Prevalence and mechanism of bladder dysfunction in Guillain-Barré Syndrome.

PubMed

Sakakibara, Ryuji; Uchiyama, Tomoyuki; Kuwabara, Satoshi; Mori, Masahiro; Ito, Takashi; Yamamoto, Tatsuya; Awa, Yusuke; Yamaguchi, Chiharu; Yuki, Nobuhiro; Vernino, Steven; Kishi, Masahiko; Shirai, Kohji

2009-01-01

To examine the prevalence and mechanism of urinary dysfunction in GBS. Urinary symptoms were observed and neurological examinations made repeatedly during hospitalization of 65 consecutive patients with clinico-neurophysiologically definite GBS. The patients included 41 men, 24 women; mean age, 41 years old; mean Hughes motor grade, 3; AIDP, 28, AMAN, 37. Urodynamic studies consisted of uroflowmetry, measurement of post-micturition residuals, medium-fill water cystometry, and external anal sphincter electromyography. Urinary dysfunction was observed in 27.7% of GBS cases (urinary retention, 9.2%). Urinary dysfunction was related to the Hughes motor grade (P < 0.05), defecatory dysfunction (P < 0.05), age (P < 0.05), and negatively related to serum IgG class anti-ganglioside antibody GalNAc-GD1a (P < 0.05). Urinary dysfunction was more common in AIDP (39%) than in AMAN (19%). No association was found between antibody titer against neuronal nicotinic acetylcholine receptors and urinary dysfunction. Urodynamic studies in nine patients, mostly performed within 8 weeks after disease onset, revealed post-void residual in 3 (mean 195 ml), among those who were able to urinate; decreased bladder sensation in 1; detrusor overactivity in 8; low compliance in 1; underactive detrusor in 7 (both overactive and underactive detrusor in 5); and nonrelaxing sphincter in 2. In our series of GBS cases, 27.7% of the patients had urinary dysfunction, including urinary retention in 9.2%. Underactive detrusor, overactive detrusor, and to a lesser extent, hyperactive sphincter are the major urodynamic abnormalities. The underlying mechanisms of urinary dysfunction appear to involve both hypo- and hyperactive lumbosacral nerves. Neurourol. Urodynam. 28:432-437, 2009. (c) 2009 Wiley-Liss, Inc.

The impact of naloxegol on anal sphincter function - Using a human experimental model of opioid-induced bowel dysfunction.

PubMed

Grønlund, Debbie; Poulsen, Jakob L; Krogh, Klaus; Brock, Christina; Liao, Donghua; Gregersen, Hans; Drewes, Asbjørn M; Olesen, Anne E

2018-05-30

Opioid treatment interferes with anal sphincter function and its regulation during defecation. This may result in straining, incomplete evacuation, and contribute to opioid-induced bowel dysfunction (OIBD). Employing an experimental model of oxycodone-induced OIBD, we hypothesized that co-administration of the peripherally acting μ-opioid antagonist naloxegol would improve anal sphincter function in comparison to placebo. In a double-blind randomized crossover trial, 24 healthy males were assigned to a six-day treatment of oral oxycodone 15 mg twice daily in combination with either oral naloxegol 25 mg once daily or placebo. At baseline and at day 6, anal resting pressure and the recto-anal inhibitory reflex (RAIR) were evaluated using manometry and rectal balloon distension. Furthermore, the functional lumen imaging probe was used to measure distensibility of the anal canal. Gastrointestinal symptoms were assessed with the Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire and the Bristol Stool Form Scale. During oxycodone treatment, naloxegol improved RAIR-induced sphincter relaxation by 15% (-45.9 vs -38.8 mm Hg; P < 0.01). No differences in anal resting pressure and anal canal distensibility were found between treatments (all P > 0.5). Naloxegol improved PAC-SYM symptoms (mean score over days; 2.6 vs 4.5, P < 0.001) and improved stool consistency scores (mean score over days; 3.3 vs 2.9, P < 0.01). In this experimental model of OIBD, naloxegol improved the RAIR and reduced gastrointestinal symptoms. Hence, in contrast to conventional laxatives, naloxegol may regulate opioid-induced anal sphincter dysfunction and facilitate the defecation process. Copyright © 2018 Elsevier B.V. All rights reserved.

[The importance of x-ray cinematography of deglutition for indicating the need for myotomy of the pharyngoesophageal sphincter].

PubMed

Augustiny, N; Schmid, H; Brühlmann, W F

1987-05-01

Fourteen patients were examined one to four years after cricopharyngeal myotomy that had been carried out because of dysfunction of the pharyngo-esophageal sphincter. Twelve patients were examined radiologically. Eleven of the 14 patients were clinically improved or cured. In two patients who were not improved, the underlying condition was a polymyositis. The other patients suffered from an idiopathic dysfunction. Because of the small numbers involved, no detailed statistical analysis was carried out. Nevertheless, our results indicate that: Cricopharyngeus myotomy produces marked improvement or cure in patients with idiopathic dysfunction. Weak propulsive peristalsis of the pharyngeal constrictors is a prognostic factor indicating a poor clinical result of surgery. There is little chance of clinical improvement in patients with polymyositis.

Vagal sensory innervation of the gastric sling muscle and antral wall: implications for gastro-esophageal reflux disease?

PubMed

Powley, T L; Gilbert, J M; Baronowsky, E A; Billingsley, C N; Martin, F N; Phillips, R J

2012-10-01

The gastric sling muscle has not been investigated for possible sensory innervation, in spite of the key roles the structure plays in lower esophageal sphincter (LES) function and gastric physiology. Thus, the present experiment used tracing techniques to label vagal afferents and survey their projections in the lesser curvature. Sprague-Dawley rats received injections of dextran biotin into the nodose ganglia. Fourteen days postinjection, animals were euthanized and their stomachs were processed to visualize the vagal afferent innervation. In different cases, neurons, muscle cells, or interstitial cells of Cajal (ICC) were counterstained. The sling muscle is innervated throughout its length by vagal afferent intramuscular arrays (IMAs) associated with ICC. In addition, the distal antral attachment site of the sling muscle is innervated by a novel vagal afferent terminal specialization, an antral web ending. The muscle wall of the distal antrum is also innervated by conventional IMAs and intraganglionic laminar endings, the two types of mechanoreceptors found throughout stomach smooth muscle. The innervation of sling muscle by IMAs, putative stretch receptors, suggests that sling sensory feedback may generate vago-vagal or other reflexes with vagal afferent limbs. The restricted distribution of afferent web endings near the antral attachments of sling fibers suggests the possibility of specialized mechanoreceptor functions linking antral and pyloric activity to the operation of the LES. Dysfunctional sling afferents could generate LES motor disturbances, or normative compensatory sensory feedback from the muscle could compromise therapies targeting only effectors. © 2012 Blackwell Publishing Ltd.

Improvement of Anal Function by Adipose-Derived Stem Cell Sheets.

PubMed

Inoue, Yusuke; Fujita, Fumihiko; Yamaguchi, Izumi; Kinoe, Hiroko; Kawahara, Daisuke; Sakai, Yusuke; Kuroki, Tamotsu; Eguchi, Susumu

2018-01-01

One of the most troublesome complications of anal preserving surgery is anal sphincter dysfunction. The aim of this study was to evaluate functional recovery after implantation of adipose-derived stem cell (ADSC) sheets, novel biotechnology, for an anal sphincter resection animal model. Eighteen female Sprague-Dawley rats underwent removal of the nearest half of the internal and external anal sphincter muscle. Nine rats received transplantation with ADSC sheets to the resected area while the remaining rats received no transplantation. The rats were evaluated for the anal function by measuring their resting pressure before surgery and on postoperative days 1, 7, 14, 28, and 56. In addition, the rats were examined for the presence of smooth muscle and also to determine its origin. The improvement of the anal pressure was significantly greater in the ADSC sheet transplantation group compared with the control group. Histologically, at the vicinity of the remaining smooth muscle, reproduction of smooth muscle was detected. Using in fluorescence in situ hybridization, the cells were shown to be from the recipient. Regenerative therapy using ADSC sheet has the potential to recover anal sphincter dysfunction due to anorectal surgery. © 2017 S. Karger AG, Basel.

[Simultaneous double prosthesis implant more artificial urinary sphincter via transscrotal: surgical technique].

PubMed

Martínez-Salamanca, Juan Ignacio; Moncada, Ignacio; del Portillo, Luis; Sola, Ignacio; Martínez-Ballesteros, Claudio; Carballido, Joaquín

2011-04-01

Moderate-severe urinary incontinence and refractory-to-treatment erectile dysfunction after radical prostatectomy are two entities causing an important loss of quality of life to patients. The double implant of penile prosthesis and artificial urinary sphincter is a safe and effective option in these cases. This article describes preoperative considerations and the most important technical steps to do it satisfactorily.

Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument.

PubMed

Ihn, Myong Hoon; Kang, Sung-Bum; Kim, Duck-Woo; Oh, Heung-Kwon; Lee, Soo Young; Hong, Sa Min

2014-08-01

Until recently, no studies have prospectively evaluated bowel function after sphincter-preserving surgery for rectal cancer with the use of a validated bowel function scoring system. The aim of this study was to investigate possible risk factors for altered bowel function after sphincter-preserving surgery. This was a prospective study. The study was conducted between January 2006 and May 2012 at the authors' institution. Patients who underwent sphincter-preserving rectal cancer surgery were recruited. Bowel function was assessed 1 day before (baseline) and at 1 year after sphincter-preserving surgery or temporary ileostomy takedown with the use of the Memorial Sloan Kettering Cancer Center questionnaire. Multivariable analysis was performed to identify the factors associated with altered bowel function after surgery. Overall, 266 patients were eligible for the analysis. The tumor was located in the upper, middle, and lower rectum in 68 (25.5%), 113 (42.5%), and 85 (32.0%) patients. Intersphincteric resection and temporary ileostomy were performed in 18 (6.8%) and 129 (48.5%) patients. The mean Memorial Sloan Kettering Cancer Center score was 64.5 ± 7.6 at 1 year after sphincter-preserving surgery or temporary ileostomy takedown. The Memorial Sloan Kettering Cancer Center score decreased in 163/266 patients (61.3%) between baseline and 1 year after surgery. Tumor location (p = 0.01), operative method (p = 0.03), anastomotic type (p = 0.01), and temporary ileostomy (p = 0.01) were associated with altered bowel function after sphincter-preserving surgery in univariate analyses. In multivariable analysis, only tumor location was independently associated with impaired bowel function after sphincter-preserving rectal cancer surgery. This study was limited by its nonrandomized design and the lack of measurement before preoperative chemoradiotherapy. We suggest that preoperative counseling should be implemented to inform patients of the risk of bowel dysfunction, especially in patients with lower rectal cancer, although this study cannot exclude the effect of chemoradiotherapy owing to the limitation of study.

Lubiprostone Increases Small Intestinal Smooth Muscle Contractions Through a Prostaglandin E Receptor 1 (EP1)-mediated Pathway.

PubMed

Chan, Walter W; Mashimo, Hiroshi

2013-07-01

Lubiprostone, a chloride channel type 2 (ClC-2) activator, was thought to treat constipation by enhancing intestinal secretion. It has been associated with increased intestinal transit and delayed gastric emptying. Structurally similar to prostones with up to 54% prostaglandin E2 activity on prostaglandin E receptor 1 (EP1), lubiprostone may also exert EP1-mediated procontractile effect on intestinal smooth muscles. We investigated lubiprostone's effects on intestinal smooth muscle contractions and pyloric sphincter tone. Isolated murine small intestinal (longitudinal and circular) and pyloric tissues were mounted in organ baths with modified Krebs solution for isometric recording. Basal muscle tension and response to electrical field stimulation (EFS; 2 ms pulses/10 V/6 Hz/30 sec train) were measured with lubiprostone (10(-10)-10(-5) M) ± EP1 antagonist. Significance was established using Student t test and P < 0.05. Lubiprostone had no effect on the basal tension or EFS-induced contractions of longitudinal muscles. With circular muscles, lubiprostone caused a dose-dependent increase in EFS-induced contractions (2.11 ± 0.88 to 4.43 ± 1.38 N/g, P = 0.020) that was inhibited by pretreatment with EP1 antagonist (1.69 ± 0.70 vs. 4.43 ± 1.38 N/g, P = 0.030). Lubiprostone had no effect on circular muscle basal tension, but it induced a dose-dependent increase in pyloric basal tone (1.07 ± 0.01 to 1.97 ± 0.86 fold increase, P < 0.05) that was inhibited by EP1 antagonist. In mice, lubiprostone caused a dose-dependent and EP1-mediated increase in contractility of circular but not longitudinal small intestinal smooth muscles, and in basal tone of the pylorus. These findings suggest another mechanism for lubiprostone's observed clinical effects on gastrointestinal motility.

Vagal Sensory Innervation of the Gastric Sling Muscle and Antral Wall: Implications for GERD?

PubMed Central

Powley, Terry L.; Gilbert, Jared M.; Baronowsky, Elizabeth A.; Billingsley, Cherie N.; Martin, Felecia N.; Phillips, Robert J.

2012-01-01

Background The gastric sling muscle has not been investigated for possible sensory innervation, in spite of the key roles the structure plays in lower esophageal sphincter (LES) function and gastric physiology. Thus, the present experiment used tracing techniques to label vagal afferents and survey their projections in the lesser curvature. Methods Sprague Dawley rats received injections of dextran biotin into the nodose ganglia. Fourteen days post-injection, animals were euthanized and their stomachs were processed to visualize the vagal afferent innervation. In different cases, neurons, muscle cells, or interstitial cells of Cajal were counterstained. Key Results The sling muscle is innervated throughout its length by vagal afferent intramuscular arrays (IMAs) associated with interstitial cells of Cajal. In addition, the distal antral attachment site of the sling muscle is innervated by a novel vagal afferent terminal specialization, an antral web ending. The muscle wall of the distal antrum is also innervated by conventional IMAs and intraganglionic laminar endings (IGLEs), the two types of mechanoreceptors found throughout stomach smooth muscle. Conclusions & Inferences The innervation of sling muscle by IMAs, putative stretch receptors, suggests that sling sensory feedback may generate vago-vagal or other reflexes with vagal afferent limbs. The restricted distribution of afferent web endings near the antral attachments of sling fibers suggests the possibility of specialized mechanoreceptor functions linking antral and pyloric activity to the operation of the LES. Dysfunctional sling afferents could generate LES motor disturbances, or normative compensatory sensory feedback from the muscle could compromise therapies targeting only effectors. PMID:22925069

Novel Neurostimulation of Autonomic Pelvic Nerves Overcomes Bladder-Sphincter Dyssynergia

PubMed Central

Peh, Wendy Yen Xian; Mogan, Roshini; Thow, Xin Yuan; Chua, Soo Min; Rusly, Astrid; Thakor, Nitish V.; Yen, Shih-Cheng

2018-01-01

The disruption of coordination between smooth muscle contraction in the bladder and the relaxation of the external urethral sphincter (EUS) striated muscle is a common issue in dysfunctional bladders. It is a significant challenge to overcome for neuromodulation approaches to restore bladder control. Bladder-sphincter dyssynergia leads to undesirably high bladder pressures, and poor voiding outcomes, which can pose life-threatening secondary complications. Mixed pelvic nerves are potential peripheral targets for stimulation to treat dysfunctional bladders, but typical electrical stimulation of pelvic nerves activates both the parasympathetic efferent pathway to excite the bladder, as well as the sensory afferent pathway that causes unwanted sphincter contractions. Thus, a novel pelvic nerve stimulation paradigm is required. In anesthetized female rats, we combined a low frequency (10 Hz) stimulation to evoke bladder contraction, and a more proximal 20 kHz stimulation of the pelvic nerve to block afferent activation, in order to produce micturition with reduced bladder-sphincter dyssynergia. Increasing the phase width of low frequency stimulation from 150 to 300 μs alone was able to improve voiding outcome significantly. However, low frequency stimulation of pelvic nerves alone evoked short latency (19.9–20.5 ms) dyssynergic EUS responses, which were abolished with a non-reversible proximal central pelvic nerve cut. We demonstrated that a proximal 20 kHz stimulation of pelvic nerves generated brief onset effects at lower current amplitudes, and was able to either partially or fully block the short latency EUS responses depending on the ratio of the blocking to stimulation current. Our results indicate that ratios >10 increased the efficacy of blocking EUS contractions. Importantly, we also demonstrated for the first time that this combined low and high frequency stimulation approach produced graded control of the bladder, while reversibly blocking afferent signals that elicited dyssynergic EUS contractions, thus improving voiding by 40.5 ± 12.3%. Our findings support advancing pelvic nerves as a suitable neuromodulation target for treating bladder dysfunction, and demonstrate the feasibility of an alternative method to non-reversible nerve transection and sub-optimal intermittent stimulation methods to reduce dyssynergia. PMID:29618971

Pathophysiology of gastro-esophageal reflux disease: a role for mucosa integrity?

PubMed

Farré, R

2013-10-01

Gastro-esophageal reflux disease (GERD) is very prevalent and has a high burden on health security system costs. Nevertheless, pathophysiology is complex and not well-understood. Several mechanisms have been proposed: decreased salivation, impaired esophageal clearance, decreased lower esophageal sphincter pressure resting tone, presence of hiatal hernia, increased number of transient lower esophageal sphincter relaxations (TLESRs), increased acid, and pepsin secretion, pyloric incompetence provoking duodeno-gastro-esophageal reflux of bile acids and trypsin. Independent of the relevance of each mechanism, the ultimate phenomenon is that mucosal epithelium is exposed for a longer time to agents as acid and pepsin or is in contact to luminal agents not commonly present in gastric refluxate as trypsin or bile acids. This leads to a visible damage of the epithelium (erosive esophagitis -EE) or impairing mucosal integrity without any sign of macroscopic alteration as occurs in non-erosive reflux disease (NERD). Luminal factors are not the only responsible for such impairment; more recent data indicate that endogenous factors may also play a role. This review will update the most recent findings on the putative pathophysiological mechanisms and specially will focus on the role of esophageal mucosal integrity in GERD. Methodologies used for the evaluation of mucosal integrity, its relevance in EE and NERD, its involvement in symptoms perception and the effect of luminal and endogenous factors will be discussed. © 2013 John Wiley & Sons Ltd.

Sphincter of Oddi Dysfunction

MedlinePlus

... causes episodes of severe abdominal pain. Doctor-Patient Communication Doctors often consider SOD in patients who experience ... with a long-term digestive disorder. Doctor–Patient Communication How to Help Your Doctor Help You How ...

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions.

PubMed

Murad-Regadas, Sthela Maria; Regadas, Francisco Sergio P; Rodrigues, Lusmar Veras; Furtado, Débora Couto; Gondim, Ana Cecília; Dealcanfreitas, Iris Daiana

2011-01-01

The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy. To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome. Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (≤50y x >50y) and stratified by mode of delivery and parity: group I (≤50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166). Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries. Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

Lower urinary tract dysfunction in critical illness polyneuropathy.

PubMed

Reitz, André

2013-01-01

Critical illness polyneuropathy is a frequent complication of critical illness in intensive care units. Reports on autonomic systems like lower urinary tract and bowel functions in patients with CIP are not available in medical literature. This study performed during primary rehabilitation of patients with critical illness polyneuropathy explores if sensory and motor pathways controlling the lower urinary tract function are affected from the disease. Neurourological examinations, urodynamics, electromyography and lower urinary tract imaging were performed in 28 patients with critical illness polyneuropathy. Sacral sensation was impaired in 1 patient (4%). Sacral reflexes were absent in 8 patients (30%). Anal sphincter resting tone was reduced in 3 (12%), anal sphincter voluntary contraction was absent or reduced in 8 patients (30%). Urodynamic findings were detrusor overactivity and detrusor overactivity incontinence in 9 (37.5%), incomplete voiding in 8 (30%), abnormal sphincter activity in 4 (16%), abnormal bladder sensation in 4 (16%) and detrusor acontractility in 2 patients (8.3%). Morphological abnormalities of the lower urinary tract had 10 patients (41.6%). Sensory and motor pathways controlling the lower urinary tract might be affected from CIP. During urodynamics dysfunctions of the storage as well as the voiding phase were found. Morphological lower urinary tract abnormalities were common.

Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation.

PubMed

Gourcerol, G; Tissier, F; Melchior, C; Touchais, J Y; Huet, E; Prevost, G; Leroi, A M; Ducrotte, P

2015-02-01

Pyloric pressure and compliance have never been investigated in health nor gastroparesis. We hypothesised that pyloric pressure and/or compliance may be altered in gastroparesis. Fasting pyloric pressure and compliance were investigated in 21 healthy volunteers (HV), 27 gastroparetic patients (GP) and 5 patients who had undergone oesophagectomy without pyloroplasty as positive controls. Under videofluoroscopic control, pyloric compliance and pressure were measured by the EndoFLIP technique. Gastric emptying half time (T1/2 ) using (13) C-octanoic acid breath test, as well as symptoms and quality of life (GIQLI score) were also monitored. Mean fasting pyloric compliance was measured at 25.2 ± 2.4 mm²/mmHg in HV, and was lower both in GP (16.9 ± 2.1 mm²/mmHg; P < 0.05) and patients with oesophagectomy (10.9 ± 2.9 mm²/mmHg; P < 0.05). By contrast, fasting pyloric pressure was not different among groups. Fasting pyloric compliance and pressure correlated with T1/2 in GP (R = -0.43; P = 0.04). Fasting pyloric compliance, but not pressure, correlated with symptoms and GIQLI score. Pyloric dilation in 10 GP with low fasting pyloric compliance (<10 mm²/mmHg) increased compliance from 7.4 ± 0.4 to 20.1 ± 4.9 mm²/mmHg (P < 0.01) and improved the GIQLI score from 72.5 ± 5.5 to 89.3 ± 6.1 (P = 0.04). This prospective study assessed pyloric compliance for the first time, and showed that fasting pyloric compliance is decreased in gastroparetic patients and is associated with T1/2 , symptoms and quality of life. This suggests that pyloric compliance may be a new relevant metric in gastroparetic patients, and may be useful to target patients for pyloric dilation or botulinum toxin injection. © 2014 John Wiley & Sons Ltd.

Hydrogen sulfide synthesis enzymes reduced in lower esophageal sphincter of patients with achalasia.

PubMed

Zhang, L; Zhao, W; Zheng, Z; Wang, T; Zhao, C; Zhou, G; Jin, H; Wang, B

2016-10-01

The etiology of achalasia remains largely unknown. Considerable evidence reveals that the lower esophageal sphincter dysfunction is due to the lack of inhibitory neurotransmitter, secondary to esophageal neuronal inflammation or loss. Recent studies suggest hydrogen sulfide may act as an inhibitory transmitter in gastrointestinal tract, but study about hydrogen sulfide in human esophagus still lack. The aim of the study was to investigate if hydrogen sulfide synthesis enzymes could be detected in human esophagus and if the synthesis of the endogenous hydrogen sulfide could be affected in achalasia patients. Tissue samples in cardia, lower esophageal sphincter, 2 cm and 4 cm above lower esophageal sphincter were obtained from achalasia patients undergoing peroral endoscopic myotomy. Control tissues in lower esophageal sphincter were obtained from esophageal carcinoma patients. Expression of cystathionine-β-synthase and cystathionine-γ-lyase in lower esophageal sphincter of achalasia patients and control were detected by immunohistochemical staining. In addition, expression of cystathionine-β-synthase and cystathionine-γ-lyase were compared among different parts of esophagus in achalasia patients. Compared with control, the expression of cystathionine-β-synthase and cystathionine-γ-lyase in lower esophageal sphincter of achalasia patients was significantly reduced (χ 2 = 11.429, P = 0.010). The expression of cystathionine-β-synthase and cystathionine-γ-lyase were lower in lower esophageal sphincter than that in 2 cm and 4 cm above lower esophageal sphincter, respectively (all P < 0.05). In conclusion, the expression of hydrogen sulfide synthesis enzymes, cystathionine-β-synthase and cystathionine-γ-lyase, can be detected in human esophagus and is reduced in patients with achalasia, which implicates the involvement of the two hydrogen sulfide synthesis enzymes in the pathophysiology of achalasia. © 2015 International Society for Diseases of the Esophagus.

The first teleautomatic low-voltage prosthesis with multiple therapeutic applications: a new version of the German artificial sphincter system.

PubMed

Ruthmann, Olaf; Richter, Sabine; Seifert, Gabriel; Karcz, Wojciech; Goldschmidboing, Frank; Lemke, Thomas; Biancuzzi, Gionvanni; Woias, Peter; Schmidt, Thomas; Schwarzbqch, Stefan; Vodermayer, Bernahard; Hopt, Ulrich; Schrag, Hans-Jurgen

2010-08-01

To date, there are no artificial sphincter prostheses for urinary or fecal incontinence that may be implemented elsewhere instead, for example, in the upper gastrointestinal tract. Conventional systems are conceptually similar but are constructed specifically for distinct applications and are manual in operation. The German Artificial Sphincter System (GASS) II is the evolution of a highly integrative, modular, telemetric sphincter prosthesis with more than one application. Redesigning and integrating multilayer actuators into the pump allows us to reduce the input voltage to -10 to +20 V (V(PP) = 30 V). This provides for a flow rate of 2.23 mL/min and a counterpressure stability of 260 mbar. Furthermore, multiple applications have become feasible due to our standardized connection system, therapy-specific compression units, and application-specific software. These innovations allow us to integrate not only severe fecal and urinary incontinence, erectile dysfunction, and therapy-resistant reflux disease, but also morbid adiposity into the gamut of therapeutic GASS applications.

Pyloric duplications: review and case study.

PubMed

Cooper, S; Abrams, R S; Carbaugh, R A

1995-12-01

Gastric duplications are unusual congenital anomalies that often require surgical treatment. Pyloric duplications are particularly rare; few are reported in the English literature. This article reviews the literature on pyloric duplications and describes a pyloric duplication associated with hypertrophic pyloric stenosis in a 5-week-old child and a duplication that recurred 7 years later.

Anal endosonography and manometry: comparison in patients with defecation problems.

PubMed

Schäfer, R; Heyer, T; Gantke, B; Schäfer, A; Frieling, T; Häussinger, D; Enck, P

1997-03-01

Correlations between anal sphincter function as assessed by anorectal manometry and anal sphincter anatomy measured by endoluminal ultrasound have been reported in the literature both for patients and for healthy individuals but have not been confirmed by other authors. For a larger series of patients (152 consecutive patients, mean age 54.1 +/- 15.5 years; female:male ratio, 111:41) with anorectal dysfunctions such as incontinence (n = 92), constipation (n = 37), and other symptoms (n = 23), diagnostic work-up included conventional multilumen anorectal manometry to evaluate internal sphincter pressure at rest, maximum external sphincter squeeze pressure during contraction, and endoanal sonography to determine anal sphincter integrity and to measure dorsal, left lateral, and right lateral diameter of the internal anal sphincter (IAS) and external anal sphincter (EAS) muscles. Maximum squeeze pressure was significantly correlated to muscle thickness of the EAS (P = 0.001). No association was found between resting pressure and IAS diameter. Women had significantly lower resting and squeeze pressures than men (P = 0.008 and P = 0.003, respectively), but age-related changes of function were only found for resting pressure. Endosonographic values of IAS and EAS did not differ between genders but were significantly correlated with age (P = 0.008 and P = 0.02, respectively). Because all correlations were rather weak, they only can explain a small portion of data variance. Anal manometry and anal ultrasound, therefore, are of complementary value and are both indicated in adequate clinical problems.

Ultrasound follow-up of infantile hypertrophic pyloric stenosis (IHPS) during conservative therapy: ultrasound findings as criteria for diagnosis and cure.

PubMed

Miura, Sachiko; Haku, Eijitsu; Hirai, Toshiko; Marugami, Nagaaki; Itoh, Takahiro; Tanaka, Takehiro; Kichikawa, Kimihiko; Ohishi, Hajime

2008-06-01

During conservative therapy of infantile hypertrophic pyloric stenosis (IHPS) with atropine sulfate, there are many patients who do not achieve normal values of pyloric wall thickness and canal length even though they are clinically cured (vomiting has ceased); an objective criterion for cure has not yet been established. The aim of this study was to examine whether the appearance of pyloric wall stratification can be used as a criterion for cure. Twenty infants with IHPS who were treated conservatively were enrolled. Two of them ultimately required surgery. Ultrasound examinations were done serially and the pyloric wall thickness and canal length were measured. The echogenicity of the pyloric wall and the presence of wall stratification were noted. On admission, all infants satisfied the ultrasound criteria for IHPS and had a heterogeneous pyloric wall without stratification. With conservative therapy, symptoms disappeared, the pyloric wall thickness and the canal length gradually decreased, the echogenicity gradually became homogeneous and hypoechoic, and wall stratification appeared (in most cases before the pyloric wall thickness and the canal length had normalized). The absence of wall stratification suggests that cellular interstitial changes, such as edema or inflammation, are present in the pyloric wall in the acute stage. Pyloric wall stratification was absent during the acute stage, but it appeared after initiation of treatment but before the pyloric wall thickness and the canal length had normalized. The presence of pyloric wall stratification can be used as a criterion for cure; the absence of wall stratification can be added to ultrasound diagnostic criteria for IHPS.

Sphincter of Oddi Function and Risk Factors for Dysfunction

PubMed Central

Afghani, Elham; Lo, Simon K.; Covington, Paul S.; Cash, Brooks D.; Pandol, Stephen J.

2017-01-01

The sphincter of Oddi (SO) is a smooth muscle valve regulating the flow of biliary and pancreatic secretions into the duodenum, initially described in 1887 by the Italian anatomist, Ruggero Oddi. SO dysfunction (SOD) is a broad term referring to numerous biliary, pancreatic, and hepatic disorders resulting from spasms, strictures, and relaxation of this valve at inappropriate times. This review brings attention to various factors that may increase the risk of SOD, including but not limited to: cholecystectomy, opiates, and alcohol. Lack of proper recognition and treatment of SOD may be associated with clinical events, including pancreatitis and biliary symptoms with hepatic enzyme elevation. Pharmacologic and non-pharmacologic approaches are discussed to help recognize, prevent, and treat SOD. Future studies are needed to assess the treatment benefit of agents such as calcium-channel blockers, glyceryl trinitrate, or tricyclic antidepressants in patients with SOD. PMID:28194398

Sphincter of Oddi Function and Risk Factors for Dysfunction.

PubMed

Afghani, Elham; Lo, Simon K; Covington, Paul S; Cash, Brooks D; Pandol, Stephen J

2017-01-01

The sphincter of Oddi (SO) is a smooth muscle valve regulating the flow of biliary and pancreatic secretions into the duodenum, initially described in 1887 by the Italian anatomist, Ruggero Oddi. SO dysfunction (SOD) is a broad term referring to numerous biliary, pancreatic, and hepatic disorders resulting from spasms, strictures, and relaxation of this valve at inappropriate times. This review brings attention to various factors that may increase the risk of SOD, including but not limited to: cholecystectomy, opiates, and alcohol. Lack of proper recognition and treatment of SOD may be associated with clinical events, including pancreatitis and biliary symptoms with hepatic enzyme elevation. Pharmacologic and non-pharmacologic approaches are discussed to help recognize, prevent, and treat SOD. Future studies are needed to assess the treatment benefit of agents such as calcium-channel blockers, glyceryl trinitrate, or tricyclic antidepressants in patients with SOD.

Experience with the artificial urinary sphincter in children and young adults.

PubMed

Mitchell, M E; Rink, R C

1983-12-01

The artificial urinary sphincter (model AS 791-792), American Medical Systems, Minnetonka, Minn.) has been implanted in 41 patients (mean age 13.9 years) who were incontinent in spite of intensive efforts with other modes of management. Neurogenic bladder dysfunction is present in 34 patients. Seven patients have non-neuropathic dysfunction of the bladder neck and urethra (3 with exstrophy/epispadias, 3 incontinent after multiple bladder and urethral procedures, and 1 incontinent after a pelvic fracture). Twenty-two patients have had intestinocystoplasty performed and 11 patients had previous urinary diversion. Mean follow-up for a given device is 23 months (range 6 to 47 months). Of these patients, 80.5% are totally or acceptably dry. Five patients (12.2%) were rated as fair, and three were failures (7.3%). Complications have been significant in that reoperation has been necessary in 16 patients. Indications for patient selection is emphasized.

Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment

PubMed Central

Testoni, Pier Alberto

2014-01-01

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches. PMID:25493002

Mortal hyperkalemia disturbances in rats are NO-system related. The life saving effect of pentadecapeptide BPC 157.

PubMed

Barisic, Ivan; Balenovic, Diana; Klicek, Robert; Radic, Bozo; Nikitovic, Bojana; Drmic, Domagoj; Udovicic, Mario; Strinic, Dean; Bardak, Darija; Berkopic, Lidija; Djuzel, Viktor; Sever, Marko; Cvjetko, Ivan; Romic, Zeljko; Sindic, Aleksandra; Bencic, Martina Lovric; Seiwerth, Sven; Sikiric, Predrag

2013-02-10

We demonstrate the full counteracting ability of stable gastric pentadecapeptide BPC 157 against KCl-overdose (intraperitoneal (i), intragastric (ii), in vitro (iii)), NO-system related. (i) We demonstrated potential (/kg) of: BPC 157 (10ng, 10μg ip, complete counteraction), l-arginine (100mg ip, attenuation) vs. L-NAME (5mg ip, deadly aggravation), given alone and/or combined, before or after intraperitoneal KCl-solution application (9mEq/kg). Therapy was confronted with promptly unrelenting hyperkalemia (>12mmol/L), arrhythmias (and muscular weakness, hypertension, low pressure in lower esophageal and pyloric sphincter) with an ultimate and a regularly inevitable lethal outcome within 30min. Previously, we established BPC 157-NO-system interaction; now, a huge life-saving potential. Given 30min before KCl, all BPC 157 regimens regained sinus rhythm, had less prolongation of QRS, and had no asystolic pause. BPC 157 therapy, given 10min after KCl-application, starts the rescue within 5-10min, completely restoring normal sinus rhythm at 1h. Likewise, other hyperkalemia-disturbances (muscular weakness, hypertension, low sphincteric pressure) were also counteracted. Accordingly with NO-system relation, deadly aggravation by L-NAME: l-arginine brings the values to the control levels while BPC 157 always completely nullified lesions, markedly below those of controls. Combined with l-arginine, BPC 157 exhibited no additive effect. (ii) Intragastric KCl-solution application (27mEq/kg) - (hyperkalemia 7mmol/L): severe stomach mucosal lesions, sphincter failure and peaked T waves were fully counteracted by intragastric BPC 157 (10ng, 10μg) application, given 30min before or 10min after KCl. (iii). In HEK293 cells, hyperkalemic conditions (18.6mM potassium concentrations), BPC 157 directly affects potassium conductance, counteracting the effect on membrane potential and depolarizations caused by hyperkalemic conditions. Copyright © 2013 Elsevier B.V. All rights reserved.

Duodenocutaneous fistula in rats as a model for "wound healing-therapy" in ulcer healing: the effect of pentadecapeptide BPC 157, L-nitro-arginine methyl ester and L-arginine.

PubMed

Skorjanec, S; Kokot, A; Drmic, D; Radic, B; Sever, M; Klicek, R; Kolenc, D; Zenko, A; Lovric Bencic, M; Belosic Halle, Z; Situm, A; Zivanovic Posilovic, G; Masnec, S; Suran, J; Aralica, G; Seiwerth, S; Sikiric, P

2015-08-01

While very rarely reported, duodenocutanenous fistula research might alter the duodenal ulcer disease background and therapy. Our research focused on rat duodenocutaneous fistulas, therapy, stable gastric pentadecapeptide BPC 157, an anti-ulcer peptide that healed other fistulas, nitric oxide synthase-substrate L-arginine, and nitric oxide synthase-inhibitor L-nitro-arginine methyl ester (L-NAME). The hypothesis was, duodenal ulcer-healing, like the skin ulcer, using the successful BPC 157, with nitric oxide-system involvement, the "wound healing-therapy", to heal the duodenal ulcer, the fistula-model that recently highlighted gastric and skin ulcer healing. Pressure in the lower esophageal and pyloric sphincters was simultaneously assessed. Duodenocutaneous fistula-rats received BPC 157 (10 μg/kg or 10 ng/kg, intraperitoneally or perorally (in drinking water)), L-NAME (5 mg/kg intraperitoneally), L-arginine (100 mg/kg intraperitoneally) alone and/or together, throughout 21 days. Duodenocutaneous fistula-rats maintained persistent defects, continuous fistula leakage, sphincter failure, mortality rate at 40% until the 4(th) day, all fully counteracted in all BPC 157-rats. The BPC 157-rats experienced rapidly improved complete presentation (maximal volume instilled already at 7(th) day). L-NAME further aggravated the duodenocutaneous fistula-course (mortality at 70% until the 4(th) day); L-arginine was beneficial (no mortality; however, maximal volume instilled not before 21(st) day). L-NAME-worsening was counteracted to the control level with the L-arginine effect, and vice versa, while BPC 157 annulled the L-NAME effects (L-NAME + L-arginine; L-NAME + BPC 157; L-NAME + L-arginine + BPC 157 brought below the level of the control). It is likely that duodenocutaneous fistulas, duodenal/skin defect simultaneous healing, reinstated sphincter function, are a new nitric oxide-system related phenomenon. In conclusion, resolving the duodenocutanenous fistulashealing, nitric oxide-system involvement, should illustrate further wound healing therapy to heal duodenal ulcers.

[Regulation of pyloric rhythm by I(A) and I(h) in crayfish stomatogastric ganglion].

PubMed

Kuang, Guo-Hui; Liu, Yi-Hui; Ren, Wei

2012-06-25

The stomatogastric ganglion (STG) of shellfish includes 30 neurons and produces pyloric rhythms. It is the common model to study central pattern generator (CPG). Regulation of pyloric rhythms not only is related to the property of single neurons in STG but also depends on the connections and property of the whole neuronal network. It has been found that transient potassium current (I(A)) and hyperpolarization-activated cation current (I(h)) exist in certain types of neurons of STG. However, roles played by these two currents in maintaining and regulating the pyloric rhythms are unknown. In the present study, in vitro electrophysiological recordings were performed on crayfish STG to examine the role played by I(A) and I(h) in regulation of pyloric rhythm. 4AP (2 mmol/L), a specific inhibitor of I(A), caused a decrease in pyloric cycle (P < 0.01), an increase in PD (pyloric dilator) ratio, a decrease in PY (pyloric) ratio (P < 0.01) and delay of phases of LP and PY firing. ZD7288 (100 μmol/L), a specific inhibitor of I(h), caused a decrease in pyloric cycle (P < 0.01), an increase in PD ratio (P < 0.01), an increase in LP (lateral pyloric) ratio (P < 0.01), a decrease in PY ratio (P < 0.01) and delay of phases of LP and PY firing. These results indicate that I(A) and I(h) play important roles in regulating pyloric rhythms in crayfish STG.

A rhythmic modulatory gating system in the stomatogastric nervous system of Homarus gammarus. III. Rhythmic control of the pyloric CPG.

PubMed

Cardi, P; Nagy, F

1994-06-01

1. Two modulatory neurons, P and commissural pyloric (CP), known to be involved in the long-term maintenance of pyloric central pattern generator operation in the rock lobster Homarus gammarus, are members of the commissural pyloric oscillator (CPO), a higher-order oscillator influencing the pyloric network. 2. The CP neuron was endogenously oscillating in approximately 30% of the preparations in which its cell body was impaled. Rhythmic inhibitory feedback from the pyloric pacemaker anterior burster (AB) neuron stabilized the CP neuron's endogenous rhythm. 3. The organization of the CPO is described. Follower commissural neurons, the F cells, and the CP neuron receive a common excitatory postsynaptic potential from another commissural neuron, the large exciter (LE). When in oscillatory state, CP in turn excites the LE neuron. This positive feedback may maintain long episodes of CP oscillations. 4. The pyloric pacemaker neurons follow the CPO rhythm with variable coordination modes (i.e., 1:1, 1:2) and switch among these modes when their membrane potential is modified. The CPO inputs strongly constrain the pyloric period, which as a result may adopt only a few discrete values. This effect is based on mechanisms of entrainment between the CPO and the pyloric oscillator. 5. Pyloric constrictor neurons show differential sensitivity from the pyloric pacemaker neurons with respect to the CPO inputs. Consequently, their bursting period can be a shorter harmonic of the bursting period of the pyloric pacemakers neurons. 6. The CPO neurons seem to be the first example of modulatory gating neurons that also give timing cues to a rhythmic pattern generating network.

Prolonged-Release Oxycodone/Naloxone Improves Anal Sphincter Relaxation Compared to Oxycodone Plus Macrogol 3350.

PubMed

Poulsen, Jakob Lykke; Brock, Christina; Grønlund, Debbie; Liao, Donghua; Gregersen, Hans; Krogh, Klaus; Drewes, Asbjørn Mohr

2017-11-01

Opioid analgesics inhibit anal sphincter function and contribute to opioid-induced bowel dysfunction (OIBD). However, it is unknown whether the inhibition can be reduced by opioid antagonism with prolonged-release (PR) naloxone and how this compares to laxative treatment. To compare the effects of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350 on anal sphincter function and gastrointestinal symptoms. A randomized, double-blind, crossover trial was conducted in 20 healthy men. Participants were treated for 5 days with combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Resting anal pressure, anal canal distensibility, and relaxation of the internal sphincter to rectal distension were evaluated before treatment (baseline) and on day 5. The Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire, stool frequency, and stool consistency were assessed daily. Both PR oxycodone/naloxone and PR oxycodone plus macrogol treatment decreased sphincter relaxation compared to baseline (- 27.5%; P < 0.001 and - 14.7%; P = 0.01). However, sphincter relaxation was increased after PR naloxone/oxycodone treatment compared to macrogol (difference = + 17.6%; P < 0.001). Resting anal pressure and anal canal distensibility did not differ between treatments. PAC-SYM abdominal symptoms score was lower during PR naloxone compared to macrogol (0.2 vs. 3.2; P = 0.002). The number of bowel movements was lower during PR naloxone versus macrogol (4.2 vs. 5.4; P = 0.035). Relaxation of the internal anal sphincter was significantly better after PR oxycodone/naloxone treatment compared to PR oxycodone plus macrogol 3350. These findings highlight that OIBD may require specific therapy against the complex, pan-intestinal effects of opioids.

Management of cricopharyngeus muscle dysfunction.

PubMed

Kuhn, Maggie A; Belafsky, Peter C

2013-12-01

The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter (UES). In dysphagia, cricopharyngeus muscle dysfunction (CPD) refers to the muscle's failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD, and the resultant clinical manifestation is solid food or solid and liquid dysphagia. Several diagnostic tools are available for dysphagia clinicians to distinguish CPD from other causes of UES dysfunction. For CPD, accurate diagnosis is paramount for the recommendation of appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia. Copyright © 2013 Elsevier Inc. All rights reserved.

Modulation of network pacemaker neurons by oxygen at the anaerobic threshold.

PubMed

Hill, Andrew A V; Simmers, John; Meyrand, Pierre; Massabuau, Jean-Charles

2012-07-01

Previous in vitro and in vivo studies showed that the frequency of rhythmic pyloric network activity in the lobster is modulated directly by oxygen partial pressure (PO(2)). We have extended these results by (1) increasing the period of exposure to low PO(2) and by (2) testing the sensitivity of the pyloric network to changes in PO(2) that are within the narrow range normally experienced by the lobster (1 to 6 kPa). We found that the pyloric network rhythm was indeed altered by changes in PO(2) within the range typically observed in vivo. Furthermore, a previous study showed that the lateral pyloric constrictor motor neuron (LP) contributes to the O(2) sensitivity of the pyloric network. Here, we expanded on this idea by testing the hypothesis that pyloric pacemaker neurons also contribute to pyloric O(2) sensitivity. A 2-h exposure to 1 kPa PO(2), which was twice the period used previously, decreased the frequency of an isolated group of pacemaker neurons, suggesting that changes in the rhythmogenic properties of these cells contribute to pyloric O(2) sensitivity during long-term near-anaerobic (anaerobic threshold, 0.7-1.2 kPa) conditions.

Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Sphincterotomy for Suspected Sphincter of Oddi Dysfunction (SOD) Post Roux-En-Y Gastric Bypass.

PubMed

Lim, Chin Hong; Jahansouz, Cyrus; Freeman, Martin L; Leslie, Daniel B; Ikramuddin, Sayeed; Amateau, Stuart K

2017-10-01

Sphincter of Oddi dysfunction (SOD) is thought to be a cause of chronic abdominal pain post Roux-en-Y gastric bypass, and current practice of performing endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy is not supported by evidence. In addition to the complexity and risks of the procedure in patients with Roux-en-Y anatomy, the outcomes are uncertain and debatable. We performed a retrospective review and analysis of post-gastric bypass patients who had undergone ERCP with sphincterotomy to determine the effectiveness in patients with suspected SOD. Over a period of 5 years at the University of Minnesota, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had a previous Roux-en-Y gastric bypass and whom had a subsequent ERCP for suspected SOD. Patients were categorized by modified Milwaukee classification, and outcomes were evaluated by patients' self-reporting of symptoms at follow-up. We identified 50 patients who underwent laparoscopic-assisted gastrostomy for endoscopic retrograde cholangiopancreatography post Roux-en-Y gastric bypass over the study period. Within this group, 35 patients (70%) were suspected to have SOD. Nine patients (25.7%) were classified as type I, 19 patients (54.3%) type II, and seven patients (20%) type III. Thirty-four patients (97.1%) had biliary sphincterotomy, and 17 patients (48.6%) had both biliary and pancreatic sphincterotomy. Fourteen (40%) had repeated ERCP. At median follow-up of 11.5 months, type I SOD had two responders (25%), type II had nine responders (52.9%), and type III had one responder (14.3%). A subgroup analysis did not show significant differences in improvement of symptoms between patients whom had single versus repeated ERCP or biliary sphincterotomy alone versus both biliary and pancreatic sphincterotomy. Three patients (9%) had post-ERCP pancreatitis. SOD in patients post Roux-en-Y gastric bypass is complex due to multiple confounding factors. Rome III and Milwaukee classification systems assist us in the diagnosis and treatment of sphincter dysfunction until we have a better way to predict treatment response post sphincterotomy. Current treatment is based on the type of disorder and anatomy of biliary ducts. Types I and II sphincter dysfunction particularly associated with dilated biliary duct on imaging have the best response to endoscopic sphincterotomy and therefore should be considered taking into account the risks and benefit. Repeated sphincterotomy and concurrent pancreatic sphincterotomy is generally not useful.

Velopharyngeal Dysfunction Evaluation and Treatment.

PubMed

Meier, Jeremy D; Muntz, Harlan R

2016-11-01

Velopharyngeal dysfunction (VPD) can significantly impair a child's quality of life and may have lasting consequences if inadequately treated. This article reviews the work-up and management options for patients with VPD. An accurate perceptual speech analysis, nasometry, and nasal endoscopy are helpful to appropriately evaluate patients with VPD. Treatment options include nonsurgical management with speech therapy or a speech bulb and surgical approaches including double-opposing Z-plasty, sphincter pharyngoplasty, pharyngeal flap, or posterior wall augmentation. Copyright © 2016 Elsevier Inc. All rights reserved.

Botulinum toxin type A inhibits rat pyloric myoelectrical activity and substance P release in vivo.

PubMed

Hou, Yi-Ping; Zhang, Yong-Ping; Song, Yan-Feng; Zhu, Chun-Min; Wang, Yin-Chun; Xie, Gui-Lin

2007-02-01

The effect of botulinum toxin type A (BTX-A) on rat pyloric myoelectrical activity in vivo and the content and distribution of substance P (SP) in pylorus were investigated, respectively, with electromyography, radioimmunoassay, and immunohistochemistry. A pair of electrodes for recording pyloric myoelectrical activity and a guide cannula for drug injection were implanted into the pylorus. The changes of pyloric myoelectrical activity were recorded followed vehicle, 10, 20, and 40 U/kg body mass of BTX-A injection. Pyloric tissues were dissected for radioimmunoassay and immunohistochemistry after recording. The 3 dosages of BTX-A injections caused the reduction of slow wave of pyloric myoelectrical activity in amplitude but not in frequency and the diminishment of spike activity in amplitude and spike burst. The inhibitory effect of 20 U/kg BTX-A was significantly different from that of 10 U/kg (p<0.05), but not from the effect of 40 U/kg administration (p>0.05). After BTX-A intrasphincteric injection, SP content was reduced in the pylorus, and cell number of SP-immunoreactivity was decreased more in myenteric nerve plexus of circular muscle and in mucosa of pylori. In conclusion, BTX-A inhibits pyloric myoelectrical slow activity in amplitude and spike activity and weakens pyloric smooth muscle contractility depending on threshold of dose or concentration. BTX-A-induced inhibition of pyloric myoelectrical activity implies a mechanism of inhibiting SP release from the autonomic and enteric nervous terminals in the pylorus.

[A modern look at benign stenosing lesions. Etiology and pathogenesis of diagnostic capabilities. A systematic review].

PubMed

Pakhabova, E Iu; Belova, G V

2012-01-01

The problem of nonneoplastic stenosis of major duodenal papilla is on joint of gastroenterology and surgery and present a challenge for physicians. This article reviews what is known about the pathogenesis, epidemiology and diagnostics of papillostenosis and sphincter of Oddi dysfunction.

Penile agenesis and congenital hypertrophic pyloric stenosis: an association or a random coexistence?

PubMed

Yagmurlu, Aydin; Vargun, Rahsan; Gollu, Gulnur; Gokcora, I Haluk

2004-01-01

A neonate with penile agenesis and congenital hypertrophic pyloric stenosis is presented. The patterns of associated anomalies with penile agenesis, and those of congenital hypertrophic pyloric stenosis are discussed.

Cauda equina syndrome: evaluation of the clinical outcome.

PubMed

Tamburrelli, F C; Genitiempo, M; Bochicchio, M; Donisi, L; Ratto, C

2014-01-01

Cauda equina syndrome is a rare but highly impairing syndrome involving lower limbs as well as urinary, defecatory and sexual function. In the literature the most investigated sphincter dysfunction is the urinary. Bowel and sexual function are often overlooked since they become more relevant after the acute phase. Eight consecutive male patients affected by cauda equina syndrome with sphincter dysfunction due to herniated disc disease of lumbar spine were treated between 2007 and 2009. Five patients were followed-up for at least two years. Sexual function was evaluated by IIEF-5 questionnaire; bowel function was investigated by means of clinical and instrumental investigation and manometry. Although little clinical improved, patients still complained severe symptoms at first year follow-up while all but one improved significantly in the following year. At two years follow-up only the patient whose cauda equina syndrome was misdiagnosed and surgically treated late respect to the onset of the syndrome, complained a persistent severe sexual and bowel dysfunction. Our results show that a long-term follow-up is mandatory to evaluate the real outcome of surgical managed cauda equine syndrome because short-term evaluation could be misleading about the residual capacity of late neurologic improving. Despite the relatively low number of cases evaluated, our results confirm that early diagnosing and treating the syndrome are relevant for the final outcome.

Effect of Endoscopic Sphincterotomy for Suspected Sphincter of Oddi Dysfunction on Pain-Related Disability Following Cholecystectomy

PubMed Central

Cotton, Peter B.; Durkalski, Valerie; Romagnuolo, Joseph; Pauls, Qi; Fogel, Evan; Tarnasky, Paul; Aliperti, Giuseppe; Freeman, Martin; Kozarek, Richard; Jamidar, Priya; Wilcox, Mel; Serrano, Jose; Brawman-Mintzer, Olga; Elta, Grace; Mauldin, Patrick; Thornhill, Andre; Hawes, Robert; Wood-Williams, April; Orrell, Kyle; Drossman, Douglas; Robuck, Patricia

2015-01-01

IMPORTANCE Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy. OBJECTIVE To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predictive of pain relief. DESIGN, SETTING, AND PATIENTS Multicenter, sham-controlled, randomized trial involving 214 patients with pain after cholecystectomy without significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis randomly assigned (August 6, 2008-March 23, 2012) to undergo sphincterotomy or sham therapy at 7 referral medical centers. One-year follow-up was blinded. The final follow-up visit was March 21, 2013. INTERVENTIONS After ERCP, patients were randomized 2:1 to sphincterotomy (n = 141) or sham (n = 73) irrespective of manometry findings. Those randomized to sphincterotomy with elevated pancreatic sphincter pressures were randomized again (1:1) to biliary or to both biliary and pancreatic sphincterotomies. Seventy-two were entered into an observational study with conventional ERCP managemeny. MAIN OUTCOMES AND MEASURES Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention. RESULTS Twenty-seven patients (37%; 95%CI, 25.9%-48.1%) in the sham treatment group vs 32 (23%; 95%CI, 15.8%-29.6%) in the sphincterotomy group experienced successful treatment (adjusted risk difference, −15.6%; 95% CI, −28.0% to −3.3%; P = .01). Of the patients with pancreatic sphincter hypertension, 14 (30%; 95% CI, 16.7%-42.9%) who underwent dual sphincterotomy and 10 (20%; 95% CI, 8.7%-30.5%) who underwent biliary sphincterotomy alone experienced successful treatment. Thirty-seven treated patients (26%; 95% CI,19%-34%) and 25 patients (34%; 95% CI, 23%-45%) in the sham group underwent repeat ERCP interventions (P = .22). Manometry results were not associated with the outcome. No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 15 patients (11%) after primary sphincterotomies and in 11 patients (15%) in the sham group. Of the nonrandomized patients in the observational study group, 5 (24%; 95%CI, 6%-42%) who underwent biliary sphincterotomy, 12 (31%; 95%CI, 16%-45%) who underwent dual sphincterotomy, and 2 (17%; 95%CI, 0%-38%) who did not undergo sphincterotomy had successful treatment. CONCLUSIONS AND RELEVANCE In patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy vs sham did not reduce disability due to pain. These findings do not support ERCP and sphincterotomy for these patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: 00688662 PMID:24867013

Neurophysiology and new techniques to assess esophageal sensory function: an update.

PubMed

Brock, Christina; McCallum, Richard W; Gyawali, C Prakash; Farmer, Adam D; Frøkjaer, Jens Brøndum; McMahon, Barry P; Drewes, Asbjørn Mohr

2016-09-01

This review aims to discuss the neurophysiology of the esophagus and new methods to assess esophageal nociception. Pain and other symptoms can be caused by diseases in the mucosa or muscular or sphincter dysfunction, together with abnormal pain processing, either in the peripheral or central nervous systems. Therefore, we present new techniques in the assessment of esophageal function and the potential role of the mucosal barrier in the generation and propagation of pain. We discuss the assessment and role of esophageal sphincters in nociception, as well as imaging and electrophysiological techniques, with examples of their use in understanding the sensory system following noxious stimuli to the esophagus. Additionally, we discuss the mechanisms behind functional diseases of the esophagus. We conclude that the new methods have identified many of the mechanisms behind malfunction of the mucosa, disturbances of muscular and sphincter functions, and the central response to different stimuli. Taken together, this has increased our understanding of esophageal disorders and may lead to new treatment modalities. © 2016 New York Academy of Sciences.

Pyloric motor response to central and peripheral nitric oxide in the ferret.

PubMed

Lingenfelser, T; Blackshaw, L A; Sun, W M; Dent, J

1997-09-01

This study has investigated the relative importance of central nervous and peripheral nitroxidergic mechanisms in the control of pyloric motility. In 10 urethane-anaesthetized ferrets, drugs were administered directly to the CNS via a 0.5-mm-diameter cannula inserted into the 4th ventricle, approximately at the obex. Drugs were also given directly to the upper GI tract by close intra-arterial (i.a.) injection at the coeliac axis. Antropyloroduodenal pressures were recorded with a five-channel sleeve/sidehole micromanometric assembly (1.35 x 1.75 mm o.d.), which was introduced via the duodenum. Pyloric motility was stimulated throughout the main part of each study with a continuous i.v. infusion of CCK-8 (30 pmol min-1). This infusion produced an immediate and sustained increase in tonic and phasic pyloric activity, and sustained abolition of antral pressure waves. CCK-8 also induced a duodenal motor response, but this was short-lived (11.4 +/- 7.9 min). Coeliac axis injection of the NO donor S-nitroso-N-acetyl-penicillamine (SNAP) decreased phasic pyloric activity (from 330 +/- 35 to 148 +/- 21 mmHg min-1 after SNAP 5 micrograms, P < 0.01). By comparison central SNAP administration over the same dose range had no effect on CCK-stimulated pyloric motlity. Inhibition of endogenous NO synthase with L-Nitro Arginine Methyl Ester (L-NAME, 100 mg kg-1 close i.a.) caused a marked increase of phase pyloric motor activity from 349 +/- 59 to 1044 +/- 140 mmHg min-1 (P < 0.01). In addition, SNAP caused marked stimulation of pyloric tone from 2.6 +/- 0.5 to 13.1 +/- 2.8 mmHg (P < 0.01). Central nervous administration of L-NAME caused modest enhancement of phasic pyloric activity (248 +/- 31 to 283 +/- 32 mmHg min-1 P < 0.05) and pyloric tone (2.6 +/- 0.5 to 3.7 +/- 0.7 mmHg, P < 0.05). Our data indicate that motor activity of the ferret pylorus is potently modulated by NO released within the upper gut. Additionally, there is potential for modulation of pyloric motility by central nervous system production of NO.

Is anorectal endosonography valuable in dyschesia?

PubMed Central

Van Outryve, S M; Van Outryve, M J; De Winter, B Y; Pelckmans, P A

2002-01-01

Aims: Dyschesia can be provoked by inappropriate defecation movements. The aim of this prospective study was to demonstrate dysfunction of the anal sphincter and/or the musculus (m.) puborectalis in patients with dyschesia using anorectal endosonography. Methods: Twenty consecutive patients with a medical history of dyschesia and a control group of 20 healthy subjects underwent linear anorectal endosonography (Toshiba models IUV 5060 and PVL-625 RT). In both groups, the dimensions of the anal sphincter and the m. puborectalis were measured at rest, and during voluntary squeezing and straining. Statistical analysis was performed within and between the two groups. Results: The anal sphincter became paradoxically shorter and/or thicker during straining (versus the resting state) in 85% of patients but in only 35% of control subjects. Changes in sphincter length were statistically significantly different (p<0.01, χ2 test) in patients compared with control subjects. The m. puborectalis became paradoxically shorter and/or thicker during straining in 80% of patients but in only 30% of controls. Both the changes in length and thickness of the m. puborectalis were significantly different (p<0.01, χ2 test) in patients versus control subjects. Conclusions: Linear anorectal endosonography demonstrated incomplete or even absent relaxation of the anal sphincter and the m. puborectalis during a defecation movement in the majority of our patients with dyschesia. This study highlights the value of this elegant ultrasonographic technique in the diagnosis of “pelvic floor dyssynergia” or “anismus”. PMID:12377809

Inhibitory effects of botulinum toxin on pyloric and antral smooth muscle.

PubMed

James, Arlene N; Ryan, James P; Parkman, Henry P

2003-08-01

Botulinum toxin injection into the pylorus is reported to improve gastric emptying in gastroparesis. Classically, botulinum toxin inhibits ACh release from cholinergic nerves in skeletal muscle. The aim of this study was to determine the effects of botulinum toxin on pyloric smooth muscle. Guinea pig pyloric muscle strips were studied in vitro. Botulinum toxin type A was added; electric field stimulation (EFS) was performed every 30 min for 6 h. ACh (100 microM)-induced contractile responses were determined before and after 6 h. Botulinum toxin caused a concentration-dependent decrease of pyloric contractions to EFS. At a low concentration (2 U/ml), botulinum toxin decreased pyloric contractions to EFS by 43 +/- 9% without affecting ACh-induced contractions. At higher concentrations (10 U/ml), botulinum toxin decreased pyloric contraction to EFS by 75 +/- 7% and decreased ACh-induced contraction by 79 +/- 9%. In conclusion, botulinum toxin inhibits pyloric smooth muscle contractility. At a low concentration, botulinum toxin decreases EFS-induced contractile responses without affecting ACh-induced contractions suggesting inhibition of ACh release from cholinergic nerves. At higher concentrations, botulinum toxin directly inhibits smooth muscle contractility as evidenced by the decreased contractile response to ACh.

Neurogenic bladder in spinal cord injury patients

PubMed Central

Taweel, Waleed Al; Seyam, Raouf

2015-01-01

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury. PMID:26090342

Functional mapping of the pelvic floor and sphincter muscles from high-density surface EMG recordings.

PubMed

Peng, Yun; He, Jinbao; Khavari, Rose; Boone, Timothy B; Zhang, Yingchun

2016-11-01

Knowledge of the innervation of pelvic floor and sphincter muscles is of great importance to understanding the pathophysiology of female pelvic floor dysfunctions. This report presents our high-density intravaginal and intrarectal electromyography (EMG) probes and a comprehensive innervation zone (IZ) imaging technique based on high-density EMG readings to characterize the IZ distribution. Both intravaginal and intrarectal probes are covered with a high-density surface electromyography electrode grid (8 × 8). Surface EMG signals were acquired in ten healthy women performing maximum voluntary contractions of their pelvic floor. EMG decomposition was performed to separate motor-unit action potentials (MUAPs) and then localize their IZs. High-density surface EMG signals were successfully acquired over the vaginal and rectal surfaces. The propagation patterns of muscle activity were clearly visualized for multiple muscle groups of the pelvic floor and anal sphincter. During each contraction, up to 218 and 456 repetitions of motor units were detected by the vaginal and rectal probes, respectively. MUAPs were separated with their IZs identified at various orientations and depths. The proposed probes are capable of providing a comprehensive mapping of IZs of the pelvic floor and sphincter muscles. They can be employed as diagnostic and preventative tools in clinical practices.

A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries?

PubMed

Seamon, Mark J; Pieri, Paola G; Fisher, Carol A; Gaughan, John; Santora, Thomas A; Pathak, Abhijit S; Bradley, Kevin M; Goldberg, Amy J

2007-04-01

We sought to determine whether the performance of pyloric exclusion during repair of penetrating advanced duodenal injuries prevents postoperative duodenal fistulas and improves clinical outcome. A retrospective chart review of patients from 1995 to 2004 with penetrating duodenal injuries >or=grade II and all combined pancreaticoduodenal injuries was performed. Patients managed either without or with pyloric exclusion were compared on the basis of age, sex, mechanism, injury grade, Injury Severity Score (ISS), hemodynamic stability, the presence of vascular injury or associated injuries, postoperative complications, length of hospital stay, and mortality. Fifteen of 29 patients were managed without pyloric exclusion and 14 with exclusion. Both groups were similar with respect to age, sex, mechanism, injury grade, ISS, hemodynamic stability, the presence of vascular injury, associated abdominal injuries, and mortality rates. A trend toward a higher overall complication rate (71% vs. 33%), pancreatic fistula rate (40% vs. 0%), and length of hospital stay (24.3 days vs. 13.5 days) was evident in the pyloric exclusion group. No duodenal fistula was detected in either patient group. In our study population, the performance of pyloric exclusion for penetrating advanced duodenal injury and combined pancreatic and duodenal injuries did not improve clinical outcome. The trend toward a greater overall complication rate, pancreatic fistula rate, and increased length of hospital stay in the pyloric exclusion group suggests that simple repair without pyloric exclusion is both adequate and safe for most penetrating duodenal injuries.

Neuroanatomy, neurophysiology, and dysfunction of the female lower urinary tract: a review.

PubMed

Unger, Cécile A; Tunitsky-Bitton, Elena; Muffly, Tyler; Barber, Matthew D

2014-01-01

The 2 major functions of the lower urinary tract are the storage and emptying of urine. These processes are controlled by complex neurophysiologic mechanisms and are subject to injury and disease. When there is disruption of the neurologic control centers, dysfunction of the lower urinary tract may occur. This is sometimes referred to as the "neurogenic bladder." The manifestation of dysfunction depends on the level of injury and severity of disruption. Patients with lesions above the spinal cord often have detrusor overactivity with no disruption in detrusor-sphincter coordination. Patients with well-defined suprasacral spinal cord injuries usually present with intact reflex detrusor activity but have detrusor sphincter dyssynergia, whereas injuries to or below the sacral spinal cord usually lead to persistent detrusor areflexia. A complete gynecologic, urologic, and neurologic examination should be performed when evaluating patients with neurologic lower urinary tract dysfunction. In addition, urodynamic studies and neurophysiologic testing can be used in certain circumstances to help establish diagnosis or to achieve better understanding of a patient's vesicourethral functioning. In the management of neurogenic lower urinary tract dysfunction, the primary goal is improvement of a patient's quality of life. Second to this is the prevention of chronic damage to the bladder and kidneys, which can lead to worsening impairment and symptoms. Treatment is often multifactorial, including behavioral modifications, bladder training programs, and pharmacotherapy. Surgical procedures are often a last resort option for management. An understanding of the basic neurophysiologic mechanisms of the lower urinary tract can guide providers in their evaluation and treatment of patients who present with lower urinary tract disorders. As neurologic diseases progress, voiding function often changes or worsens, necessitating a good understanding of the underlying physiology in question.

Pentadecapeptide BPC 157 and the esophagocutaneous fistula healing therapy.

PubMed

Cesarec, Vedran; Becejac, Tomislav; Misic, Marija; Djakovic, Zeljko; Olujic, Danijela; Drmic, Domagoj; Brcic, Luka; Rokotov, Dinko Stancic; Seiwerth, Sven; Sikiric, Predrag

2013-02-15

Esophagocutaneous fistulas are a failure of the NO-system, due to NO-synthase blockage by the NOS-blocker L-NAME consequently counteracted by l-arginine and gastric pentadecapeptide BPC 157 (l-arginine

Trends in obstetric anal sphincter injuries over 10 years.

PubMed

Tyagi, V; Perera, M; Guerrero, K

2013-11-01

Obstetric anal sphincter injuries (OASIS) is a known complication of vaginal delivery and has significant public health issues, as it can cause both short- and long-term morbidity in women. The most commonly reported complications include different grades of faecal/flatus incontinence, pain and sexual dysfunction. In our study, we found a rising trend in OASIS rates in vaginal deliveries, with the rising rate of forceps and the falling rate of SVD, which is at least partly due to increased awareness and training in OASIS. However, there is an actual increase in the number of such tears at vaginal deliveries. Midwifery and obstetric practices have certainly changed over the last decade and we discuss the possible factors, which might be contributing to such a rise.

Dynamic translabial ultrasound versus echodefecography combined with the endovaginal approach to assess pelvic floor dysfunctions: How effective are these techniques?

PubMed

Murad-Regadas, S M; Karbage, S A; Bezerra, L S; Regadas, F S P; da Silva Vilarinho, A; Borges, L B; Regadas Filho, F S P; Veras, L B

2017-07-01

The aim of this study was to evaluate the role of dynamic translabial ultrasound (TLUS) in the assessment of pelvic floor dysfunction and compare the results with echodefecography (EDF) combined with the endovaginal approach. Consecutive female patients with pelvic floor dysfunction were eligible. Each patient was assessed with EDF combined with the endovaginal approach and TLUS. The diagnostic accuracy of the TLUS was evaluated using the results of EDF as the standard for comparison. A total of 42 women were included. Four sphincter defects were identified with both techniques, and EDF clearly showed if the defect was partial or total and additionally identified the pubovisceral muscle defect. There was substantial concordance regarding normal relaxation and anismus. Perfect concordance was found with rectocele and cystocele. The rectocele depth was measured with TLUS and quantified according to the EDF classification. Fair concordance was found for intussusception. There was no correlation between the displacement of the puborectal muscle at maximum straining on EDF with the displacement of the anorectal junction (ARJ), compared at rest with maximal straining on TLUS to determine perineal descent (PD). The mean ARJ displacement was similar in patients with normal and those with excessive PD on TLUS. Both modalities can be used as a method to assess pelvic floor dysfunction. The EDF using 3D anorectal and endovaginal approaches showed advantages in identification of the anal sphincters and pubodefects (partial or total). There was good correlation between the two techniques, and a TLUS rectocele classification based on size that corresponds to the established classification using EDF was established.

Urinary incontinence and voiding dysfunction after radical retropubic prostatectomy (prospective urodynamic study).

PubMed

Majoros, Attila; Bach, Dietmar; Keszthelyi, Attila; Hamvas, Antal; Romics, Imre

2006-01-01

During this prospective study we analyzed the effects of radical retropubic prostatectomy (RRP) on bladder and sphincter function by comparing preoperative and postoperative urodynamic data. The aim of the study was to determine the reason for urinary incontinence after RRP and explain why one group of patients will be immediately continent after catheter removal, while others need some time to reach complete continence. Urodynamic examination was performed in 63 patients 3-7 days before and 2 months after surgery. Forty-three (68.2%) and 53 (84.1%) patients regained continence at 2 and 9 months following RRP, respectively. Ten patients (15.9%) were immediately continent after catheter removal. Urodynamic stress incontinence was detected in 18 (28.6%), and detrusor overactivity incontinence in 2 (3.2%) patients 2 months after surgery. The amplitude of preoperative maximal voluntary sphincteric contractions was significantly higher in the postoperative continent group (125 vs. 96.5 cmH(2)O, P < 0.0001). The patients who were immediately continent following catheter removal had no lower urinary tract symptoms (LUTS) and urodynamic abnormality preoperatively, and they had significantly higher preoperative and postoperative maximum urethral closure pressure (at rest and during voluntary sphincter contraction) than those who became continent later on. These data suggest that the main cause of incontinence after RRP is sphincteric weakness. In the continent group, those who became immediately continent had significantly higher maximum urethral closure pressure values at rest and at voluntary sphincteric contraction even before the surgery. Neurourol. Urodynam. (c) 2005 Wiley-Liss, Inc.

Conservative treatment of esophageal perforation related to a peptic ulcer with pyloric stenosis.

PubMed

Tanaka, Ryo; Kosugi, Shin-Ichi; Sato, Daisuke; Hirukawa, Hiroshi; Tada, Tetsuya; Ichikawa, Hiroshi; Hanyu, Takaaki; Ishikawa, Takashi; Kobayashi, Takashi; Wakai, Toshifumi

2014-08-01

We report a case of esophageal perforation (Boerhaave syndrome) caused by vomiting related to a duodenal ulcer with pyloric stenosis. A 45-year-old male presented with left chest pain and dyspnea after forceful vomiting. Chest radiography and computed tomography (CT) revealed a massive left pleural effusion and left tension pneumothorax. Abdominal CT revealed pyloric stenosis with a remarkably dilated stomach. Tube thoracostomy and nasogastric suction were immediately performed and we selected conservative treatment based on the following factors-a stable general condition without sepsis, early diagnosis, and good drainage. Esophagogastroduodenoscopy on hospital day 9 demonstrated a healing ulcer in the lower esophagus and pyloric stenosis. We performed distal gastrectomy as elective surgery for pyloric stenosis due to a duodenal ulcer on hospital day 30. In summary, an esophageal perforation with contamination spreading to the thoracic cavity was successfully treated with conservative treatment.

Neurostimulation and neuromodulation: a guide to selecting the right urologic patient.

PubMed

Schmidt, R A; Doggweiler, R

1998-01-01

Sensory input has an important influence on the integrity of neural circuitry. Central nervous system circuitry is programmed and reinforced by everyday experience. Even the simplest of behaviors participate in this process. A balance between inhibition and facilitation must be maintained for the CNS to function normally. For example, the bladder stores urine because of the inhibition from a closed sphincter, and relaxation of the sphincter disinhibits the bladder to permit voiding. This synergistic 'seesaw' in reflex neural activity preserves the functional and anatomical integrity of the lower urinary tract. Dysfunction and anatomical change results when an unnatural bias develops between inhibitory and facilitatory neural activity. Neurostimulation has an inherent conditioning effect on neural excitability and can restore the neural equilibrium. Voiding diaries are very useful in documenting these changes.

[Symptomatic vertebral hemangioma related to pregnancy. A case report].

PubMed

Jankowski, Roman; Nowak, Stanisław; Kasprzyk, Mariusz; Szpurek, Dariusz; Zukiel, Ryszard; Sokół, Bartosz; Szmeja, Jacek; Szubert, Sebastian

2012-01-01

Hemangioma is the most common primary tumor of the spine. Pregnancy is a risk factor increasing the possibility of disclosure or exacerbation of symptoms of spinal hemangioma. This paper presents a case of 32-year-old woman with hemangioma of Th6 vertebrae, which was revealed by paresis of the lower limbs and sphincters dysfunction at 34 weeks gestation. Pregnancy has ended with a cesarean section. Then posterolateral thoracotomy and removal of hemangioma were performed. Spinal cord was decompressed and stabilization of the spine with metal implants was carried out. Histological examination discovered cavernous hemangioma weaving. The patient is followed up in the outpatient clinic. Despite the improvement of neurological status--enhancement of the sensory function and development of bladder and rectal sphincter automatism--she did not regain the ability to walk alone.

OnabotulinumtoxinA in the treatment of neurogenic bladder

PubMed Central

Gulamhusein, Aziz; Mangera, Altaf

2012-01-01

This review examines the evidence for use of onabotulinumtoxinA in the treatment of neurogenic lower urinary tract dysfunction. Since its first use in 1988 to treat detrusor sphincter dyssynergia, use of botulinum toxin has increased in this group of patients. We discuss the mechanism of action, patient selection, dosing, efficacy, and side effect profile of this now licensed treatment option. PMID:22977301

Sacral neuromodulations for female lower urinary tract, pelvic floor, and bowel disorders.

PubMed

Wehbe, Salim A; Whitmore, Kristene; Ho, Mat H

2010-10-01

In recent years, sacral neuromodulation (SNM) has been investigated for the treatment of various types of lower urinary tract and bowel dysfunctions. This review discusses recently published data related to the therapeutic applications of SNM in female lower urinary tract, pelvic floor, and bowel disorders. SNM has been employed initially in the treatment of refractory idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. Since then, several studies, including randomized and controlled trials, have confirmed the therapeutic effects of SNM in these disorders. The applications of SNM are now extended to the treatment of other female pelvic problems, such as fecal incontinence, chronic constipation, interstitial cystitis/painful bladder syndrome, sexual dysfunction, and neurogenic disorders, with similar promising results. SNM is approved by the Food and Drug Administration for the treatment of idiopathic overactive bladder, urge urinary incontinence, and chronic nonobstructive urinary retention. SNM is not yet an approved method for the treatment of other pelvic disorders, but data supporting its benefit are emerging. The major advantage of SNM lies in its potential to treat the bladder, urethral sphincter, anal sphincters, and pelvic floor muscles simultaneously, which might result in better therapeutic effects.

Bladder, bowel, and sexual dysfunction in Parkinson's disease.

PubMed

Sakakibara, Ryuji; Kishi, Masahiko; Ogawa, Emina; Tateno, Fuyuki; Uchiyama, Tomoyuki; Yamamoto, Tatsuya; Yamanishi, Tomonori

2011-01-01

Bladder dysfunction (urinary urgency/frequency), bowel dysfunction (constipation), and sexual dysfunction (erectile dysfunction) (also called "pelvic organ" dysfunctions) are common nonmotor disorders in Parkinson's disease (PD). In contrast to motor disorders, pelvic organ autonomic dysfunctions are often nonresponsive to levodopa treatment. The brain pathology causing the bladder dysfunction (appearance of overactivity) involves an altered dopamine-basal ganglia circuit, which normally suppresses the micturition reflex. By contrast, peripheral myenteric pathology causing slowed colonic transit (loss of rectal contractions) and central pathology causing weak strain and paradoxical anal sphincter contraction on defecation (PSD, also called as anismus) are responsible for the bowel dysfunction. In addition, hypothalamic dysfunction is mostly responsible for the sexual dysfunction (decrease in libido and erection) in PD, via altered dopamine-oxytocin pathways, which normally promote libido and erection. The pathophysiology of the pelvic organ dysfunction in PD differs from that in multiple system atrophy; therefore, it might aid in differential diagnosis. Anticholinergic agents are used to treat bladder dysfunction in PD, although these drugs should be used with caution particularly in elderly patients who have cognitive decline. Dietary fibers, laxatives, and "prokinetic" drugs such as serotonergic agonists are used to treat bowel dysfunction in PD. Phosphodiesterase inhibitors are used to treat sexual dysfunction in PD. These treatments might be beneficial in maximizing the patients' quality of life.

Bladder, Bowel, and Sexual Dysfunction in Parkinson's Disease

PubMed Central

Sakakibara, Ryuji; Kishi, Masahiko; Ogawa, Emina; Tateno, Fuyuki; Uchiyama, Tomoyuki; Yamamoto, Tatsuya; Yamanishi, Tomonori

2011-01-01

Bladder dysfunction (urinary urgency/frequency), bowel dysfunction (constipation), and sexual dysfunction (erectile dysfunction) (also called “pelvic organ” dysfunctions) are common nonmotor disorders in Parkinson's disease (PD). In contrast to motor disorders, pelvic organ autonomic dysfunctions are often nonresponsive to levodopa treatment. The brain pathology causing the bladder dysfunction (appearance of overactivity) involves an altered dopamine-basal ganglia circuit, which normally suppresses the micturition reflex. By contrast, peripheral myenteric pathology causing slowed colonic transit (loss of rectal contractions) and central pathology causing weak strain and paradoxical anal sphincter contraction on defecation (PSD, also called as anismus) are responsible for the bowel dysfunction. In addition, hypothalamic dysfunction is mostly responsible for the sexual dysfunction (decrease in libido and erection) in PD, via altered dopamine-oxytocin pathways, which normally promote libido and erection. The pathophysiology of the pelvic organ dysfunction in PD differs from that in multiple system atrophy; therefore, it might aid in differential diagnosis. Anticholinergic agents are used to treat bladder dysfunction in PD, although these drugs should be used with caution particularly in elderly patients who have cognitive decline. Dietary fibers, laxatives, and “prokinetic” drugs such as serotonergic agonists are used to treat bowel dysfunction in PD. Phosphodiesterase inhibitors are used to treat sexual dysfunction in PD. These treatments might be beneficial in maximizing the patients' quality of life. PMID:21918729

Innervation of Extrahepatic Biliary Tract, With Special Reference to the Direct Bidirectional Neural Connections of the Gall Bladder, Sphincter of Oddi and Duodenum in Suncus murinus, in Whole-Mount Immunohistochemical Study.

PubMed

Yi, S-Q; Ren, K; Kinoshita, M; Takano, N; Itoh, M; Ozaki, N

2016-06-01

Sphincter of Oddi dysfunction is one of the most important symptoms in post-cholecystectomy syndrome. Using either electrical or mechanical stimulation and retrogradely transported neuronal dyes, it has been demonstrated that there are direct neural pathways connecting gall bladder and the sphincter of Oddi in the Australian opossum and the golden hamster. In the present study, we employed whole-mount immunohistochemistry staining to observe and verify that there are two different plexuses of the extrahepatic biliary tract in Suncus murinus. One, named Pathway One, showed a fine, irregular but dense network plexus that ran adhesively and resided on/in the extrahepatic biliary tract wall, and the plexus extended into the intrahepatic area. On the other hand, named Pathway Two, exhibiting simple, thicker and straight neural bundles, ran parallel to the surface of the extrahepatic biliary tract and passed between the gall bladder and duodenum, but did not give off any branches to the liver. Pathway Two was considered to involve direct bidirectional neural connections between the duodenum and the biliary tract system. For the first time, morphologically, we demonstrated direct neural connections between gall bladder and duodenum in S. murinus. Malfunction of the sphincter of Oddi may be caused by injury of the direct neural pathways between gall bladder and duodenum by cholecystectomy. From the viewpoint of preserving the function of the major duodenal papilla and common bile duct, we emphasize the importance of avoiding kocherization of the common bile duct so as to preserve the direct neural connections between gall bladder and sphincter of Oddi. © 2015 Blackwell Verlag GmbH.

Manometric assessment of esophageal motor function in patients with primary biliary cirrhosis.

PubMed

Bektas, Mehmet; Seven, Gulseren; Idilman, Ramazan; Yakut, Mustafa; Doğanay, Beyza; Kabacam, Gökhan; Ustun, Yusuf; Korkut, Esin; Kalkan, Çağdaş; Sahin, Günay; Cetinkaya, Hulya; Bozkaya, Hakan; Yurdaydin, Cihan; Bahar, Kadir; Cinar, Kubilay; Soykan, Irfan

2014-03-01

Primary biliary cirrhosis is associated with other autoimmune diseases including Sjögren's syndrome, and scleroderma. Esophageal dysmotility is well known in scleroderma, and Sjögren's syndrome. The aim of this study is to investigate whether any esophageal motor dysfunction exists in patients with primary biliary cirrhosis. The study was performed in 37 patients (36 women, mean age: 56.29 ± 10.01 years) who met diagnostic criteria for primary biliary cirrhosis. Thirty-seven functional dyspepsia patients, were also included as a control group. Patients entering the study were asked to complete a symptom questionnaire. Distal esophageal contraction amplitude, and lower esophageal sphincter resting pressure were assessed. Manometric findings in primary biliary cirrhosis patients vs. controls were as follows: Median lower esophageal sphincter resting pressure (mmHg): (24 vs 20, p=0.033); median esophageal contraction amplitude (mmHg): (71 vs 56, p=0.050); mean lower esophageal sphincter relaxation duration (sc, x ± SD): (6.10 ± 1.18 vs 8.29 ± 1.92, p<0.001); and median lower esophageal sphincter relaxation (%) (96 vs 98, p=0.019); respectively. No significant differences were evident in median peak velocity (sc) (3.20 vs 3.02, p=0.778) between patients with primary biliary cirrhosis and the functional dyspepsia patients. Esophageal dysmotility was found in 17 (45.9%) primary biliary cirrhosis patients (non-specific esophageal motor disorder in ten patients, hypomotility of esophagus in five patients, nutcracker esophagus in one patient and hypertensive lower esophageal sphincter in one patient). Esophageal dysmotility was detected in 45.9% of patients. The study suggests that subclinic esophageal dysmotility is frequent in patients with primary biliary cirrhosis. Crown Copyright © 2014. Published by Elsevier B.V. All rights reserved.

Best practice in the assessment of bladder function in infants

PubMed Central

Leonard, Michael; Castagnetti, Marco

2014-01-01

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be ‘reflexive’ or ‘uninhibited’, with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic ‘detrusor sphincter dyssynergy’ seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of ‘early prophylactic treatment (clean intermittent catheterization and anticholinergics)’ versus initial ‘watchful waiting and treatment as needed’ is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux. PMID:25083164

Conversations for Providers Caring for Rectal Cancer Patients: Comparison of Long-Term Patient-Centered Outcomes for Low Rectal Cancer Patients Facing Ostomy or Sphincter-Sparing Surgery

PubMed Central

Herrinton, Lisa J.; Altschuler, Andrea; McMullen, Carmit K.; Bulkley, Joanna E.; Hornbrook, Mark C.; Sun, Virginia; Wendel, Christopher S.; Grant, Marcia; Baldwin, Carol M.; Demark-Wahnefried, Wendy; Temple, Larissa K.F.; Krouse, Robert S.

2017-01-01

For some low rectal cancer patients, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients eligible for sphincter-sparing surgery may not be well served by the surgery and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries, or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects following the two surgeries has not been synthesized. We therefore conducted a systematic review to examine this ? This systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. Our goals are: 1) improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) increase the patient’s participation in the decision; (3) alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, improve patients’ long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery, as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. PMID:26999757

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery.

PubMed

Herrinton, Lisa J; Altschuler, Andrea; McMullen, Carmit K; Bulkley, Joanna E; Hornbrook, Mark C; Sun, Virginia; Wendel, Christopher S; Grant, Marcia; Baldwin, Carol M; Demark-Wahnefried, Wendy; Temple, Larissa K F; Krouse, Robert S

2016-09-01

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society. © 2016 American Cancer Society.

Functional Magnetic Resonance Imaging with Concurrent Urodynamic Testing Identifies Brain Structures Involved in Micturition Cycle in Patients with Multiple Sclerosis.

PubMed

Khavari, Rose; Karmonik, Christof; Shy, Michael; Fletcher, Sophie; Boone, Timothy

2017-02-01

Neurogenic lower urinary tract dysfunction, which is common in patients with multiple sclerosis, has a significant impact on quality of life. In this study we sought to determine brain activity processes during the micturition cycle in female patients with multiple sclerosis and neurogenic lower urinary tract dysfunction. We report brain activity on functional magnetic resonance imaging and simultaneous urodynamic testing in 23 ambulatory female patients with multiple sclerosis. Individual functional magnetic resonance imaging activation maps at strong desire to void and at initiation of voiding were calculated and averaged at Montreal Neuroimaging Institute. Areas of significant activation were identified in these average maps. Subgroup analysis was performed in patients with elicitable neurogenic detrusor overactivity or detrusor-sphincter dyssynergia. Group analysis of all patients at strong desire to void yielded areas of activation in regions associated with executive function (frontal gyrus), emotional regulation (cingulate gyrus) and motor control (putamen, cerebellum and precuneus). Comparison of the average change in activation between previously reported healthy controls and patients with multiple sclerosis showed predominantly stronger, more focal activation in the former and lower, more diffused activation in the latter. Patients with multiple sclerosis who had demonstrable neurogenic detrusor overactivity and detrusor-sphincter dyssynergia showed a trend toward distinct brain activation at full urge and at initiation of voiding respectively. We successfully studied brain activation during the entire micturition cycle in female patients with neurogenic lower urinary tract dysfunction and multiple sclerosis using a concurrent functional magnetic resonance imaging/urodynamic testing platform. Understanding the central neural processes involved in specific parts of micturition in patients with neurogenic lower urinary tract dysfunction may identify areas of interest for future intervention. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Causes and risk factors of urinary incontinence: Avicenna's point of view vs. contemporary findings.

PubMed

Nojavan, Fatemeh; Sharifi, Hossein; Ghanbari, Zinat; Kamalinejad, Mohammad; Mokaberinejad, Roshanak; Emami, Maryam

2015-02-22

To extract the causes and risk factors of urinary incontinence from an old medical text by Avicenna entitled "Canon of Medicine" and comparing it with contemporary studies. In this study, etiology and risk factors of urinary incontinence were extracted from Avicenna's "Canon of Medicine". Commentaries written on this book and other old reliable medical texts about bladder and its diseases were also studied. Then the achieved information was compared with contemporary findings of published articles. Urinary incontinence results from bladder dysfunction in reservoir phase. Bladder's involuntary muscles and voluntary external sphincter are two main components which are involved in this process. Urinary incontinence can exist without obvious structural and neuronal etiologies. According to Avicenna, distemperment of muscular tissue of bladder and external sphincter is the cause for urinary incontinence in such cases. Distemperment is the result of bothering qualities in tissue, i.e.: "wet" and "cold". They are the two bothering qualities which are caused by extracorporeal and intracorporeal factors. Interestingly, the positive associations of some of these factors with urinary incontinence have been shown in recent researches. "Cold" and "wet" distemperment of bladder and external sphincter can be independent etiologies of urinary incontinence which should be investigated. 

[Gastric adenomyoma clinically simulating hypertrophic pyloric stenosis].

PubMed

Sánchez García, S; Rubio Solís, D; Anes González, G; González Sánchez, S

2016-01-01

Gastric adenomyomas are extremely uncommon benign tumors in children. On histologic examination, these tumors have an epithelial component similar to pancreatic ducts. We present a case of a pyloric adenomyoma that clinically simulated hypertrophic pyloric stenosis in a newborn girl. Imaging tests, fundamentally magnetic resonance imaging, were very important in the characterization and diagnosis of this entity. Copyright © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

HYPERTROPHIC PYLORIC STENOSIS

PubMed Central

Gans, Stephen L.

1959-01-01

Hypertrophic pyloric stenosis, a relatively common condition, is caused by hyperplasia of the musculature of the pylorus. The diagnosis is made by a history of projectile vomiting and failure to gain weight, the observation of gastric peristaltic waves, and the palpation of a pyloric “tumor.” A method of palpating this tumor is described in detail. Roentgenological studies are rarely indicated. Pylorotomy for treatment of hypertrophic pyloric stenosis was not successful until the development of necessary supporting measures. Preparation for operation consists of intravenous administration of fluids and electrolytes and sometimes serum or whole blood. The position of the tumor governs the choice between two different incisions. The operative procedure herein described is essentially that devised by Ramstedt many years ago, with modifications to facilitate the procedure. PMID:13651960

Vagal Afferent Innervation of the Lower Esophageal Sphincter

PubMed Central

Powley, Terry L.; Baronowsky, Elizabeth A.; Gilbert, Jared M.; Hudson, Cherie N.; Martin, Felecia N.; Mason, Jacqueline K.; McAdams, Jennifer L.; Phillips, Robert J.

2013-01-01

To supply a fuller morphological characterization of the vagal afferents innervating the lower esophageal sphincter (LES), specifically to label vagal terminals in the tissues forming the LES in the gastroesophageal junction, the present experiment employed injections of dextran biotin into the nodose ganglia of rats. Four types of vagal afferents innervated the LES. Clasp and sling muscle fibers were directly and prominently innervated by intramuscular arrays (IMAs). Individual IMA terminals subtended about 16° of arc of the esophageal circumference, and, collectively, the terminal fields were distributed within the muscle ring to establish a 360° annulus of mechanoreceptors in the sphincter wall. 3D morphometry of the terminals established that, compared to sling muscle IMAs, clasp muscle IMAs had more extensive arbors and larger receptive fields. In addition, at the cardia, local myenteric ganglia between smooth muscle sheets and striated muscle bundles were innervated by intraganglionic laminar endings (IGLEs), in a pattern similar to the innervation of the myenteric plexus throughout the stomach and esophagus. Finally, as previously described, the principle bundle of sling muscle fibers that links LES sphincter tissue to the antropyloric region of the lesser curvature was innervated by exceptionally long IMAs as well as by unique web ending specializations at the distal attachment of the bundle. Overall, the specialized varieties of densely distributed vagal afferents innervating the LES underscore the conclusion that these sensory projections are critically involved in generating LES reflexes and may be promising targets for managing esophageal dysfunctions. PMID:23583280

Pyloric obstruction secondary to epicardial pacemaker implantation: a case report.

PubMed

Bedoya Nader, G; Kellihan, H B; Bjorling, D E; McAnulty, J

2017-02-01

A 10-year old Lhasa Apso dog was presented for an acute history of exercise intolerance and hind limb weakness. High grade second degree atrioventricular block with an atrial rate of 200 beats per minute, ventricular rate of 40 beats per minute and an intermittent ventricular escape rhythm, was diagnosed on electrocardiograph. A transdiaphragmatic, unipolar, epicardial pacemaker was implanted without immediate surgical complications. Severe vomiting was noted 12 h post-operatively. Abdominal ultrasound and a barium study supported a diagnosis of pyloric outflow obstruction and exploratory abdominal surgery was performed. The pyloric outflow tract appeared normal and no other causes of an outflow obstruction were identified. The epicardial generator was repositioned from the right to the left abdominal wall. Pyloric cell pacing was presumed to be the cause for the pyloric obstruction and severe vomiting, and this was thought to be due to close proximity of the pacemaker generator to the pylorus situated in the right abdominal wall. Repositioning of the pulse generator to the left abdominal wall resulted in resolution of vomiting. Copyright © 2016 Elsevier B.V. All rights reserved.

Pyloric stenosis and maternal Bendectin exposure.

PubMed

Aselton, P; Jick, H; Chentow, S J; Perera, D R; Hunter, J R; Rothman, K J

1984-08-01

As part of a long-term follow-up of structural disorders present at birth or shortly thereafter in infants born at Group Health Cooperative of Puget Sound, all infants with a diagnosis of pyloric stenosis born between July 1, 1977 and June 30, 1982, were identified. Automated pharmacy profiles were examined to determine whether an association between maternal Bendectin use in the first trimester and infantile hypertrophic pyloric stenosis existed. Among the 3,835 women exposed to Bendectin while pregnant, in this group of 13,346 births, 13 had infants who developed pyloric stenosis, and among the 9,511 women not exposed, 13 had infants who developed pyloric stenosis, resulting in a risk ratio estimate of 2.5 (95% confidence interval (CI) 1.2-5.2). When mothers were divided according to the number of prescriptions for Bendectin filled, the relative risk estimate increased from 1.2 (95% CI 0.4-4.4) in women who filled only one prescription to 7.6 (95% CI 4.9-11.6) in women who filled five or more prescriptions for Bendectin during their pregnancy.

Birth defects in relation to Bendectin use in pregnancy. II. Pyloric stenosis.

PubMed

Mitchell, A A; Schwingl, P J; Rosenberg, L; Louik, C; Shapiro, S

1983-12-01

To test the hypothesis that the use of Bendectin in pregnancy increases the risk of pyloric stenosis, we determined rates of antenatal Bendectin exposure among 325 infants with pyloric stenosis and among two control groups comprising infants with other defects; one consisted of 3,153 infants with other conditions, and the other, a subset of that group, consisted of 724 infants with defects that may have had their origins at any time in pregnancy. Comparisons between the cases and the two control series yielded estimated relative risks of 0.9 (95% confidence interval, 0.6 to 1.2) and 1.0 (0.7 to 1.4), respectively. The findings from this large case-control study suggest that Bendectin does not increase the risk of pyloric stenosis.

Spinning top urethra and lower urinary tract dysfunction in a young female.

PubMed

Dogra, P N; Ansari, M S

2004-06-07

Spinning top urethra (STU) denotes a particular urethral configuration that is a dilated posterior urethra mainly seen in young girls or women. STU deformity arises secondary to detrusor instability, leading to a rise the intravesical pressure against a closed sphincter. We describe a case of spinning top urethra in a 30-year-old woman who presented with lower urinary tract symptoms and left flank pain.

Spinning Top Urethra and Lower Urinary Tract Dysfunction in a Young Female

PubMed Central

Dogra, P.N.; Ansari, M.S.

2004-01-01

Spinning top urethra (STU) denotes a particular urethral configuration that is a dilated posterior urethra mainly seen in young girls or women. STU deformity arises secondary to detrusor instability, leading to a rise the intravesical pressure against a closed sphincter. We describe a case of spinning top urethra in a 30-year-old woman who presented with lower urinary tract symptoms and left flank pain. PMID:15349536

[Rectal cancer--review of methods and treatment results].

PubMed

Grotowski, Maciej

2004-03-01

Rectal cancer poses a significant worldwide problem. Until the late 19 century surgeons were convinced that surgical attempts of treating rectal cancers were doomed to failure. Currently, surgery is associated with a poor prognosis, a high likelihood of permanent colostomy and a high rate of local recurrence in patients with regional disease. Functional changes such as bladder dysfunction and impotence remain distressingly common consequences of conventional surgery. An important understanding of rectal cancer pathology allied to modern surgical techniques such as intestinal stapling guns has led to an increased number of sphincter saving operations. The technique of sharp dissection along definable planes known as total mesorectal excision (TME) produces the complete resection of an intact package of the rectum and surrounding mesorectum, enveloped within the visceral pelvic fascia with uninvolved circumferential margins. As a result of TME, 5-year survival figures have risen from 45-50% to 78%, local recurrence rates have declined from 30% to 5-8%, sphincter preservation has risen by at least 20%, and the rates of bladder dysfunction and impotence have declined from 50-70% to 15%. In some selected cases transanal techniques with or without radiotherapy have improved the success of local excision. The value of laparoscopic surgery for rectal cancer in terms of cancer outcome can only be assessed by large clinical trials with sufficient follow-up.

Disturbed Colonic Motility Contributes to Anorectal Symptoms and Dysfunction After Radiotherapy for Carcinoma of the Prostate

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yeoh, Eric K., E-mail: eric.yeoh@health.sa.gov.a; Bartholomeusz, Dylan L.; Holloway, Richard H.

2010-11-01

Purpose: To evaluate the role of colonic motility in the pathogenesis of anorectal symptoms and dysfunction after radiotherapy (RT) for carcinoma of the prostate. Patients and Methods: Thirty-eight patients, median age 71 (range, 50-81) years with localized prostate carcinoma randomized to one of two radiation dose schedules underwent colonic transit scintigraphy and assessment of anorectal symptoms (questionnaire), anorectal function (manometry), and anal sphincteric morphology (endoanal ultrasound) before and at 1 month and 1 year after RT. Results: Whole and distal colonic transit increased 1 month after RT, with faster distal colonic transit only persisting at 1 year. Frequency and urgencymore » of defecation, fecal incontinence, and rectal bleeding increased 1 month after RT and persisted at 1 year. Basal anal pressures remained unchanged, but progressive reductions occurred in anal squeeze pressures and responses to increased intra-abdominal pressure. Rectal compliance decreased progressively in the patients, although no changes in anorectal sensory function ensued. Radiotherapy had no effect on the morphology of the internal and external anal sphincters. Distal colonic retention was weakly related to rectal compliance at 1 month, but both faster colonic transit and reduced rectal compliance were more frequent with increased fecal urgency. At 1 year, a weak inverse relationship existed between colonic half-clearance time and frequency of defecation, although both faster whole-colonic transit and reduced rectal compliance occurred more often with increased stool frequency. Conclusion: Colonic dysmotility contributes to anorectal dysfunction after RT for carcinoma of the prostate. This has implications for improving the management of anorectal radiation sequelae.« less

Stable gastric pentadecapeptide BPC 157 in trials for inflammatory bowel disease (PL-10, PLD-116, PL 14736, Pliva, Croatia). Full and distended stomach, and vascular response.

PubMed

Sikiric, P; Seiwerth, S; Brcic, L; Blagaic, A B; Zoricic, I; Sever, M; Klicek, R; Radic, B; Keller, N; Sipos, K; Jakir, A; Udovicic, M; Tonkic, A; Kokic, N; Turkovic, B; Mise, S; Anic, T

2006-12-01

Gastric pentadecapeptide BPC 157 (GEPPPGKPADDAGLV, M.W. 1419, safe in clinical trials for inflammatory bowel disease (PL 10, PLD 116, PLD 14736, Pliva, Croatia)) has a particular cytoprotective/adaptive cytoprotective activity. The cytoprotective/adaptive cytoprotection researches largely neglect that stomach distension could per se jeopardize the mucosal integrity, with constantly stretched mucosa and blood vessels, and sphincters more prone for reflux induction. After absolute alcohol instillation in fully distended rat stomach, gastric, esophageal and duodenal lesions occur. Throughout next 3 min, left gastric artery blood vessels clearly disappear at the serosal site, indicative for loss of vessels both integrity and function. Contrary, constant vessels presentation could predict the beneficial effect of applied agent. After pentadecapeptide BPC 157 instillation into the stomach the vessels presentation remains constant, and lesions of stomach, esophagus, and duodenum are inhibited. Standards (atropine, ranitidine, omeprazole) could only slightly improve the vessels presentation compared to control values, and they have only a partial effect on the lesions. In this review we emphasize BPC 157 unusual stability, and some of its important effects: effectiveness against various lesions in gastrointestinal tract, on nitric oxide (NO)-system, and NO-agents effects, on somatosensory neurons, salivary glands function, recovery of AMP-ADP-ATP system, endothelium protection, effect on endothelin, and on angiogenesis promotion. It also antagonizes other alcohol effects, including acute and chronic intoxication. Given peripherally, it counteracts the consequence of central dopamine system disturbances (receptor blockade), and induces serotonin release in substantia nigra. Therapeutic potential of BPC 157 as a cytoprotective agent is also seen in its capability to heal various wounds. Given directly into the stomach, BPC 157 instantly recovers disturbed lower esophageal and pyloric sphincter pressure in rats after 12-20 months of untreated esophagitis. All these could be suggestive for its role as a natural protectant in gastric juice with particular function throughout stomach distension.

Is Gastroesophageal Reflux Disease and Achalasia Coincident or Not?

PubMed Central

Jung, Da Hyun; Park, Hyojin

2017-01-01

Achalasia and gastroesophageal reflux disease (GERD) are on opposite ends of the spectrum of lower esophageal sphincter dysfunction. Heartburn is the main symptom of GERD. However, heartburn and regurgitation are frequently observed in patients who have achalasia. The diagnosis of achalasia might be delayed because these symptoms are misinterpreted as gastroesophageal reflux. Here, we reviewed the clinical characteristics of patients with the erroneous diagnosis of GERD who actually had untreated achalasia. PMID:27771944

Use of Sacral Nerve Stimulation for the Treatment of Overlapping Constipation and Fecal Incontinence

PubMed Central

Sreepati, Gouri; James-Stevenson, Toyia

2017-01-01

Patient: Female, 51 Final Diagnosis: Fecal incontinence Symptoms: Constipation • fecal incontinence Medication: — Clinical Procedure: Sacral nerve stimulator Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Fecal incontinence and constipation are common gastrointestinal complaints, but rarely occur concurrently. Management of these seemingly paradoxical processes is challenging, as treatment of one symptom may exacerbate the other. Case Report: A 51-year-old female with lifelong neurogenic bladder secondary to spina bifida occulta presented with progressive symptoms of daily urge fecal incontinence as well as hard bowel movements associated with straining and a sensation of incomplete evacuation requiring manual disimpaction. Pelvic floor testing showed poor ability to squeeze the anal sphincter, which indicated sphincter weakness as a major contributor to her fecal incontinence symptoms. Additionally, on defecography she was unable to widen her posterior anorectal angle or relax the anal sphincter during defecation consistent with dyssynergic defecation. A sacral nerve stimulator was placed for management of her fecal incontinence. Interestingly, her constipation also dramatically improved with sacral neuromodulation. Conclusions: This unique case highlights the emerging role of sacral nerve stimulation in the treatment of complex pelvic floor dysfunction with improvement in symptoms beyond fecal incontinence in a patient with dyssynergic-type constipation. PMID:28265107

Down regulated expression of the beta1 subunit of the big-conductance Ca2+ sensitive K+ channel in sphincter of Oddi cells from rabbits fed with a high cholesterol diet.

PubMed

Du, Pang; Cui, Guang-Bin; Wang, Ya-Rong; Zhang, Xiao-Yong; Ma, Ke-Jun; Wei, Jing-Guo

2006-12-01

Hypercholesterolemia, which is closely related to gallbladder bile stasis, can cause sphincter of Oddi dysfunction (SOD) by increasing the tension of sphincter of Oddi (SO). Intracellular calcium ion concentration ([Ca(2+)](i)) could influence the tension of SO. The beta1 subunit of the big-conductance Ca(2+) sensitive K(+) channel (BK(Ca)) can enhance the sensitivity of the BK(Ca) channel to [Ca(2+)](i). Absence and decline of the BKCa channel subunit beta1 could lead to many diseases. However, the relationship between hypercholesterolemia and the expression of beta1 subunit is not well understood. In this study, we successfully expressed and purified the rabbit BK(Ca) beta1 subunit protein and prepared its polyclonal antibody. The specificity of the prepared antibody was determined by Western blotting. A SOD rabbit model induced by a high cholesterol diet was established and the expression of the beta1 subunit of SO was determined by immunohistochemical staining and western blotting. Compared with the controls, our results demonstrated that hypercholesterolemia could decrease the expression of the beta1 subunit in the SO cells from rabbits. This indicates that lower expression of BKCa channel beta1 subunit might induce SOD.

Histological development of the digestive system of the Amazonian pimelodid catfish Pseudoplatystoma punctifer.

PubMed

Gisbert, E; Moreira, C; Castro-Ruiz, D; Oztürk, S; Fernández, C; Gilles, S; Nuñez, J; Duponchelle, F; Tello, S; Renno, J F; García-Dávila, C; Darias, M J

2014-11-01

The organogenesis of the digestive system was described in the Amazonian pimelodid catfish species Pseudoplatystoma punctifer from hatching (3.5 mm total length, TL) to 41 days post-fertilization (dpf) (58.1 mm TL) reared at 28°C. Newly hatched larvae showed a simple digestive tract, which appeared as a straight undifferentiated and unfolded tube lined by a single layer of columnar epithelial cells (future enterocytes). During the endogenous feeding period, comprised between 20 and 96 h post-fertilization (3.5 to 6.1 mm TL), the larval digestive system experienced a fast transformation with the almost complete development and differentiation of most of digestive organs (buccopahrynx, oesophagus, intestine, liver and exocrine pancreas). Yolk reserves were not completely depleted at the onset of exogenous feeding (4 dpf, 6.1 mm TL), and a period of mixed nutrition was observed up to 6 to 7 dpf (6.8 to 7.3 mm TL) when yolk was definitively exhausted. The stomach was the organ that latest achieved its complete differentiation, characterized by the development of abundant gastric glands in the fundic stomach between 10 and 15 dpf (10.9 to 15.8 mm TL) and the formation of the pyloric sphincter at the junction of the pyloric stomach and the anterior intestine at 15 dpf (15.8 mm TL). The above-mentioned morphological and histological features observed suggested the achievement of a digestive system characteristic of P. punctifer juveniles and adults. The ontogeny of the digestive system in P. punctifer followed the same general pattern as in most Siluriform species so far, although some species-specific differences in the timing of differentiation of several digestive structures were noted, which might be related to different reproductive guilds, egg and larval size or even different larval rearing practices. According to present findings on the histological development of the digestive system in P. punctifer, some recommendations regarding the rearing practices of this species are also provided in order to improve the actual larval rearing techniques of this fast-growing Neotropical catfish species.

Phenotypic flexibility of digestive system in Atlantic cod (Gadus morhua).

PubMed

Blier, P U; Dutil, J-D; Lemieux, H; Bélanger, F; Bitetera, L

2007-02-01

This study examined the restoration of the digestive capacity of Atlantic cod (Gadus morhua Linnaeus) following a long period of food deprivation. Fifty cod (48 cm, 1 kg) were food-deprived for 68 days and then fed in excess with capelin (Mallotus villosus Müller) on alternate days. Ten fish were sampled after 0, 2, 6, 14 and 28 days and the mass of the pyloric caeca, intestine and carcass determined. Two metabolic enzymes (cytochrome c oxidase and citrate synthase) were assayed in white muscle, pyloric caeca and intestine, and trypsin activity was measured in the pyloric caeca. A delay of 14 days was required before body mass started to increase markedly, whereas most of the increase in mass of both the pyloric caeca and intestine relative to fish length occurred earlier in the experiment. By day 14, the activities of trypsin and citrate synthase in the pyloric caeca as well as citrate synthase in the intestine had reached maxima. The growth of the digestive tissues and restoration of their metabolic capacities thus occur early upon refeeding and are likely required for recovery growth to take place. The phenotypic flexibility of the cod digestive system is therefore remarkable: increases in trypsin activity and size of pyloric caeca resulted in a combined 29-fold increase in digestive capacity of the fish during the refeeding period. Our study suggests that Atlantic cod are able to cope with marked fluctuations in food availability in their environment by making a rapid adjustment of their digestive capacity as soon as food availability increases.

Congenital pyloric atresia, presentation, management, and outcome: a report of 20 cases.

PubMed

Al-Salem, Ahmed H; Abdulla, Mohamed Ramadan; Kothari, Mukul R; Naga, Mohamed Ibrahim

2014-07-01

Congenital pyloric atresia (CPA) is a very rare anomaly. It is usually seen as an isolated condition with excellent prognosis. Few cases are familial. These are usually associated with other hereditary conditions and have a poor prognosis. This is a review of our experience with 20 patients with CPA outlining aspects of diagnosis, associated anomalies and management. This is a retrospective analysis of 20 cases seen over a 22 year period (December 1990 to December 2012). Their records reviewed for: age, sex, presentation, prenatal history, associated anomalies, investigations, treatment, operative findings and the outcome. 20 cases (9 Males, 11 Females) were treated. 7 patients were full term and the remaining 13 were prematures. Their mean birth weight was 2.1 kg (1.1 kg to 3.9 kg). Polyhydramnios was seen in 13 patients (65%). Two were brothers and four were members of the same family. Isolated CPA was seen in 7 (35%); 13 had an associated conditions: epidermolysis bullosa (EB) in 8 (40%) and multiple intestinal atresias (MIA) in 5 (25%). Three patients had associated esophageal atresia. All were operated on except two who died early due to unrelenting sepsis. The variety of pyloric atresias encountered were as follows: pyloric diaphragm in 13 including double diaphragms in 2, pyloric atresia with a gap in 4 and pyloric atresia without gap in 3. Ten died postoperatively giving an overall survival of 40%. CPA is a very rare condition. Isolated CPA carries a good prognosis. Association of CPA with other familial and congenital anomalies like EB and MIA carries a poor prognosis. © 2014.

Fundamentals and clinical perspective of urethral sphincter instability as a contributing factor in patients with lower urinary tract dysfunction--ICI-RS 2014.

PubMed

Kirschner-Hermanns, Ruth; Anding, Ralf; Rosier, Peter; Birder, Lori; Andersson, Karl Erik; Djurhuus, Jens Christian

2016-02-01

Urethral pathophysiology is often neglected in discussions of bladder dysfunction. It has been debated whether "urethral sphincter instability," referred to based on observed "urethral pressure variations," is an important aspect of overactive bladder syndrome (OAB). The purpose of this report is to summarize current urethral pathophysiology evidence and outline directions for future research based on a literature review and discussions during the ICI-RS meeting in Bristol in 2014. Urethral pathophysiology with a focus on urethral pressure variation (UPV) was presented and discussed in a multidisciplinary think tank session at the ICI_R meeting in Bristol 2014. This think tank session was based on collaboration between physicians and basic science researchers. Experimental animal studies or studies performed in clinical series (predominantly symptomatic women) provided insights into UPV, but the findings were inconsistent and incomplete. However, UPV is certainly associated with lower urinary tract symptoms (likely OAB), and thus, future research on this topic is relevant. Future research based on adequately defined clinical (and urodynamic) parameters with precisely defined patient groups might shed better light on the cause of OAB symptoms. Further fundamental investigation of urethral epithelial-neural interactions via the release of mediators should enhance our knowledge and improve the management of patients with OAB. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.

Renal preservation in children with neurogenic bladder-sphincter dysfunction followed in a national program.

PubMed

Wide, Peter; Glad Mattsson, Gunilla; Mattsson, Sven

2012-04-01

Neurogenic bladder-sphincter dysfunction (NBSD) constitutes the major reason for morbidity in children with spina bifida. The aim of this study was to identify risk factors for renal damage in children with NBSD followed according to the Swedish national guidelines. Records and cystometries from 6 to 16 years (median 11) follow up of 41 consecutive children born 1993-2003 with NBSD were evaluated. The children were divided into a high pressure group (baseline pressure above 30 cmH(2)O at maximal clean intermittent catheterization volume in at least two cystometries) and a low pressure group. Most children (34/41) were followed from birth. Although renal scarring on DMSA-scintigraphy was found in 5/41 children, all but one had normal renal function. Two already had renal scars on entering the follow-up program at age 2.5 and 3 years. Renal scarring was more frequent in the high pressure group (P < 0.01). Most children with renal scars (4/5) had a combination of low compliant bladder and insufficient compliance with treatment and follow up. High baseline pressure is confirmed as a risk factor that, in combination with complex social issues, creates a demanding situation for families and professionals. A structured early follow up with treatment compliance effectively prevents renal damage. Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Maximum upper esophageal sphincter (UES) admittance: a non-specific marker of UES dysfunction.

PubMed

Cock, C; Besanko, L; Kritas, S; Burgstad, C M; Thompson, A; Heddle, R; Fraser, R J L; Omari, T I

2016-02-01

Assessment of upper esophageal sphincter (UES) motility is challenging, as functionally, UES relaxation and opening are distinct. We studied novel parameters, UES admittance (inverse of nadir impedance), and 0.2-s integrated relaxation pressure (IRP), in patients with cricopharyngeal bar (CPB) and motor neuron disease (MND), as predictors of UES dysfunction. Sixty-six healthy subjects (n = 50 controls 20-80 years; n = 16 elderly >80 years), 11 patients with CPB (51-83 years) and 16 with MND (58-91 years) were studied using pharyngeal high-resolution impedance manometry. Subjects received 5 × 5 mL liquid (L) and viscous (V) boluses. Admittance and IRP were compared by age and between groups. A p < 0.05 was considered significant. In healthy subjects, admittance was reduced (L: p = 0.005 and V: p = 0.04) and the IRP higher with liquids (p = 0.02) in older age. Admittance was reduced in MND compared to both healthy groups (Young: p < 0.0001 for both, Elderly L: p < 0.0001 and V: p = 0.009) and CPB with liquid (p = 0.001). Only liquid showed a higher IRP in MND patients compared to controls (p = 0.03), but was similar to healthy elderly and CPB patients. Only admittance differentiated younger controls from CPB (L: p = 0.0002 and V: p < 0.0001), with no differences in either parameter between CPB and elderly subjects. The effects of aging and pathology were better discriminated by UES maximum admittance, demonstrating greater statistical confidence across bolus consistencies as compared to 0.2-s IRP. Maximum admittance may be a clinically useful determinate of UES dysfunction. © 2015 John Wiley & Sons Ltd.

Argon Plasma Coagulation Therapy Versus Topical Formalin for Intractable Rectal Bleeding and Anorectal Dysfunction After Radiation Therapy for Prostate Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yeoh, Eric, E-mail: eric.yeoh@health.sa.gov.au; School of Medicine, University of Adelaide, Adelaide; Tam, William

Purpose: To evaluate and compare the effect of argon plasma coagulation (APC) and topical formalin for intractable rectal bleeding and anorectal dysfunction associated with chronic radiation proctitis. Methods and Materials: Thirty men (median age, 72 years; range, 49-87 years) with intractable rectal bleeding (defined as ≥1× per week and/or requiring blood transfusions) after radiation therapy for prostate carcinoma were randomized to treatment with APC (n=17) or topical formalin (n=13). Each patient underwent evaluations of (1) anorectal symptoms (validated questionnaires, including modified Late Effects in Normal Tissues–Subjective, Objective, Management, and Analytic and visual analogue scales for rectal bleeding); (2) anorectal motormore » and sensory function (manometry and graded rectal balloon distension); and (3) anal sphincteric morphology (endoanal ultrasound) before and after the treatment endpoint (defined as reduction in rectal bleeding to 1× per month or better, reduction in visual analogue scales to ≤25 mm, and no longer needing blood transfusions). Results: The treatment endpoint was achieved in 94% of the APC group and 100% of the topical formalin group after a median (range) of 2 (1-5) sessions of either treatment. After a follow-up duration of 111 (29-170) months, only 1 patient in each group needed further treatment. Reductions in rectal compliance and volumes of sensory perception occurred after APC, but no effect on anorectal symptoms other than rectal bleeding was observed. There were no differences between APC and topical formalin for anorectal symptoms and function, nor for anal sphincteric morphology. Conclusions: Argon plasma coagulation and topical formalin had comparable efficacy in the durable control of rectal bleeding associated with chronic radiation proctitis but had no beneficial effect on anorectal dysfunction.« less

Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME

PubMed Central

Djakovic, Zeljko; Djakovic, Ivka; Cesarec, Vedran; Madzarac, Goran; Becejac, Tomislav; Zukanovic, Goran; Drmic, Domagoj; Batelja, Lovorka; Zenko Sever, Anita; Kolenc, Danijela; Pajtak, Alen; Knez, Nikica; Japjec, Mladen; Luetic, Kresimir; Stancic-Rokotov, Dinko; Seiwerth, Sven; Sikiric, Predrag

2016-01-01

AIM To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular. METHODS Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NO-system. In the 4 d after esophagogastric anastomosis creation, rats received medication (/kg intraperitoneally once daily: BPC 157 (10 μg, 10 ng), L-NAME (5 mg), or L-arginine (100 mg) alone and/or combined or BPC 157 (10 μg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage (sum of the longest diameters, mm), esophagitis (scored 0-5), weak anastomosis (mL H2O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter (cm H2O), progressive weight loss (g) and mortality. Immediate effect assessed blood vessels disappearance (scored 0-5) at the stomach surface immediately after anastomosis creation. RESULTS BPC 157 (all regimens) fully counteracted the perilous disease course from the very beginning (i.e., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening (with L-NAME administration) and amelioration (with L-arginine), either L-arginine amelioration prevails (attenuated esophageal and gastric lesions) or they counteract each other (L-NAME + L-arginine); with the addition of BPC 157 (L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability (as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening (obtained with L-NAME administration that was counteracted); or amelioration (L-arginine + BPC 157-rats correspond to BPC 157-rats). CONCLUSION Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy. PMID:27895400

Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME.

PubMed

Djakovic, Zeljko; Djakovic, Ivka; Cesarec, Vedran; Madzarac, Goran; Becejac, Tomislav; Zukanovic, Goran; Drmic, Domagoj; Batelja, Lovorka; Zenko Sever, Anita; Kolenc, Danijela; Pajtak, Alen; Knez, Nikica; Japjec, Mladen; Luetic, Kresimir; Stancic-Rokotov, Dinko; Seiwerth, Sven; Sikiric, Predrag

2016-11-07

To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular. Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NO-system. In the 4 d after esophagogastric anastomosis creation, rats received medication (/kg intraperitoneally once daily: BPC 157 (10 μg, 10 ng), L-NAME (5 mg), or L-arginine (100 mg) alone and/or combined or BPC 157 (10 μg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage (sum of the longest diameters, mm), esophagitis (scored 0-5), weak anastomosis (mL H 2 O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter (cm H 2 O), progressive weight loss (g) and mortality. Immediate effect assessed blood vessels disappearance (scored 0-5) at the stomach surface immediately after anastomosis creation. BPC 157 (all regimens) fully counteracted the perilous disease course from the very beginning ( i.e ., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening (with L-NAME administration) and amelioration (with L-arginine), either L-arginine amelioration prevails (attenuated esophageal and gastric lesions) or they counteract each other (L-NAME + L-arginine); with the addition of BPC 157 (L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability (as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening (obtained with L-NAME administration that was counteracted); or amelioration (L-arginine + BPC 157-rats correspond to BPC 157-rats). Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy.

Constipation and paradoxical puborectalis contraction in anismus and Parkinson's disease: a dystonic phenomenon?

PubMed

Mathers, S E; Kempster, P A; Swash, M; Lees, A J

1988-12-01

Anismus, or constipation due to functional obstruction at the pelvic outlet by paradoxical contraction of the striated sphincter muscles during defaecation straining, is described in ten constipated patients and four patients with Parkinson's disease and constipation. The dysfunctional pattern of muscle recruitment resembled that characteristic of dystonia elsewhere in the body and was indistinguishable in patients with idiopathic anismus and those with extrapyramidal motor disturbance due to Parkinson's disease. These findings suggest that anismus may be a focal dystonic phenomenon.

Constipation and paradoxical puborectalis contraction in anismus and Parkinson's disease: a dystonic phenomenon?

PubMed Central

Mathers, S E; Kempster, P A; Swash, M; Lees, A J

1988-01-01

Anismus, or constipation due to functional obstruction at the pelvic outlet by paradoxical contraction of the striated sphincter muscles during defaecation straining, is described in ten constipated patients and four patients with Parkinson's disease and constipation. The dysfunctional pattern of muscle recruitment resembled that characteristic of dystonia elsewhere in the body and was indistinguishable in patients with idiopathic anismus and those with extrapyramidal motor disturbance due to Parkinson's disease. These findings suggest that anismus may be a focal dystonic phenomenon. PMID:3221217

The effect of yoga on puborectalis paradox.

PubMed

Dolk, A; Holmström, B; Johansson, C; Frostell, C; Nilsson, B Y

1991-08-01

Nine patients with severe defaecation difficulties primarily considered to be due to puborectalis dysfunction (puborectalis paradox), verified by electromyography (EMG) of the striated anal sphincter muscles, were offered training in Yogic techniques of relaxation and muscle control in order to change the activity of the pelvic floor muscles during attempted defaecation. Five patients completed the training program of 20 2-hour sessions and were re-examined clinically and with EMG. One patient regained a normal EMG pattern but none of the patients improved clinically.

Quantitative Reevaluation of the Effects of Short- and Long-Term Removal of Descending Modulatory Inputs on the Pyloric Rhythm of the Crab, Cancer borealis1,2,3

PubMed Central

Hamood, Albert W.; Haddad, Sara A.; Otopalik, Adriane G.; Rosenbaum, Philipp

2015-01-01

Abstract The crustacean stomatogastric ganglion (STG) receives descending neuromodulatory inputs from three anterior ganglia: the paired commissural ganglia (CoGs), and the single esophageal ganglion (OG). In this paper, we provide the first detailed and quantitative analyses of the short- and long-term effects of removal of these descending inputs (decentralization) on the pyloric rhythm of the STG. Thirty minutes after decentralization, the mean frequency of the pyloric rhythm dropped from 1.20 Hz in control to 0.52 Hz. Whereas the relative phase of pyloric neuron activity was approximately constant across frequency in the controls, after decentralization this changed markedly. Nine control preparations kept for 5–6 d in vitro maintained pyloric rhythm frequencies close to their initial values. Nineteen decentralized preparations kept for 5–6 d dropped slightly in frequency from those seen at 30 min following decentralization, but then displayed stable activity over 6 d. Bouts of higher frequency activity were intermittently seen in both control and decentralized preparations, but the bouts began earlier and were more frequent in the decentralized preparations. Although the bouts may indicate that the removal of the modulatory inputs triggered changes in neuronal excitability, these changes did not produce obvious long-lasting changes in the frequency of the decentralized preparations. PMID:25914899

The study between the dynamics and the X-ray anatomy and regularizing effect of gallbladder on bile duct sphincter of the dog.

PubMed

Wei, Jing-Guo; Wang, Yao-Cheng; Liang, Guo-Min; Wang, Wei; Chen, Bao-Ying; Xu, Jia-Kuan; Song, Li-Jun

2003-05-01

To study the relationship between the radiological anatomy and the dynamics on bile duct sphincter in bile draining and regularizing effect of gallbladder. Sixteen healthy dogs weighing 18 kg to 25 kg were divided randomly into control group and experimental group (cholecystectomy group). Cineradiography, manometry with perfusion, to effect of endogenous cholecystokinin and change of ultrastructure were employed. According to finding of the choledochography and manometry, in control group the intraluminal basal pressure of cephalic cyclic smooth muscle of choledochal sphincter cCS was 9.0+/-2.0 mmHg and that of middle oblique smooth muscle of choledochal sphincter (mOS) was 16.8+/-0.5 mmHg, the intraluminal basal pressure of cCS segment was obviously lower than that of mOS (P<0.01) in the interval period of bile draining, but significative difference of intraluminal basal pressure of the mOS segment was not found between the interval period of bile draining (16.8+/-0.5 mmHg) and the bile flowing period (15.9+/-0.9 mmHg) (P>0.05). The motility of cCS was mainly characterized by rhythmically concentric contraction, just as motility of cCS bile juice was pumped into the mOS segment in control group. And motility of mOS segment showed mainly diastolic and systolic activity of autonomically longitudinal peristalsis. There was spasmodic state in cCS and mOS segment and reaction to endogenous cholecystokinin was debased after cholecystectomy. The change of ultrastructure of cCS portion showed mainly that the myofilaments of cell line in derangement and mitochondria is swelling. During fasting, the cCS portion has a function as similar cardiac "pump" and it is main primary power source in bile draining, and mOS segment serves mainly as secondary power in bile draining. The existence of the intact gallbladder is one of the important factors in guaranteeing the functional coordination between the cCS and mOS of bile duct sphincter. There is dysfunction in the cCS and mOS with cholecystectomy.

[Social integration of women operated for obstetric urogenital fistula].

PubMed

Diarra, A; Tembely, A; Berthe, H J G; Diakité, M L; Traoré, B; Ouattara, K

2013-10-01

To study the social integration of women supported in the urology department of the University Hospital of Point G for obstetric urogenital fistula. Prospective study conducted over a period of 13 months from June 2008 to June 2009 in the Department of Urology at the University Hospital of Point G. The study included all patients who have been operated on at least twice for obstetric fistula genitourinary. Records of surgical, medical records and tracking sheets for each patient were the media database. Situation before treatment: before surgical treatment, 76.92% of patients were rejected by their spouses. The family attended the patient in 84.62% of cases. Situation after treatment: after treatment, 90.31% of women with fistula lived in the matrimonial home or family. The resumption of business activity was announced by 11.2% of patients. Among the women, 93.7% participated in housework. The number of patient intervention ranged from two to five. Healing (fistula closed and no sphincter dysfunction) was complete in 50% of cases. Among the women, 11.54% had sphincter dysfunction after closure of the fistula, which makes a total of fistula closed more than 61% after at least two attempts. The urogenital fistulas are not a fatal disease but is a real handicap for women who suffer to conduct a socio-cultural and economic mainstream. Generally excluded from the ongoing operations of the company, these women are more integrated after successful surgical treatment of the fistula. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Relationship of bladder dysfunction with upper urinary tract deterioration in cerebral palsy.

PubMed

Gündoğdu, Gökhan; Kömür, Mustafa; Avlan, Dinçer; Sarı, Ferda Bacaksızlar; Delibaş, Ali; Taşdelen, Bahar; Naycı, Ali; Okuyaz, Cetin

2013-10-01

Although lower urinary tract dysfunction (LUTD) in patients with cerebral palsy (CP) has been previously documented by clinical observations and urodynamic tests, its correlation with upper urinary tract deterioration (UUTD) has not been demonstrated. This paper documents symptoms and urodynamic findings of LUTD and their relationship with UUTD in 33 children with CP. By sonography, 4 of these children were found to have UUTD. Age was found to correlate with UUTD, but gender difference and mental or motor functions did not. When comparing urinary symptoms with UUTD, incontinence (n = 31) did not correlate, but on the other hand symptoms of detrusor sphincter dyssynergia (interrupted voiding, urinary retention, hesitancy; n = 5) and culture proven febrile urinary tract infections (n = 4) did. Abnormal urodynamics findings were not diagnostic. We conclude that, apart from incontinence, dysfunctional voiding symptoms and febrile urinary tract infections are valuable indicators of UUTD. Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Upper esophageal sphincter abnormalities: frequent finding on high-resolution esophageal manometry and associated with poorer treatment response in achalasia.

PubMed

Chavez, Yamile H; Ciarleglio, Maria M; Clarke, John O; Nandwani, Monica; Stein, Ellen; Roland, Bani C

2015-01-01

Abnormalities of the upper esophageal sphincter (UES) on high-resolution esophageal manometry (HREM) have been observed in both symptomatic and asymptomatic individuals and are often interpreted as incidental findings of unclear clinical significance. Our primary aims were: (1) to assess the frequency of UES abnormalities in consecutive patients referred for HREM studies; and (2) to characterize the demographics, clinical symptoms, and manometric profiles associated with UES abnormalities as compared with those with normal UES function. We performed a retrospective study of 200 consecutive patients referred for HREM. Patients were divided into those with normal and abnormal UES function, including impaired relaxation (residual pressure >12 mm Hg), hypertensive (>104 mm Hg), and hypotensive (<34 mm Hg) resting pressure. Clinical and manometric profiles were compared. A total of 32.5% of patients had UES abnormalities, the majority of which were hypertensive (55.4%). Patients with achalasia were significantly more likely to have UES abnormalities as compared with normal UES function (57.2% vs. 42.9%, P=0.04), with the most frequent abnormality being a hypertensive UES (50%). In addition, patients with impaired lower esophageal sphincter (LES) relaxation (esophagogastric junction outflow obstruction or achalasia) were more likely to have an UES abnormality present as compared with those with normal LES relaxation (53.1% vs. 28.6%, P=0.01). When we assessed for treatment response among patients with achalasia, we found that subjects with evidence of UES dysfunction had significantly worse treatment outcomes as compared with those without UES abnormalities present (20% improved vs. 100%, P=0.015). This remained true even after adjusting for type of treatment received (surgical myotomy, per-oral endoscopic mytotomy, botulinum toxin injection, pneumatic dilatation, medical therapy, P=0.67) and achalasia subtype (P=1.00). UES abnormalities are a frequent finding on HREM studies, especially in patients with impaired LES relaxation, including both achalasia and esophagogastric junction outflow obstruction. Interestingly, the most common UES abnormality associated with achalasia was a hypertensive resting UES, despite the fact that achalasia is thought to spare striated muscle. Among patients with achalasia, we found a significant association between the lack of treatment response and the presence of UES dysfunction. The routine evaluation of UES function in patients referred for manometry may enhance our understanding of esophageal motility disorders and may yield important prognostic information, particularly in subjects with achalasia. Future prospective studies are needed to further delineate the underlying mechanism between UES dysfunction with achalasia and other esophageal motility disorders to predict treatment response and guide therapeutic treatment modalities.

Predictive factors of Gastrointestinal motility Dysfunction after gastrojejunostomy for peptic ulcer stenosis.

PubMed

Ayadi, Sofiene; Daghfous, Amine; Saidani, Ahmed; Haddad, Anis; Magherbi, Houcine; Jouini, Mohamed; Kacem, Montassar; Ben Safta, Zoubeir

2014-10-01

Despite the establishment of effective medical therapies in peptic ulcer disease, gastric outlet obstruction remains one of the most common health problem in Tunisia. Various operations have been attempted, which may lead to postoperative morbidity. Gastrointestinal (GI) motility dysfunction is the most common complications. to determine the predictive factor of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis. We carried out a retrospective study to evaluate the postoperative recovery of the motility of the upper gastrointestinal tract after gastrojejunostomy for peptic ulcer stenosis. During the 9- year study, 138 patients underwent operations for ulcer peptic stenosis. Among the patients, 116 (84,1%) were treated with gastrojejunostomy. Descriptive statistics, univariate and multivariate analyses were performed. The mean age of patients was 47.85 years (range: 19- 92years) and most. Were male (84, 5 %). Ninety two (79.3%) patients had a documented history of peptic ulcer disease. The duration of symptoms ranged from 10 to 372 days (mean: 135.86 days). Eighty two (71%) patients were operated on through laparotomy. Laparoscopic procedure was performed in 29% of the patients. There was no operative mortality. Perioperative morbidity occurred in 12.4% (14 patients). Gastrointestinal motility dysfunction occurred in 12 patients (10.3%). It was treated by nasogastric aspiration and prokinetics. By univariate analysis; diabetes (0,010), cachexia (0,049), ASA class (0.05) were all statistically associated with gastrointestinal motility dysfunction in this series. Multivariate logistic regression analysis (table 2) showed that the cachexia (0,009), ASA class (0.02) were the main predictors of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis in the followed patients. Gastrointestinal motility dysfunction is the most common complications after gastrojejunostomy for pyloric adult stenosis. Surgery must be preceded by careful medical preparation. It is more likely to occur in patients with an ASA class 2 or greater. Those patients should be considered for other treatment options, such as endoscopic balloon dilation.

Proctalgia fugax: would you recognize it?

PubMed

Babb, R R

1996-04-01

Proctalgia fugax is characterized by sudden and sometimes severe rectal pain that occurs by day or night at irregular intervals. The pain results from dysfunction of the internal anal sphincter. Proctalgia fugax has a uniform clinical picture, and it can be easily diagnosed when recognized. The patient can be assured that nothing serious is wrong. Expensive tests, such as computed tomography or magnetic resonance imaging of the pelvis, are not required. Treatment may be difficult, but if the attacks of pain are numerous and severe,, a calcium channel blocker such as nifedipine (Adalat, Procardia) should be tried.

The Inhibitory Effect of Botulinum Toxin Type A on Rat Pyloric Smooth Muscle Contractile Response to Substance P In Vitro

PubMed Central

Shao, Yu-Feng; Xie, Jun-Fan; Ren, Yin-Xiang; Wang, Can; Kong, Xiang-Pan; Zong, Xiao-Jian; Fan, Lin-Lan; Hou, Yi-Ping

2015-01-01

A decrease in pyloric myoelectrical activity and pyloric substance P (SP) content following intrasphincteric injection of botulinum toxin type A (BTX-A) in free move rats have been demonstrated in our previous studies. The aim of the present study was to investigate the inhibitory effect of BTX-A on rat pyloric muscle contractile response to SP in vitro and the distributions of SP and neurokinin 1 receptor (NK1R) immunoreactive (IR) cells and fibers within pylorus. After treatment with atropine, BTX-A (10 U/mL), similar to [D-Arg1, D-Phe5, D-Trp7,9, Leu11]-SP (APTL-SP, 1 μmol/L) which is an NK1R antagonist, decreased electric field stimulation (EFS)-induced contractile tension and frequency, whereas, subsequent administration of APTL-SP did not act on contractility. Incubation with BTX-A at 4 and 10 U/mL for 4 h respectively decreased SP (1 μmol/L)-induced contractions by 26.64% ± 5.12% and 74.92% ± 3.62%. SP-IR fibers and NK1R-IR cells both located within pylorus including mucosa and circular muscle layer. However, fewer SP-fibers were observed in pylorus treated with BTX-A (10 U/mL). In conclusion, BTX-A inhibits SP release from enteric terminals in pylorus and EFS-induced contractile responses when muscarinic cholinergic receptors are blocked by atropine. In addition, BTX-A concentration- and time-dependently directly inhibits SP-induced pyloric smooth muscle contractility. PMID:26501321

The Inhibitory Effect of Botulinum Toxin Type A on Rat Pyloric Smooth Muscle Contractile Response to Substance P In Vitro.

PubMed

Shao, Yu-Feng; Xie, Jun-Fan; Ren, Yin-Xiang; Wang, Can; Kong, Xiang-Pan; Zong, Xiao-Jian; Fan, Lin-Lan; Hou, Yi-Ping

2015-10-15

A decrease in pyloric myoelectrical activity and pyloric substance P (SP) content following intrasphincteric injection of botulinum toxin type A (BTX-A) in free move rats have been demonstrated in our previous studies. The aim of the present study was to investigate the inhibitory effect of BTX-A on rat pyloric muscle contractile response to SP in vitro and the distributions of SP and neurokinin 1 receptor (NK1R) immunoreactive (IR) cells and fibers within pylorus. After treatment with atropine, BTX-A (10 U/mL), similar to [D-Arg¹, D-Phe⁵, D-Trp(7,9), Leu(11)]-SP (APTL-SP, 1 μmol/L) which is an NK1R antagonist, decreased electric field stimulation (EFS)-induced contractile tension and frequency, whereas, subsequent administration of APTL-SP did not act on contractility. Incubation with BTX-A at 4 and 10 U/mL for 4 h respectively decreased SP (1 μmol/L)-induced contractions by 26.64% ± 5.12% and 74.92% ± 3.62%. SP-IR fibers and NK1R-IR cells both located within pylorus including mucosa and circular muscle layer. However, fewer SP-fibers were observed in pylorus treated with BTX-A (10 U/mL). In conclusion, BTX-A inhibits SP release from enteric terminals in pylorus and EFS-induced contractile responses when muscarinic cholinergic receptors are blocked by atropine. In addition, BTX-A concentration- and time-dependently directly inhibits SP-induced pyloric smooth muscle contractility.

Lower urinary tract and sexual dysfunction in neurological patients.

PubMed

Vodušek, David B

2014-01-01

Lower urinary tract dysfunction (LUTD) and sexual dysfunction (SD) are common in neurological patients due to a combination of lesions affecting relevant neural control, constraints imposed by sensorimotor and cognitive deficits and--particularly for SD--psychosocial consequences of chronic neurological disease. This review summarizes the etiology, diagnosis and treatment of LUTD and SD in neurological patients. LUTD may lead to serious health problems; both LUTD and SD significantly affect quality of life. Management of patients with spinal cord injury and dysraphism is undertaken in specialized centers according to established guidelines. Treatment of neurological patients with noncomplicated neurogenic LUTD or SD should preferentially be guided by a neurologist. For rational treatment of urinary symptoms, an accurate assessment is mandatory; the bladder and the sphincter need to be defined as normal, over- or underactive. Urodynamic testing is the gold standard for functional diagnosis; assessment of residual urine and uroflow are the minimal requirements before considering management. Dysfunction of desire, arousal and orgasm (ejaculation) may be diagnosed by medical history and are amenable to counselling and treatment, which is--in the case of erectile dysfunction--evidence based. Further high-quality studies are necessary to test the best approaches for diagnosing and managing particular types of neurogenic LUTD and SD in the different neurological patient populations. © 2014 S. Karger AG, Basel.

Pharyngeal dilation in cricopharyngeus muscle dysfunction and Zenker diverticulum.

PubMed

Belafsky, Peter C; Rees, Catherine J; Allen, Jacqueline; Leonard, Rebecca J

2010-05-01

Prolonged obstruction at the level of the lower esophageal sphincter is associated with a dilated, poorly contractile esophagus. The association between prolonged obstruction at the level of the upper esophageal sphincter (UES) and dilation and diminished contractility of the pharynx is uncertain. The purpose of this investigation was to evaluate the association between prolonged obstruction at the level of the UES and dilation and diminished contractility of the pharynx. Case-control study. The fluoroscopic swallow studies of all persons with cricopharyngeus muscle dysfunction (CPD) diagnosed between January 1, 2006 and December 31, 2008 were retrospectively reviewed from a clinical database. Three categories of CPD were defined: nonobstructing cricopharyngeal bars (CPBs), obstructing CPBs, and Zenker diverticulum (ZD). The primary outcome measure was the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength on fluoroscopy. Secondary outcome measures included pharyngeal area in the lateral fluoroscopic view and UES opening. The outcome measures were compared between groups and to a cohort of nondysphagic age- and gender-matched controls with the analysis of variance. A total of 100 fluoroscopic swallow studies were evaluated. The mean age (+ or -standard deviation) of the cohort was 70 years (+ or -10 years). Thirty-six percent were female. The mean PCR progressively increased, indicating diminishing pharyngeal strength, from the normal (0.08), to the nonobstructing CPB (0.13), to the obstructing CPB (0.22), to the ZD group (0.28) (P < .001 with trend for linearity). There was a linear increase in pharyngeal area from the normal (8.75 cm(2)) to the nonobstructing CPB (10.00 cm(2)), to the obstructing CPB (10.46 cm(2)), to the ZD group (11.82 cm(2)) (P < .01 with trend for linearity). The data suggest that there is an association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of the pharynx. Laryngoscope, 2010.

Lateral internal sphincterotomy for surgically recurrent chronic anal fissure.

PubMed

Liang, Jennifer; Church, James M

2015-10-01

Lateral internal sphincterotomy cures chronic anal fissure by preventing internal sphincter hypertonia. However, cutting sphincter predisposes to sphincter dysfunction, manifests as incontinence of gas, liquid, or stool. Surgeons, therefore, can be too cautious in its use, making ineffective superficial incisions or avoiding the operation altogether. This study is designed to confirm the role of redo lateral internal sphincterotomy in the treatment of surgically recurrent chronic anal fissure. Patients undergoing repeat lateral internal sphincterotomy for surgically recurrent chronic anal fissure were accessed from a prospectively maintained database. Chronicity was defined by symptoms persisting more than 3 weeks. Contralateral sphincterotomy was performed with electrocautery through a stab incision over the intersphincteric plane. The length of sphincter division was the same as the length of the fissure. Phone questionnaire was administered and fecal continence was assessed by modified Cleveland Clinic Incontinence Score. Patients were asked to rank their overall satisfaction with the operation, and pre- and postoperative quality of life. There were 57 patients, 24 women and 33 men; mean age was 47.9 ± 14.8 years. Mean follow-up was 12.5 ± 4.2 years (range 6.2 to 25.2 years). Presenting symptoms included pain (100%), bleeding (80%), pruritus ani (39%), constipation (26%), and diarrhea. Fifty patients (90%) presented with 1 fissure, and 40 were posterior. Most procedures were performed on an outpatient basis. Fissure healing rate was 98%, and 2 patients (4%) developed minor incontinence postoperatively (one of gas, the other, gas and seepage). Overall satisfaction was 9.7 ± .9 out of 10 with a significant improvement in the quality of life from 5.7 ± 2.4 out of 10 to 9.3 ± 1.4 out of 10 (P < .001). Judicious repeat lateral sphincterotomy cures recurrent chronic fissures with minimal risk of incontinence. Copyright © 2015 Elsevier Inc. All rights reserved.

The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right.

PubMed

Weksler, Natan; Velan, Gad J; Semionov, Michael; Gurevitch, Boris; Klein, Moti; Rozentsveig, Vsevolod; Rudich, Tzvia

2007-12-01

It is a common practice to the link low back pain with protruding disc even when neurological signs are absent. Because pain caused by sacroiliac joint dysfunction can mimic discogenic or radicular low back pain, we assumed that the diagnosis of sacroiliac joint dysfunction is frequently overlooked. To assess the incidence of sacroiliac joint dysfunction in patients with low back pain and positive disc findings on CT scan or MRI, but without claudication or objective neurological deficits. Fifty patients with low back pain and disc herniation, without claudication or neurological abnormalities such as decreased motor strength, sensory alterations or sphincter incontinence and with positive pain provocation tests for sacroiliac joint dysfunction were submitted to fluoroscopic diagnostic sacroiliac joint infiltration. The mean baseline VAS pain score was 7.8 +/- 1.77 (range 5-10). Thirty minutes after infiltration, the mean VAS score was 1.3 +/- 1.76 (median 0.000E+00 with an average deviation from median = 1.30) (P = 0.0002). Forty-six patients had a VAS score ranging from 0 to 3, 8 weeks after the fluoroscopic guided infiltration. There were no serious complications after treatment. An unanticipated motor block that required hospitalization was seen in four patients, lasting from 12 to 36 h. Sacroiliac joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients.

PACAP/Receptor System in Urinary Bladder Dysfunction and Pelvic Pain Following Urinary Bladder Inflammation or Stress

PubMed Central

Girard, Beatrice M.; Tooke, Katharine; Vizzard, Margaret A.

2017-01-01

Complex organization of CNS and PNS pathways is necessary for the coordinated and reciprocal functions of the urinary bladder, urethra and urethral sphincters. Injury, inflammation, psychogenic stress or diseases that affect these nerve pathways and target organs can produce lower urinary tract (LUT) dysfunction. Numerous neuropeptide/receptor systems are expressed in the neural pathways of the LUT and non-neural components of the LUT (e.g., urothelium) also express peptides. One such neuropeptide receptor system, pituitary adenylate cyclase-activating polypeptide (PACAP; Adcyap1) and its cognate receptor, PAC1 (Adcyap1r1), have tissue-specific distributions in the LUT. Mice with a genetic deletion of PACAP exhibit bladder dysfunction and altered somatic sensation. PACAP and associated receptors are expressed in the LUT and exhibit neuroplastic changes with neural injury, inflammation, and diseases of the LUT as well as psychogenic stress. Blockade of the PACAP/PAC1 receptor system reduces voiding frequency in preclinical animal models and transgenic mouse models that mirror some clinical symptoms of bladder dysfunction. A change in the balance of the expression and resulting function of the PACAP/receptor system in CNS and PNS bladder reflex pathways may underlie LUT dysfunction including symptoms of urinary urgency, increased voiding frequency, and visceral pain. The PACAP/receptor system in micturition pathways may represent a potential target for therapeutic intervention to reduce LUT dysfunction. PMID:29255407

Central control of micturition in women: Brain-bladder pathways in continence and urgency urinary incontinence.

PubMed

Arya, Nisha G; Weissbart, Steven J

2017-04-01

Urinary incontinence disproportionately affects women. Anatomical textbooks typically describe continence mechanisms in women in the context of the pelvic floor support of the urinary bladder and the urethral sphincters. However, the urinary bladder and urethral sphincters are under the central control of the brain through a complex network of neurons that allow storage of urine followed by voiding when socially appropriate. Recent studies suggest that the most common type of urinary incontinence in women, urgency urinary incontinence, involves significant dysfunction of the central control of micturition. In this paper, we review the anatomy and functional connectivity of the nervous system structures involved in the control of micturition. Clinical application of this anatomy in the context of urgency urinary incontinence is also discussed. Understanding the anatomy of the neural structures that control continence will allow clinicians to better understand the underlying pathology of urge incontinence and consider new ways of treating this distressing condition. Clin. Anat. 30:373-384, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

A crying baby: not simply infant colic.

PubMed

Onesimo, Roberta; Giorgio, Valentina; Monaco, Serena; Fundarò, Carlo

2012-08-21

Hypertrophic pyloric stenosis is a relatively common condition, but atypical presentations can present a diagnostic challenge. We describe the case of a 9-week-old Latin male infant who presented with a 2-day history of intermittent crying and poor feeding. He was suspected to have intussusception but was affected by and successfully treated for hypertrophic pyloric stenosis. Diagnostic tools of atypical HPS cases are discussed.

A Cross-Sectional Review of Reporting Variation in Postoperative Bowel Dysfunction After Rectal Cancer Surgery.

PubMed

Chapman, Stephen J; Bolton, William S; Corrigan, Neil; Young, Neville; Jayne, David G

2017-02-01

Postoperative bowel dysfunction affects quality of life after sphincter-preserving rectal cancer surgery, but the extent of the problem is not clearly defined because of inconsistent outcome measures used to characterize the condition. The purpose of this study was to assess variation in the reporting of postoperative bowel dysfunction and to make recommendations for standardization in future studies. If possible, a quantitative synthesis of bowel dysfunction symptoms was planned. MEDLINE and EMBASE databases, as well as the Cochrane Library, were queried systematically between 2004 and 2015. The studies selected reported at least 1 component of bowel dysfunction after resection of rectal cancer. The main outcome measures were reporting, measurement, and definition of postoperative bowel dysfunction. Of 5428 studies identified, 234 met inclusion criteria. Widely reported components of bowel dysfunction were incontinence to stool (227/234 (97.0%)), frequency (168/234 (71.8%)), and incontinence to flatus (158/234 (67.5%)). Urgency and stool clustering were reported less commonly, with rates of 106 (45.3%) of 234 and 61 (26.1%) of 234. Bowel dysfunction measured as a primary outcome was associated with better reporting (OR = 3.49 (95% CI, 1.99-6.23); p < 0.001). Less than half of the outcomes were assessed using a dedicated research tool (337/720 (46.8%)), and the remaining descriptive measures were infrequently defined (56/383 (14.6%)). Heterogeneity in the reporting, measurement, and definition of postoperative bowel dysfunction precluded pooling of results and limited interpretation. Considerable variation exists in the reporting, measurement, and definition of postoperative bowel dysfunction. These inconsistencies preclude reliable estimates of incidence and meta-analysis. A broadly accepted outcome measure may address this deficit in future studies.

Certain aspects of normal and abnormal motility of sphincter of Oddi.

PubMed

Coelho, J C; Moody, F G

1987-01-01

Applications of electromyographic and endoscopic manometric techniques in experimental and clinical studies have enhanced our knowledge of the normal physiology and motility disturbances of the sphincter of Oddi. The sphincter of Oddi has an active role in coordinating the time and rate of secretion of biliopancreatic juice into the duodenum. In the opossum, the sphincter of Oddi exhibits spontaneous contractions that migrate distally along the sphincter and expels its contents into the duodenum. Although the motor activity of the sphincter of Oddi is independent from that of the duodenum, there is a correlation between the frequency of bursts of spike potentials in the sphincter of Oddi and the migrating motor complex phases in the duodenum. Abnormal motility of the sphincter of Oddi has been reported during endoscopic manometric evaluation of patients with choledocholithiasis and sphincter of Oddi dyskinesia. Patients with common bile duct stones have an increase in the frequency of retrograde propagation of phasic waves. Elevation of basal pressure as well as an increase in the frequency and amplitude of sphincter of Oddi phasic waves and the common bile duct-duodenum gradient pressure may occur in patients with sphincter of Oddi dyskinesia. Endoscopic manometric studies of the sphincter of Oddi may become an important method to diagnose sphincter of Oddi dyskinesia.

Gastric mucosal defence mechanism during stress of pyloric obstruction in albino rats.

PubMed

Somasundaram, K; Ganguly, A K

1987-04-01

1. The integrity of the gastric mucosa and its ability to secrete mucus are believed to be essential for protection of gastric mucosa against ulceration induced by aggressive factors active in any stress situation. This study involves a three-compartmental analysis of gastric mucosal barrier in pylorus-ligated albino rats. 2. Quantitative analyses of histologically identifiable gastric mucosal epithelial neutral glycoproteins and gastric adherent mucus from oxyntic and pyloric gland areas, and components of non-dialysable mucosubstances in gastric secretion were made under stress of pyloric obstruction for 4, 8, and 16 h durations. Epithelial mucin was identified by periodic acid-Schiff (PAS) staining technique and assessed from the ratio of gastric mucosal thickness to the depth of PAS positive materials in it. The remaining visible mucus adhered to the gastric mucosa was estimated by Alcian blue binding technique. The results were compared with that of identical control groups. 3. A significant reduction in mucosal epithelial PAS positive materials after 8 or 16 h of pylorus ligation was observed. 4. The Alcian blue binding capacity of the pyloric gland area was increased significantly after 4 h of pylorus ligation, while after 8 or 16 h it was reduced in both oxyntic and pyloric gland areas. 5. Significant reductions in the rate of gastric secretion and volume, as well as concentration of the components of non-dialysable mucosubstances, were observed, indicating decreased synthesis of mucus glycoproteins. 6. Disruption of the mucosal barrier may have occurred due to decreased mucus synthesis and acid-pepsin accumulation; both could be due to stress associated with gastric distension. 7. The present findings confirm the role of mucus in protecting the underlying gastric epithelium during stress. The adherent mucus offers a first line of defence and epithelial mucus a second line of defence.

Intramural distribution of immunoreactive vasoactive intestinal polypeptide (VIP), substance P, somatostatin and mammalian bombesin in the oesophago-gastro-pyloric region of the human gut.

PubMed

Ferri, G L; Adrian, T E; Soimero, L; Blank, M; Cavalli, D; Biliotti, G; Polak, J M; Bloom, S R

1989-04-01

The intramural distribution of vasoactive intestinal polypeptide (VIP), substance P, somatostatin and mammalian bombesin was studied in the oesophago-gastro-pyloric region of the human gut. At each of 21 sampling sites encompassing this entire area, the gut wall was separated into mucosa, submucosa and muscularis externa, and extracted for radioimmunoassay. VIP levels in the mucosa were very high in the proximal oesophagus (1231 +/- 174 pmol/g, mean +/- SEM) and showed varied, but generally decreasing concentrations towards the stomach, followed by a clear-cut increase across the pyloric canal (distal antrum: 73 +/- 16 pmol/g, proximal duodenum: 366 +/- 62 pmol/g); consistent levels were found in submucosa and muscle (200-400 pmol/g) at most sites, the stomach again showing lower concentrations. By contrast, substance P was present in small amounts as far as the proximal stomach, but sharply increased across the pyloric canal, especially in mucosa and submucosa (distal antrum: 20 +/- 6.5 and 5.5 +/- 1.3 pmol/g; proximal duodenum: 62 +/- 8.5 and 34 +/- 11 pmol/g, respectively). Somatostatin concentrations were very low in the mucosa of the oesophagus and stepwise increased in the cardiac, mid-gastric and pyloric mucosa (cardia: 224 +/- 72 pmol/g; distal antrum: 513 +/- 152 pmol/g; proximal duodenum: 1013 +/- 113 pmol/g); concentrations in the submucosa and muscularis were generally low, with the exception of antrum and duodenum. Mammalian bombesin was comparatively well represented throughout the oesophageal muscularis (5-8 pmol/g), but most abundant in the stomach in all layers (oxyntic mucosa: 24 +/- 2.7 pmol/g; submucosa: 20 +/- 5.7 pmol/g; muscle: 28 +/- 5.0 pmol/g).(ABSTRACT TRUNCATED AT 250 WORDS)

Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness.

PubMed

Windle, E M; Beddow, D; Hall, E; Wright, J; Sundar, N

2010-02-01

Artificial nutrition support is required to optimise nutritional status in many patients. Traditional methods of placing feeding tubes may incur clinical risk and financial costs. A technique facilitating placement of nasogastric and post-pyloric tubes via electromagnetic visual guidance may reduce the need for X-ray exposure, endoscopy time and the use of parenteral nutrition. The present study aimed to audit use of such a system at initial implementation in patients within an acute NHS Trust. A retrospective review was undertaken of dietetic and medical records for the first 14 months of using the Cortrak system. Data were collected on referral origin, preparation of the patient prior to insertion, placement success rates and need for X-ray. Cost analysis was also performed. Referrals were received from primary consultants or consultant intensivists, often on the advice of the dietitian. Fifty-nine percent of patients received prokinetic therapy at the time of placement. Thirty-nine tube placements were attempted. Sixty-nine percent of referrals for post-pyloric tube placement resulted in successful placement. X-ray films were requested for 22% of all attempted post-pyloric placements. Less than half of nasogastric tubes were successfully passed, although none of these required X-ray confirmation. The mean cost per tube insertion attempt was 111 pounds. This system confers advantages, particularly in terms of post-pyloric tube placement, even at this early stage of implementation. A reduction in clinical risk and cost avoidance related to X-ray exposure, the need for endoscopic tube placement and parenteral nutrition have been achieved. The implementation of this system should be considered in other centres.

Pathophysiology of chronic childhood constipation: functional and morphological evaluation by anorectal manometry and endosonography and colonic transit study.

PubMed

Keshtgar, Alireza S; Ward, Harry C; Clayden, Graham S

2013-04-01

Chronic idiopathic constipation (IC) is a common problem in children. We hypothesised that hypertonicity and overactivity of the internal anal sphincter (IAS) contributed to childhood IC. This was a prospective study of children who were admitted for investigation and treatment of chronic constipation at the gastrointestinal motility clinic in Guy's and St. Thomas' Hospital, NHS Foundation Trust, London. All children had a colonic transit marker study followed by anorectal manometry and anal endosonography under ketamine anesthesia. We used a validated symptom severity (SS) score questionnaire for assessment of constipation and fecal incontinence on admission to hospital and during follow-up for 12months. The SS score of 0 was the best and 65 the worst. Of 92 children, 57 were male and median (range) age was 8.46years (3.35-14.97). Duration of symptoms was 4.7years (0.3-13). Soiling was present in 88 (96%) patients, delay in defecation of once every 2 to 3days or less frequently in 86 (93%) and a palpable fecaloma (megarectum) on abdominal examination in 76 (83%). 42 children had 'fecal impaction' requiring disimpaction of stool from the rectum under general anesthesia and 50 had 'no impaction'. The median IAS resting pressure was within the normal range measuring 55mm Hg (25-107) and median amplitude and frequency of the IAS contractions were 10mm Hg (2.0-58) and 17cycles per min (5.0-34), respectively. The median IAS thickness was 0.93mm (0.5-2.0). There was no correlation between amplitude and frequency of anorectal contractions and anal sphincter resting pressure. The mean right colonic transit time was 8.55 (standard deviation ±13.22) h, left colonic transit time was 11.51h (±13.21), rectosigmoid transit time was 25.91h (±18.89) and total colonic transit time was 45.97h (±17.69). The anal sphincter resting pressure is normal in children with chronic IC. Increased frequency and amplitude of IAS contractions seen in these patients do not cause raised anal sphincter resting pressure or obstructive defecation. Further studies should be done to investigate the role of external anal sphincter dysfunction in pathophysiology of childhood constipation and fecal incontinence. Copyright © 2013 Elsevier Inc. All rights reserved.

Clinical role of a modified seton technique for the treatment of trans-sphincteric and supra-sphincteric anal fistulas.

PubMed

Tokunaga, Yukihiko; Sasaki, Hirokazu; Saito, Tohru

2013-03-01

We have devised a modified seton technique that resects the external fistula tract while preserving the anal sphincter muscle. This study assessed the technique when used for the management of complex anal fistulas. Between January 2006 and December 2007, 239 patients (208 males and 31 females, median age: 41 years) underwent surgery for complex anal fistulas using the technique. Of the 239 patients, 198 patients had trans-sphincteric fistula and 41 patients had supra-sphincteric fistula. The durations of the surgeries were 17 min (47, 13) [median (range, interquartile range)] for trans-sphincteric fistulas and 38 (44, 16) for supra-sphincteric fistulas. The durations of the surgeries were significantly (P < 0.05) longer for supra-sphincteric fistula than trans-sphincteric fistula. The hospital stays were 4 (13, 2) days and 5 (14, 3) days, respectively, for trans- and supra-sphincteric fistulas. The durations of seton placement until the spontaneous dropping of the seton were 42 (121, 48) and 141 (171, 55) days respectively. The recurrence rate was 0 % in patients with trans-sphincteric fistulas and 4.9 % (2 of 41) in patients with supra-sphincteric fistulas (P < 0.01). Serious incontinence was not observed. The technique provided favorable results for the treatment of complex anal fistulas and could be safely applied while preserving the sphincter function and conserving fecal continence.

[Postoperative complications after larynx resection: assessment with video-cinematography].

PubMed

Kreuzer, S; Schima, W; Schober, E; Strasser, G; Denk, D M; Swoboda, H

1998-02-01

In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.

Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency.

PubMed

Macura, Katarzyna Jadwiga; Thompson, Richard Eugene; Bluemke, David Alan; Genadry, Rene

2015-11-28

To define the magnetic resonance imaging (MRI) parameters differentiating urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD) in women with stress urinary incontinence (SUI). The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic (UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the high-resolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and the volunteer groups: (1) urethral angle; (2) bladder neck descent; (3) status of the periurethral ligaments, (4) vaginal shape; (5) urethral sphincter integrity, length and muscle thickness at mid urethra; (6) bladder neck funneling; (7) status of the puborectalis muscle; (8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows: (1) urethral mobility angle on Q-tip test; (2) Valsalva leak point pressure (VLPP) measured at 250 cc bladder volume; and (3) maximum urethral closure pressure (MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2O. The ISD incontinence was defined with MUCP pressure below 20 cm H2O, and VLPP pressure less or equal to 60 cm H2O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic (ROC) analysis. All statistical analyses were performed using STATA version 9.0 (StataCorp LP, College Station, TX). In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group (P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis (area under the ROC = 0.944). MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options.

Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency

PubMed Central

Macura, Katarzyna Jadwiga; Thompson, Richard Eugene; Bluemke, David Alan; Genadry, Rene

2015-01-01

AIM: To define the magnetic resonance imaging (MRI) parameters differentiating urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD) in women with stress urinary incontinence (SUI). METHODS: The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic (UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the high-resolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and the volunteer groups: (1) urethral angle; (2) bladder neck descent; (3) status of the periurethral ligaments, (4) vaginal shape; (5) urethral sphincter integrity, length and muscle thickness at mid urethra; (6) bladder neck funneling; (7) status of the puborectalis muscle; (8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows: (1) urethral mobility angle on Q-tip test; (2) Valsalva leak point pressure (VLPP) measured at 250 cc bladder volume; and (3) maximum urethral closure pressure (MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2O. The ISD incontinence was defined with MUCP pressure below 20 cm H2O, and VLPP pressure less or equal to 60 cm H2O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic (ROC) analysis. All statistical analyses were performed using STATA version 9.0 (StataCorp LP, College Station, TX). RESULTS: In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group (P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis (area under the ROC = 0.944). CONCLUSION: MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options. PMID:26644825

Bendectin (Debendox) as a risk factor for pyloric stenosis.

PubMed

Eskenazi, B; Bracken, M B

1982-12-15

The maternal use of Bendectin (Debendox) in the first trimester of pregnancy was examined in a case-control (n = 1,427 and 3,001, respectively) study of malformed infants whose mothers were interviewed between 1974 and 1976. Mothers of infants with congenital malformation showed an increased likelihood (odds ratio = 1.40) of having used Bendectin, with a stronger association of Bendectin with birth defects for mothers who also smoked (odds ratio = 2.91). A significant association was observed between the occurrence of pyloric stenosis in the infant and exposure to Bendectin in utero (odds ratio = 4.33). When maternal sociodemographic factors, including smoking, and smoking alone, were controlled, the association between Bendectin and pyloric stenosis was further increased (odds ratio = 4.63 and 5.24, respectively). Except for a possible association of Bendectin with heart valve anomalies (odds ratio = 2.99), we were unable to document other significantly increased risks for congenital malformations.

Prematurity Affects Age of Presentation of Pyloric Stenosis.

PubMed

Costanzo, Caitlyn M; Vinocur, Charles; Berman, Loren

2017-02-01

Term infants with hypertrophic pyloric stenosis (HPS) typically present between 4 and 6 weeks. There is limited consensus, however, regarding age of presentation of premature infants. We aim to determine if there is an association between the degree of prematurity and chronological age of presentation of HPS. A total of 2988 infants who had undergone a pyloromyotomy for HPS were identified from the 2012 and 2013 NSQIP-P Participant Use Files. Two hundred seventeen infants (7.3%) were born prematurely. A greater degree of prematurity was associated with an older chronological age of presentation ( P < .0001). Prematurity was significantly associated with an increase in overall postoperative morbidity, reintubation, readmission, and postoperative length of stay. When clinicians evaluate an infant with nonbilious emesis with a history of prematurity, they should consider pyloric stenosis if the calculated postconceptional age is between 44 and 50 weeks. When counseling families of premature infants, surgeons should discuss the increased incidence of postpyloromyotomy morbidity.

Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders.

PubMed

Regan, Julie; Murphy, Anne; Chiang, Mindy; McMahon, Barry P; Coughlan, Tara; Walshe, Margaret

2014-05-06

Adequate upper oesophageal sphincter (UOS) opening is critical to safe and efficient swallowing due to the close proximity of the UOS to the airway entrance. Many people with neurological conditions, progressive and non-progressive, present with UOS dysfunction. The consequences for the person include difficulty swallowing food with subsequent choking and aspiration (passage of material into the trachea beyond the level of the true vocal cords). Clinical complications include aspiration pneumonia, weight loss, dehydration and malnutrition. Tube feeding is often indicated but is associated with increased mortality. Quality of life is also frequently impacted. A range of interventions exist that aim to improve UOS function and swallowing. These include compensatory strategies, rehabilitation techniques, pharmacological interventions and surgery. Over the last two decades, botulinum toxin has been gaining popularity as an intervention for UOS dysfunction, with some evidence to suggest that it is successful in improving swallow function. Despite a number of studies investigating its efficacy, there is a lack of consensus regarding whether this intervention is effective in improving swallowing for individuals with UOS dysfunction associated with neurological disease. To establish the efficacy and safety of botulinum toxin use aimed at improving UOS dysfunction in people with swallowing difficulties (dysphagia) associated with non-progressive and progressive neurological disease. We searched the following electronic databases for published trials: the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (1950 to 2013); EMBASE (1980 to 2013); AMED (Allied and Complementary Medicine) (1941 to 2013); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1937 to 2013). We also searched major clinical trials registers: CCT (http://www.controlled-trials.com); Clinical Trials (http://www.clinicaltrials.gov); Chinese Clinical Trial Register (www.chictr.org); ACTR (http://www.actr.org.au/. We examined the reference lists of all potentially relevant studies to identify further relevant trials. We handsearched published abstracts of conference proceedings from both the Dysphagia Research Society and the European Society of Swallowing Disorders. Digestive Disease Week (published in Gastroenterology) was also handsearched. Additionally, we searched ProQuest Dissertations & Theses for dissertation abstracts. Only randomised controlled trials were sought. Independent searches were completed by JR, AM, MC and MW. Two review authors (JR and MW) independently inspected titles, abstracts and key words identified from the literature search. No randomised controlled studies were retrieved. Twenty-nine studies were excluded, mainly on the basis of trial design. It was not possible to reach a conclusion on the efficacy and safety of botulinum toxin as an intervention for people with UOS dysfunction and neurological disease. There is insufficient evidence to inform clinical practice. Directions for future research are provided.

Endoscopic manometry of the sphincter of Oddi in sphincterotomized patients.

PubMed

Ugljesić, M; Bulajić, M; Milosavljević, T; Stimec, B

1995-01-01

Endoscopic sphincterotomy (ES) of the sphincter of Oddi (SO) has been accepted as an effective method in extraction of common bile duct stones in postcholecystectomy patients. The purpose of this study was to examine the completeness of the performed ES and observe the post sphincterotomy pancreatic duct sphincter (PDS) activity using endoscopic manometry. Activity of the sphincter of Oddi was examined in 15 sphincterotomized patients using endoscopic manometry one to 2.5 years after endoscopic sphincterotomy for choledocholithiasis. In eight patients absence of choledochoduodenal gradient, baseline pressure and the sphincter of Oddi phasic activity up to 2.5 years after endoscopic sphincterotomy indicated a complete sphincterotomy. In seven patients with incomplete endoscopic sphincterotomy, manometry exhibited either a lower choledochoduodenal gradient and baseline pressure without phasic activity of the sphincter of Oddi (three patients), a sphincter of Oddi activity without choledochoduodenal gradient (one patient), or a complete restitution of the sphincter of Oddi activity 1 to 2 years after endoscopic sphincterotomy (three patients). In five patients, with complete endoscopic sphincterotomy, measurements of pancreatic sphincter activity showed lower values of the pancreatic ductal pressure and baseline pressure, while the pancreatic sphincter phasic activity was equal to that found in the control group. Endoscopic manometry is method which enables us to test the completeness of endoscopic sphincterotomy and to follow the restitution of the phasic contractile function of the sphincter. Manometric findings reveal pancreatic sphincter in most patients as a separate sphincteric entity, the function of which is reduced but not eliminated by a complete endoscopic sphincterotomy.

Convergence of inhibitory neural inputs regulate motor activity in the murine and monkey stomach

PubMed Central

Shaylor, Lara A.; Hwang, Sung Jin; Sanders, Kenton M.

2016-01-01

Inhibitory motor neurons regulate several gastric motility patterns including receptive relaxation, gastric peristaltic motor patterns, and pyloric sphincter opening. Nitric oxide (NO) and purines have been identified as likely candidates that mediate inhibitory neural responses. However, the contribution from each neurotransmitter has received little attention in the distal stomach. The aims of this study were to identify the roles played by NO and purines in inhibitory motor responses in the antrums of mice and monkeys. By using wild-type mice and mutants with genetically deleted neural nitric oxide synthase (Nos1−/−) and P2Y1 receptors (P2ry1−/−) we examined the roles of NO and purines in postjunctional inhibitory responses in the distal stomach and compared these responses to those in primate stomach. Activation of inhibitory motor nerves using electrical field stimulation (EFS) produced frequency-dependent inhibitory junction potentials (IJPs) that produced muscle relaxations in both species. Stimulation of inhibitory nerves during slow waves terminated pacemaker events and associated contractions. In Nos1−/− mice IJPs and relaxations persisted whereas in P2ry1−/− mice IJPs were absent but relaxations persisted. In the gastric antrum of the non-human primate model Macaca fascicularis, similar NO and purine neural components contributed to inhibition of gastric motor activity. These data support a role of convergent inhibitory neural responses in the regulation of gastric motor activity across diverse species. PMID:27634009

Convergence of inhibitory neural inputs regulate motor activity in the murine and monkey stomach.

PubMed

Shaylor, Lara A; Hwang, Sung Jin; Sanders, Kenton M; Ward, Sean M

2016-11-01

Inhibitory motor neurons regulate several gastric motility patterns including receptive relaxation, gastric peristaltic motor patterns, and pyloric sphincter opening. Nitric oxide (NO) and purines have been identified as likely candidates that mediate inhibitory neural responses. However, the contribution from each neurotransmitter has received little attention in the distal stomach. The aims of this study were to identify the roles played by NO and purines in inhibitory motor responses in the antrums of mice and monkeys. By using wild-type mice and mutants with genetically deleted neural nitric oxide synthase (Nos1 -/- ) and P2Y1 receptors (P2ry1 -/- ) we examined the roles of NO and purines in postjunctional inhibitory responses in the distal stomach and compared these responses to those in primate stomach. Activation of inhibitory motor nerves using electrical field stimulation (EFS) produced frequency-dependent inhibitory junction potentials (IJPs) that produced muscle relaxations in both species. Stimulation of inhibitory nerves during slow waves terminated pacemaker events and associated contractions. In Nos1 -/- mice IJPs and relaxations persisted whereas in P2ry1 -/- mice IJPs were absent but relaxations persisted. In the gastric antrum of the non-human primate model Macaca fascicularis, similar NO and purine neural components contributed to inhibition of gastric motor activity. These data support a role of convergent inhibitory neural responses in the regulation of gastric motor activity across diverse species. Copyright © 2016 the American Physiological Society.

The Musculature of the Bladder-neck of the Male in Health and Disease

PubMed Central

Macalpine, J. B.

1934-01-01

Two muscles, one voluntary the other involuntary, and an inch or more apart, exist at the bladder-neck, both functioning as sphincters. This dual musculature is explained by the emergence of the ejaculatory ducts between them. If both these muscles are open when semen is discharged, secretion may escape into the bladder or to the exterior; also any urine in the bladder would flow out. The internal sphincter is usually tightly contracted during ejaculation. Instances are given in which the internal sphincter is paralysed or injured, e.g. after operation, in prostatic hypertrophy, and in certain nervous diseases. Two instances are reported of direct injury to this localized area, with the result, in all cases, that ejaculation failed. In prostatic hypertrophy the internal sphincter is dilated by the growing adenoma, and at operation it is further stretched and perhaps cut across. Continence then depends on the external sphincter. Two cases are reported in which the external sphincter had previously been paralysed, total incontinence resulting. Recent work on the trigonal muscle; its function in opening the internal sphincter. Influence of this muscle on prostatic enlargement. In central nervous disease the dilatation of the internal sphincter resulting in funnel-neck is very common. Series of cases of nervous disease examined in order to determine the frequency of this sign are reported. Other cases occurring apart from nervous disease are also reported. The part played by the sphincters in ejaculation is discussed and illustrated by reports of further cases of paralysis of the sphincter. It is shown that in the normal way the external sphincter weakens during coitus, and especially during ejaculation, but when the internal sphincter is paralysed no weakening is evident. Penile erection is associated with spasm of the internal sphincter, and spasm of the internal sphincter is produced by irritation, e.g. vesical stone may produce priapism. The varying types of adenoma bear different relationship to the internal sphincter. The view that submucosal glands give rise to prostatic enlargement is supported. The influence of prostatic enlargement on the internal sphincter is discussed. ImagesFig. 3 PMID:19990023

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

PubMed

Buck, J R; Sorensen, V J; Fath, J J; Horst, H M; Obeid, F N

1992-09-01

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases.

PubMed

Stănciulea, O; Eftimie, M; David, L; Tomulescu, V; Vasilescu, C; Popescu, I

2013-01-01

Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome. A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes. Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%. Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. Celsius.

Sacral neuromodulation for women with Fowler's syndrome.

PubMed

Swinn, M J; Kitchen, N D; Goodwin, R J; Fowler, C J

2000-10-01

Neuromodulation of the sacral nerves has been found to be an effective therapy for a variety of lower urinary tract dysfunctions. The reported success rate for the period of trial stimulation (peripheral nerve evaluation test) prior to permanent implantation of a sacral nerve stimulator is variable, but generally reported to be in the region of 30-50%. We present here the results of the peripheral nerve evaluation test in 38 patients with urinary retention. 34 of the 38 had been found to have an abnormality of their striated urethral sphincter on electromyography using a concentric needle electrode, i.e., they had the disorder which was described by Fowler and coworkers in 1988. The overall success rate in this group was 68%. We believe that our relatively high success rate is due to sacral neuromodulation working via a mechanism which involves the urethral sphincter, an abnormality which had been demonstrated in 89% of these patients. Twelve of the patients subsequently underwent permanent implantation of a sacral nerve stimulator, and all of them have experienced a return of voiding. However, in 2 patients, there is a persisting need for self-catheterization. There is, however, a high reoperation rate.

Combined sphincter repair and postanal repair for the treatment of complicated injuries to the anal sphincters.

PubMed Central

Browning, G. G.; Henry, M. M.; Motson, R. W.

1988-01-01

The management of seven patients with multiple injuries to the anal sphincter musculature and its nerve supply, from major pelvic trauma, anal fistula surgery, or obstetric trauma, was reviewed. All were either incontinent of solid stools or had defunctioning colostomies. Anal manometry was abnormal in all patients. Concentric needle electromyography (EMG) showed anterior division of the external sphincter in all the patients; five also had posterior division of both the external sphincter and puborectalis. EMG abnormalities were found in the lateral quadrants of these muscles, particularly the external sphincter. Single fibre needle EMG showed evidence of reinnervation in the external sphincter in six patients, and in the puborectalis in two, indicating partial denervation of the muscles. Treatment was by anterior sphincter repair using an overlapping technique, combined with postanal repair; the repairs were protected by a defunctioning colostomy. When assessed 4-60 months (mean 17 months) after colostomy closure all seven patients were continent of solid and semi-formed stools, but had urgency of defaecation. None could control liquid stool or flatus. After complicated sphincter injuries planned surgical reconstruction, based on EMG assessment of the sphincter muscles, can restore acceptable continence. PMID:3190132

A Predictive Model to Identify Patients With Fecal Incontinence Based on High-Definition Anorectal Manometry.

PubMed

Zifan, Ali; Ledgerwood-Lee, Melissa; Mittal, Ravinder K

2016-12-01

Three-dimensional high-definition anorectal manometry (3D-HDAM) is used to assess anal sphincter function; it determines profiles of regional pressure distribution along the length and circumference of the anal canal. There is no consensus, however, on the best way to analyze data from 3D-HDAM to distinguish healthy individuals from persons with sphincter dysfunction. We developed a computer analysis system to analyze 3D-HDAM data and to aid in the diagnosis and assessment of patients with fecal incontinence (FI). In a prospective study, we performed 3D-HDAM analysis of 24 asymptomatic healthy subjects (control subjects; all women; mean age, 39 ± 10 years) and 24 patients with symptoms of FI (all women; mean age, 58 ± 13 years). Patients completed a standardized questionnaire (FI severity index) to score the severity of FI symptoms. We developed and evaluated a robust prediction model to distinguish patients with FI from control subjects using linear discriminant, quadratic discriminant, and logistic regression analyses. In addition to collecting pressure information from the HDAM data, we assessed regional features based on shape characteristics and the anal sphincter pressure symmetry index. The combination of pressure values, anal sphincter area, and reflective symmetry values was identified in patients with FI versus control subjects with an area under the curve value of 1.0. In logistic regression analyses using different predictors, the model identified patients with FI with an area under the curve value of 0.96 (interquartile range, 0.22). In discriminant analysis, results were classified with a minimum error of 0.02, calculated using 10-fold cross-validation; different combinations of predictors produced median classification errors of 0.16 in linear discriminant analysis (interquartile range, 0.25) and 0.08 in quadratic discriminant analysis (interquartile range, 0.25). We developed and validated a novel prediction model to analyze 3D-HDAM data. This system can accurately distinguish patients with FI from control subjects. Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.

Cytomegalovirus Gastric Ulcer Complicated with Pyloric Obstruction in a Patient with Ulcerative Colitis.

PubMed

Kang, Sung Hwan; Lee, Kee Myung; Shin, Sung Jae; Lim, Sun Kyo; Hwang, Jae Chul; Kim, Jin Hong

2017-06-25

In patients with inflammatory bowel disease (IBD), cytomegalovirus (CMV) infections could aggravate the course of IBD but it is difficult to distinguish CMV infection from IBD exacerbation endoscopically. Usually, CMV tends to localize to the colon and other organic involvements were reported very rare in the IBD patients. Herein, we report a case that CMV gastric ulcer complicated with pyloric obstruction in a patient with ulcerative colitis during ganciclovir therapy, which was resolved by surgical gastrojejunostomy with review of literature.

Recurrent obstetric anal sphincter injury and the risk of long-term anal incontinence.

PubMed

Jangö, Hanna; Langhoff-Roos, Jens; Rosthøj, Susanne; Sakse, Abelone

2017-06-01

Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to clarify whether the recurrence of obstetric anal sphincter injury affects the risk of anal and fecal incontinence at long-term follow-up. The objective of the study was to evaluate whether recurrent obstetric anal sphincter injury influenced the risk of anal and fecal incontinence more than 5 years after the second vaginal delivery. We performed a secondary analysis of data from a postal questionnaire study in women with obstetric anal sphincter injury in the first delivery and 1 subsequent vaginal delivery. The questionnaire was sent to all Danish women who fulfilled inclusion criteria and had 2 vaginal deliveries 1997-2005. We performed uni- and multivariable analyses to assess how recurrent obstetric anal sphincter injury affects the risk of anal incontinence. In 1490 women with a second vaginal delivery after a first delivery with obstetric anal sphincter injury, 106 had a recurrent obstetric anal sphincter injury. Of these, 50.0% (n = 53) reported anal incontinence compared with 37.9% (n = 525) of women without recurrent obstetric anal sphincter injury. Fecal incontinence was present in 23.6% (n = 25) of women with recurrent obstetric anal sphincter injury and in 13.2% (n = 182) of women without recurrent obstetric anal sphincter injury. After adjustment for third- or fourth-degree obstetric anal sphincter injury in the first delivery, maternal age at answering the questionnaire, birthweight of the first and second child, years since first and second delivery, and whether anal incontinence was present before the second pregnancy, the risk of flatal and fecal incontinence was still increased in patients with recurrent obstetric anal sphincter injury (adjusted odds ratio, 1.68 [95% confidence interval, 1.05-2.70), P = .03, and adjusted odds ratio, 1.98 [95% confidence interval, 1.13-3.47], P = .02, respectively). More women with recurrent obstetric anal sphincter injury reported affected the quality of life because of anal incontinence (34.9%, n = 37) compared with women without recurrent obstetric anal sphincter injury (24.2%, n = 335), although this difference did not reach statistical significance after adjustment (adjusted odds ratio, 1.53 [95% confidence interval, 0.92-2.56] P = .10). Women opting for vaginal delivery after obstetric anal sphincter injury should be informed about the risk of recurrence, which is associated with an increased risk of long-term flatal and fecal incontinence. Copyright © 2017 Elsevier Inc. All rights reserved.

Pathophysiology and Natural History of Anorectal Sequelae Following Radiation Therapy for Carcinoma of the Prostate

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yeoh, Eric K., E-mail: eric.yeoh@health.sa.gov.au; Discipline of Medicine, University of Adelaide, Adelaide; Holloway, Richard H.

2012-12-01

Purpose: To characterize the prevalence, pathophysiology, and natural history of chronic radiation proctitis 5 years following radiation therapy (RT) for localized carcinoma of the prostate. Methods and Materials: Studies were performed in 34 patients (median age 68 years; range 54-79) previously randomly assigned to either 64 Gy in 32 fractions over 6.4 weeks or 55 Gy in 20 fractions over 4 weeks RT schedule using 2- and later 3-dimensional treatment technique for localized prostate carcinoma. Each patient underwent evaluations of (1) gastrointestinal (GI) symptoms (Modified Late Effects in Normal Tissues Subjective, Objective, Management and Analytic scales including effect on activitiesmore » of daily living [ADLs]); (2) anorectal motor and sensory function (manometry and graded balloon distension); and (3) anal sphincteric morphology (endoanal ultrasound) before RT, at 1 month, and annually for 5 years after its completion. Results: Total GI symptom scores increased after RT and remained above baseline levels at 5 years and were associated with reductions in (1) basal anal pressures, (2) responses to squeeze and increased intra-abdominal pressure, (3) rectal compliance and (4) rectal volumes of sensory perception. Anal sphincter morphology was unchanged. At 5 years, 44% and 21% of patients reported urgency of defecation and rectal bleeding, respectively, and 48% impairment of ADLs. GI symptom scores and parameters of anorectal function and anal sphincter morphology did not differ between the 2 RT schedules or treatment techniques. Conclusions: Five years after RT for prostate carcinoma, anorectal symptoms continue to have a significant impact on ADLs of almost 50% of patients. These symptoms are associated with anorectal dysfunction independent of the RT schedules or treatment techniques reported here.« less

Fecal incontinence, sexual complaints, and anorectal function after third-degree obstetric anal sphincter injury (OASI): 5-year follow-up.

PubMed

Visscher, A P; Lam, T J; Hart, N; Felt-Bersma, R J F

2014-05-01

Our aim was to evaluate alterations in anorectal function after anal sphincteroplasty for third-degree obstetric anal sphincter injury (OASI) in relation to clinical outcome. In this retrospective, descriptive, cross-sectional study conducted between 1998 and 2008, women with persisting fecal incontinence (FI) after 3a OASI and all women with grade 3b or 3c OASI were sent for anorectal function evaluation (AFE) consisting of anal manometry and endosonography 3 months after sphincteroplasty. In 2011, questionnaires regarding FI (Vaizey/Wexner), urinary incontinence (UI) [International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF)], sexual function [Female Sexual Function Index (FSFI)], and quality of life (QOL) (Rand-36) were sent and women were asked to undergo additional AFE. Sixty-six women underwent AFE. Mean follow-up was 5.0 years. Forty (61%) patients returned questionnaires regarding FI and UI. Prevalence of FI was 63% flatus, 50% liquid stool, and 20% solid stool. Thirty-two of 40 also reported on QOL and SF. Sexual dysfunction was present in the majority of women (cutoff value 26.55) and more pronounced in larger OASI. Sixteen of 40 women underwent additional AFE. Women with combined internal (IAS) and external (EAS) anal sphincter injury (n = 6) had worse FI (P < 0.050) and lower anal pressures (P = 0.040) than women with isolated EAS injury (n = 10). Follow-up after third-degree OASI suggests poor anorectal and sexual function. Women with combined external and internal OASI show more deterioration in anorectal function and experience worse FI. Therefore, special attention should be paid to these women in order to mitigate these symptoms later in life.

Endoanal ultrasonography in fecal incontinence: Current and future perspectives.

PubMed

Albuquerque, Andreia

2015-06-10

Fecal incontinence has a profound impact in a patient's life, impairing quality of life and carrying a substantial economic burden due to health costs. It is an underdiagnosed condition because many affected patients are reluctant to report it and also clinicians are usually not alert to it. Patient evaluation with a detailed clinical history and examination is very important to indicate the type of injury that is present. Endoanal ultrasonography is currently the gold standard for sphincter evaluation in fecal incontinence and is a simple, well-tolerated and non-expensive technique. Most studies revealed 100% sensitivity in identifying sphincter defect. It is better than endoanal magnetic resonance imaging for internal anal sphincter defects, equivalent for the diagnosis of external anal sphincter defects, but with a lower capacity for assessment of atrophy of this sphincter. The most common cause of fecal incontinence is anal sphincter injury related to obstetric trauma. Only a small percentage of women are diagnosed with sphincter tears immediately after vaginal delivery, but endoanal ultrasonography shows that one third of these women have occult sphincter defects. Furthermore, in patients submitted to primary repair of these tears, ultrasound revealed a high frequency of persistent sphincter defects after surgery. Three-dimensional endoanal ultrasonography is currently largely used and accepted for sphincter evaluation in fecal incontinence, improving diagnostic accuracy and our knowledge of physiologic and pathological sphincters alterations. Conversely, there is currently no evidence to support the use of elastography in fecal incontinence evaluation.

Minimally invasive surgery for esophageal achalasia.

PubMed

Chen, Huan-Wen; Du, Ming

2016-07-01

Esophageal achalasia is due to the esophagus of neuromuscular dysfunction caused by esophageal functional disease. Its main feature is the lack of esophageal peristalsis, the lower esophageal sphincter pressure and to reduce the swallow's relaxation response. Lower esophageal muscular dissection is one of the main ways to treat esophageal achalasia. At present, the period of muscular layer under the thoracoscope esophagus dissection is one of the treatment of esophageal achalasia. Combined with our experience in minimally invasive esophageal surgery, to improved incision and operation procedure, and adopts the model of the complete period of muscular layer under the thoracoscope esophagus dissection in the treatment of esophageal achalasia.

Minimally invasive surgery for esophageal achalasia

PubMed Central

Chen, Huan-Wen

2016-01-01

Esophageal achalasia is due to the esophagus of neuromuscular dysfunction caused by esophageal functional disease. Its main feature is the lack of esophageal peristalsis, the lower esophageal sphincter pressure and to reduce the swallow’s relaxation response. Lower esophageal muscular dissection is one of the main ways to treat esophageal achalasia. At present, the period of muscular layer under the thoracoscope esophagus dissection is one of the treatment of esophageal achalasia. Combined with our experience in minimally invasive esophageal surgery, to improved incision and operation procedure, and adopts the model of the complete period of muscular layer under the thoracoscope esophagus dissection in the treatment of esophageal achalasia. PMID:27499977

[HIV-associated myelopathy: an uncommon indicator of AIDS].

PubMed

Konaté, A; Ceballos, P; Rivière, S; Faucherre, V; Ciurana, A J; Le Quellec, A

2001-10-01

Spinal cord lesions are an uncommon mode of discovering acquired immunodeficiency syndrome because they usually appear at a later stage. We report a 58-year-old patient who had a spastic paraparesia and sphincter dysfunction. The spinal cord magnetic resonance imaging showed spontaneous hypersignals on T2-weighted images at the cervical and thoracic levels, enhanced with gadolinium, and without swelling. No cause was found. The HIV serology was positive and allowed us to consider an HIV-associated myelopathy. The antiretroviral therapy led to functional recovery. An HIV serology is suggested whenever an unexplained intramedullary lesion is discovered. Indeed, the diagnosis of HIV-associated myelopathy implies a specific therapeutic approach.

Cultured smooth muscle cells of the human vesical sphincter are more sensitive to histamine than are detrusor smooth muscle cells.

PubMed

Neuhaus, Jochen; Oberbach, Andreas; Schwalenberg, Thilo; Stolzenburg, Jens-Uwe

2006-05-01

To compare histamine receptor expression in cultured smooth muscle cells from the human detrusor and internal sphincter using receptor-specific agonists. Smooth muscle cells from the bladder dome and internal sphincter were cultured from 5 male patients undergoing cystectomy for bladder cancer therapy. Calcium transients in cells stimulated with carbachol, histamine, histamine receptor 1 (H1R)-specific heptanecarboxamide (HTMT), dimaprit (H2R), and R-(alpha)-methylhistamine (H3R) were measured by calcium imaging. Histamine receptor proteins were detected by Western blot analysis and immunocytochemistry. H1R, H2R, and H3R expression was found in tissue and cultured cells. Carbachol stimulated equal numbers of detrusor and sphincter cells (60% and 51%, respectively). Histamine stimulated significantly more cells than carbachol in detrusor (100%) and sphincter (99.34%) cells. Calcium responses to carbachol in detrusor and sphincter cells were comparable and did not differ from those to histamine in detrusor cells. However, histamine and specific agonists stimulated more sphincter cells than did carbachol (P <0.001), and the calcium increase was greater in sphincter cells than in detrusor cells. Single cell analysis revealed comparable H2R responses in detrusor and sphincter cells, but H1R and H3R-mediated calcium reactions were significantly greater in sphincter cells. Histamine very effectively induces calcium release in smooth muscle cells. In sphincter cells, histamine is even more effective than carbachol regarding the number of reacting cells and the intracellular calcium increase. Some of the variability in the outcome of antihistaminic interstitial cystitis therapies might be caused by the ineffectiveness of the chosen antihistaminic or unintentional weakening of sphincteric function.

Safety of repair for severe duodenal injuries.

PubMed

Velmahos, George C; Constantinou, Constantinos; Kasotakis, George

2008-01-01

There is ongoing debate about the management of severe duodenal injuries (SDIs), and earlier studies have recommended pyloric exclusion. The objective of this study was to compare primary repair with pyloric exclusion to examine if primary repair can be safely used in SDIs. The medical records of 193 consecutive patients who were admitted between August 1992 and January 2004 with duodenal injuries were reviewed. After excluding early deaths (n = 50), low-grade duodenal injuries (n = 81), and pancreatoduodenectomies for catastrophic trauma (n = 12), a total of 50 patients with SDIs (grade III, IV, or V) were analyzed. Primary repair (PR--simple duodenorrhaphy or resection and primary anastomosis) was performed in 34 (68%) and pyloric exclusion (PE) in 16 (32%). Characteristics and outcomes of these two groups were compared. PE and PR patients were similar for age, injury severity score, abdominal abbreviated injury score, physiologic status on admission, time to operation, and most abdominal organs injured. PE patients had more pancreatic injuries (63% vs. 24%, p < 0.01), a higher frequency of injuries to the first and second part of the duodenum (79% vs. 42%, p = 0.02), and a nonsignificant trend toward more grade IV and V injuries (37% vs. 18%, p = 0.11). There was no difference in morbidity (including complications specific to the duodenal repair), mortality, and intensive care unit and hospital length of stay between the two groups. Pyloric exclusion is not necessary for all patients with SDIs, as previously suggested. Selected SDI patients can be safely managed by simple primary repair.

Dynamic rectus abdominis muscle sphincter for stoma continence: an acute functional study in a dog model.

PubMed

Bardoel, J W; Stadelmann, W K; Perez-Abadia, G A; Galandiuk, S; Zonnevijlle, E D; Maldonado, C; Stremel, R W; Tobin, G R; Kon, M; Barker, J H

2001-02-01

Fecal stomal incontinence is a problem that continues to defy surgical treatment. Previous attempts to create continent stomas using dynamic myoplasty have had limited success due to denervation atrophy of the muscle flap used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation. To address the problem of denervation atrophy, a stomal sphincter was designed using the most caudal segment of the rectus abdominis muscle, preserving its intercostal innervation as well as its vascular supply. The purpose of the present study was to determine whether this rectus abdominis muscle island flap sphincter design could maintain stomal continence acutely. In this experiment, six dogs were used to create eight rectus abdominis island flap stoma sphincters around a segment of distal ileum. Initially, the intraluminal stomal pressures generated by the sphincter using different stimulation frequencies were determined. The ability of this stomal sphincter to generate continence at different intraluminal bowel pressures was then assessed. In all cases, the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mmHg). In addition, each sphincter was able to maintain stomal continence at all intraluminal bowel pressures tested.

Can Anal Sphincter Defects Be Identified by Palpation?

PubMed

Shek, Ka Lai; Atan, Ixora Kamisan; Dietz, Hans Peter

The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects. This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging. Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small. Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

Diagnosis of Swallowing Disorders: How We Interpret Pharyngeal Manometry.

PubMed

Cock, Charles; Omari, Taher

2017-03-01

We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases. In our Centre, we base our interpretation of HRIM recordings upon a qualitative assessment of pressure-impedance waveforms during individual swallows, as well as a quantitative assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility. Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.

Sphincter tears in primiparous women: Is age a factor?

PubMed Central

BOWLING, C. Bryce; WHEELER, Thomas L.; GERTEN, Kimberly A.; CHAPMAN, Victoria R.; BURGIO, Kathryn L.; RICHTER, Holly E.

2011-01-01

Introduction and Hypothesis Anal sphincter tears during vaginal delivery may result in serious sequelae. We examined whether younger primiparous patients were at increased risk for sphincter tears during vaginal delivery. Methods Data from an obstetric automated record were analyzed. Primiparous women delivering term infants (n = 5,937) were included to test for an association between age and sphincter tear rates. Three age groups were considered: young adolescents (≤16 years), older adolescents (17-20 years) and adults (≥21 years). Results No significant difference was found in tear rates among age cohorts (9.2%, 8.0%, and 9.6% respectively; p = 0.12). Logistic regression modeling revealed that young adolescents were not more likely to have sphincter tears compared to older cohorts. Conclusions Younger adolescents may not be at increased risk of anal sphincter tears. Decisions regarding interventions to decrease sphincter tears during vaginal delivery should not be made on the basis of maternal age alone. PMID:18985267

Do changes in anal sphincter anatomy correlate with anal function in women with a history of vaginal delivery?

PubMed

Murad-Regadas, Sthela Maria; Dealcanfreitas, Iris Daiana; Regadas, Francisco Sergio Pinheiro; Rodrigues, Lusmar Veras; Fernandes, Graziela Olivia da Silva; Pereira, Jacyara de Jesus Rosa

2014-01-01

To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function. Female with fecal incontinence and vaginal delivery were assessed with Wexner's score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score. Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects. Fecal incontinence symptoms did not correlate with anal pressures and anal sphincter anatomy changes, but women with sphincter defects have shorter anterior EAS and IAS and a longer gap.

Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures.

PubMed

Bedair, Elsaid M; El Hennawy, Hany M; Moustafa, Ahmed Abdu; Meki, Gad Youssef; Bosat, Bosat Elwany

2014-11-01

The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures. We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B). The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%). Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients. © 2014 by the American Institute of Ultrasound in Medicine.

Electrical stimulation of anal sphincter or pudendal nerve improves anal sphincter pressure.

PubMed

Damaser, Margot S; Salcedo, Levilester; Wang, Guangjian; Zaszczurynski, Paul; Cruz, Michelle A; Butler, Robert S; Jiang, Hai-Hong; Zutshi, Massarat

2012-12-01

Stimulation of the pudendal nerve or the anal sphincter could provide therapeutic options for fecal incontinence with little involvement of other organs. The goal of this project was to assess the effects of pudendal nerve and anal sphincter stimulation on bladder and anal pressures. Ten virgin female Sprague Dawley rats were randomly allocated to control (n = 2), perianal stimulation (n = 4), and pudendal nerve stimulation (n = 4) groups. A monopolar electrode was hooked to the pudendal nerve or placed on the anal sphincter. Aballoon catheter was inserted into the anus to measure anal pressure, and a catheter was inserted into the bladder via the urethra to measure bladder pressure. Bladder and anal pressures were measured with different electrical stimulation parameters and different timing of electrical stimulation relative to spontaneous anal sphincter contractions. Increasing stimulation current had the most dramatic effect on both anal and bladder pressures. An immediate increase in anal pressure was observed when stimulating either the anal sphincter or the pudendal nerve at stimulation values of 1 mA or 2 mA. No increase in anal pressure was observed for lower current values. Bladder pressure increased at high current during anal sphincter stimulation, but not as much as during pudendal nerve stimulation. Increased bladder pressure during anal sphincter stimulation was due to contraction of the abdominal muscles. Electrical stimulation caused an increase in anal pressures with bladder involvement only at high current. These initial results suggest that electrical stimulation can increase anal sphincter pressure, enhancing continence control.

Sphincter lesions observed on ultrasound after transanal endoscopic surgery.

PubMed

Mora López, Laura; Serra-Aracil, Xavier; Navarro Soto, Salvador

2015-12-14

To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification. A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the "modified" Starck classification, which incorporates the variable "sphincter fragmentation". The results were correlated with the Wexner incontinence questionnaire. Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities. TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders.

Urethral sphincters response to cavernosus muscles stimulation with identification of cavernoso-urethral reflex.

PubMed

Shafik, A; Shafik, A A; Shafik, I; el-Sibai, O

2005-01-01

The functional activity of the urethral sphincters during cavernosus muscles' contraction at coitus has been poorly addressed in the literature. We investigated the hypothesis that cavernosus muscles' contraction affects reflex contraction of the urethral sphincters to guard against semen reflux into the urinary bladder or urine leakage from the bladder during orgasm and ejaculation. The electromyographic (EMG) response of the external (EUS) and internal (IUS) urethral sphincters to ischio- (ICM) and bulbo- (BCM) cavernosus muscle stimulation was studied in 15 healthy volunteers (9 men, 6 women, age 39.3 +/- 8.2 SD years). An electrode was applied to each of ICM and BCM (stimulating electrodes) and the 2 urethral sphincters (recording electrodes). The test was repeated after individual anesthetization of the urethral sphincters and the 2 cavernosus muscles, and after using saline instead of lidocaine. Upon stimulation of each of the 2 cavernosus muscles, the EUS and IUS recorded increased EMG activity. Repeated cavernosus muscles' stimulation evoked the urethral sphincteric response without fatigue. The urethral sphincters did not respond to stimulation of the anesthetized cavernosus muscles nor did the anesthetized urethral sphincters respond to cavernosus muscle stimulation. Saline infiltration instead of lidocaine did not affect the urethral sphincteric response to cavernosal muscle stimulation. Results were reproducible. Cavernosus muscles' contraction is suggested to effect EUS and IUS contraction. This action seems to be reflex and mediated through the 'cavernoso-urethral reflex.' Urethral sphincters contraction upon cavernosus muscles contraction during sexual intercourse presumably prevents urine leak from the urinary bladder to urethra, prevents retrograde ejaculation, and propels ejaculate from the posterior to the penile urethra. The cavernoso-urethral reflex can act a diagnostic tool in the investigations of patients with ejaculatory disorders.

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

PubMed

Ramm, Olga; Woo, Victoria G; Hung, Yun-Yi; Chen, Hsuan-Chih; Ritterman Weintraub, Miranda L

2018-02-01

To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor. This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations. The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89). Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.

Ultrasonographic features of normalization of the pylorus after pyloromyotomy for hypertrophic pyloric stenosis.

PubMed

Yoshizawa, J; Eto, T; Higashimoto, Y; Saitou, T; Maie, M

2001-04-01

The purpose of this study was to describe the time course, early postoperative changes, and morphologic features of normalization of the pylorus after pyloromyotomy for hypertrophic pyloric stenosis. The subjects were 17 infants (9 boys, 8 girls) who underwent umbilical incision Ramstedt pyloromyotomy. The pyloric muscle mass was measured immediately before the operation and then at intervals from 3 days to 6 months after the operation using a 7.5-MHz ultrasound probe. In longitudinal section, the dorsal part of the pyloric muscle thickened transiently and then thinned to normal values by 5 months after the operation. It was 5.1 +/- 0.8 mm (mean +/- SD) preoperatively, increased to 6.0 +/- 0.3 mm by day 3 after the operation (P <.05), and thinned to 2.8 +/- 0.2 mm by 5 months after the operation. Concomitantly, the length of the pylorus gradually decreased (from 20.1 +/- 2.9 mm preoperatively to 16.9 +/- 2.7 mm by 3 days postoperatively [P <.05] and to less than 15 mm, by 4 months). In transverse section, the muscle normalized as in the longitudinal section. At the site of the incision it was 4.3 +/- 0.4 mm thick preoperatively, thickened to 4.6 +/- 0.4 mm by 3 days after the operation (P <.05), thinned to 2.1 +/- 0.9 mm by 7 days (P <.05), and then increased slightly, but always was less than 3.0 mm. Morphologically, in transverse section, the incised area looked like a wedge by 3 days after the operation. After pyloromyotomy for hypertrophic pyloric stenosis, there is an early transient increase in muscle thickness within the first few postoperative days followed by a slow decrease that reaches normal thickness (<3 mm) by 5 months. This decrease in thickness is accompanied by a gradual decrease in length to 75% of the preoperative value by 5 months. The morphologic features in this normalization are first a wedge (day 3), then a flat tire (days 7 and 14), and finally an elongated ring (5 months). J Pediatr Surg 36:582-586. Copyright 2001 by W.B. Saunders Company.

Consequences of acute and long-term removal of neuromodulatory input on the episodic gastric rhythm of the crab Cancer borealis

PubMed Central

Marder, Eve

2015-01-01

For decades, the episodic gastric rhythm of the crustacean stomatogastric nervous system (STNS) has served as an important model system for understanding the generation of rhythmic motor behaviors. Here we quantitatively describe many features of the gastric rhythm of the crab Cancer borealis under several conditions. First, we analyzed spontaneous gastric rhythms produced by freshly dissected preparations of the STNS, including the cycle frequency and phase relationships among gastric units. We find that phase is relatively conserved across frequency, similar to the pyloric rhythm. We also describe relationships between these two rhythms, including a significant gastric/pyloric frequency correlation. We then performed continuous, days-long extracellular recordings of gastric activity from preparations of the STNS in which neuromodulatory inputs to the stomatogastric ganglion were left intact and also from preparations in which these modulatory inputs were cut (decentralization). This allowed us to provide quantitative descriptions of variability and phase conservation within preparations across time. For intact preparations, gastric activity was more variable than pyloric activity but remained relatively stable across 4–6 days, and many significant correlations were found between phase and frequency within animals. Decentralized preparations displayed fewer episodes of gastric activity, with altered phase relationships, lower frequencies, and reduced coordination both among gastric units and between the gastric and pyloric rhythms. Together, these results provide insight into the role of neuromodulation in episodic pattern generation and the extent of animal-to-animal variability in features of spontaneously occurring gastric rhythms. PMID:26156388

Recurrence of obstetric third-degree and fourth-degree anal sphincter injuries.

PubMed

Boggs, Edgar W; Berger, Howard; Urquia, Marcelo; McDermott, Colleen D

2014-12-01

To examine outcomes after primary obstetric anal sphincter injuries in a subsequent pregnancy. This was a retrospective analysis of prospectively collated data from a large perinatal database between 2006 and 2010. Primiparous vaginal deliveries with an obstetric anal sphincter injury were identified and tracked to identify their subsequent delivery characteristics and perineal outcomes. A primary obstetric anal sphincter injury occurred in 5.3% of primiparous vaginal deliveries (9,857/186,239); of those patients, 2,093 had a subsequent delivery, and 91.9% delivered vaginally (1,923/2,093). The recurrent obstetric anal sphincter injury rate was also found to be 5.3% (102/1,923). The adjusted odds ratios (ORs) for primary obstetric anal sphincter injuries were significantly increased in large-for-gestational-age neonates for both third-degree laceration (adjusted OR 2.1, 95% confidence interval [CI] 1.9-2.2) and fourth-degree laceration (adjusted OR 2.7, 95% CI 2.3-3.1) and almost all obstetric interventions studied. The adjusted ORs for recurrent obstetric anal sphincter injuries were significant for large-for-gestational-age (25/102, adjusted OR 2.2, 95% CI 1.3-3.6) and instrumental deliveries (15/102, adjusted OR 2.4, 95% CI 1.2-4.6). In this study population, the incidence of recurrent obstetric anal sphincter injuries was similar to that of primary obstetric anal sphincter injuries, and most patients went on to deliver vaginally for subsequent deliveries. The risk of recurrent obstetric anal sphincter injuries was doubled in those who delivered a large-for-gestational-age neonate and in those who had an instrumental delivery.

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury

PubMed Central

AIKEN, Catherine E.; AIKEN, Abigail R.; PRENTICE, Andrew

2014-01-01

Background Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. Methods A retrospective 5-year cohort study in a UK obstetrics center including high-risk delivery unit and low-risk birthing center. 4831 nulliparous women with vertex-presenting, single, live-born infants at term were included. The cohort was stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Results 325 of 4831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, there was no association between duration of the second stage and the likelihood of sustaining sphincter injuries. Factors associated with increased likelihood of sustaining sphincter injury included older maternal age, higher birthweight and Southeast Asian ethnicity. By contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6% per 15 minutes in the second stage of labor prior to delivery. Conclusions For spontaneous vaginal deliveries, duration of the second stage of labor is not an independent risk factor for obstetric anal sphincter injuries. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. PMID:25439012

Length and pressure of the reconstructed lower esophageal sphincter is determined by both crural closure and Nissen fundoplication.

PubMed

Louie, Brian E; Kapur, Seema; Blitz, Maurice; Farivar, Alexander S; Vallières, Eric; Aye, Ralph W

2013-02-01

Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication. Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair. Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p < 0.001), and mean sphincter pressure was increased by 13.7 mmHg (p < 0.001). Groups 1 and 2 had similar sphincter length and pressure changes. Crural closure and fundal wrap contribute equally to sphincter length, although crural closure appears to contribute more to sphincter pressure. The Nissen fundoplication restores the function of the gastroesophageal junction and thus the reflux barrier by means of two main components: the crural closure and the construction of a 360° fundal wrap. Each of these components is equally important in establishing both increased sphincter length and pressure.

[Infantile hypertrophic pyloric stenosis. Report of 142 cases].

PubMed

Jlidi, Said; Ben Youssef, Dhouha; Ghorbel, Sofiene; Mattoussi, Nadia; Khemakhem, Rachid; Nouira, Faouzi; Chaouachi, Béji

2008-01-01

Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants before the first three months of life. Analysis of our results and comparison with literature to determine particularities of HPS in our country. We conducted a retrospective review of 142 patients presenting HPS, between 1990 and 2003. In this study male sex was predominant, with a sex-ratio of 3.8/1. The classical symptom of projectile vomiting was always present, a pyloric tumor was palpated in 19.7% of the cases, metabolic disturbance was noted in 44.3% of patients. The diagnosis was confirmed by ultrasonography and sometimes contrast upper gastrointestinal study. All the infants were treated surgically unless three patients dying before operation, because of a late diagnosis. Postoperative courses were uneventful in 87.4% of cases. Three patients were dead after operation, because of medical complication. The cause of HPS is unknown. The diagnosis is suggested by clinic features and confirmed by imaging. Early diagnosis prevents from metabolic complications due to vomiting. Surgical treatment allows early feeding and is associated with a low complication rate and a good long-term outcome.

Internal sphincter and the nature of haemorrhoids.

PubMed Central

Hancock, B D

1977-01-01

Internal anal sphincter activity has been studied in 84 patients with haemorrhoids and 40 asymptomatic subjects. Activity was estimated by measuring maximum resting anal pressure with a water filled anal balloon probe 7 mm in diameter connected to a strain gauge pressure transducer. There was greater activity of the internal sphincter in patients with haemorrhoids than in controls, but there was no significant relationship between sphincter activity and duration of symptoms, predominant symptom (bleeding or prolapse), severity of symptoms, history of pain, history of straining at stool, or size of haemorrhoids. Straining at stool occurred significantly more often in patients whose main complaint was prolapse than in those whose main complaint was bleeding. Anal dilatation reduced sphincter activity and the best clinical results were obtained in those with the most active sphincter. An internal sphincter abnormality may be an aetiological factor in some patients but there must be other factors as well. Straining at stool may determine whether bleeding or prolapse is the predominant symptom. Images Fig. 1 PMID:892612

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

PubMed Central

EVERS, Emily C.; BLOMQUIST, Joan L.; MCDERMOTT, Kelly C.; HANDA, Victoria L.

2012-01-01

Objective To investigate the long-term impact of anal sphincter laceration on anal incontinence. Study Design Five to ten years after first delivery, anal incontinence and other bowel symptoms were measured using the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetrical exposures were assessed with review of hospital records. Symptoms and quality of life impact were compared between 90 women with at least one anal sphincter laceration, 320 who delivered vaginally without sphincter laceration and 527 who delivered by cesarean. Results Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio 2.32; 95% confidence interval 1.27, 4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality of life scores were similar between women who delivered by cesarean and those who delivered vaginally without sphincter laceration. Conclusion(s) Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery. PMID:22831810

Pressures in the sphincter of Oddi in patients with gallstones, common duct stones, and recurrent pancreatitis.

PubMed

Guelrud, M; Mendoza, S; Vicent, S; Gomez, M; Villalta, B

1983-02-01

To determine the significance of manometric pressure, measurements of the sphincter of Oddi in a control group and in patients with cholelithiasis with common duct stones with and without recurrent pancreatitis were studied. Sphincter of Oddi pressure was recorded continuously and by station pull-through by a triple lumen catheter. The basal sphincter of Oddi pressure, the mean pressure gradient between common duct and duodenum, and the sphincter of Oddi wave amplitude were measured. There was no significant difference between control subjects and patients with gallstones and common duct stones. In patients with common duct stones and recurrent pancreatitis the basal sphincter of Oddi pressure, the pressure gradient between common duct and duodenum, and the wave amplitude were significantly increased over control patients. These studies suggest that abnormalities in the sphincter of Oddi motor function are more common in patients with common duct stones with recurrent pancreatitis than in similar patients without pancreatitis.

Childhood-onset HAM/TSP with progressive cognitive impairment.

PubMed

Zorzi, Giovanna; Mancuso, Roberta; Nardocci, Nardo; Farina, Laura; Guerini, Franca Rosa; Ferrante, Pasquale

2010-04-01

HTLV-I associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a chronic myelopathy, usually with adult-onset. Very few cases of childhood-onset have been described, most presenting with progressive paraparesis and sphincteric disturbances as in the adult form. Here we report a young male with childhood-onset of HAM/TSP and progressive cognitive and behavioral disturbances. A serological screening revealed HTLV-I infection, confirmed by Western Immunoblotting analysis. Molecular characterization of amplified HTLV-I proviral DNA has been performed both in the patient and his mother by LTR sequence analysis, and HLA genotype inheritance was evaluated. Our case indicates the possibility that cognitive dysfunctions may be one manifestation of HTLV-I infection in childhood.

Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

PubMed

Hehir, Mark P; Rubeo, Zachary; Flood, Karen; Mardy, Anne H; O'Herlihy, Colm; Boylan, Peter C; D'Alton, Mary E

2018-03-01

Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p < 0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p = 0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p = 0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury.

PubMed

Aiken, Catherine E; Aiken, Abigail R; Prentice, Andrew

2015-03-01

Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery. For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. © 2014 Wiley Periodicals, Inc.

Reinnervation of Urethral and Anal Sphincters With Femoral Motor Nerve to Pudendal Nerve Transfer

PubMed Central

Ruggieri, Michael R.; Braverman, Alan S.; Bernal, Raymond M.; Lamarre, Neil S.; Brown, Justin M.; Barbe, Mary F.

2012-01-01

Aims Lower motor neuron damage to sacral roots or nerves can result in incontinence and a flaccid urinary bladder. We showed bladder reinnervation after transfer of coccygeal to sacral ventral roots, and genitofemoral nerves (L1, 2 origin) to pelvic nerves. This study assesses the feasibility of urethral and anal sphincter reinnervation using transfer of motor branches of the femoral nerve (L2–4 origin) to pudendal nerves (S1, 2 origin) that innervate the urethral and anal sphincters in a canine model. Methods Sacral ventral roots were selected by their ability to stimulate bladder, urethral sphincter, and anal sphincter contraction and transected. Bilaterally, branches of the femoral nerve, specifically, nervus saphenous pars muscularis [Evans HE. Miller’s anatomy of the dog. Philadelphia: W.B. Saunders; 1993], were transferred and end-to-end anastomosed to transected pudendal nerve branches in the perineum, then enclosed in unipolar nerve cuff electrodes with leads to implanted RF micro-stimulators. Results Nerve stimulation induced increased anal and urethral sphincter pressures in five of six transferred nerves. Retrograde neurotracing from the bladder, urethral sphincter, and anal sphincter using fluorogold, fast blue, and fluororuby, demonstrated urethral and anal sphincter labeled neurons in L2–4 cord segments (but not S1–3) in nerve transfer canines, consistent with rein-nervation by the transferred femoral nerve motor branches. Controls had labeled neurons only in S1–3 segments. Postmortem DiI and DiO labeling confirmed axonal regrowth across the nerve repair site. Conclusions These results show spinal cord reinnervation of urethral and anal sphincter targets after sacral ventral root transection and femoral nerve transfer (NT) to the denervated pudendal nerve. These surgical procedures may allow patients to regain continence. PMID:21953679

Functional asymmetry of pelvic floor innervation and its role in the pathogenesis of fecal incontinence.

PubMed

Enck, Paul; Hinninghofen, Heidemarie; Wietek, Beate; Becker, Horst D

2004-01-01

While the regular and symmetric innervation of the pelvic floor has been regarded as "established" for many years, recent data indicate that asymmetry of innervation of the sphincters may exists and may contribute to the occurrence and severity of incontinence symptoms in case of pelvic floor trauma. A systematic review of published papers on asymmetry of sphincter innervation was performed including studies in healthy volunteers and patients with incontinence. 234 consecutive patients with fecal incontinence were investigated by means of side-separated mass surface EMG from the left and right side anal canal, these data were correlated to clinical and anamnestic findings. The literature survey indicates that asymmetry of sphincter innervation exists in a subgroup of healthy male and female volunteers, and may be a risk factor to become incontinent in case of trauma. Patients with incontinence in whom asymmetry of sphincter innervation could be shown more frequently reported a history of pelvic floor trauma during childbirth. Childbirth per se but not the number of deliveries predicted sphincter asymmetry. Asymmetrically innervated sphincters show a compromised sphincter function in routine anorectal manometry. Assessment of sphincter innervation asymmetry may be of value in clinical routine testing of patients with incontinence. However, a new technology is needed to replace mass surface EMG by multi-electrode arrays on a sphincter probe. This is one of the goals of the EU-sponsored research project OASIS. Copyright 2004 S. Karger AG, Basel

[Evaluation of sphincter damage degree with anal endosonography for children with fecal incontinence].

PubMed

Sun, Xiaobing; Li, Dianguo; Wang, Ruoyi; Sun, Xiaogang; Liu, Qian

2014-03-01

To evaluate the application of anal endosonography in the morphology of internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis (PR) in order to provide necessary information for analysis of the etiology of fecal incontinence and formulation of the therapeutic schedule. From December 2010 to November 2012, 18 children of anorectal malformation (n=14) or Hirschsprung's disease(n=4) with fecal incontinence received anal endosonography. The morphology of IAS, EAS and PR was observed. The damage of anal sphincter was classified according to Starck criteria. Anorectal mamometry and anal clinical score were measured simultaneously. Spearman analysis was performed to examine the correlation of anal sphincter damage with anorectal mamometric score and anal clinical score. According to Starck criteria, anal sphincter damage was small in 11 children, moderate in 6, and severe in 1. PR damage was found in 4 cases. Starck score was positively correlated with manometric score(P<0.05), while not correlated with anal clinical score(P>0.05). Anal endosonography can clearly display the morphology of IAS, EAS and PR, and their integrity and damage degree. It is a very valuable technique to evaluate the anal sphincter of the children with fecal incontinence, which however can not reflect the function of anal sphincter and anal continence thoroughly.

In vitro effects of famotidine and ranitidine on lower esophageal sphincter tone in rats.

PubMed

Özer, Mahmut; Duman, Mustafa; Taş, Şükrü; Demırcı, Yeliz; Aydin, Muhammet Fatih; Reyhan, Enver; Atici, Ali Emre; Bostanci, Erdal Birol; Akoğlu, Musa; Genç, Ece

2012-01-01

The aim of this study was to investigate the effects of the H2 receptor antagonists famotidine and ranitidine on lower esophageal sphincter pressure in the rat isolated lower esophageal sphincter preparation contracted with carbachol. Lower esophageal sphincter tissues of eight rats for each group were placed in a standard organ bath. After contraction with carbachol, freshly prepared famotidine and ranitidine were added directly to the tissue bath in cumulatively increasing concentrations. Activities were recorded on an online computer using the software BSL PRO v 3.7, which also analyzed the data. Ranitidine caused a small statistically insignificant relaxation in the contracted lower esophageal sphincter at the two applied concentrations. Although 1.5 x 10⁻⁵ M famotidine did not cause a significant relaxation in lower esophageal sphincter tone, this value for 4.5 x 10⁻⁵ M famotidine was 9.33%, and the relaxation was significant when compared with controls (p<0.05). Neither famotidine nor ranitidine caused any direct significant change in lower esophageal sphincter tone in the therapeutic dose range applied to the organ bath. However, the higher dose of famotidine caused a significant relaxation in the lower esophageal sphincter tone. Further in vivo human studies may affect the usage of these drugs during gastroesophageal reflux disease treatment.

Neural Mechanisms Underlying Lower Urinary Tract Dysfunction

PubMed Central

Ogawa, Teruyuki; Miyazato, Minoru; Kitta, Takeya; Furuta, Akira; Chancellor, Michael B.; Tyagi, Pradeep

2014-01-01

This article summarizes anatomical, neurophysiological, and pharmacological studies in humans and animals to provide insights into the neural circuitry and neurotransmitter mechanisms controlling the lower urinary tract and alterations in these mechanisms in lower urinary tract dysfunction. The functions of the lower urinary tract, to store and periodically release urine, are dependent on the activity of smooth and striated muscles in the bladder, urethra, and external urethral sphincter. During urine storage, the outlet is closed and the bladder smooth muscle is quiescent. When bladder volume reaches the micturition threshold, activation of a micturition center in the dorsolateral pons (the pontine micturition center) induces a bladder contraction and a reciprocal relaxation of the urethra, leading to bladder emptying. During voiding, sacral parasympathetic (pelvic) nerves provide an excitatory input (cholinergic and purinergic) to the bladder and inhibitory input (nitrergic) to the urethra. These peripheral systems are integrated by excitatory and inhibitory regulation at the levels of the spinal cord and the brain. Therefore, injury or diseases of the nervous system, as well as disorders of the peripheral organs, can produce lower urinary tract dysfunction, leading to lower urinary tract symptoms, including both storage and voiding symptoms, and pelvic pain. Neuroplasticity underlying pathological changes in lower urinary tract function is discussed. PMID:24578802

Role of pelvic floor in lower urinary tract function.

PubMed

Chermansky, Christopher J; Moalli, Pamela A

2016-10-01

The pelvic floor plays an integral part in lower urinary tract storage and evacuation. Normal urine storage necessitates that continence be maintained with normal urethral closure and urethral support. The endopelvic fascia of the anterior vaginal wall, its connections to the arcus tendineous fascia pelvis (ATFP), and the medial portion of the levator ani muscles must remain intact to provide normal urethral support. Thus, normal pelvic floor function is required for urine storage. Normal urine evacuation involves a series of coordinated events, the first of which involves complete relaxation of the external urethral sphincter and levator ani muscles. Acquired dysfunction of these muscles will initially result in sensory urgency and detrusor overactivity; however, with time the acquired voiding dysfunction can result in intermittent urine flow and incomplete bladder emptying, progressing to urinary retention in severe cases. This review will start with a discussion of normal pelvic floor anatomy and function. Next various injuries to the pelvic floor will be reviewed. The dysfunctional pelvic floor will be covered subsequently, with a focus on levator ani spasticity and stress urinary incontinence (SUI). Finally, future research directions of the interaction between the pelvic floor and lower urinary tract function will be discussed. Copyright © 2015 Elsevier B.V. All rights reserved.

Long-lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: a pilot study.

PubMed

Terre, Rosa; Valles, Margarida; Panades, Agusti; Mearin, Fermin

2008-01-01

To evaluate the efficacy of botulinum toxin (BTX-A) injection in the cricopharyngeus muscle in patients with neurological dysphagia caused by alteration in the upper esophageal sphincter (UES) opening and with preserved pharyngeal contraction. A prospective pilot study was undertaken in 10 patients (7 brain lesions and 3 cervical spinal cord injuries), with a minimum time-lapse of 6 months from neurological lesion to BTX-A injection. Dysfunction of the UES opening and the presence of pharyngeal contraction were diagnosed by videofluoroscopy (VDF) and esophageal manometry (EM). The BTX-A (100 U) injection was guided by endoscopy. Clinical, VDF, and EM follow-ups were carried out at 3 weeks, 3 and 6 months, and at 1 year post-injection. Prior to treatment, 6 patients were fed by nasogastric tube. VDF showed impairment of the UES opening, residue in pyriform sinuses, and aspiration in all cases. During follow-up, there was a decrease in the number of patients that had aspiration: 3 patients at one year. During swallowing, EM showed a mean UES relaxation of 90% (range: 74.5-100%), residual pressure 3.2 mmHg (range: 0-13 mmHg) and pharyngeal amplitude 52 mmHg (range: 25-80 mmHg). At follow-up, a significant improvement in UES relaxation (98% (89-100%)) and pharyngeal contraction (97 mmHg (35-165 mmHg)) was observed. At 3 months, 6 patients were eating exclusively by mouth. One single injection of BTX-A in the UES has long-lasting effectiveness in patients with neurological dysphagia caused by alteration in the UES opening and with pharyngeal contraction. Nevertheless, a randomized control trial should be done to confirm these results and rule out the effect of potential spontaneous improvement of neurological injury.

Distribution and physiological effects of B-type allatostatins (myoinhibitory peptides, MIPs) in the stomatogastric nervous system of the crab Cancer borealis.

PubMed

Szabo, Theresa M; Chen, Ruibing; Goeritz, Marie L; Maloney, Ryan T; Tang, Lamont S; Li, Lingjun; Marder, Eve

2011-09-01

The crustacean stomatogastric ganglion (STG) is modulated by a large number of amines and neuropeptides that are found in descending pathways from anterior ganglia or reach the STG via the hemolymph. Among these are the allatostatin (AST) B types, also known as myoinhibitory peptides (MIPs). We used mass spectrometry to determine the sequences of nine members of the AST-B family of peptides that were found in the stomatogastric nervous system of the crab Cancer borealis. We raised an antibody against Cancer borealis allatostatin-B1 (CbAST-B1; VPNDWAHFRGSWa) and used it to map the distribution of CbAST-B1-like immunoreactivity (-LI) in the stomatogastric nervous system. CbAST-B1-LI was found in neurons and neuropil in the commissural ganglia (CoGs), in somata in the esophageal ganglion (OG), in fibers in the stomatogastric nerve (stn), and in neuropilar processes in the STG. CbAST-B1-LI was blocked by preincubation with 10(-6) M CbAST-B1 and was partially blocked by lower concentrations. Electrophysiological recordings of the effects of CbAST-B1, CbAST-B2, and CbAST-B3 on the pyloric rhythm of the STG showed that all three peptides inhibited the pyloric rhythm in a state-dependent manner. Specifically, all three peptides at 10(-8) M significantly decreased the frequency of the pyloric rhythm when the initial frequency of the pyloric rhythm was below 0.6 Hz. These data suggest important neuromodulatory roles for the CbAST-B family in the stomatogastric nervous system. Copyright © 2011 Wiley-Liss, Inc.

Distribution and physiological effects of B-type allatostatins (myoinhibitory peptides, MIPs) in the stomatogastric nervous system of the crab, Cancer borealis

PubMed Central

Szabo, Theresa M.; Chen, Ruibing; Goeritz, Marie L.; Maloney, Ryan T.; Tang, Lamont S.; Li, Lingjun; Marder, Eve

2011-01-01

The crustacean stomatogastric ganglion (STG) is modulated by a large number of amines and neuropeptides that are found in descending pathways from anterior ganglia or reach the STG via the hemolymph. Among these are the allatostatin (AST) – B types also known as myoinhibitory peptides (MIPs). We used mass spectrometry to determine the sequences of nine members of the AST-B family of peptides that were found in the stomatogastric nervous system of the crab, Cancer borealis. We raised an antibody against Cancer borealis Allatostatin-B1 (CbAST-B1) (VPNDWAHFRGSWa) and used it to map the distribution of CbAST-B1-like immunoreactivity (-LI) in the stomatogastric nervous system. CbAST-B1-LI was found in neurons and neuropil in the commissural ganglia (CoGs), in somata in the esophageal ganglion (OG), in fibers in the stomatogastric nerve (stn), and in neuropilar processes in the STG. CbAST-B1-LI was blocked by preincubation with 10-6 M CbAST-B1, and partially blocked by lower concentrations. Electrophysiological recordings of the effects of CbAST-B1, CbAST-B2, and CbAST-B3 on the pyloric rhythm of the STG showed that all three peptides inhibited the pyloric rhythm in a state-dependent manner. Specifically, all three peptides at 10-8 M significantly decreased the frequency of the pyloric rhythm when the initial frequency of the pyloric rhythm was below 0.6 Hz. These data suggest important neuromodulatory roles for the CbAST-B family in the stomatogastric nervous system. PMID:21491432

Anal sphincter injury. Management and results of Parks sphincter repair.

PubMed Central

Browning, G G; Motson, R W

1984-01-01

The surgical management of a consecutive series of 97 patients with complete division of the anal sphincter musculature is reported. The sphincter damage followed operative, traumatic, or obstetric injury and resulted in frank fecal incontinence or the urgent necessity of a defunctioning colostomy. All patients were treated by delayed sphincter repair using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There were no deaths. The repair was completely successful in 65 (78%) and partially successful in 11 (13%) of the 83 patients assessed from 4 to 116 months after surgery. Complications occurred in 27 patients but did not usually affect the eventual clinical outcome. Provided there has been no major neurological damage to the sphincter complex, surgical reconstruction can be expected to restore continence in most patients. Images Fig. 1. Fig. 2. Fig. 3. Fig. 4. Fig. 5. PMID:6703796

Analysis of chronic morphologic changes of small bowel in electrically stimulated canine island-flap rectus abdominis muscle stomal sphincters.

PubMed

Majzoub, R K; Bardoel, J W; Ackermann, D; Maldonado, C; Barker, J; Stadelmann, W K

2001-11-01

Dynamic myoplasty to achieve fecal continence has been used in humans with varying results. A potential complication of the use of dynamic skeletal sphincters to attain fecal continence is the development of ischemic strictures within the bowel encircled by the functional sphincter. This study examines the histologic changes present in the bowel wall used to create a functional dynamic island-flap stomal sphincter in a chronic canine model. The rectus abdominis muscles of canines were used to create island-flap stomal sphincters. Eight dynamic island-flap stomal sphincters were created from the rectus abdominis muscles in mongrel dogs by wrapping them around a blind loop of distal ileum that was no longer in continuity with the terminal small bowel. Temporary pacing electrodes were secured intramuscularly near the intercostal nerve entry point and connected to a subcutaneously placed pulse stimulator. Two different training protocols resulting in different contractile properties were used: Program A (n = 4) and Program B (n = 4). The island-flap sphincters were trained over 3 months to generate stomal intraluminal pressures of more than 60 mmHg in all animals. The intact sphincters, normal bowel, and contralateral stomal bowel were obtained when the animals were killed. Specimens were processed with paraffin embedding, sectioned, and stained with trichrome and hematoxylin-and-eosin stains. Measurements of the different bowel layers were made with a micrometer. The muscular sphincters were biopsied before and after training. Fiber-type histochemistry was performed with a monoclonal antibody to the fast isoforms of myosin. Pretrained and posttrained skeletal muscle specimens were examined histologically. The bowel wall within the functional dynamic stomal sphincter did not exhibit any significant architectural changes related to ischemic fibrosis or mucosal damage. A significant fiber-type conversion was achieved in both training groups with Programs A and B, with a >50 percent conversion from fatigue-prone (type II) muscle fibers to fatigue-resistant (type I) muscle fibers. Biopsy specimens revealed that fiber-type transformation was uniform throughout the sphincters. Skeletal muscle fibers within both groups demonstrated a reduction in their fiber diameter. There was no evidence of significant fibrosis or deposition of fat within the skeletal muscle of the sphincters. Results of our experiment suggest that our anterior abdominal wall dynamic island-flap stomal sphincter, which generates a contractile force over the bowel wall capable of producing enough stomal pressure to achieve fecal continence, is not intrinsically harmful to the bowel that it encircles. The transformation of skeletal muscle to fatigue-resistant (type I) fibers occurred uniformly throughout the skeletal muscle sphincters without evidence of muscle fiber damage or significant fibrosis.

Evolving paradigms in the treatment of opioid-induced bowel dysfunction.

PubMed

Poulsen, Jakob Lykke; Brock, Christina; Olesen, Anne Estrup; Nilsson, Matias; Drewes, Asbjørn Mohr

2015-11-01

In recent years prescription of opioids has increased significantly. Although effective in pain management, bothersome gastrointestinal adverse effects are experienced by a substantial proportion of opioid-treated patients. This can lead to difficulties with therapy and subsequently inadequate pain relief. Collectively referred to as opioid-induced bowel dysfunction, these adverse effects are the result of binding of exogenous opioids to opioid receptors in the gastrointestinal tract. This leads to disturbance of three important gastrointestinal functions: motility, coordination of sphincter function and secretion. In the clinic this manifests in a wide range of symptoms such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation, although the most known adverse effect is opioid-induced constipation. Traditional treatment with laxatives is often insufficient, but in recent years a number of novel pharmacological approaches have been introduced. In this review the pathophysiology, symptomatology and prevalence of opioid-induced bowel dysfunction is presented along with the benefits and caveats of a suggested consensus definition for opioid-induced constipation. Finally, traditional treatment is appraised and compared with the latest pharmacological developments. In conclusion, opioid antagonists restricted to the periphery show promising results, but use of different definitions and outcome measures complicate comparison. However, an international working group has recently suggested a consensus definition for opioid-induced constipation and relevant outcome measures have also been proposed. If investigators within this field adapt the suggested consensus and include symptoms related to dysfunction of the upper gut, it will ease comparison and be a step forward in future research.

The eminent anatomists who discovered the upper oesophageal sphincter.

PubMed

Marchese-Ragona, R; Ottaviano, G; Masiero, S; Staffieri, C; Martini, A; Staffieri, A; Mion, M; Zaninotto, G; Restivo, D A

2014-10-01

To discover the anatomist who first identified the upper oesophageal sphincter. The authors searched dozens of antique anatomy textbooks kept in the old section of the 'Vincenzo Pinali' Medical Library of Padua University, looking for descriptions of the upper oesophageal sphincter. The oesophageal sphincter was drawn correctly only in 1601, by Julius Casserius, in the book De vocis auditusque organis historia anatomica… (which translates as 'An Anatomical History on the Organs of Voice and Hearing …'), and was properly described by Antonio Maria Valsalva in 1704 in the book De aure humana tractatus… ('Treatise on the Human Ear …'). Anatomists Casserius and Valsalva can be considered the discoverers of the 'oesophageal sphincter'.

Patient characteristics and treatment outcome in functional anorectal pain.

PubMed

Atkin, Gary K; Suliman, Amna; Vaizey, Carolynne J

2011-07-01

Functional anorectal pain occurs in the absence of any clinical abnormality. It is common and disabling; it has previously been reported in only a few studies involving small patient numbers. This study aimed to report the clinical characteristics and treatment outcomes for patients with functional anorectal pain. Patient demographics, clinical history, and tests results for all referrals for anorectal physiological testing between 1997 and 2009 were prospectively recorded. For patients with functional anorectal pain, further information was gained from clinical notes. Clinical history, anorectal physiology, and radiological imaging data were recorded for all patients; treatment outcome was noted for patients treated and followed up at the present unit. One hundred seventy patients, 99 female, with a median age of 48 years (range, 18-86), were studied. Patients were classified as having chronic proctalgia (pain duration ≥20 min, 158 patients) or proctalgia fugax (pain duration <20 min, 12 patients). The pain was most commonly located in the anal canal (90%) and aggravated by defecation or sitting (66%). A third of patients had a history of psychological disturbance. Internal anal sphincter thickness correlated with resting anal pressures. Patients with proctalgia fugax had a higher internal anal sphincter thickness and resting pressure than patients with chronic proctalgia, whereas patients with a family history of similar symptoms were more likely to have proctalgia fugax and higher resting pressures and internal anal sphincter thickness compared with those without a family history of these symptoms. Patients referred for treatment underwent a range of interventions including biofeedback (29 patients, 17 improved), tricyclic antidepressants (26 patients, 10 improved), Botox injection (9 patients, 5 improved), and sacral nerve stimulation (3 patients, 2 improved). Biofeedback had the greatest treatment effect, especially in patients with defecatory dysfunction. Biofeedback is beneficial in the subset of patients with functional anorectal pain and difficulty with defecation. Tricyclic antidepressants, Botox, and sacral nerve stimulation may also have a role.

Successful implantation of physiologically functional bioengineered mouse internal anal sphincter.

PubMed

Raghavan, Shreya; Miyasaka, Eiichi A; Hashish, Mohamed; Somara, Sita; Gilmont, Robert R; Teitelbaum, Daniel H; Bitar, Khalil N

2010-08-01

We have previously developed bioengineered three-dimensional internal anal sphincter (IAS) rings from circular smooth muscle cells isolated from rabbit and human IAS. We provide proof of concept that bioengineered mouse IAS rings are neovascularized upon implantation into mice of the same strain and maintain concentric smooth muscle alignment, phenotype, and IAS functionality. Rings were bioengineered by using smooth muscle cells from the IAS of C57BL/6J mice. Bioengineered mouse IAS rings were implanted subcutaneously on the dorsum of C57BL/6J mice along with a microosmotic pump delivering fibroblast growth factor-2. The mice remained healthy during the period of implantation, showing no external signs of rejection. Mice were killed 28 days postsurgery and implanted IAS rings were harvested. IAS rings showed muscle attachment, neovascularization, healthy color, and no external signs of infection or inflammation. Assessment of force generation on harvested IAS rings showed the following: 1) spontaneous basal tone was generated in the absence of external stimulation; 2) basal tone was relaxed by vasoactive intestinal peptide, nitric oxide donor, and nifedipine; 3) acetylcholine and phorbol dibutyrate elicited rapid-rising, dose-dependent, sustained contractions repeatedly over 30 min without signs of muscle fatigue; and 4) magnitudes of potassium chloride-induced contractions were 100% of peak maximal agonist-induced contractions. Our preliminary results confirm the proof of concept that bioengineered rings are neovascularized upon implantation. Harvested rings maintain smooth muscle alignment and phenotype. Our physiological studies confirm that implanted rings maintain 1) overall IAS physiology and develop basal tone, 2) integrity of membrane ionic characteristics, and 3) integrity of membrane associated intracellular signaling transduction pathways for contraction and relaxation by responding to cholinergic, nitrergic, and VIP-ergic stimulation. IAS smooth muscle tissue could thus be bioengineered for the purpose of implantation to serve as a potential graft therapy for dysfunctional internal anal sphincter in fecal incontinence.

Pregnancy-associated glycoprotein, chymosin and pepsinogen immunoreactivity of proteins extracted from fetal gastric tissue in bovine species.

PubMed

Bella, A; Sousa, N M; Dehimi, M L; Beckers, J F

2012-06-01

The objective of this work was to investigate the expression of gastric aspartic proteinases in fundic and pyloric mucosa removed from bovine fetuses. For this purpose, fractions issued from classical biochemical protocols were analyzed by proteolytic method, by PAG-RIA and by Western blot with the use of antisera raised against both pepsinogens and PAG. A strong reaction of proteins extracted from the fundic mucosa collected at the beginning of pregnancy was revealed with both anti-bPAG-I and anti-bPAG-II antisera, suggesting the expression of pepsinogen F in bovine species. Concerning pyloric mucosa, the analysis by Western blot highlighted a very strong immunoreaction with the anti-bovine chymosin serum. Amino-terminal sequencing allowed to identify bovine fetuin and albumin in fundic extracts, chymosin in the pyloric mucosa extracts, as well as some unknown proteins in both mucosa. Despite no N-terminal microsequence corresponding to the hypothetical pepsinogen F could be identified, it cannot be excluded that an existing bovine pepsinogen F-like molecule could be degraded during the purification procedure or that co-purified proteins could be responsible for masking its N-terminal microsequence. Copyright © 2011 Elsevier Ltd. All rights reserved.

Management of blunt duodenal injuries.

PubMed

Sriussadaporn, Suvit; Pak-art, Rattaplee; Sriussadaporn, Sukanya; Kritayakirana, Kritaya

2004-11-01

Blunt duodenal injuries are relatively rare. Diagnosis is usually delayed resulting in significant morbidity and mortality. Treatment of the injured duodenum varies according to severity of injury and duration before diagnosis. Duodenal fistulas are serious complications with potential mortality. The purpose of this study was to examine results of treatment of patients with blunt duodenal injuries at our institution. This is a retrospective study of patients who sustained blunt duodenal injuries and were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1990 to December 2003. During the study period, management of duodenal injuries at our institution depended largely on severity of injuries, timing of diagnosis and the presence of retroperitoneal infections. Intramural hematoma of the duodenum was treated conservatively. Uncomplicated wounds of the duodenum (grade II and grade III injury) with no obvious retroperitoneal infections were treated by simple duodenal repair. Pyloric exclusion was performed in cases of difficult duodenal repair and/or delayed diagnosis (> 24 hours after injury) with obvious evidence of retroperitoneal infections. Twenty six patients were entered into the study. Five patients (19.2%) had intramural hematoma of the duodenum, all were successfully treated by conservative treatment. Twenty one patients (80.8%) had transmural tear of the duodenal wall. Ten of them (47.6%) underwent simple repair, 10 (47.6%) underwent simple repair of the duodenal wounds combined with pyloric exclusion (2 of them underwent the operations elsewhere), and 1 (4.8%) underwent pancreaticoduodenectomy. Seven patients who had transmural tear of the duodenum developed complications (33.3%). Two patients had duodenal fistulas (9.5%); 1 in the simple repair group and 1 in the pyloric exclusion group. One patient who underwent pyloric exclusion had leakage of the gastrojejunostomy anastomosis with intact duodenal repair resulting in a complicated and prolonged hospital course. There was no mortality in this study. The outcome in management of blunt duodenal injuries at our institution was acceptable with low morbidity and no mortality. Intramural hematomas were safely treated conservatively. Uncomplicated duodenal wounds were treated by simple suture repair. Pyloric exclusion was a useful additional procedure in patients with complicated duodenal injuries. Retroperitoneal infections was a strong indication to perform this procedure in addition to simple repair of the duodenal wounds. Pancreaticoduodenectomy should be reserved for only severed combined duodenal and pancreatic head injuries.

Maternal body mass index and risk of obstetric anal sphincter injury.

PubMed

Blomberg, Marie

2014-01-01

To estimate the association between maternal obesity and risk of three different degrees of severity of obstetric anal sphincter injury. The study population consisted of 436,482 primiparous women with singleton term vaginal cephalic births between 1998 and 2011 identified in the Swedish Medical Birth Registry. Women were grouped into six categories of BMI. BMI 18.5-24.9 was set as reference. Primary outcome was third-degree perineal laceration, partial or total, and fourth-degree perineal laceration. Adjustments were made for year of delivery, maternal age, fetal head position at delivery, infant birth weight and instrumental delivery. The overall prevalence of third- or four-degree anal sphincter injury was 6.6% (partial anal sphincter injury 4.6%, total anal sphincter injury 1.2%, unclassified as either partial and total 0.2%, or fourth degree lacerations 0.6%). The risk for a partial, total, or a fourth-degree anal sphincter injury decreased with increasing maternal BMI most pronounced for total anal sphincter injury where the risk among morbidly obese women was half that of normal weight women, OR 0.47 95% CI 0.28-0.78. Obese women had a favourable outcome compared to normal weight women concerning serious pelvic floor damages at birth.

Voiding dysfunction: another etiology of vulvovaginitis in young girls.

PubMed

Romero, P; Rodríguez, E; Muñoz, M; Delucchi, A; Guerrero, J L; Lillo, A M; Cano, F; Matilde Osses, Sra; Romero, M I; Gonzalez Roca, C

2011-08-01

To determine the prevalence of voiding dysfunction (VD) in patients with persistent vulvovaginitis (PVV), and to evaluate the clinical response of PVV in the treatment of VD. Girls four years or older who consulted for PVV for at least one month and who did not respond to general measures. A physical examination was performed with visual inspection and colposcopy; vaginal samples for culture and vaginoscopy were carried out. On every patient urodynamic studies were performed. Girls who were diagnosed with VD were treated. A pediatric gynecologist did the follow-up; a successful response was considered when inflammatory symptoms and vaginal discharge ceased. Twenty patients were included, mean age 8.6 years (range: 4.6-14 years); 75% prepubertal symptoms lasted for 1.8 years; 19 (95%) had urodynamia, 10 (52.6%) had an overactive bladder, 8 (42.1%) external bladder sphincter dyssynergia, 1 (5.2%) hypotonic bladder, and 13 (65%) showed improvement. VD is an important cause when considering the etiology of PVV. 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Leg raise increases pressure in lower and upper esophageal sphincter among patients with gastroesophageal reflux disease.

PubMed

Bitnar, P; Stovicek, J; Andel, R; Arlt, J; Arltova, M; Smejkal, M; Kolar, P; Kobesova, A

2016-07-01

The purpose of this study was to determine the relation between posturally increased intra-abdominal pressure and lower/upper esophageal sphincter pressure changes in patients with gastroesophageal reflux disease. We used high resolution manometry to measure pressure changes in lower and upper esophageal sphincter during bilateral leg rise. We also examined whether the rate of lower and upper esophageal sphincter pressure would increase during leg raise differentially in individuals with versus without normal resting pressure. Fifty eight patients with gastroesophageal reflux disease participated in the study. High resolution manometry was performed in relaxed supine position, then lower and upper esophageal sphincter pressure was measured. Finally, the subjects were instructed to keep their legs lifted while performing 90-degree flexion at the hips and knees and the pressure was measured again. Paired t-test and independent samples t-test were used. There was a significant increase in both lower (P < 0.001) and upper esophageal sphincter pressure (P = 0.034) during leg raise compared to the initial resting position. Individuals with initially higher pressure in lower esophageal sphincter (>10 mmHg) exhibited a greater pressure increase during leg raise than those with initially lower pressure (pressure ≤10 mmHg; P = 0.002). Similarly individuals with higher resting upper esophageal sphincter pressure (>44 mmHg) showed a greater pressure increase during leg raise than those with lower resting pressure (≤44 mmHg; P < 0.001). The results illustrate the influence of postural leg activities on intraesophageal pressure in patients with gastroesophageal reflux disease, indicating by means of high resolution manometry that diaphragmatic postural and sphincter function are likely interrelated in this population. Copyright © 2015 Elsevier Ltd. All rights reserved.

On the etiology of the electric activity of the external anal and urethral sphincters.

PubMed

Shafik, Ali A; Shafik, Ismail A; El Sibai, Olfat

2014-10-01

In a previous study, the external anal sphincter (EAS) in dogs, known to consist of skeletal muscle fibers, was proved to contain bundles of smooth muscle fibers in between as well. Cause of electric activity in the external anal and urethral sphincters is not known; the current study investigated this point. Slices from external anal and urethral sphincters of 21 cadavers (12 male, 9 female). Eighth were fully and mat wide neonates, 13 were adults, were stained with hematoxylin and eosin, Masson's trichrome and succinic dehydrogenase, and examined microscopically. Eighteen healthy volunteers, electromyography activity of their external anal and urethral sphincters was recorded at rest, on coughing, after pudendal nerve block and after drotaverine administration, (a smooth muscle relaxant). Anal and urethral pressures were also measured. Microscopic studies have shown that both external anal and urethral sphincters were formed of bundles of smooth muscle fibers present in between the skeletal muscle fibers. Bilateral pudendal nerve block did not abolish the external anal or the urethral sphincters electromyography activity at rest, or on coughing, and did not cause significant anal or urethral pressure changes (p > .05). Drotaverine administration lead to disappearance of the electromyography activity and significant decline of the anal and urethral pressures (p < .05). The results were reproducible when the tests were repeated in the same subject. Histologic examination revealed the presence of smooth muscle fibers, between the skeletal fibers of the external anal and urethral sphincters. Evidence suggests that the smooth muscle fibers are the source of the electric activity of the sphincters and might explain some physiologic phenomena such as the external anal contraction on rectal distension or on coughing.

Transverse myelitis caused by hepatitis E: previously undescribed in adults

PubMed Central

Sarkar, Pamela; Morgan, Catherine; Ijaz, Samreen

2015-01-01

We report the case of a 62-year-old Caucasian woman who was admitted with urinary retention and lower limb paraesthesia following a week's prodromal illness of headache and malaise. Liver function tests showed a picture of acute hepatocellular dysfunction. She developed reduced lower limb power, brisk reflexes, extensor plantars, a sensory level at T8 and reduced anal sphincter tone, establishing a clinical diagnosis of transverse myelitis. A spinal MRI showed no evidence of cauda equina or spinal cord compression. Cerebrospinal fluid (CSF) analysis showed raised protein and raised white cell count. Hepatitis E IgM and IgG were positive and hepatitis E virus was found in her CSF. She was treated with methylprednisolone and is slowly recovering with physiotherapy. PMID:26150621

Esophageal motor dysfunction plays a key role in GERD with globus sensation--analysis of factors promoting resistance to PPI therapy.

PubMed

Tsutsui, Hideaki; Manabe, Noriaki; Uno, Masako; Imamura, Hiroshi; Kamada, Tomoari; Kusunoki, Hiroaki; Shiotani, Akiko; Hata, Jiro; Harada, Tamotsu; Haruma, Ken

2012-09-01

Patients with gastroesophageal reflux disease (GERD) also have various extra-esophageal symptoms. Laryngopharyngeal reflux disease (LPRD) is a subtype of GERD associated with globus sensation, but proton pump inhibitor (PPI) therapy achieves disappointing results. This study investigated esophageal motility in GERD patients with globus sensation who were resistant to PPI therapy. The subjects were 350 patients with globus sensation. All patients underwent both laryngoscopy and upper gastrointestinal endoscopy to exclude organic disease. After 4 weeks of treatment with rabeprazole sodium (20 mg daily), the patients were divided into PPI-responsive and PPI-resistant groups. Then we investigated esophageal motility in the PPI-resistant group by a multichannel intraluminal impedance and manometry study. A total of 119 patients (55.6%) were resistant to PPI therapy, among whom 57 patients (47.9%) had abnormal esophageal motility. They included 36 patients (66.4%) with ineffective esophageal motility, 9 patients (14.4%) with achalasia, 6 patients (9.6%) with diffuse esophageal spasm, 5 patients (8%) with nutcracker esophagus, and 1 patient (1.6%) with hypertensive lower esophageal sphincter. There were significant differences of upper esophageal sphincter pressure and esophageal body peristalsis between the patients with PPI-resistant LPRD and healthy controls matched for age and sex. Among patients with PPI-resistant LPRD, 47.9% had abnormal esophageal motility.

Use of the rectus abdominis muscle for abdominal stoma sphincter construction: an anatomical feasibility study.

PubMed

Bardoel, J W; Stadelmann, W K; Tobin, G R; Werker, P M; Stremel, R W; Kon, M; Barker, J H

2000-02-01

Permanent fecal abdominal stomas significantly decrease quality of life. Previous attempts to create continent stomas by using dynamic myoplasty procedures have resulted in disappointing outcomes, primarily owing to denervation atrophy of the muscle flap that was used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation that is received by the flap to force contraction. On the basis of these problems, we designed two separate studies: an anatomical study addressing flap denervation and a functional study addressing muscle fatigue. The present study addresses the first topic and was designed to develop a rectus abdominis muscle flap into a sphincter that was anatomically situated to create a stoma while preserving as much innervation as possible. In 24 rectus abdominis muscles of human cadavers, the neurovascular anatomy was defined, then the anatomical feasibility of two different muscle flap configurations was considered. The flaps investigated were the peninsula flap and island flap designs, with both using the most caudal segment of the rectus abdominis muscle in construction of the sphincter. Neither flap design required the killing of a nerve for stoma sphincter creation, resulting in minimal muscle denervation. The conclusion of our comparison was that the above, in conjunction with other features of the island flap design, such as muscle overlap after sphincter formation and abdominal wall positioning of the sphincter, made the island flap design better suited to stoma sphincter construction.

Optimization of the artificial urinary sphincter: modelling and experimental validation

NASA Astrophysics Data System (ADS)

Marti, Florian; Leippold, Thomas; John, Hubert; Blunschi, Nadine; Müller, Bert

2006-03-01

The artificial urinary sphincter should be long enough to prevent strangulation effects of the urethral tissue and short enough to avoid the improper dissection of the surrounding tissue. To optimize the sphincter length, the empirical three-parameter urethra compression model is proposed based on the mechanical properties of the urethra: wall pressure, tissue response rim force and sphincter periphery length. In vitro studies using explanted animal or human urethras and different artificial sphincters demonstrate its applicability. The pressure of the sphincter to close the urethra is shown to be a linear function of the bladder pressure. The force to close the urethra depends on the sphincter length linearly. Human urethras display the same dependences as the urethras of pig, dog, sheep and calf. Quantitatively, however, sow urethras resemble best the human ones. For the human urethras, the mean wall pressure corresponds to (-12.6 ± 0.9) cmH2O and (-8.7 ± 1.1) cmH2O, the rim length to (3.0 ± 0.3) mm and (5.1 ± 0.3) mm and the rim force to (60 ± 20) mN and (100 ± 20) mN for urethra opening and closing, respectively. Assuming an intravesical pressure of 40 cmH2O, and an external pressure on the urethra of 60 cmH2O, the model leads to the optimized sphincter length of (17.3 ± 3.8) mm.

Maternal Body Mass Index and Risk of Obstetric Anal Sphincter Injury

PubMed Central

2014-01-01

Objective. To estimate the association between maternal obesity and risk of three different degrees of severity of obstetric anal sphincter injury. Methods. The study population consisted of 436,482 primiparous women with singleton term vaginal cephalic births between 1998 and 2011 identified in the Swedish Medical Birth Registry. Women were grouped into six categories of BMI. BMI 18.5–24.9 was set as reference. Primary outcome was third-degree perineal laceration, partial or total, and fourth-degree perineal laceration. Adjustments were made for year of delivery, maternal age, fetal head position at delivery, infant birth weight and instrumental delivery. Results. The overall prevalence of third- or four-degree anal sphincter injury was 6.6% (partial anal sphincter injury 4.6%, total anal sphincter injury 1.2%, unclassified as either partial and total 0.2%, or fourth degree lacerations 0.6%). The risk for a partial, total, or a fourth-degree anal sphincter injury decreased with increasing maternal BMI most pronounced for total anal sphincter injury where the risk among morbidly obese women was half that of normal weight women, OR 0.47 95% CI 0.28–0.78. Conclusion. Obese women had a favourable outcome compared to normal weight women concerning serious pelvic floor damages at birth. PMID:24839604

Magnetic Resonance Imaging of the anal canal using high resolution sequences and phased array coil: visualization of anal sphincter complex.

PubMed

Laghi, A; Iafrate, F; Paolantonio, P; Iannaccone, R; Baeli, I; Ferrari, R; Catalano, C; Passariello, R

2002-04-01

To assess the normal anatomy of the anal sphincter complex using high-resolution MR imaging with phased -array coil. Twenty patients, 13 males and 7 females, ranging in age between 27 and 56 years underwent MRI evaluation of the pelvic region, using a superconductive 1.5 T magnet (maximum gradient strength, 25 mT/m; minimum rise time 600 microseconds, equipped with phased-array coil. High-resolution T2-weighted Turbo Spin Echo sequences (TR, 4055 ms; TE, 132 ms; matrix 390x512; in-plane resolution, 0.67x0.57 mm) were acquired on multiple axial, sagittal and coronal planes. Images were reviewed by two experienced gastrointestinal radiologists in order to evaluate the normal anal sphincter complex. Optimal image quality of the anal sphincter complex was obtained in all cases. Different muscular layers were observed between the upper and lower aspects of the anal canal. In the lower part of the anal canal, internal and external sphincter muscles could be observed; in the upper part, puborectal and internal sphincter muscles were depicted. Good visualization of intersphincteric space, levator ani muscle and ischioanal space was also obtained in all cases. High-resolution MR images with phased-array coil provide optimal depiction of the anal canal and the anal sphincter complex.

Frequency of operative trauma to anal sphincters: evaluation with endoanal ultrasound.

PubMed

Stamatiadis, Apostolos; Konstantinou, Evangelos; Theodosopoulou, Eleni; Mamoura, Konstantinia

2002-01-01

Sphincter trauma after anorectal surgery is usually asymptomatic. Frequency of trauma cannot be established with the clinical examination only. The frequency of operative sphincter defects and their correlation with disorders of continence was evaluated with the endoanal ultrasound. This study includes 123 subjects who had undergone anorectal surgery in the past and were examined with endoanal ultrasound for various indications such as continence disorders, recurrent fistula, idiopathic perineal pain, or simple postoperative follow-up. No subjects had isolated external anal sphincter defects. Nineteen of 123 patients (15%) had minor or major continence disorders, 55 patients (45%) had no sphincter defects, 42 (34%) had only internal anal sphincter (IAS) defects, and 26 (21%) had simultaneously external and internal anal sphincter (EAS) defects. The incidence of IAS and EAS trauma after Milligan-Morgan hemorrhoidectomy was 1/18 (5.5%) and 0/18 respectively; after fistula repair, 24/42 (57%) and 12/42 (29%); and after anal dilatation, 13/17 (76%) and 4/17 (24%). Sixteen of 26 patients (62%) with EAS trauma and 51/68 patients (75%) with IAS trauma did not report any disorders of continence. In patients with two or more operations, the frequency of IAS trauma was 74%, 30% for EAS trauma, and 26% for continence disorders.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

PubMed

Oberwalder, M; Dinnewitzer, A; Baig, M K; Nogueras, J J; Weiss, E G; Efron, J; Vernava, A M; Wexner, S D

2006-07-01

Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups. A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

The impact of an intervention programme employing a hands-on technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis.

PubMed

Fretheim, Atle; Odgaard-Jensen, Jan; Røttingen, John-Arne; Reinar, Liv Merete; Vangen, Siri; Tanbo, Tom

2013-10-22

To re-evaluate previously published findings from an uncontrolled before-after evaluation of an intervention programme to reduce the incidence of anal sphincter tears. A key component of the programme was the use of a hands-on technique where the birth attendant presses the neonate's head during the final stage of delivery while simultaneously supporting the woman's perineum with the other hand. Interrupted time-series analysis using segmented regression modelling. Obstetric departments of five Norwegian hospitals. All women giving births vaginally in the study hospitals, 2002-2008. The main data source was the Medical Birth Registry of Norway. We estimated the change in incidence of anal sphincter tears before and after implementation of the intervention in the five intervention hospitals, taking into account the trends in incidence before and after implementation. Incidence of anal sphincter tears and episiotomies. There were 75 543 registered births at the five included hospitals. We found a 2% absolute reduction in incidence of anal sphincter tears associated with the hospital intervention programme, representing almost a halving in the number of women experiencing serious anal sphincter tears. This is a substantially smaller estimate than previously reported. However, it does represent a highly significant decrease in anal sphincter injuries. The programme was also associated with a significant increase in episiotomies. The intervention programme was associated with a significant reduction in the incidence of obstetric anal sphincter tears. Still, the findings should be interpreted with caution as they seem to contradict the findings from randomised controlled studies of similar interventions.

Maternal Asian ethnicity and the risk of anal sphincter injury.

PubMed

Davies-Tuck, Miranda; Biro, Mary-Anne; Mockler, Joanne; Stewart, Lynne; Wallace, Euan M; East, Christine

2015-03-01

To examine associations between maternal Asian ethnicity (South Asian and South East/East Asian) and anal sphincter injury. Retrospective cross-sectional study, comparing outcomes for Asian women with those of Australian and New Zealand women. A large metropolitan maternity service in Victoria, Australia. Australian/New Zealand, South Asian and South East/East Asian women who had a singleton vaginal birth from 2006 to 2012. The relation between maternal ethnicity and anal sphincter injury was assessed by logistic regression, adjusting for potential confounders. Anal sphincter injury was defined as a third or fourth degree tear (with or without episiotomy). Among 32,653 vaginal births there was a significant difference in the rate of anal sphincter injury by maternal region of birth (p < 0.001). After adjustment for confounders, nulliparous women born in South Asian and South East/East Asia were 2.6 (95% confidence interval 2.2-3.3; p < 0.001) and 2.1 (95% confidence interval 1.7-2.5; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. Parous women born in South Asian and South East/East Asia were 2.4 (95% confidence interval 1.8-3.2; p < 0.001) and 2.0 (95% confidence interval 1.5-2.7; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. There are ethnic differences in the rates of anal sphincter injury not fully explained by known risk factors for such trauma. This may have implications for care provision. © 2014 Nordic Federation of Societies of Obstetrics and Gynecology.

[Applicability of 3/4D transperineal ultrasound for the diagnosis of anal sphincter injury during the immediate pospartum].

PubMed

García-Mejido, José Antonio; Gutiérrez Palomino, Laura; Fernández Palacín, Ana; Sainz-Bueno, José Antonio

The most common cause of anal sphincter injuries in women is vaginal birth. Endo-anal ultrasound is currently used for the diagnosis of anal sphincter defect. However, due to the inconvenience caused, it is not an applicable technique during the immediate post-partum. The aim of this study was to determine whether transperineal ultrasound in 3/4D is a useful diagnostic method for the assessment of anal sphincter during the immediate post-partum. A prospective study was conducted on the vaginal deliveries performed between September 2012 and June 2013 in the Valme University Hospital (Seville). Obstetric and foetal parameters that could influence the onset of perineal tears were studied. The patients underwent a transperineal 3/4D ultrasound and a multislice study (48hours after birth). The study included 146 puerperal women. The sphincter complex was assessed in all of them during the immediate post-partum. External anal injuries were observed in 10.3% of the cases. In 8.2% of cases, the primary suture of the external anal sphincter was detected during ultrasound examination, and 2.1% of asymptomatic lesions were diagnosed only with post-partum ultrasound. None of the patients reported discomfort or pain. The 3-dimensional transperineal ultrasound is helpful in determining the primary repair of the anal sphincter during the immediate post-partum, with no discomfort for patients, as well as for establishing those early sphincter injuries that go unnoticed during vaginal delivery. Copyright © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal.

PubMed

Sioutis, D; Thakar, R; Sultan, A H

2017-11-01

To determine the accuracy of clinical diagnosis of obstetric anal sphincter injuries (OASIS) using three-dimensional (3D) endoanal ultrasound (EA-US) and to compare symptoms and anal manometry measurements between women with anal sphincters adequately repaired and those with persistent anal sphincter defects. The EA-US images of women with clinically diagnosed and repaired OASIS, defined as third- or fourth-degree perineal tear, who attended the perineal clinic at Croydon University Hospital over a 10-year period (2003-2013) were reanalyzed by a single expert blind to symptoms and the results of clinical examination. St Mark's Incontinence Scores (SMIS) and anal manometry measurements were obtained and compared between women with an intact anal sphincter and those with an anal sphincter scar and between those with an intact anal sphincter and those with a defect. Anal manometry measurements were compared between women with an external anal sphincter (EAS) defect and those with an internal anal sphincter (IAS) defect. The images of 908 women were reanalyzed. No evidence of OASIS was found in 64 (7.0%) women, an EAS scar alone was detected in 520 (57.3%) and an anal sphincter defect in 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect, 90 had an IAS defect and 122 had a combined IAS and EAS defect. SMIS results were significantly higher in women with an anal sphincter defect compared with those with no evidence of OASIS (P = 0.018), but there was no significant difference in scores between women with an intact sphincter and those with an EAS scar only. Women with a defect had a significantly lower maximum resting pressure (median (range), 44 (8-106) vs 55 (29-86) mmHg; P < 0.001) and maximum squeeze pressure (median (range), 74 (23-180) vs 103 (44-185) mmHg; P < 0.001) compared with those in the intact group. Similar, but less marked, differences were observed in women with an EAS scar compared with those who had an intact anal sphincter. The anal length was significantly shorter in women with a defect compared with those in the intact group (median (range), 20 (10-40) vs 25 (10-40) mm; P = 0.003). Seven percent of women with a clinical diagnosis of OASIS were wrongly diagnosed. We believe that this rate may differ from that of other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of EA-US in the immediate postpartum period needs further evaluation as the accurate interpretation of the images is dependent on the expertise of the staff involved. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Gender influences sphincter of Oddi response to cholecystokinin in the prairie dog.

PubMed

Tierney, S; Qian, Z; Yung, B; Lipsett, P A; Pitt, H A; Sostre, S; Lillemoe, K D

1995-10-01

Although gallstones and disorders of biliary tract motility are both more common in women than men, sphincter of Oddi motility has not previously been compared between the sexes. In this study, cholescintigraphy (under ketamine and diazepam anesthesia) was used to determine gallbladder emptying rate and ejection fraction in response to cholecystokinin (CCK) in eight male and six female prairie dogs fed a nonlithogenic diet. Ten days later, under alpha-chloralose anesthesia, sphincter of Oddi phasic wave activity was monitored for 10-min intervals before (control), during 20 min of CCK infusion, and for 20 min after infusion. Gallbladder emptying rate and ejection fraction and baseline sphincter of Oddi frequency, amplitude, and motility index (= frequency x amplitude) did not differ significantly between the sexes. Sphincter of Oddi phasic wave frequency was increased during CCK infusion in both males and females, but the change in amplitude was significantly greater in females, than males. We conclude that the increased incidence of biliary tract disease in women may be due to altered sphincter of Oddi hormonal response.

Use of imipramine hydrochloride for treatment of urospermia in a stallion with a dysfunctional bladder.

PubMed

Turner, R M; Love, C C; McDonnell, S M; Sweeney, R W; Twitchell, E D; Habecker, P L; Reilly, L K; Pozor, M A; Kenney, R M

1995-12-15

An 8-year-old stallion was evaluated because of recurrent urinary tract infections and chronic intermittent urospermia. After extensive diagnostic testing, it was hypothesized that the stallion had a reflex dyssynergia of the bladder and urethral sphincter. Initial attempts to manage the urospermia included semen fractionation, semen collection after voluntary urination, and use of semen extenders. None of these efforts reliably yielded a quality ejaculate. Administration of imipramine hydrochloride (1.2 mg/kg of body weight, PO, 4 hours prior to semen collection) was initiated in an attempt to enhance bladder neck closure during ejaculation. This treatment, combined with voluntary urination prior to ejaculation, resulted in ejaculates containing little or no urine. Using this protocol, 19 of 20 mares bred during the subsequent 2 years became pregnant. By the third year, the bladder dysfunction had progressed, and the urospermia was no longer manageable. Bladder catheterization, followed by manual expression of the bladder per rectum, were necessary prior to each semen collection to obtain a urine-free ejaculate. Three-and-a-half years after initial examination, transitional cell carcinoma of the bladder with metastasis was identified, and the stallion was euthanatized. It is not known whether the transitional cell carcinoma was related to the dysfunctional bladder. Imipramine hydrochloride did not eliminate, but did reduce, the frequency and degree of urospermia in the affected stallion for approximately 2 years.

Vasoactive intestinal polypeptide mediates cholecystokinin-induced relaxation of the sphincter of Oddi.

PubMed Central

Wiley, J W; O'Dorisio, T M; Owyang, C

1988-01-01

This study evaluates the hypothesis that cholecystokinin (CCK) relaxes the sphincter of Oddi via vasoactive intestinal polypeptide (VIP). Isolated canine sphincter of Oddi were suspended in organ baths under standard conditions. Responses to cholecystokinin octapeptide (CCK-8) and VIP were recorded on a pen recorder via an isometric transducer. 10(-11)-10(-7) M CCK-8 and 4 X 10(-11)-5 X 10(-7) M VIP generated dose-related sphincter of Oddi relaxation, which was unaffected by atropine, propranolol, and phentolamine. The effect of CCK-8 was antagonized by dibutyryl cGMP (Bt2 cGMP) (10(-3) M), the VIP-antagonist (N-Ac-Tyr1, D-Phe2)-growth hormone-releasing factor-(1-29)-NH2, and abolished by tetrodotoxin. In contrast, VIP's relaxing action was tetrodotoxin insensitive. 10(-11)-10(-7) M CCK-8 stimulated dose-dependent release of VIP (0.5-2.2 fm/ml.mg tissue), which was not inhibited by atropine, propranolol, and phentolamine, but was antagonized by 10(-3) M Bt2 cGMP and tetrodotoxin. In addition CCK-8 and VIP generated dose-related (10(-10)-10(-7) M) increases in sphincter of Oddi cAMP levels that were not affected by atropine, propranolol, and phentolamine. Furthermore, 10(-5)-10(-2) M 8-bromo-cAMP caused dose-dependent relaxation of the sphincter of Oddi. In separate studies, a 2-h incubation in physiological solution containing 12 parts/1,000 of rabbit VIP antiserum antagonized sphincter relaxation caused by 4 nM CCK-8 and 6 nM VIP. The antiserum also significantly decreased the sphincter of Oddi cAMP level stimulated by 4 nM CCK-8 by 48 +/- 15%. These studies demonstrate that CCK-8 relaxes the canine sphincter of Oddi via a noncholinergic, nonadrenergic neural pathway involving VIP. The intracellular mechanism mediating CCK/VIP relaxation involves generation of cAMP. Images PMID:3384954

Dynamic graciloplasty for urinary incontinence: the potential for sequential closed-loop stimulation.

PubMed

Zonnevijlle, Erik D H; Perez-Abadia, Gustavo; Stremel, Richard W; Maldonado, Claudio J; Kon, Moshe; Barker, John H

2003-11-01

Muscle tissue transplantation applied to regain or dynamically assist contractile functions is known as 'dynamic myoplasty'. Success rates of clinical applications are unpredictable, because of lack of endurance, ischemic lesions, abundant scar formation and inadequate performance of tasks due to lack of refined control. Electrical stimulation is used to control dynamic myoplasties and should be improved to reduce some of these drawbacks. Sequential segmental neuromuscular stimulation improves the endurance and closed-loop control offers refinement in rate of contraction of the muscle, while function-controlling stimulator algorithms present the possibility of performing more complex tasks. An acute feasibility study was performed in anaesthetised dogs combining these techniques. Electrically stimulated gracilis-based neo-sphincters were compared to native sphincters with regard to their ability to maintain continence. Measurements were made during fast bladder pressure changes, static high bladder pressure and slow filling of the bladder, mimicking among others posture changes, lifting heavy objects and diuresis. In general, neo-sphincter and native sphincter performance showed no significant difference during these measurements. However, during high bladder pressures reaching 40 cm H(2)O the neo-sphincters maintained positive pressure gradients, whereas most native sphincters relaxed. During slow filling of the bladder the neo-sphincters maintained a controlled positive pressure gradient for a prolonged time without any form of training. Furthermore, the accuracy of these maintained pressure gradients proved to be within the limits set up by the native sphincters. Refinements using more complicated self-learning function-controlling algorithms proved to be effective also and are briefly discussed. In conclusion, a combination of sequential stimulation, closed-loop control and function-controlling algorithms proved feasible in this dynamic graciloplasty-model. Neo-sphincters were created, which would probably provide an acceptable performance, when the stimulation system could be implanted and further tested. Sizing this technique down to implantable proportions seems to be justified and will enable exploration of the possible benefits.

Relationship Among Anal Sphincter Injury, Patulous Anal Canal, and Anal Pressures in Patients with Anorectal Disorders

PubMed Central

Prichard, David; Harvey, Doris M.; Fletcher, Joel G.; Zinsmeister, Alan R.; Bharucha, Adil E.

2015-01-01

Background & Aims The anal sphincters and puborectalis are routinely imaged with an endoanal magnetic resonance imaging (MRI) coil, which does not assess co-aptation of the anal canal at rest. Using a MRI torso coil, we identified a patulous anal canal in some patients with anorectal disorders. We aimed to evaluate the relationship between anal sphincter and puborectalis injury, a patulous anal canal, and anal pressures. Methods We performed a retrospective analysis of data from 119 patients who underwent MRI and manometry analysis of anal anatomy and pressures, respectively, from February 2011 through March 2013 at the Mayo Clinic. Anal pressures were determined by high-resolution manometry, anal sphincter and puborectalis injury was determined by endoanal MRI, and anal canal integrity was determined by torso MRI. Associations between manometric and anatomical parameters were evaluated with univariate and multivariate analyses. Results Fecal incontinence (55 patients, 46%) and constipation (36 patients. 30%) were the main indications for testing; 49 patients (41%) had a patulous anal canal, which was associated with injury to more than 1 muscle (all P≤.001) and internal sphincter (P<.01), but not puborectalis (P=.09) or external sphincter (P=.06) injury. Internal (P<.01) and external sphincter injury (P=.02) and a patulous canal (P<.001), but not puborectalis injury, predicted anal resting pressure. A patulous anal canal was the only significant predictor (P<.01) of the anal squeeze pressure increment. Conclusions Patients with anorectal disorders commonly have a patulous anal canal, associated with more severe anal injury, anal resting pressure, and squeeze pressure increment. It is therefore important to identify patulous anal canal because it appears to be a marker of not only anal sphincter injury but disturbances beyond sphincter injury, such as damage to the anal cushions or anal denervation. PMID:25869638

Effects of the temporary placement of a self-expandable metallic stent in benign pyloric stenosis.

PubMed

Choi, Won Jae; Park, Jong-Jae; Park, Jain; Lim, Eun-Hye; Joo, Moon Kyung; Yun, Jae-Won; Noh, Hyejin; Kim, Sung Ho; Choi, Woo Seok; Lee, Beom Jae; Kim, Ji Hoon; Yeon, Jong Eun; Kim, Jae Seon; Byun, Kwan Soo; Bak, Young-Tae

2013-07-01

The use of self-expandable metallic stents (SEMS) is an established palliative treatment for malignant stenosis in the gastrointestinal tract; therefore, its application to benign stenosis is expected to be beneficial because of the more gradual and sustained dilatation in the stenotic portion. We aimed in this prospective observational study to evaluate the efficacy and safety of temporary SEMS placement in benign pyloric stenosis. Twenty-two patients with benign stenosis of the prepylorus, pylorus, and duodenal bulb were enrolled and underwent SEMS placement. We assessed symptom improvement, defined as an increase of at least 1 degree in the gastric-outlet-obstruction scoring system after stent insertion. No major complications were observed during the procedures. After stent placement, early symptom improvement was achieved in 18 of 22 patients (81.8%). During the follow-up period (mean 10.2 months), the stents remained in place successfully for 6 to 8 weeks in seven patients (31.8%). Among the 15 patients (62.5%) with stent migration, seven (46.6%) showed continued symptomatic improvement without recurrence of obstructive symptoms. Despite the symptomatic improvement, temporary SEMS placement is premature as an effective therapeutic tool for benign pyloric stenosis unless a novel stent is developed to prevent migration.

Effects of the Temporary Placement of a Self-Expandable Metallic Stent in Benign Pyloric Stenosis

PubMed Central

Choi, Won Jae; Park, Jain; Lim, Eun-Hye; Joo, Moon Kyung; Yun, Jae-Won; Noh, Hyejin; Kim, Sung Ho; Choi, Woo Seok; Lee, Beom Jae; Kim, Ji Hoon; Yeon, Jong Eun; Kim, Jae Seon; Byun, Kwan Soo; Bak, Young-Tae

2013-01-01

Background/Aims The use of self-expandable metallic stents (SEMS) is an established palliative treatment for malignant stenosis in the gastrointestinal tract; therefore, its application to benign stenosis is expected to be beneficial because of the more gradual and sustained dilatation in the stenotic portion. We aimed in this prospective observational study to evaluate the efficacy and safety of temporary SEMS placement in benign pyloric stenosis. Methods Twenty-two patients with benign stenosis of the prepylorus, pylorus, and duodenal bulb were enrolled and underwent SEMS placement. We assessed symptom improvement, defined as an increase of at least 1 degree in the gastric-outlet-obstruction scoring system after stent insertion. Results No major complications were observed during the procedures. After stent placement, early symptom improvement was achieved in 18 of 22 patients (81.8%). During the follow-up period (mean 10.2 months), the stents remained in place successfully for 6 to 8 weeks in seven patients (31.8%). Among the 15 patients (62.5%) with stent migration, seven (46.6%) showed continued symptomatic improvement without recurrence of obstructive symptoms. Conclusions Despite the symptomatic improvement, temporary SEMS placement is premature as an effective therapeutic tool for benign pyloric stenosis unless a novel stent is developed to prevent migration. PMID:23898381

The incidence of duodenal and gastric ulcers in a large health maintenance organization.

PubMed

Kurata, J H; Honda, G D; Frankl, H

1985-06-01

We report the incidence of peptic ulcers (duodenal, pyloric canal, gastric, and combined) verified by radiologic, endoscopic, or surgical evidence in a large Health Maintenance Organization (HMO) in Los Angeles, California. For members age 15 and above, the peptic ulcer incidence rate was 0.86 per 1,000 person-years (p-y) (males 1.10, females 0.63). The male to female sex ratio was 1.7. Two hundred twenty-two duodenal, 17 pyloric canal, 89 gastric, and 21 combined first-time diagnosed ulcer cases were located. For duodenal and pyloric canal ulcer, the incidence rate for members age 15 and above was 0.58 per 1,000 p-y (males 0.76, females 0.40). For gastric ulcer, the incidence rate for members age 15 and above was 0.21 per 1,000 p-y (males 0.23, females 0.18). The combined ulcer rate was 0.05 per 1,000 p-y (males 0.07, females 0.02). Gastric ulcer rates were two times higher in 1980 than in 1977. Peptic ulcer age-specific incidence rates increased with age. Incidence rates were much lower than those reported in previous studies, but the gastric to duodenal ulcer ratio and the age and sex relation to ulcer incidence were similar to those previously reported.

Management of lower urinary tract dysfunction: a stepwise approach.

PubMed

Thom, Matthew; Campigotto, Mary; Vemulakonda, Vijaya; Coplen, Douglas; Austin, Paul F

2012-02-01

To evaluate management patterns of lower urinary tract (LUT) dysfunction and establish a treatment algorithm to guide pediatric healthcare providers. 390 children with non-neurogenic LUT dysfunction were followed over 7 months; 115 patients were excluded due to incomplete data. Children were categorized based on presenting complaints and pelvic ultrasound into three groups: daytime urinary incontinence (UI) with complete emptying (CE), UI with incomplete emptying (IE), or IE without UI. Every child underwent behavioral modification (BM) including timed voiding, double voiding, deep breathing, and treatment of constipation if present. BM failures received secondary treatment including medications (alpha blockers, anticholinergics), physical therapy, and/or botulinum toxin type A injection of the external sphincter at a dose of 100 units. BM improved symptoms in 152 (55%): 68% (46% dry), 49% (27% dry), and 59% (29% dry) from the three groups, respectively. Of the 45% who showed no change in symptoms, 98 (80%) improved with addition of medication, the majority (89) after starting alpha blocker therapy. Children with IE responded better to alpha blockers, 83 (77%) compared to 38% with CE, whereas those with CE demonstrated more symptom resolution with anticholinergics, 6 (38%) compared to 13% of those with IE. Only 6 (2%) patients were refractory to non-operative treatment with all showing improvement after injection of botulinum toxin type A, 4 (67%) of whom became completely dry. Diagnosis of UI and/or IE with stratification of children into particular symptom groups appears beneficial in determining the appropriate therapy for children with LUT dysfunction. Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Anal Sphincter Augmentation Using Biological Material.

PubMed

Alam, Nasra N; Narang, Sunil K; Köckerling, Ferdinand; Daniels, Ian R; Smart, Neil J

2015-01-01

The aim of this review is to provide an overview of the use of biological materials in the augmentation of the anal sphincter either as part of an overlapping sphincter repair (OSR) or anal bulking procedure. A systematic search of PubMed was conducted using the search terms "anal bulking agents," "anal sphincter repair," or "overlapping sphincter repair." Five studies using biological material as part of an overlapping sphincter repair (OSR) or as an anal bulking agent were identified. 122 patients underwent anal bulking with a biological material. Anorectal physiology was conducted in 27 patients and demonstrated deterioration in maximum resting pressure, and no significant change in maximum squeeze increment. Quality of life scores (QoLs) demonstrated improvements at 6 weeks and 6 months, but this had deteriorated at 12 months of follow up. Biological material was used in 23 patients to carry out an anal encirclement procedure. Improvements in QoLs were observed in patients undergoing OSR as well as anal encirclement using biological material. Incontinence episodes decreased to an average of one per week from 8 to 10 preoperatively. Sphincter encirclement with biological material has demonstrated improvements in continence and QoLs in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As an anal bulking agent the benefits are short-term.

Substance P stimulates sphincter of Oddi motility and inhibits trans-sphincteric flow in the Australian brush-tailed possum.

PubMed

Cox, M R; Padbury, R T; Harvey, J R; Baker, R A; Toouli, J; Saccone, G T

1998-04-01

Substance P containing nerves are widely distributed throughout the gastrointestinal tract. The aims of this study were to determine the distribution of substance P containing nerves in the extrahepatic biliary tree of the Australian brush-tailed possum and to characterize the effect of exogenous substance P on the sphincter of Oddi (SO) motility and transphincteric flow in vivo. Immunohistochemical staining of fixed specimens (n = 8) found moderate numbers of substance P containing nerve cell bodies and fibres throughout the neural plexuses of the SO, in particular in the serosal and intraluminal nerve trunks of the SO and gallbladder. Synthetic porcine substance P (1-2000 ng kg-1), administered by close intra-arterial injection (i.a.; n = 7), produced a dose-dependent elevation in basal pressure [P < 0.01] and an associated dose-dependent reduction in trans-sphincteric flow [P < 0.0001]. Substance P had no significant dose-dependent effect on SO phasic contraction amplitude or frequency. Tetrodotoxin (9 micrograms kg-1, i.a.) did not inhibit the effect of substance P on SO motility and trans-sphincteric flow (n = 5). In conclusion, substance P containing nerves are found throughout the possum extrahepatic biliary tree. Exogenous substance P stimulates SO motility and reduces trans-sphincteric flow in vivo by acting directly on the sphincter smooth muscle.

Differences in outcome with subspecialty care: pyloromyotomy in North Carolina.

PubMed

Pranikoff, Thomas; Campbell, Brendan T; Travis, Jeffrey; Hirschl, Ronald B

2002-03-01

Proponents of subspecialization in surgery claim that fellowship training improves the quality of care. Others claim that general training is adequate for most routine surgical procedures. The authors questioned whether there were differences in outcomes when general surgeons (GEN) operate on children and infants with common surgical conditions compared with the care of their pediatric surgical (PED) colleagues. The authors retrospectively reviewed the Healthcare Investment Analysts North Carolina Information Network database to identify patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis in North Carolina during the period from October 1995 through September 1998 (n = 780). Information obtained included demographics, insurance type, hospital, length of stay, total hospital charges, occurrence of mucosal perforation, and type of surgeon (general v pediatric). Of the 780 pyloromyotomies performed, 363 (48%) were performed by pediatric surgeons. Pediatric surgeons cared for more Medicaid patients than general surgeons (PED, 52% v GEN, 40%; P =.001). Infants treated by pediatric surgeons had a lower incidence of mucosal perforation (PED, 0.5% v GEN, 2.9%; P =.0015), which was associated with decreased overall total hospital charges (no perforation, $4,806 plus minus 79 v perforation, $6,592 plus minus 492; P =.002). When patients with uncomplicated pyloric stenosis were evaluated (96% of cases), those cared for by pediatric surgeons had lower total hospital charges (PED, $4,496 plus minus 95 v GEN, $5,121 plus minus 121; P =.0001) and shorter length of stay (PED, 2.7 plus minus 0.1 days v GEN, 3.1 plus minus 0.1 days; P =.01). In North Carolina, general surgeons treat more than half the patients who have pyloric stenosis, though fewer with Medicaid. The cost and incidence of mucosal perforation were increased in infants with pyloric stenosis when care was provided by general rather than pediatric surgeons. Copyright 2002 by W.B. Saunders Company.

Use of GDNF-Releasing Nanofiber Nerve Guide Conduits for the Repair of Conus Medullaris/Cauda Equina Injury in the Nonhuman Primate

DTIC Science & Technology

2013-10-01

Electromyography (EMG) recordings of the external anal sphincter were obtained pre- operatively as baseline records. The external anal sphincter muscle was chosen...Lee U, Chang HH, Christe KL, Havton LA. Evoked voiding contractions and corresponding urethral sphincter electromyography in non-human primates differ

Predicting obstetric anal sphincter injuries in a modern obstetric population.

PubMed

Meister, Melanie R L; Cahill, Alison G; Conner, Shayna N; Woolfolk, Candice L; Lowder, Jerry L

2016-09-01

Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks. Copyright © 2016 Elsevier Inc. All rights reserved.

Anal sphincter lacerations and upright delivery postures--a risk analysis from a randomized controlled trial.

PubMed

Altman, Daniel; Ragnar, Inga; Ekström, Asa; Tydén, Tanja; Olsson, Sven-Eric

2007-02-01

To evaluate obstetric sphincter lacerations after a kneeling or sitting position at second stage of labor in a multivariate risk analysis model. Two hundred and seventy-one primiparous women with normal pregnancies and spontaneous labor were randomized, 138 to a kneeling position and 133 to a sitting position. Medical data were retrieved from delivery charts and partograms. Risk factors were tested in a multivariate logistic regression model in a stepwise manner. The trial was completed by 106 subjects in the kneeling group and 112 subjects in the sitting group. There were no significant differences with regard to duration of second stage of labor or pre-trial maternal characteristics between the two groups. Obstetrical sphincter tears did not differ significantly between the two groups but an intact perineum was more common in the kneeling group (p<0.03) and episiotomy (mediolateral) was more common in the sitting group (p<0.05). Three grade IV sphincter lacerations occurred in the sitting group compared to none in the kneeling group (NS). Multivariate risk analysis indicated that prolonged duration of second stage of labor and episiotomy were associated with an increased risk of third- or fourth-degree sphincter tears (p<0.01 and p<0.05, respectively). Delivery posture, maternal age, fetal weight, use of oxytocin, and use of epidural analgesia did not increase the risk of obstetrical anal sphincter lacerations in the two upright postures. Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.

Circumferential urinary sphincter surface electromyography: A novel diagnostic method for intrinsic sphincter deficiency.

PubMed

Heesakkers, John; Gerretsen, Reza; Izeta, Ander; Sievert, Karl-Dietrich; Farag, Fawzy

2016-02-01

The diagnosis of intrinsic sphincter deficiency (ISD) in patients with stress urinary incontinence (SUI) is not well established. We explored the possibility of applying a new tool: minimally invasive circumferential sphincter surface electromyography (CSS-EMG) to assess the muscular integrity of the urethral sphincter in patients with SUI/ISD. CSS-EMG of the urethral sphincter and urodynamic studies were performed in 44 women with SUI. A urethral pressure profile (UPP) was measured in four directions. Maximal urethral closure pressure (MUCP) <40 cm/H2 O or the presence of SUI without urethral hypermobility was used to define ISD. Twenty-one patients had urodynamic SUI, 23 had no SUI and 12 patients had ISD. The mean average rectified value (ARV) of the motor unit action potential (MUAP), an indicator of the strength of urethral rhabdosphincter, was estimated. ARV measured in the 12 o'clock quadrant during maximal contraction was the only CSS-EMG parameter that had significant predictive value for ISD. With an increase in the 12 o'clock ARV value, the likelihood of ISD decreases (Odds Ratio 0.36 95% confidence interval 0.67-0.92). In the ROC curve with ARV measured in the 12 o'clock quadrant during maximal contraction, the explained area was 0.794 (P = 0.02); implying that ARV measured at the 12 o'clock quadrant during maximal contraction was able to predict ISD significantly. Myogenic changes of the urethral sphincter that contribute to ISD can be assessed with CSS-EMG. This new concept for assessing the functionality of the female urethral sphincter may assist with better understanding of the pathophysiology, the diagnosis and the treatment of SUI. © 2014 Wiley Periodicals, Inc.

Is severe perineal damage increased in women with prior anal sphincter injury?

PubMed

Edwards, Heather; Grotegut, Chad; Harmanli, Ozgur H; Rapkin, David; Dandolu, Vani

2006-11-01

There is conflicting data in the literature regarding the risk of obstetric anal sphincter laceration in patients with a prior laceration. This retrospective chart review seeks to examine the risk of recurrence of obstetric anal sphincter lacerations. Patients who sustained anal sphincter laceration at delivery during a 13-year time period from January 1991 to December 2003 were identified from the medical records database at Temple University Hospital. All subsequent deliveries in this group of patients were extracted from the database. Chart review was performed on all subsequent deliveries with specific attention to demographic factors such as age, race, parity, etc., maternal weight, fetal weight, presence of maternal diabetes, and labor characteristics such as induction or augmentation of labor, instrumentation at delivery (vacuum or forceps), use of episiotomy, and degree of perineal laceration. There were 23 451 vaginal deliveries at Temple University Hospital between January 1, 1991 and December 31, 2003. Anal sphincter laceration was noted in 778 subjects. Subsequent deliveries among the group of patients with prior sphincter tears numbered 271. Six (2.4%) patients had recurrence of anal sphincter lacerations, and five of them were third degree lacerations. The rate of recurrent lacerations was not significantly different from the rate of initial lacerations (2.4% vs. 3.3%; odds ratio 0.72, 95% confidence interval 0.33-1.59; p = 0.4). Women who sustained recurrent lacerations were older, more obese (mean weight 92 kg vs. 82 kg), had larger babies (3506 g vs. 3227 g), and were more likely to have episiotomies (66.7% vs. 7%) or instrumental deliveries (33.3 vs. 6.5%). Prior anal sphincter laceration does not result in an increased rate of recurrence. Operative vaginal delivery particularly with episiotomy is a risk factor for both initial and recurrent laceration.

Effect of hepatic venous sphincter contraction on transmission of central venous pressure to lobar and portal pressure.

PubMed

Lautt, W W; Legare, D J; Greenway, C V

1987-11-01

In dogs anesthetized with pentobarbital, central vena caval pressure (CVP), portal venous pressure (PVP), and intrahepatic lobar venous pressure (proximal to the hepatic venous sphincters) were measured. The objective was to determine some characteristics of the intrahepatic vascular resistance sites (proximal and distal to the hepatic venous sphincters) including testing predictions made using a recent mathematical model of distensible hepatic venous resistance. The stimulus used was a brief rise in CVP produced by transient occlusion of the thoracic vena cava in control state and when vascular resistance was elevated by infusions of norepinephrine or histamine, or by nerve stimulation. The percent transmission of the downstream pressure rise to upstream sites past areas of vascular resistance was elevated. Even small increments in CVP are partially transmitted upstream. The data are incompatible with the vascular waterfall phenomenon which predicts that venous pressure increments are not transmitted upstream until a critical pressure is overcome and then further increments would be 100% transmitted. The hepatic sphincters show the following characteristics. First, small rises in CVP are transmitted less than large elevations; as the CVP rises, the sphincters passively distend and allow a greater percent transmission upstream, thus a large rise in CVP is more fully transmitted than a small rise in CVP. Second, the amount of pressure transmission upstream is determined by the vascular resistance across which the pressure is transmitted. As nerves, norepinephrine, or histamine cause the hepatic sphincters to contract, the percent transmission becomes less and the distensibility of the sphincters is reduced. Similar characteristics are shown for the "presinusoidal" vascular resistance and the hepatic venous sphincter resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of the thickness of the anal sphincters with age and its relevance in faecal incontinence.

PubMed

Papachrysostomou, M; Pye, S D; Wild, S R; Smith, A N

1994-08-01

Ultrasonographic studies in healthy volunteers showed that the external anal sphincter (EAS) and internal anal sphincter (IAS) thicknesses were inversely related at rest. The functional importance of the two sphincters in continence control was demonstrated in the relationship between the sum of the thicknesses of the two sphincters and the anal canal resting pressure. The aims of the present study were to assess the morphometric appearance of the anal sphincters by endosonography in faecally incontinent patients and to contrast this with that of older healthy subjects. Twenty-eight female patients with neurogenic faecal incontinence (FI) were studied. An older group of 7 healthy women, aged 41-75 years, and a young group of 11 nulliparous healthy women, aged 20-23 years, served as control groups. Anal endosonography was performed with a radial rotating endoprobe, with the subject in the left lateral position. Conventional anal manometry was performed in all subjects. The EAS in the FI group was thicker than the EAS in the old (p < 0.04) but did not differ from the EAS in the young. The IAS thickness in the FI group did not differ from that in the older group. In both these groups the IAS was thicker than in the young women (p < 0.01). The anal pressures in the FI group were reduced compared with the normal groups (p < 0.04). There was a direct relationship between the two sphincters in FI (p < 0.001). The increased thickness of the IAS in the FI group does not seem to compensate for function and results in a failure of the sphincter mechanism to maintain continence, whereas in healthy elderly subjects the increased IAS thickness appears to be compensatory and important for continence control.

Can three-dimensional high-resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence?

PubMed

Rezaie, A; Iriana, S; Pimentel, M; Murrell, Z; Fleshner, P; Zaghiyan, K

2017-05-01

Endoanal ultrasound (EAUS) is the gold standard for detecting anal sphincter defects in patients with faecal incontinence (FI), while anorectal manometry evaluates sphincter function. Three-dimensional high-resolution anorectal manometry (3D HRAM) is a newer modality with the potential to assess both sphincter function and anatomy. The purpose of the present study was to compare 3D HRAM with 3D EAUS for the detection of anal sphincter defects in patients with FI. A linkage analysis was performed between the 3D HRAM and 3D EAUS databases of a tertiary referral centre to identify patients with FI who underwent both 3D EAUS and 3D HRAM. With 3D HRAM, a defect was defined as any pressure measurement below 25 mmHg at rest with at least 18° of continuous expansion. The 3D HRAM findings were compared with those of 3D EAUS. The study cohort included 39 patients with a mean age of 64.7 ± 15.2 years (SD); and 31 (79%) were female. Eight (21%) patients had an anal sphincter defect on EAUS with a median size of 93° (range 40°-136°). Fourteen (36%) had a defect shown by 3D HRAM with a median size of 144° (36°-180°). The sensitivity, specificity and positive and negative predictive values of 3D HRAM in detecting a sphincter defect were 75%, 74%, 43% and 92%, respectively. With a negative predictive value of 92%, 3D HRAM may be a useful screening method for ruling out a sphincter defect in patients with FI, thereby avoiding both EAUS and manometry in selected patients. Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.

Internal anal sphincter myopathy causing proctalgia fugax and constipation: further clinical and radiological characterization in a patient.

PubMed

Guy, R J; Kamm, M A; Martin, J E

1997-02-01

We report a case of a distinctive familial internal anal sphincter myopathy with unique histological and radiological features. A 67-year-old woman presented with a 20-year history of proctalgia fugax and outlet obstruction; other family members were similarly affected. Computed tomograpy and magnetic resonance imaging demonstrated a grossly hypertrophied internal anal sphincter. Strip myectomy of the sphincter was carried out with improvement in evacuation but little relief of proctalgia. Further relief of symptoms was obtained using oral and transdermal nitrates and a calcium antagonist. Histological examination of the excised muscle revealed hypertrophy and an abnormal arrangement of fibres in whorls; many fibres contained vacuoles with inclusion bodies positive for periodic acid-Schiff. This description of a specific anal sphincter myopathy illustrates the potential importance of histopathological studies of smooth muscle in functional disorders of the gut.

Myelitis and Lupus: Clinical Manifestations, Diagnosis and Treatment. Review.

PubMed

Chiganer, Edson Hernán; Hryb, Javier Pablo; Carnero Contentti, Edgar

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple systems. Myelopathy is one of 19 neuropsychiatric syndromes related to SLE defined by the American College of Rheumatology. Although infrequent, it is a severe manifestation, leading to motor and sensory deficits, and sphincter dysfunction. The pathogenesis is not clearly known, but may be related to arterial thrombosis and vasculitis. Diagnosis is based on clinical findings, laboratory tests and the use of gadolinium-enhanced magnetic resonance imaging. The standard therapy is the combination of intravenous cyclophosphamide and glucocorticoids. In refractory disease, other treatments such as plasmapheresis or rituximab have been used. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

The urethral closure function in continent and stress urinary incontinent women assessed by urethral pressure reflectometry.

PubMed

Saaby, Marie-Louise

2014-02-01

Stress urinary incontinence (SUI) occurs when the bladder pressure exceeds the urethral pressure in connection with physical effort or exertion or when sneezing or coughing and depends both on the strength of the urethral closure function and the abdominal pressure to which it is subjected. The urethral closure function in continent women and the dysfunction causing SUI are not known in details. The currently accepted view is based on the concept of a sphincteric unit and a support system. Our incomplete knowledge relates to the complexity of the closure apparatus and to inadequate assessment methods which so far have not provided robust urodynamic diagnostic tools, severity measures, or parameters to assess outcome after intervention. Urethral Pressure Reflectometry (UPR) is a novel method that measures the urethral pressure and cross-sectional area (by use of sound waves) simultaneously. The technique involves insertion of only a small, light and flexible polyurethane bag in the urethra and therefore avoids the common artifacts encountered with conventional methods. The UPR parameters can be obtained at a specific site of the urethra, e.g. the high pressure zone, and during various circumstances, i.e. resting and squeezing. During the study period, we advanced the UPR technique to enable faster measurement (within 7 seconds by the continuous technique) which allowed assessment during increased intra-abdominal pressure induced by physical straining. We investigated the urethral closure function in continent and SUI women during resting and straining by the "fast" UPR technique. Thereby new promising urethral parameters were provided that allowed characterization of the closure function based on the permanent closure forces (primarily generated by the sphincteric unit, measured by the Po-rest) and the adjunctive closure forces (primarily generated by the support system, measured by the abdominal to urethral pressure impact ratio (APIR)). The new parameters enabled a more detailed description of the efficiency of the closure function and the extent and nature of a possible dysfunction in the individual woman. The urethral closure equation (UCE) and urethral opening pressure at an abdominal pressure of 50 cm H2O (Po-Abd 50), respectively, which combine the permanent and the adjunctive closure forces, could separate continent and SUI women and thus appear to be excellent diagnostic tests. Moreover, the parameters showed highly significant negative correlation with ICIQ-SF, pad test and the number of incontinence episodes per week and are therefore valid as urodynamic severity measures. UPR in SUI women before and after TVT demonstrated a more efficient urethral closure function after the operation. The Po-rest was unchanged suggesting that the sphincteric unit was virtually unaltered and hence the permanent closure forces unchanged. However, the resting opening elastance increased by 18% indicating that at the resting state the TVT somewhat improves the closure function by providing increased resistance against the dilation of the urethra, which probably explains the decreased maximum urine flow rate found after TVT in this and previous studies. The APIR increased in all patients after TVT suggesting that the support system was re-established and thus the adjunctive closure forces improved, regardless of the type of pre-operative dysfunction. The new UPR parameters may be used as outcome measures after treatment.

[Anal sphincter injury caused by falling off a trampoline].

PubMed

Pakarinen, Mikko

2013-01-01

A girl of preschool age fell off a trampoline in a sitting position onto an iron bar sticking up from the ground. In addition to a laceration of the terminal portion of the rectum, she was found to have a severe sphincter injury. The sphincters were repaired by a surgeon the next morning. After one month from the surgery the anal canal pressure was found to be symmetrical with good contractile force of the sphincters. No abnormalities were found in a contrast study or in rectoscopy. The protective stoma was closed after three months from the injury and fecal continence was normal after one and a half years.

Multidisciplinary training in perineal care during labor and delivery for the reduction of anal sphincter injuries.

PubMed

Frost, Jonathan; Gundry, Rowan; Young, Helen; Naguib, Adel

2016-08-01

To determine whether the introduction of a multidisciplinary intrapartum perineal-care training program reduced the rate of obstetric anal sphincter injuries in patients undergoing vaginal deliveries. A prospective observational cohort study enrolled women undergoing vaginal deliveries at a district general hospital maternity unit in the United Kingdom between April 1, 2012 and March 31, 2014. All women experiencing obstetric anal sphincter injuries during the study period were identified and the rate of obstetric anal sphincter injuries before (2012-2013) a multidisciplinary training program was implemented was compared with the rate after (2013-2014) implementation using logistic regression analysis. The study enrolled 4920 patients. Following the implementation of the training program, the rate of obstetric anal sphincter injuries decreased from 4.8% to 3.1% of vaginal deliveries (odds ratio 0.66; 95% confidence interval 0.493-0.899; P = 0.008). The integration of intrapartum perineal-care training into mandatory annual staff training was associated with a statistically and clinically significant reduction in the rate of obstetric anal sphincter injuries. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

[Physiology of the urethral sphincteric vesico-prostatic complex].

PubMed

Carmignani, L; Gadda, F; Dell'Orto, P; Ferruti, M; Grisotto, M; Rocco, F

2001-09-01

We propose a review of the literature about innervation and physiology of the urethral sphincteric complex. Parasympathetic innervation of the pelvic viscera comes from ventral branches of the sacral nerves (S2-S4). The orthosympathetic component derives from superior hypogastric plexus and runs down the hypogastric nerves to form the right and left pelvic plexus together with the parasympathetic component. The pelvic plexus is situated inferolaterally with respect to the rectum and runs on the surface of the levator ani muscle down to the prostatic apex. The pelvic plexus gives innervation to the rectum, the bladder, the prostate and the urethral sphincteric complex. The pelvic muscular floor is innervated by the somatic component (pudendal nerve) derived from the sacral branches (S2-S4). Bladder neck and smooth muscle urethral sphincter innervation is given mostly by the orthosympathetic component. The rhabdosphincter innervation comes from the pudendal nerve and from the pelvic plexus; its role in the continence mechanism is probably to give steady tonic urethral compression. Levator ani muscle takes part in the sphincteric complex with its anteromedial pubococcygeal portion. It plays its role strengthening the sphincteric tone during increase of the abdominal pressure or during active quick stop cessation of the urinary stream.

Appearance and quantification of infectious hematopoietic necrosis virus in female sockeye salmon (Oncorhynchus nerka) during their spawning migration

USGS Publications Warehouse

Mulcahy, D.; Jenes, C.K.; Pascho, R.J.

1984-01-01

The incidence and amount of infectious hematopoietic necrosis (IHN) virus was determined in 10 organs and body fluids from each of 100 female sockeye salmon(Oncorhynchus nerka) before, during, and after their spawning migration into freshwater. Virus was found in high concentrations only in fish sampled during and after spawning. Infection rates increased from nil to 100 percent within 2 weeks. In spawning fish, incidences of IHN virus were high in all organs and fluids except brain and serum, and the highest concentrations were in the pyloric caeca and lower gut. Immediately before spawning, IHN virus was found most frequently in the gills, less frequently in the pyloric caeca and spleen, and rarely in other organs.

Artificial urinary sphincter implantation: an important component of complex surgery for urinary tract reconstruction in patients with refractory urinary incontinence.

PubMed

Zhang, Fan; Liao, Limin

2018-01-08

We review our outcomes and experience of artificial urinary sphincter implantation for patients with refractory urinary incontinence from different causes. Between April 2002 and May 2017, a total of 32 patients (median age, 40.8 years) with urinary incontinence had undergone artificial urinary sphincter placement during urinary tract reconstruction. Eighteen patients (56.3%) were urethral injuries associated urinary incontinence, 9 (28.1%) had neurogenic urinary incontinence and 5 (15.6%) were post-prostatectomy incontinence. Necessary surgeries were conducted before artificial urinary sphincter placement as staged procedures, including urethral strictures incision, sphincterotomy, and augmentation cystoplasty. The mean follow-up time was 39 months. At the latest visit, 25 patients (78.1%) maintained the original artificial urinary sphincter. Four patients (12.5%) had artificial urinary sphincter revisions. Explantations were performed in three patients. Twenty-four patients were socially continent, leading to the overall success rate as 75%. The complication rate was 28.1%; including infections (n = 4), erosions (n = 4), and mechanical failure (n = 1). The impact of urinary incontinence on the quality of life measured by the visual analogue scale dropped from 7.0 ± 1.2 to 2.2 ± 1.5 (P <0.001). The primary sources for artificial urinary sphincter implantation in our center are unique, and the procedure is an effective treatment as a part of urinary tract reconstruction in complicated urinary incontinence cases with complex etiology.

Novel disposable transnasal endoscopy for assessment of esophageal motor function.

PubMed

Lim, Chul-Hyun; Choi, Myung-Gyu; Baeg, Myong-Ki; Moon, Sung Jin; Kim, Jin Su; Cho, Yu Kyung; Park, Jae Myung; Lee, In Seok; Kim, Sang Woo; Choi, Kyu Yong

2014-01-01

A novel disposable transnasal endoscopy (DTE) with a portable system has been developed to provide unsedated esophagoscopy by modifying capsule endoscopy. The aim of this study was to assess the feasibility of DTE to evaluate esophageal motor function. Patients with or suspected esophageal motility disorders and healthy volunteers were enrolled. Participants underwent esophageal high-resolution manometry and DTE in random order on different days. Motility was observed with DTE at 1, 8, and 16 cm above the gastroesophageal junction. Twenty healthy volunteers and 20 symptomatic subjects participated (8 achalasia, 5 scleroderma, 3 diffuse esophageal spasm, 1 hypertensive peristalsis, 1 peristaltic dysfunction, and 22 normal esophageal function). The normal findings on DTE were as follows. As the subject swallowed water, swallow-induced relaxation with elevation of the lower esophageal sphincter caused the endoscope to cross the Z-line into the gastric lumen. After the passage of water and air, complete closure of the lower esophageal sphincter occurred, with the return of the endoscope to its previous position. During the resting stage of the esophageal body, an air bubble could be seen in the center of the radially wrinkled and occluded lumen. The endoscopic diagnosis was in agreement with the clinical diagnosis in all but 2. Most of the participants reported acceptable discomfort during DTE and 62.5% of the subjects preferred DTE to manometry. DTE can accurately characterize normal esophageal motor function, allowing the diagnosis of esophageal motility disorders. DTE has potential widespread applications, especially in outpatient clinics.

Hypertrophy of the muscularis propria of the lower esophageal sphincter and the body of the esophagus in patients with primary motility disorders of the esophagus.

PubMed

Mittal, Ravinder K; Kassab, Ghassan; Puckett, James L; Liu, Jianmin

2003-08-01

Patients with diffuse esophageal spasm (DES) and nutcracker esophagus/high amplitude esophageal contraction (HAEC) have a thicker esophageal muscularis propria than do healthy subjects. The goals of this study were to determine the esophageal muscle cross-sectional area (MCSA), a measure of muscle mass, in patients with achalasia of the esophagus; and to compare it with that in patients with DES, patients with HAEC, and normal subjects. Using a high-frequency ultrasound probe catheter, concurrent manometry and ultrasound images of the esophagus were recorded in four subject groups: normal volunteers, patients with HAEC, patients with DES, and patients with achalasia of the esophagus. Recordings were obtained from the lower esophageal sphincter (LES) and multiple sites in the esophagus 2, 4, 6, 8, and 10 cm above the LES. The LES and esophageal muscle thickness as well as esophageal MCSA were greater in all three patient groups than in the normal subject group. Muscle thickness and MCSA were observed to be greatest in patients with achalasia, which were greater than in patients with DES, which were greater than in those with HAEC, which in turn were greater than in normal subjects. We propose that an increase in the MCSA is an important feature of patients with primary motility disorders of the esophagus. The degree of increase in muscle mass may be an important determinant of the type and the severity of esophageal motor dysfunction.

Gait analysis of young male patients diagnosed with primary bladder neck obstruction.

PubMed

Zago, Matteo; Camerota, Tommaso Ciro; Pisu, Stefano; Ciprandi, Daniela; Sforza, Chiarella

2017-08-01

Primary bladder neck obstruction (PBNO) represents an inappropriate or inadequate relaxation of the bladder neck during micturition. Based on the observation of an increased rate of postural imbalances in male patients with PBNO, we hypothesized a possible role of an unbalanced biomechanics of the pelvis on urethral sphincters activity. Our aim was to identify kinematic imbalances, usually disregarded in PBNO patients, and which could eventually be involved in the etiopathogenesis of the disease. Seven male adult patients (39.6±7.1years) were recruited; in all patients, PBNO was suspected at bladder diary and uroflowmetry, and was endoscopically confirmed with urethroscopy. Participants gait was recorded with a motion capture system (BTS Spa, Italy) to obtain three-dimensional joint angles and gait parameters. Multivariate statistics based on a Principal Component model allowed to assess the similarity of patients' gait patterns with respect to control subjects. The main finding is that patients with PBNO showed significant discordance in the observations at the ankle and pelvis level. Additionally, 6/7 patients demonstrated altered trunk positions compared to normal curves. We suggest that the identified postural imbalances could represent the cause for an anomalous activation of pelvic floor muscles (hypertonia). The consequent urinary sphincters hypercontraction may be responsible for the development of voiding dysfunction in male patients with no significant morphological alterations. Results reinforced the hypothesis of an etiopathogenetic role of postural imbalances on primary bladder neck obstruction in male patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

A technique for sequential segmental neuromuscular stimulation with closed loop feedback control.

PubMed

Zonnevijlle, Erik D H; Abadia, Gustavo Perez; Somia, Naveen N; Kon, Moshe; Barker, John H; Koenig, Steven; Ewert, D L; Stremel, Richard W

2002-01-01

In dynamic myoplasty, dysfunctional muscle is assisted or replaced with skeletal muscle from a donor site. Electrical stimulation is commonly used to train and animate the skeletal muscle to perform its new task. Due to simultaneous tetanic contractions of the entire myoplasty, muscles are deprived of perfusion and fatigue rapidly, causing long-term problems such as excessive scarring and muscle ischemia. Sequential stimulation contracts part of the muscle while other parts rest, thus significantly improving blood perfusion. However, the muscle still fatigues. In this article, we report a test of the feasibility of using closed-loop control to economize the contractions of the sequentially stimulated myoplasty. A simple stimulation algorithm was developed and tested on a sequentially stimulated neo-sphincter designed from a canine gracilis muscle. Pressure generated in the lumen of the myoplasty neo-sphincter was used as feedback to regulate the stimulation signal via three control parameters, thereby optimizing the performance of the myoplasty. Additionally, we investigated and compared the efficiency of amplitude and frequency modulation techniques. Closed-loop feedback enabled us to maintain target pressures within 10% deviation using amplitude modulation and optimized control parameters (correction frequency = 4 Hz, correction threshold = 4%, and transition time = 0.3 s). The large-scale stimulation/feedback setup was unfit for chronic experimentation, but can be used as a blueprint for a small-scale version to unveil the theoretical benefits of closed-loop control in chronic experimentation.

Novel findings in the management of acute pancreatitis.

PubMed

Bolado, Federico; de-Madaria, Enrique

2016-09-01

Acute pancreatitis (AP) is a potentially serious disease whose incidence is on the increase. Pancreas divisum does not meet the required criteria to be considered an aetiological factor. Sphincter of Oddi dysfunction may be another cause of idiopathic AP. Less invasive methods cannot replace Sphincter of Oddi manometry in diagnosis. Almost half of patients with systemic inflammatory response syndrome develop organ failure, but the mechanisms involved are not completely understood. Obesity is a risk factor for severity in AP; the cause could be the presence of free unsaturated fatty acids, which have pro-inflammatory activity. Prognosis is better in patients with isolated extra-pancreatic necrosis than in those with parenchymal necrosis or with both. The mortality rate among those with infected pancreatic necrosis is 15-20%. The "moderately severe" group is widely heterogeneous and this category may require redefinition. Laparoscopic treatment of pseudocysts is an alternative to endoscopic drainage and could be the first-line option in patients requiring cholecystectomy. The use of lumen-apposing metal stents to treat pancreatic necrosis is cost-effective. Quality of life in some patients following an attack of AP is significantly impaired even at 1 year. Aggressive fluid therapy is not superior to standard fluid therapy in preventing post-ERCP AP. The role of statins in AP prevention is still unclear. Aggressive fluid resuscitation and the use of lactated Ringer solution seem to be beneficial in the treatment of AP. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

In Search of the Optimal Surgical Treatment for Velopharyngeal Dysfunction in 22q11.2 Deletion Syndrome: A Systematic Review

PubMed Central

Spruijt, Nicole E.; ReijmanHinze, Judith; Hens, Greet; Vander Poorten, Vincent; Mink van der Molen, Aebele B.

2012-01-01

Background Patients with the 22q11.2 deletion syndrome (22qDS) and velopharyngeal dysfunction (VPD) tend to have residual VPD following surgery. This systematic review seeks to determine whether a particular surgical procedure results in superior speech outcome or less morbidity. Methodology/ Principal Findings A combined computerized and hand-search yielded 70 studies, of which 27 were deemed relevant for this review, reporting on a total of 525 patients with 22qDS and VPD undergoing surgery for VPD. All studies were levels 2c or 4 evidence. The methodological quality of these studies was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias. Heterogeneous groups of patients were reported on in the studies. The surgical procedure was often tailored to findings on preoperative imaging. Overall, 50% of patients attained normal resonance, 48% attained normal nasal emissions scores, and 83% had understandable speech postoperatively. However, 5% became hyponasal, 1% had obstructive sleep apnea (OSA), and 17% required further surgery. There were no significant differences in speech outcome between patients who underwent a fat injection, Furlow or intravelar veloplasty, pharyngeal flap pharyngoplasty, Honig pharyngoplasty, or sphincter pharyngoplasty or Hynes procedures. There was a trend that a lower percentage of patients attained normal resonance after a fat injection or palatoplasty than after the more obstructive pharyngoplasties (11–18% versus 44–62%, p = 0.08). Only patients who underwent pharyngeal flaps or sphincter pharyngoplasties incurred OSA, yet this was not statistically significantly more often than after other procedures (p = 0.25). More patients who underwent a palatoplasty needed further surgery than those who underwent a pharyngoplasty (50% versus 7–13%, p = 0.03). Conclusions/ Significance In the heterogeneous group of patients with 22qDS and VPD, a grade C recommendation can be made to minimize the morbidity of further surgery by choosing to perform a pharyngoplasty directly instead of only a palatoplasty. PMID:22470558

Effects of adrenomedullin on cyclic AMP formation and on relaxation in iris sphincter smooth muscle.

PubMed

Yousufzai, S Y; Ali, N; Abdel-Latif, A A

1999-12-01

To determine whether iris sphincter and other tissues of the iris-ciliary body secrete adrenomedullin (ADM), a novel hypotensive peptide that is classified into the calcitonin gene-related peptide (CGRP) family and to determine the binding sites for ADM and compare the effects of ADM and CGRP in the absence and presence of their receptor antagonists on cAMP formation and relaxation in the iris sphincter. Sphincter muscle was incubated in Krebs-Ringer bicarbonate buffer in the absence and presence of ADM for 10 minutes. Accumulation of cAMP in the tissue extract was determined by radioimmunoassay (RIA). The binding of [125I]ADM to iris sphincter membranes was carried out by rapid filtration. Distribution of ADM in the ocular tissues was determined by RIA. Changes in muscle tension were recorded isometrically. Immunoreactive ADM was present in all tissues of the cat iris-ciliary body. In the isolated cat iris sphincter, ADM increased cAMP accumulation in a time- (t1/2 = 2.2 minutes) and concentration- (EC50 = 13 nM) dependent manner, and this effect was sixfold more efficacious than CGRP. ADM, CGRP, vasoactive intestinal peptide, prostaglandin E2, isoproterenol, and forskolin increased cAMP formation in cat sphincter by 12.5-, 2-, 2.2-, 1-, 2.6-, and 2.4-fold, respectively. The rank of the effects of ADM on cAMP formation in iris sphincter isolated from different animal species was in the following order: cat > dog > bovine > human > rabbit. In the cat iris sphincter, the CGRP antagonist, CGRP(8 to 37), was more effective than the ADM antagonist, ADM (26 to 52), in inhibiting both ADM- and CGRP-induced cAMP formation. ADM and CGRP inhibited carbachol-induced contraction in a concentration-dependent manner with IC50 values of 10 and 90 nM, respectively. Both ADM and CGRP displaced the binding of [125I]ADM to sphincter membranes effectively, with IC50 values of 0.81 and 1.15 nM, respectively. In iris sphincter isolated from cat and other mammalian species including human, ADM is a much more efficacious activator of adenylate cyclase and a much more effective relaxant than CGRP. Its biological effects may be due to direct involvement of ADM receptors, but also to activation of CGRP receptors. Activation of ADM receptors by the peptide leads to concentration-dependent increases in cAMP accumulation and subsequent inhibition (relaxation) of smooth muscle contraction. These findings suggest a role for ADM as a local modulator of smooth muscle tone. A possible function for this potent hypotensive peptide in the regulation of intraocular pressure remains to be investigated.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution.

PubMed

Crawshaw, Benjamin P; Augestad, Knut M; Keller, Deborah S; Nobel, Tamar; Swendseid, Brian; Champagne, Bradley J; Stein, Sharon L; Delaney, Conor P; Reynolds, Harry L

2015-03-01

Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated. A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Robustness of a rhythmic circuit to short- and long-term temperature changes.

PubMed

Tang, Lamont S; Taylor, Adam L; Rinberg, Anatoly; Marder, Eve

2012-07-18

Recent computational and experimental work has shown that similar network performance can result from variable sets of synaptic and intrinsic properties. Because temperature is a global perturbation that differentially influences every biological process within the nervous system, one might therefore expect that individual animals would respond differently to temperature. Nonetheless, the phase relationships of the pyloric rhythm of the stomatogastric ganglion (STG) of the crab, Cancer borealis, are remarkably invariant between 7 and 23°C (Tang et al., 2010). Here, we report that, when isolated STG preparations were exposed to more extreme temperature ranges, their networks became nonrhythmic, or "crashed", in a reversible fashion. Animals were acclimated for at least 3 weeks at 7, 11, or 19°C. When networks from the acclimated animals were perturbed by acute physiologically relevant temperature ramps (11-23°C), the network frequency and phase relationships were independent of the acclimation group. At high acute temperatures (>23°C), circuits from the cold-acclimated animals produced less-regular pyloric rhythms than those from warm-acclimated animals. At high acute temperatures, phase relationships between pyloric neurons were more variable from animal to animal than at moderate acute temperatures, suggesting that individual differences across animals in intrinsic circuit parameters are revealed at high temperatures. This shows that individual and variable neuronal circuits can behave similarly in normal conditions, but their behavior may diverge when confronted with extreme external perturbations.

Pathogenesis of infectious hematopoietic necrosis virus in adult sockeye salmon (Oncorhynchus nerka)

USGS Publications Warehouse

Mulcahy, D.M.; Burke, J.; Pascho, R.J.; Jenes, C.K.

1982-01-01

The concentration of infectious hematopoietic necrosis (IHN) virus was determined in eight organs and two body fluids from each of 60 adult sockeye salmon (Oncorhynchus nerka). Included in the sample were 4 males and 56 prespawning, spawning, or spent female fish. All fish were infected, and virus was present in nearly all organs. There was an overall tendency for the mean concentration to increase in many of the organs over time as the fish progressed in ripeness. In prespawning females, IHN virus could be detected in all organs and in ovarian fluid but not in serum; the incidences were highest in the gills, spleen, and pyloric ceca, and the titers were highest in the pyloric ceca and liver. Incidences of infection in the organs were higher in spawning than in prespawning females and higher still in spent females in which the incidence of virus was 100% in all organs except brains (78%) and sera (67%). Virus concentrations in organs or fluids ranged from 5 to 4.0 × 109 plaque-forming units per millilitre. In males, the highest incidences of virus were found in gills, pyloric ceca, and liver. The gills were the only organ in which the virus concentration in males exceeded that of females.Key words: infectious hematopoietic necrosis, IHN, fish virus, viral pathogenesis, sockeye salmon

Adult idiopathic hypertrophic pyloric stenosis - a common presentation with an uncommon diagnosis

PubMed Central

Mubarik, Ateeq; Muddassir, Salman; Haq, Furqan

2018-01-01

ABSTRACT Background and Objectives: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare but well-defined entity in adults with only 200-300 cases reported so far in the literature.We describe a case of AIHPS and the relevant literature review. Methods and Results: The patient presented with acute onset upper abdominal pain associated with nausea, vomiting, foul-smelling black tarry stools, and anorexia. On the Esophagogastroduodenoscopy (EGD), pylorus demonstrated a unique “cervix sign.” The patient had multiple endoscopic dilations with minimal relief. She then underwent a distal partial gastrectomy with a Billroth 1 gastroduodenostomy with considerable  improvement in her symptoms on follow up. Conclusion: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare disease which is also underreported due to a difficulty in diagnosis. The most common symptoms of AIHPS are postprandial nausea, vomiting, early satiety, and epigastric pain as seen in our patient. Endoscopy usually shows ?Cervix sign? a unique sign showing a fixed, markedly narrowed pylorus with a smooth border. Multiple treatments have been proposed for AIHPS, including endoscopic dilation, pyloromyotomy with or without pyloroplasty, gastrectomy with a Billroth 1 gastroduodenostomy. Currently, there is no evidence of one surgical technique being superior to another. Further research needs to be done on AIHPS before one technique can be standardized as the standard of care. PMID:29686790

Rectal sphincter pressure monitoring device.

PubMed

Hellbusch, L C; Nihsen, B J

1989-05-01

A silicone, dual cuffed catheter designed for the control of nasal hemorrhage was used for rectal sphincter pressure monitoring. Patients with lipomyelomeningocele and tethered spinal cord were monitored during their operative procedures to aid in distinguishing sacral nerve roots from other tissues. Stimulation of sacral nerve roots was done with a disposable nerve stimulator. The use of a catheter with two balloons helps to keep the outer balloon placed against the rectal sphincter.

Designing micro- and nanostructures for artificial urinary sphincters

NASA Astrophysics Data System (ADS)

Weiss, Florian M.; Deyhle, Hans; Kovacs, Gabor; Müller, Bert

2012-04-01

The dielectric elastomers are functional materials that have promising potential as actuators with muscle-like mechanical properties due to their inherent compliancy and overall performance: the combination of large deformations, high energy densities and unique sensory capabilities. Consequently, such actuators should be realized to replace the currently available artificial urinary sphincters building dielectric thin film structures that work with several 10 V. The present communication describes the determination of the forces (1 - 10 N) and deformation levels (~10%) necessary for the appropriate operation of the artificial sphincter as well as the response time to master stress incontinence (reaction time less than 0.1 s). Knowing the dimensions of the presently used artificial urinary sphincters, these macroscopic parameters form the basis of the actuator design. Here, we follow the strategy to start from organic thin films maybe even monolayers, which should work with low voltages but only provide small deformations. Actuators out of 10,000 or 100,000 layers will finally provide the necessary force. The suitable choice of elastomer and electrode materials is vital for the success. As the number of incontinent patients is steadily increasing worldwide, it becomes more and more important to reveal the sphincter's function under static and stress conditions to realize artificial urinary sphincters, based on sophisticated, biologically inspired concepts to become nature analogue.

The diagnostic accuracy of endovaginal and transperineal ultrasound for detecting anal sphincter defects: The PREDICT study.

PubMed

Roos, A-M; Abdool, Z; Sultan, A H; Thakar, R

2011-07-01

To determine the accuracy and predictive value of transperineal (TPU) and endovaginal ultrasound (EVU) in the detection of anal sphincter defects in women with obstetric anal sphincter injuries and/or postpartum symptoms of faecal incontinence. One hundred and sixty-five women were recruited, four women were excluded as they were seen years after their last delivery. TPU and EVU, followed by endonanal ultrasound (EAU), were performed using the B&K Viking 2400 scanner. Sensitivity and specificity, as well as predictive values with 95% confidence intervals, for detecting anal sphincter defects were calculated for EVU and TPU, using EAU as the reference standard. On EAU a defect was found in 42 (26%) women: 39 (93%) had an external (EAS) and 23 (55%) an internal anal sphincter (IAS) defect. Analysable images of one level of the EAS combined with an analysable IAS were available in 140 (87%) women for EVU and in 131 (81%) for TPU. The sensitivity and specificity for the detection of any defect was 48% (30-67%) and 85% (77-91%) for EVU and 64% (44-81%) and 85% (77-91%) for TPU, respectively. Although EAU using a rotating endoprobe is the validated reference standard in the identification of anal sphincter defects, it is not universally available. However while TPU and/or EVU with conventional ultrasound probes can be useful in identifying normality, for clinical purposes they are not sensitive enough to identify an underlying sphincter defect. Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study.

PubMed

Marschalek, Marie-Louise; Worda, Christof; Kuessel, Lorenz; Koelbl, Heinz; Oberaigner, Willi; Leitner, Hermann; Marschalek, Julian; Husslein, Heinrich

2018-03-14

In view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors. This was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors. Age >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01). Episiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries. © 2018 the Authors. Birth published by Wiley Periodicals, Inc.

Assessment of brain activity during voluntary anal sphincter contraction: Comparative study in women with and without fecal incontinence.

PubMed

Parés, D; Martínez-Vilalta, M; Ortiz, H; Soriano-Mas, C; Maestre-Gonzalez, Y; Pujol, J; Grande, L

2018-04-14

Voluntary anal sphincter function is driven by an extended network of brain structures, most of which are still unknown. Disturbances in this function may cause fecal incontinence. The aim of this study was to characterize the cerebral areas involved in voluntary contraction of the anorectal sphincter in healthy women and in a group of patients with fecal incontinence by using a standardized functional magnetic resonance imaging (fMRI) protocol. This comparative study included 12 healthy women (mean age 53.17 ± 4.93 years) and 12 women with fecal incontinence (56.25 ± 6.94 years). An MRI-compatible anal manometer was used to register voluntary external anal sphincter contraction. During brain fMRI imaging, participants were cued to perform 10-s series of self-paced anal sphincter contractions at an approximate rate of 1 Hz. Brain structures linked to anal sphincter contractions were mapped and the findings were compared between the 2 study groups. There were no differences in the evoked brain activity between the 2 groups. In healthy women, group fMRI analysis revealed significant activations in medial primary motor cortices, supplementary motor area, bilateral putamen, and cerebellum, as well as in the supramarginal gyrus and visual areas. In patients with fecal incontinence, the activation pattern involved similar regions without significant differences with healthy women. This brain fMRI-anorectal protocol was able to map the brain regions linked to voluntary anal sphincter function in healthy and women with fecal incontinence. © 2018 John Wiley & Sons Ltd.

Anal Sphincters Evaluation by Endoanal Ultrasound in Obstructed Defecation.

PubMed

Albuquerque, Andreia; Macedo, Guilherme

2017-12-01

To evaluate anal sphincter abnormalities detected by endoanal ultrasound in obstructed defecation due to rectocele and rectal intussusception. The retrospective analysis includes 45 patients with obstructed defecation syndrome due to rectocele and/or rectal intussusception with or without fecal incontinence, and submitted to endoanal ultrasound. Ninety-three percent (n = 42) were women (mean age of 63 ± 12 years), and 47% (n = 21) of the patients had fecal incontinence. In total, 29% (n = 13) had a previous anorectal surgery, and 93% (n = 39) of the women had a previous vaginal delivery. An isolated rectal intussusception was diagnosed in 20% (n = 9) of the patients, an isolated rectocele in 24% (n = 11), and rectal intussusception and rectocele in 56% (n = 25). Thirty-six percent of patients had anal sphincter lacerations (n = 16): 12% (n = 2) had only internal laceration, 69% (n = 11) had only external laceration, and 19% (n = 3) had both. Two patients had a thinner internal anal sphincter with 0.9 and 1.2 mm, respectively. In total, 25% of the patients without fecal incontinence had an occult anal sphincter laceration, and all were women with an external sphincter laceration in the anterior quadrant and a previous vaginal delivery. In patients with obstructed defecation and fecal incontinence, 48% had sphincter lacerations. Previous anorectal surgery was a predictor of anal sphincter laceration (odds ratio [OR] 4.8; 95% confidence interval [CI] = 1.214-18.971; P = .025), but fecal incontinence (OR 2.7; 95% CI = 0.774-9.613; P = .119) and previous vaginal delivery (OR 1.250; 95% CI = 0.104-15.011; P = .860) were not. Endoanal ultrasound should be considered in obstructed defecation with or without fecal incontinence, especially if surgical correction is planned. © 2017 by the American Institute of Ultrasound in Medicine.

Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome?

PubMed

Ramage, L; Yen, C; Qiu, S; Simillis, C; Kontovounisios, C; Tan, E; Tekkis, P

2018-01-01

Introduction This study aimed to ascertain whether missed obstetric anal sphincter injury at delivery had worse functional and quality of life outcomes than primary repair immediately following delivery. Materials and methods Two to one propensity matching was undertaken of patients presenting to a tertiary pelvic floor unit with ultrasound evidence of missed obstetric anal sphincter injury within 24 months of delivery with patients who underwent primary repair at the time of delivery by parity, grade of injury and time to assessment. Outcomes compared included Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score, Short Form-36, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire and anorectal physiology results. Results Thirty-two missed anal sphincter injuries were matched two to one with sixty-two patients who underwent primary repair of an anal sphincter defect. Mean time to follow-up was 9.31 ± 6.79 months. Patients with a missed anal sphincter injury had suffered more incontinence, as seen in higher the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ; 30.56% ± 14.41% vs. 19.75% ± 15.65%, P = 0.002) and Wexner scores (6.00 ± 3.76 vs. 3.67 ± 4.06, P = 0.009). They also had a worse BBUSQ urinary domain score (28.25% ± 14.9% vs. 17.01 ± 13.87%, P = 0.001) and worse physical functioning as measured by the Short Form-36 questionnaire (P = 0.045). There were no differences in other outcomes compared, including anorectal physiology and sexual function. Discussion In the short-term, patients with a missed obstetric anal sphincter injury had significantly worse faecal incontinence and urinary function scores, however quality of life and sexual function were largely comparable between groups. Conclusions Longer-term follow-up is needed to assess the effects of missed obstetric anal sphincter injury over time.

Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex.

PubMed

van Meegdenburg, Maxime M; Trzpis, Monika; Heineman, Erik; Broens, Paul M A

2016-09-01

Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter. If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses. Copyright © 2016 Elsevier Ltd. All rights reserved.

Morphology of certain viruses of Salmonid fishes. II. In vivo studies of infectious Hematopoietic Necrosis Virus

USGS Publications Warehouse

Amend, Donald F.; Chambers, Velma C.

1970-01-01

Juvenile sockeye salmon (Oncorhynchus nerka) were injected with the infectious hematopoietic necrosis (IHN) virus, and tissue samples from the anterior kidney, spleen, liver, intestine, and pyloric caeca of moribund fish were prepared for electron microscopy. Bullet-shaped virus particles measuring 158 × 90 mμ were observed in the hematopoietic tissues of the anterior kidney and spleen. Virus particles were also observed in the outer connective tissues of the pancreas or pyloric caeca, or both. No virus was found in the intestine or liver. The healthy appearance of erythrocytes, reticular cells, and endothelial cells in necrotic areas of the spleen and anterior kidney, and the absence of lymphocytes in these areas, suggested that lymphocytes might be one source of the virus.

[Psychosomatic approach to encopresis].

PubMed

Boige, N; Missonnier, S; Bellaïche, M; Foucaud, P

1999-12-01

Encopresis most often results from functional constipation and a behaviour disorder characterised by retention of faeces. Rarely it is a passive or active expulsion of normal faeces. It indicates a failure in the education of sphincter control, often with a preferential development of autoerotic versus relational investments. A depressive component is frequent. We propose a bidisciplinary approach with a somatic and psychological evaluation of the encopretic child from the first visit. The physical examination assesses constipation and stercoral stasis. Associated psychopathological symptoms or a pathogenic psychosocial situation must be sought. The therapeutic means must be directed towards the different etiologic features. Explanations of the physiopathology of the symptom and discussion with the child and the parents on the origin of the dysfunction must be accomplished first. A medical treatment of the constipation is generally indicated. Psychotherapy is initiated according to the background and associated psychopathological symptoms.

[Female stress urinary incontinence. Surgical repair with pubovaginal sling techniques].

PubMed

Escribano Patiño, Gregorio; Hernández Fernández, Carlos; Subirá Ríos, David; Castaño González, Irene; Moralejo Gárate, Mercedes; Martinez Salamanca, Juan Ignacio

2002-11-01

To review the treatment of female stress urinary incontinence by new systems of tension-free urethral sling TVT type (Tension free vaginal tape) or IVS (intravaginal slingplasty), and the bone anchoring trasvaginal sling procedure Infast. We describe the surgical techniques of the various procedures and perform a bibliographic review on the topic. The pubovaginal sling has become the gold standard in the treatment of female stress urinary incontinence, mainly if there is sphincter intrinsic dysfunction. The concept of tension free medium urethra support has been the most important contribution, that questions the classification of incontinence in types I, II and III, because the pubocervical tension free sling can correct all three. Tension free urethral sling techniques have demonstrated to be effective, minimally invasive with a low complication rate, easily reproducible, and with good continence results in the mid-term.

Species differences in the effects of prostanoids on MAP kinase phosphorylation, myosin light chain phosphorylation and contraction in bovine and cat iris sphincter smooth muscle.

PubMed

Kaddour-Djebbar, I; Ansari, H R; Akhtar, R A; Abdel-Latif, A A

2005-01-01

There is evidence from our own laboratory and that of others that EP-receptor ligands are strong contractile agonists in bovine iris sphincter and that FP-receptor agonists are strong contractile agonists in cat iris sphincter. Here, we have investigated the effects of prostaglandin (PG) receptor agonists of the FP-, EP-, TP- and DP-class on myosin light chain (MLC) phosphorylation, p42/p44 MAP kinase phosphorylation and contraction in the iris sphincter of bovine and cat. Using three signal transduction mechanism assays, namely MLC phosphorylation, MAP kinase phosphorylation and contraction, we demonstrated that in bovine iris sphincter the rank order of potency of the PG agonists in the contractile and MLC phosphorylation assays is as follows: E2>U46619>F2alpha>D2, and in cat F2alpha>D2>E2>U46619. In the MAP kinase assay, in bovine iris sphincter the rank order of potency is E2>F2alpha and in cat F2alpha>E2. These conclusions are supported by the following findings: (1) In the contractile assay, in the bovine sphincter the EC50s for PGF2alpha, PGE2, U46619 and PGD2 were found to be 1.4x10(-7), 5.0x10(-9), 9.0x10(-9) and 1.3x10(-6)M, respectively, and the corresponding values in the cat were 1.9x10(-8), 2.3x10(-7), 1.5x10(-6) and 6.9x10(-8)M, respectively. (2) In the MLC phophorylation assay, in the bovine sphincter PGF2alpha, PGE2, U46619 and PGD2 increased MLC phophorylation by 118%, 165%, 153% and 72%, respectively, and the corresponding values in cat were 175%, 99%, 90% and 95%, respectively. (3) In the MAP kinase assay, in the bovine iris sphincter PGF2alpha and PGE2, increased MAP kinase phosphorylation by 276% and 328%, respectively, and the corresponding values in cat were 308% and 245%, respectively. The data presented demonstrate pronounced species differences in the effects of the prostanoids on the MLC kinase signaling pathway in bovine and cat irides and furthermore confirm the existence of FP-receptors in that of the bovine.

Mean Absorbed Dose to the Anal-Sphincter Region and Fecal Leakage among Irradiated Prostate Cancer Survivors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Alsadius, David, E-mail: david.alsadius@oncology.gu.se; Hedelin, Maria; Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institute, Stockholm

2012-10-01

Purpose: To supplement previous findings that the absorbed dose of ionizing radiation to the anal sphincter or lower rectum affects the occurrence of fecal leakage among irradiated prostate-cancer survivors. We also wanted to determine whether anatomically defining the anal-sphincter region as the organ at risk could increase the degree of evidence underlying clinical guidelines for restriction doses to eliminate this excess risk. Methods and Materials: We identified 985 men irradiated for prostate cancer between 1993 and 2006. In 2008, we assessed long-term gastrointestinal symptoms among these men using a study-specific questionnaire. We restrict the analysis to the 414 men whomore » had been treated with external beam radiation therapy only (no brachytherapy) to a total dose of 70 Gy in 2-Gy daily fractions to the prostate or postoperative prostatic region. On reconstructed original radiation therapy dose plans, we delineated the anal-sphincter region as an organ at risk. Results: We found that the prevalence of long-term fecal leakage at least once per month was strongly correlated with the mean dose to the anal-sphincter region. Examining different dose intervals, we found a large increase at 40 Gy; {>=}40 Gy compared with <40 Gy gave a prevalence ratio of 3.8 (95% confidence interval 1.6-8.6). Conclusions: This long-term study shows that mean absorbed dose to the anal-sphincter region is associated with the occurrence of long-term fecal leakage among irradiated prostate-cancer survivors; delineating the anal-sphincter region separately from the rectum and applying a restriction of a mean dose <40 Gy will, according to our data, reduce the risk considerably.« less

Extradural cold block for selective neurostimulation of the bladder: development of a new technique.

PubMed

Schumacher, S; Bross, S; Scheepe, J R; Seif, C; Jünemann, K P; Alken, P

1999-03-01

Cryotechnique for selective block of the urethral sphincter and simultaneous activation of the bladder was developed to achieve physiological micturition during sacral anterior root stimulation (SARS). In ten foxhounds SARS of S2 was carried out while extradurally both spinal nerves S2 were cooled down from positive 25C in a stepwise fashion until a sphincter block was observed. Subsequently, SARS of S2 was performed while the pudendal nerves were cooled down from + 15C. The effects of spinal and pudendal nerve cold block on the urethral sphincter and bladder during SARS and the recovery time were monitored by urodynamic investigation. A complete cold block of the urethral sphincter during spinal nerve cooling was achieved in all cases. During pudendal nerve cooling, the sphincter was completely blocked in two, and incompletely blocked in four dogs. Cold block temperature of the spinal nerves averaged +11.7C and of the pudendal nerves +6.2C. During SARS and spinal nerve cooling, an increase in intravesical pressure up to 13 cm. water was recognized, and recovery time was on average 6.6 minutes. Intravesical pressure remained unchanged during pudendal nerve cooling, with recovery time being less than 1 minute. The cold block was always reversible. Cryotechnique is an excellent method for selective and reversible block of the urethral sphincter during SARS to avoid detrusor-sphincter-dyssynergia. The application of cryotechnique in functional electrical stimulation leads to an improvement of quality of life in para- or tetraplegic patients because of selective nerve stimulation with optimization of micturition, standing, walking and grasping and does so without the necessity of surgical dorsal root rhizotomy.

Paradoxical sphincter contraction is rarely indicative of anismus

PubMed Central

Voderholzer, W; Neuhaus, D; Klauser, A; Tzavella, K; Muller-Lissner, S; Schindlbeck, N

1997-01-01

Background—Anismus is thought to be a cause of chronic constipation by producing outlet obstruction. The underlying mechanism is paradoxical contraction of the anal sphincter or puborectalis muscle. However, paradoxical sphincter contraction (PSC) also occurs in healthy controls, so anismus may be diagnosed too often because it may be based on a non-specific finding related to untoward conditions during the anorectal examination. 
Aims—To investigate the pathophysiological importance of PSC found at anorectal manometry in constipated patients and in patients with stool incontinence. 
Methods—Digital rectal examination and anorectal manometry were performed in 102 chronically constipated patients, 102 patients with stool incontinence, and in 18 controls without anorectal disease. In 120 of the 222 subjects defaecography was also performed. Paradoxical sphincter contraction was defined as a sustained increase in sphincter pressure during straining. Anismus was assumed when PSC was present on anorectal manometry and digital rectal examination and the anorectal angle did not widen on defaecography. 
Results—Manometric PSC occurred about twice as often in constipated patients as in incontinent patients (41.2% versus 25.5%, p<0.017) and its prevalence was similar in incontinent patients and controls (25.5% versus 22.2%). Oroanal or rectosigmoid transit times in constipated patients with and without PSC did not differ significantly (total 64.6 (8.9) hours versus 54.2 (8.1) hours; rectosigmoid 14.9 (2.4) hours versus 13.8 (2.5) hours). 
Conclusions—Paradoxical sphincter contraction is a common finding in healthy controls as well as in patients with chronic constipation and stool incontinence. Hence, PSC is primarily a laboratory artefact and true anismus is rare. 

 Keywords: anismus; paradoxical sphincter contraction; constipation; stool incontinence; anorectal manometry PMID:9301508

Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head.

PubMed

Pirhonen, J P; Grenman, S E; Haadem, K; Gudmundsson, S; Lindqvist, P; Siihola, S; Erkkola, R U; Marsal, K

1998-11-01

Anal sphincter rupture is a serious complication of vaginal delivery and almost half the affected women have persistent defecatory symptoms despite adequate primary repair. During the past decade, the incidence of anal sphincter ruptures has been increasing in Sweden and is currently estimated to occur in 2.5% of vaginal deliveries. The aim of the study was to report the frequency of anal sphincter ruptures in two university hospitals in two Scandinavian countries, Malmö in Sweden and Turku in Finland, and analyze the potential determinants. Retrospective analysis of a population of 30,933 deliveries (26,541 vaginal) during the years 1990 to 1994. The incidence of anal sphincter ruptures in Malmö, Sweden was 2.69%, and in Turku, Finland 0.36%. There were no significant population differences for the known risk factors (fetal weight, nulliparity or fetal head circumference). However, there is a difference in manual support given to the perineum and to the baby's head when crowning through the vaginal introitus between Malmö and Turku. The proportion of operative vaginal deliveries and abnormal presentations was significantly higher in Turku reflected in the lower Apgar score at 5 minutes and longer duration of second phase of labor. When high risk deliveries (operative vaginal delivery, abnormal presentation and newborns over 4,000 g) were excluded, the risk for anal sphincter ruptures was estimated to be 13 times higher in Malmö than in Turku. The difference in the incidence of anal sphincter rupture between Malmö, Sweden and Turku, Finland may be due to the difference in manual control of the baby's head when crowning.

Effect of gastrointestinal hormones on the biliary sphincter of the opossum.

PubMed

Becker, J M; Moody, F G; Zinsmeister, A R

1982-06-01

The smooth muscle sphincter enveloping the terminal portion of the common bile duct in the opossum exhibits spontaneous electrical activity and simultaneous rhythmic contractions. The aim of our study was to define the influence of four gastrointestinal hormones on biliary sphincter electrical and mechanical activity. An array of five monopolar extracellular electrodes was placed along the opossum choledochal sphincteric smooth muscle and contiguous duodenum. A catheter in continuity with a pressure transducer, drop counter, and saline reservoir was placed in the common duct for simultaneous measurement of ductal pressure and flow. The cystic and distal common hepatic ducts were then ligated to isolate the common bile duct from the gallbladder and liver. In each opossum, biliary sphincteric and duodenal myoelectric activity, common bile duct and gallbladder pressure, and common duct flow were recorded simultaneously before and after the intravenous administration of five different doses of an enteric hormone. Ten animals were given 0.1-10.0 international dog units per kilogram body wt of cholecystokinin, 10 received 0.01-1.00 microgram/kg body wt of cholecystokinin-octapeptide, 10 were given 0.1-10.0 micrograms/kg body wt of secretin, and 5 were given 0.1-10.0 micrograms/kg body wt of pentagastrin. Cholecystokinin, cholecystokinin-octapeptide, and pentagastrin all effected a significant increase in sphincter electrical spike activity and common duct pressure with a decrease in common duct flow. This contractile response was consistent at a wide range of hormonal levels. Secretin had little effect on biliary pressure, flow, and myoelectric activity. The data lend support to the concept that cholecystokinin and gastrin contract the biliary sphincter, metering bile flow at the time of gallbladder emptying in the opossum.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gavioli, Margherita; Losi, Lorena; Luppi, Gabriele

Purpose: To assess the frequency and magnitude of changes in lower rectal cancer resulting from preoperative therapy and its impact on sphincter-saving surgery. Preoperative therapy can increase the rate of preserving surgery by shrinking the tumor and enhancing its distance from the anal sphincter. However, reliable data concerning these modifications are not yet available in published reports. Methods and Materials: A total of 98 cases of locally advanced cancer of the lower rectum (90 Stage uT3-T4N0-N+ and 8 uT2N+M0) that had undergone preoperative therapy were studied by endorectal ultrasonography. The maximal size of the tumor and its distance from themore » anal sphincter were measured in millimeters before and after preoperative therapy. Surgery was performed 6-8 weeks after therapy, and the histopathologic margins were compared with the endorectal ultrasound data. Results: Of the 90 cases, 82.5% showed tumor downsizing, varying from one-third to two-thirds or more of the original tumor mass. The distance between the tumor and the anal sphincter increased in 60.2% of cases. The median increase was 0.73 cm (range, 0.2-2.5). Downsizing was not always associated with an increase in distance. Preserving surgery was performed in 60.6% of cases. It was possible in nearly 30% of patients in whom the cancer had reached the anal sphincter before the preoperative therapy. The distal margin was tumor free in these cases. Conclusion: The results of our study have shown that in very low rectal cancer, preoperative therapy causes tumor downsizing in >80% of cases and in more than one-half enhances the distance between the tumor and anal sphincter. These modifications affect the primary surgical options, facilitating or making sphincter-saving surgery possible.« less

STDs and Pregnancy

MedlinePlus

... Status of EPT Legal/Policy Toolkit Gemifloxacin Procaine Penicillin G Shortage Additional Resources Archive Drug Notices Azithromycin ... Pyloric Stenosis Cefixime Spectinomycin – Alternative Treatments Alternatives to Penicillin G Updating the STD Treatment Guidelines 2010 Guidelines ...

STDs and Infertility

MedlinePlus

... Status of EPT Legal/Policy Toolkit Gemifloxacin Procaine Penicillin G Shortage Additional Resources Archive Drug Notices Azithromycin ... Pyloric Stenosis Cefixime Spectinomycin – Alternative Treatments Alternatives to Penicillin G Updating the STD Treatment Guidelines 2010 Guidelines ...

Canonical correlation analysis of factors involved in the occurrence of peptic ulcers.

PubMed

Bayyurt, Nizamettin; Abasiyanik, M Fatih; Sander, Ersan; Salih, Barik A

2007-01-01

The impact of risk factors on the development of peptic ulcers has been shown to vary among different populations. We sought to establish a correlation between these factors and their involvement in the occurrence of peptic ulcers for which a canonical correlation analysis was applied. We included 7,014 patient records (48.6% women, 18.4% duodenal ulcer [DU], 4.6% gastric ulcer [GU]) of those underwent upper gastroendoscopy for the last 5 years. The variables measured are endoscopic findings (DU, GU, antral gastritis, erosive gastritis, pangastritis, pyloric deformity, bulbar deformity, bleeding, atrophy, Barret esophagus and gastric polyp) and risk factors (age, gender, Helicobacter pylori infection, smoking, alcohol, and nonsteroidal anti-inflammatory drugs [NSAIDs] and aspirin intake). We found that DU had significant positive correlation with bulbar deformity (P=2.6 x 10(-23)), pyloric deformity (P=2.6 x 10(-23)), gender (P=2.6 x 10(-23)), H. pylori (P=1.4 x 10(-15)), bleeding (P=6.9 x 10(-15)), smoking (P=1.4 x 10(-7)), aspirin use (P=1.1 x 10(-4)), alcohol intake (P=7.7 x 10(-4)), and NSAIDs (P=.01). GU had a significantly positive correlation with pyloric deformity (P=1,6 x 10(-15)), age (P=2.6 x 10(-14)), bleeding (P=3.7 x 10(-8)), gender (P=1.3 x 10(-7)), aspirin use (P=1.1 x 10(-6)), bulbar deformity (P=7.4 x 10(-4)), alcohol intake (P=.03), smoking (P=.04), and Barret esophagus (P=.03). The level of significance was much higher in some variables with DU than with GU and the correlations with GU in spite of being highly significant the majority, were small in magnitude. In conclusion, Turkish patients with the following endoscopic findings bulbar deformity and pyloric deformity are high-risk patients for peptic ulcers with the risk of the occurrence of DU being higher than that of GU. Factors such as H. pylori, smoking, alcohol use, and NSAIDs use (listed in a decreasing manner) are risk factors that have significant impact on the occurrence of DU; aspirin has a significant impact on both DU and GU.

Hereditary vacuolar internal anal sphincter myopathy causing proctalgia fugax and constipation: a new case contribution.

PubMed

de la Portilla, Fernando; Borrero, Juan José; Rafel, Enrique

2005-03-01

Hereditary anal sphincter myopathy is rare. We present a family with one affected member with proctalgia fugax, constipation and internal anal sphincter hypertrophy. Ultrastructural findings show vacuolization of smooth muscle cells without the characteristic polyglucosan inclusion. Further relief of symptoms was obtained using an oral calcium antagonist. Based on clinical presentation, endosonography and morphological findings, we consider our case is a histological variant of the vacuolar myopathy originally described.

In vitro and in vivo assessment of an intelligent artificial anal sphincter in rabbits.

PubMed

Huang, Zong-Hai; Shi, Fu-Jun; Chen, Fei; Liang, Fei-Xue; Li, Qiang; Yu, Jin-Long; Li, Zhou; Han, Xin-Jun

2011-10-01

Artificial sphincters have been developed for patients with fecal incontinence, but finding a way to make such sphincters more "intelligent" remains a problem. We assessed the function of a novel intelligent artificial anal sphincter (IAAS) in vitro and in vivo in rabbits. After the prosthesis was activated, rabbits were continent of feces during 81.4% of the activation time. The fecal detection unit provided 100% correct signals on stool in vitro and 65.7% in vivo. The results indicated that the IAAS could efficiently maintain continence and detect stool; however, the IAAS is still in the preliminary experimental stage and more work is needed to improve the system. © 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Repair of an incompetent urethral sphincter in a mare.

PubMed

Schumacher, Jim; Brink, Palle

2011-01-01

To describe successful surgical treatment of urinary incontinence caused by a ruptured and/or transected urethral sphincter in a mare. Clinical report. A 7-year-old, Swedish Warmblood mare with urinary incontinence. The urethral sphincter, which had been damaged during removal of a cystic urolith, was repaired by apposing the ends of the disrupted urethralis muscle and tunica muscularis. The mare was no longer incontinent after repair of the defect by apposition of the ends of the urethralis muscle and tunica muscularis. Transection and/or rupture of the urethral sphincter of a mare may result in urinary incontinence. Apposition of the ends of the ruptured or transected urethralis muscle and tunica muscularis can correct urinary incontinence caused by this defect. © Copyright 2010 by The American College of Veterinary Surgeons.

Open-label study evaluating outpatient urethral sphincter injections of onabotulinumtoxinA to treat women with urinary retention due to a primary disorder of sphincter relaxation (Fowler's syndrome).

PubMed

Panicker, Jalesh N; Seth, Jai H; Khan, Shahid; Gonzales, Gwen; Haslam, Collette; Kessler, Thomas M; Fowler, Clare J

2016-05-01

To assess the efficacy (defined as improvements in maximum urinary flow rate [Qmax ] of ≥50%, post-void residual urine volume [PVR] and scores on the International Prostate Symptom Score [IPSS] questionnaire) and safety of urethral sphincter injections of onabotulinumtoxinA in women with a primary disorder of urethral sphincter relaxation, characterised by an elevated urethral pressure profile (UPP) and specific findings at urethral sphincter electromyography (EMG), i.e. Fowler's syndrome. In this open-label pilot Institutional Review Board-approved study, 10 women with a primary disorder of urethral sphincter relaxation (elevated UPP, sphincter volume, and abnormal EMG) presenting with obstructed voiding (five) or in complete urinary retention (five) were recruited from a single tertiary referral centre. Baseline symptoms were assessed using the IPSS, and Qmax and PVR were measured. After 2% lidocaine injection, 100 U of onabotulinumtoxinA was injected into the striated urethral sphincter, divided on either side, under EMG guidance. Patients were reviewed at 1, 4 and 10 weeks after injection, and assessed using the IPSS, Qmax and PVR measurements. The UPP was repeated at week 4. The mean (range) patient age was 40 (25-65) years, and the mean symptom scores on the IPSS improved from 25.6 to 14.1, and the mean 'bother' score reduced from 6.1 to 3.5 at week 10. As compared with a baseline mean Qmax of 8.12 mL/s in the women who could void, the Qmax improved to 15.8 mL/s at week 10. Four of the five women in complete retention could void spontaneously, with a mean Qmax of 14.3 mL/s at week 10. The mean PVR decreased from 260 to 89 mL and the mean static UPP improved from 113 cmH2 O at baseline to 90 cmH2 O. No serious side-effects were reported. Three women with a history of recurrent urinary tract infections developed a urinary tract infection. There were no reports of stress urinary incontinence. Seven of the 10 women opted to return for repeat injections. This pilot study shows an improvement in patient-reported lower urinary tract symptoms, and the objective parameters of Qmax , PVR and UPP, at 10 weeks after urethral sphincter injections of onabotulinumtoxinA. No serious side-effects were reported. This treatment could represent a safe outpatient treatment for young women in retention due to a primary disorder of urethral sphincter relaxation. However, a larger study is required to confirm the findings of this pilot study. © 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.

Motor pattern of the sphincter of Oddi in patients with bilioenteric shunt: a manometric study.

PubMed

Ponce, J; Garrigues, V; Pertejo, V; Sala, T; Berenguer, J

1988-10-01

An endoscopic biliary manometry was performed on 11 patients with a surgical bilioenteric shunt--choledochoduodenostomy--and no pressure gradient between common bile duct and duodenum. Basal pressure and frequency of the phasic waves of the sphincter of Oddi were significantly higher in these patients than in controls or in patients with retained common bile duct stones. These results suggest a functional adaptation of the sphincter of Oddi in an attempt to recover the normal pressure in the biliary tract.

Upper GI and small bowel series

MedlinePlus

... the stomach may indicate the following problems: Gastric cancer Gastric ulcer - benign Gastritis Polyps (a tumor that is usually noncancerous and grows on the mucus membrane ) Pyloric stenosis ... ring Primary or idiopathic intestinal pseudo-obstruction

The effects of restraint on uptake of radioactive sulfate in the salivary and gastric secretions of rats with pyloric ligation

NASA Technical Reports Server (NTRS)

Chayvialle, J. A.; Lambert, R.; Ruet, D.

1980-01-01

The effects of restraint on the amount of nondialysable radioactive sulfate in the gastric wall and the gastric juice and saliva were investigated. It was found that restraint provokes a significant decrease in salivary radioactive sulfate. This, in turn, is responsible for the decrease of sulfate in the gastric contents observed under these conditions in rats with pyloric ligation. Esophageal ligation associated with this prevents passage of saliva and lowers the amount of radioactive sulfate in the gastric juice. Restraint causes then an increase in the amount of sulfate in the gastric juice, the value observed being very much lower than that of rats with a free esophagus. At the level of the gastric wall, the change observed during restraint does not reach a significant threshold.

Prolapsing Gastric Polyp Causing Intermittent Gastric Outlet Obstruction.

PubMed

Kosai, Nik Ritza; Gendeh, Hardip Singh; Norfaezan, Abdul Rashid; Razman, Jamin; Sutton, Paul Anthony; Das, Srijit

2015-06-01

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy, with an incidence up to 5%. The majority of gastric polyps are asymptomatic, occurring secondary to inflammation. Prior reviews discussed Helicobacter pylori (H pylori)-associated singular gastric polyposis; however, we present a rare and unusual case of recurrent multiple benign gastric polyposis post H pylori eradication resulting in intermittent gastric outlet obstruction. A 70-year-old independent male, Chinese in ethnicity, with a background of diabetes mellitus, hypertension, and a simple renal cyst presented with a combination of melena, anemia, and intermittent vomiting of partially digested food after meals. Initial gastroscopy was positive for H pylori; thus he was treated with H pylori eradication and proton pump inhibitors. Serial gastroscopy demonstrated multiple sessile gastric antral polyps, the largest measuring 4 cm. Histopathologic examination confirmed a benign hyperplastic lesion. Computed tomography identified a pyloric mass with absent surrounding infiltration or metastasis. A distal gastrectomy was performed, whereby multiple small pyloric polyps were found, the largest prolapsing into the pyloric opening, thus explaining the intermittent nature of gastric outlet obstruction. Such polyps often develop from gastric ulcers and, if left untreated, may undergo neoplasia to form malignant cells. A distal gastrectomy was an effective choice of treatment, taking into account the polyp size, quantity, and potential for malignancy as opposed to an endoscopic approach, which may not guarantee a complete removal of safer margins and depth. Therefore, surgical excision is favorable for multiple large gastric polyps with risk of malignancy.

Prolapsing Gastric Polyp Causing Intermittent Gastric Outlet Obstruction

PubMed Central

Kosai, Nik Ritza; Gendeh, Hardip Singh; Norfaezan, Abdul Rashid; Razman, Jamin; Sutton, Paul Anthony; Das, Srijit

2015-01-01

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy, with an incidence up to 5%. The majority of gastric polyps are asymptomatic, occurring secondary to inflammation. Prior reviews discussed Helicobacter pylori (H pylori)–associated singular gastric polyposis; however, we present a rare and unusual case of recurrent multiple benign gastric polyposis post H pylori eradication resulting in intermittent gastric outlet obstruction. A 70-year-old independent male, Chinese in ethnicity, with a background of diabetes mellitus, hypertension, and a simple renal cyst presented with a combination of melena, anemia, and intermittent vomiting of partially digested food after meals. Initial gastroscopy was positive for H pylori; thus he was treated with H pylori eradication and proton pump inhibitors. Serial gastroscopy demonstrated multiple sessile gastric antral polyps, the largest measuring 4 cm. Histopathologic examination confirmed a benign hyperplastic lesion. Computed tomography identified a pyloric mass with absent surrounding infiltration or metastasis. A distal gastrectomy was performed, whereby multiple small pyloric polyps were found, the largest prolapsing into the pyloric opening, thus explaining the intermittent nature of gastric outlet obstruction. Such polyps often develop from gastric ulcers and, if left untreated, may undergo neoplasia to form malignant cells. A distal gastrectomy was an effective choice of treatment, taking into account the polyp size, quantity, and potential for malignancy as opposed to an endoscopic approach, which may not guarantee a complete removal of safer margins and depth. Therefore, surgical excision is favorable for multiple large gastric polyps with risk of malignancy. PMID:25578789

ROBUSTNESS OF A RYTHMIC CIRCUIT TO SHORT AND LONG-TERM TEMPERATURE CHANGES

PubMed Central

TANG, LAMONT S.; TAYLOR, ADAM L.; RINBERG, ANATOLY; MARDER, EVE

2012-01-01

Recent computational and experimental work has shown that similar network performance can result from variable sets of synaptic and intrinsic properties. Because temperature is a global perturbation that differentially influences every biological process within the nervous system, one might therefore expect that individual animals would respond differently to temperature. Nonetheless, the phase relationships of the pyloric rhythm of the stomatogastric ganglion (STG) of the crab, Cancer borealis, are remarkably invariant between 7 and 23 °C (Tang et al., 2010). Here, we report that when isolated STG preparations were exposed to more extreme temperature ranges, their networks became non-rhythmic, or “crashed”, in a reversible fashion. Animals were acclimated for at least 3 weeks at 7 °C, 11 °C, or 19 °C. When networks from the acclimated animals were perturbed by acute physiologically relevant temperature ramps (11–23 °C), the network frequency and phase relationships were independent of the acclimation group. At high acute temperatures (>23 °C), circuits from the cold-acclimated animals produced less-regular pyloric rhythms than those from warm-acclimated animals. At high acute temperatures, phase relationships between pyloric neurons were more variable from animal to animal than at moderate acute temperatures, suggesting that individual differences across animals in intrinsic circuit parameters are revealed at high temperatures. This shows that individual and variable neuronal circuits can behave similarly in normal conditions, but their behavior may diverge when confronted with extreme external perturbations. PMID:22815521

Chronic anal fissure: morphometric analysis of the anal canal at 3.0 Tesla MR imaging.

PubMed

Erden, Ayşe; Peker, Elif; Gençtürk, Zeynep Bıyıklı

2017-02-01

OBJECTıVE: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system. Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation. The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. CONCLUSıON: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study.

PubMed

Norderval, S; Røssaak, K; Markskog, A; Vonen, B

2012-08-01

To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Mechanisms of Barrett’s esophagus (clinical): LES dysfunction, hiatal hernia, peristaltic defects

PubMed Central

Roman, Sabine; Kahrilas, Peter J

2014-01-01

Summary Barrett’s esophagus, with the potential to develop into esophageal adenocarcinoma (EAC), is a major complication of gastroesophageal reflux disease (GERD). However, about 50% of patients developing EAC had no known GERD beforehand. Hence, while GERD symptoms, esophagitis, and Barrett’s have a number of common determinants (esophagogastric junction (EGJ) incompetence, impaired esophageal clearance mechanisms, hiatus hernia) they also have some independent determinants. Further, although excess esophageal acid exposure plays a major role in the genesis of long-segment Barrett’s esophagus there is minimal evidence supporting this for short-segment Barrett’s. Hence, these may have unique pathophysiological features as well. Long-segment Barrett’s seems to share most, if not all, of the risk factors for esophagitis, particularly high-grade esophagitis. However, it is uncertain if EGJ function and acid clearance are more severely impaired in patients with long-segment Barrett’s compared to patients with high-grade esophagitis. With respect to short-segment Barrett’s, the acid pocket may play an important pathogenic role. Conceptually, extension of the acid pocket into the distal esophagus, also known as intra-sphincteric reflux, provides a mechanism or acid exposure of the distal esophageal mucosa without the occurrence of discrete reflux events, which are more likely to prompt reflux symptoms and lead to the development of esophagitis. Hence, intra-sphincteric reflux related to extension of the acid/no acid interface at the proximal margin of the acid pocket may be key in the development of short segment Barrett’s. However, currently this is still somewhat speculative and further studies are required to confirm this. PMID:25743453

Gastroesophageal reflux disease in COPD: links and risks.

PubMed

Lee, Annemarie L; Goldstein, Roger S

2015-01-01

COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment.

Gastroesophageal reflux disease in COPD: links and risks

PubMed Central

Lee, Annemarie L; Goldstein, Roger S

2015-01-01

COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment. PMID:26392769

Republished: Symptomatic reflux disease: the present, the past and the future

PubMed Central

Boeckxstaens, Guy; El-Serag, Hashem B; Smout, André J P M; Kahrilas, Peter J

2015-01-01

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future. PMID:25583739

Symptomatic reflux disease: the present, the past and the future

PubMed Central

Boeckxstaens, Guy; El-Serag, Hashem B; Smout, André J P M; Kahrilas, Peter J

2014-01-01

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future. PMID:24607936

The unusual history and the urological applications of botulinum neurotoxin.

PubMed

Hanchanale, Vishwanath S; Rao, Amrith Raj; Martin, Francis L; Matanhelia, Shyam S

2010-01-01

Botulinum neurotoxin (BoNT) is probably the most potent biological toxin that can affect humans. Since its discovery by Justinus Kerner, BoNT has seen use in a wide range of cosmetic and non-cosmetic conditions such as cervical dystonia, cerebral palsy, migraines and hyperhidrosis. We tried to trace its history from its inception to its recent urological applications. Historical articles about botulinum toxin were reviewed and a Medline search was performed for its urological utility. We hereby present a brief review of historical aspects of BoNT and its applications in urology. In 1793, the first known outbreak of botulism occurred due to 'spoiled' sausage in Wildebad, Germany. The German physician and poet Justinus Kerner published the first accurate description of the clinical symptoms of botulism (sausage poison). He was also the first to mention its potential therapeutic applications. In urology, BoNT has been used in bladder and urethral lesions with varying degree of success. Recently, BoNT applications were explained for prostatic disorders. BoNT applications in urology are in the treatment of detrusor external sphincter dyssynergia, detrusor overactivity, detrusor underactivity, spastic conditions of the urethral sphincter, chronic prostate pain, interstitial cystitis, non-fibrotic bladder outflow obstruction (including benign prostatic hyperplasia) and acute urinary retention in women. Justinus Kerner is the godfather of botulism research. The role of BoNT in urology has evolved exponentially and it is widely used as an adjuvant in voiding dysfunction. In the future, its utility will broaden and guide the urologist in managing various urological disorders. Copyright © 2010 S. Karger AG, Basel.

Mechanisms of Barrett's oesophagus (clinical): LOS dysfunction, hiatal hernia, peristaltic defects.

PubMed

Roman, Sabine; Kahrilas, Peter J

2015-02-01

Barrett's oesophagus, with the potential to develop into oesophageal adenocarcinoma (OAC), is a major complication of gastrooesophageal reflux disease (GORD). However, about 50% of patients developing OAC had no known GORD beforehand. Hence, while GORD symptoms, oesophagitis, and Barrett's have a number of common determinants (oesophagogastric junction (OGJ) incompetence, impaired oesophageal clearance mechanisms, hiatus hernia) they also have some independent determinants. Further, although excess oesophageal acid exposure plays a major role in the genesis of long-segment Barrett's oesophagus there is minimal evidence supporting this for short-segment Barrett's. Hence, these may have unique pathophysiological features as well. Long-segment Barrett's seems to share most, if not all, of the risk factors for oesophagitis, particularly high-grade oesophagitis. However, it is uncertain if OGJ function and acid clearance are more severely impaired in patients with long-segment Barrett's compared to patients with high-grade oesophagitis. With respect to short-segment Barrett's, the acid pocket may play an important pathogenic role. Conceptually, extension of the acid pocket into the distal oesophagus, also known as intra-sphincteric reflux, provides a mechanism or acid exposure of the distal osophageal mucosa without the occurrence of discrete reflux events, which are more likely to prompt reflux symptoms and lead to the development of oesophagitis. Hence, intra-sphincteric reflux related to extension of the acid/no acid interface at the proximal margin of the acid pocket may be key in the development of short segment Barrett's. However, currently this is still somewhat speculative and further studies are required to confirm this. Copyright © 2014 Elsevier Ltd. All rights reserved.

Heme oxygenase-1 upregulation modulates tone and fibroelastic properties of internal anal sphincter

PubMed Central

Krishna, Chadalavada Vijay; Singh, Jagmohan; Kumar, Sumit

2014-01-01

A compromise in the internal anal sphincter (IAS) tone and fibroelastic properties (FEP) plays an important role in rectoanal incontinence. Herein, we examined the effects of heme oxygenase (HO)-1 upregulation on these IAS characteristics in young rats. We determined the effect of HO-1 upregulator hemin on HO-1 mRNA and protein expressions and on basal IAS tone and its FEP before and after HO-1 inhibitor tin protoporphyrin IX. For FEP, we determined the kinetics of the IAS smooth muscle responses, by the velocities of relaxation, and recovery of the IAS tone following 0 Ca2+ and electrical field stimulation. To characterize the underlying signal transduction for these changes, we determined the effects of hemin on RhoA-associated kinase (RhoA)/Rho kinase (ROCK) II, myosin-binding subunit of myosin light chain phosphatase 1, fibronectin, and elastin expression levels. Hemin increased HO-1 mRNA and protein similar to the increases in the basal tone, and in the FEP of the IAS. Underlying mechanisms in the IAS characteristics are associated with increases in the genetic and translational expressions of RhoA/ROCKII, and elastin. Fibronectin expression levels on the other hand were found to be decreased following HO-1 upregulation. The results of our study show that the hemin/HO-1 system regulates the tone and FEP of IAS. The hemin/HO-1 system thus provides a potential target for the development of new interventions aimed at treatment of gastrointestinal motility disorders, specifically the age-related IAS dysfunction. PMID:25035109

Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation. A newly identified condition.

PubMed

Kamm, M A; Hoyle, C H; Burleigh, D E; Law, P J; Swash, M; Martin, J E; Nicholls, R J; Northover, J M

1991-03-01

A newly identified myopathy of the internal anal sphincter is described. In the affected family, at least one member from each of five generations had severe proctalgia fugax; onset was usually in the third to fifth decades of life. Three members of the family have been studied in detail. Each had severe pain intermittently during the day and hourly during the night. Constipation was an associated symptom, in particular difficulty with rectal evacuation. Clinically the internal anal sphincter was thickened and of decreased compliance. The maximum anal canal pressure was usually increased with marked ultraslow wave activity. Anal endosonography confirmed a grossly thickened internal anal sphincter. Two patients were treated by internal anal sphincter strip myectomy; one showed marked improvement and one was relieved of the constipation but had only slight improvement of the pain. The hypertrophied muscle in two of the patients showed unique myopathic changes, consisting of vacuolar changes with periodic acid-Schiff-positive polyglycosan bodies in the smooth muscle fibers and increased endomysial fibrosis. In vitro organ-bath studies showed insensitivity of the muscle to noradrenaline, isoprenaline, carbachol, dimethylpiperazinium, and electrical-field stimulation. Immunohistochemical studies for substance P, calcitonin gene-related peptide, galanin, neuropeptide Y, and vasoactive intestinal peptide showed staining in a similar distribution to that in control tissue. A specific autosomal-dominant inherited myopathy of the internal anal sphincter that causes anal pain and constipation has been identified and characterized.

Stimulated pressure profile at rest: a noninvasive method for assessing urethral sphincter function.

PubMed

Meyer, S; Kuntzer, T; De Grandi, P; Bachelard, O; Schreyer, A

1998-10-01

To validate a method for assessing urethral sphincter muscle function by recording rises in intraurethral pressure during repetitive pudendal nerve stimulations. A supine urethral pressure profile at rest was performed on 12 stress-continent and 28 stress-incontinent patients during repetitive pudendal nerve stimulations applied near the ischial spine, and the intraurethral pressure increases were calculated for each third of the urethral functional length. No significant difference in intraurethral pressure increases was seen between continent and stress-incontinent women. On the various regression curves, the intraurethral pressure increases showed a significant correlation with maximal urethral closure pressure values at rest and at stress (r = 0.36 to 0.54) and with the patient's age (r = 0.46), but not with pudendal nerve conduction times to the urethral sphincter on either side (r = 0.14 and 0.19). This method (1) measures intraurethral pressure increases that correlate well with the anatomic location of the urethral sphincter muscle, (2) shows there is no significant difference between them in continent and stress-incontinent patients, except in patients with a low-pressure urethra, and (3) demonstrates that they correlate well with the maximal urethral closure pressure and the patient's age, but not with pudendal motor latencies to the urethral sphincter. This method gives us a mapping of the urethral sphincter activity, explaining why some patients with a low-pressure urethra have less urinary loss than others with the same urethral closure pressure.

Biomimetic artificial sphincter muscles: status and challenges

NASA Astrophysics Data System (ADS)

Leung, Vanessa; Fattorini, Elisa; Karapetkova, Maria; Osmani, Bekim; Töpper, Tino; Weiss, Florian; Müller, Bert

2016-04-01

Fecal incontinence is the involuntary loss of bowel content and affects more than 12% of the adult population, including 45% of retirement home residents. Severe fecal incontinence is often treated by implanting an artificial sphincter. Currently available implants, however, have long-term reoperation rates of 95% and definitive explantation rates of 40%. These statistics show that the implants fail to reproduce the capabilities of the natural sphincter and that the development of an adaptive, biologically inspired implant is required. Dielectric elastomer actuators (DEA) are being developed as artificial muscles for a biomimetic sphincter, due to their suitable response time, reaction forces, and energy consumption. However, at present the operation voltage of DEAs is too high for artificial muscles implanted in the human body. To reduce the operating voltage to tens of volts, we are using microfabrication to reduce the thickness of the elastomer layer to the nanometer level. Two microfabrication methods are being investigated: molecular beam deposition and electrospray deposition. This communication covers the current status and a perspective on the way forward, including the long-term prospects of constructing a smart sphincter from low-voltage sensors and actuators based on nanometer-thin dielectric elastomer films. As DEA can also provide sensory feedback, a biomimetic sphincter can be designed in accordance with the geometrical and mechanical parameters of its natural counterpart. The availability of such technology will enable fast pressure adaption comparable to the natural feedback mechanism, so that tissue atrophy and erosion can be avoided while maintaining continence du ring daily activities.

Thermal responses of shape memory alloy artificial anal sphincters

NASA Astrophysics Data System (ADS)

Luo, Yun; Takagi, Toshiyuki; Matsuzawa, Kenichi

2003-08-01

This paper presents a numerical investigation of the thermal behavior of an artificial anal sphincter using shape memory alloys (SMAs) proposed by the authors. The SMA artificial anal sphincter has the function of occlusion at body temperature and can be opened with a thermal transformation induced deformation of SMAs to solve the problem of severe fecal incontinence. The investigation of its thermal behavior is of great importance in terms of practical use in living bodies as a prosthesis. In this work, a previously proposed phenomenological model was applied to simulate the thermal responses of SMA plates that had undergone thermally induced transformation. The numerical approach for considering the thermal interaction between the prosthesis and surrounding tissues was discussed based on the classical bio-heat equation. Numerical predictions on both in vitro and in vivo cases were verified by experiments with acceptable agreements. The thermal responses of the SMA artificial anal sphincter were discussed based on the simulation results, with the values of the applied power and the geometric configuration of thermal insulation as parameters. The results obtained in the present work provided a framework for the further design of SMA artificial sphincters to meet demands from the viewpoint of thermal compatibility as prostheses.

Endoanal MRI of the anal sphincter complex: correlation with cross-sectional anatomy and histology.

PubMed Central

Hussain, S M; Stoker, J; Zwamborn, A W; Den Hollander, J C; Kuiper, J W; Entius, C A; Laméris, J S

1996-01-01

The purpose of this study was to correlate the in vivo endoanal MRI findings of the anal sphincter with the cross-sectional anatomy and histology. Fourteen patients with rectal tumours were examined with a rigid endoanal MR coil before undergoing abdominoperineal resection. In addition, 12 cadavers were used to obtain cross-sectional anatomical sections. The images were correlated with the histology and anatomy of the resected rectal specimens as well as with the cross-sectional anatomical sections of the 12 cadavers. The findings in 8 patients, 11 rectal preparations, and 10 cadavers, could be compared. In these cases, there was an excellent correlation between endoanal MRI and the cross-sectional cadaver anatomy and histology. With endoanal MRI, all muscle layers of the anal canal wall, comprising the internal anal sphincter, longitudinal muscle, the external anal sphincter and the puborectalis muscle were clearly visible. The levator ani muscle and ligamentous attachments were also well demonstrated. The perianal anatomical spaces, containing multiple septae, were clearly visible. In conclusion, endoanal MRI is excellent for visualising the anal sphincter complex and the findings show a good correlation with the cross-sectional anatomy and histology. Images Fig. 1 Fig. 2 PMID:8982844

Internal anal sphincter: Clinical perspective.

PubMed

Kumar, Lalit; Emmanuel, Anton

2017-08-01

To summarise current knowledge of Internal anal sphincter. The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research. The PubMed database was used to identify relevant studies relating to internal anal sphincter. The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques. Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm. Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Supraspinal control of external anal sphincter motility: effects of vesical distension in humans and cats.

PubMed

Vitton, V; Grimaud, J-C; Bouvier, M; Abysique, A

2006-11-01

A pontine centre located near the micturition centre controlling external anal sphincter (EAS) motility via noradrenergic neurones has been described in cats. The aim of this study was to determine (i) whether a similar centre controls EAS motility in humans and (ii) whether this centre is involved in vesico-sphincteric reflexes in cats and humans. The effects of an alpha-1-adrenoceptor antagonist (nicergoline) and those of vesical distension on the electrical activity of the EAS were studied in paraplegic and non-paraplegic volunteers. The effects of vesical distension by injecting saline at physiological levels on the responses of the EAS to pudendal nerve stimulation were investigated in intact cats and cats with nerve sections. In non-paraplegic subjects, nicergoline and vesical distension abolished the activity of the EAS. These effects were no longer observed in paraplegic patients. In cats, vesical distension inhibited the reflex response of the EAS to pudendal nerve stimulation. This vesico-sphincteric reflex, which was no longer observed in spinal animals, persisted after nicergoline injection. These findings indicate that in humans, there exists a supra-spinal centre facilitating the tonic activity of the EAS via noradrenergic neurones not involved in the inhibitory vesico-sphincteric reflex.

Liver Function Assessment by Magnetic Resonance Imaging.

PubMed

Ünal, Emre; Akata, Deniz; Karcaaltincaba, Musturay

2016-12-01

Liver function assessment by hepatocyte-specific contrast-enhanced magnetic resonance imaging is becoming a new biomarker. Liver function can be assessed by T1 mapping (reduction rate) and signal intensity measurement (relative enhancement ratio) before and after GD-EOB-DTPA (gadoxetic acid) administration, as alternative to Tc-99m galactosyl serum albumin scintigraphy, 99m Tc-labeled mebrofenin scintigraphy, and indocyanine green clearance test. Magnetic resonance imaging assessment of liver function can enable diagnosis of cirrhosis, nonalcoholic fatty liver disease associated fibrosis and steatohepatitis, primary sclerosing cholangitis, toxic hepatitis, and chemotherapy and radiotherapy-related changes, which may be only visible on hepatobiliary phase images. Simple visual assessment of signal intensity at hepatobiliary phase images is important for the diagnosis of different patterns of liver dysfunction including diffuse, lobar, segmental, and subsegmental forms. Furthermore, preoperative assessment of liver function is feasible before oncologic hepatic surgery, which may be important to prevent posthepatectomy liver failure and to estimate future remnant volume. Functional magnetic resonance cholangiography obtained by T1-weighted images at hepatobiliary phase can allow diagnosis of acalculous cholecystitis, biliary leakage, bile reflux to the stomach, sphincter of oddi dysfunction, and lesions with communication to biliary tree. Functional information can be easily obtained when Gd-EOB-DTPA is used for liver magnetic resonance imaging. Copyright © 2016 Elsevier Inc. All rights reserved.

Treatment implications of high-resolution manometry findings: options for patients with esophageal dysmotility.

PubMed

Bolkhir, Ahmed; Gyawali, C Prakash

2014-03-01

High-resolution manometry (HRM) has significantly impacted diagnosis and management of achalasia in particular, and has improved characterization of other motor disorders. Achalasia, the most profound esophageal motor disorder, is characterized by esophageal outflow obstruction from abnormal relaxation of the lower esophageal sphincter (LES) during swallowing, and presents with transit symptoms (dysphagia, regurgitation). Esophageal body motor disorders include both inhibitory nerve dysfunction associated with hypermotility or spasm, and hypomotility disorders with poor contraction. The implications of hypermotility disorders are both perceptive and obstructive. On the other hand, hypomotility disorders have reflux implications because of abnormal barrier function at the LES, and abnormal bolus clearance. Esophageal outflow obstruction in achalasia responds favorably to disruption of the LES, and outcome may be predicted by HRM subtyping of achalasia. Identification of dominant (perceptive vs. obstructive) mechanisms of symptom generation help direct therapy of hypermotility disorders, while hypomotility disorders typically require management of concurrent reflux disease.

Clinical significance of anismus in encopresis.

PubMed

Catto-Smith, A G; Nolan, T M; Coffey, C M

1998-09-01

Treatments designed to relieve paradoxical contraction of the anal sphincters during defecation (anismus) have had limited success in children with encopresis. This has raised doubts as to the clinical relevance of this diagnosis in childhood as anorectal dysfunction. Our aim was to determine whether, in patients who had treatment-resistant encopresis, the presence of electromyographic anismus was associated with increased faecal retention. Sixty-eight children with soiling (mean age 8.7+/-2.06 years) were assessed by clinical examination, abdominal radiography and then with anorectal manometry. Patients with electromyographic anismus (n=32; 47%) had significantly increased radiographic rectal faecal retention and were significantly less likely to be able to defecate water-filled balloons. There were no significant differences in response to prior therapy, history of primary encopresis, behavioural adjustment or in sociodemographic data. Our results suggest that electromyographic anismus is associated with obstructed defecation and faecal retention.

Botulinum toxin for conditions of the female pelvis.

PubMed

El-Khawand, Dominique; Wehbe, Salim; Whitmore, Kristene

2013-07-01

Botulinum toxin has recently been approved by the Food and Drug Administration (FDA) for the treatment of urinary incontinence associated with neurogenic detrusor overactivity. However, it has also been used off-label for a multitude of other conditions in the female pelvis, including urological, gynecological, and colorectal. This article reviews the most recent data regarding its efficacy and safety, and administration techniques for those conditions. A literature review of the most relevant reports published between 1985 and 2012. Urinary incontinence related to neurogenic detrusor overactivity is currently the only approved indication in the female pelvis. Other supported off-label uses include: idiopathic detrusor overactivity, interstitial cystitis/bladder pain syndrome, detrusor sphincter dyssynergia, high-tone pelvic floor dysfunction, anal fissure, anismus, and functional anal pain. Botulinum toxin may effectively and safely be used in many conditions of the female pelvis. More high quality research is needed to better clarify its role in the therapeutic algorithm for those indications.

Videocystography with synchronous detrusor pressure and flow rate recordings.

PubMed

Arnold, E P; Brown, A D; Webster, J R

1974-08-01

The addition of pressure and flow rate recordings to conventional cystourethrography is relatively inexpensive in terms of cost and of radiologist's time, each investigation requiring approximately half an hour.The value of this investigation in males lies in assessing the severity and site of outlet obstruction, particularly when the prostate is not clinically enlarged. Its value in demonstrating detrusor instability in cases of obstruction and in patients with post-prostatectomy problems is discussed. It is essential to the adequate assessment of sphincter mechanisms in both males and females. The particular importance of this in the female lies in the poor results of routine surgery for incontinence where this is due to detrusor instability.Finally the importance in neurological patients of a urodynamic evaluation of continence mechanisms and voiding dysfunction, both as a preliminary assessment and as a guide to the efficacy of treatment, is outlined.Various criticisms of the technique are reviewed and appropriate rebuttals provided.

Back pain caused by a pseudo-tumorous vertebral collapse: atypical presentation of primary vertebral hydatidosis.

PubMed

Mrabet, D; Rekik, S; Khiari, H; Mizouni, H; Meddeb, N; Cheour, I; Elleuch, M; Mnif, E; Mrabet, A; Sahli, H; Sellami, S

2011-03-24

Hydatidosis, also known as echinococcosis, is a rare but serious parasitic disease in endemic areas. Primary spinal location is extremely rare. This case report describes a rare instance of hydatid cyst that caused severe and progressive low-back pain and neurologic dysfunction. Spine MRI showed a unique vertebral collapse of Th12 body with multicystic lesions filling the spinal canal. In addition, hydatidosis serodiagnostic test was positive at 1/725. Treatment depended on the actual surgical removal of the cysts. Surgery consisted in excision and extirpation of the cysts, associated with decompressive laminectomy. The diagnosis was confirmed on the basis of histological results. No coincidental hydatid visceral involvement was found. Antihelminthic drugs (Albendazole) were promptly given before surgery for a long period. The outcome was satisfactorily marked by total regression of the motor deficit and sphincter disorders.

An assessment of the complications of the Brantley Scott artificial sphincter.

PubMed

Heathcote, P S; Galloway, N T; Lewis, D C; Stephenson, T P

1987-08-01

A Brantley Scott artificial sphincter has been inserted into 95 patients since 1981; more than half of the patients had lower urinary tract neuropathy and most of the others post-TUR incontinence. The main problem with the device has been cuff failure (12), which should be resolved by the new "dipped" cuffs. The major surgical complication has been erosion (10), usually associated with infection. Twenty-four patients had variable degrees of incontinence but the artificial sphincter remains the cornerstone of continence control when other methods have failed or are inappropriate.

Rat model of anal sphincter injury and two approaches for stem cell administration

PubMed Central

Trébol, Jacobo; Georgiev-Hristov, Tihomir; Vega-Clemente, Luz; García-Gómez, Ignacio; Carabias-Orgaz, Ana; García-Arranz, Mariano; García-Olmo, Damián

2018-01-01

AIM To establish a rat model of anal sphincter injury and test different systems to provide stem cells to injured area. METHODS Adipose-derived stem cells (ASCs) were isolated from BDIX rats and were transfected with green fluorescent protein (GFP) for cell tracking. Biosutures (sutures covered with ASCs) were prepared with 1.5 x 106 GFP-ASCs, and solutions of 106 GFP-ASCs in normal saline were prepared for injection. Anorectal normal anatomy was studied on Wistar and BDIX female rats. Then, we designed an anal sphincter injury model consisting of a 1-cm extra-mucosal miotomy beginning at the anal verge in the anterior middle line. The sphincter lesion was confirmed with conventional histology (hematoxylin and eosin) and immunofluorescence with 4', 6-diamidino-2-phenylindole (commonly known as DAPI), GFP and α-actin. Functional effect was assessed with basal anal manometry, prior to and after injury. After sphincter damage, 36 BDIX rats were randomized to three groups for: (1) Cell injection without repair; (2) biosuture repair; and (3) conventional suture repair and cell injection. Functional and safety studies were conducted on all the animals. Rats were sacrificed after 1, 4 or 7 d. Then, histological and immunofluorescence studies were performed on the surgical area. RESULTS With the described protocol, biosutures had been covered with at least 820000-860000 ASCs, with 100% viability. Our studies demonstrated that some ASCs remained adhered after suture passage through the muscle. Morphological assessment showed that the rat anal anatomy is comparable with human anatomy; two sphincters are present, but the external sphincter is poorly developed. Anal sphincter pressure data showed spontaneous, consistent, rhythmic anal contractions, taking the form of “plateaus” with multiple twitches (peaks) in each pressure wave. These basal contractions were very heterogeneous; their frequency was 0.91-4.17 per min (mean 1.6980, SD 0.57698), their mean duration was 26.67 s and mean number of peaks was 12.53. Our morphological assessment revealed that with the aforementioned surgical procedure, both sphincters were completely sectioned. In manometry, the described activity disappeared and was replaced by a gentle oscillation of basal line, without a recognizable pattern. Surprisingly, these findings appeared irrespective of injury repair or not. ASCs survived in this potentially septic area for 7 d, at least. We were able to identify them in 84% of animals, mainly in the muscular section area or in the tissue between the muscular endings. ASCs formed a kind of “conglomerate” in rats treated with injections, while in the biosuture group, they wrapped the suture. ASCs were also able to migrate to the damaged zone. No relevant adverse events or mortality could be related to the stem cells in our study. We also did not find unexpected tissue growths. CONCLUSION The proposed procedure produces a consistent sphincter lesion. Biosutures and injections are suitable for cell delivery. ASCs survive and are completely safe in this clinical setting. PMID:29391927

Rat model of anal sphincter injury and two approaches for stem cell administration.

PubMed

Trébol, Jacobo; Georgiev-Hristov, Tihomir; Vega-Clemente, Luz; García-Gómez, Ignacio; Carabias-Orgaz, Ana; García-Arranz, Mariano; García-Olmo, Damián

2018-01-26

To establish a rat model of anal sphincter injury and test different systems to provide stem cells to injured area. Adipose-derived stem cells (ASCs) were isolated from BDIX rats and were transfected with green fluorescent protein (GFP) for cell tracking. Biosutures (sutures covered with ASCs) were prepared with 1.5 x 10 6 GFP-ASCs, and solutions of 10 6 GFP-ASCs in normal saline were prepared for injection. Anorectal normal anatomy was studied on Wistar and BDIX female rats. Then, we designed an anal sphincter injury model consisting of a 1-cm extra-mucosal miotomy beginning at the anal verge in the anterior middle line. The sphincter lesion was confirmed with conventional histology (hematoxylin and eosin) and immunofluorescence with 4', 6-diamidino-2-phenylindole (commonly known as DAPI), GFP and α-actin. Functional effect was assessed with basal anal manometry, prior to and after injury. After sphincter damage, 36 BDIX rats were randomized to three groups for: (1) Cell injection without repair; (2) biosuture repair; and (3) conventional suture repair and cell injection. Functional and safety studies were conducted on all the animals. Rats were sacrificed after 1, 4 or 7 d. Then, histological and immunofluorescence studies were performed on the surgical area. With the described protocol, biosutures had been covered with at least 820000-860000 ASCs, with 100% viability. Our studies demonstrated that some ASCs remained adhered after suture passage through the muscle. Morphological assessment showed that the rat anal anatomy is comparable with human anatomy; two sphincters are present, but the external sphincter is poorly developed. Anal sphincter pressure data showed spontaneous, consistent, rhythmic anal contractions, taking the form of "plateaus" with multiple twitches (peaks) in each pressure wave. These basal contractions were very heterogeneous; their frequency was 0.91-4.17 per min (mean 1.6980, SD 0.57698), their mean duration was 26.67 s and mean number of peaks was 12.53. Our morphological assessment revealed that with the aforementioned surgical procedure, both sphincters were completely sectioned. In manometry, the described activity disappeared and was replaced by a gentle oscillation of basal line, without a recognizable pattern. Surprisingly, these findings appeared irrespective of injury repair or not. ASCs survived in this potentially septic area for 7 d, at least. We were able to identify them in 84% of animals, mainly in the muscular section area or in the tissue between the muscular endings. ASCs formed a kind of "conglomerate" in rats treated with injections, while in the biosuture group, they wrapped the suture. ASCs were also able to migrate to the damaged zone. No relevant adverse events or mortality could be related to the stem cells in our study. We also did not find unexpected tissue growths. The proposed procedure produces a consistent sphincter lesion. Biosutures and injections are suitable for cell delivery. ASCs survive and are completely safe in this clinical setting.

Three-Dimensional Endoanal Ultrasound Features of the Anal Sphincter in Asian Primigravidae.

PubMed

Wickramasinghe, Dakshitha Praneeth; Senaratne, Supun; Senanayake, Hemantha; Samarasekera, Dharmabandu Nandadeva

2018-04-17

The normal parameters of 3-dimensional endoanal ultrasound (3DEAUS) of the anal sphincter have not been reported for primigravidae or pregnant women at present. 3DEAUS parameters in Asian primigravidae were assessed in this study. We analyzed 3DEAUS data of 101 consecutives Asian primigravidae, assessed in the early third trimester. The assessment was performed with a rigid ultrasonic probe (Olympus ® RU 12M-R1 probe and EU-ME1 ultrasound system (Olympus Corp., Shinjuku, Japan). The Wilcoxon signed-rank test was used to detect the differences in pressure in different quadrants. The participants had a mean age of 24.7 (standard deviation [SD], 5.1) years. The Cleveland Clinic Incontinence Score was normal in all participants. The anal sphincter complex had 3 characteristic segments that were identifiable: upper, middle and lower. The puborectalis muscle was identified as a striated "V"-shaped sling, and its mean thickness was 7.44 (SD, 1.41) mm. The mean thickness of internal (IAS) and external (EAS) sphincters at the mid-sphincter level were 1.78 (SD, 0.59) and 5.49 (SD, 1.21) mm, respectively. The EAS measured 6.02 (SD, 1.07) mm at the lower sphincter level. The statistically significant differences seen in the in quadrants were: the IAS was thicker anteriorly (Z = -2.642; P = .008), the EAS at both midsphincter level (Z = -3.70; P < .001) and lower sphincter level (Z = -7.712; P < .001) was thicker posteriorly, and the IAS was thicker at the 9 o'clock position (Z = -2.081; P = .037). Good symmetry at all 3 levels was seen in the EAS (including the puborectalis muscle). Normal values of 3DEAUS for primigravidae have been identified and may serve as reference values for other laboratories. © 2018 by the American Institute of Ultrasound in Medicine.

Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound.

PubMed

Shek, K L; Guzman-Rojas, R; Dietz, H P

2014-12-01

Obstetric anal sphincter tears are common and an important factor in the etiology of anal incontinence. The objective of the study was to evaluate the prevalence of residual defects of the external anal sphincter (EAS) after primary repair of obstetric anal sphincter injury using four-dimensional (4D) transperineal ultrasound and to correlate sonographic findings of residual defects and levator avulsion with significant symptoms of anal incontinence, defined as St Mark's fecal incontinence score (SMIS) of ≥ 5. This was a retrospective observational study. One-hundred and forty women were seen after primary repair of obstetric anal sphincter tears in a dedicated perineal clinic at a tertiary hospital in Australia. They all underwent a standardized interview, and physical and 4D transperineal ultrasound examination. Mean follow-up interval was 1.9 months after delivery. Eighty-nine (64%) women had a 3a/3b tear, 28 (20%) a 3c/4(th) degree tear and 23 (16%) an unclassified 3(rd) degree tear. Thirty-five (25%) patients reported symptoms of anal incontinence. Nine had an SMIS of ≥ 5. A residual defect was found in 56 (40%) cases and levator avulsion in 27 (19%). On multivariate logistic regression, residual defects (P = 0.03; odds ratio (OR) = 6.38; 95% CI, 1.23-33.0) and levator avulsion (P = 0.047; OR = 4.38; 95% CI, 1.02-18.77) were found to be independent risk factors for anal incontinence. Residual defects of the EAS were found on transperineal ultrasound in 40% of women after primary repair of obstetric anal sphincter injuries. Although most were asymptomatic, residual anal sphincter defects and levator avulsion were associated with significant symptoms of anal incontinence as quantified using the SMIS. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Electrical Stimulation Followed by Mesenchymal Stem Cells Improves Anal Sphincter Anatomy and Function in a Rat Model at a Time Remote From Injury.

PubMed

Sun, Li; Yeh, Judy; Xie, Zhuojun; Kuang, Mei; Damaser, Margot S; Zutshi, Massarat

2016-05-01

We have explored cell-based therapy to aid anal sphincter repair, but a conditioning injury is required to direct stem cells to the site of injury because symptoms usually manifest at a time remote from injury. We aimed to investigate the effect of local electrical stimulation followed by mesenchymal stem cell delivery on anal sphincter regeneration at a time remote from injury. With the use of a rat model, electrical stimulation parameters and cell delivery route were selected based on in vivo cytokine expression and luciferase-labeled cell imaging of the anal sphincter complex. Three weeks after a partial anal sphincter excision, rats were randomly allocated to 4 groups based on different local interventions: no treatment, daily electrical stimulation for 3 days, daily stimulation for 3 days followed by stem cell injection on the third day, and daily electrical stimulation followed by stem cell injection on the first and third days. Histology-assessed anatomy and anal manometry evaluated physiology 4 weeks after intervention. The electrical stimulation parameters that significantly upregulated gene expression of homing cytokines also achieved mesenchymal stem cell retention when injected directly in the anal sphincter complex in comparison with intravascular and intraperitoneal injections. Four weeks after intervention, there was significantly more new muscle in the area of injury and significantly improved anal resting pressure in the group that received daily electrical stimulation for 3 days followed by a single injection of 1 million stem cells on the third day at the site of injury. This was a pilot study and therefore was not powered for functional outcome. In this rat injury model with optimized parameters, electrical stimulation with a single local mesenchymal stem cell injection administered 3 weeks after injury significantly improved both new muscle formation in the area of injury and anal sphincter pressures.

Species differences in the effects of prostaglandins on inositol trisphosphate accumulation, phosphatidic acid formation, myosin light chain phosphorylation and contraction in iris sphincter of the mammalian eye: interaction with the cyclic AMP system.

PubMed

Yousufzai, S Y; Chen, A L; Abdel-Latif, A A

1988-12-01

Comparative studies on the effects of prostaglandins (PGs) on 1,2-diacylglycerol, measured as phosphatidic acid (PA), and inositol trisphosphate (IP3) production, cyclic AMP (cAMP) formation, myosin light chain (MLC) phosphorylation and contraction in the iris sphincter smooth muscle of rabbit, bovine and other mammalian species were undertaken and functional and biochemical relationships between the IP3-Ca++ and cAMP second messenger systems were demonstrated. The findings obtained from these studies can be summarized as follows: 1) all PGs investigated, including PGE2, PGF2 alpha, PGF2 alpha-ester, PGE1 and PGA2 increased IP3 accumulation and PA formation, and the extent of stimulation was dependent on the animal species. Thus, PGF2 alpha-ester (1 microM), the most potent of the PGs, increased IP3 accumulation in rabbit and bovine sphincters by 33 and 58%, respectively, and increased PA formation by 67 and 56%, respectively. The PG increased IP3 accumulation in both rabbit and bovine sphincters very rapidly (T1/2 values about 26 sec) and in a dose-dependent manner. 2) The PG had no effect on MLC phosphorylation in the rabbit sphincter, but it increased that of the bovine by 36%. 3) The PG increased cAMP formation by 75% in the rabbit sphincter but it had no effect on that of the bovine. 4) The PG induced a maximal contractile response in the bovine sphincter but it had no effect on that of the rabbit. 5) In the bovine, PGA2 induced IP3 accumulation and contraction, without an effect on cAMP formation; however, in the rabbit, cat and dog it increased cAMP formation and had no effect on IP3 accumulation and contraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Challenges faced in the clinical application of artificial anal sphincters.

PubMed

Wang, Ming-hui; Zhou, Ying; Zhao, Shuang; Luo, Yun

2015-09-01

Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials.

Long-term outcomes of urinary tract reconstruction in patients with neurogenic urinary tract dysfunction

PubMed Central

Johnson, E. U.; Singh, Gurpreet

2013-01-01

The advent of specialized spinal units and better understanding of the pathophysiology of neurogenic urinary tract dysfunction has made long-term survival of these patients a reality. This has, in turn, led to an increase in quality and choice of management modalities offered to these patients including complex anatomic urinary tract reconstructive procedures tailored to the unique needs of each individual with variable outcomes. We performed a literature review evaluating the long-term outcomes of these reconstructive procedures. To achieve this, we conducted a world-wide electronic literature search of long-term outcomes published in English. As the premise of this review is long-term outcomes, we have focused on pathologies where evidence of long-term outcome is available such as patients with spinal injuries and spina bifida. Therapeutic success following urinary tract reconstruction is usually measured by preservation of renal function, improvement in quality-of-life, the satisfactory achievement of agreed outcomes and the prevention of serious complications. Prognostic factors include neuropathic detrusor overactivity; sphincter dyssynergia; bladder over distension; high pressure storage and high leak point pressures; vesicoureteric reflex, stone formation and urinary tract infections. Although, the past decade has witnessed a reduction in the total number of bladder reconstructive surgeries in the UK, these procedures are essentially safe and effective; but require long-term clinical and functional follow-up/monitoring. Until tissue engineering and gene therapy becomes more mainstream, we feel there is still a place for urinary tract reconstruction in patients with neurogenic lower urinary tract dysfunction. PMID:24235796

Can We Define and Characterize the Aging Lower Urinary Tract?—ICI-RS 2015

PubMed Central

Vahabi, Bahareh; Wagg, Adrian S.; Rosier, Peter F.W.M.; Rademakers, Kevin L.J.; Denys, Marie-Astrid; Pontari, Michel; Lovick, Thelma; Valentini, Francoise A.; Nelson, Pierre P.; Andersson, Karl-Erik; Fry, Christopher H.

2017-01-01

The prevalence of lower urinary tract (LUT) symptoms increases with age but the etiology is unknown. This article aims to identify research directions that clarify the basis of this association. The initial question is whether biological age is the variable of interest or a time-dependent accumulation of factors that impact on LUT function at rates that differ between individuals. In particular, the accumulation of conditions or agents due to inflammatory states or tissue ischemia is important. Much of the above has been concerned with changes to bladder function and morphology. However, the outflow tract function is also affected, in particular changes to the function of external sphincter skeletal muscle and associated sacral motor nerve control. Nocturia is a cardinal symptom of LUT dysfunction and is more prevalent with aging. Urine production is determined by diurnal changes to the production of certain hormones as well as arterial blood pressure and such diurnal rhythms are blunted in subjects with nocturia, but the causal links remain to be elucidated. Changes to the central nervous control of LUT function with age are also increasingly recognized, whether in mid-brain/ brainstem regions that directly affect LUT function or in higher centers that determine psychosocial and emotional factors impinging on the LUT. In particular, the linkage between increasing white matter hyperintensities and LUT dysfunction during aging is recognized but not understood. Overall, a more rational approach is being developed to link LUT dysfunction with factors that accumulate with age, however, the precise causal pathways remain to be characterized. PMID:28444710

Esophageal dysfunction in different stages of Parkinson's disease.

PubMed

Suttrup, I; Suttrup, J; Suntrup-Krueger, S; Siemer, M-L; Bauer, J; Hamacher, C; Oelenberg, S; Domagk, D; Dziewas, R; Warnecke, T

2017-01-01

Dysphagia is a clinically relevant symptom in patients with Parkinson's disease (PD) leading to pronounced reduction in quality of life and other severe complications. Parkinson's disease-related dysphagia may affect the oral and pharyngeal, as well as the esophageal phase of swallowing. To examine the nature and extend of esophageal dysphagia in different stages of PD and their relation to oropharyngeal dysfunction, we examined 65 PD patients (mean age 66.3±9.7 years, mean disease duration 7.9±5.8 years, mean Hoehn & Yahr [H&Y] stage 2.89±0.91) and divided into three groups (early [H&Y I+II; n=21], intermediate [H&Y III; n=25], and advanced stadium [H&Y IV+V; n=19]), using esophageal high-resolution manometry (HRM) to detect esophageal motor disorders. Oropharyngeal impairment was assessed using fiberoptic endoscopic evaluation of swallowing. Major esophageal motor disorders were detected in nearly one third of the PD patients. Minor impairment of the esophageal body was present in 95% of participants and throughout all disease stages with pathological findings especially in peristalsis and intrabolus pressure (IBP). The IBP was found to significantly increase in the advanced stadium. Although dysfunction of the upper and lower esophageal sphincters was observed in individual patients, alterations in these esophageal segments revealed no statistical significance compared with normative data. No clear association was found between the occurrence of oropharyngeal dysphagia and esophageal impairment. Esophageal body impairment in PD is a frequent phenomenon during all disease stages, which possibly reflects α-synucleinopathy in the enteric nervous system. © 2016 John Wiley & Sons Ltd.

Outcome of self-expandable metallic stent deployment in patients with malignant gastroduodenal outlet obstruction and Niti-S and WallFlex comparison: a multicenter retrospective clinical study.

PubMed

Kato, Hironari; Kawamoto, Hirofumi; Matsumoto, Kazuya; Moriyama, Ichiro; Kamada, Hideki; Tsutsumi, Koichiro; Goto, Daisuke; Fukuba, Nobuhiko; Kato, Kiyohito; Sonoyama, Hiroki; Isomoto, Hajime; Okada, Hiroyuki

2016-08-01

Several studies report on the outcomes of self-expandable metallic stents (SEMSs) deployment for malignant gastric outlet obstruction (GOO). However, data was mostly based on the analysis of single-center studies including only a small number of patients. This study aimed to evaluate clinical outcomes after the deployment of SEMS in patients with malignant GOO and to compare the clinical outcomes of two metallic stents with different designs. Altogether 125 consecutive patients from five institutions were included. Clinical outcomes were evaluated according to technical success, clinical success, stent patency period, survival period and complications. A comparison of clinical outcomes between Niti-S pyloric/duodenal and WallFlex duodenal stents was also undertaken. Rates for clinical and technical success were 100% and 92.0%, respectively. The median stent patency and survival periods were 72.0 days (range 3-775 days) and 75.0 days (range 3-775 days), respectively. The rate of overall adverse events was 28.8%. The rate of stent dysfunction was 16.8%, and that of adverse events, except stent dysfunction was 12.0%. Massive bleeding occurred in two patients as a late complication. The clinical success rate for Niti-S stent was significantly higher than that for WallFlex stent (96.2% vs 84.8%, P = 0.023). We successfully deployed a SEMS in malignant GOO. The selection of a SEMS with a lower axial force may be important for patients to resume the oral food intake. Additionally, consideration must be given to the appropriate management of fatal bleeding as a late complication. © 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.

Immediate effects of endoscopic sphincterotomy on sphincter of Oddi motility.

PubMed

Błaut, U; Marecik, J; Gniady, J; Laskiewicz, J; Thor, P J

2000-01-01

The evidence exists that incomplete sphincterotomy in patients with biliary tract diseases may result in early symptoms reoccurrence or lack of improvement. Sphincter of Oddi manometry (SOM) can be used to verify the completeness of the procedure. The purpose of the study was to investigate the immediate effects of biliary endoscopic sphincterotomy (BES) and common bile duct stones (CBDS) clearance on biliary sphincter of Oddi (SO) motility. Moreover the percentage of incomplete sphincterotomies was estimated. 26 patients (6 male, 20 female, 24-93 years) with confirmed choledocholithiasis were investigated. All underwent BES followed by CBDS extraction, and then SO manometry (SOM) was performed. Moreover 6 patients underwent SOM prior to BES. SOM was performed with a triple lumen 5 Fr catheter attached to the water perfused low compliance system. Immediately after sphincterotomy and extraction of the CBDS common bile duct pressure dropped from a mean of 10.9 mmHg to 2.9 mmHg (p < 0.05). Similarly basal biliary sphincter pressure decreased from 22.7 mmHg to 7.3 mmHg (p < 0.05). 20 patients presented duodeno-choledochal gradient of less than 5 mmHg. However only 10 patients had also basal sphincter pressure lower than 5 mmHg. The phasic sphincter activity was abolished in 16 patients, whereas phasic contractions persisted in 10 patients. Seven patients displayed uncoordinated, low amplitude contractility. BES significantly decreases SO and CBD pressures, but when performed for CBDS extraction, commonly does not abolish SO motor activity nor ablate choledocho-duodenal gradient. Therefore to confirm the completeness of sphincterotomy, SO manometry is recommended.

Paradoxical sphincter contraction is rarely indicative of anismus.

PubMed

Voderholzer, W A; Neuhaus, D A; Klauser, A G; Tzavella, K; Müller-Lissner, S A; Schindlbeck, N E

1997-08-01

Anismus is thought to be a cause of chronic constipation by producing outlet obstruction. The underlying mechanism is paradoxical contraction of the anal sphincter or puborectalis muscle. However, paradoxical sphincter contraction (PSC) also occurs in healthy controls, so anismus may be diagnosed too often because it may be based on a non-specific finding related to untoward conditions during the anorectal examination. To investigate the pathophysiological importance of PSC found at anorectal manometry in constipated patients and in patients with stool incontinence. Digital rectal examination and anorectal manometry were performed in 102 chronically constipated patients, 102 patients with stool incontinence, and in 18 controls without anorectal disease. In 120 of the 222 subjects defaecography was also performed. Paradoxical sphincter contraction was defined as a sustained increase in sphincter pressure during straining. Anismus was assumed when PSC was present on anorectal manometry and digital rectal examination and the anorectal angle did not widen on defaecography. Manometric PSC occurred about twice as often in constipated patients as in incontinent patients (41.2% versus 25.5%, p < 0.017) and its prevalence was similar in incontinent patients and controls (25.5% versus 22.2%). Oroanal or rectosigmoid transit times in constipated patients with and without PSC did not differ significantly (total 64.6 (8.9) hours versus 54.2 (8.1) hours; rectosigmoid 14.9 (2.4) hours versus 13.8 (2.5) hours). Paradoxical sphincter contraction is a common finding in healthy controls as well as in patients with chronic constipation and stool incontinence. Hence, PSC is primarily a laboratory artefact and true anismus is rare.

Regenerative medicine provides alternative strategies for the treatment of anal incontinence.

PubMed

Gräs, Søren; Tolstrup, Cæcilie Krogsgaard; Lose, Gunnar

2017-03-01

Anal incontinence is a common disorder but current treatment modalities are not ideal and the development of new treatments is needed. The aim of this review was to identify the existing knowledge of regenerative medicine strategies in the form of cellular therapies or bioengineering as a treatment for anal incontinence caused by anal sphincter defects. PubMed was searched for preclinical and clinical studies in English published from January 2005 to January 2016. Animal studies have demonstrated that cellular therapy in the form of local injections of culture-expanded skeletal myogenic cells stimulates repair of both acute and 2 - 4-week-old anal sphincter injuries. The results from a small clinical trial with ten patients and a case report support the preclinical findings. Animal studies have also demonstrated that local injections of mesenchymal stem cells stimulate repair of sphincter injuries, and a complex bioengineering strategy for creation and implantation of an intrinsically innervated internal anal sphincter construct has been successfully developed in a series of animal studies. Cellular therapies with myogenic cells and mesenchymal stem cells and the use of bioengineering technology to create an anal sphincter are new potential strategies to treat anal incontinence caused by anal sphincter defects, but the clinical evidence is extremely limited. The use of culture-expanded autologous skeletal myogenic cells has been most intensively investigated and several clinical trials were ongoing at the time of this report. The cost-effectiveness of such a therapy is an issue and muscle fragmentation is suggested as a simple alternative.

The identification of specialized pacemaking cells in the anal sphincters.

PubMed

Shafik, Ahmed; El Sibai, Olfat; Ahmed, Ismail

2006-07-01

Interstitial cells of Cajal (ICC) are claimed to generate the electrical activity in the colon and stomach. As the external (EAS) and internal (IAS) anal sphincters exhibit resting electrical activity, we hypothesized the presence of ICC in these sphincters. This hypothesis was investigated in the current study. Specimens from the EAS and IAS were taken from normal areas of the anorectum which had been surgically excised by abdominoperineal operation for rectal cancer of 28 patients (16 men, 12 women, mean age 42.2+/-4.8 years). The specimens were subjected to c-kit immunohistochemistry. Controls for the specificity of the antisera consisted of tissue incubation with normal rabbit serum substituted for the primary antiserum. Fusiform, c-kit positive, ICC-like cells were detected in the anal sphincters; they had dendritic processes. They were clearly distinguishable from the non-branching, c-kit negative smooth and striated muscle cells of the anal sphincters. The specimens contained also c-kit positive mast cells, but they had a rounded body with no dendritic processes. Immunoreactivity was absent in negative controls in which the primary antibody was omitted. We have identified, for the first time, cells in EAS and IAS with morphological and immunological phenotypes similar to ICCs of the gut. These cells appear to be responsible for initiating the slow waves recorded from the anal sphincters and for controlling their activity. A deficiency or absence of these cells may affect the anal motile activity. Studies are needed to explore the role of these cells in anal motility disorders.

Morphologic changes of the anal sphincter musculature during and after temporary stool deviation.

PubMed

Sailer, M; Fein, M; Fuchs, K H; Bussen, D; Grun, C; Thiede, A

2001-04-01

Temporary stool deviation, using a stoma, is a well-known surgical principle to protect low colorectal or coloanal anastomoses. The purpose of this study was to evaluate any morphologic changes with regard to the anal sphincter muscles during and after temporary ileostomy. Forty-four patients with rectal carcinomas were studied prospectively. All patients underwent low anterior resection. Reconstruction was performed using either a coloanal pouch or a straight end-to-end anastomosis. A protective stoma was fashioned in all 44 patients (ileostomy n=41; colostomy n=3). Stoma closure was carried out after a median of 85 days (41-330 days). Using a standard protocol, anal-sphincter thickness [m. puborectalis, external anal sphincter (EAS) and internal anal (IAS) sphincter] was assessed by means of endoanal ultrasonography preoperatively, at the time of stoma closure, and every 3 months thereafter for 1 year. The diameter of the puborectal muscle decreased from a median preoperative value of 6.3 mm to 5.7 mm at the time of stoma closure (P=0.03). After 3 months, 6.2 mm was measured. This value remained stable for the complete follow-up period. Similar results were recorded for the EAS. The IAS thickness remained stable throughout the study period, measuring between 2.1 mm and 2.4 mm. Temporary stool deviation does lead to morphologic changes of the anal sphincter. While the smooth muscle remains unchanged, the striated counterpart undergoes atrophic transformation. However, after passage reconstruction, i.e., stoma closure, a rapid regeneration of the voluntary muscles is observed.

Effect of hemorrhoidectomy on anorectal physiology.

PubMed

Vyslouzil, Kamil; Zboril, Pavel; Skalický, Pavel; Vomácková, Katherine

2010-02-01

The aim of this study was to determine whether overactivity of the anal sphincter in patients with hemorhhoids is primary or secondary and thus assess indication of lateral internal sphincterotomy to surgical treatment of hemorrhoids. Tonic contraction of the sphincter muscle in patients with advanced stages of hemorrhoids is considered by many authors as a primary cause, and therefore, they complete hemorrhoid surgery with lateral internal sphincteroomy. If hypertension of anal sphincter is secondary during hemorrhoid disease, lateral internal sphincterotomy is not indicated. Although examinations made immediately after sphincterotomy proved no changes of anal continence, certain sequelae of lateral internal sphincterotomy cannot be excluded and may later negatively affect patient's anal continence. The prospective study comprised 385 patients treated in 2002-2006 by Hemoron or surgery according to Milligan-Morgan or Longo. Patients with history of another disease of the anal canal, radiotherapy of pelvis, Crohn's disease or ulcerous colitis were excluded. Manometry was performed before and after surgery at intervals of 1, 3, 6 and 12 months after operation using a perfusion flow method, six-channels catheter with radial arrangement of channel tips. In all three groups (Hemoron, sec. Milligan-Morgan, sec. Longo), there were 60-65% of patients with third degree hemorrhoids. Normal resting anal pressure before surgery was recorded in only 25% of men and 30% of women. Patients with advanced hemorrhoid degrees were found to have significant hypertension of the anal sphincter. The most significantly improved state of sphincter overactivity was observed after surgery according to Longo and application of Hemoron. After surgery, according to Milligan-Morgan, recovery of anal sphincter tension was the longest; even 6 months after operation, a mean increased resting anal pressure persisted (91-110 mmHg) in 25% of men and 19% of women. After 12 months, recovery of anal tension occurred in this group also--mean increased anal pressure was recorded in only three patients (1.67%). Overactivity of the anal sphincter in patients with hemorrhoids is secondary and according to our results. Hypertension of the sphincter muscle in patients with hemorrhoids is significantly increased in patients with advanced degrees of hemorrhoids. Therefore, it is not recommended to postpone surgery and indicate patients with advanced degrees of hemorrhoids to hemorrhoidectomy.

Species differences in the effects of substance P on inositol trisphosphate accumulation and cyclic AMP formation, and on contraction in isolated iris sphincter of the mammalian eye: differences in receptor density.

PubMed

Tachado, S D; Akhtar, R A; Yousufzai, S Y; Abdel-Latif, A A

1991-12-01

The effects of substance P (SP) on inositol trisphosphate (IP3) accumulation, myosin light chain (MLC) phosphorylation, cAMP formation and contraction were studied in iris sphincter smooth muscle of different mammalian species. SP receptor density was also examined in membrane fractions from this tissue. The data obtained can be summarized as follows. (1) In the iris sphincters of rabbit, bovine and pig, SP receptors are coupled to the phospholipase C system, whereas in dog, cat and human these receptors are coupled to the adenylate cyclase system. (2) In those species which employ the phospholipase C system, SP induced IP3 accumulation, MLC phosphorylation and contraction in a dose-dependent manner; in contrast, in those species in which SP induced the formation of cAMP we found the neuropeptide to cause muscle relaxation. The findings on cAMP formation in intact tissue were confirmed in iris sphincter membranes. Both the effect of SP on IP3 accumulation in rabbit and bovine sphincters and its effect on cAMP formation in the dog were blocked by the SP antagonist, (D-Pro2, D-Trp7, 9)-SP. (3) The density of SP receptors in rabbit, bovine and dog were found to be 227, 110.9 and 13.6 fmol mg-1 protein, respectively, and the Kd values were 1.9, 1.8 and 1.3 nM, respectively. (4) Of the neuropeptides investigated SP, neurokinin A and neurokinin B had significant stimulatory effects on IP3 accumulation and on contraction in the rabbit iris sphincter; however, neither neurokinin Y nor the calcitonin gene-related peptide (CGRP) had any effect on these responses. In addition, none of the neuropeptides studied had any effect on IP3 or on contraction in the dog iris sphincter. While it is possible that SP may have dual actions, with the predominant action dependent on the species, the data presented could suggest the presence of two SP receptor subtypes, one coupled to phospholipase C and the other to adenylate cyclase. The results of this investigation indicate major species differences in biochemical and functional responsiveness to SP and in SP receptor density in the iris sphincter of the mammalian eye, and support a modulatory role for the neuropeptide in muscle response in this tissue.

Neuromodulatory changes in short-term synaptic dynamics may be mediated by two distinct mechanisms of presynaptic calcium entry.

PubMed

Oh, Myongkeun; Zhao, Shunbing; Matveev, Victor; Nadim, Farzan

2012-12-01

Although synaptic output is known to be modulated by changes in presynaptic calcium channels, additional pathways for calcium entry into the presynaptic terminal, such as non-selective channels, could contribute to modulation of short term synaptic dynamics. We address this issue using computational modeling. The neuropeptide proctolin modulates the inhibitory synapse from the lateral pyloric (LP) to the pyloric dilator (PD) neuron, two slow-wave bursting neurons in the pyloric network of the crab Cancer borealis. Proctolin enhances the strength of this synapse and also changes its dynamics. Whereas in control saline the synapse shows depression independent of the amplitude of the presynaptic LP signal, in proctolin, with high-amplitude presynaptic LP stimulation the synapse remains depressing while low-amplitude stimulation causes facilitation. We use simple calcium-dependent release models to explore two alternative mechanisms underlying these modulatory effects. In the first model, proctolin directly targets calcium channels by changing their activation kinetics which results in gradual accumulation of calcium with low-amplitude presynaptic stimulation, leading to facilitation. The second model uses the fact that proctolin is known to activate a non-specific cation current I ( MI ). In this model, we assume that the MI channels have some permeability to calcium, modeled to be a result of slow conformation change after binding calcium. This generates a gradual increase in calcium influx into the presynaptic terminals through the modulatory channel similar to that described in the first model. Each of these models can explain the modulation of the synapse by proctolin but with different consequences for network activity.

Organ differences in the impact of p27(kip1) deficiency on carcinogenesis induced by N-methyl-N-nitrosourea.

PubMed

Ogawa, Kumiko; Murasaki, Toshiya; Sugiura, Satoshi; Nakanishi, Makoto; Shirai, Tomoyuki

2013-06-01

To evaluate the impact of p27 on carcinogenesis in various organs, N-methyl-N-nitrosourea (MNU), a direct-acting alkylating agent, was given to p27 knock-out mice. Groups of 20-40 male and female mice with null, hetero- or wild-type p27 alleles were given drinking water containing 240 ppm MNU or distilled water every other week for five cycles. The incidence and multiplicity of the induced proliferative lesions were then histologically evaluated at weeks 14 and 20. MNU treatment induced various lesions including squamous hyperplasia and squamous cell carcinoma in the forestomach, atypical hyperplasia and adenocarcinomas in the fundic and pyloric glands, adenomas and adenocarcinomas in the duodenum, malignant lymphomas in the thymus, liver, kidney and spleen and alveolar hyperplasia, adenomas, adenocarcinomas and malignant lymphomas in the lung. Although the incidences of the lesions in the forestomach, fundic and pyloric glands did not differ among the p27 genotypes, those of alveolar hyperplasia of the lung and malignant lymphoma of the thymus were significantly increased in p27-null males as compared with both wild- and hetero-type animals. Moreover, in both p27(+/+) and p27(+/-) cases, the rates for p27-positive cells were obviously increased in proliferative lesions of the pyloric gland and the lung. However, an increased rate of p27-positive cells was not observed in malignant lymphoma of the thymus. These findings suggest that p27 does not control the cell cycle equally in all organs affected by MNU-induced carcinogenesis. Copyright © 2011 John Wiley & Sons, Ltd.

Characterization of the binding specificity of Anguilla anguilla agglutinin (AAA) in comparison to Ulex europaeus agglutinin I (UEA-I).

PubMed

Baldus, S E; Thiele, J; Park, Y O; Hanisch, F G; Bara, J; Fischer, R

1996-08-01

Using immunochemical and immunohistochemical methods, the binding site of Anguilla anguilla agglutinin (AAA) was characterized and compared with the related fucose-specific lectin from Ulex europaeus (UEA-I). In solid-phase enzyme-linked immunoassays, the two lectins recognized Fuc alpha 1-2Gal beta-HSA. AAA additionally cross-reacted with neoglycolipids bearing lacto-N-fucopentaose (LNFP) I [H type 1] and II [Le(a)] and lactodifucotetraose (LDFT) as glycan moieties. UEA-I, on the other hand, bound to a LDFT-derived neoglycolipid but not to the other neoglycolipids tested. Binding of AAA to gastric mucin was competitively neutralized by Le(a)-specific monoclonal antibodies. UEA-I binding, on the other hand, was reduced after co-incubation with H type 2- and Le(y)-specific monoclonal antibodies. According to our results, AAA reacts with fucosylated type 1 chain antigens, whereas UEA-I binds only to the alpha 1-2-fucosylated LDFT-derived neoglycolipid. In immunohistochemical studies, the reactivity of AAA and UEA-I in normal pyloric mucosa from individuals with known Lewis and secretor status was analysed. AAA showed a broad reaction in the superficial pyloric mucosa from secretors and non-secretors, but AAA reactivity was more pronounced in Le(a+b-) individuals. On the other hand, UEA-I stained the superficial pyloric mucosa only from secretor individuals. A staining of deep mucous glands by the lectins was found in all specimens. Both reacted with most human carcinomas of different origin. Slight differences in their binding pattern were observed and may be explained by the different fine-specificities of the lectins.

The frequency preference of neurons and synapses in a recurrent oscillatory network.

PubMed

Tseng, Hua-an; Martinez, Diana; Nadim, Farzan

2014-09-17

A variety of neurons and synapses shows a maximal response at a preferred frequency, generally considered to be important in shaping network activity. We are interested in whether all neurons and synapses in a recurrent oscillatory network can have preferred frequencies and, if so, whether these frequencies are the same or correlated, and whether they influence the network activity. We address this question using identified neurons in the pyloric network of the crab Cancer borealis. Previous work has shown that the pyloric pacemaker neurons exhibit membrane potential resonance whose resonance frequency is correlated with the network frequency. The follower lateral pyloric (LP) neuron makes reciprocally inhibitory synapses with the pacemakers. We find that LP shows resonance at a higher frequency than the pacemakers and the network frequency falls between the two. We also find that the reciprocal synapses between the pacemakers and LP have preferred frequencies but at significantly lower values. The preferred frequency of the LP to pacemaker synapse is correlated with the presynaptic preferred frequency, which is most pronounced when the peak voltage of the LP waveform is within the dynamic range of the synaptic activation curve and a shift in the activation curve by the modulatory neuropeptide proctolin shifts the frequency preference. Proctolin also changes the power of the LP neuron resonance without significantly changing the resonance frequency. These results indicate that different neuron types and synapses in a network may have distinct preferred frequencies, which are subject to neuromodulation and may interact to shape network oscillations. Copyright © 2014 the authors 0270-6474/14/3412933-13$15.00/0.

Genetics Home Reference: epidermolysis bullosa with pyloric atresia

MedlinePlus

... PubMed Pulkkinen L, Uitto J. Mutation analysis and molecular genetics of epidermolysis bullosa. Matrix Biol. 1999 Feb;18( ... Sadowski S, Pfendner E, Uitto J. Epidermolysis bullosa. I. Molecular genetics of the junctional and hemidesmosomal variants. J Med ...

Laparoscopic insertion of artificial periprostatic urinary sphincter.

PubMed

Gamé, Xavier; Bram, Raphael; Abu Anz, Sami; Doumerc, Nicolas; Guillotreau, Julien; Malavaud, Bernard; Rischmann, Pascal

2009-02-01

The objective of this case report is to describe the laparoscopic insertion of an artificial periprostatic urinary sphincter. We report the case of a paraplegic patient in whom an artificial urinary sphincter was inserted in a periprostatic position by way of laparoscopy to treat stress urinary incontinence. In addition to laparoscopy being minimally invasive, its advantages include the excellent quality of retroprostatic dissection and the perfect visualization it gives at the level of cuff positioning with respect to the anatomic landmarks. It is more appropriate to be able to cleave the interprostatorectal space to ensure passage of the cuff under perfectly safe conditions.

Comment on "A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial".

PubMed

El-Said, Mohammed Mohammed; Emile, Sameh Hany

2018-04-25

In the study by Sarveazad et al. adipose tissue-derived stem cells were injected to reinforce anal sphincter repair. The authors came to the conclusion that injection of stem cells during repair surgery for fecal incontinence may cause replacement of fibrous tissue, which may be a key point in treatment of fecal incontinence. The authors emphasized in their "Discussion" section that the ability of stem cells to differentiate into muscle fibers, replacing the fibrous tissue at the site of repair, is their main action, which may not be accurate. We think that healing of repaired anal sphincter begins with granulation tissue formation, which then matures into fibrous tissue that becomes infiltrated by muscle fibers from the approximated cut ends of the sphincter, resulting in regain of sphincter muscle continuity. This is supported by many experimental studies that have evaluated local injection of stem cells during sphincteroplasty in rats and shown that the injected stem cells do not differentiate into muscle fibers but may induce healing by a strong fibrous tissue. Further studies are needed to determine the main mechanism of action of mesenchymal stems cells in augmenting anal sphincter repair.

A 20-year follow-up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury.

PubMed

Abdul-Rahman, Ahmad; Ismail, Soran; Hamid, Rizwan; Shah, Julian

2010-11-01

To assess the long-term (20 years) effectiveness of the UroLume wallstent(TM) (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in patients with spinal cord injury (SCI). Twelve patients with quadriplegia secondary to SCI underwent external striated sphincter stenting with the UroLume wallstent in place of sphincterotomy for DESD ≈ 20 years ago. The mean (range) age was 41.8 (26-65) years. Eleven patients had cervical level injury whilst one had a thoracic injury. All the patients were shown to have high-pressure neurogenic detrusor overactivity and DESD with incomplete emptying on preoperative video-cystometrograms (VCMG). Six of the 12 patients have now been followed-up for a mean (range) of 20 (19-21) years. Of the remaining six, two were lost to follow-up at 1 and 3 years, but both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within 1 year of insertion. Another patient with an adequately functioning stent died 7 years after stent insertion from a chest infection. The twelfth patient developed bladder cancer 14 years after stent insertion and underwent cystectomy with urinary diversion. VCMG follow-up of the six patients showed a significantly sustained reduction of maximum detrusor pressure and duration of detrusor contraction at the 20-year follow-up. Five of these six patients developed bladder neck dyssynergia of varying degrees as shown on VCMG within the first 9 years of follow-up. All were successfully treated with bladder neck incision (BNI) where the last BNI needed was at 12 years. We did not encounter any problem with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. Urethral stenting using the UroLume wallstent is effective in the management of DESD in patients with SCI and provides an acceptable long-term (20-year follow-up) alternative to sphincterotomy. The failures manifest within the first few years and can be managed easily with stent removal without any significant problems. Bladder neck dyssynergia was the long-term complication which was treated successfully with BNI. It has no significant interference with erectile function, being reversible, minimally invasive and has a shorter hospital stay. © 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.

Combined cystometrography and electromyography of the external urethral sphincter following complete primary repair of bladder exstrophy.

PubMed

Borer, Joseph G; Strakosha, Ruth; Bauer, Stuart B; Diamond, David A; Pennison, Melanie; Rosoklija, Ilina; Khoshbin, Shahram

2014-05-01

Concern in patients with bladder exstrophy after reconstruction regarding potential injury to pelvic neurourological anatomy and a resultant functional deficit prompted combined (simultaneous) cystometrography and electromyography after complete primary repair of bladder exstrophy. We determined whether complete primary repair of bladder exstrophy would adversely affect the innervation controlling bladder and external urethral sphincter function. Complete primary repair of bladder exstrophy was performed via a modified Mitchell technique in newborns without osteotomy. Postoperative evaluation included combined cystometrography and needle electrode electromyography via the perineum, approximating the external urethral sphincter muscle complex. Electromyography was done to evaluate the external urethral sphincter response to sacral reflex stimulation and during voiding. Nine boys and 4 girls underwent combined cystometrography/electromyography after complete primary repair of bladder exstrophy. Age at study and time after complete primary repair of bladder exstrophy was 3 months to 10 years (median 11.5 months). Cystometrography revealed absent detrusor overactivity and the presence of a sustained detrusor voiding contraction in all cases. Electromyography showed universally normal individual motor unit action potentials of biphasic pattern, amplitude and duration. The external urethral sphincter sacral reflex response was intact with a normal caliber with respect to Valsalva, Credé, bulbocavernosus and anocutaneous (bilateral) stimulation. Synergy was documented by abrupt silencing of external urethral sphincter electromyography activity during voiding. After complete primary repair of bladder exstrophy combined cystometrography/electromyography in patients with bladder exstrophy showed normal neurourological findings, including sacral reflex responses, sustained detrusor voiding contraction and synergic voiding, in all patients postoperatively. These findings confirm the safety of complete primary repair of bladder exstrophy. Based on our results we have discontinued routine electromyography in these patients. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Manometric Changes to the Lower Esophageal Sphincter After Magnetic Sphincter Augmentation in Patients With Chronic Gastroesophageal Reflux Disease.

PubMed

Warren, Heather F; Louie, Brian E; Farivar, Alexander S; Wilshire, Candice; Aye, Ralph W

2017-07-01

To evaluate the manometric changes, function, and impact of magnetic sphincter augmentation (MSA) on the lower esophageal sphincter (LES). Implantation of a MSA around the gastroesophageal junction has been shown to be a safe and effective therapy for gastroesophageal reflux disease, but its effect on the LES has not been elucidated. Retrospective case control study (n = 121) evaluating manometric changes after MSA. Inclusion criteria consisted of a confirmed diagnosis of gastroesophageal reflux disease by an abnormal esophageal pH study (body mass index <35 kg/m, hiatal hernia <3 cm, and absence of endoscopic Barrett disease). Manometric changes, pH testing, and proton pump inhibitor use were assessed preoperatively and 6 and 12 months after MSA. MSA was associated with an overall increase in the median LES resting pressure (18 pre-MSA vs 23 mm Hg post-MSA; P = 0.0003), residual pressure (4 vs 9 mm Hg; P < 0.0001), and distal esophageal contraction amplitude (80 vs 90 mm Hg; P = 0.02). The percent peristalsis remained unaltered (94% vs 87%; P = 0.71).Overall, patients with a manometrically defective LES were restored 67% of the time to a normal sphincter with MSA. Those with a structurally defective or severely defective LES improved to a normal LES in 77% and 56% of patients, respectively. Only 18% of patients with a normal preoperative manometric LES deteriorated to a lower category. MSA results in significant manometric improvement of the LES without apparent deleterious effects on the esophageal body. A manometrically defective LES can be restored to normal sphincter, whereas a normal LES remains stable.

Study of pelvic floor and sphincter muscles in congenital pouch colon with the help of three-dimensional CT scan.

PubMed

Maletha, Madhukar; Kureel, S N; Khan, Tanvir Roshan; Wakhlu, Ashish

2010-12-01

Congenital pouch colon (CPC) is a pouch-like dilatation of shortened colon associated with anorectal malformation (ARM). The disease is prevalent in northern India. Postoperatively, the continence results are not as good as in other ARMs and there is higher incidence of incontinence and perineal soiling in these patients. The present study aimed to evaluate the pelvic floor and sphincter muscle characteristics in patients of CPC with the help of 64-slice computerized tomography with three-dimensional (3D) volumetric reconstructions of images, thus, to know the overall quality of these muscles in the patients. The study was conducted in patients admitted over a period of July 2007 to November 2008 in our department. Totally, eight patients of CPC were subjected to 64-slice CT with three-dimensional reconstructions of images and different parameters such as quality of pelvic floor muscles, configuration of vertical and parasagittal fibres, shape and thickness of sphincter muscle complex, attenuation values of sphincters were studied. The 3D reconstructed images of pelvis in patients of CPC showed a well-developed pelvic floor and sphincter muscle complex. The length of the parasagittal fibres, transverse width of the vertical fibres and CT attenuation values of these structures with overall muscle quality were found to be good in these patients. In cases of CPC, the pelvic floor muscles including striated muscle complex (vertical and parasagittal fibres) are well developed. Higher rates of incontinence and soiling in CPC are not because of poorly developed pelvic floor and sphincter muscles. Three-dimensional CT can also provide important anatomical information that can help the operating surgeon while performing surgery.

Functional Outcome of Human Adipose Stem Cell Injections in Rat Anal Sphincter Acute Injury Model

PubMed Central

Juntunen, Miia; Narra Girish, Nathaniel; Tuominen, Heikki; Huhtala, Heini; Nieminen, Kari; Hyttinen, Jari; Miettinen, Susanna

2018-01-01

Abstract Anal incontinence is a devastating condition that significantly reduces the quality of life. Our aim was to evaluate the effect of human adipose stem cell (hASC) injections in a rat model for anal sphincter injury, which is the main cause of anal incontinence in humans. Furthermore, we tested if the efficacy of hASCs could be improved by combining them with polyacrylamide hydrogel carrier, Bulkamid. Human ASCs derived from a female donor were culture expanded in DMEM/F12 supplemented with human platelet lysate. Female virgin Sprague‐Dawley rats were randomized into four groups (n = 14–15/group): hASCs in saline or Bulkamid (3 × 105/60 μl) and saline or Bulkamid without cells. Anorectal manometry (ARM) was performed before anal sphincter injury, at two (n = 58) and at four weeks after (n = 33). Additionally, the anal sphincter tissue was examined by micro‐computed tomography (μCT) and the histological parameters were compared between the groups. The median resting and peak pressure during spontaneous contraction measured by ARM were significantly higher in hASC treatment groups compared with the control groups without hASCs. There was no statistical difference in functional results between the hASC‐carrier groups (saline vs. Bulkamid). No difference was detected in the sphincter muscle continuation between the groups in the histology and μCT analysis. More inflammation was discovered in the group receiving saline with hASC. The hASC injection therapy with both saline and Bulkamid is a promising nonsurgical treatment for acute anal sphincter injury. Traditional histology combined with the 3D μCT image data lends greater confidence in assessing muscle healing and continuity. Stem Cells Translational Medicine 2018;7:295–304 PMID:29383878

Pyloric Stenosis (For Parents)

MedlinePlus

... poops) over a period of 1 or 2 days show signs of dehydration, such as more than 4 to 6 hours between wet diapers, a sunken "soft spot" on the head, or sunken eyes Reviewed by: J. Fernando del Rosario, MD Date reviewed: March 2017 ...

Immunocytochemical evidence for PDBu-induced activation of RhoA/ROCK in human internal anal sphincter smooth muscle cells

PubMed Central

Singh, Jagmohan; Maxwell, Pinckney J.

2011-01-01

Studies were performed to determine the unknown status of PKC and RhoA/ROCK in the phorbol 12,13-dibutyrate (PDBu)-stimulated state in the human internal anal sphincter (IAS) smooth muscle cells (SMCs). We determined the effects of PDBu (10−7 M), the PKC activator, on PKCα and RhoA and ROCK II translocation in the human IAS SMCs. We used immunocytochemistry and fluorescence microcopy in the basal state, following PDBu, and before and after PKC inhibitor calphostin C (10−6 M), cell-permeable RhoA inhibitor C3 exoenzyme (2.5 μg/ml), and ROCK inhibitor Y 27632 (10−6 M). We also determined changes in the SMC lengths via computerized digital micrometry. In the basal state PKCα was distributed almost uniformly throughout the cell, whereas RhoA and ROCK II were located in the higher intensities toward the periphery. PDBu caused significant translocation of PKCα, RhoA, and ROCK II. PDBu-induced translocation of PKCα was attenuated by calphostin C and not by C3 exoenzyme and Y 27632. However, PDBu-induced translocation of RhoA was blocked by C3 exoenzyme, and that of ROCK II was attenuated by both C3 exoenzyme and Y 27632. Contraction of the human IAS SMCs caused by PDBu in parallel with RhoA/ROCK II translocation was attenuated by C3 exoenzyme and Y 27632 but not by calphostin C. In human IAS SMCs RhoA/ROCK compared with PKC are constitutively active, and contractility by PDBu is associated with RhoA/ROCK activation rather than PKC. The relative contribution of RhoA/ROCK vs. PKC in the pathophysiology and potential therapy for the IAS dysfunction remains to be determined. PMID:21566015

Association between symptoms of sleep-disordered breathing and speech in children with craniofacial malformations.

PubMed

Moraleda-Cibrián, Marta; Berger, Mary; Edwards, Sean P; Kasten, Steven J; Buchman, Steven R; O'Brien, Louise M

2014-06-15

Sleep-disordered breathing (SDB) and speech difficulties are common problems in children with craniofacial malformations (CFM). The present study was designed to investigate whether resonance issues identified during speech assessment are associated with parental report of SDB symptoms in children with CFM. Children aged 2-18 years with congenital CFM attending at the Craniofacial Anomalies Program from March 2007 to April 2011 were screened for SDB symptoms using the Sleep-Related Breathing Disturbance Scale of the Pediatric Sleep Questionnaire. Speech evaluation, based on the Pittsburgh Weighted Speech Scale score, was the tool used to investigate velopharyngeal dysfunction (VPD) based on speech perceptual assessment. A total of 488 children with congenital CFM were included. Overall 81% were Caucasian and 24% were overweight/obese. Twenty-four percent of children screened positive for SDB and 35% had VPD. Children with VPD were no more likely to screen positive for SDB than children without VPD (26% vs. 23%, p = 0.38). However, children with previous sphincter pharyngoplasty (SP) were more likely to have hyponasality (51% vs. 12%, p = 0.0001) and reduced or absent nasal emission (33% vs. 16%, p = 0.008). In a logistic regression, the adjusted odds ratio for SDB for those with hyponasality was 2.10 (95%CI 1.21-3.61, p = 0.008) and for those with reduced or absent nasal emission was 1.75 (95%CI 1.06-2.88, p = 0.028). Symptoms of sleep disordered breathing are common in children with craniofacial malformations especially if they have undergone sphincter pharyngoplasty; many of these children can be identified by measures of resonance on routine speech evaluation.

A human model of restricted upper esophageal sphincter opening and its pharyngeal and UES deglutitive pressure phenomena

PubMed Central

Jiao, Hongmei; Mei, Ling; Sharma, Tarun; Kern, Mark; Sanvanson, Patrick

2016-01-01

Oropharyngeal dysphagia due to upper esophageal sphincter (UES) dysfunction is commonly encountered in the clinical setting. Selective experimental perturbation of various components of the deglutitive apparatus can provide an opportunity to improve our understanding of the swallowing physiology and pathophysiology. The aim is to characterize the pharyngeal and UES deglutitive pressure phenomena in an experimentally induced restriction of UES opening in humans. We studied 14 volunteers without any dysphagic symptoms (7 men, 66 ± 11 yr) but with various supraesophageal reflux symptoms. To induce UES restriction, we used a handmade device that with adjustment could selectively apply 0, 20, 30, or 40 mmHg pressure perpendicularly to the cricoid cartilage. Deglutitive pharyngeal and UES pressure phenomena were determined during dry and 5- and 10-ml water swallows × 3 for each of the UES perturbations. External cricoid pressure against the UES resulted in a significant increase in hypopharyngeal intrabolus pressure and UES nadir deglutitive relaxation pressure for all tested swallowed volumes (P < 0.05). Application of external cricoid pressure increased the length of the UES high pressure zone from 2.5 ± 0.2 to 3.1 ± 0.2, 3.5 ± 0.1, and 3.7 ± 0.1 cm for 20, 30, and 40 mmHg cricoid pressure, respectively (P < 0.05). External cricoid pressure had no significant effect on pharyngeal peristalsis. On the other hand, irrespective of external cricoid pressure deglutitive velopharyngeal contractile integral progressively increased with increased swallowed volumes (P < 0.05). In conclusion, acute experimental restriction of UES opening by external cricoid pressure manifests the pressure characteristics of increased resistance to UES transsphincteric flow observed clinically without affecting the pharyngeal peristaltic contractile function. PMID:27198193

Bimodal effect of oxidative stress in internal anal sphincter smooth muscle

PubMed Central

Singh, Jagmohan; Kumar, Sumit

2015-01-01

Changes in oxidative stress may affect basal tone and relaxation of the internal anal sphincter (IAS) smooth muscle in aging. We examined this issue by investigating the effects of the oxidative stress inducer 6-anilino-5,8-quinolinedione (LY-83583) in basal as well as U-46619-stimulated tone, and nonadrenergic, noncholinergic (NANC) relaxation in rat IAS. LY-83583, which works via generation of reactive oxygen species in living cells, produced a bimodal effect in IAS tone: lower concentrations (0.1 nM to 10 μM) produced a concentration-dependent increase, while higher concentrations (50–100 μM) produced a decrease in IAS tone. An increase in IAS tone by lower concentrations was associated with an increase in RhoA/Rho kinase (ROCK) activity. This was evident by the increase in RhoA/ROCK in the particulate fractions, in ROCK activity, and in the levels of phosphorylated (p) Thr696-myosin phosphatase target subunit 1 and pThr18/Ser19-20-kDa myosin light chain. Conversely, higher concentrations of LY-83583 produced inhibitory effects on RhoA/ROCK. Interestingly, both the excitatory and inhibitory effects of LY-83583 in the IAS were reversed by superoxide dismutase. The excitatory effects of LY-83583 were found to resemble those with neuronal nitric oxide synthase (nNOS) inhibition by l-NNA, since it produced a significant increase in the IAS tone and attenuated NANC relaxation. These effects of LY-83583 and l-NNA were reversible by l-arginine. This suggests the role of nNOS inhibition and RhoA/ROCK activation in the increase in IAS tone by LY-83583. These data have important implications in the pathophysiology and therapeutic targeting of rectoanal disorders, especially associated with IAS dysfunction. PMID:26138467

Perianal implantation of bioengineered human internal anal sphincter constructs intrinsically innervated with human neural progenitor cells.

PubMed

Raghavan, Shreya; Miyasaka, Eiichi A; Gilmont, Robert R; Somara, Sita; Teitelbaum, Daniel H; Bitar, Khalil N

2014-04-01

The internal anal sphincter (IAS) is a major contributing factor to pressure within the anal canal and is required for maintenance of rectoanal continence. IAS damage or weakening results in fecal incontinence. We have demonstrated that bioengineered, intrinsically innervated, human IAS tissue replacements possess key aspects of IAS physiology, such as the generation of spontaneous basal tone and contraction/relaxation in response to neurotransmitters. The objective of this study is to demonstrate the feasibility of implantation of bioengineered IAS constructs in the perianal region of athymic rats. Human IAS tissue constructs were bioengineered from isolated human IAS circular smooth muscle cells and human enteric neuronal progenitor cells. After maturation of the bioengineered constructs in culture, they were implanted operatively into the perianal region of athymic rats. Platelet-derived growth factor was delivered to the implanted constructs through a microosmotic pump. Implanted constructs were retrieved from the animals 4 weeks postimplantation. Animals tolerated the implantation well, and there were no early postoperative complications. Normal stooling was observed during the implantation period. At harvest, implanted constructs were adherent to the perirectal rat tissue and appeared healthy and pink. Immunohistochemical analysis revealed neovascularization. Implanted smooth muscle cells maintained contractile phenotype. Bioengineered constructs responded in vitro in a tissue chamber to neuronally evoked relaxation in response to electrical field stimulation and vasoactive intestinal peptide, indicating the preservation of neuronal networks. Our results indicate that bioengineered innervated IAS constructs can be used to augment IAS function in an animal model. This is a regenerative medicine based therapy for fecal incontinence that would directly address the dysfunction of the IAS muscle. Copyright © 2014 Mosby, Inc. All rights reserved.

Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries.

PubMed

Wu, Jennifer M; Williams, Kathryn S; Hundley, Andrew F; Connolly, AnnaMarie; Visco, Anthony G

2005-08-01

The purpose of this study was to determine whether an occiput posterior (OP) fetal head position increases the risk for anal sphincter injury when compared with an occiput anterior (OA) position in vacuum-assisted deliveries. We conducted a retrospective cohort study of 393 vacuum-assisted singleton vaginal deliveries. Maternal demographics and obstetric and neonatal data were collected from an obstetric database and chart review. Within the OP group, 41.7% developed a third- or fourth-degree laceration compared with 22.0% in the OA group (OR 2.5, 95% CI 1.4-4.7). In a logistic regression model that controlled for BMI, race, nulliparity, length of second stage, episiotomy, birth weight, head circumference, and fetal head position, OP position was 4.0 times (95% CI 1.7-9.6) more likely to be associated with an anal sphincter injury than OA position. Among vacuum deliveries, an OP head position confers an incrementally increased risk for anal sphincter injury over an OA position.

Defining an at-risk population for obstetric anal sphincter laceration.

PubMed

Minaglia, Steven M; Kimata, Chieko; Soules, Karen A; Pappas, Tamara; Oyama, Ian A

2009-11-01

The purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort. An institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress. Fifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P < .0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5). Five cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

[Effects of choledochal perfusion with biliary acid solutions on activity of the sphincter of Oddi (author's transl)].

PubMed

Bevilacqua, R G; Margarido, N F; Soares, L A; Mansur, R; Koch, V; Gonçalves, E L

1979-06-01

The changes of sphincter of Oddi's resistance, induced by choledochal perfusion of conjugated (taurocolic) and non-conjugated (colic) biliary acid solutions, in anesthetized dogs, were studied. The perfusions were made at a constant flow and intracholedochal pressures were registered. The mean number of contractions per minute, the mean maximal pressures and the mean minimal pressures in each study periods were analysed. The choledochal perfusion with the biliary acids solutions induced a slight but significative increase in sphincteric resistance. After 15 minutes, the perfusion with colic acid solution induced maximal pressures significantly more elevated than the ones observed with taurocolic acid solution. The non-conjugated solution induced a pressure tracing significantly distinct from the tracing observed with the conjugated acid solution. No changes in resistance were observed with a 2% NaCl solution. This implies that the observed changes in resistance were not related to osmotic stimulation of the sphincter of Oddi.

Results of Parks operation for faecal incontinence after anal sphincter injury.

PubMed Central

Browning, G G; Motson, R W

1983-01-01

Parks operation for faecal incontinence was performed on 97 patients with total loss of anorectal control due to injury. All had sustained complete division of the anal sphincters as a result of trauma, anal surgery, or obstetric tears and either were incontinent or had been given a colostomy. In all patients the divided sphincters were repaired using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There was no operative mortality. Continence was completely restored in 65 (78%) and improved in a further 11 (13%) of the 83 patients assessed from four to 116 months postoperatively. Minor complications which did not affect the eventual clinical outcome occurred in 23 patients. Factors associated with failure of the operation included breakdown of the repair in the early postoperative period, fistula, and pelvic floor neuropathy. The results show that even after severe injury to the sphincters surgical reconstruction can restore continence in most patients. Images FIG 1 FIG 2 FIG 3 PMID:6407612

Fecal incontinence after minor anorectal surgery.

PubMed

Zbar, A P; Beer-Gabel, M; Chiappa, A C; Aslam, M

2001-11-01

Fecal leakage after open lateral internal anal sphincterotomy for chronic anal fissure is common, but underreported. The aim of this study was to prospectively assess the physiologic and morphologic effects of sphincterotomy, comparing continent and incontinent patients after surgery. This group was further compared with an unselected group of patients presenting with incontinence after hemorrhoidectomy. Between January 1997 and June 1999, 23 patients were prospectively followed up through internal sphincterotomy with conventional and vector volume anorectal manometry, parametric assessment of the rectoanal inhibitory reflex, and endoanal magnetic resonance imaging. Fourteen continent patients were compared with 9 incontinent postoperative cases, 9 patients referred with incontinence after hemorrhoidectomy, and 33 healthy volunteers without anorectal disease. Significant differences were noted between continent and incontinent postsphincterotomy cases for all resting conventional and vector volume parameters and for some squeeze parameters. Although there was a significant reduction in postoperative high pressure zone length at rest, there were no differences between the postoperative groups. There was an increase in sphincter asymmetry of 6.7 percent (+/- 3.5 percent) in incontinent postsphincterotomy patients and a decrease of 2.8 percent (+/- 3.2 percent) in continent cases. Significant differences were noted for resting parameters between incontinent postsphincterotomy and posthemorrhoidectomy patients, with a higher resting sphincter asymmetry in the latter group. The area under the rectoanal inhibitory curve was smaller in postsphincterotomy incontinent patients when compared with continent cohorts over the distal and intermediate sphincter zones at rest with a reduced latency of inhibition. There was no difference in the magnetic resonance images of the sphincterotomy site between incontinent and continent postsphincterotomy cases and no posthemorrhoidectomy case had evidence of sphincteric damage. There are complex significant differences in the postoperative physiology of patients undergoing lateral internal sphincterotomy who become incontinent when compared with those who maintain continence. These physiologic changes are not reflected in detectable morphologic sphincteric differences. It is unknown whether these changes predict for long-term incontinence, and it is suggested that postoperative incontinence after minor anorectal surgery is not necessarily related either to a preexisting sphincter defect or inadvertent intraoperative sphincter injury.

Ultrasound imaging of the anal sphincter complex: a review

PubMed Central

Abdool, Z; Sultan, A H; Thakar, R

2012-01-01

Endoanal ultrasound is now regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence. The advent of three-dimensional ultrasound has further improved our understanding of the two-dimensional technique. Endoanal ultrasound requires specialised equipment and its relative invasiveness has prompted clinicians to explore alternative imaging techniques. Transvaginal and transperineal ultrasound have been recently evaluated as alternative imaging modalities. However, the need for technique standardisation, validation and reporting is of paramount importance. We conducted a MEDLINE search (1950 to February 2010) and critically reviewed studies using the three imaging techniques in evaluating anal sphincter integrity. PMID:22374273

Analysis of fiber type transformation and histology in chronic electrically stimulated canine rectus abdominis muscle island-flap stomal sphincters.

PubMed

Majzoub, Ramsey K; Bardoel, Janou W J M; Maldonado, Claudio; Barker, John H; Stadelmann, Wayne K

2003-01-01

Dynamic skeletal muscle flaps are designed to perform a specific functional task through contraction and relaxation of their muscle fibers. The most commonly used dynamic skeletal flaps today are for cardiomyoplasty and anal or urinary myoplasty. Low-frequency chronic stimulation of these flaps enables them to use their intrinsic energy stores in a more efficient manner through aerobic metabolic pathways for increased endurance and improved work capacity. The purpose of this study was to (1) determine whether fiber type transformation from fatigue-prone (type II) muscle fibers to fatigue-resistant (type I) muscle fibers could be demonstrated in the authors' chronic canine stomal sphincter model where the rectus abdominis muscle was used to create a functional stomal sphincter, (2) assess whether there is any correlation between the degree of muscle fiber type transformation and the continence times, and (3) examine the long-term effects of the training regimens on the skeletal muscle fibers through histologic and volumetric analysis. Eight dynamic island-flap sphincters were created from a part of the rectus abdominis muscle in mongrel dogs by preserving the deep inferior epigastric vascular pedicle and the most caudal investing intercostal nerve. The muscular sphincters were wrapped around a blind loop of distal ileum and trained with pacing electrodes. Two different training protocols were used. In group A (n = 4), a preexisting anal dynamic graciloplasty training protocol was used. A revised protocol was used in group B (n = 4). Muscle biopsy specimens were obtained before and after training from the rectus abdominis muscle sphincter. Fiber type transformation was assessed using a monoclonal antibody directed against the fatigue-prone type II fibers. Pretraining and posttraining skeletal muscle specimens were examined histologically. A significant fiber type conversion was achieved in both group A and group B animals, with each group achieving greater than 50 percent conversion from fatigue-prone (type II) muscle fibers to fatigue-resistant (type I) muscle fibers. The continence time was different for both groups. Biopsy specimens 1 cm from the electrodes revealed that fiber type transformation was uniform throughout this region of the sphincters. Skeletal muscle fibers within both groups demonstrated a reduction in their fiber diameter and volume. Fiber type transformation is possible in this unique canine island-flap rectus abdominis sphincter model. The relative design of the flap with preservation of the skeletal muscle resting length and neuronal and vascular supply are important characteristics when designing a functional dynamic flap for stomal continence.

Local transdermal delivery of phenylephrine to the anal sphincter muscle using microneedles

PubMed Central

Baek, Changyoon; Han, MeeRee; Min, Junghong; Prausnitz, Mark R.; Park, Jung-Hwan; Park, Jungho

2014-01-01

We propose pretreatment using microneedles to increase perianal skin permeability for locally targeted delivery of phenylephrine (PE), a drug that increases resting anal sphincter pressure to treat fecal incontinence. Microneedle patches were fabricated by micromolding poly-lactic-acid. Pre-treatment of human cadaver skin with microneedles increased PE delivery across the skin by up to 10-fold in vitro. In vivo delivery was assessed in rats receiving treatment with or without use of microneedles and with or without PE. Resting anal sphincter pressure was then measured over time using water-perfused anorectal manometry. For rats pretreated with microneedles, topical application of 30% PE gel rapidly increased the mean resting anal sphincter pressure from 7 ± 2 cm H2O to a peak value of 43 ± 17 cm H2O after 1 h, which was significantly greater than rats receiving PE gel without microneedle pretreatment. Additional safety studies showed that topically applied green fluorescent protein–expressing E. coli penetrated skin pierced with 23- and 26-gauge hypodermic needles, but E. coli was not detected in skin pretreated with microneedles, which suggests that microneedle-treated skin may not be especially susceptible to infection. In conclusion, this study demonstrates local transdermal delivery of PE to the anal sphincter muscle using microneedles, which may provide a novel treatment for fecal incontinence. PMID:21586307

[External sphincterotomy using bipolar vaporisation in saline. First results].

PubMed

Even, L; Guillotreau, J; Mingat, N; Castel-Lacanal, E; Braley, E; Malavaud, B; Marque, P; Rischmann, P; Gamé, X

2012-07-01

The aim of this study was to assess the feasibility, efficacy and tolerance of external urethral sphincter vaporization in saline for treating detrusor-sphincter dyssynergia. Between 2009 and 2011 a monocentric prospective study of ten men mean age 58±9 years with neurogenic detrusor-sphincter dyssynergia was carried out. Preoperative evaluation included kidney ultrasound scan, 24-hour creatinine clearance, urodynamics, retrograde and voiding urethrocystography and an at least 6 months temporary stent sphincterotomy. Postoperative assessment was composed of an ultrasound scan post-void residual volume measurement when the urethral catheter were removed and 1 year after the procedure, a retrograde and voiding urethrocystography at 3 months and a flexible cystoscopy at 1 year. At the catheter removal, eight patients emptied their bladder at completion, a supra-pubic catheter was temporary left in one case and a patient had a permanent urinary retention. For a mean follow-up of 22±11 months, eight patients emptied their bladder at completion and two had a complete urinary retention related to a detrusor underactivity. An orchitis occurred in one case 1 month after the procedure and an urethral stricture in four cases in 12.75±5.68 months on average. External urethral sphincter vaporisation saline was feasible and efficient for treating detrusor-sphincter dyssynergia but was associated with a high risk of urethral stricture. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Cell Therapy for Stress Urinary Incontinence.

PubMed

Hart, Melanie L; Izeta, Ander; Herrera-Imbroda, Bernardo; Amend, Bastian; Brinchmann, Jan E

2015-08-01

Urinary incontinence (UI) is the involuntary loss of urine and is a common condition in middle-aged and elderly women and men. Stress urinary incontinence (SUI) is caused by leakage of urine when coughing, sneezing, laughing, lifting, and exercise, even standing leads to increased intra-abdominal pressure. Other types of UI also exist such as urge incontinence (also called overactive bladder), which is a strong and unexpected sudden urge to urinate, mixed forms of UI that result in symptoms of both urge and stress incontinence, and functional incontinence caused by reduced mobility, cognitive impairment, or neuromuscular limitations that impair mobility or dexterity. However, for many SUI patients, there is significant loss of urethral sphincter muscle due to degeneration of tissue, the strain and trauma of pregnancy and childbirth, or injury acquired during surgery. Hence, for individuals with SUI, a cell-based therapeutic approach to regenerate the sphincter muscle offers the advantage of treating the cause rather than the symptoms. We discuss current clinically relevant cell therapy approaches for regeneration of the external urethral sphincter (striated muscle), internal urethral sphincter (smooth muscle), the neuromuscular synapse, and blood supply. The use of mesenchymal stromal/stem cells is a major step in the right direction, but they may not be enough for regeneration of all components of the urethral sphincter. Inclusion of other cell types or biomaterials may also be necessary to enhance integration and survival of the transplanted cells.

Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction

PubMed Central

Chandrasekhara, Vinay; Koh, Joyce; Lattimer, Lakshmi; Dunbar, Kerry B; Ravich, William J; Clarke, John O

2017-01-01

AIM To evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement. METHODS All balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES). RESULTS Four hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission. CONCLUSION UES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES. PMID:28465785

D(2) receptors receive paracrine neurotransmission and are consistently targeted to a subset of synaptic structures in an identified neuron of the crustacean stomatogastric nervous system.

PubMed

Oginsky, Max F; Rodgers, Edmund W; Clark, Merry C; Simmons, Robert; Krenz, Wulf-Dieter C; Baro, Deborah J

2010-02-01

Dopamine (DA) modulates motor systems in phyla as diverse as nematodes and arthropods up through chordates. A comparison of dopaminergic systems across a broad phylogenetic range should reveal shared organizing principles. The pyloric network, located in the stomatogastric ganglion (STG), is an important model for neuromodulation of motor networks. The effects of DA on this network have been well characterized at the circuit and cellular levels in the spiny lobster, Panulirus interruptus. Here we provide the first data about the physical organization of the DA signaling system in the STG and the function of D(2) receptors in pyloric neurons. Previous studies showed that DA altered intrinsic firing properties and synaptic output in the pyloric dilator (PD) neuron, in part by reducing calcium currents and increasing outward potassium currents. We performed single cell reverse transcriptase-polymerase chain reaction (RT-PCR) experiments to show that PD neurons exclusively expressed a type 2 (D(2alphaPan)) DA receptor. This was confirmed by using confocal microscopy in conjunction with immunohistochemistry (IHC) on STG whole-mount preparations containing dye-filled PD neurons. Immunogold electron microscopy showed that surface receptors were concentrated in fine neurites/terminal swellings and vesicle-laden varicosities in the synaptic neuropil. Double-label IHC experiments with tyrosine hydroxylase antiserum suggested that the D(2alphaPan) receptors received volume neurotransmissions. Receptors were further mapped onto three-dimensional models of PD neurons built from Neurolucida tracings of confocal stacks from the IHC experiments. The data showed that D(2alphaPan) receptors were selectively targeted to approximately 40% of synaptic structures in any given PD neuron, and were nonuniformly distributed among neurites.

Trypsin from unicorn leatherjacket (Aluterus monoceros) pyloric caeca: purification and its use for preparation of fish protein hydrolysate with antioxidative activity.

PubMed

Zamani, Abbas; Benjakul, Soottawat

2016-02-01

Fish proteases, especially trypsin, could be used to prepare fish protein hydrolysates with antioxidative activities. In this study, trypsin from the pyloric caeca of unicorn leatherjacket was purified by ammonium sulfate precipitation and soybean trypsin inhibitor (SBTI)-Sepharose 4B affinity chromatography. Hydrolysate from Indian mackerel protein isolate with different degrees of hydrolysis (20, 30 and 40% DH) was prepared using the purified trypsin, and antioxidative activities (1,1-diphenyl-2-picrylhydrazyl and 2,2'-azinobis(3-ethylbenzothiazoline-6-sulfonic acid) radical-scavenging activities, ferric-reducing antioxidant power and ferrous-chelating activity) of the hydrolysate were determined. Trypsin was purified 26.43-fold with a yield of 13.43%. The purified trypsin had a molecular weight (MW) of 23.5 kDa and optimal activity at pH 8.0 and 55 °C. It displayed high stability in the pH range of 6.0-11.0 and was thermally stable up to 50 °C. Both SBTI (0.05 mmol L(-1)) and N-p-tosyl-L-lysine-chloromethylketone (5 mmol L(-1)) completely inhibited trypsin activity. Antioxidative activities of the hydrolysate from Indian mackerel protein isolate increased with increasing DH up to 40% (P < 0.05). Based on sodium dodecyl sulfate polyacrylamide gel electrophoresis, the hydrolysate with 40% DH had a MW lower than 6.5 kDa. The purified protease from unicorn leatherjacket pyloric caeca was identified as trypsin based on its ability to hydrolyze a specific synthetic substrate and the response to specific trypsin inhibitors. The purified trypsin could hydrolyze Indian mackerel protein isolate, and the resulting hydrolysate exhibited antioxidative activity depending on its DH. © 2015 Society of Chemical Industry.

Coordination of distinct but interacting rhythmic motor programs by a modulatory projection neuron using different co-transmitters in different ganglia

PubMed Central

Kwiatkowski, Molly A.; Gabranski, Emily R.; Huber, Kristen E.; Chapline, M. Christine; Christie, Andrew E.; Dickinson, Patsy S.

2013-01-01

SUMMARY While many neurons are known to contain multiple neurotransmitters, the specific roles played by each co-transmitter within a neuron are often poorly understood. Here, we investigated the roles of the co-transmitters of the pyloric suppressor (PS) neurons, which are located in the stomatogastric nervous system (STNS) of the lobster Homarus americanus. The PS neurons are known to contain histamine; using RT-PCR, we identified a second co-transmitter as the FMRFamide-like peptide crustacean myosuppressin (Crust-MS). The modulatory effects of Crust-MS application on the gastric mill and pyloric patterns, generated in the stomatogastric ganglion (STG), closely resembled those recorded following extracellular PS neuron stimulation. To determine whether histamine plays a role in mediating the effects of the PS neurons in the STG, we bath-applied histamine receptor antagonists to the ganglion. In the presence of the antagonists, the histamine response was blocked, but Crust-MS application and PS stimulation continued to modulate the gastric and pyloric patterns, suggesting that PS effects in the STG are mediated largely by Crust-MS. PS neuron stimulation also excited the oesophageal rhythm, produced in the commissural ganglia (CoGs) of the STNS. Application of histamine, but not Crust-MS, to the CoGs mimicked this effect. Histamine receptor antagonists blocked the ability of both histamine and PS stimulation to excite the oesophageal rhythm, providing strong evidence that the PS neurons use histamine in the CoGs to exert their effects. Overall, our data suggest that the PS neurons differentially utilize their co-transmitters in spatially distinct locations to coordinate the activity of three independent networks. PMID:23393282

Coordination of distinct but interacting rhythmic motor programs by a modulatory projection neuron using different co-transmitters in different ganglia.

PubMed

Kwiatkowski, Molly A; Gabranski, Emily R; Huber, Kristen E; Chapline, M Christine; Christie, Andrew E; Dickinson, Patsy S

2013-05-15

While many neurons are known to contain multiple neurotransmitters, the specific roles played by each co-transmitter within a neuron are often poorly understood. Here, we investigated the roles of the co-transmitters of the pyloric suppressor (PS) neurons, which are located in the stomatogastric nervous system (STNS) of the lobster Homarus americanus. The PS neurons are known to contain histamine; using RT-PCR, we identified a second co-transmitter as the FMRFamide-like peptide crustacean myosuppressin (Crust-MS). The modulatory effects of Crust-MS application on the gastric mill and pyloric patterns, generated in the stomatogastric ganglion (STG), closely resembled those recorded following extracellular PS neuron stimulation. To determine whether histamine plays a role in mediating the effects of the PS neurons in the STG, we bath-applied histamine receptor antagonists to the ganglion. In the presence of the antagonists, the histamine response was blocked, but Crust-MS application and PS stimulation continued to modulate the gastric and pyloric patterns, suggesting that PS effects in the STG are mediated largely by Crust-MS. PS neuron stimulation also excited the oesophageal rhythm, produced in the commissural ganglia (CoGs) of the STNS. Application of histamine, but not Crust-MS, to the CoGs mimicked this effect. Histamine receptor antagonists blocked the ability of both histamine and PS stimulation to excite the oesophageal rhythm, providing strong evidence that the PS neurons use histamine in the CoGs to exert their effects. Overall, our data suggest that the PS neurons differentially utilize their co-transmitters in spatially distinct locations to coordinate the activity of three independent networks.

The stem cell organisation, and the proliferative and gene expression profile of Barrett's epithelium, replicates pyloric-type gastric glands

PubMed Central

Lavery, Danielle L; Nicholson, Anna M; Poulsom, Richard; Jeffery, Rosemary; Hussain, Alia; Gay, Laura J; Jankowski, Janusz A; Zeki, Sebastian S; Barr, Hugh; Harrison, Rebecca; Going, James; Kadirkamanathan, Sritharan; Davis, Peter; Underwood, Timothy; Novelli, Marco R; Rodriguez–Justo, Manuel; Shepherd, Neil; Jansen, Marnix; Wright, Nicholas A; McDonald, Stuart A C

2014-01-01

Objective Barrett's oesophagus shows appearances described as ‘intestinal metaplasia’, in structures called ‘crypts’ but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands. Methods Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry. Results Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell. Conclusions Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus. PMID:24550372

Epidermolysis bullosa with congenital pyloric atresia: novel mutations in the beta 4 integrin gene (ITGB4) and genotype/phenotype correlations.

PubMed

Nakano, A; Pulkkinen, L; Murrell, D; Rico, J; Lucky, A W; Garzon, M; Stevens, C A; Robertson, S; Pfendner, E; Uitto, J

2001-05-01

Epidermolysis bullosa with pyloric atresia (EB-PA: OMIM 226730), also known as Carmi syndrome, is a rare autosomal recessive genodermatosis that manifests with neonatal mucocutaneous fragility associated with congenital pyloric atresia. The disease is frequently lethal within the first year, but nonlethal cases have been reported. Mutations in the genes encoding subunit polypeptides of the alpha 6 beta 4 integrin (ITGA6 and ITGB4) have been demonstrated in EB-PA patients. To extend the repertoire of mutations and to identify genotype-phenotype correlations, we examined seven new EB-PA families, four with lethal and three with nonlethal disease variants. DNA from patients was screened for mutations using heteroduplex analysis followed by nucleotide sequencing of PCR products spanning all beta 4 integrin-coding sequences. Mutation analysis disclosed 12 distinct mutations, 11 of them novel. Four mutations predicted a premature termination codon as a result of nonsense mutations or small out-of-frame insertions or deletions, whereas seven were missense mutations. This brings the total number of distinct ITGB4 mutations to 33. The mutation database indicates that premature termination codons are associated predominantly with the lethal EB-PA variants, whereas missense mutations are more prevalent in nonlethal forms. However, the consequences of the missense mutations are position dependent, and substitutions of highly conserved amino acids may have lethal consequences. In general, indirect immunofluorescence studies of affected skin revealed negative staining for beta 4 integrin in lethal cases and positive, but attenuated, staining in nonlethal cases and correlated with clinical phenotype. The data on specific mutations in EB-PA patients allows prenatal testing and preimplantation genetic diagnosis in families at risk.

Clinicopathological characteristics of duodenal epithelial neoplasms: Focus on tumors with a gastric mucin phenotype (pyloric gland-type tumors).

PubMed

Mitsuishi, Takehiro; Hamatani, Shigeharu; Hirooka, Shinichi; Fukasawa, Nei; Aizawa, Daisuke; Hara, Yuko; Dobashi, Akira; Goda, Kenichi; Fukuda, Takahiro; Saruta, Masayuki; Urashima, Mitsuyoshi; Ikegami, Masahiro

2017-01-01

Epithelial tumors less commonly occur in the duodenum than in the stomach or large intestine. The clinicopathological characteristics of duodenal epithelial tumors remain a matter of debate. We therefore studied resected specimens to investigate the clinicopathological characteristics of duodenal epithelial tumors. Among duodenal epithelial tumors resected endoscopically or surgically in our hospital, we studied the clinicopathological characteristics of 110 adenomas or intramucosal carcinomas. The grade of atypia of all tumors was classified into 3 groups according to the World Health Organization (WHO) 2010 classification. The tumors were immunohistochemically evaluated to determine the frequency of differentiation toward fundic glands. As for patient characteristics, there were 76 men (75.2%) and 25 women (24.8%), with a median age of 65 years (range, 34 to 84). The tumors most commonly arose in the first to second part of the duodenum. Many lesions were flat, and the median tumor diameter was 8.0 mm. The lesions were classified into 2 types according to mucin phenotype: intestinal-type tumors (98 lesions, 89.1%) and gastric-type tumors (12 lesions, 10.9%). Intestinal-type tumors were subdivided into 2 groups: tubular-type tumors (91 lesions, 82.7%) and tubulovillous-type tumors (7 lesions, 6.4%). Gastric-type tumors were classified into 2 types: foveolar type (3 lesions, 2.7%) and pyloric gland-type (PG) tumors (9 lesions, 8.2%). The grade of atypia was significantly higher in gastric-type tumors (p<0.01). PG tumors were gastric-type tumors characterized by pyloric glands and findings suggesting differentiation toward fundic glands. About 10% of the duodenal tumors had a gastric-type mucin phenotype. Gastric-type tumors showed high-grade atypia. In particular, PG tumors showed similarities to PG tumors of the stomach, such as differentiation toward fundic glands.

A modeling approach on why simple central pattern generators are built of irregular neurons.

PubMed

Reyes, Marcelo Bussotti; Carelli, Pedro Valadão; Sartorelli, José Carlos; Pinto, Reynaldo Daniel

2015-01-01

The crustacean pyloric Central Pattern Generator (CPG) is a nervous circuit that endogenously provides periodic motor patterns. Even after about 40 years of intensive studies, the rhythm genesis is still not rigorously understood in this CPG, mainly because it is made of neurons with irregular intrinsic activity. Using mathematical models we addressed the question of using a network of irregularly behaving elements to generate periodic oscillations, and we show some advantages of using non-periodic neurons with intrinsic behavior in the transition from bursting to tonic spiking (as found in biological pyloric CPGs) as building components. We studied two- and three-neuron model CPGs built either with Hindmarsh-Rose or with conductance-based Hodgkin-Huxley-like model neurons. By changing a model's parameter we could span the neuron's intrinsic dynamical behavior from slow periodic bursting to fast tonic spiking, passing through a transition where irregular bursting was observed. Two-neuron CPG, half center oscillator (HCO), was obtained for each intrinsic behavior of the neurons by coupling them with mutual symmetric synaptic inhibition. Most of these HCOs presented regular antiphasic bursting activity and the changes of the bursting frequencies was studied as a function of the inhibitory synaptic strength. Among all HCOs, those made of intrinsic irregular neurons presented a wider burst frequency range while keeping a reliable regular oscillatory (bursting) behavior. HCOs of periodic neurons tended to be either hard to change their behavior with synaptic strength variations (slow periodic burster neurons) or unable to perform a physiologically meaningful rhythm (fast tonic spiking neurons). Moreover, 3-neuron CPGs with connectivity and output similar to those of the pyloric CPG presented the same results.

The stem cell organisation, and the proliferative and gene expression profile of Barrett's epithelium, replicates pyloric-type gastric glands.

PubMed

Lavery, Danielle L; Nicholson, Anna M; Poulsom, Richard; Jeffery, Rosemary; Hussain, Alia; Gay, Laura J; Jankowski, Janusz A; Zeki, Sebastian S; Barr, Hugh; Harrison, Rebecca; Going, James; Kadirkamanathan, Sritharan; Davis, Peter; Underwood, Timothy; Novelli, Marco R; Rodriguez-Justo, Manuel; Shepherd, Neil; Jansen, Marnix; Wright, Nicholas A; McDonald, Stuart A C

2014-12-01

Barrett's oesophagus shows appearances described as 'intestinal metaplasia', in structures called 'crypts' but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands. Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry. Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell. Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

INHIBITORY ACTIVITY OF MANGIFERIN ON HELICOBACTER PYLORI-INDUCED INFLAMMATION IN HUMAN GASTRIC CARCINOMA AGS CELLS

PubMed Central

Zhang, Qiu-jie; Yue, Lu

2017-01-01

Background: Gastric cancer is a serious health issue caused by H. pylori and claims more lives in developing and undeveloped countries. Hence, the need for a natural drug with several pharmacological activities with no adverse effect are highly recommended. The target of this study was to verify the anti-H. pyloric efficacy of mangiferin (MF) on H. pylori-infected AGS cells. Materials and methods: AGS cells were co-cultured with H. pylori and incubated with increased concentration of MF (10, 20, 50 and 100 μg/mL) or amoxicillin (AMX) and DMSO (control) group to assess its anti-H. pyloric effect by checking inhibitory zone, bacterial drug sensitivity test (MIC and MBC), adhesion and invasive property and various inflammatory markers. Results: Co-culturing of H. pylori-infected AGS cells with MF (100 μg) considerably increased (p<0.05) the inhibitory zone as well as substantially lowered (p<0.05) in the levels of MBC and MIC with decreased adhesion and invasive property in a dose-dependent manner and thus endorsing its anti H. pyloric activity and are almost equivalent to antibiotic AMX. Meanwhile, inflammatory markers such as NF-κΒ subunit p65, interleukins-1β, IL-8, and TNF-α were also markedly suppressed (p<0.01) on treatment with MF. In addition, the protein expression of inflammatory enzymes like COX-2 and iNOS were notably downregulated (p<0.05) in AGS cells incubated with MF. Conclusion: We, concluded that MF treatment with H. pylori-infected AGS cells significantly suppressed the adhesion and invasion process as well as deactivated NF-p65 thereby blocking inflammatory response and thus lower the incidence of gastric carcinoma. PMID:28480404

D2 Receptors Receive Paracrine Neurotransmission and Are Consistently Targeted to a Subset of Synaptic Structures in an Identified Neuron of the Crustacean Stomatogastric Nervous System

PubMed Central

Oginsky, Max F.; Rodgers, Edmund W.; Clark, Merry C.; Simmons, Robert; Krenz, Wulf-Dieter C.; Baro, Deborah J.

2014-01-01

Dopamine (DA) modulates motor systems in phyla as diverse as nematodes and arthropods up through chordates. A comparison of dopaminergic systems across a broad phylogenetic range should reveal shared organizing principles. The pyloric network, located in the stomatogastric ganglion (STG), is an important model for neuromodulation of motor networks. The effects of DA on this network have been well characterized at the circuit and cellular levels in the spiny lobster, Panulirus interruptus. Here we provide the first data about the physical organization of the DA signaling system in the STG and the function of D2 receptors in pyloric neurons. Previous studies showed that DA altered intrinsic firing properties and synaptic output in the pyloric dilator (PD) neuron, in part by reducing calcium currents and increasing outward potassium currents. We performed single cell reverse transcriptase-polymerase chain reaction (RT-PCR) experiments to show that PD neurons exclusively expressed a type 2 (D2αPan) DA receptor. This was confirmed by using confocal microscopy in conjunction with immunohistochemistry (IHC) on STG whole-mount preparations containing dye-filled PD neurons. Immunogold electron microscopy showed that surface receptors were concentrated in fine neurites/terminal swellings and vesicle-laden varicosities in the synaptic neuropil. Double-label IHC experiments with tyrosine hydroxylase antiserum suggested that the D2αPan receptors received volume neurotransmissions. Receptors were further mapped onto three-dimensional models of PD neurons built from Neurolucida tracings of confocal stacks from the IHC experiments. The data showed that D2αPan receptors were selectively targeted to approximately 40% of synaptic structures in any given PD neuron, and were nonuniformly distributed among neurites. PMID:19941347

Intestinal morphology of the wild Atlantic salmon (Salmo salar).

PubMed

Løkka, Guro; Austbø, Lars; Falk, Knut; Bjerkås, Inge; Koppang, Erling Olaf

2013-08-01

The worldwide-industrialized production of Atlantic salmon (Salmo salar) has increased dramatically during the last decades, followed by diseases related to the on-going domestication process as a growing concern. Even though the gastrointestinal tract seems to be a target for different disorders in farmed fish, a description of the normal intestinal status in healthy, wild salmon is warranted. Here, we provide such information in addition to suggesting a referable anatomical standardization for the intestine. In this study, two groups of wild Atlantic salmon were investigated, consisting of post smolts on feed caught in the sea and of sexually mature, starved individuals sampled from a river. The two groups represent different stages in the anadromous salmon life cycle, which also are part of the production cycle of farmed salmon. Selected regions of gastrointestinal tract were subjected to morphological investigations including immunohistochemical, scanning electron microscopic, and morphometric analyses. A morphology-based nomenclature was established, defining the cardiac part of the stomach and five different regions of the Atlantic salmon intestine, including pyloric caeca, first segment of the mid-intestine with pyloric caeca, first segment of the mid-intestine posterior to pyloric caeca, second segment of the mid-intestine and posterior intestinal segment. In each of the above described regions, for both groups of fish, morphometrical measurements and regional histological investigations were performed with regards to magnitude and direction of mucosal folding as well as the composition of the intestinal wall. Additionally, immunohistochemistry showing cells positive for cytokeratins, α-actin and proliferating cell nuclear antigen, in addition to alkaline phosphatase reactivity in the segments is presented. Copyright © 2013 Wiley Periodicals, Inc., a Wiley Company.

Can we define and characterize the aging lower urinary tract?-ICI-RS 2015.

PubMed

Vahabi, Bahareh; Wagg, Adrian S; Rosier, Peter F W M; Rademakers, Kevin L J; Denys, Marie-Astrid; Pontari, Michel; Lovick, Thelma; Valentini, Francoise A; Nelson, Pierre P; Andersson, Karl-Erik; Fry, Christopher H

2017-04-01

The prevalence of lower urinary tract (LUT) symptoms increases with age but the etiology is unknown. This article aims to identify research directions that clarify the basis of this association. The initial question is whether biological age is the variable of interest or a time-dependent accumulation of factors that impact on LUT function at rates that differ between individuals. In particular, the accumulation of conditions or agents due to inflammatory states or tissue ischemia is important. Much of the above has been concerned with changes to bladder function and morphology. However, the outflow tract function is also affected, in particular changes to the function of external sphincter skeletal muscle and associated sacral motor nerve control. Nocturia is a cardinal symptom of LUT dysfunction and is more prevalent with aging. Urine production is determined by diurnal changes to the production of certain hormones as well as arterial blood pressure and such diurnal rhythms are blunted in subjects with nocturia, but the causal links remain to be elucidated. Changes to the central nervous control of LUT function with age are also increasingly recognized, whether in mid-brain/brainstem regions that directly affect LUT function or in higher centers that determine psycho-social and emotional factors impinging on the LUT. In particular, the linkage between increasing white matter hyperintensities and LUT dysfunction during aging is recognized but not understood. Overall, a more rational approach is being developed to link LUT dysfunction with factors that accumulate with age, however, the precise causal pathways remain to be characterized. Neurourol. Urodynam. 36:854-858, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Botulinum toxin treatment for oropharyngeal dysphagia in patients with stroke.

PubMed

Terré, R; Panadés, A; Mearin, F

2013-11-01

In a previous pilot study, we demonstrated that a single injection of botulinum toxin A (BTX-A) in the cricopharyngeus muscle is effective in patients with neurologic dysphagia with upper esophageal sphincter (UES) opening dysfunction and presence of some pharyngeal contraction (>25 mmHg). The aim of this study was to confirm the long-lasting efficacy of this procedure after stroke. We prospectively studied 23 patients with stroke for at least 6 months before administration of a BTX-A injection. Baseline diagnosis of UES opening dysfunction and presence of some pharyngeal contraction were assessed by videofluoroscopy (VFS) and esophageal manometry (EM). Clinical and VFS follow-up was made at 3 weeks and 3, 6, and 12 months postinjection. Eighteen patients (78%) were fed by gastrostomy tube prior to treatment. Videofluoroscopy showed UES relaxation impairment, residue in pyriform sinuses, and aspiration in all cases. After BTX-A, the number of patients with aspiration and pharyngeal residue decreased to 52% and 70%, respectively (p < 0.05 for both); residue was severe in only 4%. Esophageal manometry showed a mean pharyngeal amplitude 66.8 mmHg (range: 25-120 mmHg). We observed a significant improvement in feeding mode during follow-up: after 3 months, 70% of patients were eating exclusively by mouth. Lower residual pressure and minor pharyngeal delay time at baseline were all predictive factors for treatment effectiveness. A single injection of BTX-A is efficacious for a period of at least 12 months in improving oropharyngeal dysphagia in stroke patients with UES opening dysfunction and some pharyngeal contraction (>25 mmHg). © 2013 John Wiley & Sons Ltd.

Robot-assisted intersphincteric resection facilitates an efficient sphincter-saving in patients with low rectal cancer.

PubMed

Kim, Jin Cheon; Lee, Jong Lyul; Alotaibi, Abdulrahman Muaod; Yoon, Yong Sik; Kim, Chan Wook; Park, In Ja

2017-08-01

Few investigations of robot-assisted intersphincteric resection (ISR) are presently available to support this procedure as a safe and efficient procedure. We aimed to evaluate the utility of robot-assisted ISR by comparison between ISR and abdominoperineal resection (APR) using both robot-assisted and open approaches. The 558 patients with lower rectal cancer (LRC) who underwent curative operation was enrolled between July 2010 and June 2015 to perform either by robot-assisted (ISR vs. APR = 310 vs. 34) or open approaches (144 vs. 70). Perioperative and functional outcomes including urogenital and anorectal dysfunctions were measured. Recurrence and survival were examined in 216 patients in which >3 years had elapsed after the operation. The robot-assisted approach was the most significant parameter to determine ISR achievement among potent parameters (OR = 3.467, 95% CI = 2.095-5.738, p < 0.001). Early surgical complications occurred more frequently in the open ISR group (16 vs. 7.7%, p = 0.01). The voiding and male sexual dysfunctions were significantly more frequent in the open ISR (p < 0.05). The fecal incontinence and lifestyle alteration score was greater in the open ISR than in the robot-assisted ISR at 12 and 24 months, respectively (p < 0.05). However, the 3-year cumulative rates of local recurrence and survival did not differ between the two groups. The current procedure of robot-assisted ISR replaced a significant portion of APR to achieve successful SSO via mostly transabdominal approach and double-stapled anastomosis. The robot-assisted ISR with minimal invasiveness might be a help to reduce anorectal and urogenital dysfunctions.

[Sacral neuromodulation in urology - development and current status].

PubMed

Schwalenberg, T; Stolzenburg, J-U; Kriegel, C; Gonsior, A

2012-01-01

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2 - S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase - called peripheral nerve evaluation (PNE test) - sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the "two stage approach" with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50 - 80 %) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of "tined lead electrodes" (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology. © Georg Thieme Verlag KG Stuttgart · New York.

USE OF A PHYSIOLOGICALLY BASED TOXICOKINETIC MODEL TO SIMULATE CHRONIC DIETARY EXPOSURE IN FISH

EPA Science Inventory

A physiologically based toxicokinetic (PBTK) model was developed to describe dietary uptake of hydrophobic organic chemicals by fish. The GI tract was modeled as four compartments corresponding to the stomach, pyloric ceca, upper intestine, and lower intestine. Partitioning coeff...

Hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin--Knoxville, Tennessee, 1999.

PubMed

1999-12-17

In February 1999, pertussis was diagnosed in six neonates born at hospital A in Knoxville, Tennessee. Because a health-care worker at hospital A was most likely the source of exposure, the local health department recommended on February 25, 1999, that erythromycin be prescribed as postexposure prophylaxis for the approximately 200 infants born at hospital A during February 1-24, 1999. In March 1999, local pediatric surgeons noticed an increased number of cases of infantile hypertrophic pyloric stenosis (IHPS) in the area, with seven cases occurring during a 2-week period. All seven IHPS cases were in infants born in hospital A during February who were given erythromycin orally for prophylaxis following possible exposure to pertussis, although none had pertussis diagnosed. The Tennessee Department of Health and CDC investigated the cluster of IHPS cases and its possible association with use of erythromycin. This report summarizes the results of the investigation, which suggest a causal role of erythromycin in this cluster of IHPS cases.

Idiopathic gastroesophageal reflux disease in an adult horse.

PubMed

Baker, Shannon J; Johnson, Philip J; David, Andrew; Cook, Cristi Reeves

2004-06-15

Chronic gastroesophageal reflux disease was diagnosed in a 22-year-old female Tennessee Walking Horse that had signs of bruxism and ptyalism. Esophageal ulceration was detected via endoscopy. Compared with the damage to the proximal portions of the esophagus, the severity of the ulceration increased toward the gastroesophageal junction. Esophageal ulceration attributable to chronic gastric acid reflux is usually secondary to pyloric outflow obstruction in horses. In the horse of this report, there was no evidence of either a chronic pyloric or duodenal obstruction that could have resulted in esophageal ulceration. Esophageal ulceration in this horse was attributed to gastroesophageal reflux disease, a common condition in humans in which the underlying abnormality is functional incompetence of the gastroesophageal junction. Treatment is directed at decreasing gastric acidity and protecting the ulcerated mucosa. In the horse of this report, treatment was unsuccessful and the horse was euthanatized; a physical cause of gastroesophageal reflux disease was not identified during an extensive postmortem examination.

Technical innovation: Intragastric Single Port Sleeve Gastrectomy (IGSG). A feasibility survival study on porcine model.

PubMed

Estupinam, Oscar; Oliveira, André Lacerda de Abreu; Antunes, Fernanda; Galvão, Manoel; Phillips, Henrique; Scheffer, Jussara Peters; Rios, Marcelo; Zorron, Ricardo

2018-01-01

To perform technically the laparoscopic sleeve gastrectomy (LSG) using a unique Intragastric Single Port (IGSG) in animal swine model, evidencing an effective and safe procedure, optimizing the conventional technique. IGSG was performed in 4 minipigs, using a percutaneous intragastric single port located in the pre-pyloric region. The gastric stapling of the greater curvature started from the pre-pyloric region towards the angle of His by Endo GIA™ system and the specimen was removed through the single port. In the postoperative day 30, the animals were sacrificed and submitted to autopsy. All procedures were performed without conversion, and all survived 30 days. The mean operative time was 42 min. During the perioperative period no complications were observed during invagination and stapling. No postoperative complications occurred. Post-mortem examination showed no leaks or infectious complications. Intragastric Single Port is a feasible procedure that may be a suitable alternative technique of sleeve gastrectomy for the treatment of morbid obesity.

Case of a tumor comprising gastric cancer and duodenal neuroendocrine tumor

PubMed Central

Kaneko, Hiroaki; Miyake, Akio; Ishii, Yasuaki; Sue, Soichiro; Miwa, Haruo; Sasaki, Tomohiko; Tamura, Toshihide; Kondo, Masaaki; Maeda, Shin

2016-01-01

The present report describes a rare case of a tumor composed of early gastric cancer and a duodenal neuroendocrine tumor (NET). A 78-year-old woman underwent esophagogastroduodenoscopy at a local institution for screening of the upper gastrointestinal tract which revealed a protruded tumor through the pyloric ring from the pyloric antrum. The tumor was too large to treat at the facility; consequently, she was referred to our hospital for further management. Esophagogastroduodenoscopy with tumor biopsy of the lesion revealed the diagnosis of early gastric cancer. Endoscopic submucosal dissection was performed with sufficient free margins in both vertical and horizontal directions. Histopathological findings showed NET confined to the submucosal layer and covered by well-differentiated adenocarcinoma. Immunohistochemical stainings showed that the two lesions existed continuously. While the possibility of a collision cancer was considered, it was suggested that the two lesions existed continuously. Finally, the tumor was diagnosed as gastric cancer composed of duodenal NET G1, with a lymphatic invasion of NET component. PMID:27688667

A pilot study of sphincter-sparing management of adenocarcinoma of the rectum.

PubMed

Steele, G; Busse, P; Huberman, M S; LeClair, J M; Falchuk, Z M; Mayer, R J; Bothe, A; Ravikumar, T S; Stone, M; Jessup, J M

1991-06-01

After analysis of 26 prospectively accrued patients with distal rectal adenocarcinomas who underwent sphincter preservation treatment, we have concluded that tumors that invade only the submucosa can safely be treated with surgery alone and that tumors that invade the muscularis or further can be safely treated with surgery combined with chemoradiotherapy. None of the patients had either local or distant recurrence, with a median follow-up of 21 months. All patients have been fully continent. The results, although preliminary, imply that resection of distal rectal adenocarcinoma with sphincter preservation, and adjuvant therapy when appropriate, have achieved local and distant control equal to the conventional Miles' abdominoperineal resection, but without the need for a permanent colostomy.

Current Evaluation of Upper Oesophageal Sphincter Opening in Dysphagia Practice: An International SLT Survey

ERIC Educational Resources Information Center

Regan, Julie; Walshe, Margaret; McMahon, Barry P.

2012-01-01

Background: The assessment of adequate upper oesophageal sphincter (UOS) opening during swallowing is an integral component of dysphagia evaluation. Aims: To ascertain speech and language therapists' (SLTs) satisfaction with current methods for assessing UOS function in people with dysphagia and to identify challenges encountered by SLTs with UOS…

Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation: further clinical and histological characterization in a patient.

PubMed

König, P; Ambrose, N S; Scott, N

2000-01-01

Hereditary internal anal sphincter myopathy is a very rare condition, only three families have so far been described in the literature. In this case report further clinical and histological findings of one affected member of one of the above families are presented.

Effect of clebopride on lower esophageal sphincter pressure.

PubMed

Ribeiro, V; da Silva, A L; Castro, L de P

1981-01-01

In 12 individuals without gastrointestinal symptoms, the IV administration of metoclopramide and of clebopride produced both a significant increase on the lower esophageal sphincter pressure. The increase induced by clebopride was significantly higher than that induced by metoclopramide. The tolerability of clebopride was satisfactory with just mild drowsiness being noted in most cases.

[Pelvic floor and pregnancy].

PubMed

Fritel, X

2010-05-01

Congenital factor, obesity, aging, pregnancy and childbirth are the main risk factors for female pelvic floor disorders (urinary incontinence, anal incontinence, pelvic organ prolapse, dyspareunia). Vaginal delivery may cause injury to the pudendal nerve, the anal sphincter, or the anal sphincter. However the link between these injuries and pelvic floor symptoms is not always determined and we still ignore what might be the ways of prevention. Of the many obstetrical methods proposed to prevent postpartum symptoms, episiotomy, delivery in vertical position, delayed pushing, perineal massage, warm pack, pelvic floor rehabilitation, results are disappointing or limited. Caesarean section is followed by less postnatal urinary incontinence than vaginal childbirth. However this difference tends to disappear with time and following childbirth. Limit the number of instrumental extractions and prefer the vacuum to forceps could reduce pelvic floor disorders after childbirth. Ultrasound examination of the anal sphincter after a second-degree perineal tear is useful to detect and repair infra-clinic anal sphincter lesions. Scientific data is insufficient to justify an elective cesarean section in order to avoid pelvic floor symptoms in a woman without previous disorders. Copyright 2010 Elsevier Masson SAS. All rights reserved.

Quantifying Contributions of the Cricopharyngeus to Upper Esophageal Sphincter Pressure Changes by Means of Intramuscular Electromyography and High-Resolution Manometry

PubMed Central

Jones, Corinne A.; Hammer, Michael J.; Hoffman, Matthew R.; McCulloch, Timothy M.

2014-01-01

Objectives We sought to determine whether the association between cricopharyngeus muscle activity and upper esophageal sphincter pressure may change in a task-dependent fashion. We hypothesized that more automated tasks related to swallow or airway protection would yield a stronger association than would more volitional tasks related to tidal breathing or voice production. Methods Six healthy adult subjects underwent simultaneous intramuscular electromyography of the cricopharyngeus muscle and high-resolution manometry of the upper esophageal sphincter. Correlation coefficients were calculated to characterize the association between the time-linked series. Results Cricopharyngeus muscle activity was most strongly associated with upper esophageal sphincter pressure during swallow and effortful exhalation tasks (r = 0.77 and 0.79, respectively; P < .01). The association was also less variable during swallow and effortful exhalation. Conclusions These findings suggest a greater coupling for the more automatic tasks, and may suggest less coupling and more flexibility for the more volitional, voice-related tasks. These findings support the important role of central patterning for respiratory- and swallow-related tasks. PMID:24633943

Histomorphology of canine urethral sphincter systems, including three-dimensional reconstruction and magnetic resonance imaging.

PubMed

Stolzenburg, Jens-Uwe; Neuhaus, Jochen; Liatsikos, Evangelos N; Schwalenberg, Thilo; Ludewig, Eberhard; Ganzer, Roman

2006-03-01

To present a detailed anatomic description and comparison of the smooth and striated urethral sphincter in male and female dogs. We performed a thorough histologic evaluation, three-dimensional reconstruction, and magnetic resonance imaging of the lower urinary tract of male and female dogs. The lower urinary tract anatomy was investigated in 16 male and 18 female dogs by serial sectioning, including immunohistochemical staining and three-dimensional reconstruction. Magnetic resonance imaging performed in 5 male and 5 female dogs before histologic investigation helped to demonstrate the anatomy in vivo. A urethral sphincter muscle in both sexes existed without muscular connection to the pelvic floor. It ran circularly and consisted of an inner smooth and outer striated muscular part. In the female dog, the striated muscle encircled the urethra and vagina in the caudal third of the membranous urethra (musculus urethrovaginalis). A urinary diaphragm (diaphragma urogenitale) could not be found histologically or by magnetic resonance imaging. The dog is a suitable animal model for investigations of the urethral sphincter. In the female dog, attention should be given to the special topography of the musculus urethrovaginalis.

2D DIGE Does Not Reveal all: A Scotopic Report Suggests Differential Expression of a Single "Calponin Family Member" Protein for Tetany of Sphincters!

PubMed

Chaudhury, Arun

2015-01-01

Using 2D differential gel electrophoresis (DIGE) and mass spectrometry (MS), a recent report by Rattan and Ali (2015) compared proteome expression between tonically contracted sphincteric smooth muscles of the internal anal sphincter (IAS), in comparison to the adjacent rectum [rectal smooth muscles (RSM)] that contracts in a phasic fashion. The study showed the differential expression of a single 23 kDa protein SM22, which was 1.87 fold, overexpressed in RSM in comparison to IAS. Earlier studies have shown differences in expression of different proteins like Rho-associated protein kinase II, myosin light chain kinase, myosin phosphatase, and protein kinase C between IAS and RSM. The currently employed methods, despite its high-throughput potential, failed to identify these well-characterized differences between phasic and tonic muscles. This calls into question the fidelity and validatory potential of the otherwise powerful technology of 2D DIGE/MS. These discrepancies, when redressed in future studies, will evolve this recent report as an important baseline study of "sphincter proteome." Proteomics techniques are currently underutilized in examining pathophysiology of hypertensive/hypotensive disorders involving gastrointestinal sphincters, including achalasia, gastroesophageal reflux disease (GERD), spastic pylorus, seen during diabetes or chronic chemotherapy, intestinal pseudo-obstruction, and recto-anal incontinence. Global proteome mapping may provide instant snapshot of the complete repertoire of differential proteins, thus expediting to identify the molecular pathology of gastrointestinal motility disorders currently labeled "idiopathic" and facilitating practice of precision medicine.

Electrodynamic smooth muscle sphincter: development and biomechanical evaluation of a novel porcine artificial smooth muscle sphincter in a new in vitro stoma simulator.

PubMed

Schrag, H J; Karwath, D; Grub, C; Fragoza Padilla, F; Noack, T; Hopt, U T

2005-07-01

Many authors have suggested that the activity of the enteric inhibitory nerves is important in regulating normal gastrointestinal motility and inducing smooth muscle relaxation. Hitherto, no experimental or clinical models exist that transfer these physiological aspects to creating an autologous artificial sphincter for the treatment of major incontinence. Therefore, this study was performed to determine the contractile and relaxant capacity of gastrointestinal muscle types and to investigate the efficiency of a novel smooth muscle sphincter, based on the non-adrenergic, non-cholinergic (NANC) receptive relaxation under electrical field stimulation (EFS). For the first step, the isometric tension from isolated circular porcine fundus and colon muscle strips was recorded during pharmacological stimulation (TTX, L-NNA and atropine) and EFS. As a result, a continent electrodynamic smooth muscle sphincter (ESMS) was created by wrapping a fundus muscle flap around an isolated segment of porcine distal colon. The EFS of the free nerve fibers of the flap was realized using a circular platinum wire electrode. Parameters such as threshold of continence, intra/preluminal pressure and fluid passage were analyzed in a newly designed in vitro stoma simulator. Electrical field stimulation produced a maximal and voltage-dependent fundus relaxation to --12.4 mN/mm(2) (frequency of 40 Hz, pulse duration, train duration and voltage of 5 ms, 1 s and 60 mA respectively), which were abolished by N-nitro-L -arginine (L-NNA; 10(-4) M) in a dose-dependent manner, confirming that relaxant responses were mediated by NANC nerves. The results of eight ESMS showed that circular electrical stimulation of the muscle flap caused muscle relaxation with a concomitant and effective reduction in the occlusion pressure. The NANC-induced relaxation mechanism of porcine fundus preparations could be transferred to an efficient smooth muscle sphincter with a high threshold of continence and electrically controlled defecation.

Functional Outcome of Human Adipose Stem Cell Injections in Rat Anal Sphincter Acute Injury Model.

PubMed

Kuismanen, Kirsi; Juntunen, Miia; Narra Girish, Nathaniel; Tuominen, Heikki; Huhtala, Heini; Nieminen, Kari; Hyttinen, Jari; Miettinen, Susanna

2018-03-01

Anal incontinence is a devastating condition that significantly reduces the quality of life. Our aim was to evaluate the effect of human adipose stem cell (hASC) injections in a rat model for anal sphincter injury, which is the main cause of anal incontinence in humans. Furthermore, we tested if the efficacy of hASCs could be improved by combining them with polyacrylamide hydrogel carrier, Bulkamid. Human ASCs derived from a female donor were culture expanded in DMEM/F12 supplemented with human platelet lysate. Female virgin Sprague-Dawley rats were randomized into four groups (n = 14-15/group): hASCs in saline or Bulkamid (3 × 10 5 /60 μl) and saline or Bulkamid without cells. Anorectal manometry (ARM) was performed before anal sphincter injury, at two (n = 58) and at four weeks after (n = 33). Additionally, the anal sphincter tissue was examined by micro-computed tomography (μCT) and the histological parameters were compared between the groups. The median resting and peak pressure during spontaneous contraction measured by ARM were significantly higher in hASC treatment groups compared with the control groups without hASCs. There was no statistical difference in functional results between the hASC-carrier groups (saline vs. Bulkamid). No difference was detected in the sphincter muscle continuation between the groups in the histology and μCT analysis. More inflammation was discovered in the group receiving saline with hASC. The hASC injection therapy with both saline and Bulkamid is a promising nonsurgical treatment for acute anal sphincter injury. Traditional histology combined with the 3D μCT image data lends greater confidence in assessing muscle healing and continuity. Stem Cells Translational Medicine 2018;7:295-304. © 2018 The Authors Stem Cells Translational Medicine published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.

Reflection of the State of Hunger in Impulse Activity of Nose Wing Muscles and Upper Esophageal Sphincter during Search behavior in Rabbits.

PubMed

Kromin, A A; Dvoenko, E E; Zenina, O Yu

2016-07-01

Reflection of the state of hunger in impulse activity of nose wing muscles and upper esophageal sphincter muscles was studied in chronic experiments on rabbits subjected to 24-h food deprivation in the absence of locomotion and during search behavior. In the absence of apparent behavioral activity, including sniffing, alai nasi muscles of hungry rabbits constantly generated bursts of action potentials synchronous with breathing, while upper esophageal sphincter muscles exhibited regular aperiodic low-amplitude impulse activity of tonic type. Latent form of food motivation was reflected in the structure of temporal organization of impulse activity of alai nasi muscles in the form of bimodal distribution of interpulse intervals and in temporal structure of impulse activity of upper esophageal sphincter muscles in the form of monomodal distribution. The latent form of food motivation was manifested in the structure of temporal organization of periods of the action potentials burst-like rhythm, generated by alai nasi muscles, in the form of monomodal distribution, characterized by a high degree of dispersion of respiratory cycle periods. In the absence of physical activity hungry animals sporadically exhibited sniffing activity, manifested in the change from the burst-like impulse activity of alai nasi muscles to the single-burst activity type with bimodal distribution of interpulse intervals and monomodal distribution of the burst-like action potentials rhythm periods, the maximum of which was shifted towards lower values, which was the cause of increased respiratory rate. At the same time, the monomodal temporal structure of impulse activity of the upper esophageal sphincter muscles was not changed. With increasing food motivation in the process of search behavior temporal structure of periods of the burst-like action potentials rhythm, generated by alai nasi muscles, became similar to that observed during sniffing, not accompanied by animal's locomotion, which is typical for the increased respiratory rhythm frequency. Increased hunger motivation was reflected in the temporal structure of impulse activity of upper esophageal sphincter muscles in the form of a shift to lower values of the maximum of monomodal distribution of interpulse intervals on the histogram, resulting in higher impulse activity frequency. The simultaneous increase in the frequency of action potentials bursts generation by alai nasi muscles and regular impulse activity of upper esophageal sphincter muscles is a reliable criterion for enhanced food motivation during search behavior in rabbits.

Botulinum Toxin and Gastrointestinal Tract Disorders

PubMed Central

Weiser, Kirsten; Kennedy, Abigail

2008-01-01

The history of botulinum toxin is fascinating. First recognized as the cause of botulism nearly 200 years ago, it was originally feared as a deadly poison. Over the last 30 years, however, botulinum toxin has been transformed into a readily available medication used to treat a variety of medical disorders. Interest in the use of botulinum toxin has been particularly strong for patients with spastic smooth muscle disorders of the gastrointestinal tract. Patients with achalasia, diffuse esophageal spasm, gastroparesis, sphincter of Oddi dysfunction, and anal fissures have all been treated with botulinum toxin injections, often with impressive results. However, not all patients respond to botulinum toxin therapy, and large randomized controlled trials are lacking for many conditions commonly treated with botulinum toxin. This paper reviews the history, microbiology, and pharmacology of botulinum toxin, discusses its mechanism of action, and then presents recent evidence from the literature regarding the use of botulinum toxin for the treatment of a variety of gastrointestinal tract disorders. PMID:21960915

A theoretical framework to guide a study of patients' bowel symptoms and self-care strategies following sphincter-saving surgery for rectal cancer.

PubMed

Landers, Margaret; McCarthy, Geraldine; Savage, Eileen

2013-08-01

A paucity of research is available on patients' bowel symptom experiences and self-care strategies following sphincter-saving surgery for rectal cancer. Most research undertaken to date on patients' bowel symptoms following surgery for rectal cancer has been largely atheoretical. The purpose of this paper is to describe the process of choosing a theoretical framework to guide a study of patients' bowel symptoms and self-care strategies following sphincter-saving surgery for rectal cancer. As a result of a thorough literature review, we determined that the Symptom Management Theory provided the most comprehensive framework to guide our research. Copyright © 2013 Elsevier Inc. All rights reserved.

THE EFFECT OF SODIUM CHLORIDE ON THE CHEMICAL CHANGES IN THE BLOOD OF THE DOG AFTER PYLORIC AND INTESTINAL OBSTRUCTION.

PubMed

Haden, R L; Orr, T G

1923-06-30

Experiments to determine the effect of furnishing an ample supply of sodium chloride on the toxemia of pyloric and intestinal obstruction are reported. A fall in chlorides is the first and seemingly most significant change to take place in the blood after pyloric and intestinal obstruction. The chloride is apparently utilized by the body as a protective measure against the primary toxic substance. Two dogs with pyloric obstruction were given 50 cc. of 10 per cent NaCl subcutaneously daily. One lived 3 days, the other 4. The blood showed little change, except a marked terminal rise in chlorides. Animals given a like amount of distilled water or 25 per cent glucose showed the changes typical of untreated animals. The obstruction of the pylorus was released in six dogs 48 to 72 hours after the initial operation. Two died within 24 hours after the second operation with a high non-protein nitrogen in the blood. Two survived but showed a high level of non-protein nitrogen in the blood and a high nitrogen excretion in the urine, low blood chlorides, and a marked alkalosis. One dog in such a state died on the 13th day from peritonitis, arising in a wound infection. The other showed a marked fall in non-protein nitrogen in the blood following the administration of 10 gm. of sodium chloride by mouth, but died following the intravenous injection of 25 per cent sodium chloride. Two animals were given 50 cc. of 10 per cent NaCl subcutaneously, at the time of the second operation. The blood rapidly returned to normal and complete recovery followed. Two dogs with the duodenum obstructed by section and inversion of the cut ends were treated with 10 per cent sodium chloride after the obstruction had existed for 48 hours and the characteristic blood changes had developed. The non-protein nitrogen returned to normal within 48 hours after treatment was begun. One dog died following a lateral anastomosis for relief of the obstruction. A second operation was not attempted in the other animal. Two dogs in which the duodenum was obstructed by section and inversion of the cut ends were given 500 cc. of 0.85 per cent NaCl subcutaneously on the day of operation and each day thereafter until death. One dog lived 21 days, the other 28. Both dogs showed a marked alkalosis, but never any rise in the non-protein nitrogen of the blood. The animals at autopsy showed intussusception of the ileum with extensive ulceration. In one there was a perforation and terminal peritonitis. The operation wounds healed normally. Three dogs with section of the duodenum were given 500 cc. of distilled water every day. One died in 24 hours, one in 48 hours, and the third in 72 hours. Autopsy showed no cause for death other than toxemia. One dog with section of the duodenum was given 500 cc. of 2 per cent glucose every day. The blood showed a rapid rise in non-protein nitrogen and carbon dioxide-combining power, and a fall in chlorides. The animal died 72 hours after operation. Three dogs with section of the duodenum were given 500 cc. of 1 per cent sodium bicarbonate every day. One dog died in 72 hours, one lived 7 days, and the third lived 9 days. All developed a high non-protein nitrogen in the blood and two showed marked clinical symptoms of an alkalosis. These results demonstrate that solutions of sodium chloride have a marked effect in preventing and controlling the toxemia of pyloric and intestinal obstruction as shown in clinical symptoms and in chemical changes in the blood. Dogs given an abundant supply of distilled water died more quickly than untreated control animals. Solutions of glucose have no specific value, and sodium bicarbonate solutions prolong life only a short while. Good therapeutic results have been obtained with very concentrated sodium chloride solutions, and with dry sodium chloride given by mouth. It seems evident that sodium chloride has a specific action in preventing and possibly in controlling the changes produced by the toxic body. Sodium chloride is a valuable therapeutic agent in pyloric and high intestinal obstruction.

Diagnostic outcome of contrast videofluoroscopic swallowing studies in 216 dysphagic dogs.

PubMed

Pollard, Rachel E; Marks, Stanley L; Cheney, Diane M; Bonadio, Cecily M

2017-07-01

Determining the anatomic and functional origin for dysphagia is critical for development of an appropriate therapeutic plan and determination of the prognosis. The purpose of this retrospective study was to report the quantitative and qualitative outcome of contrast videofluoroscopic swallowing studies in a large cohort of dysphagic dogs presenting to a tertiary veterinary care hospital. The videofluoroscopic swallowing studies were reviewed to generate values for pharyngeal constriction ratio, timing of swallowing events (maximum pharyngeal contraction, opening of upper esophageal sphincter, closing of upper esophageal sphincter, and reopening of epiglottis), type of esophageal peristalsis generated, and esophageal transit time. One or more anatomic locations for origin of dysphagia were assigned (pharyngeal, cricopharyngeal, esophageal (primary motility disorder), other esophageal (stricture, vascular ring anomaly, mass), lower esophageal sphincter/hiatus. Sixty-one of 216 studies (28%) were deemed unremarkable. Twenty-seven of 216 dogs (13%) had pharyngeal dysphagia, 17/216 dogs (8%) had cricopharyngeal dysphagia, 98/216 dogs (45%) had dysphagia secondary to esophageal dysmotility, 19/216 dogs (9%) had dysphagia secondary to focal esophageal disorders, and 97/216 dogs (45%) had dysphagia of lower esophageal sphincter/hiatus origin. Multiple abnormalities were present in 82/216 (38%) dogs. Elevated pharyngeal constriction ratio was associated with pharyngeal, cricopharyngeal, and esophageal motility disorders, delayed upper esophageal sphincter opening was associated with cricopharyngeal disorders, a lower percentage of primary esophageal peristaltic waves was associated with cricopharyngeal, pharyngeal, or primary esophageal motility disorders. In conclusion, videofluoroscopic swallowing studies was pivotal in the diagnosis of dysphagia with 155/216 (72%) dogs receiving a final diagnosis. © 2017 American College of Veterinary Radiology.

The male bulbospongiosus muscle and its relation to the external anal sphincter.

PubMed

Peikert, Kevin; Platzek, Ivan; Bessède, Thomas; May, Christian Albrecht

2015-04-01

The bulbospongiosus muscle is part of the superficial muscular layer of the perineum and pelvic floor. Its morphology remains controversial in the literature. Therefore, we reinvestigated the fascial arrangement and fiber courses of the bulbospongiosus muscle and its topographical relation to the external anal sphincter. The perineum was dissected in 9 male cadavers (mean ± SD age 78.3 ± 10.7 years). Select samples were obtained for histology and immunohistochemistry. In 43 patients (mean age 60.7 ± 12 years) the topographical relation between the bulbospongiosus muscle and the external anal sphincter was determined by magnetic resonance imaging. The perineum contains several fascial layers consisting of elastic and collagen fibers as well as bundles of smooth muscle cells. The bulbospongiosus muscle was subdivided into a ventral and dorsal portion, which developed in 4 variants. The ventral insertion formed a morphological unity with the ischiocavernous muscle while the dorsal origin had a variable relation to the external anal sphincter (5 variants). A muscle-like or connective tissue-like connection was frequently present between the muscles. However, in some cases the muscles were completely separated. We suggest a concept of variations of bulbospongiosus muscle morphology that unifies the conflicting literature. Its ventral fiber group and the ischiocavernosus muscle form a functional and morphological unity. While the bulbospongiosus muscle and the external anal sphincter remain independent muscles, their frequent connection might have clinical implications for perineal surgery and anogenital disorders. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Stress urinary incontinence in female neurological patients: long-term functional outcomes after artificial urinary sphincter (AMS 800TM ) implantation.

PubMed

Phé, Véronique; Léon, Priscilla; Granger, Benjamin; Denys, Pierre; Bitker, Marc-Olivier; Mozer, Pierre; Chartier-Kastler, Emmanuel

2017-03-01

To report the long-term functional outcomes of artificial urinary sphincter (AUS) implantation in female adult neurological patients suffering from stress urinary incontinence (SUI) due to sphincter deficiency. Female patients with neurological disease suffering from SUI due to sphincter deficiency who underwent AUS (AMS 800 TM ) implantation between 1984 and 2011 were included. Continence rate defined as no need for pads and survival rates of the device without needing explantation or revision using Kaplan-Meier curves were reported. Overall, 26 patients, median age 49.2 years (IQR 28.5-59.7) were included. The median follow-up time was 7.5 years (IQR 3.9-23.8). At the end of follow-up period, 15 patients (57.7%) still had their primary AUS. The AUS was explanted in five women because of infection or erosion. Survival rates, without AUS explantation were 90%, 84%, 84%, and 74% at 5, 10, 15, 20 years, respectively. Survival rates without AUS revision were 75%, 51%, 51%, and 51% at 5, 10, 15, 20 years, respectively. 71.4% of patients with AUS were continent. When considering the 26 initial patients, including the patients in whom the AUS was explanted, the continence rate was 57.7%. For treating neurogenic sphincter deficiency in the long term, the AMS 800 TM can offer a satisfying rate of continence to female patients, with a tolerable rate of explantation and revision. Neurourol. Urodynam. 36:764-769, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Long-term functional outcomes after artificial urinary sphincter implantation in men with stress urinary incontinence.

PubMed

Léon, Priscilla; Chartier-Kastler, Emmanuel; Rouprêt, Morgan; Ambrogi, Vanina; Mozer, Pierre; Phé, Véronique

2015-06-01

To evaluate long-term functional outcomes of artificial urinary sphincters (AUSs) and to determine how many men required explantation because of stress urinary incontinence (SUI) caused by sphincter deficiency after prostate surgery. Men who had undergone placement of an AUS (American Medical Systems AMS 800®) between 1984 and 1992 to relieve SUI caused by sphincter deficiency after prostate surgery were included. Continence, defined as no need for pads, was assessed at the end of the follow-up. Kaplan-Meier survival curves estimated the survival rate of the device without needing explantation or revision. In all, 57 consecutive patients were included with a median (interquartile range, IQR) age of 69 (64-72) years. The median (IQR) duration of follow-up was 15 (8.25-19.75) years. At the end of follow-up, 25 patients (43.8%) still had their primary AUS. The AUS was explanted in nine men because of erosion (seven) and infection (two). Survival rates, without AUS explantation, were 87%, 87%, 80%, and 80% at 5, 10, 15, and 20 years, respectively. Survival rates, without AUS revision, were 59%, 28%, 15%, and 5% at 5, 10, 15, and 20 years, respectively. At the end of the follow-up, in intention-to-treat analysis, 77.2% of patients were continent. In the long term (>10 years) the AMS 800 can offer a high rate of continence to men with SUI caused by sphincter deficiency, with a tolerable rate of explantation and revision. © 2014 The Authors. BJU International © 2014 BJU International.

Systemic glyceryl trinitrate reduces anal sphincter tone: is there a therapeutic indication?

PubMed

Connolly, C; Tierney, S; Grace, P

2018-05-01

Nitric oxide (NO) has diverse roles as a biological messenger. [1] Topically applied nitrate donors cause relaxation of the internal anal sphincter (IAS) and facilitate healing of anal fissures [2,3]. Systemic nitrates are commonly used for the treatment of ischaemic heart disease, yet the effects of systemically administered nitrates on the smooth muscle of the IAS are unknown. Our aim was to test the hypothesis that systemically administered nitrates at a normal dose, cause inhibition of anal sphincter activity. With fully informed consent, anal manometry was performed on nine volunteers. Maximum and mean anal resting pressure (representing the IAS), maximum squeeze pressure (representing the external anal sphincter), heart rate and blood pressure were measured, before and after administration of a normal 400 μg dose of sublingual glyceryl trinitrate spray. Data are expressed as mean (± standard error of the mean (SEM)). In four females and five males ranging from 19 to 50 years of age, administration of GTN resulted in a significant reduction in systolic blood pressure from 138 ± 5 to 127 ± 4 mmHg, P < 0.01. Mean resting pressure, over 5 min, was significantly reduced from 70 ± 10 to 62 ± 10 mmHg P < 0.05. The maximum resting pressure was also significantly reduced from 109 ± 12 to 86 ± 10 mmHg P = 0.04. Maximum squeeze pressure, heart rate and diastolic blood pressure were not significantly reduced. Systemic nitrates significantly inhibit internal anal sphincter function.

Artificial Muscle Devices: Innovations and Prospects for Fecal Incontinence Treatment.

PubMed

Fattorini, Elisa; Brusa, Tobia; Gingert, Christian; Hieber, Simone E; Leung, Vanessa; Osmani, Bekim; Dominietto, Marco D; Büchler, Philippe; Hetzer, Franc; Müller, Bert

2016-05-01

Fecal incontinence describes the involuntary loss of bowel content, which is responsible for stigmatization and social exclusion. It affects about 45% of retirement home residents and overall more than 12% of the adult population. Severe fecal incontinence can be treated by the implantation of an artificial sphincter. Currently available implants, however, are not part of everyday surgery due to long-term re-operation rates of 95% and definitive explantation rates of 40%. Such figures suggest that the implants fail to reproduce the capabilities of the natural sphincter. This article reviews the artificial sphincters on the market and under development, presents their physical principles of operation and critically analyzes their performance. We highlight the geometrical and mechanical parameters crucial for the design of an artificial fecal sphincter and propose more advanced mechanisms of action for a biomimetic device with sensory feedback. Dielectric electro-active polymer actuators are especially attractive because of their versatility, response time, reaction forces, and energy consumption. The availability of such technology will enable fast pressure adaption comparable to the natural feedback mechanism, so that tissue atrophy and erosion can be avoided while maintaining continence during daily activities.

Surgical anatomy of the prostate in the era of radical robotic prostatectomy.

PubMed

Walz, Jochen; Graefen, Markus; Huland, Hartwig

2011-05-01

New insights in the anatomy of the prostate and the surrounding tissue evolve the technique of radical prostatectomy for the treatment of prostate cancer. Regarding the course of the erectile nerves along the prostate, recent studies confirmed the presence of parasympathetic pro-erectile nerve fibers at the anterolateral aspect of the prostate. Another study of intraoperative electrostimulation of those nerves confirmed an increase in intracavernosal pressure by stimulations between the 1 and 3 o'clock position. Therefore, it is very likely that these anterior nerve fibers have an effect on erectile function. Regarding the urethral sphincter in the male, a study showed no attachment of the external sphincter to the levator ani muscle, probably resulting in an absence of a levator ani support to the continence mechanism. The male urinary sphincter seems to be in isolation responsible for urinary continence. The nerve fibers at the anterolateral aspect of the prostate seem to participate in erectile function, which renders the concept of a high anterior release during nerve sparing beneficial. The isolated urinary sphincter mechanism results in the need to conserve as much urethral length as possible during radical prostatectomy to avoid urinary incontinence.

Preliminary Study of a Novel Puborectalis-Like Artificial Anal Sphincter.

PubMed

Jin, Wentian; Yan, Guozheng; Wu, Hao; Lu, Shan; Zhou, Zerun

2017-09-01

Artificial anal sphincter (AAS) is an in situ implanted device that acts as a treatment for fecal incontinence regardless of etiology by augmenting the incompetent sphincteric structures. However, AAS is impeded from becoming a valid therapy by its high rate of ischemic complication and malfunction. This article presents an original puborectalis-like artificial anal sphincter (PAAS) that features a low risk of ischemia necrosis and rectal perception remodeling. The device retains continence by reproducing the action, including the pulling and angulating the rectum, of the puborectalis muscle, which forms the anorectal angle and reduces the required clamping pressure. Three rectal pressure sensors were embedded to maintain the pressure exerted on the rectal wall in a safe range and to monitor the distention of the rectum. A series of in vitro studies were conducted with a porcine rectum, and this PAAS prototype manifested the ability of maintaining continence with a clamping pressure considerably lower than that required by other AAS devices. The pressure sensors exhibit good linearity, and the function of rectal perception remodeling has also revealed high reliability with a success rate of 93.3%. © 2017 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Restoration of bladder function in spastic neuropathic bladder using sacral deafferentation and different techniques of neurostimulation.

PubMed

Schumacher, S; Bross, S; Scheepe, J R; Alken, P; Jünemann, K P

1999-01-01

Conventional sacral anterior root stimulation (SARS) results in simultaneous activation of both the detrusor muscle and the external urethral sphincter. We evaluated the possibilities of different neurostimulation techniques to overcome stimulation induced detrusor-sphincter-dyssynergia and to achieve a physiological voiding. The literature was reviewed on different techniques of sacral anterior root stimulation of the bladder and the significance of posterior rhizotomy in patients with supraconal spinal cord injury suffering from the loss of voluntary bladder control, detrusor hyperreflexia and sphincter spasm. The achievement of selective detrusor activation would improve current sacral neurostimulation of the bladder, including the principle of "poststimulus voiding". This is possible with the application of selective neurostimulation in techniques of anodal block, high frequency block, depolarizing prepulses and cold block. Nowadays, sacral deafferentation is a standard therapy in combination with neurostimulation of the bladder because in conclusion advantages of complete rhizotomy predominate. The combination of sacral anterior root stimulation and sacral deafferentation is a successful procedure for restoration of bladder function in patients with supraconal spinal cord injury. Anodal block technique and cryotechnique are excellent methods for selective bladder activation to avoid detrusor-sphincter-dyssynergia and thus improve stimulation induced voiding.

[Use of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation 
for colorectal malignant obstruction].

PubMed

Xiao, Dinghua; Liu, Shaojun; Yan, Hanguang; Wang, Xiaoyan

2018-05-28

To explore the function of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction, and to improve the success rate of colonic stent placement in such patients.
 Methods: A total of 49 patients with colorectal cancer complicated with almost complete obstruction or colorectal cancer were enrolled for this study. The esophageal small balloon or papillary sphincter knife was used in the guide wires. The guide wires gradually crossed the tumor gap and they were placed in the contralateral intestinal cavity with balloon progression. X-ray was then used to confirm whether the guide wire was inserted in the lesion intestinal cavity, and then the metal bare stent was inserted.
 Results: The guide wires was successfully inserted with conventional methods in these 49 cases, while they were also successfully placed the guide wire and the stent in the new way.
 Conclusion: For the patients with colorectal cancer complicated with complete obstruction or colorectal cancer located in obviously angled location, the use of esophageal small balloon or papillary sphincter knife can help the guide wire insert. They greatly improve the success rate of stent implantation.

Aerobic metabolism on muscle contraction in porcine iris sphincter.

PubMed

Kanda, Hidenori; Kaneda, Takeharu; Kato, Asami; Yogo, Takuya; Harada, Yasuji; Hara, Yasusi; Urakawa, Norimoto; Shimizu, Kazumasa

2016-12-01

Eyes are supplied O 2 through the cornea and vessels of the retina and iris, which are tissues characterized by aerobic metabolism. Meanwhile, there are no reports on the association between iris sphincter contraction and aerobic metabolism. In this paper, we studied the aforementioned association. Eyes from adult pigs of either sex were obtained from a local abattoir. A muscle strip was connected to a transducer to isometrically record the tension. O 2 consumption was measured using a Clark-type polarograph connected to a biological oxygen monitor. Creatine phosphate (PCr) and adenosine triphosphate (ATP) contents were measured in the muscle strips by high-performance liquid chromatography (HPLC). Iris sphincter muscles were measured in resting, contractile or hypoxic phases. Contraction was induced by hyperosmotic 65 mM KCl (H-65K + ) or carbachol (CCh), and hypoxia was induced by aeration with N 2 instead of O 2 or by addition of sodium cyanide (NaCN). H-65K + - and CCh-induced muscle contraction, involved increasing O 2 consumption. Hypoxia and NaCN significantly decreased H-65K + - and CCh-induced muscle contraction and/or O 2 consumption and PCr contents. Our results suggest that the contractile behavior in porcine iris sphincter highly depends on mitogen oxidative metabolism.

Laparoscopic intersphincteric resection: indications and results.

PubMed

Scala, Dario; Niglio, Antonello; Pace, Ugo; Ruffolo, Fulvio; Rega, Daniela; Delrio, Paolo

2016-03-01

Surgical treatment of distal rectal cancer has long been based only on abdominoperineal excision, resulting in a permanent stoma and not always offering a definitive local control. Sphincter saving surgery has emerged in the last 20 years and can be offered also to patients with low lying tumours, provided that the external sphincter is not involved by the disease. An intersphincteric resection (ISR) is based on the resection of the rectum with a distal dissection proceeding into the space between the internal and the external anal sphincter. Originally described as an open procedure, it has also been developed with the laparoscopic approach, and also this technically demanding procedure is inscribed among those offered to the patient by a minimally invasive surgery. Indications have to be strict and patient selection is crucial to obtain both oncological and functional optimal results. The level of distal dissection and the extent of internal sphincter resected are chosen according to the distal margin of the tumour and is based on MRI findings: accurate imaging is therefore mandatory to better define the surgical approach. We here present our actual indications for ISR, results in terms of operative time, median hospital stay for ISR in our experience and review the updated literature.

A PHYSIOLOGICALLY BASED TOXICOKINETIC MODEL FOR DIETARY UPTAKE OF HYDROPHOBIC ORGANIC COMPOUNDS BY FISH: I. FEEDING STUDIES WITH 2,2',5,5'-TETRACHLOROBIPHENYL

EPA Science Inventory

A physiologically-based toxicokinetic (PBTK) model was developed to describe dietary uptake of hydrophobic organic compounds by fish. The gastrointestinal (GI) tract was modeled using four compartments corresponding to the stomach, pyloric ceca, upper intestine, and lower intesti...

Trypsin from the pyloric caeca of bluefish (Pomatomus saltatrix).

PubMed

Klomklao, Sappasith; Benjakul, Soottawat; Visessanguan, Wonnop; Kishimura, Hideki; Simpson, Benjamin K

2007-12-01

Trypsin was purified from the pyloric caeca of bluefish (Pomatomus saltatrix) by ammonium sulfate precipitation, acetone precipitation and soybean trypsin inhibitor-Sepharose 4B affinity chromatography. Bluefish trypsin migrated as a single band using both sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and native-PAGE and had a molecular mass of 28 kDa. The optima pH and temperature for the hydrolysis of benzoyl-dl-arginine-p-nitroanilide (BAPNA) were 9.5 and 55 degrees C, respectively. The enzyme was stable over a broad pH range (7 to 12), but was unstable at acidic pH, and at temperatures greater than 40 degrees C. The enzyme was inhibited by specific trypsin inhibitors: soybean trypsin inhibitor (SBTI), N-p-tosyl-l-lysine chloromethyl ketone (TLCK) and the serine protease inhibitor phenylmethyl sulfonylfluoride (PMSF). CaCl2 partially protected trypsin against activity loss at 40 degrees C, but NaCl (0 to 30%) decreased the activity in a concentration dependent manner. The N-terminal amino acid sequence of trypsin was determined as IVGGYECKPKSAPVQVSLNL and was highly homologous to other known vertebrate trypsins.

Methanol extract of Bauhinia purpurea leaf possesses anti-ulcer activity.

PubMed

Zakaria, Z A; Abdul Hisam, E E; Norhafizah, M; Rofiee, M S; Othman, F; Hasiah, A H; Vasudevan, M

2012-01-01

The aim of the present study was to determine the anti-ulcer activity of a methanol extract of Bauhinia purpurea leaf (MEBP). MEBP was administered at doses of 100, 500 and 1,000 mg/kg and its effects on acute toxicity, absolute ethanol- and indomethacin-induced gastric ulceration, and pyloric ligation tests in rats were investigated. At a dose of 5,000 mg/kg, MEBP did not cause any signs of toxicity in rats when given orally. Oral administration of MEBP exerted anti-ulcer activity (p < 0.05) in all models tested. However, a dose-dependent protection was observed only in the indomethacin-induced gastric ulceration model. Histological studies supported the observed anti-ulcer activity of MEBP. In the pyloric ligation assay, MEBP significantly increased gastric wall mucus secretion (p < 0.05), but did not affect the acidity of the gastric contents. MEBP exhibited anti-ulcer activity, which could be due to the presence of flavonoids, saponins or other polyphenols, thereby validating the traditional use of B. purpurea in the treatment of ulcers. Copyright © 2012 S. Karger AG, Basel.

UROLOGICAL PROBLEMS IN THE AGED

PubMed Central

Barnes, Roger W.

1956-01-01

The preponderance of men over 60 years of age on the Urology Service at the Los Angeles County General Hospital is due to the prevalence of prostatic disease. Approximately two-thirds of patients with prostatic hypertrophy of Grade I or smaller size and who have less than 60 cc. of residual urine can be treated nonsurgically. Prostatic operation, when done expertly, is well tolerated by most aged patients. The end results are usually good except in those who have complicating central nervous system lesions. The approach chosen for removal of the prostate is determined by the training and experience of the surgeon. Urinary obstruction due to carcinoma of the prostate can be relieved by hormonal treatment in most cases. Carcinoma of the bladder when discovered early can be controlled for many years by repeated transurethral resection and frequent observation; when discovered late, successful definitive treatment is rarely possible. Vesical dysfunction due to neurological and/or senile changes is best treated by use of an in-dwelling urethral catheter. Mild dysfunction may respond somewhat to medication and sphincter muscle exercise. Infections respond well to anti-infection drugs unless there is an organic urological lesion. Untoward reactions to drugs are more common in aged patients. Calculi, when they are found in the bladder, should be crushed and evacuated; when in the kidney, let alone unless symptoms are annoying. Renal tumors should be removed unless the patient is more than 80 years of age. Elderly patients tolerate urological operation well when it is done expertly. PMID:13364682

Advances in stem cell therapy for the lower urinary tract.

PubMed

Lin, Ching-Shwun

2010-02-26

Lower urinary tract diseases are emotionally and financially burdensome to the individual and society. Current treatments are ineffective or symptomatic. Conversely, stem cells (SCs) are regenerative and may offer long-term solutions. Among the different types of SCs, bone marrow SCs (BMSCs) and skeletal muscle-derived SCs (SkMSCs) have received the most attention in pre-clinical and clinical trial studies concerning the lower urinary tract. In particular, clinical trials with SkMSCs for stress urinary incontinence have demonstrated impressive efficacy. However, both SkMSCs and BMSCs are difficult to obtain in quantity and therefore neither is optimal for the eventual implementation of SC therapy. On the other hand, adipose tissue-derived SCs (ADSCs) can be easily and abundantly obtained from "discarded" adipose tissue. Moreover, in several head-on comparison studies, ADSCs have demonstrated equal or superior therapeutic potential compared to BMSCs. Therefore, across several different medical disciplines, including urology, ADSC research is gaining wide attention. For the regeneration of bladder tissues, possible differentiation of ADSCs into bladder smooth muscle and epithelial cells has been demonstrated. For the treatment of bladder diseases, specifically hyperlipidemia and associated overactive bladder, ADSCs have also demonstrated efficacy. For the treatment of urethral sphincter dysfunction associated with birth trauma and hormonal deficiency, ADSC therapy was also beneficial. Finally, ADSCs were able to restore erectile function in various types of erectile dysfunction (ED), including those associated with diabetes, hyperlipidemia, and nerve injuries. Thus, ADSCs have demonstrated remarkable therapeutic potentials for the lower urinary tract.

[The artificial sphincter: therapy for faecal incontinence].

PubMed

Baumgartner, U

2012-08-01

Faecal incontinence (FI) challenges a patient's professional, social and sexual life. Often the patient becomes depressive and socially isolated. If able to break open for therapy the patient should receive as first line a conservative treatment (like dietary measures, pelvic re-education, biofeedback, bulking agents, irrigation). When is the time to implant an artificial anal sphincter? If conservative therapy fails as well as surgical options (like a sphincteroplasty - if indicated a reconstruction of the pelvic floor if insufficient, or a sacral nerve stimulation) an ultimo surgical procedure should be offered to appropriate and compliant patients: an artificial anal sphincter. Worldwide, there are two established devices on the market: the artificial bowel sphincter® (ABS) from A. M. S. (Minnetonka, MN, USA) and the soft anal band® from A. M. I. (Feldkirch, Austria). How to implant the artificial anal sphincter? Both devices consist of a silicon cuff which can be filled with fluid. Under absolute aseptic conditions this cuff is placed in the lithotomy position by perianal incisions around the anal canal below the pelvic floor. A silicon tube connects the anal cuff with a reservoir (containing fluid) which is placed either behind the pubis bone in front of the bladder (ABS) or below the costal arch (anal band). With a pump placed in the scrotum/labia (ABS) or by pressing the balloon (anal band) in both types operated by the patient the fluid is shifted forth and back between the anal cuff and the reservoir closing or opening the anal canal. Both systems are placed completely subcutaneously. Both devices improve significantly the anal continence. Both systems have a high rate of reoperations. However, the causes for the redos are different. The ABS is associated with high infection and anal penetration rates of the cuff leading to an explantation rate to up to 60 % of the implants. This kind of complication seems to be much lower with the anal band. The major problem in the anal band is a defunctioning valve which occasionally has to be replaced. Despite these problems both types of artificial anal sphincters improve faecal incontinence significantly and, thus, quality of life of incontinent patients. Georg Thieme Verlag KG Stuttgart · New York.

The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries.

PubMed

Benavides, Lorena; Wu, Jennifer M; Hundley, Andrew F; Ivester, Thomas S; Visco, Anthony G

2005-05-01

A forceps-assisted vaginal delivery is a well-recognized risk factor for anal sphincter injury. Some studies have shown that occiput posterior (OP) fetal head position is also associated with an increased risk for third- or fourth-degree lacerations. The objective of this study was to assess whether OP position confers an incrementally increased risk for anal sphincter injury above that present with forceps deliveries. This was a retrospective cohort study of 588 singleton, cephalic, forceps-assisted vaginal deliveries performed at our institution between January 1996 and October 2003. Maternal demographics, labor and delivery characteristics, and neonatal factors were examined. Statistical analysis consisted of univariate statistics, Student t test, chi2, and logistic regression. The prevalence of occiput anterior (OA) and OP positions was 88.4% and 11.6%, respectively. The groups were similar in age, marital status, body mass index, use of epidural, frequency of inductions, episiotomies, and shoulder dystocias. The OA group had a higher frequency of rotational forceps (16.2% vs 5.9%, P = .03), greater birth weights (3304 +/- 526 g vs 3092 +/- 777 g, P = .004), and a larger percentage of white women (48.8% vs 34.3%, P = .04). Overall, 35% of forceps deliveries resulted in a third- or fourth-degree laceration. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (51.5% vs 32.9%, P = .003), giving an odds ratio of 2.2 (CI: 1.3-3.6). In a logistic regression model that controlled for occiput posterior position, maternal body mass index, race, length of second stage, episiotomy, birth weight, and rotational forceps, OP head position was 3.1 (CI: 1.6-6.2) times more likely to be associated with anal sphincter injury than OA head position. Forceps-assisted vaginal deliveries have been associated with a greater risk for anal sphincter injury. Within this population of forceps deliveries, an OP position further increases the risk of third- or fourth-degree lacerations when compared with an OA position.

Peroral endoscopic pyloromyotomy is efficacious and safe for refractory gastroparesis: prospective trial with assessment of pyloric function.

PubMed

Jacques, Jérémie; Pagnon, Lauriane; Hure, Florent; Legros, Romain; Crepin, Sabrina; Fauchais, Anne-Laure; Palat, Sylvain; Ducrotté, Philippe; Marin, Benoit; Fontaine, Sebastien; Boubaddi, Nour Edine; Clement, Marie-Pierre; Sautereau, Denis; Loustaud-Ratti, Veronique; Gourcerol, Guillaume; Monteil, Jacques

2018-06-12

 Gastroparesis is a functional disorder with a variety of symptoms that is characterized by delayed gastric emptying in the absence of mechanical obstruction. A recent series of retrospective studies has demonstrated that peroral endoscopic pyloromyotomy (G-POEM) is a promising endoscopic procedure for treating patients with refractory gastroparesis. The aim of this prospective study was to evaluate the feasibility, safety, and efficacy of G-POEM.  20 patients with refractory gastroparesis (10 diabetic and 10 nondiabetic) were prospectively included in the trial. Patients were treated by G-POEM after evaluation of pyloric function using an endoscopic functional luminal imaging probe. Clinical responses were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and quality of life was assessed using the Patient Assessment of Upper Gastrointestinal Disorders - Quality of Life scale and the Gastrointestinal Quality of Life Index scores. Gastric emptying was measured using 4-hour scintigraphy before G-POEM and at 3 months.  Feasibility of the procedure was 100 %. Compared with baseline values, G-POEM significantly improved symptoms (GCSI: 1.3 vs. 3.5; P  < 0.001), quality of life, and gastric emptying (T½: 100 vs. 345 minutes, P  < 0.001; %H2: 56.0 % vs. 81.5 %, P  < 0.001; %H4: 15.0 % vs. 57.5 %, P  = 0.003) at 3 months. The clinical success of G-POEM using the functional imaging probe inflated to 50 mL had specificity of 100 % and sensitivity of 72.2 % ( P  = 0.04; 95 % confidence interval 0.51 - 0.94; area under the curve 0.72) at a distensibility threshold of 9.2 mm 2 /mmHg.  G-POEM was efficacious and safe for treating refractory gastroparesis, especially in patients with low pyloric distensibility. © Georg Thieme Verlag KG Stuttgart · New York.

Sphincter-sparing local excision and hypofractionated radiation therapy for anorectal melanoma: a 20-year experience.

PubMed

Kelly, Patrick; Zagars, Gunar K; Cormier, Jancie N; Ross, Merrick I; Guadagnolo, B Ashleigh

2011-10-15

Anorectal melanoma is a rare disease with a poor prognosis. Because survival is determined by distant failure, many centers have adopted sphincter-sparing excision for primary tumor control. However, this approach is associated with high rates of local failure (∼50%). In this study, the authors report their 20-year experience with sphincter-sparing excision combined with radiation therapy (RT) for the treatment of localized anorectal melanoma. The authors reviewed the records of 54 patients with localized anorectal melanoma who were treated at the University of Texas MD Anderson Cancer Center from 1989 to 2008. All patients underwent definitive local excision with or without sentinel lymph node biopsy or lymph node dissection. RT (25-36 grays in 5-6 fractions) was delivered to extended fields that targeted the primary site and draining pelvic/inguinal lymphatics in 39 patients and to limited fields that targeted only the primary site in 15 patients. The 5-year rates of local control (LC), lymph node control (NC), and sphincter preservation were 82%, 88%, and 96%, respectively. However, because of the high rate of distant metastasis, the overall survival (OS) rate at 5 years was only 30%. Although there were no significant differences in LC, NC, or OS based on RT field extent, patients who received extended-field RT had higher rates of lymphedema than patients who received limited-field RT. The current results indicated that combined sphincter-sparing local excision and RT is a well tolerated approach that provides effective LC for patients with anorectal melanoma. Inclusion of the inguinal lymph node basins in the RT fields did not improve outcomes and was associated with an increased risk of lymphedema. Copyright © 2011 American Cancer Society.

Design of sEMG assembly to detect external anal sphincter activity: a proof of concept.

PubMed

Shiraz, Arsam; Leaker, Brian; Mosse, Charles Alexander; Solomon, Eskinder; Craggs, Michael; Demosthenous, Andreas

2017-10-31

Conditional trans-rectal stimulation of the pudendal nerve could provide a viable solution to treat hyperreflexive bladder in spinal cord injury. A set threshold of the amplitude estimate of the external anal sphincter surface electromyography (sEMG) may be used as the trigger signal. The efficacy of such a device should be tested in a large scale clinical trial. As such, a probe should remain in situ for several hours while patients attend to their daily routine; the recording electrodes should be designed to be large enough to maintain good contact while observing design constraints. The objective of this study was to arrive at a design for intra-anal sEMG recording electrodes for the subsequent clinical trials while deriving the possible recording and processing parameters. Having in mind existing solutions and based on theoretical and anatomical considerations, a set of four multi-electrode probes were designed and developed. These were tested in a healthy subject and the measured sEMG traces were recorded and appropriately processed. It was shown that while comparatively large electrodes record sEMG traces that are not sufficiently correlated with the external anal sphincter contractions, smaller electrodes may not maintain a stable electrode tissue contact. It was shown that 3 mm wide and 1 cm long electrodes with 5 mm inter-electrode spacing, in agreement with Nyquist sampling, placed 1 cm from the orifice may intra-anally record a sEMG trace sufficiently correlated with external anal sphincter activity. The outcome of this study can be used in any biofeedback, treatment or diagnostic application where the activity of the external anal sphincter sEMG should be detected for an extended period of time.

Ingestion of a carbonated beverage decreases lower esophageal sphincter pressure and increases frequency of transient lower esophageal sphincter relaxation in normal subjects.

PubMed

Shukla, Akash; Meshram, Megha; Gopan, Amrit; Ganjewar, Vaibhav; Kumar, Praveen; Bhatia, Shobna J

2012-06-01

Transient lower esophageal sphincter relaxation (tLESR) and decreased basal lower esophageal sphincter (LES) pressure are postulated mechanisms of gastroesophageal reflux (GER). There is conflicting evidence on the effect of carbonated drinks on lower esophageal sphincter function. This study was conducted to assess the effect of a carbonated beverage on tLESR and LES pressure. High resolution manometry tracings (16 channel water-perfused, Trace 1.2, Hebbard, Australia) were obtained in 18 healthy volunteers (6 men) for 30 min each at baseline, and after 200 mL of chilled potable water and 200 mL of chilled carbonated cola drink (Pepsi [Pepsico India Ltd]). The sequence of administration of the drinks was determined by random number method generated by a computer. The analysis of tracings was done using TRACE 1.2 software by a physician who was unaware of the sequence of administration of fluids. The mean (SD) age of the participant was 37.3 (12.9) years. The median (range) frequency of tLESr was higher after the carbonated beverage (10.5 [0-26]) as compared to baseline (0 [0-3], p = 0.005) as well as after water (1 [0-14], p = 0.010). The LES pressure decreased after ingestion of the carbonated beverage (18.5 [11-37] mmHg) compared to baseline (40.5 [25-66] mmHg, p = 0.0001) and after water (34 [15-67] mmHg, p = 0.003). Gastric pressure was not different in the three groups. Ingestion of a carbonated beverage increases tLESr and lowers LES pressure in healthy subjects.

Comparison of angiotensin II (Ang II) effects in the internal anal sphincter (IAS) and lower esophageal sphincter smooth muscles.

PubMed

Rattan, Satish; Fan, Ya-Ping; Puri, Rajinder N

2002-03-22

Studies were performed to compare the actions of Ang II in the internal anal sphincter (IAS) vs. lower esophageal sphincter (LES) smooth muscles in vitro, in opossum and rabbit. Studies also were carried out in isolated smooth muscle cells. In opossum, Ang II produced no discernible effects in the IAS, but did produce a concentration-dependent contraction in the LES. Conversely, in the rabbit, while Ang II caused a modest response in the LES, it caused a significant contraction in the IAS. The contractile responses of Ang II in the opossum LES were mostly resistant to different neurohumoral antagonists but were antagonized by AT1 antagonist losartan. AT2 antagonist PD 123,319, rather than inhibiting, prolonged the contractile action of Ang II. The contractile actions of Ang II in the opossum LES were not modified by the tyrosine kinase inhibitors (genistein and tyrphostin 1 x 10(-6) M) but were partially attenuated by the PKC inhibitor H-7 (1 x 10(-6) M), Ca2+ channel blocker nicardipine (1 x 10(-5) M), Rho kinase inhibitor HA-1077 (1 x 10(-7) M) or p(44/42) MAP kinase inhibitor PD 98059 (5 x 10(-5) M). The combination of HA-1077 and H-7 did not cause an additive attenuation of Ang II responses. Western blot analyses revealed the presence of both AT1 and AT2 receptors. We conclude that Ang lI-induced contraction of sphincteric smooth muscle occurs primarily by the activation of AT1 receptors at the smooth muscle cells and involves multiple pathways, influx of Ca2+, and PKC, Rho kinase and p(44/42) MAP kinase.

The participation of the nitrergic pathway in increased rate of transitory relaxation of lower esophageal sphincter induced by rectal distension in dogs.

PubMed

Palheta, Michel Santos; Graça, José Ronaldo Vasconcelos da; Santos, Armênio Aguiar dos; Lopes, Liziane Hermógenes; Palheta Júnior, Raimundo Campos; Nobre E Souza, Miguel Ângelo

2014-01-01

The rectal distension in dogs increases the rate of transitory lower esophageal sphincter relaxation considered the main factor causing gastroesophageal reflux. The aim of this study was evaluate the participation of the nitrergic pathway in the increased transitory lower esophageal sphincter relaxation rate induced by rectal distension in anesthetized dogs. Male mongrel dogs (n = 21), weighing 10-15 kg, were fasted for 12 hours, with water ad libitum. Thereafter, they were anesthetized (ketamine 10 mg.Kg-1 + xylazine 20 mg.Kg-1), so as to carry out the esophageal motility evaluation protocol during 120 min. After a 30-minute basal period, the animals were randomly intravenous treated whith: saline solution 0.15M (1ml.Kg-1), L-NAME (3 mg.Kg-1), L-NAME (3 mg.Kg-1) + L-Arginine (200 mg.Kg-1), glibenclamide (1 mg.Kg-1) or methylene blue (3 mg.Kg-1). Forty-five min after these pre-treatments, the rectum was distended (rectal distension, 5 mL.Kg-1) or not (control) with a latex balloon, with changes in the esophageal motility recorded over 45 min. Data were analyzed using ANOVA followed by Student Newman-Keuls test. In comparison to the respective control group, rectal distension induces an increase in transitory lower esophageal sphincter relaxation. Pre-treatment with L-NAME or methylene blue prevents (P<0.05) this phenomenon, which is reversible by L-Arginine plus L-NAME. However, pretreating with glibenclamide failed to abolish this process. Therefore, these experiments suggested, that rectal distension increases transitory lower esophageal sphincter relaxation in dogs via through nitrergic pathways.

Quality of life after surgery for rectal cancer: do we still need a permanent colostomy?

PubMed

Renner, K; Rosen, H R; Novi, G; Hölbling, N; Schiessel, R

1999-09-01

A permanent colostomy is a serious limitation of the quality of life. Besides cure of cancer, preservation of sphincter function is an important goal of surgery for rectal cancer. In a prospective study a concept offering every patient with rectal cancer either sphincter salvage or a "neosphincter" was investigated, and the impact of this strategy on oncologic results, sphincter function, and quality of life was analyzed. From 1992 to 1997, 276 patients were accepted for the study. Two hundred sixty-one patients had elective surgery, and 15 patients had emergency surgery for their rectal tumors. The postoperative mortality rate was 4 percent. A radical resection (R0) was possible in 197 patients (75 percent). Anterior resection was the most common procedure (n = 87), and intersphincteric resection with coloanal anastomosis was the preferred method for low tumors (n = 65). Abdominoperineal resection was necessary in 15 cases. Thirteen patients had an immediate restoration of sphincter function by means of a dynamic graciloplasty, and 2 patients needed emergency abdominoperineal resection for bleeding. The follow-up was relatively short (median, 36.4 months) at the time of data analysis and showed a local recurrence rate of 8 percent. Although postoperative continence according to the Williams score revealed satisfactory results, subjective quality of life and the scale for specific symptoms showed a significantly worse outcome in patients with ultralow (coloanal) anastomoses compared with those with anterior resection. We conclude that for elective curative surgery of rectal cancer, a permanent colostomy is not necessary provided all presently available techniques of sphincter salvage and restoration are applied. However, the patient has to be informed about possible side effects associated with surgical procedures such as coloanal anastomosis or neosphincter reconstruction, to avoid severe psychological difficulties.

Innovation in the imaging perianal fistula: a step towards personalised medicine

PubMed Central

Sahnan, Kapil; Adegbola, Samuel O.; Tozer, Philip J.; Patel, Uday; Ilangovan, Rajpandian; Warusavitarne, Janindra; Faiz, Omar D.; Hart, Ailsa L.; Phillips, Robin K. S.; Lung, Phillip F. C.

2018-01-01

Background: Perianal fistula is a topic both hard to understand and to teach. The key to understanding the treatment options and the likely success is deciphering the exact morphology of the tract(s) and the amount of sphincter involved. Our aim was to explore alternative platforms better to understand complex perianal fistulas through three-dimensional (3D) imaging and reconstruction. Methods: Digital imaging and communications in medicine images of spectral attenuated inversion recovery magnetic resonance imaging (MRI) sequences were imported onto validated open-source segmentation software. A specialist consultant gastrointestinal radiologist performed segmentation of the fistula, internal and external sphincter. Segmented files were exported as stereolithography files. Cura (Ultimaker Cura 3.0.4) was used to prepare the files for printing on an Ultimaker 3 Extended 3D printer. Animations were created in collaboration with Touch Surgery™. Results: Three examples of 3D printed models demonstrating complex perianal fistula were created. The anatomical components are displayed in different colours: red: fistula tract; green: external anal sphincter and levator plate; blue: internal anal sphincter and rectum. One of the models was created to be split in half, to display the internal opening and allow complexity in the intersphincteric space to better evaluated. An animation of MRI fistulography of a trans-sphincteric fistula tract with a cephalad extension in the intersphincteric space was also created. Conclusion: MRI is the reference standard for assessment of perianal fistula, defining anatomy and guiding surgery. However, communication of findings between radiologist and surgeon remains challenging. Feasibility of 3D reconstructions of complex perianal fistula is realized, with the potential to improve surgical planning, communication with patients, and augment training. PMID:29854001

Proctalgia fugax.

PubMed

Potter, M A; Bartolo, D C

2001-11-01

Proctalgia fugax is a benign, self-limiting pain experienced in the perineum. It is common, but most sufferers do not seek medical advice. The aetiology is unclear, but a variation of irritable bowel syndrome, pelvic floor myalgia, and internal anal sphincter spasm have all been suggested. A careful history can elicit the characteristic history, and simple reassurance is often all that is necessary. For persistent symptoms, therapies that induce internal anal sphincter relaxation are of value.

Risk factors for anal sphincter tears in vacuum-assisted delivery.

PubMed

Ryman, P; Ahlberg, M; Ekéus, C

2015-10-01

The aim of the present study was to describe the prevalence of anal sphincter tears (AST) in relation to obstetric management and technique during vacuum extraction deliveries (VE) (re: indications, the station of the fetal head at application of the cup, number of tractions, the length for the extraction, cup detachments, pain relief, episiotomy, fetal presentation, and experience of the operator) as well as maternal and infant anthropometrics. Descriptive study. Data on six hundred vacuum extraction deliveries were consecutively collected from six different delivery units in Sweden. Each unit contributed with data on 100 deliveries. The final study population included 596 women who delivered by vacuum extraction. There was no correlation between the management of the vacuum extraction and risk for anal sphincter tear. Women from Africa had nearly a fourfold risk for anal sphincter tear during vacuum-assisted delivery compared with Swedish-born women (OR 3.82 CI 1.47-9.89). Compared with infants with birth weight less than 4000 g, birth weight above 4000 g was associated with increased risk of AST (OR 1.87 CI 1.06-3.28). In this study, the obstetric management in VE-assisted deliveries did not impact the risk of AST. Copyright © 2015 Elsevier B.V. All rights reserved.

Use of a spiral rectal diaphragm technique to control anal sphincter incontinence in a cat.

PubMed

Pavletic, Michael; Mahn, Matt; Duddy, Jean

2012-09-15

A 10-year-old castrated male domestic shorthair cat was examined for a mass involving the right anal sac region. The mass was diagnosed as a fibrosarcoma, and resulted in progressive tenesmus, requiring repeated resection. Surgical removal of the fibrosarcoma was performed on 4 occasions, including complete resection of the anal sphincter muscles and portions of the rectum. A perineal urethrostomy was required during the third surgical procedure secondary to tumor invasion of the preputial tissues. To reduce involuntary loss of feces, the remaining rectal wall was rotated approximately 225° prior to surgical closure during the second, third, and fourth surgical procedures. This procedure created a natural spiral diaphragm within the rectal lumen. The elastic spiral barrier reduced inadvertent fecal loss and facilitated fecal distention of the terminal portion of the colon, allowing the patient to anticipate the impending passage of feces and to use the litter tray on a daily basis. With complete loss of the terminal portion of the rectum and anal sphincter muscles, spiraling the rectum created a deformable threshold barrier to reduce excessive loss of stool secondary to fecal incontinence. On the basis of the positive outcome in this patient, this novel technique may be a useful option to consider for the treatment of cats with loss of anal sphincter function.

Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry.

PubMed

Roman, S; Holloway, R; Keller, J; Herbella, F; Zerbib, F; Xiao, Y; Bernard, L; Bredenoord, A J; Bruley des Varannes, S; Chen, M; Fox, M; Kahrilas, P J; Mittal, R K; Penagini, R; Savarino, E; Sifrim, D; Wu, J; Decullier, E; Pandolfino, J E; Mion, F

2017-02-01

Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non-events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria. All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non-events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria. Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition. © 2016 John Wiley & Sons Ltd.

Comparison of saddle, lumbar epidural and caudal blocks on anal sphincter tone: A prospective, randomized study.

PubMed

Shon, Yoon-Jung; Huh, Jin; Kang, Sung-Sik; Bae, Seung-Kil; Kang, Ryeong-Ah; Kim, Duk-Kyung

2016-10-01

Objective To compare the effects of saddle, lumbar epidural and caudal blocks on anal sphincter tone using anorectal manometry. Methods Patients undergoing elective anorectal surgery with regional anaesthesia were divided randomly into three groups and received a saddle (SD), lumbar epidural (LE), or caudal (CD) block. Anorectal manometry was performed before and 30 min after each regional block. The degree of motor blockade of the anal sphincter was compared using the maximal resting pressure (MRP) and the maximal squeezing pressure (MSP). Results The study analysis population consisted of 49 patients (SD group, n = 18; LE group, n = 16; CD group, n = 15). No significant differences were observed in the percentage inhibition of the MRP among the three regional anaesthetic groups. However, percentage inhibition of the MSP was significantly greater in the SD group (83.6 ± 13.7%) compared with the LE group (58.4 ± 19.8%) and the CD group (47.8 ± 16.9%). In all groups, MSP was reduced significantly more than MRP after each regional block. Conclusions Saddle block was more effective than lumbar epidural or caudal block for depressing anal sphincter tone. No differences were detected between lumbar epidural and caudal blocks.

Anal sphincter fibrillation: is this a new finding that identifies resistant chronic anal fissures that respond to botulinum toxin?

PubMed

Moon, A; Chitsabesan, P; Plusa, S

2013-08-01

Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery. It would be useful to identify predictors of poor response to medical therapy. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail botulinum toxin (BT) treatment. A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures, referred to one consultant surgeon between 2007 and 2011, was undertaken. These were correlated with treatment plans and healing rates. Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude 'saw tooth' waveform or anal sphincter fibrillation (ASF) and higher anal sphincter pressures. Nine (82%) of these patients had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only one (7%) had resolution following BT. ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

Mechanism of continence after repair of posterior urethral disruption: evidence of rhabdosphincter activity.

PubMed

Whitson, Jared M; McAninch, Jack W; Tanagho, Emil A; Metro, Michael J; Rahman, Nadeem U

2008-03-01

Controversy exists regarding continence mechanisms in patients who undergo posterior urethral reconstruction after pelvic fracture. Some evidence suggests that continence after posterior urethroplasty is maintained by the bladder neck or proximal urethral mechanism without a functioning distal mechanism. We studied distal urethral sphincter activity in patients who have undergone posterior urethroplasty for pelvic fracture. A total of 12 patients who had undergone surgical repair of urethral disruption involving the prostatomembranous region underwent videourodynamics with urethral pressure profiles at rest, and during stress and hold maneuvers. Bladder pressure and urethral pressure, including proximal and distal urethral sphincter activity and pressure, were assessed in each patient. All 12 patients had daytime continence of urine postoperatively with a followup after anastomotic urethroplasty of 12 to 242 months (mean 76). Average maximum urethral pressure was 71 cm H2O. Average maximum urethral closure pressure was 61 cm H2O. The average urethral pressure seen during a brief hold maneuver was 111 cm H2O. Average functional sphincteric length was 2.5 cm. Six of the 12 patients had clear evidence of distal urethral sphincter function, as demonstrated by the profile. Continence after anastomotic urethroplasty for posttraumatic urethral strictures is maintained primarily by the proximal bladder neck. However, there is a significant contribution of the rhabdosphincter in many patients.

[Development and assessment of a workshop on repair of third and fourth degree obstetric tears].

PubMed

Emmanuelli, V; Lucot, J-P; Closset, E; Cosson, M; Deruelle, P

2013-04-01

To evaluate the educational interest of a workshop on diagnosis and repair of obstetric anal sphincter injuries (OASIS). To evaluate the theoretical and anatomical knowledge of OASIS repair by French residents in obstetrics and gynecology. The workshop was composed of slides, video of repair and training using cadaveric sow's anal sphincters. All subjects were tested with a questionnaire before and after the course. Thirty residents participated. Classification of OASIS was known by 13.3% of the residents before the training versus 93.3% after the workshop (P<0.001). Initially, only 6.7% correctly classified operative procedures of OASIS versus 86.7% after the workshop (P<0.001). Per pre-test, 90% of residents did not know how to identify the internal anal sphincter (IAS) versus 3% at post-test (P<0.001). Seventy percent of trainees correctly identified the external anal sphincter (EAS) at the beginning of training. Before the course, no resident knew the repair of the IAS and only one third knew the technical repair of the EAS. After the workshop, the theoretical knowledge of EAS and IAS repair were acquired by all (P<0.001). Structured hands-on training improves significantly the knowledge of OASIS diagnosis and repair. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Wolfram (DIDMOAD) syndrome: a multidisciplinary clinical study in nine Turkish patients and review of the literature.

PubMed

Simsek, E; Simsek, T; Tekgül, S; Hosal, S; Seyrantepe, V; Aktan, G

2003-01-01

To study Wolfram syndrome (WFS) with multidisciplinary consultations and compare the results with the literature. Nine patients fulfilled the ascertainment criteria of WFS (insulin-dependent diabetes mellitus and optic atrophy). All patients were evaluated by the departments of paediatrics, ophthalmology, audiology, urology and medical biology. The earliest manifestation of WFS was insulin-dependent diabetes mellitus (at a median age of 6.9 y), followed by optic atrophy (8.9 y), diabetes insipidus (10.2 y) and deafness (10.5 y). Short stature was found in five cases, delayed puberty in two cases and hypergonadotropic hypogonadism in one case. Audiography disclosed hearing loss at high frequency in all patients (100%), but only five patients had clinical subjective hearing problems. Intravenous pyelography revealed hydroureteronephrosis in eight patients. Urodynamics revealed a normal bladder in only one patient. Three patients had a low-capacity, low-compliance bladder, detrusor external sphincteric dyssynergia and emptying problem, while five had an atonic bladder. Ocular findings were optic atrophy, low visual acuity and colour vision defects. Visual field tests revealed concentric and/or peripheral diminution in five patients. Visual evoked potentials were abnormal (reduced amplitude to both flash and pattern stimulation) in seven patients. Cranial magnetic resonance imaging showed mild or moderate atrophy of the optic nerves, chiasm, cerebellum, basal ganglia and brainstem in six patients; there was a partially empty sella in one case. There was no evidence of mitochondrial tRNA(Leu) (UUR) A to G (nucleotide 3243) mutation. Wolfram syndrome should be evaluated in a multidisciplinary manner. Some specific and dynamic tests are necessary to make a more precise estimate of the prevalence and median age of the components of WFS. Short stature is a common feature in WFS. Hypogonadism may be hypogonadotropic or hypergonadotropic. Bladder dysfunction does not always present as a large atonic bladder in WFS. A low-capacity, high-pressure bladder with sphincteric dyssynergia is also common.

Association between Symptoms of Sleep-Disordered Breathing and Speech in Children with Craniofacial Malformations

PubMed Central

Moraleda-Cibrián, Marta; Berger, Mary; Edwards, Sean P.; Kasten, Steven J.; Buchman, Steven R.; O'Brien, Louise M.

2014-01-01

Study Objective: Sleep-disordered breathing (SDB) and speech difficulties are common problems in children with craniofacial malformations (CFM). The present study was designed to investigate whether resonance issues identified during speech assessment are associated with parental report of SDB symptoms in children with CFM. Methods: Children aged 2-18 years with congenital CFM attending at the Craniofacial Anomalies Program from March 2007 to April 2011 were screened for SDB symptoms using the Sleep-Related Breathing Disturbance Scale of the Pediatric Sleep Questionnaire. Speech evaluation, based on the Pittsburgh Weighted Speech Scale score, was the tool used to investigate velopharyngeal dysfunction (VPD) based on speech perceptual assessment. Results: A total of 488 children with congenital CFM were included. Overall 81% were Caucasian and 24% were overweight/obese. Twenty-four percent of children screened positive for SDB and 35% had VPD. Children with VPD were no more likely to screen positive for SDB than children without VPD (26% vs. 23%, p = 0.38). However, children with previous sphincter pharyngoplasty (SP) were more likely to have hyponasality (51% vs. 12%, p = 0.0001) and reduced or absent nasal emission (33% vs. 16%, p = 0.008). In a logistic regression, the adjusted odds ratio for SDB for those with hyponasality was 2.10 (95%CI 1.21-3.61, p = 0.008) and for those with reduced or absent nasal emission was 1.75 (95%CI 1.06-2.88, p = 0.028). Conclusion: Symptoms of sleep disordered breathing are common in children with craniofacial malformations especially if they have undergone sphincter pharyngoplasty; many of these children can be identified by measures of resonance on routine speech evaluation. Citation: Moraleda-Cibrián M, Berger M, Edwards SP, Kasten SJ, Buchman SR, O'Brien LM. Association between symptoms of sleep-disordered breathing and speech in children with craniofacial malformations. J Clin Sleep Med 2014;10(6):671-676. PMID:24932148

Plasticity in reflex pathways to the lower urinary tract following spinal cord injury

PubMed Central

de Groat, William C.; Yoshimura, Naoki

2013-01-01

The lower urinary tract has two main functions, storage and periodic expulsion of urine, that are regulated by a complex neural control system in the brain and lumbosacral spinal cord. This neural system coordinates the activity of two functional units in the lower urinary tract: (1) a reservoir (the urinary bladder) and (2) an outlet (consisting of bladder neck, urethra and striated muscles of the external urethra sphincter). During urine storage the outlet is closed and the bladder is quiescent to maintain a low intravesical pressure. During micturition the outlet relaxes and the bladder contracts to promote efficient release of urine. This reciprocal relationship between bladder and outlet is generated by reflex circuits some of which are under voluntary control. Experimental studies in animals indicate that the micturition reflex is mediated by a spinobulbospinal pathway passing through a coordination center (the pontine micturition center) located in the rostral brainstem. This reflex pathway is in turn modulated by higher centers in the cerebral cortex that are involved in the voluntary control of micturition. Spinal cord injury at cervical or thoracic levels disrupts voluntary control of voiding as well as the normal reflex pathways that coordinate bladder and sphincter function. Following spinal cord injury the bladder is initially areflexic but then becomes hyperreflexic due to the emergence of a spinal micturition reflex pathway. However the bladder does not empty efficiently because coordination between the bladder and urethral outlet is lost. Studies in animals indicate that dysfunction of the lower urinary tract after spinal cord injury is dependent in part on plasticity of bladder afferent pathways as well as reorganization of synaptic connections in the spinal cord. Reflex plasticity is associated with changes in the properties of ion channels and electrical excitability of afferent neurons and appears to be mediated in part by neurotrophic factors released in the spinal cord and/or the peripheral target organs. PMID:21596038

Anal sphincter dysfunction in patients treated with primary radiotherapy for anal cancer: a study with the functional lumen imaging probe.

PubMed

Haas, Susanne; Faaborg, Pia; Liao, Donghua; Laurberg, Søren; Gregersen, Hans; Lundby, Lilly; Christensen, Peter; Krogh, Klaus

2018-04-01

Sphincter-sparing radiotherapy or chemoradiation are standard treatments for patients with anal cancer. The ultimate treatment goal is full recovery from anal cancer with preserved anorectal function. Unfortunately, long-term survivors often suffer from severe anorectal symptoms. The aim of the present study was to characterize changes in anorectal physiology after radiotherapy for anal cancer. We included 13 patients (10 women, age 63.4 ± 1.9) treated with radiotherapy or chemoradiation for anal cancer and 14 healthy volunteers (9 women, age 61.4 ± 1.5). Symptoms were assessed with scores for fecal incontinence and low anterior resection syndrome. Anorectal physiology was examined with anorectal manometry and the Functional Lumen Imaging Probe. Patients had a median Wexner fecal incontinence score of 5 (0-13) and a median LARS score of 29 (0-39). Compared to healthy volunteers, patients had lower mean (±SE) anal -resting (38 ± 5 vs. 71 ± 6, p < .001) and -squeeze pressures (76 ± 11 vs. 165 ± 15, p < .001). Patients also had lower anal yield pressure (15.5 ± 1.3 mmHg vs. 28.0 ± 2.0 mmHg, p < .001), higher distensibility, and lower resistance to flow (reduced resistance ratio of the anal canal during distension, q = 5.09, p < .001). No differences were found in median (range) rectal volumes at first sensation (70.5 (15-131) vs. 57 (18-132) ml, p > .4), urge (103 (54-176) vs. 90 (32-212), p > .6) or maximum tolerable volume (173 (86-413) vs. 119.5 (54-269) ml, p > .10). Patients treated with radiotherapy or chemoradiation for anal cancer have low anal resting and squeeze pressures as well as reduced resistance to distension and flow.

Effects of Infant Starvation on Learning Abilities.

ERIC Educational Resources Information Center

Klein, Pnina S.

Explored were the effects of starvation during infancy on the learning abilities of 50 children when evaluated between 5 and 14 years of age. All Ss had suffered from pyloric stenosis, a condition which prevents passage of food from the stomach, in infancy for periods ranging from 2 days to 3 weeks. Ss were given five tests of various learning…

Use of GDNF-Releasing Nanofiber Nerve Guide Conduits for the Repair of Conus medullaris/Cauda Equina Injury in the Non-Human Primate

DTIC Science & Technology

2011-10-01

Cauda equina, non-human primate, ventral root. neural repair, electromyography , magnetic resonance imaging 16. SECURITY CLASSIFICATION OF: 17...of a guidance channel without GDNF release and a peripheral nerve graft to bridge the tissue gap. A comprehensive set of electrodiagnostic, imaging ... Electromyography (EMG) recordings of the external anal sphincter are obtained pre-operatively as baseline records. The external anal sphincter muscle

Reconstruction of the anus, rectovaginal septum, and distal part of the vagina after postirradiation necrosis. Report of a unique case

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nowacki, M.P.; Towpik, E.

1988-08-01

Successful repair of postirradiation total loss of the anal sphincters, rectovaginal septum, and distal part of the vagina is reported. Gracilis muscle flap was used as a substitute sphincter. Part of the muscle was wrapped-up in a split skin graft. To the authors' knowledge, this is the first report on new application of gracilis muscle and split skin graft in perineal reconstruction.

Long-term effect of sphincteric fatigue during bladder neurostimulation.

PubMed

Li, J S; Hassouna, M; Sawan, M; Duval, F; Elhilali, M M

1995-01-01

Commercially available stimulators lack several features, including multiple channel capability and flexible stimulation parameters. These factors limit clinical application. A new computerized electrical stimulator system was developed by our team and evaluated for its efficacy in bladder evacuation in an animal model after spinal cord transection. The system can generate a wide range of stimulation characteristics and has the feature of being a programmable multichannel pacemaker. It has enabled us to induce a reversible fatigue to the external sphincter that results in proper bladder emptying on stimulation. Using this new bladder pacemaker, 8 dogs were studied. We applied the concept of fatiguing of the external sphincter via the pudendal nerve to avoid rhizotomy. We determined the optimal stimulation parameters that can reliably empty the dog's bladder for the duration of the experiment, which lasted for 8 months. The new computerized electrical stimulation system achieved the objective of reducing bladder outlet resistance without the need for sacral rhizotomy.

Electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter system*

PubMed Central

Zan, Peng; Yang, Bang-hua; Shao, Yong; Yan, Guo-zheng; Liu, Hua

2010-01-01

This paper reports on the electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter. The coupling coils and human tissues, including the skin, fat, muscle, liver, and blood, were considered. Specific absorption rate (SAR) and current density were analyzed by a finite-length solenoid model. First, SAR and current density as a function of frequency (10–107 Hz) for an emission current of 1.5 A were calculated under different tissue thickness. Then relations between SAR, current density, and five types of tissues under each frequency were deduced. As a result, both the SAR and current density were below the basic restrictions of the International Commission on Non-Ionizing Radiation Protection (ICNIRP). The results show that the analysis of these data is very important for developing the artificial anal sphincter system. PMID:21121071

Electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter system.

PubMed

Zan, Peng; Yang, Bang-hua; Shao, Yong; Yan, Guo-zheng; Liu, Hua

2010-12-01

This paper reports on the electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter. The coupling coils and human tissues, including the skin, fat, muscle, liver, and blood, were considered. Specific absorption rate (SAR) and current density were analyzed by a finite-length solenoid model. First, SAR and current density as a function of frequency (10-10(7) Hz) for an emission current of 1.5 A were calculated under different tissue thickness. Then relations between SAR, current density, and five types of tissues under each frequency were deduced. As a result, both the SAR and current density were below the basic restrictions of the International Commission on Non-Ionizing Radiation Protection (ICNIRP). The results show that the analysis of these data is very important for developing the artificial anal sphincter system.

Diagnostic pitfalls in sporadic transthyretin familial amyloid polyneuropathy (TTR-FAP).

PubMed

Planté-Bordeneuve, V; Ferreira, A; Lalu, T; Zaros, C; Lacroix, C; Adams, D; Said, G

2007-08-14

Transthyretin familial amyloid polyneuropathies (TTR-FAPs) are autosomal dominant neuropathies of fatal outcome within 10 years after inaugural symptoms. Late diagnosis in patients who present as nonfamilial cases delays adequate management and genetic counseling. Clinical data of the 90 patients who presented as nonfamilial cases of the 300 patients of our cohort of patients with TTR-FAP were reviewed. They were 21 women and 69 men with a mean age at onset of 61 (extremes: 38 to 78 years) and 17 different mutations of the TTR gene including Val30Met (38 cases), Ser77Tyr (16 cases), Ile107Val (15 cases), and Ser77Phe (5 cases). Initial manifestations included mainly limb paresthesias (49 patients) or pain (17 patients). Walking difficulty and weakness (five patients) and cardiac or gastrointestinal manifestations (five patients), were less common at onset. Mean interval to diagnosis was 4 years (range 1 to 10 years); 18 cases were mistaken for chronic inflammatory demyelinating polyneuropathy, which was the most common diagnostic error. At referral a length-dependent sensory loss affected the lower limbs in 2, all four limbs in 20, and four limbs and anterior trunk in 77 patients. All sensations were affected in 60 patients (67%), while small fiber dysfunction predominated in the others. Severe dysautonomia affected 80 patients (90%), with postural hypotension in 52, gastrointestinal dysfunction in 50, impotence in 58 of 69 men, and sphincter disturbance in 31. Twelve patients required a cardiac pacemaker. Nerve biopsy was diagnostic in 54 of 65 patients and salivary gland biopsy in 20 of 30. Decreased nerve conduction velocity, increased CSF protein, negative biopsy findings, and false immunolabeling of amyloid deposits were the main causes of diagnostic errors. We conclude that DNA testing, which is the most reliable test for TTR-FAP, should be performed in patients with a progressive length-dependent small fiber polyneuropathy of unknown origin, especially when associated with autonomic dysfunction.

The effects of obesity on oesophageal function, acid exposure and the symptoms of gastro-oesophageal reflux disease.

PubMed

Anggiansah, R; Sweis, R; Anggiansah, A; Wong, T; Cooper, D; Fox, M

2013-03-01

Obese patients have an increased risk of gastro-oesophageal reflux disease; however, the mechanism underlying this association is uncertain. To test the hypothesis that mechanical effects of obesity on oesophageal function increase acid exposure and symptoms. Height, weight and waist circumference (WC) were measured in patients with typical reflux symptoms referred for manometry and 24 h ambulatory pH studies. Symptom severity was assessed by questionnaire. The association between obesity [WC, body mass index (BMI)], oesophageal function, acid exposure and reflux symptoms was assessed. Physiological measurements were obtained from 582 patients (median age 48, 56% female) of whom 406 (70%) completed symptom questionnaires. The prevalence of general obesity was greater in women (BMI ≥ 30 kg/m(2) ; F 23%:M 16%; P = 0.056), however more men had abdominal obesity (WC ≥ 99 cm (M 41%:F 28%; P = 0.001)). Oesophageal acid exposure increased with obesity (WC: R = 0.284, P < 0.001) and was associated also with lower oesophageal sphincter (LOS) pressure, reduced abdominal LOS length and peristaltic dysfunction (all P < 0.001). Univariable regression showed a negative association of WC with both LOS pressure and abdominal LOS length (R = -0.221 and -0.209 respectively; both P < 0.001). However, multivariable analysis demonstrated that the effects of increasing WC on oesophageal function do not explain increased acid reflux in obese patients. Instead, independent effects of obesity and oesophageal dysfunction on acid exposure were present. Reflux symptoms increased with acid exposure (R = 0.300; P < 0.001) and this association explained increased symptom severity in obese patients. Abdominal obesity (waist circumference) is associated with oesophageal dysfunction, increased acid exposure and reflux symptoms; however, this analysis does not support the mechanical hypothesis that the effects of obesity on oesophageal function are the cause of increased acid exposure in obese patients. © 2013 Blackwell Publishing Ltd.

Complete Penile Duplication with Structurally Normal Penises: A Case Report.

PubMed

Karagözlü Akgül, Ahsen; Uçar, Murat; Çelik, Fatih; Kırıştıoğlu, İrfan; Kılıç, Nizamettin

2018-03-28

Diphallia is a very rare anomaly and seen once in every 5.5 million live births. True diphallia with normal penile structures is extremely rare (1,2,3,4,5,6,7). We present the surgical management of a 4-year-old patient with complete penile duplication without any penile or urethral pathology. The patient's first physical examination revealed complete penile duplication, urine flow from both penises, meconium flow from right urethra, and anal atresia. Further evaluations showed double colon and rectum, double bladder, and large recto-vesical fistula. Two cavernous bodies and one spongious body were detected in each penile body. Surgical treatment plan consisted of right total penectomy and end-to-side urethra-urethrostomy. No postoperative complications and no voiding dysfunction were detected during the 18 months follow-up. Penile duplication is a rare anomaly, which presents differently in each patient. Because of this, the treatment should be individualized and end-to-side urethra-urethrostomy may be an alternative to removing posterior urethra. This approach eliminates the risk of damaging prostate gland and sphincter.

[Tuberculous meningoencephalitis--own observations].

PubMed

Garlicki, Aleksander; Kluba-Wojewoda, Urszula; Bociaga-Jasik, Monika; Kalinowska-Nowak, Anna; Sobczyk-Krupiarz, Iwona; Mach, Tomasz

2003-01-01

Nine cases of the tuberculous meningoencephalitis in adult men and women treated in years 1993-2000 have been presented. The diagnosis was established on the basis of clinical picture and examination of the cerebrospinal fluid (CSF). Routine analysis of CSF was done, as well as the microscopic examination, biological assay, and culture on the Lowenstein-Jensena medium and using Bactec 460 TB system. Only in one case Mycobacterium tuberculosis was found in the smear of CSF stained by Ziehl-Nielsen method. In one case the biologic assay was positive and Mycobacterium tuberculosis was cultured on Lowenstein-Jensen medium. In another 4 cases the pathogen was detected by Bactec 460 TB technique. In 4 cases Mycobacterium tuberculosis was also cultured from the secretion of the respiratory tract, and in one patient urine. On chest X-ray characteristic changes for pulmonary tuberculosis were observed in 5 cases (56%). Seven patients (78%) had hydrocephalus detected on CT scan of the head. One patient died, one (11%) developed persistent complication in form of spastic paralysis of lower extremities and sphincters dysfunction. Seven patients (78%) recovered completely after the 12 months therapy with standard chemotherapeutic regimen for tuberculosis.

Pseudobulbar paralysis in the Renaissance: Cosimo I de' Medici case.

PubMed

Arba, F; Inzitari, D; Lippi, D

2014-07-01

Cosimo I de' Medici (1519-1574) was the first Grand Duke of Tuscany. He was one of the most important members of the Medici family. He was an excellent conqueror and a good politician. Moreover, he was able to attract and encourage artists, scientists and architects to promote Florence as the cultural capital of the Italian Renaissance. Historical chronicles report that he suffered from a stroke when he was 49 years old. Together with the acute manifestation of stroke, he displayed peculiar symptoms. He had gait disturbances and sphincter dysfunctions. His language became poor and hard to understand. His mood was very fluctuating and in the last years of his life he was a short-tempered man. In addition, he had a characteristic symptom, so-called pathological laughing and crying. The course of his disease was slow and stuttering. Taken together, these data seem to be one of the first reports of pseudobulbar paralysis. The disease of Cosimo I was probably due to a chronic cerebral vasculopathy, known as small vessels disease. We discuss this hypothesis regarding an ancient clinical case, with the support of current studies.

[Anatomy of the levator ani muscle and implications for obstetrics and gynaecology].

PubMed

Nyangoh Timoh, K; Bessede, T; Zaitouna, M; Peschaud, F; Chevallier, J-M; Fauconnier, A; Benoit, G; Moszkowicz, D

2015-01-01

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery. Copyright © 2015. Published by Elsevier SAS.

Effects of Age, Gender, Bolus Condition, Viscosity, and Volume on Pharyngeal and Upper Esophageal Sphincter Pressure and Temporal Measurements during Swallowing

ERIC Educational Resources Information Center

Butler, Susan G.; Stuart, Andrew; Castell, Donald; Russell, Gregory B.; Koch, Kenneth; Kemp, Shannon

2009-01-01

Purpose: The purpose of this study was to determine the effects of trial (i.e., Trial 1 vs. Trial 2); viscosity (i.e., saliva, thin, nectar-thick, honey-thick, and pudding-thick water); volume (i.e., 5 mL vs. 10 mL); age (i.e., young vs. older adults); and gender on pharyngeal (i.e., upper and lower) and upper esophageal sphincter (UES) pressures,…

The importance of the orientation of the electrode plates in recording the external anal sphincter EMG by non-invasive anal plug electrodes.

PubMed

Binnie, N R; Kawimbe, B M; Papachrysostomou, M; Clare, N; Smith, A N

1991-02-01

Two non-invasive anal plug electrodes of similar size have been compared, one with the electrode plates orientated circularly in the anal canal and the other with the plates in the long axis of the anal canal. There was a significant increase in the amplitude in the EMG signals recorded at rest and during squeeze from the external anal sphincter with a longitudinally placed electrode in 117 patients. Inappropriate contraction of the external anal sphincter when straining at stool was more readily detected using the longitudinal electrode in 52 patients investigated for intractable constipation. The longitudinal electrode detected the amplitude of the response to the elicitation of a pudeno-anal reflex more readily than the circular electrode. When in 12 of the 117 the pudeno-anal reflex EMG signal was either absent or not detected with the circumferential plug electrode, the longitudinal electrode detected the presence of a low amplitude response in 11 of these. When the non-invasive longitudinal electrode was compared to invasive fine wire stainless steel electrodes, a correlation was found for external anal sphincter resting EMG (r = 0.99, p less than 0.01), voluntary squeeze EMG (r = 0.99, p less than 0.001) and strain EMG (r = 0.91, p less than 0.01). The longitudinal anal plug electrode thus facilitates surface acquisition of EMG activity.

Long-term functional outcomes after artificial urinary sphincter implantation in women with stress urinary incontinence.

PubMed

Phé, Véronique; Benadiba, Steeve; Rouprêt, Morgan; Granger, Benjamin; Richard, François; Chartier-Kastler, Emmanuel

2014-06-01

To assess the long-term outcomes obtained after artificial urinary sphincter (AUS) implantation in women with stress urinary incontinence (SUI). Women with SUI caused by intrinsic sphincter deficiency who underwent an AUS placement between 1984 and 1992 were included. Explantation, revision and deactivation rates of the AUS were reported. Continence, defined as no pad use, was assessed at the end of the follow-up. Kaplan-Meier survival curves were generated to evaluate the survival rate of the device without explantation or revision. A total of 34 patients were included. The median (interquartile range [IQR]) age of the patients at surgery was 56.5 (50-64.7) years and the median (IQR) follow-up was 17 (12-19) years. Overall, 26 women (74%) still had their AUS in place at the end of the follow-up, while eight patients underwent an explantation of the device. The 10-, 15- and 20-year device survival rates without explantation were 80, 80 and 74%, respectively. The 10-, 15- and 20-year survival rates of the device without revision were 79, 65 and 40%, respectively. After 20 years of follow-up, 11 women still had successful outcomes (61%). The AUS provided satisfactory very long-term functional results among women with SUI caused by intrinsic sphincter deficiency. © 2013 The Authors. BJU International © 2013 BJU International.

Experience with the artificial urinary sphincter model AS800 in 148 patients.

PubMed

Fishman, I J; Shabsigh, R; Scott, F B

1989-02-01

The latest version of the artificial urinary sphincter, AS800, was used in 148 patients with urinary incontinence of different etiologies. Followup ranged from 3 to 37 months, with an average of 20.8 months. There were 112 (76 per cent) male and 36 (24 per cent) female patients. The cuff was implanted around the bladder neck in 78 patients (53 per cent) and around the bulbar urethra in 70 (47 per cent). Socially acceptable urinary control was achieved in 90 per cent of the 139 patients with active devices in place. It was necessary to remove the sphincter in 11 patients (7.4 per cent). The reasons for removal were infection and erosion in 8 patients (5.4 per cent), infection without erosion in 2 (1.3 per cent), and erosion due to excess pressure and poor tissues in 1 (0.7 per cent). Comparison of success and failure rates associated with incontinence of different etiologies revealed that patients with incontinence after failure of a conventional antistress incontinence operation and those with incontinence after transurethral resection or radical prostactectomy had the highest success rate, and that patients with incontinence secondary to pelvic fracture or exstrophy and epispadias had the highest failure rates. The deactivation feature (the lock) of the new artificial sphincter model was beneficial for primary deactivation, urethral catheterization or cystoscopy, or for elective nocturnal decompression of the bladder neck or urethral tissues.

The immediate effect of vaginal and caesarean delivery on anal sphincter measurements.

PubMed

Karcaaltincaba, Deniz; Erkaya, Salim; Isik, Hatice; Haberal, Ali

2016-08-01

This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o'clock positions at the distal level were measured before delivery and within 24-48 h after delivery. A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o'clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). There was significant muscle thinning of both the IAS and EAS at the 12 o'clock position after vaginal delivery, but not after caesarean delivery. © The Author(s) 2016.

Macrophage density in pharyngeal and laryngeal muscles greatly exceeds that in other striated muscles: an immunohistochemical study using elderly human cadavers

PubMed Central

Rhee, Sunki; Kitamura, Kei; Masaaki, Kasahara; Katori, Yukio; Murakami, Gen; Abe, Shin-ichi

2016-01-01

Macrophages play an important role in aging-related muscle atrophy (i.e., sarcopenia). We examined macrophage density in six striated muscles (cricopharyngeus muscle, posterior cricoarytenoideus muscle, genioglossus muscle, masseter muscle, infraspinatus muscle, and external anal sphincter). We examined 14 donated male cadavers and utilized CD68 immunohistochemistry to clarify macrophage density in muscles. The numbers of macrophages per striated muscle fiber in the larynx and pharynx (0.34 and 0.31) were 5–6 times greater than those in the tongue, shoulder, and anus (0.05–0.07) with high statistical significance. Thick muscle fibers over 80 µm in diameter were seen in the pharynx, larynx, and anal sphincter of two limited specimens. Conversely, in the other sites or specimens, muscle fibers were thinner than 50 µm. We did not find any multinuclear muscle cells suggestive of regeneration. At the beginning of the study, we suspected that mucosal macrophages might have invaded into the muscle layer of the larynx and pharynx, but we found no evidence of inflammation in the mucosa. Likewise, the internal anal sphincter (a smooth muscle layer near the mucosa) usually contained fewer macrophages than the external sphincter. The present result suggest that, in elderly men, thinning and death of striated muscle fibers occur more frequently in the larynx and pharynx than in other parts of the body. PMID:27722010

Preoperative determination of appropriate cutting line for proximal gastrectomy to avoid postoperative jejunal ulcer.

PubMed

Takahashi, Naoto; Kashimura, Hirotaka; Nimura, Hiroshi; Watanabe, Atsushi; Yano, Kentaro; Aoki, Hiroaki; Koyama, Tomoki; Sasaki, Toshiyuki; Shida, Atsuo; Mitsumori, Norio; Aoki, Teruaki; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2012-01-01

Although proximal gastrectomy has become a procedure of choice for patients' early cancer in the upper third of stomach, no clinical guide for optimal gastric resection in order to avoid postoperative jejunal ulcer is available. The aim of this study was to investigate whether determining the distribution of parietal and chief cells of the stomach using Congo red test is clinically relevant. The F-line was defined as a boundary line between fundic and intermediate area of the stomach according to the pathological findings in 29 patients who underwent total gastrectomy for early gastric cancer, whereas the f-line was regarded as a boundary line between intermediate and pyloric area. In the additional 6 patients undergoing vagus-preserving proximal gastrectomy with jejunal pouch interposition, endoscopic Congo red test was preoperatively performed to determine the F-f-line. The distances from the pyloric ring to f-line on the lesser and greater curvatures were variable. Long-term outcomes of proximal gastrectomy guided by preoperative endoscopic Congo red test were favorable. It is suggested that preoperative endoscopic Congo red test is useful to determine the appropriate cutting line in order to avoid postoperative jejunal ulcer after proximal gastrectomy.

A newly thermoactive and detergent-stable lipase from annular sea bream (Diplodus annularis): Biochemical properties.

PubMed

Smichi, Nabil; Miled, Nabil; Gargouri, Youssef; Fendri, Ahmed

2017-01-01

A lipolytic activity was located in the annular seabream pyloric caeca, from which a digestive lipase (AsDL) was purified. Pure AsDL has an apparent molecular mass of 50 kDa. The purified lipase is thermoactive as it displays its maximal activity on short- and long-chain triacylglycerols at a temperature of 50 °C. The enzyme is alkaline resistant as it retains 90% of its maximal activity when incubated during 1 H at pH 10. No colipase was detected in the annular seabream pyloric caeca. Similar results were reported for the sardine and the gray mullet digestive systems. This is in line with the idea that colipase might have evolved in mammal animals simultaneously with the appearance of an exocrine pancreas. AsDL is a serine enzyme, like all known lipases from different origins. Interestingly, the pure lipase was found to be insensitive to Triton X-100, a synthetic detergent, addition even at a concentration as high as 12 mM. The purified enzyme has potential applications in detergent and food industry because of its thermal activity and alkaline nature. © 2015 International Union of Biochemistry and Molecular Biology, Inc.

In vivo antiulcer activity of the aqueous extract of Bauhinia purpurea leaf.

PubMed

Zakaria, Z A; Abdul Hisam, E E; Rofiee, M S; Norhafizah, M; Somchit, M N; Teh, L K; Salleh, M Z

2011-09-02

Bauhinia purpurea (Fabaceae) is a medicinal plant traditionally used to treat various ailments, including ulcers. In order to establish pharmacological properties of the leaf of Bauhinia purpurea, studies were performed on antiulcer activity of the plant's aqueous extract. The Bauhinia purpurea aqueous extract (BPAE) was prepared in the doses of 100, 500 and 1,000 mg/kg. Antiulcer activity of BPAE was evaluated by absolute ethanol- and indomethacin-induced gastric ulcer, and pyloric ligation models. Acute toxicity was also carried out. BPAE, at the dose of 5,000 mg/kg, did not cause any signs of toxicity to rats when given orally. Oral administration of BPAE exhibited antiulcer activity (p<0.05) in all models used. However, the dose-dependent activity was observed only in the absolute ethanol-induced gastric ulcer model. Histological studies supported the observed antiulcer activity of BPAE. In pyloric ligation assay, BPAE increased the gastric wall mucus secretion. The BPAE exhibits antiulcer activity, which could be due to the presence of saponins or sugar-free polyphenols, and, thus, confirmed the traditional uses of Bauhinia purpurea in the treatment of ulcers. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Enzymatic correlates of energy status in wild yellow perch inhabiting clean and contaminated environments.

PubMed

Gauthier, Charles; Campbell, Peter G C; Couture, Patrice

2011-09-01

Enzymes representing a variety of metabolic pathways were examined in yellow perch (Perca flavescens) collected from a metal-contaminated region (Rouyn-Noranda, Québec, Canada) to determine which were most closely related to fish condition factor, pyloric caeca weight, and visceral lipid accumulation, as well to seek a better understanding of the influence of metal contamination on the physiology and biometrics of perch. Compared to laboratory fish, wild perch were under important energy restrictions. The condition factor of wild fish was correlated with indicators of aerobic metabolism (citrate synthase, cytochrome C oxidase), protein anabolism (nucleoside diphosphokinase), and indicators of lipid accumulation (glucose-6-phosphate dehydrogenase, visceral lipid index). Pyloric caeca weights were well correlated with indicators of protein anabolism, but only when both seasons were examined together, possibly indicating a lag in the response of enzymes to changes in diet. The addition of contaminant stress to existing energy restrictions led to changes in the relationships between enzymes and biometrics, reducing the predictive power of the models for perch in contaminated lakes. The present study broadens our knowledge of the impact of metal contamination on energy accumulation and tissue metabolic capacities in wild perch. Copyright © 2011 SETAC.

Upper GI tract lesions in familial adenomatous polyposis (FAP): enrichment of pyloric gland adenomas and other gastric and duodenal neoplasms.

PubMed

Wood, Laura D; Salaria, Safia N; Cruise, Michael W; Giardiello, Francis M; Montgomery, Elizabeth A

2014-03-01

Patients with familial adenomatous polyposis (FAP), an autosomal dominant cancer predisposition syndrome caused by mutations in the APC gene, develop neoplasms in both the upper and lower gastrointestinal (GI) tract. To clarify the upper GI tract lesions in FAP patients in a tertiary care setting, we reviewed specimens from 321 endoscopies in 66 patients with FAP. Tubular adenomas in the small bowel were the most common neoplasms (present in 89% of patients), although only 1 patient developed invasive carcinoma of the small bowel. Several types of gastric neoplasms were identified--65% of patients had at least 1 fundic gland polyp, and 23% of patients had at least 1 gastric foveolar-type gastric adenoma. Pyloric gland adenomas were also enriched, occurring in 6% of patients--this is a novel finding in FAP patients. Despite the high frequency of gastric neoplasms, only 1 patient developed carcinoma in the stomach. The very low frequency of carcinoma in these patients suggests that current screening procedures prevent the vast majority of upper GI tract carcinomas in patients with FAP, at least in the tertiary care setting.

Tube pancreatico-duodenostomy for management of a severe penetrating pancreaticoduodenal injury.

PubMed

Hatzigeorgiadis, Anestis; Boulas, Konstantinos A; Barettas, Nikolaos; Papageorgiou, Irene; Blouhos, Konstantinos

2014-05-27

Optimal management of penetrating pancreaticoduodenal injuries and better outcomes are associated with simple, fast damage control surgery and shorter operative time. The performance of pyloric exclusion and tube duodenostomy has markedly decreased. However, there is still a trend toward their performance in cases of delay duodenal repair or severe pancreaticoduodenal injury. The present report describes a case of a hemodynamically stable patient with a single penetrating gunshot trauma causing an AAST-OIS grade III pancreatic head injury and grade IV injury of the second portion of the duodenum. The patient was treated in our Level IV rural trauma center and submitted to primary closure of the posterolateral duodenal wall (the laceration of the contralateral inner medial duodenal wall could not be repaired), external duodenal and pancreatic drainage, and duodenal decompression by tube pancreatico-duodenostomy (insertion of a 18 Fr Foley catheter through the laceration of the pancreatic head toward the duodenal lumen), tube cholangiostomy, and pyloric exclusion accompanied with a feeding jejunostomy. Tube pancreatico-duodenostomy, which is described for the first time in the literature, turned out to be effective and can be considered as an option in pancreaticoduodenal trauma when the inner medial duodenal wall cannot be repaired.

Management of combined pancreatoduodenal injuries.

PubMed Central

Feliciano, D V; Martin, T D; Cruse, P A; Graham, J M; Burch, J M; Mattox, K L; Bitondo, C G; Jordan, G L

1987-01-01

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs. PMID:3592810

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

PubMed

Guzmán Rojas, R A; Salvesen, K Å; Volløyhaug, I

2018-05-01

To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Anal incontinence after childbirth

PubMed Central

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-01-01

Background Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. Methods We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Results Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01–2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40–3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4–282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2–28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0–50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9–28.5) but not with birth weight (adjusted RR for birth weight 4000 g or more: 1.4, 95% CI 0.6–3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5–2.7). Interpretation Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour. PMID:11868640

Anal incontinence after childbirth.

PubMed

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-02-05

Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01-2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40-3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4-282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2-28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0-50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9-28.5) but not with birth weight (adjusted RR for nirth weight 4000 g or more: 1.4, 95% CI 0.6-3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5-2.7). Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour.

Balloon dilation of the esophago-gastric junction affects lower and upper esophageal sphincter function in achalasia.

PubMed

Wauters, L; Van Oudenhove, L; Selleslagh, M; Vanuytsel, T; Boeckxstaens, G; Tack, J; Omari, T; Rommel, N

2014-01-01

Pneumatic dilation of the lower esophageal sphincter (LES) in achalasia has an unappreciated effect on upper esophageal sphincter (UES) function. We studied UES pressure patterns at baseline and alterations in UES parameters resulting from therapy. High-resolution manometry (HRM) tracings from 50 achalasia patients, seen at a tertiary center between January 2009 and July 2011, were reviewed. Manometric parameters studied were (i) LES: resting pressure (restP), 4-second integrated relaxation pressure (IRP4); (ii) UES: resting pressure (restP), minimal relaxation pressure (MRP), peak pressure (PP), relaxation interval (RI), intrabolus pressure (IBP), and deglutitive sphincter resistance (DSR). Mixed models analyses with LES and UES parameters as dependent variables and treatment stage as within-subject independent variable of interest were used. Correlations between treatment-induced changes in LES, UES, and esophageal body (EB) parameters were performed. Pre- and posttreatment HRM tracings were available from 50 patients (mean age 52.7 ± 18.6 years, 29 men). Upper esophageal sphincter parameters MRP (17.9 ± 1.2 vs 15.2 ± 0.9 mmHg; p = 0.02) and IBP (31.5 ± 1.5 vs 27.4 ± 1.2 mmHg; p = 0.009) were significantly reduced after initial balloon dilation and this effect was significant in type II achalasia (p = 0.002 and p = 0.0006). Peak pressure, RI, and DSR were not. The therapeutic effect on LES IRP4 correlated significantly with the change in UES MRP, statistically mediated by the change in EB deglutitive pressure (p = 0.004 and p = 0.0002). We present the first HRM study demonstrating that pneumatic dilation of the LES affects intraesophageal and UES pressures in patients with achalasia. © 2013 John Wiley & Sons Ltd.

Capecitabine and Oxaliplatin in the Preoperative Multimodality Treatment of Rectal Cancer: Surgical End Points From National Surgical Adjuvant Breast and Bowel Project Trial R-04

PubMed Central

O'Connell, Michael J.; Colangelo, Linda H.; Beart, Robert W.; Petrelli, Nicholas J.; Allegra, Carmen J.; Sharif, Saima; Pitot, Henry C.; Shields, Anthony F.; Landry, Jerome C.; Ryan, David P.; Parda, David S.; Mohiuddin, Mohammed; Arora, Amit; Evans, Lisa S.; Bahary, Nathan; Soori, Gamini S.; Eakle, Janice; Robertson, John M.; Moore, Dennis F.; Mullane, Michael R.; Marchello, Benjamin T.; Ward, Patrick J.; Wozniak, Timothy F.; Roh, Mark S.; Yothers, Greg; Wolmark, Norman

2014-01-01

Purpose The optimal chemotherapy regimen administered concurrently with preoperative radiation therapy (RT) for patients with rectal cancer is unknown. National Surgical Adjuvant Breast and Bowel Project trial R-04 compared four chemotherapy regimens administered concomitantly with RT. Patients and Methods Patients with clinical stage II or III rectal cancer who were undergoing preoperative RT (45 Gy in 25 fractions over 5 weeks plus a boost of 5.4 Gy to 10.8 Gy in three to six daily fractions) were randomly assigned to one of the following chemotherapy regimens: continuous intravenous infusional fluorouracil (CVI FU; 225 mg/m2, 5 days per week), with or without intravenous oxaliplatin (50 mg/m2 once per week for 5 weeks) or oral capecitabine (825 mg/m2 twice per day, 5 days per week), with or without oxaliplatin (50 mg/m2 once per week for 5 weeks). Before random assignment, the surgeon indicated whether the patient was eligible for sphincter-sparing surgery based on clinical staging. The surgical end points were complete pathologic response (pCR), sphincter-sparing surgery, and surgical downstaging (conversion to sphincter-sparing surgery). Results From September 2004 to August 2010, 1,608 patients were randomly assigned. No significant differences in the rates of pCR, sphincter-sparing surgery, or surgical downstaging were identified between the CVI FU and capecitabine regimens or between the two regimens with or without oxaliplatin. Patients treated with oxaliplatin experienced significantly more grade 3 or 4 diarrhea (P < .001). Conclusion Administering capecitabine with preoperative RT achieved similar rates of pCR, sphincter-sparing surgery, and surgical downstaging compared with CVI FU. Adding oxaliplatin did not improve surgical outcomes but added significant toxicity. The definitive analysis of local tumor control, disease-free survival, and overall survival will be performed when the protocol-specified number of events has occurred. PMID:24799484

Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04.

PubMed

O'Connell, Michael J; Colangelo, Linda H; Beart, Robert W; Petrelli, Nicholas J; Allegra, Carmen J; Sharif, Saima; Pitot, Henry C; Shields, Anthony F; Landry, Jerome C; Ryan, David P; Parda, David S; Mohiuddin, Mohammed; Arora, Amit; Evans, Lisa S; Bahary, Nathan; Soori, Gamini S; Eakle, Janice; Robertson, John M; Moore, Dennis F; Mullane, Michael R; Marchello, Benjamin T; Ward, Patrick J; Wozniak, Timothy F; Roh, Mark S; Yothers, Greg; Wolmark, Norman

2014-06-20

The optimal chemotherapy regimen administered concurrently with preoperative radiation therapy (RT) for patients with rectal cancer is unknown. National Surgical Adjuvant Breast and Bowel Project trial R-04 compared four chemotherapy regimens administered concomitantly with RT. Patients with clinical stage II or III rectal cancer who were undergoing preoperative RT (45 Gy in 25 fractions over 5 weeks plus a boost of 5.4 Gy to 10.8 Gy in three to six daily fractions) were randomly assigned to one of the following chemotherapy regimens: continuous intravenous infusional fluorouracil (CVI FU; 225 mg/m(2), 5 days per week), with or without intravenous oxaliplatin (50 mg/m(2) once per week for 5 weeks) or oral capecitabine (825 mg/m(2) twice per day, 5 days per week), with or without oxaliplatin (50 mg/m(2) once per week for 5 weeks). Before random assignment, the surgeon indicated whether the patient was eligible for sphincter-sparing surgery based on clinical staging. The surgical end points were complete pathologic response (pCR), sphincter-sparing surgery, and surgical downstaging (conversion to sphincter-sparing surgery). From September 2004 to August 2010, 1,608 patients were randomly assigned. No significant differences in the rates of pCR, sphincter-sparing surgery, or surgical downstaging were identified between the CVI FU and capecitabine regimens or between the two regimens with or without oxaliplatin. Patients treated with oxaliplatin experienced significantly more grade 3 or 4 diarrhea (P < .001). Administering capecitabine with preoperative RT achieved similar rates of pCR, sphincter-sparing surgery, and surgical downstaging compared with CVI FU. Adding oxaliplatin did not improve surgical outcomes but added significant toxicity. The definitive analysis of local tumor control, disease-free survival, and overall survival will be performed when the protocol-specified number of events has occurred. © 2014 by American Society of Clinical Oncology.

Mediation by prostaglandins of the stimulatory effect of substance P on cyclic AMP production in dog iris sphincter smooth muscle.

PubMed

Marathe, G K; Yousufzai, S Y; Abdel-Latif, A A

1996-10-25

The purpose of the present study was to examine the mechanism of the stimulatory effect of substance P (SP) on cyclic AMP (cAMP) accumulation in dog iris sphincter. We found that: (1) SP increased cAMP accumulation in a time- and concentration-dependent manner, the T1/2 and EC50 values being 1.2 min and 44 nM, respectively. SP has no effect on inositol trisphosphate and muscle contraction in this tissue. (2) SP-stimulated cAMP formation was inhibited by quinacrine, a non-specific phospholipase A2 inhibitor (IC50 = 9.5 microM), and by indomethacin (Indo), a cyclooxygenase inhibitor (IC50 = 3.5 nM), in a concentration-dependent manner, suggesting that SP induces cAMP accumulation via an Indo-sensitive pathway. (3) SP-induced arachidonic acid release and SP-induced prostaglandin E2 (PGE2) release were inhibited concentration dependently by quinacrine and Indo, with IC50 values of 11 microM and 0.8 nM, respectively. (4) PGE2 (1 microM) increased cAMP formation in the sphincter muscle by 94%, and, furthermore, the PG, but not SP, stimulated the activity of adenylyl cyclase in membrane fractions isolated from this tissue. (5) Indo (1 microM) blocked the relaxing effect of SP (1 microM) in iris sphincter precontracted with carbachol (1 microM). (6) The inhibitory effect of Indo on SP-induced cAMP accumulation was species specific. Increases in cAMP represent a mechanism by which extracellular SP can regulate smooth muscle function. Thus, we conclude from these studies that in dog iris sphincter SP-induced cAMP accumulation is mediated through PGs, and that in this cholinergically innervated muscle SP via cAMP could function, in part, to modulate the physiological responses to muscarinic receptor stimulation.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

PubMed

Wickramasinghe, Dakshitha Praneeth; Senaratne, Supun; Senanayake, Hemantha; Samarasekera, Dharmabandhu Nandadeva

2016-09-01

The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

[Clinical significance of detection of internal anal sphincter in children with functional constipation].

PubMed

Hou, Xiang-yu; Wang, Ling-yun; Wang, Wei-lin; Li, Yong; Bai, Yu-zuo

2011-10-01

To investigate the structural and functional changes of internal anal sphincter (IAS) in children with functional constipation (FC), and to evaluate the association between the thickness of IAS and the severity of clinical symptoms. A total of 35 children with FC(constipation group,17 with incontinence) between June 2008 and December 2008 at the Shengjing Hospital of China Medical University were evaluated using anal manometry and endosonography. These patients were compared to 23 hospitalized children who were excluded for digestive and endocrinal diseases(control group). A validated symptom score(SS) was used to assess the severity of symptoms. The sum of SS ranged between 0 and 65. Anorectal manometry showed reflex relaxation of IAS in response to distension of rectal balloon in all patients. Rectal perceptional threshold in FC group was significantly higher than that in the controls[(42.4 ± 19.5) ml vs.(29.1 ± 15.6) ml, P<0.05]. The lowest volume for inducing reflex relaxation of IAS was significantly higher than that in the controls [(55.6 ± 31.6) ml vs.(30.5 ±13.8) ml, P<0.05]. The thickening of IAS was noted in all the patients[(3.8 ± 1.7) mm vs.(2.5 ± 1.0) mm, P<0.05]. However, there was no significant difference between FC and control in median resting anal sphincter pressure[(170.8 ± 62.3) mm Hg vs. (161.3 ± 51.1) mm Hg, P>0.05]. The median symptom score was 9.3 ± 4.3 in the FC group. The thickness of IAS correlated significantly with total symptom severity score(r=0.407, P<0.05). There was no correlation between thickness of IAS and age, sex, or duration of disease(P>0.05). Structural and functional changes of internal anal sphincter exist in children with functional constipation. The thickness of internal anal sphincter correlates significantly with symptom severity.

Sphincter of Oddi botulinum toxin injection to prevent pancreatic fistula after distal pancreatectomy.

PubMed

Hackert, Thilo; Klaiber, Ulla; Hinz, Ulf; Kehayova, Tzveta; Probst, Pascal; Knebel, Phillip; Diener, Markus K; Schneider, Lutz; Strobel, Oliver; Michalski, Christoph W; Ulrich, Alexis; Sauer, Peter; Büchler, Markus W

2017-05-01

Postoperative pancreatic fistula represents the most important complication after distal pancreatectomy. The aim of this study was to evaluate the use of a preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula (German Clinical Trials Register number: DRKS00007885). This was an investigator-initiated, prospective clinical phase I/II trial with an exploratory study design. We included patients who underwent preoperative endoscopic sphincter botulinum toxin injection (100 units of Botox). End points were the feasibility, safety, and postoperative outcomes, including postoperative pancreatic fistula within 30 days after distal pancreatectomy. Botulinum toxin patients were compared with a control collective of patients undergoing distal pancreatectomy without botulinum toxin injection by case-control matching in a 1:1 ratio. Between February 2015 and February 2016, 29 patients were included. All patients underwent successful sphincter of Oddi botulinum toxin injection within a median of 6 (range 0-10) days before operation. One patient had an asymptomatic, self-limiting (48 hours) increase in serum amylase and lipase after injection. Distal pancreatectomy was performed in 24/29 patients; 5 patients were not resectable. Of the patients receiving botulinum toxin, 7 (29%) had increased amylase levels in drainage fluid on postoperative day 3 (the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula grade A) without symptoms or need for reintervention. Importantly, no clinically relevant fistulas (International Study Group of Pancreatic Surgery grades B/C) were observed in botulinum toxin patients compared to 33% postoperative pancreatic fistula grade B/C in case-control patients (P < .004). Preoperative sphincter of Oddi botulinum toxin injection is a novel and safe approach to decrease the incidence of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. The results of the present trial suggest its efficacy in the prevention of clinically relevant postoperative pancreatic fistula and are validated currently in the German Federal Government-sponsored, multicenter, randomized controlled PREBOT trial. Copyright © 2016 Elsevier Inc. All rights reserved.

Esophageal Dysmotility in Patients following Total Laryngectomy.

PubMed

Zhang, Teng; Maclean, Julia; Szczesniak, Michal; Bertrand, Paul P; Quon, Harry; Tsang, Raymond K; Wu, Peter I; Graham, Peter; Cook, Ian J

2018-02-01

Objectives Dysphagia is common in total laryngectomees, with some symptoms suggesting esophageal dysmotility. Tracheoesophageal (TE) phonation requires effective esophagopharyngeal air passage. Hence, esophageal dysmotility may affect deglutition or TE phonation. This study aimed to determine (1) the characteristics of esophageal dysmotility in laryngectomees, (2) whether clinical history is sensitive in detecting esophageal dysmotility, and (3) the relationship between esophageal dysmotility and TE prosthesis dysfunction. Study Design Multidisciplinary cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods For 31 participants undergone total laryngectomy 1 to 12 years prior, clinical histories were taken by a gastroenterologist and a speech pathologist experienced in managing dysphagia. Esophageal high-resolution manometry was performed and analyzed using Chicago Classification v3.0. Results Interpretable manometric studies were obtained in 23 (1 normal manometry). Esophageal dysmotility patterns included achalasia, esophagogastric junction outflow obstruction, diffuse esophageal spasm, and other major (30%) and minor (50%) peristaltic disorders. The sensitivity of predicting any esophageal dysmotility was 28%, but it is noteworthy that patients with achalasia and diffuse esophageal spasm (DES) were predicted. Two of 4 participants with TE puncture leakage had poor esophageal clearance. Of 20 TE speakers, 12 had voice problems, no correlation between poor voice, and any dysmotility pattern. Conclusions Peristaltic and lower esophageal sphincter dysfunction are common in laryngectomees. Clinical history, while not predictive of minor motor abnormalities, predicted correctly cases with treatable spastic motor disorders. Dysmotility was not associated with poor phonation, although TE puncture leakage might be linked to poor esophageal clearance. Esophageal dysmotility should be considered in the laryngectomees with persisting dysphagia or leaking TE puncture.

International spinal cord injury bowel function basic data set (Version 2.0).

PubMed

Krogh, K; Emmanuel, A; Perrouin-Verbe, B; Korsten, M A; Mulcahey, M J; Biering-Sørensen, F

2017-07-01

International expert working group. To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research. Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS). The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set. The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score. The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

Is testosterone important in LUT function in men and women? ICI-RS 2015.

PubMed

Badawi, Jasmin Katrin; Bosch, Ruud; Djurhuus, Jens Christian; Hanna-Mitchell, Ann T

2017-04-01

This review article is a collaborative report based upon the Authors' presentations and Group discussion on the role of testosterone (T) in the male and female lower urinary tract (LUT) which took place at the 6th International Consultation on Incontinence Research Society's (ICI-RS) annual meeting, in Bristol, UK (September 8-10, 2015). It comprises overviews and opinions on both the current state of knowledge of the role of T in LUT function and dysfunction in both sexes. Results from animal studies suggest that T treatment may be beneficial for disorders of the LUT in women including urinary incontinence and pelvic organ prolapse. The need for clinical studies to evaluate the effect of T treatment in peri- and post-menopausal women, taking into account the type of applied androgen, the application form, timing and dosage, is especially emphasized. In males, findings on the impact of T on the male external urethral sphincter underscores that there is still much to learn about its role in male LUT physiology. The important topic of the use of T therapy in the treatment of enuresis in the young, both sexes, is also discussed. The importance of understanding the steroidogenic pathways linking T with estradiol is discussed as being of paramount importance in researching the unique actions of T in the LUT. The overall conclusion is that further research into the role of T in LUT function and dysfunction across genders and age groups (young to old) is extremely important. Neurourol. Urodynam. 36:859-862, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Augmentation of Deglutitive Thyrohyoid Muscle Shortening by the Shaker Exercise

PubMed Central

Mepani, Rachel; Antonik, Stephen; Massey, Benson; Kern, Mark; Logemann, Jerilyn; Pauloski, Barbara; Rademaker, Alfred; Easterling, Caryn

2010-01-01

Earlier studies of the effect of 6 weeks of the Shaker Exercise have shown significant increase in UES opening and anterior excursion of larynx and hyoid during swallowing in patients with upper esophageal sphincter (UES) dysfunction, resulting in elimination of aspiration and resumption of oral intake. This effect is attributed to strengthening of the suprahyoid muscles, as evidenced by comparison of electromyographic changes in muscle fatigue before and after completion of the exercise regime. The effect of this exercise on thyrohyoid muscle shortening is unknown. Therefore the aim of this study was to determine the effect of the exercise on thyrohyoid muscle shortening. We studied 11 dysphagic patients with UES dysfunction. Six were randomized to traditional swallowing therapy and five to the Shaker Exercise. Videofluoroscopy was used to measure deglutitive thyrohyoid shortening before and after completion of assigned therapy regimen. Maximum thyrohyoid muscle shortening occurred at close temporal proximity to the time of maximal thyroid cartilage excursion. The percent change in thyrohyoid distance from initiation of deglutition to maximal anterior/superior hyoid excursion showed no statistically significant difference between the two groups prior to either therapy (p = 0.54). In contrast, after completion of therapy, the percent change in thyrohyoid distance in the Shaker Exercise group was significantly greater compared to the traditional therapy (p = 0.034). The Shaker Exercise augments the thyrohyoid muscle shortening in addition to strengthening the suprahyoid muscles. The combination of increased thyrohyoid shortening and suprahyoid strengthening contributes to the Shaker Exercise outcome of deglutitive UES opening augmentation. PMID:18685891

Combination therapy for male erectile dysfunction and urinary incontinence.

PubMed

Zafirakis, Helen; Wang, Run; Westney, O Lenaine

2008-01-01

Urinary incontinence (UI) and erectile dysfunction (ED) are both very prevalent conditions. Insertion of an artificial urinary sphincter (AUS) and penile prosthesis (PP) is an effective and proven method of treatment for both conditions. With advancing age, as well as with increasing populations of patients radically treated for prostate cancer, the occurrence of both conditions found in the same patient is increasing. The purpose of this article was to analyze the available evidence for simultaneous surgical management of male ED and UI using prosthetic devices. The existing literature pertaining to dual implantation of AUS and PP was reviewed. The concomitant insertion of the PP with the male perineal sling was also considered. Concurrent ED and UI are increasingly seen in the post radical prostatectomy population, who are often younger and less willing to suffer with these conditions. Insertion of an AUS and PP, either simultaneously or as a two-stage procedure, appears to be a safe, efficacious and long-lasting method of treatment. The improvements in design of both the AUS and PP as well as the development of the single transverse scrotal incision have made simultaneous insertion of these prostheses possible. Dual implantation of the PP and male sling looks promising in a selected population. In conclusion, the insertion of the AUS and PP for the treatment of concurrent UI and ED is safe and effective. Simultaneous insertion of these prostheses in the same patient offers potential advantages in operative and recovery time and is associated with high patient satisfaction. Combination therapy should therefore be included in the arsenal of treatment of these conditions.

Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver, sphincter, and gallbladder in patients with sphincter of Oddi spasm.

PubMed

Krishnamurthy, Gerbail T; Krishnamurthy, Shakuntala; Watson, Randy D

2004-01-01

The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111-185 MBq (3-5 mCi) technetium-99m mebrofenin after 6-8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (+/-SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%+/-31%) than in controls (61%+/-36%) and the opioid group (61%+/-25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%+/-4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%+/-18%) and the SOS group (48%+/-29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (+/-193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the sphincter and gallbladder in response to CCK-8, most of the bile emptied from the gallbladder refluxes into intrahepatic ducts, and reenters the gallbladder immediately after cessation of hormone infusion. The characteristic features of gallbladder filling, emptying, and paradoxical refilling with cholecystokinin provide objective parameters for noninvasive diagnosis of SOS by quantitative cholescintigraphy.

Targeted Proteolysis of Plectin Isoform 1a Accounts for Hemidesmosome Dysfunction in Mice Mimicking the Dominant Skin Blistering Disease EBS-Ogna

PubMed Central

Walko, Gernot; Vukasinovic, Nevena; Gross, Karin; Fischer, Irmgard; Sibitz, Sabrina; Fuchs, Peter; Reipert, Siegfried; Jungwirth, Ute; Berger, Walter; Salzer, Ulrich; Carugo, Oliviero; Castañón, Maria J.; Wiche, Gerhard

2011-01-01

Autosomal recessive mutations in the cytolinker protein plectin account for the multisystem disorders epidermolysis bullosa simplex (EBS) associated with muscular dystrophy (EBS-MD), pyloric atresia (EBS-PA), and congenital myasthenia (EBS-CMS). In contrast, a dominant missense mutation leads to the disease EBS-Ogna, manifesting exclusively as skin fragility. We have exploited this trait to study the molecular basis of hemidesmosome failure in EBS-Ogna and to reveal the contribution of plectin to hemidesmosome homeostasis. We generated EBS-Ogna knock-in mice mimicking the human phenotype and show that blistering reflects insufficient protein levels of the hemidesmosome-associated plectin isoform 1a. We found that plectin 1a, in contrast to plectin 1c, the major isoform expressed in epidermal keratinocytes, is proteolytically degraded, supporting the notion that degradation of hemidesmosome-anchored plectin is spatially controlled. Using recombinant proteins, we show that the mutation renders plectin's 190-nm-long coiled-coil rod domain more vulnerable to cleavage by calpains and other proteases activated in the epidermis but not in skeletal muscle. Accordingly, treatment of cultured EBS-Ogna keratinocytes as well as of EBS-Ogna mouse skin with calpain inhibitors resulted in increased plectin 1a protein expression levels. Moreover, we report that plectin's rod domain forms dimeric structures that can further associate laterally into remarkably stable (paracrystalline) polymers. We propose focal self-association of plectin molecules as a novel mechanism contributing to hemidesmosome homeostasis and stabilization. PMID:22144912

Role of body mass index in school-aged children with lower urinary tract dysfunction: Does weight classification predict treatment outcome?

PubMed

Arlen, Angela M; Cooper, Christopher S; Leong, Traci

2017-10-01

Lower urinary tract (LUT) dysfunction comprises a large percentage of pediatric urology referrals. Childhood obesity is a major health concern, and has been associated with voiding symptoms. We assessed the impact of body mass index (BMI) on treatment outcomes of children presenting with LUT or bladder-bowel dysfunction (BBD). Children aged 5-17 years diagnosed with non-neurogenic LUT dysfunction and no prior urologic diagnoses were identified. Patient demographics including BMI, lower urinary tract symptoms, constipation, medical and psychologic comorbidities, imaging, and treatment outcomes were evaluated. BMI was normalized by age and gender according to percentiles: underweight < 5th, healthy 5th to <85th, overweight 85th to <95th, and obese > 95th percentile. Uni- and multivariate analyses were performed to identify predictors of treatment response. During an 18-month period, 100 children (54 girls, 46 boys) met the inclusion criteria. The mean age at diagnosis was 7.7 ± 2.4 years, and mean length of follow-up 15.3 ± 13.1 months. Sixty-nine patients were a normal weight, 22 were overweight, and nine were obese. Fifteen percent of the children had complete treatment response, 63% partial response, and 22% non-response. On univariate analysis, children with elevated BMI (p = 0.04) or history of urinary tract infection (p = 0.01) were statistically more likely to not respond to treatment. Controlling for all other variables, children with BMI > 85th percentile had 3.1 times (95% CI 1.11-8.64; p = 0.03) increased odds of treatment failure (Table). BBD management includes implementation of a bowel program and timed voiding regimen, with additional treatment modalities tailored on the basis of the prevailing symptoms. We observed that school-aged children with a BMI ≥ 85th percentile were over three times more likely to experience treatment failure when controlling for all other patient characteristics including constipation and a history of urinary tract infection. Limitations of the study include the relatively small sample size, lack of uroflow with electromyography to confirm the presence or the absence of detrusor sphincter dyssynergia, and inconsistent anticholinergic dosing. Nearly one-third of school-aged children presenting to our institution with LUT or BBD were overweight or obese when normalized for age and gender. Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response. Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Quantitative anal sphincter electromyography in primiparous women with anal incontinence

PubMed Central

Gregory, W. Thomas; Lou, Jau-Shin; Simmons, Kimberly; Clark, Amanda L.

2010-01-01

OBJECTIVE The purpose of this study was to determine whether evidence of denervation/reinnervation of the external anal sphincter is associated with anal incontinence symptoms immediately after delivery. STUDY DESIGN After a first vaginal delivery, 42 women completed an anal incontinence questionnaire. They also underwent concentric needle electromyography of the external anal sphincter. For each subject, motor unit action potential and interference pattern parameters were determined. RESULTS For the motor unit action potential, no difference was observed between patients with and without anal incontinence symptoms (t-test). For the interference pattern, the amplitude/turn was greater in subjects with fecal urgency (318 ± 48 [SD] μV) and fecal incontinence (332 ± 48 μV), compared with those without fecal urgency (282 ± 38 μV) and fecal incontinence (286 ± 41 μV; P = .02, t-test). CONCLUSION In this group of postpartum women with mild anal incontinence symptoms, interference pattern analysis shows evidence of denervation and subsequent reinnervation. PMID:18455531

[Transient lower esophageal sphincter relaxation and the related esophageal motor activities].

PubMed

Han, Seung Hyo; Hong, Su Jin

2012-03-01

Transient lower esophageal sphincter (LES) relaxation (TLESR) is defined as LES relaxation without a swallow. TLESRs are observed in both of the normal individuals and the patients with gastroesophageal reflux disorder (GERD). However, TLESR is widely considered as the major mechanism of the GERD. The new equipments such as high resolution manometry and impedance pH study is helped to understand of TLESR and the related esophageal motor activities. The strong longitudinal muscle contraction was observed during development of TLESR. Most of TLESRs are terminated by TLESR related motor events such as primary peristalsis and secondary contractions. The majority of TLESRs are associated with gastroesophageal reflux. Upper esophageal sphincter (UES) contraction is mainly associated with liquid reflux during recumbent position and UES relaxation predominantly related with air reflux during upright position. The frequency of TLESR in GERD patients seems to be not different compared to normal individuals, but the refluxate of GERD patients tend to be more acidic during TLESR.

Photodynamic therapy (PDT) for perianal bowenoid papulosis

NASA Astrophysics Data System (ADS)

Gahlen, Johannes; Stern, Josef; Graschew, Georgi; Kaus, Michael R.; Tilgen, W.

1995-03-01

HPV associated bowenoid papulosis of the anogenital region are classified as carcinoma in situ. The treatment can be difficult and recurrence rates are high. Extended surgical resections may have complications such as anal sphincter insufficiency. PDT does have some advantages and less side effects in the treatment of these tumors. We treated one female patient with an extended perianal bowenoid papulosis. Previous surgical resection led to local recurrence and partial sphincter insufficiency. Twenty-four hours before local laser light radiation (Ar-Dye laser, 630 nm wavelength), a systemic photosensitizer was applied (Photofrin II, 1.5 mg/kg BW). Four courses of PDT were performed within one year. We observed a total tumor necrosis in every radiation area. The previous sphincter insufficiency improved during the sessions. Side effects were rare. Pain in the radiation was stopped within 2 - 3 days under pain medication. PDT can induce a total local tumor necrosis in perianal bowenoid papulosis. Concerning local expansion, PDT can be a curable treatment.

Use of the gluteus maximus muscle as the neosphincter for restoration of anal function after abdominoperineal resection.

PubMed

Puerta Díaz, J D; Castaño Llano, R; Lombana, L J; Restrepo, J I; Gómez, G

2013-08-01

Our aim was to evaluate complications and long-term functional outcome in patients who had sphincter reconstruction using the gluteus maximus muscle as the neosphincter after abdominoperineal resection for rectal cancer treatment. Seven patients underwent reconstruction from 2000 to 2010. First, the sigmoid colon was brought down to the perineum as a perineal colostomy, with the procedure protected by a loop ileostomy. Reconstruction of the sphincter mechanism using the gluteus maximus took place 3 months later, and after another 8-12 weeks, the loop ileostomy was closed. We studied the functional outcome of these interventions with follow-up interviews of patients and objectively assessed anorectal function using manometry and the Cleveland Clinic Florida (Jorge-Wexner) fecal incontinence score. The mean follow-up was 56 months (median 47; range 10-123 months). One patient had a perianal wound infection and another had fibrotic stricture in the colocutaneous anastomosis that required several digital dilatations. Anorectal manometry at 3-month follow-up showed resting pressures from 10 to 18 mm Hg and voluntary contraction pressures from 68 to 187 mm Hg. Four patients had excellent sphincter function (Jorge-Wexner scores ≤5). Our preliminary results show that sphincter reconstruction by means of gluteus maximus transposition can be effective in restoring gastrointestinal continuity and recovering fecal continence in patients who have undergone APR with permanent colostomy for rectal cancer. Furthermore, the reconstruction procedure can be performed 2-4 years after the APR.

Considerations in the modern management of stress urinary incontinence resulting from intrinsic sphincter deficiency.

PubMed

Hillary, Christopher James; Osman, Nadir; Chapple, Christopher

2015-09-01

Intrinsic sphincter deficiency (ISD) is a common cause of stress urinary incontinence and is associated with more severe symptoms, often being associated with failed previous surgery. Due to the impaired sphincteric function, alternative surgical approaches are often required. The purpose of this review is to appraise the contemporary literature on the diagnosis and management of ISD. A PubMed search was performed to identify articles published between 1990 and 2014 using the following terms: ISD, stress urinary incontinence and type III stress urinary incontinence. Publications were screened for relevance, and full manuscripts were retrieved. Most studies base the diagnosis of ISD upon urodynamic appearances using recognized criteria (Valsalva leak point pressure <60 cm H2O or a maximum urethral closure pressure <20 cm H2O) in addition to clinical features. A range of non-surgical and surgical treatment options are available for the patient. Pubovaginal slings are more effective than retropubic colposuspensions with outcomes comparable to those reported with midurethral slings. The artificial urinary sphincter provides long-term cure rates; however, it is associated with specific morbidity including device erosion, mechanical failure and revision. The benefits of bulking agents, however, are not sustained beyond 1 year. There are few randomized controlled trials that compare accepted treatments specifically for patients with ISD. The lack of standardization in the definition and diagnostic criteria used limits inter-study comparisons. An assessment of urethral pressure profile when combined with the clinical features may help predict outcomes of surgical intervention.

Specific movement of esophagus during transient lower esophageal sphincter relaxation in gastroesophageal reflux disease.

PubMed

Kim, Hoon Il; Hong, Su Jin; Han, Jae Pil; Seo, Jung Yeon; Hwang, Kyoung Hwa; Maeng, Hyo Jin; Lee, Tae Hee; Lee, Joon Seong

2013-07-01

Transient lower esophageal sphincter relaxation (TLESR) is the main mechanism of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the characteristics of transient lower esophageal sphincter movement in patients with or without gastroesophageal reflux by high-resolution manometry (HRM). From June 2010 to July 2010, we enrolled 9 patients with GERD (GERD group) and 9 subjects without GERD (control group), prospectively. The manometry test was performed in a semi-recumbent position for 120 minutes following ingestion of a standardized, mixed liquid and solid meal. HRM was used to identify the frequency and duration of TLESR, esophageal shortening length from incomplete TLESR, upper esophageal sphincter (UES) response, and the related esophageal motor responses during TLESR. TLESR occurred in 33 in the GERD group and 34 in the control group after 120 minutes following food ingestion. Duration of TLESR and length of esophageal shortening did not differ between 2 groups. UES pressure increase during TLESR was mostly detected in patients with GERD, and UES relaxation was observed frequently in the control group during TLESR. TLESR-related motor responses terminating in TLESR were predominantly observed in the control group. Increased UES pressure was noted frequently in the GERD group, suggesting a mechanism for preventing harmful reflux, which may be composed mainly of fluid on the larynx or pharynx. However, patients with GERD lacked the related motor responses terminating in TLESR to promote esophageal emptying of refluxate.

Prosthetic urinary sphincter

NASA Technical Reports Server (NTRS)

Helms, C. R.; Smyly, H. M. (Inventor)

1981-01-01

A pump/valve unit for controlling the inflation and deflation of a urethral collar in a prosthetic urinary sphincter device is described. A compressible bulb pump defining a reservoir was integrated with a valve unit for implantation. The valve unit includes a movable valve member operable by depression of a flexible portion of the valve unit housing for controlling fluid flow between the reservoir and collar; and a pressure sensing means which operates the valve member to relieve an excess pressure in the collar should too much pressure be applied by the patient.

[Anal fissure of cryptoglandular origin. Therapeutic options].

PubMed

Casal, Enrique; de San Ildefonso, Alberto; Sánchez, Juan; Facal, Cristina; Pampin, José

2005-12-01

Anal fistula is a frequent condition. The most commonly accepted origin is infectious. The most widely used classification is based on cryptoglandular theory and on the position of the fistulous tract in relation to the anal sphincter. Physical examination will help to identify the type of fistula and allow its treatment to be planned. The most widely used complementary tests are endoanal ultrasound and magnetic resonance imaging. We review the various therapeutic options and their results, especially fistulotomy, endorectal advancement flap, use of sedal, anodermal advancement flap, sphincterorrhaphy with sphincter repair, and fibrin glue.

[Proctalgia Fugax--what's new over the last 100 years?].

PubMed

Amosi, Doron; Werbin, Nachum; Skornick, Yehuda; Greenberg, Ron

2004-05-01

Proctalgia Fugax is a benign, self-limiting disease characterized by episodes of intense pain in the anorectal area occurring at infrequent intervals. It is common, but most suffers do not seek medical advice. Although its classical symptomatology was describe more than a century ago, the etiology is unclear. Theories regarding the etiology have centered on alteration in the internal anal sphincter function and morphology. For most patients after gathering a detailed history, reassurance and warm baths will suffice. In persistent cases therapies that induce internal anal sphincter relaxation are the main treatment modalities.

Artificial urinary sphincter

PubMed Central

Martins, Francisco E.

2017-01-01

Although currently still the gold standard treatment for post-prostatectomy urinary incontinence, the artificial urinary sphincter (AUS) (AMS800) is an invasive procedure with associated risks factors. In this paper, we aim to outline what the scientific literature and what we personally believe are the factors that are useful and/or necessary to mitigate these risks, including both patient factors and surgeon factors. We also review special populations, including transcorporal (TC) AUS approach, AUS with inflatable penile prosthesis, AUS after male urethral sling, AUS erosion management, and AUS after orthotopic urinary diversion. PMID:28904901

Biliary and pancreatic duct pressures measured by ERCP manometry in patients with suspected papillary stenosis.

PubMed

Bar-Meir, S; Geenen, J E; Hogan, W J; Dodds, W J; Stewart, E T; Arndorfer, R C

1979-03-01

Papillary stenosis is an imprecisely defined clinical syndrome which eludes definitive diagnosis. In this study we evaluated 26 patients with suspected papillary stenosis by manometric examination of the sphincter of Oddi done during ERCP examination. Basal pressure in the sphincter of Oddi was elevated in 14 of the patients. Of these 14 patients, 10 underwent sphincterotomy and all experienced improvement in clinical symptoms after their surgery. We suggest that ERCP manometry is a useful procedure for identifying patients with papillary stenosis who may benefit from sphincterotomy.

Effect of the enzymatic inhibitor of Kunitz on the gastric lesions from reserpine, from phenylbutazone, from pyloric ligation and by restraint in the rat

NASA Technical Reports Server (NTRS)

Guerrin, F.; Demaille, A.; Merveille, P.; Bel, C.

1980-01-01

The protective effects of certain polypeptides on gastric ulcerations caused from reserpine and phenylbutazone in the rate were studied. It was found that the Kunitz enzymatic inhibitor exerts a protective action in regard to gastric lesions. However, the inhibitor did not change the development of Shay ulcers and stress ulcers from restraint.

Alteration of Motor Network Function Following Injury

DTIC Science & Technology

2013-10-01

neurotransmitters/neuromodulators, suggesting that transient block does not cause a loss of ability to release chemical transmitters .  Targets... neuro - Fig. 5. Channel mRNA correlations in LP neurons. mRNA levels of BK-KCa, Shal, and H are graphed in all pairwise combinations. Each point...www.jn.org on January 4, 2012 jn.physiology.org D ow nloaded from Marder E, Eisen JS. Transmitter identification of pyloric neurons: electrically coupled

Isolation of infectious pancreatic necrosis virus (serotype Ab) from diverse species of estuarine fish

NASA Astrophysics Data System (ADS)

McAllister, P. E.; Newman, M. W.; Sauber, J. H.; Owens, W. J.

1984-03-01

Two significant fish kills occurred in the Pamlico River estuary (North Carolina, USA), one in December 1981 and January 1982, and the other in June 1982. The first involved only the southern flounder (Paralichthys lethostigma). Histopathologic examination of morbid and moribund flounder revealed extensive sloughing and necrosis of the mucosa of the pyloric caeca and intestine, and inflammation of the submucosa of the pyloric caeca. Brain and internal organ homogenates from morbid and moribund flounder were assayed on CHSE-214 cells, and a virus was isolated. Virus titers ranged from≤8.4 · 102 to 6.3 · 107 TCID50 per gram of tissue. Cross-plaque neutralization assays indicated that the southern flounder virus was infectious pancreatic necrosis virus serotype Ab. Immersion challenge showed the isolate is only slightly virulent for fry of brook trout (Salvelinus fontinalis). The second fish kill involved the southern flounder and six other species: hogchoker (Trinectes maculatus), Atlantic silverside (Menidia menidia), spot (Leiostomus xanthurus), Atlantic croaker (Micropogon undulatus), silver perch (Bairdiella chrysura), and striped mullet (Mugil cephalus). Virus was isolated from southern founder, hogchoker, Atlantic silverside, and spot. Neutralization assays indicated that the four isolates were nearly identical; however, the diversity of species affected suggests that the virus might not have been the specific cause of mortality.

Changes in cholecystokinin and peptide Y gene expression with feeding in yellowtail (Seriola quinqueradiata): relation to pancreatic exocrine regulation.

PubMed

Murashita, Koji; Fukada, Haruhisa; Hosokawa, Hidetsuyo; Masumoto, Toshiro

2007-03-01

In fish, the regulation of digestive enzyme secretion by hormonal control such as cholecystokinin (CCK) and neuropeptide Y (NPY)-related peptide is not well understood. To investigate the roles of fish CCK and peptide Y (PY) in digestive enzyme secretion, mRNA levels of CCK and PY, pyloric caeca enzyme activities and mRNA levels of pancreatic digestive enzymes (lipase, trypsin and amylase) were measured at pre- and post-prandial stages in yellowtail. Pyloric caeca were sampled at 0, 0.5, 1.5, 3, 6, 12, 24 and 48 h after feeding. The mRNA levels of trypsin and amylase increased after feeding, suggesting that transcription was induced by feed ingestion. Digestive enzyme activities decreased in exocrine pancreas after feeding, suggesting the stored enzyme was secreted from pancreas post-prandially. mRNA levels for CCK displayed a time-dependent increase, peaking between 1.5 and 3 h after-feeding followed by a rapid decrease 3 to 6 h after feeding. The mRNA expression pattern of PY was inverse to the pattern of CCK, decreasing until 1.5 h after feeding and then rising to initial levels by 12 h after feeding. These results suggest that CCK and PY work antagonistically in the exocrine pancreas of yellowtail.

Supersensitivity of the rabbit iris sphincter muscle induced by trigeminal denervation: the role of substance P.

PubMed Central

Fujiwara, M; Hayashi, H; Muramatsu, I; Ueda, N

1984-01-01

The rabbit left ophthalmic nerve (first branch of the left trigeminal nerve) was cut at the intracranial, peripheral side of the trigeminal ganglion and the effects of denervation were examined using iris sphincter muscle preparations isolated from the left and right eye, as denervated and control innervated preparations, respectively. Electrical transmural stimulation produced a substance P-operated contraction, in addition to a cholinergic one, in the preparation isolated from the right control eye. The former response was abolished in the preparation isolated from the left denervated eye, thereby indicating that the trigeminal, substance P nerve ipsilaterally innervates the iris sphincter muscle. Exogenously applied carbachol and substance P produced concentration-dependent contractions in preparations isolated from either eye. Supersensitivity characterized by a decrease in median effective concentration (EC50) values and an increase in maximal response was observed in the responses to both agents of the left denervated preparation. Such supersensitivity developed slowly after trigeminal denervation and 3 weeks was required for full development. Exogenously applied KCl produced substance P-operated and direct muscle contractions in the right control preparations. In the left denervated preparations, the substance P-operated contraction was either markedly attenuated or abolished, while the direct muscle-related contraction was enhanced after trigeminal denervation. The length of the left denervated preparation was longer than that of the right control preparation, and the resting tensions required to produce maximal carbachol contraction shifted to lower values. These physical changes of the iris sphincter muscle developed within 5 days after trigeminal denervation. In the non-denervated preparation treated with capsaicin in vitro, electrical transmural stimulation and KCl failed to produce the substance P-related contraction. However, supersensitivity to neither exogenously applied substance P, carbachol and KCl nor physical changes were observed in the capsaicin-treated preparation. These results suggest that trigeminal, substance P-related nerves tonically and ipsilaterally innervate the rabbit iris sphincter muscle and that the denervation results in non-specific supersensitivity. These findings are essentially the same as those observed in various types of smooth muscles after autonomic denervation. PMID:6205140

Immortalization of cat iris sphincter smooth muscle cells by SV40 virus: growth, morphological, biochemical and pharmacological characteristics.

PubMed

Ocklind, A; Yousufzai, S Y; Ghosh, S; Coca-Prados, M; St Jernschantz, J; Abdel-Latif, A A

1995-11-01

The purpose of this study was to establish immortalized cell cultures of cat iris sphincter smooth muscle cells for a model investigating ocular receptors and their signal transduction pathways. Cultured cat iris sphincter muscle cells were immortalized by viral transformation with SV40 virus and the morphological and immunocytochemical properties of the normal and immortalized cells were investigated. The transformed cell clone, SV-CISM-2, was further characterized biochemically and pharmacologically. The normal muscle cells showed characteristics of smooth muscle cells, as judged by their growth and the presence of smooth muscle alpha-actin and desmin. After seven passages the normal cells ceased to proliferate. In contrast, the immortalized cells retained their proliferative ability for more than 220 population doublings over 55 passages. The transformation phenotype in these cells was confirmed by their expression of the large T-antigen, the incorporation of viral DNA into cellular DNA, growth in agarose and in low-serum medium, and complete loss of contact inhibition. The immortalized cells expressed smooth muscle alpha-actin, desmin and MLC protein. Biochemical and pharmacological studies on the SV-CISM cells revealed the presence of several functional receptors including muscarinic cholinergic, beta-adrenergic, peptidergic (substance P and endothelin). Platelet-activating factor, and prostaglandin (PG). Muscarinic stimulation of these cells resulted in: (a) a dose-dependent increase in the release of arachidonic acid (AA) and (PGs) and enhancement in the production of inositol trisphosphate (IP3); and (b) a substantial increase in MLC phosphorylation (118%), an indicator of smooth muscle contractility. The stimulatory effects of carbachol on these responses were completely blocked by atropine, a muscarinic receptor antagonist. This study constitutes the first successful immortalization of iris sphincter smooth muscle cells. The SV-CISM-2 cells can serve as an important model system for investigations on the biochemical and pharmacological properties of receptors and their signal transduction pathways in smooth muscle. The advantage of these cells over normal iris sphincter cells is that they can be propagated over many generations without alterations in their morphological, biochemical and physiological characteristics.

Functional anatomy of the prostate: implications for treatment planning.

PubMed

McLaughlin, Patrick W; Troyer, Sara; Berri, Sally; Narayana, Vrinda; Meirowitz, Amichay; Roberson, Peter L; Montie, James

2005-10-01

To summarize the functional anatomy relevant to prostate cancer treatment planning. Coronal, axial, and sagittal T2 magnetic resonance imaging (MRI) and MRI angiography were fused by mutual information and registered with computed tomography (CT) scan data sets to improve definition of zonal anatomy of the prostate and critical adjacent structures. The three major prostate zones (inner, outer, and anterior fibromuscular) are visible by T2 MRI imaging. The bladder, bladder neck, and internal (preprostatic) sphincter are a continuous muscular structure and clear definition of the preprostatic sphincter is difficult by MRI. Transition zone hypertrophy may efface the bladder neck and internal sphincter. The external "lower" sphincter is clearly visible by T2 MRI with wide variations in length. The critical erectile structures are the internal pudendal artery (defined by MRI angiogram or T2 MRI), corpus cavernosum, and neurovascular bundle. The neurovascular bundle is visible along the posterior lateral surface of the prostate on CT and MRI, but its terminal branches (cavernosal nerves) are not visible and must be defined by their relationship to the urethra within the genitourinary diaphragm. Visualization of the ejaculatory ducts within the prostate is possible on sagittal MRI. The anatomy of the prostate-rectum interface is clarified by MRI, as is the potentially important distinction of rectal muscle and rectal mucosa. Improved understanding of functional anatomy and imaging of the prostate and critical adjacent structures will improve prostate radiation therapy by improvement of dose and toxicity correlation, limitation of dose to critical structures, and potential improvement in post therapy quality of life.

Relationship of the frequency scale for symptoms of gastroesophageal reflux disease with endoscopic findings of cardiac sphincter morphology.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2008-01-01

Kusano et al. developed a questionnaire for the evaluation of gastroesophageal reflux disease (GERD), the frequency scale for the symptoms of GERD (FSSG). The FSSG is now widely used in Japan. We investigated the relationship between FSSG results and cardiac sphincter endoscopic findings. The subjects were 470 patients who responded to the FSSG before undergoing endoscopy. From the FSSG results, we calculated the total, acid reflux, and dysmotility scores. Endoscopic findings were assessed in terms of the anatomic-functional-pathological (AFP) classification as the A factor, or degree and type of hiatal hernia, and the valve factor, or laxity of the cardiac sphincter. The degree of esophagitis was assessed using the modified Los Angeles classification. We investigated correlations between each score and the anatomy of the cardia. With either definition of esophagitis (grade M or greater, or grade A or greater), the total and acid reflux scores were both significantly higher in the group with reflux esophagitis than in the group without reflux esophagitis. Examination of the relationship between FSSG scores and the A factor revealed no significant differences in the total, acid reflux, or dysmotility scores whether a hiatal hernia was present or absent. Similarly, examination of the valve factor showed no significant difference in any scores between V0 and V1 versus V1 and V2, indicating no correlation between cardiac sphincter laxity and FSSG scores. The FSSG was useful in determining whether reflux esophagitis is present, but it did not predict the anatomy of the cardia.

Characterization of swallow modulation in response to bolus volume in healthy subjects accounting for catheter diameter.

PubMed

Ferris, Lara; Schar, Mistyka; McCall, Lisa; Doeltgen, Sebastian; Scholten, Ingrid; Rommel, Nathalie; Cock, Charles; Omari, Taher

2018-06-01

Characterization of the pharyngeal swallow response to volume challenges is important for swallowing function assessment. The diameter of the pressure-impedance recording catheter may influence these results. In this study, we captured key physiological swallow measures in response to bolus volume utilizing recordings acquired by two catheters of different diameter. Ten healthy adults underwent repeat investigations with 8- and 10-Fr catheters. Liquid bolus swallows of volumes 2.5, 5, 10, 20, and 30 mL were recorded. Measures indicative of distension, contractility, and flow timing were assessed. Pressure-impedance recordings with pressure-flow analysis were used to capture key distension, contractility, and pressure-flow timing parameters. Larger bolus volumes increased upper esophageal sphincter distension diameter (P < .001) and distension pressures within the hypopharynx and upper esophageal sphincter (P < .05). Bolus flow timing measures were longer, particularly latency of bolus propulsion ahead of the pharyngeal stripping wave (P < .001). Use of a larger-diameter catheter produced higher occlusive pressures, namely upper esophageal sphincter basal pressure (P < .005) and upper esophageal sphincter postdeglutitive pressure peak (P < .001). The bolus volume swallowed changed measurements indicative of distension pressure, luminal diameter, and pressure-flow timing; this is physiologically consistent with swallow modulation to accommodate larger, faster-flowing boluses. Additionally, catheter diameter predominantly affects lumen occlusive pressures. Appropriate physiological interpretation of the pressure-impedance recordings of pharyngeal swallowing requires consideration of the effects of volume and catheter diameter. NA. Laryngoscope, 128:1328-1334, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Effects of endothelin on phospholipases and generation of second messengers in cat iris sphincter and SV-CISM-2 cells.

PubMed

Abdel-Latif, A A; Ding, K H; Akhtar, R A; Yousufzai, S Y

1996-09-01

In both immortalized cat iris sphincter smooth muscle cells (SV-CISM-2 cells) and cat iris sphincter, endothelin-1 (ET-1) markedly increased the activities of phospholipase A2 (PLA2), as measured by the release of arachidonic acid (AA), phospholipase C (PLC), as measured by the production of inositol trisphosphate (IP3), and phospholipase D (PLD), as measured by the formation of phosphatidylethanol (PEt). In SV-CISM-2 cells, ET-1 induced AA release, IP3 production and PEt formation in a dose- and time-dependent manner. The dose-response studies showed that the peptide is more potent in activating PLD (EC50 = 1.2 nM) than in activating PLC (EC50 = 1.5 nM) or PLA2 (EC50 = 1.7 nM). The time course studies revealed that ET-1 activated the phospholipases in a temporal sequence in which PLA2 was stimulated first (t1/2 = 12 s), followed by PLC (t1/2 = 48 s) and lastly PLD (t1/2 = 106 s). In SV-CISM-2 cells, in contrast to the intact iris sphincter, sarafotoxin-c, an ETB receptor agonist, had no effect on the phospholipases, and indomethacin, a cyclooxygenase inhibitor, had no effect on the stimulatory effect of ET-1 on the phospholipases. These results suggest that in this smooth muscle cell line, ET-1 interacts with the ETA receptor subtype to activate, via G proteins, phospholipases A2, C and D in a temporal sequence.

Improvement in the Reflux Symptom Index Following Surgery for Cricopharyngeal Dysfunction.

PubMed

Jiang, Nancy; Sung, C Kwang; Damrose, Edward J

2017-01-01

Gastroesophageal reflux may contribute to the development of cricopharyngeal dysfunction and Zenker's diverticulum. Common dictum suggests that if upper esophageal sphincter tone is reduced through cricopharyngeal myotomy, symptoms of laryngopharyngeal reflux may worsen. We hypothesized that patients who undergo myotomy should show decreased dysphagia symptoms with concurrent worsening of reflux symptomatology and that these changes would be greater in those patients undergoing complete versus partial myotomy. A retrospective chart review was performed for patients who underwent endoscopic or open cricopharyngeal myotomy, with or without Zenker's diverticulectomy. Preoperative and postoperative reflux symptomatology was subjectively measured with the Reflux Symptom Index (RSI), and dysphagia symptomatology was measured with the Eating Assessment Tool 10 (EAT-10). Patients who underwent partial myotomy via endoscopic stapling of Zenker's diverticulum were compared with patients who underwent complete myotomy (either endoscopic laser-assisted or via an open transcervical approach). The patients were further subdivided into three groups for data analysis: endoscopic staple diverticulotomy, laser cricopharyngeal myotomy, and open approach. A total of 41 patient charts were reviewed. Of these 41 patients, 17 underwent endoscopic stapler-assisted diverticulotomy, 4 underwent endosopic laser-assisted cricopharyngeal myotomy, and 20 underwent open transcervical cricopharyngeal myotomy, with diverticulectomy as indicated. Mean pre- and postoperative RSIs were 21.8 and 8.9, respectively (P < 0.001). Mean pre- and postoperative EAT-10 scores were 19.1 and 5.0, respectively (P < 0.001). Patients' reflux symptoms significantly improved after cricopharyngeal myotomy, with significant improvement in dysphagia symptoms. Concern for worsening of reflux symptoms following surgery does not appear to be clinically common. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor.

PubMed

Bozkurt, Murat; Yumru, Ayşe Ender; Şahin, Levent

2014-12-01

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed. Copyright © 2014. Published by Elsevier B.V.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: part C--Special pharmacology.

PubMed

Bergert, F W; Conrad, D; Ehrenthal, K; Fessler, J; Gross, J; Gundermann, K; Kluthe, B; Lang Heinrich, W; Liesenfeld, A; Loew, P G; Luther, E; Pchalek, R; Seffrin, J; Sterzing, A; Wolfring, H-J; Zimmermann, U

2009-03-01

The part "Special pharmacology of the aged" of this guideline contains recommendations for typical conditions in the family doctors practice: in the January issue 2009 dementia and Morbus Parkinson, in this issue osteoporosis and urinary incontinence and in the next issue rectal incontinence and obstipation. This issue of the IJCPT contains the third part of the Pharmacotherapy guidelines for the aged by family doctors for family doctors. Part 3: Osteoporosis and urinary incontinence. Osteoporosis is a systematic disease characterized by low bone mass and declining bone structure. Exercise, adequate diet, nicotine abstinence as well as reduction of alcohol consumption may counteract the progression of the disease. Osteoporosis manifests in bone fractures with minimal trauma. Attention must be given to the risk of falling, e.g., by avoiding drugs that increase the risk of falling: e.g., psychotropic agents, analgesic drugs and antiarrhythmic agents. Specific osteoporosis medication e.g. calcium, vitamin D, biphosphonates and SERM (selective estrogen receptor modulators) is evaluated by family doctors according to indication, dosage, contraindications, long-term therapy and nature of any fracture. Duration of therapy is at least 3 - max. 5 years followed by reassessment of indication. There are 3 types of urine incontinence (urge-, stress-, and overflow-incontinence). Another standardization of urinary incontinence follows dysfunctions of the pelvic floor: detrusor muscle-dependent, due to sphincter spasm, prostate gland dependent. Urge incontinence with a dysfunction of the detrusor muscle is the most common type. Mixed types are frequent. Non-drug measures (e.g. pelvic muscle training, bladder training, toilet training are first choice treatments. Drug therapy (estrogen, imipramine) are without proven effect.

Anorectal motility abnormalities in children with encopresis and chronic constipation.

PubMed

Raghunath, Neeraj; Glassman, Mark S; Halata, Michael S; Berezin, Stuart H; Stewart, Julian M; Medow, Marvin S

2011-02-01

To evaluate the response to rectal distension in children with chronic constipation and children with chronic constipation and encopresis. We studied 27 children, aged 3 to 16 years, with chronic constipation; 12 had encopresis. Anorectal motility was measured with a solid state catheter. When the catheter was located in the internal sphincter, the balloon was inflated to 60 mL with air. There were no differences in age, sex distribution, and duration of constipation in the two groups. Comparing groups, anorectal manometry showed no differences in the resting sphincter pressure, recovery pressure, the lowest relaxation pressure, and percent relaxation. However, time to maximum relaxation, time to recovery to baseline pressure, and duration of relaxation were significantly higher in patients with constipation and encopresis, compared with patients who had constipation alone. There may be an imbalance in neuromuscular control of defecation in constipated patients with encopresis that results in incontinence as a consequence of the increased time to recovery and duration of relaxation of the internal anal sphincter. Copyright © 2011 Mosby, Inc. All rights reserved.

Episiotomy increases perineal laceration length in primiparous women.

PubMed

Nager, C W; Helliwell, J P

2001-08-01

The aim of this study was to determine the clinical factors that contribute to posterior perineal laceration length. A prospective observational study was performed in 80 consenting, mostly primiparous women with term pregnancies. Posterior perineal lacerations were measured immediately after delivery. Numerous maternal, fetal, and operator variables were evaluated against laceration length and degree of tear. Univariate and multivariate regression analyses were performed to evaluate laceration length and parametric clinical variables. Nonparametric clinical variables were evaluated against laceration length by the Mann-Whitney U test. A multivariate stepwise linear regression equation revealed that episiotomy adds nearly 3 cm to perineal lacerations. Tear length was highly associated with the degree of tear (R = 0.86, R(2) = 0.73) and the risk of recognized anal sphincter disruption. None of 35 patients without an episiotomy had a recognized anal sphincter disruption, but 6 of 27 patients with an episiotomy did (P <.001). Body mass index was the only maternal or fetal variable that showed even a slight correlation with laceration length (R = 0.30, P =.04). Episiotomy is the overriding determinant of perineal laceration length and recognized anal sphincter disruption.

[Functional anatomy of the male continence mechanism].

PubMed

Schwalenberg, T; Neuhaus, J; Dartsch, M; Weissenfels, P; Löffler, S; Stolzenburg, J-U

2010-04-01

The basic structures and organs contributing to continence in men are far less well investigated than in women. This concerns anatomical and functional aspects as well. Especially the cooperation of single components and the dynamic anchoring in the pelvic floor require further investigation. An improved anatomical-functional interpretation is needed to generate therapeutic concepts orientated at the physiology of the bladder neck.Therefore, the focus of anatomical investigations should be on the external sphincter which is the main muscle responsible for urethral closure as well as on the connective tissue, smooth muscular and neuronal structures in the pelvis. The smooth muscular structures involved are the internal sphincter, the inner parts of the external sphincter, the urethral longitudinal musculature, and parts of the centrum perinei and of the ventral suspension apparatus which fixes the position of the bladder neck and seems to be vital for continence and initiation of micturition. These new findings imply an integral concept for men as was developed for women. A first step in this regard would be a consistent and updated anatomical nomenclature.

Muscular urinary sphincter: electrically stimulated myoplasty for functional sphincter reconstruction.

PubMed

Palacio, M M; Van Aalst, V C; Perez Abadia, G A; Stremel, R W; Werker, P M; Ren, X; Petty, G D; Heilman, S J; Van Savage, J G; Garcia Fernandez, A; Kon, M; Tobin, G R; Barker, J H

1998-11-01

To reconstruct an electrically stimulated muscular urinary sphincter (MUS) using a tailored gracilis muscle free flap with intact nerve. Unilateral surgically tailored gracilis muscle free flaps were transferred into the pelvis in eight dogs, leaving the obturator nerve intact. The muscle's pedicle vessels were anastomosed to the inferior epigastric artery and vein in the pelvis and the muscle was wrapped around the bladder neck. Electrodes were inserted into the MUS and connected to a programmable pulse generator. After 8 weeks of training the MUS, the pulse generator was programmed to be "on" for 4 hours and "off' for 15 minutes in a continuous cycle. Urodynamic studies were performed periodically, and at the end of the experiment the MUS and proximal urethra were harvested for histology. Three control dogs had sham operations. All MUS's functioned well following the procedure. Histology of the MUS/urethra complex showed no evidence of stricture. Except for one dog, all urethras were easily catheterized. This electrically stimulated innervated free-flap MUS technique effectively increases bladder outlet resistance without producing urethral obstruction.

Demonstration of postovulatory sphincter action by the isthmus of the rabbit oviduct.

PubMed

Blair, W D; Beck, L R

1976-04-01

Doughnut-shaped, carbon-impregnated rubber microtransducers calibrated to measure changes in diameter are used to demonstrate the occurrence of a sphincter action in the isthmus of the rabbit oviduct following human chorionic gonadotropin (HCG)-induced ovulation. The postovulatory constricture of the isthmus is temporal and coincides with the period when ova are retained in the oviduct. The mean change in diameter of transducers positioned within the lumen of the isthmus in rabbits treated with HCG are significantly different from mean changes observed in nontreated control rabbits when tested at 8-hour intervals over a 104-hour period. The difference is due to a statistically significant decrease in transducer diameter which occurs between 16 and 56 hours post-HCG injection. Treatment with exogenous estrogen in combination with HCG enhances both the magnitude and duration of this constricture. Significant differences occur between 8 and 104 hours. Pretreatment with progesterone prior to HCG-induced ovulation completely blocks the constricture of the isthmus. Both oviducts exhibit identical responses following HCG-induced ovulation. Sphincter action is not confirmed to a small localized segment of the isthmus but occurs over a wide area.