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Careful understanding of the multiple factors which play a role in constipation precedes successful treatment. A method is described which employs elimination of factors interfering with normal bowel function. Refraining of spontaneous defecation is described.
Experimental anatomical data in primates and transcranial stimulation of the motor cortex in humans indicate that this region projects to pelvic floor musculature. We investigated this problem in intact, anesthetized cats with intracortical microstimulation (ICMS). Further, we explored the characteristics of projection to pelvic floor muscles from the lateral vestibular nucleus of the brainstem. ICMS reliably produced responses from both recorded muscles, levator ani (LA) and external ani sphincter (EAS). Responses could be obtained both from ipsi and contralateral sides, being shorter for the contralateral ones. In contrast, vestibular stimulation activates only the EAS. It is proposed that these high level inputs to pelvic floor musculature are important for appropriate coordination of defecation and micturition.
BACKGROUND/AIMS: The aim of this study was to evaluate the subjective bowel function after low anterior resection and sigmoid colectomy and to clarify the clinicopathologic factors influencing postoperative bowel habits. METHODOLOGY: Eighty-six patients who underwent low anterior resection and sigmoid colectomy replied to the questionnaire which consisted of 8 categories of bowel symptoms. The patients were divided into 2 groups: good bowel function showing less than half of symptoms (< 4) and poor bowel function showing more than half of symptoms (> or = 4). RESULTS: After low anterior resection, patients were often complicated with incomplete evacuation (75%), bowel movement at night (60%), defecation more than twice a day (46%), and soiling (27%). The mean number of defecation/day and frequency of patients with night stools was significantly higher after low anterior resection than sigmoid colectomy (2.81 vs. 2.18, P < 0.05; and 60% vs. 29%, P < 0.05). Poor bowel function after low anterior resection was frequent in patients with high ligation of the inferior mesenteric artery (82%, P < 0.05), injury to the pelvic autonomic nerve (82%, P < 0.05), and blood transfusion; while poor bowel function after sigmoid colectomy was frequent in patients with resected colon measuring 25 cm or more (81%, P < 0.05). CONCLUSIONS: These results indicate that poor bowel function after low anterior resection is associated with high ligation of the inferior mesenteric artery and injury to the pelvic autonomic nerve; while poor bowel function after sigmoid colectomy correlates with length of the resected colon. Less aggressive surgery is needed to preserve good bowel function.
UNLABELLED: Interactions between visceral, intestinal stimulation and autonomic cardiovascular function have received increasing attention over the last years. The aim of the study was to investigate the effect of long-term continuous rectal distention on rectal tone and cardiovascular function at the threshold for first sensation of distention and moderate urge to defecate compared to a resting period without distention. Continuous isobaric rectal distention was performed in 13 healthy volunteers with a ten minute pressure tracking procedure at each subject's predetermined individual threshold for either moderate urge or first sensation, separated by a ten minute resting period. Rectal volume, heart rate, systolic and diastolic blood pressure were determined continuously. RESULTS: Rectal tone decreased significantly over time at the threshold for moderate urge and first sensation. Cardiovascular measures remained stable over the distention procedures, except for a significant increase in systolic blood pressure at the threshold for moderate urge. DISCUSSION: The previously reported rectal accommodation response to rectal distention was confirmed. The increase in systolic blood pressure is most likely mediated through sympathetic efferent pathways.
The aim of this study was to investigate the relationship between the type of formula consumed and the stool characteristics and gastrointestinal symptoms of preterm infants prospectively. Seventy-five preterm infants weighing < 2000 g in our neonatal intensive care unit (NICU) were investigated. Four groups of 15 each were fed one of four commercial formula preparations (Prematil, Neonatal, Humana-0 and S-26) and the fifth group was breast-fed in a prospective, randomized, double-blind study. The stool characteristics and gastrointestinal problems were recorded daily from the first day till the time they were discharged by the nurses of NICU. No significant differences of daily weight gain was observed between the groups. No significant difference was observed in daily frequency of stool, distention, vomiting and gas passage between the groups during the enteral + parenteral and full-enteral nutrition periods. The infants fed by Prematil during the enteral + parenteral nutrition period had a higher percentage of hard stool occurrence than infants receiving Humana-0 and breast milk. In the full-enteral nutrition period, infants receiving Prematil had a higher percentage of hard stool occurrence than all the other groups, whereas breast-fed infants had a lower percentage of hard stool than all the other groups. While the group fed with Humana-0 had a higher percentage of green stool occurrence in the enteral + parenteral nutrition period, no significant difference was observed in the full-enteral nutrition period. In the enteral + parenteral nutrition period no additional therapy affected stool characteristics or the gastrointestinal system except in the case of the infant receiving phototherapy for whom the daily number of detections was significantly high. In this study, it was shown that the color and consistency of stool in preterm infant differs according to the preterm infant formulas, but no differences were observed in the frequency of defecation or in gastrointestinal system problems. When the infant formulas were compared with breast milk, it was shown that they cause a higher percentage of hard stool occurrence. An increased number of formula feedings are necessary to obtain a similar daily weight gain, but the color and the frequency of the stool and the gastrointestinal system problems were similar for breast-fed and formula-fed infants.
AIM: To examine the acute actions of the CB1 cannabinoid receptor antagonist SR141716A [N-piperidino-5-(4-chlorophenyl)- 1-(2,4-dichlorophenyl)-4-methylpyrazole-3-carboxamide] on typical behavioral pattern of psychoactive cannabinoids in rats. METHODS: At different time after injection the tail-flick response latency, the rectal temperature, the locomotor activity, and the immobility on a ring as well as the numbers of rears, self-grooming episodes (lasting 5 s), and fecal pellets were measured. RESULTS: Acute administration of SR141716A (3 mg/kg i.p.) induced a significant increase in horizontal locomotor activity assayed by an activity meter, in stereotypic activity (such as rearing and self-grooming) and in defecation, and a decrease in nociceptive threshold recorded as tail-flick latency. This dose had no effect on ring immobility and did not change the body temperature. CONCLUSION: These results demonstrate that this cannabinoid antagonist itself was inducing behavior opposite to that of CB1 receptor agonists.
INTRODUCTION: The stay in hospital after colonic resection is usually 7-12 days, with a complication rate of 20%. A multi-modal rehabilitation regimen, comprising epidural analgesia, early mobilisation, and oral nutrition, reduced the hospital stay to 2-3 days after colonic resection. METHODS: One hundred patients underwent elective colonic resection with a planned postoperative stay of two days in hospital and a regimen with epidural analgesia, oral nutrition, and mobilisation. Anaesthesia, the surgical technique, and nursing care programme were standardised. Postoperative follow-up visits were arranged for day 8 and day 30. RESULTS: The median age was 73 years. Forty patients were at high risk, ASA III-IV. Gastrointestinal function (defecation) occurred within 48 hours, except for five patients, and the median hospital stay was two days. The readmission rate was 18% with no acute, potentially lethal conditions. The total hospital stay was three days. None of the patients had cardiopulmonary complications, except for one patient, who died from cardiac failure 36 hours after surgery. Three patients had anastomotic dehiscence, two of whom were treated conservatively. CONCLUSION: The usual postoperative ileus, "medical complications", and hospital stay were reduced in high-risk patients undergoing colonic resection with a multi-modal rehabilitation programme. These results call for further comparative studies with conventional care programmes and laparoscopic colonic resection.
The paper gives colonic X-ray findings in 39 patients with rectal prolapse. Of them, 20 and 19 patients were found to have internal and external rectal prolapse, respectively. Studies were conducted by the modified irrigoscopy developed by the State Coloproctology Research Center, Ministry of Health of the Russian Federation, to explore the anatomic and functional status of the rectum and the fundus of the pelvis in patients with impaired defecation. The X-ray sign of circular invagination that had been detected by the authors allowed them to make the diagnosis of internal rectal prolapse with the greatest assurance. The modified irrigoscopy in combination with oral enterography for external rectal prolapse could show associated changes, including enterocele and sigmocele.
Abdominal pain/discomfort, bloating, need to rush to the toilet, straining, feeling of incomplete bowel emptying and alternating periods of diarrhea and constipation is the clinical definition of the irritable bowel syndrome. The internationally used syndrome definition is based on expert opinions and answers to patient questionnaires. When symptoms are registered prospectively, abdominal pain starts or worsens after meals and is not relieved by defecation. As in the general population patients with the syndrome define diarrhea as loose stools and constipation as hard stools regardless of stool frequencies. Variation in defecatory symptoms and discrepancies between these symptoms and stool consistency are the hallmarks of the syndrome, and the degree of variation per fortnight is relatively stable in the individual patient. Fermentation of carbohydrates by colonic bacteria, increased sensitivity to bowel distention by gas, gas-producing food, increased secretion of cholecystokinin after fatty meals and/or increased sympathetic nerve tone at stress can give rise to symptoms. Symptoms can start after a single period of bacterial gastroenteritis. Although patients seeking medical care for the syndrome are more often anxious, the syndrome itself is not psychosomatic. Symptoms are possibly mediated through partial degranulation of mast cells in bowel mucosa, but this does not make it an allergic disease. If bowel dysmotility can be measured, early stage or a mild case of intestinal pseudoobstruction should be considered. Hyperreactivity in the enteric nervous system and/or in the brain is the likely main cause of the symptoms. More widespread activity in the brain after exposure to stimuli originating from bowel nerves or less inhibition of this stimulation in the brain are possible mechanisms.
In 32 male dogs colopexy, vasopexy, cystopexy and castration was performed for the treatment of perineal hernia. Recurrence rate in this study is 22%, what is comparable to other studies using different methods. The degree of severity and the number of complications is lower with this technique than with others. Enlargement of the prostate was evident in 59% and bladder retroflexion in 22% of the dogs. A celiotomy allows to recognize, assess, reduce and fix displaced organs which is not possible by using other methods. The aim is to regain the tubular structure of the ampulla recti and to fix prostate and bladder cranioventrally to the pelvic entrance. The castration performed at the same time causes the prostate gland to atrophy within 2-3 weeks, what makes the pelvic entrance even wider and the dogs return to normal defecation.
Defecography of twenty-seven cases of anorectal disorders with an age range from 22 to 86 years, were evaluated from June 1989 to February 1999. There were 24 patients with constipation, 2 patients with incomplete defecation and mucous bloody stool in one case. The defecographic results were analyzed regarding the following 1) anorectal angle, defined both at rest and straining 2) abnormalities of the rectal configuration during straining, including rectocele, intussusception, infolding and ulceration. 3) pelvic floor descent. The results showed abnormal anorectal angle 5 cases, rectocele 15 cases, intussusception of the rectal wall 3 cases, infolding 11 cases, ulceration 7 cases and anal canal constriction 1 case. Consequently, the patients with anorectal disorders were found to have a variety of rectal abnormalities in which the defecography would be the imaging tool in demonstrating them.
OBJECTIVE: The aim of this study was to analyze the usefulness of biofeedback techniques based on manometrical procedures in the treatment of defecation disorders in patients with myelomeningocele. PATIENTS AND METHODS: We studied 24 patients with myelomeningocele, aged 13 days to 15 years, who were referred to our Instrumental Diagnosis Unit for evaluation of anorectal function, or constipation and/or fecal incontinence study. Biofeedback was given to 12 patients who fulfilled the following criteria: age more than 5 years, existence of anorectal sensitivity with a perceptual threshold of less than 60 ml of rectal expansion, ability to contract and relax the gluteus muscles and thus be able to exercise pressure on the anal margin, and collaboration on the part of child and the family. As a complement defecatory maneuvers were performed. RESULTS: Between 4 and 65 sessions took place (35.14 19.97) after which rectal perceptual volume decreased from 24.66 14.13 to 3.33 2.95 ml and pressure on the anal margin increased from 45.62 17.82 to 114.37 13.99 mmHg. These differences were statistically significant (p < 0.001). Clear clinical improvement was produced in 10 of 12 patients who achieved good fecal continence with spontaneous depositions. Partial improvement was produced in 2 patients. CONCLUSIONS: We consider that biofeedback based on manometrical procedures is more useful than other conservative therapies in the treatment of defecatory problems in patients with myelomeningocele. In most patients this technique produces clinical improvement with satisfactory continence and without the drawbacks of other procedures.
We have investigated the role played by the bulk and transit time of food in the bowel and the squatting position characteristically adopted by Africans and Asians for defecation in the causation of venous disorders. Refinement of carbohydrates leads to low residue diets and consequent prolonged transit time through the intestines. This, together with abandonment of squatting, as the use of water closets increased, has contributed to the increase in incidence of venous disorders among Westerners.
BACKGROUND: The aim of this study was to confirm some selection criteria for the transrectal repair of the anterior rectocele and to compare our surgical results with those reported in the literature. METHODS: From January 1992 to December 1999, 30 females (mean age 52.9 years, range 28-70 yrs) affected by anterior rectocele were prospectively evaluated with a standard questionnaire, clinical examination, proctosigmoidoscopy, colonic transit time, dynamic defecography, anal EMG, anal manometry. Then, they were submitted to transrectal repair of rectocele with anterior plication of the rectal muscular wall. Fourteen (46.6%) of them were also submitted to perineal levatorplasty. Patients were followed postoperatively (mean 25.7 months) with the same standard questionnaire, clinical examination, defecography, and manometry. Results were tested by Fisher's Exact text, Wilcoxon's test, and "t"-test. RESULTS: Rectal dyschezia, incomplete evacuation, digital help in defecating, mean stool frequency, and rectal bleeding significantly improved. After 3 months, 30% of patients had no complaints, 40% had only 1-2 episodes/month complaints, 13.3% had evacuation only using laxatives, and 16.6% were unchanged. Defecography showed a significant reduction of the rectocele in 70% of patients after 3 months. Manometric parameters were not significantly modified. Four (28.6%) out of 14 patients submitted to perineal levatorplasty complained of dyspareunia. CONCLUSIONS: Our surgical results were comparable with those reported in the literature, with more than 80% of successful outcome. Preoperative clinical data and defecography were confirmed to be basic parameters in selecting patients for surgery. Colonic transit time, anal EMG, and anorectal manometry demonstrated to be useful to recognize conditions as slow colonic transit time, peripheral denervation, and reduced voluntary contraction that could lead to a less satisfactory outcome after surgery, and might benefit with a postoperative perineal rehabilitation by biofeedback and anal electrostimulations. The perineal levatorplasty is not suitable in young females, due to the risk of dyspareunia.
Anorectal continence depends on the rectum, the muscles of the pelvic floor, and the anorectal sphincters. The function of the rectum is to delay the passage of the intestinal contents by adapting itself to propulsive waves. A pressure gradient in an oral direction allows stool to be pushed back into the more proximal intestinal segments. The puborectalis muscle is the most important muscle of continence because of its sensitivity as well as its motor activity. In contains sensatory receptor organs which trigger off the rectal sphincter reflex mechanism and produce a feeling of fullness. From the motor point of view, its contraction which the assumption of the erect posture will cause the anorectal angle and with it the reflex and voluntary contractions of the puborectalis. The association of reflex and voluntary contractions depends on muscle fibres with different biochemical and histochemical properties. The internal anal sphincter is the most important factor in maintaining the anorectal barrier to pressure at rest. At the same time, relaxation of the internal sphincter will initiate defecation. The ambivalent properties of the internal sphincter can be explained by the different electrical, pharmacological and histological properties of this sphincter. Relaxation depends on an inhibition of electric activities initiated by stimulation of the tension receptors in the parapuborectal tissues and transmitted via the lowest rectal ganglion of the mesenteric plexus to the non-adrenergic inhibiting P-neurons of this sphincter.
Miction and defecation disturbances are very frequent in the general population and far more so among neurological patients. It is essential to know the physiopathology of these disorders in clinical practice. The neurological control of these functions is carried out by automatisms that are regulated in the nuclei of the brain stem through somatic and vegetative peripheral structures that act simultaneously. The cortical, hypothalamic and reticular levels play a part in the activation or inhibition of the pontine nuclei. Continence depends on the integrity of the anatomical structures and the sensory, pressure and mechanical systems that enable the automatisms to develop. Neurological examination must be combined with studies conducted by other specialists on patients in which no neurological illness is known, but who have this kind of dysfunction. Adding a neurophysiological examination allows us to complete the clinical study and to check objectively for the existence of external anal sphincter denervation or disorders involving the exteroceptive reflexes of the sacrum. The recent appearance of techniques for treating incontinence that make use of the repeated and continuous stimulation of the sacral roots has revolutionised the way these patients are treated and calls for greater involvement of neurologists in dealing with these problems.
The authors analyse the first 25 patients with spinal cord injuries treated by G. Brindley's technique based on section of the posterior sacral nerve roots to control detrusor hyperexcitability and electrostimulation of the anterior sacral nerve roots to ensure bladder emptying and to facilitate erection and defecation. The indications for this technique are essentially unstable bladders with incontinence and certain hypoactive bladders. The following results were obtained: Acquisition of continence in 90% of cases. Bladder capacity was always greatly increased. Almost complete bladder emptying in the majority of cases. Very marked reduction in urinary tract infection. Regularization of intestinal transit. The complications of this surgery were uncommon but serious: C.S.F. leaks, Postoperative denervations. Sepsis. Material or cable failure.
Experiments were conducted in rat strains selected for high (KHA) and low (KLA) levels of the elaboration of conditioned reflex of active avoidance in shuttle box. KHA rats, as compared with the KLA ones, showed considerably higher indices of learning the shuttle avoidance, a greater number of intersignal runs during learning, a higher level of motor activity under open field conditions and its more marked extinction. These data point at the role of both associative and non-associative processes in the formation of active avoidance reflex. During 5 days of reflex training the rats of both strains retained a high level of defecation until the end of the test that pointed at the emotional strain unceasing in spite of the automatization of the reflex.