult: placebo response is high in functional disorders of the gastrointestinal tract and usually no placebo-controlled studies are available to prove the efficacy of these forms of therapy. Up to now no data was able to prove the efficacy of homoeopathy and phytotherapy, and the efficacy of acupuncture has to be questioned. In contrast to this, hyponosis, psychotherapy and some forms of diet modification seem to be useful at least in some patients with functional disorders of the gastrointestinal tract.
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Desipramine, the monoamine reuptake inhibitor, acts predominantly on noradrenergic neurones, and via alpha-2 receptors brings about the release of growth hormone in normal healthy subjects. Thirteen patients with a diagnosis of irritable bowel syndrome, 10 normal controls and eight patients with peptic ulcer disease were each given a challenge test of desipramine 1 mg/kg body weight. Growth hormone release over a 3 h period was monitored. A blunted response was defined as a failure of growth hormone levels to rise at least 5 mU/l above baseline. Of the 13 patients with irritable bowel syndrome 11 showed such a blunting. The results suggest abnormal central alpha-2 receptor functioning in irritable bowel syndrome.
OBJECTIVE: Although there is a paucity of data, environmental factors such as smoking, alcohol, and non-steroidal anti-inflammatory drugs (NSAIDs) are believed to be important in the pathogenesis of functional dyspepsia. We aimed to evaluate, in outpatients presenting for endoscopy, the role of environmental factors in functional dyspepsia. METHODS: A consecutive sample of 73 patients with functional dyspepsia completed a validated questionnaire prior to endoscopy. The comparison group consisted of outpatients attending for endoscopy who did not have functional dyspepsia (n = 658). Logistic regression analysis was used to estimate the association between functional dyspepsia and potential risk factors adjusting for age, gender, socioeconomic status, general health, and irritable bowel syndrome. RESULTS: Smoking, alcohol, aspirin, non-aspirin NSAIDs, and acetaminophen were not associated with functional dyspepsia. Patients were significantly less likely to have functional dyspepsia if they were current or past smokers, and there was a trend for patients to be less likely to have functional dyspepsia if they took NSAIDs regularly. When patients with functional dyspepsia were classified into symptom subgroups, the environmental factors were not found to be associated with ulcer-like dyspepsia (vs. nonspecific dyspepsia or organic disease). CONCLUSIONS: Smoking, alcohol, and NSAIDs are not associated with an increased risk of functional dyspepsia in outpatients presenting for endoscopy.