[show abstract][hide abstract] ABSTRACT: To prospectively assess the efficacy and safety of stapled trans-anal rectal resection (STARR) compared to standard conservative treatment, and whether preoperative symptoms and findings at defecography and anorectal manometry can predict the outcome of STARR.
Thirty patients (Female, 28; age: 51 ± 9 years) with rectocele or rectal intussusception, a defecation disorder, and functional constipation were submitted for STARR. Thirty comparable patients (Female, 30; age 53 ± 13 years), who presented with symptoms of rectocele or rectal intussusception and were treated with macrogol, were assessed. Patients were interviewed with a standardized questionnaire at study enrollment and 38 ± 18 mo after the STARR procedure or during macrogol treatment. A responder was defined as an absence of the Rome III diagnostic criteria for functional constipation. Defecography and rectoanal manometry were performed before and after the STARR procedure in 16 and 12 patients, respectively.
After STARR, 53% of patients were responders; during conservative treatment, 75% were responders. After STARR, 30% of the patients reported the use of laxatives, 17% had intermittent anal pain, 13% had anal leakage, 13% required digital facilitation, 6% experienced defecatory urgency, 6% experienced fecal incontinence, and 6% required re-intervention. During macrogol therapy, 23% of the patients complained of abdominal bloating and 13% of borborygmi, and 3% required digital facilitation. No preoperative symptom, defecographic, or manometric finding predicted the outcome of STARR. Post-operative defecography showed a statistically significant reduction (P < 0.05) of the rectal diameter and rectocele. The post-operative anorectal manometry showed that anal pressure and rectal sensitivity were not significantly modified, and that rectal compliance was reduced (P = 0.01).
STARR is not better and is less safe than macrogol in the treatment of defecation disorders. It could be considered as an alternative therapy in patients unresponsive to macrogol.
World Journal of Gastroenterology 10/2011; 17(37):4199-205. · 2.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Over the past decade, the approach to the understanding of the mechanisms involved in the aetiology of gastro-oesophageal reflux disease (GORD) symptoms has changed, and growing evidence now supports the concept that visceral hyper-sensitivity to intra-oesophageal stimuli plays a major role. Among the recent advances, one of the more consistent findings is that the contact of the refluxate, either acidic or weakly acidic, with the proximal oesophageal mucosa, is a main determinant of GORD symptoms, particularly in the large majority of patients affected by non-erosive reflux disease. The data reported in the current issue of Neurogastroenterology and Motility by Bredenoord et al., showing only a small proportion of proximal reflux in patients with Barrett's oesophagus, who are less sensitive to gastro-oesophageal reflux, further support the consistency of this finding in the pathogenesis of symptoms. In the light of these results, we shall look forward, in the management of patients, to approaches aimed at restoring the antireflux barrier, hopefully decreasing the amount of reflux and, in turn, its proximal extent.
Neurogastroenterology and Motility 09/2009; 21(8):790-5. · 2.94 Impact Factor
[show abstract][hide abstract] ABSTRACT: The present double-blind controlled study compared with a crossover design, the efficacy of cisapride with that of placebo in the treatment of constipation in 10 paraplegic patients. The trial consisted of a 5-week run-in period and two 12-week test periods, separated by a 4-week washout period. Total and segmental large-bowel transit times were assessed by means of radiopaque markers during the last week of the run-in and of the two test periods. Bowel frequency during run-in, placebo, and cisapride periods was, respectively, 2.9 · 2, 4.1 · 3, and 3.6 · 2.7 evacuations per week (NS). Neither the use of laxatives nor the modality of evacuation changed among the study periods. Oro-anal transit time during run-in, placebo, and cisapride periods was, respectively, 146 · 45, 93 · 49 (p < 0.01 vs. run-in), and 103 · 53 h (p < 0.02 vs. run-in; NS vs. placebo). The measurement of the large-bowel segmental transit times showed that transit through the right colon, left colon, and rectum did not differ during the three study periods. In conclusion, cisapride at the dosage of 10 mg four times a day was no more effective than placebo in improving bowel frequency and oro-anal or segmental large-bowel transit times in paraplegic patients.
[show abstract][hide abstract] ABSTRACT: The mechanisms underlying symptoms in gastro-oesophageal reflux disease, particularly in non-erosive reflux disease (NERD), remain to be fully elucidated. Weakly acidic reflux and the presence of gas in the refluxate could be relevant in the pathogenesis of symptoms.
To assess the relationship between symptoms and weakly acidic, acid and mixed (liquid-gas) reflux, 24 h oesophageal pH-impedance monitoring was performed in 32 NERD and in 20 oesophagitis patients. In 12 NERD patients the study was repeated following 4 weeks treatment with a proton pump inhibitor (PPI). Impedance-pH data were compared with those of 10 asymptomatic controls. Heartburn and acid regurgitation were considered in the analysis of symptoms.
15 NERD patients showed a physiological acid exposure time (pH-negative). Weakly acidic reflux was significantly less frequent in patients (25% (2%), mean (SE)) than in controls (54% (4%), p<0.01). Gas was present in 45-55% of reflux events in patient groups and controls, and decreased following PPI treatment. In NERD pH-negative patients, weakly acidic reflux accounted for 32% (10%) (vs 22% (6%) in NERD pH-positive and 12% (8%) in oesophagitis patients) and mixed reflux for more than two-thirds of all symptom-related refluxes. Multivariate logistic analysis showed that in NERD pH-negative patients, the risk of reflux perception was significantly higher when gas was present in the refluxate (odds ratio, 3.2; 95% CI, 1.2 to 10; p<0.01).
The large majority of symptoms, in all patients, are related to acid reflux. In NERD patients, the presence of gas in the refluxate significantly enhances the probability of reflux perception. These patients are also more sensitive to less acidic reflux than oesophagitis patients.
[show abstract][hide abstract] ABSTRACT: Allgrove syndrome is a rare autosomal recessive disorder characterised by childhood onset, alacrima, oesophageal achalasia, adrenocortical insufficiency, neurological and occasionally autonomic involvement. Although the disease has been associated with mutations in the ALADIN gene on chromosome 12q13, it is genetically heterogeneous. The case we report is interesting because of its onset in adulthood, long duration of disease and prominent neurological dysfunctions. After the onset of neurological abnormalities the diagnosis went unrecognised for years until the patient presented for evaluation of dysphagia. The presence of achalasia with dysphagia, adrenal insufficiency, reduced tear production, optic atrophy and peripheral motor-sensory neuropathy with axonal loss led us to clinically diagnose Allgrove syndrome even though a genetic study showed no mutations in the ALADIN gene exons. The case we report shares many clinical features with Allgrove syndrome and, even with the limitations of a single case, underlines the variability in this syndrome and the need for appropriate investigations along with a multidisciplinary approach.
[show abstract][hide abstract] ABSTRACT: The aim of this study was to introduce functional magnetic resonance imaging (fMRI) with T1-weighted turbo fast low-angle shot (FLASH) sequences in the evaluation of oesophageal motility and morphology, to formulate MRI patterns of normality in healthy subjects and to demonstrate the feasibility of the method by obtaining a preliminary experience in the study of subjects affected by oesophageal motility disorders.
Thirty healthy volunteers and seven patients with radiological and manometric diagnoses of oesophageal motility disorders underwent fMRI with dynamic T1- weighted turbo-FLASH (TFL) sequences during the administration of oral contrast material.
Evaluation of oesophageal function and morphology proved possible in all subjects, as well as the formulation of normality patterns. In patients with motility disorders, fMRI correctly visualised the typical alterations in agreement with radiological and manometric findings.
Functional MRI sequences acquired during the administration of oral contrast material can evaluate oesophageal transit, providing information on motility and morphology; furthermore, this modality can properly visualise the typical functional and morphological alterations of motility disorders.
La radiologia medica 11/2006; 111(7):881-9. · 1.46 Impact Factor
[show abstract][hide abstract] ABSTRACT: The aim of this paper was to assess the diagnostic value of magnetic resonance (MR) fluoroscopy in the study of oesophageal motility disorders and to compare MR fluoroscopy results with those of manometry and barium contrast radiography. Twenty-five subjects referred for dysphagia and three patients in follow-up after pneumatic dilatation of the lower oesophageal sphincter to treat severe achalasia underwent esophageal manometry, barium contrast radiography and MR fluoroscopy. Examinations were performed on a 1.5 T scanner. Dynamic turbo- fast low angle shot (turbo-FLASH) sequences acquired during oral contrast agent administration were used to perform MR fluoroscopy. MR fluoroscopy correctly diagnosed achalasia in nine patients, uncoordination of esophageal body motility in ten and scleroderma oesophagus in one. Diagnostic performance was satisfactory, with a sensitivity of 87.5% and a specificity of 100% in the general depiction of motility alterations. Our work demonstrates that MR fluoroscopic examination in subject affected by oesophageal motility disorders is feasible and can properly depict motility and morphology alterations, achieving correct diagnosis in the majority of cases. Studies on larger populations are necessary to obtain statistically significant results.
European Radiology 10/2006; 16(9):1926-33. · 3.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Constipation may be present in ulcerative proctitis (UP), but its pathogenesis has not yet been evaluated. The aim of this article is to investigate functional and morphologic features of the anorectal region in patients with UP and constipation.
Eleven patients with quiescent clinical, endoscopic, and histological UP and constipation and 10 patients with functional constipation (FC) underwent radiologic evaluation of intestinal transit time, anorectal manometry, and defecography. Transit time was measured with radiograms at 72 h after ingestion of radiopaque markers. Manometry was carried out using a continuous perfused catheter and a balloon inflated with increasing volumes of air. Defecography was performed after the injection of a barium-sulfate solution in the rectum, with the registration of videotapes during straining, squeezing, and evacuation.
Manometry showed in UP significantly lower values of rectal compliance than those in FC (3.10 and 5 mL/mmHg, respectively) (P = 0.03). Rectal sensitivity threshold was increased but without significant differences in UP and FC (30 and 50 mL air, respectively). At defecography, the median value of rectosacral space was increased in UP in comparison with FC (1.30 vs 0.8; P = 0.002). Lateral rectal diameter in UP was lower than in FC (6 and 8.8 cm, respectively; P = 0.016). Nonsymptomatic rectocele, mucosal prolapse, descending perineum, and abdominopelvic dyssynergy were equally present in UP and FC. The majority of UP patients showed a prolonged intestinal transit time similar to FC patients, and, more frequently, they showed low transit in the left colon in comparison with the right colon in comparison with FC patients.
This study suggests that constipation in UP may be correlated with rectal fibrosis, which reduces the transit of stools from the left colon. The concomitance of asymptomatic anorectal organic or functional alteration may contribute to worsen constipation.
[show abstract][hide abstract] ABSTRACT: Proximal acid reflux is common in gastro-oesophageal reflux disease and is a determinant of symptoms. Patients with hiatal hernia complain of more symptoms than those without and are less responsive to proton-pump inhibitors.
To evaluate the role of hiatal hernia on spatiotemporal characteristics of acid reflux.
Thirty seven consecutive gastro-oesophageal reflux disease patients underwent endoscopy, videofluoroscopy, manometry and multichannel 24-h pH test. Data were compared with those of 15 asymptomatic controls. Multivariate linear regression was used for statistical analysis.
At videofluoroscopy, hiatal hernia was found in 16 of 37 patients. The mean size of hiatal hernia was 3.4 cm. Patients showed significantly prolonged acid clearance time, both at proximal and distal oesophagus, compared with controls. Hiatal hernia patients showed a significantly delayed acid clearance, along the oesophageal body, compared with non-hiatal hernia patients. The prolonged acid exposure was maintained during upright and supine position. The presence of hiatal hernia significantly predicted acid clearance delay in the distal and proximal oesophagus [at 10 cm below upper oesophageal sphincter: Delta + 2.5 min (95% confidence interval: 0.4-4.5); P < 0.02].
The presence of hiatal hernia is a strong predictor of more prolonged proximal oesophageal acid exposure and clearance. Hiatal hernia is likely to play a role in the pathophysiology of gastro-oesophageal reflux disease symptoms, and should be taken into greater consideration in the treatment strategies of the disease.
[show abstract][hide abstract] ABSTRACT: It has been demonstrated that dilation of intercellular spaces of esophageal epithelium is a marker of tissue injury in GERD patients with a pathological esophageal acid exposure time. To evaluate the relationship among ultrastructural changes, acid esophageal exposure, and GERD symptoms, intercellular space diameters have been assessed in nonerosive reflux disease (NERD) patients with/without abnormal acid exposure time.
Following a pharmacological wash-out, 20 NERD patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Biopsies were taken at 5 cm above the lower esophageal sphincter and intercellular space diameters were measured on transmission electron microscopy photomicrographs. Seven asymptomatic controls underwent the same protocol.
Acid exposure time was in the normal range in all controls and in 11 patients (NERD pH-negative); it was abnormal in 9 patients (NERD pH-positive). Mean intercellular space diameter in NERD pH-negative and in NERD pH-positive patients was three times greater than in controls (1.45 and 1.49 microm vs 0.45, p < 0.001). Mean values of maximum intercellular spaces in all NERD patients were greater, two-fold or more, than those in controls (p < 0.001). No difference in mean and maximal space diameters was observed between NERD pH-positive and pH-negative patients.
Dilation of intercellular spaces is a feature of NERD patients, irrespective of esophageal acid exposure, and can be considered an objective, structural marker of GERD symptoms. Impaired esophageal mucosal resistance, even to small amounts of acid refluxate, plays a key role in the pathophysiology of NERD.
The American Journal of Gastroenterology 04/2005; 100(3):543-8. · 7.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Esophagopharyngeal reflux (EPR) is among the factors involved in the supraesophageal complications of reflux disease, and is diagnosed by the regurgitation of barium from the upper third of the esophagus into the pharynx in the absence of swallow during a videofluoroscopic swallowing study. EPR is detected in approximately 20% of patients undergoing these studies, and occurs in different clinical groups without disease-specific associations. The vast majority of patients with EPR show esophageal motor abnormalities on swallowing studies. Notably, prolonged esophageal clearing time is independently and strongly associated with EPR. Our data suggest that the oropharyngeal phase of deglutition is impaired in >50% of patients with both gastroesophageal reflux disease and EPR. In the subset of patients with EPR, oral abnormalities are mostly related to tongue function. Based on the data emerging from our videofluoroscopic swallowing studies, it seems plausible that EPR occurs as a result of an underlying esophageal motor dysfunction facilitated by an impaired oral deglutition. As a consequence, when examining patients for EPR, both esophageal and oropharyngeal abnormalities should be sought.
The American Journal of Medicine 08/2003; 115 Suppl 3A:124S-129S. · 4.77 Impact Factor