Research posts and overseas visitors in British gastroenterology departments.
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Education, Medical, Graduate↗
Biomedical subjects
J J Misiewicz
Publications and source records attributed to J J Misiewicz.
Anorectal physiology validated: a repeatability study of the motor and sensory tests of anorectal function.
Sixteen subjects (mean (s.d.) age 50.7 (12.8) years, three men) were studied on two separate occasions by two experienced investigators in random order. A standard protocol of anatomical, manometric and electrophysiological assessments of anorectal motor and sensory function was followed. No significant differences were found between the results obtained by the two investigators in the measurements of perineal descent, anal canal length, and canal resting pressure and squeeze pressure, pudendal nerve terminal motor latency, single-fibre electromyography fibre density of the external anal sphincter, and thresholds of mucosal electrosensitivity. This study shows that the standard tests of anorectal sensorimotor function are repeatable by different investigators. In addition, it suggests that comparison of data obtained in different centres using these techniques is valid.
Adult↗
Effect of ileal infusion of glycochenodeoxycholic acid on segmental transit, motility, and flow in the human jejunum and ileum.
The hypothesis that the presence of glycochenodeoxycholic acid (GCDC) in the human Ileal bile acid concentrations showed a 54.0 (9.3)% absorption of glycochenodeoxycholic acid by the been tested in healthy volunteers. Mean transit times, flow rates and intraluminal pressures in a 40 cm jejunal segment proximal (n = 6) and a 40 cm ileal segment distal (n = 6) to a GCDC infusion port were measured. During GCDC infusion (60 mumol/min) jejunal and ileal transit were markedly (p less than 0.05) delayed (31.6 (7.7), mean (SEM) v 14.5 (3.8) min and 37.0 (5.7) v 21.0 (3.5) min, respectively), segment volumes increased (141.1 (30.2) v 59.2 (9.9) ml and 173.2 (26.3) v 83.9 (9.5) ml; p less than 0.05), while flow rates did not change significantly (4.6 (0.6) v 4.5 (0.6) ml/min and 4.8 (0.5) v 4.2 (0.3) ml/min, respectively). Ileal pressures (distal to the GCDC infusion port) decreased (p less than 0.05) promptly (1.0 (0.1) min) after the start of GCDC infusion. Inhibition of jejunal motility was more gradual and reached significance (p less than 0.05) only 30 min after beginning of the infusion. Ileal bile acid concentrations showed a 54.0 (9.3)% absorption of glycochenodeoxycholic acid by the 40 cm ileal segment. These observations suggest the existence of an intestinal control mechanism in healthy man, whereby presence of glycochenodeoxycholic acid in the ileum inhibits motility and delays transit in the jejunum and ileum.
Adult↗
Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome.
Intraluminal pressure activity has been recorded in the unprepared true sigmoid colon of seven normal controls (mean age 37 years, range 22-55, three men) and seven patients with irritable bowel syndrome (IBS) (45 years, 24-75, four men) for 30 minutes before and 100 minutes after a standard 1000 kcal meal. Results differ from previously published data by showing much higher indices of pressure activity with amplitudes up to 490 mmHg in IBS, and 450 mmHg in controls. Study segment activity index and mean pressure wave amplitudes were significantly (p less than 0.015 and p less than 0.01) higher in IBS than controls, but per cent duration of activity was similar for the whole period of study. During the basal period in controls mean amplitudes recorded from the proximal sigmoid (40 cm from anus) were significantly (p less than 0.01) higher than those in the descending colon (50 cm), distal sigmoid (30 cm) and rectum (15 cm). This study shows that the increased colonic activity in IBS is characterised by increased amplitude, but not duration of pressure waves. In the basal state there is a high pressure zone in the proximal sigmoid colon of controls. Pressures in the unprepared colon of controls and IBS were higher than those measured under other experimental conditions.
Adult↗
Fully automated computer analysis of intracolonic pressures.
A fully automated (PC compatible) software and hardware analysis system has been designed and developed to analyse colonic pressure records quickly and objectively. Eight hours of colonic pressure trace was analysed in 48 10 minute epochs manually and by computer for the variables of mean amplitude, % duration of activity, motility index, number of peaks and activity index. Agreement between methods was good for mean amplitude: (bias -0.5 mmHg; (36.8) (2 SD, limits of agreement); -5.8 to 4.8, 95% CI of bias; 0-289, average range of values by both methods), % duration of activity: (-0.9; (13.4); -2.9 to 0.9; 0-100), motility index: (-55; (2072); -356 to 245; 0-26,220), number of peaks: (-20; (91); -44 to 3.5; 1-211), and activity index bias -5.2 mmHg. min; (127.3); -23.7, to 13.2; 0-2159. The time taken for manual analysis was 889 minutes compared with 14 minutes for the automated system. Fully automated analysis of colonic pressure records is fast, objective, and shows good agreement with labour intensive manual analysis. Previously acquired data can be reanalysed using new definitions and criteria. Widespread use of the technique could introduce uniformity in colonic pressure record analysis. In addition this wave form analysis system can be adapted to record and analyse pressure data from other regions of the gastrointestinal tract.
Colon↗
Gastrointestinal carcinoid tumours in a district general hospital. Review of a three-year consecutive series.
A consecutive series of gastrointestinal carcinoid tumours presenting over a 3-year period at a district general hospital is reported. None were diagnosed at autopsy. Sites of origin from fore-, mid- and hind-gut were all represented. Sixty-three per cent of patients had tumour-related symptoms at presentation. Of these 90% had nodal metastases and 60% had liver metastases. Carcinoid syndrome developed in most patients with liver metastases. The presentation and management of carcinoid tumours is discussed.
Adolescent↗
Temperature gradient between the rectum and the anal canal: evidence against the role of temperature sensation as a sensory modality in the anal canal of normal subjects.
Temperature difference between the rectum and anal canal is a fundamental requirement for the hypothesis that temperature sensation is of physiological importance in discrimination of anorectal contents occurring during the 'sampling reflex'. The temperature gradient between the rectum and the anal canal was measured in 47 normal subjects (mean age 51.6 years +/- 16.8 s.d., 24 men). The maximum mean difference in temperature between the rectum and the anal canal was 0.13 degrees C (0.06-0.19, 95 per cent confidence intervals) and occurred 4 cm from the anal verge. This difference is too small to be detected by the anal canal mucosa. Under normal physiological circumstances the conscious appreciation of temperature of faeces passing from the rectum to the anal canal is impossible during the anorectal sampling reflex.
Adult↗
Effect of dilatation of peptic esophageal strictures on gastroesophageal reflux, dysphagia, and stricture diameter.
In 10 patients with peptic esophageal stricture the effect of esophageal dilatation on intraesophageal pH, stricture diameter, and dysphagia has been studied. Percentage of time during which intraesophageal pH was less than 4 and the number of reflux episodes per hour did not change significantly. Stricture diameter increased slightly, but consistently, from 7.0 +/- 0.5 mm to 9.1 +/- 0.5 mm (P less than 0.01) four days after dilatation, but was not significantly different from predilatation values after 12 weeks. Improvement in symptoms of dysphagia was striking (P less than 0.01) four days and six weeks after dilatation, but worsened again at 12 weeks (P = NS). It is unlikely that esophageal dilatation adversely affects the intraesophageal environment.
Adult↗
Effect of cholecystectomy on mouth-to-cecum transit of a liquid meal.
Mouth-to-cecum transit and serum bile acid profile after ingestion of a lactulose-labeled liquid meal (440 kcal) were measured in eight patients with gallstones and a radiologically functioning gallbladder before and three to five months after cholecystectomy and in 15 controls. In the patients mouth-to-cecum transit was longer after the operation, 87.5 +/- 18.5 (mean +/- SEM) min vs 57.5 +/- 9.7 min (P less than 0.05). Mouth-to-cecum transit times before and after the operation were not different from controls (58.0 +/- 6.7 min). Serum bile acid AUCs were similar (P = NS) in patients and controls, while total bile acid and cholylglycine fasting concentrations were higher after cholecystectomy (P less than 0.05 and P less than 0.01 respectively). Cholecystectomy prolongs mouth-to-cecum transit of a liquid meal.
Adult↗
Dietary linoleic acid, gastric acid, and prostaglandin secretion.
Basal and pentagastrin-stimulated gastric acid secretion, fasting serum gastrin concentrations, and the gastric output of prostaglandin E and its major metabolite 13,14-dihydro 15-keto prostaglandin E2 were measured in 9 normal subjects before and after 14-20 days of dietary supplementation with linoleic acid. Mean maximal gastric acid output fell from 36.0 +/- 3.3 (SEM) to 30.1 +/- 2.9 mmol/h (p less than 0.05), although mean basal acid output was not significantly affected (8.3 +/- 2.1 and 7.2 +/- 1.7 mmol/h, respectively). Mean fasting serum gastrin concentrations increased from 19.2 +/- 3.1 to 30.9 +/- 3.8 ng/L (p less than 0.01) after linoleic acid, probably because of acid suppression. The mean output of prostaglandin E increased from 498 +/- 110 to 1254 +/- 465 ng/h (p less than 0.05); that of its metabolite increased from 165 +/- 18 to 1168 +/- 645 ng/h (p less than 0.01). These findings show that in normal subjects essential fatty acid weakly inhibits gastric acid secretion, but considerably increases gastric prostaglandin output.
Adult↗
Combined sensory and motor deficit in primary neuropathic faecal incontinence.
Eleven patients with idiopathic faecal incontinence (IFI) and nine normal controls were studied with techniques of mucosal electrosensitivity and rectal distention for the quantitative assessment of anal and rectal sensation and with manometric and electromyographic tests for the assessment of anorectal motor function. The tests of motor function showed pelvic floor motor neuropathy in the patients with IFI, compared with controls, anal canal resting and voluntary contraction pressures were significantly (p less than 0.05, p less than 0.002) lower, pudendal nerve terminal motor latency and external anal sphincter fibre density were significantly (p less than 0.05, p less than 0.05) raised. The results of mucosal electrosensitivity (MES) disclosed a sensory deficit in the anal canal in patients with IFI, compared with controls, MES threshold was significantly (p less than 0.002) higher. Sensory thresholds to rectal distension were similar in the two groups. This study shows that sensory deficit of the anal canal occurs in combination with the motor neuropathy of the anal canal musculature in primary neuropathic faecal incontinence.
Adult↗
Sigmoid motility in diverticular disease and the irritable bowel syndrome.
Intraluminal pressures were measured with four open ended, water perfused tubes in the fasting state and after a standard liquid meal (400 KCal, 375 ml, protein 15 g, carbohydrate 55 g, lipid 13.4 g) in six patients with sigmoid diverticular disease, 20 with the irritable bowel syndrome and in 13 controls. The pressure sensors were positioned in the true sigmoid colon at colonoscopy at 25, 35, 45, and 55 cm from the anus. Colonic pressures were significantly higher in diverticular disease than in controls before (p less than 0.02) and after the meal (p less than 0.002), some pressure amplitudes exceeding 300 cm H2O. Patients with the irritable bowel syndrome had lower (p less than 0.05) pressures than controls before the meal. Postprandial sigmoid pressures were within the mean +/- 2 SD of controls in 10, above in two and below in eight patients with the irritable bowel. Hypercontractility of the sigmoid colon in the irritable bowel syndrome was not confirmed under the conditions of this study. The association between sigmoid diverticulosis and high intraluminal pressures is confirmed.
Adult↗
Pelvic floor neuropathy: a comparative study of diabetes mellitus and idiopathic faecal incontinence.
Twenty one patients with diabetic peripheral neuropathy, 18 with idiopathic faecal incontinence and 11 normal controls were studied with techniques of mucosal electrosensitivity, rectal distension for the quantitative assessment of anorectal sensation, and manometric and electromyographic tests for the assessment of anorectal motor function. An asymptomatic sensorimotor deficit was found in the anal canal of patients with diabetic peripheral neuropathy. Mucosal electrosensitivity thresholds in the anal canal were significantly higher (p less than 0.01 v controls) and fibre density of the external anal sphincter significantly raised (p less than 0.0001 v controls). Anal manometry and pudendal nerve terminal motor latencies were similar to controls. In patients with idiopathic faecal incontinence the tests of sensory and motor function also showed a sensorimotor neuropathy; compared with controls, mucosal electrosensitivity thresholds were significantly higher (p less than 0.002), anal canal resting and maximum squeeze pressures were significantly lower (p less than 0.05 and p less than 0.002 respectively), and pudendal nerve terminal motor latencies and fibre density of the external anal sphincter were significantly raised (both p less than 0.05). Sensory thresholds to rectal distension were similar in all groups. Pelvic floor sensorimotor neuropathy in diabetic patients has several features in common with that of patients with idiopathic faecal incontinence but its functional significance remains uncertain.
Adult↗
Effect of jejunal infusion of bile acids on small bowel transit and fasting jejunal motility in man.
The effect of jejunal infusion of glycochenodeoxycholic acid and glycocholic acid on small bowel transit time, fasting jejunal motility and serum bile acid concentrations was investigated in groups of five to six healthy subjects. Glycochenodeoxycholic acid at a concentration of 15 mmol/l (total amount: 5 mmol) and glycocholic acid 15 mmol/l (total amount: 5 mmol), both with lecithin 2.5 mmol/l, delayed (p less than 0.02) small bowel transit when compared with a bile acid free infusion [158.3 (12.5) min v 111.7 (17.6) min and 103.3 (21.8) min v 70.0 (14.9) min], inhibited (p less than 0.01 and p less than 0.05 respectively) the percentage duration of pressure activity of phase 2 [13.1 (1.8)% v 28.1 (3.4)% and 29.2 (5.5)% v 34.9 (3.9)%], but did not change duration of migrating motor complex, or of its phases. Glycochenodeoxycholic acid 10 mmol/l (total amount: 3.3 mmol), either with or without lecithin, did not delay small bowel transit significantly [145.0 (13.2) min v 115.0 (19.5) and 90.0 (11.7) min v 84.0 (8.3)]. When bile acids were infused, serum bile acid curves were similar to those obtained after a liquid meal and the peak serum bile acid concentration occurred 33.7 (6.6) min before (p less than 0.001) completion of small bowel transit. These observations suggest a role for endogenous bile acids in the regulation of small gut motility.
Adult↗
Further characterisation of the 'ileal brake' reflex in man--effect of ileal infusion of partial digests of fat, protein, and starch on jejunal motility and release of neurotensin, enteroglucagon, and peptide YY.
Previous studies have shown that ileal infusion of partially digested triglyceride inhibits jejunal motility. The partial digest used in those studies contained a mixture of glycerol, free fatty acid, mono-, di-, and triglycerides. In Part I of the present study we have separately infused emulsions containing either glycerol 3.1 g (n = 6), oleic acid 9.6 g (n = 6), triolein 10 g (n = 12), or medium chain triglycerides 10 g (n = 6) into the ileum and have recorded the effect this has on jejunal motility. Five further subjects received infusions of partial hydrolysates of corn starch 10 g and lactalbumin 7 g. Marked inhibition of jejunal pressure wave activity was seen after all three lipid infusions, per cent activity falling from a control of 37.7 (7.7) to 6.2 (2.1) and 22.4 (8.2)% 30 min after completing the oleic acid and triolein infusions respectively, and from a control value of 39.5 (4.1) to 17.7 (4.7) after MCTs (all p less than 0.05). No significant fall occurred after infusion of glycerol, protein or carbohydrate. All three lipid infusions raised plasma concentrations of neurotensin, enteroglucagon and peptide YY equally effectively, although only the rise in peptide YY correlated significantly with the inhibition of jejunal pressure wave activity (r = 0.80, n = 6, p less than 0.05). In Part II of this study six subjects received a 3 ml/min jejunal infusion of an isotonic carbohydrate saline solution followed after three hours by a similar infusion of a partial digest of lipid. During each infusion flow and transit time was measured by marker and dye dilution. Jejunal infusion of the carbohydrate-saline solution was associated with low jejunal flow, 4.7 (1.0) ml/min and a mean transit time through the 50 cm study segment of 36.5 (7.1) min. By contrast jejunal infusion of partially digested triglyceride was associated with a markedly increased flow, 9.0 (1.2) ml/min, a fall in mean transit time to 20.3 (2.6) min and significant rises in pancreaticobiliary secretions. Jejunal triglyceride also increased the incidence of prolonged high amplitude jejunal pressure waves in four of six subjects. These studies suggest that there are important differences in the jejunal response to ileal versus jejunal lipid. While long and median chain free fatty acids infused into the ileum exert an inhibitory effect on jejunal motility, when infused directly into the jejunum partially digested triglyceride accelerates transit, increases jejunal flow and subtly alters the pattern of jejunal contractions.
Adult↗
Disposable pudendal nerve stimulator: evaluation of the standard instrument and new device.
A disposable version of the pudendal nerve stimulator using flexible printed circuit (FPC) technology has been developed and manufactured in our department. Evaluation of this instrument against the standard is reported.
Disposable Equipment↗
Alkaline intra-oesophageal pH and gastro-oesophageal reflux in patients with peptic oesophagitis.
Simultaneous 22-h measurements of intra-oesophageal and intragastric pH were made in 22 patients with symptoms of gastro-oesophageal reflux (7 with peptic oesophagitis, 8 with peptic oesophageal stricture, and 7 with peptic oesophagitis and previous partial gastrectomy) to determine whether alkaline intra-oesophageal pH is a consequence of alkaline gastro-oesophageal reflux. In the three groups of patients intra-oesophageal pH was greater than 7 for 16.9 +/- 4.8%, 27.5 +/- 7.6%, and 21.0 +/- 7.7%, respectively, of total recording time (p = NS). Intragastric pH greater than 7 was recorded only in the patients with partial gastrectomy (10.3 +/- 5.3% of recording time; p less than 0.01 in comparison with the other groups). Elevations of intra-oesophageal pH to greater than 7 never occurred during episodes of alkalinization of intragastric pH. These results suggest that refluxed fluids are unlikely to be the cause of alkaline intra-oesophageal pH in patients with peptic oesophagitis.
Adult↗