A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence.

    Harry Liberman, Julio Faria, Charles Ternent, garnet j,blatchford, Mark A.Christiansen, Alan G.Thorson.

    Diseases Colon Rectum 2001; 44:1567-1574.

    Os autores avaliaram prospectivamente um grupo de 90 pacientes incontinentes (84 sexo feminino) encaminhados para tratamento.

    Inicialmente foram submetidas a avaliação clínica e exame físico, resultando em indicação de tratamento clínico (n= 45) ou cirúrgico ( n=45). Em seguida todos os pacientes foram encaminhados para avaliação fisiológica através de : manometria ano-retal de perfusão, ultra-sonografia de canal anal com transdutor de 360 graus e tempo de latência do nervo pudendo.

    Finalmente, um painel de colo-proctologistas especialistas em fisiologia revisaram os dados clínicos e fisiológicos de todos os pacientes chegando-se então a um consenso sobre a melhor opção terapêutica.

    Observaram então que a adição dos métodos de fisiologia ao exame clínico modificou o manejo dos pacientes em 10% dos casos.

    No grupo com indicação clínica pré-teste a adição dos testes indicou tratamento cirúrgico em 5 pacientes (11%), principalmente pela detecção ultra-sonográfica de defeitos musculares.

    No grupo com indicação cirúrgica pré-teste , em 3 pacientes (7%) a indicação passou a ser clínica e em 1 paciente alterou-se a indicação cirúrgica de esfincteroplastia para procedimento de transposição muscular. Nesses 3 pacientes a ultra-sonografia afastou a presença de um defeito esfincteriano.

    De um modo geral, 27 dos 90 pacientes estudados (30%) obtiveram resultados anormais através dos métodos de fisiologia. Um terço dos pacientes apresentaram prolongamento do tempo de latência do pudendo. Defeitos esfincterianos ao ultra-som foram detectados em 52 pacientes (87%) , sendo que em 45 casos, a origem era causa obstétrica (87%) e em 7 pacientes devido a cirurgias ano-retais prévias( 13%).

    Os pacientes cuja avaliação fisiológica alterou seus planos terapêuticos para tratamento cirúrgico constituiam um grupo mais jovem , com menor graduação de incontinência e com menor intervalo entre o último parto vaginal e a realização dos testes.

    Baseados nesses resultados , os autores concluiram que a utilização dos métodos de fisiologia, especialmente a ultra-sonografia do canal anal, pode auxiliar significativamente o manejo dos pacientes incontinentes, embora a avaliação clínica de um colo-proctologista experiente seja também confiável.

Tutuian R, Castell DO.

Division of Gastroenterology/Hepatology, Medical University of South Carolina, South Carolina 29425, USA.

Am J Gastroenterol. 2004 Jun;99(6):1011-9.

BACKGROUND: Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is a technique that uses an FDA-approved device allowing simultaneous evaluation of bolus transit (MII) in relation to pressure changes (EM). METHODS: During a 9-month period, beginning from July 2002 through March 2003, we prospectively performed combined MII-EM on all patients referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. Manometric findings were reported based on criteria described by Spechler and Castell for liquid swallows. MII findings were reported as having normal bolus transit if >/=80% (8/10) of liquid and >/=70% (7/10) of viscous swallows had complete bolus transit. RESULTS: Three-hundred fifty studies were evaluated from patients with a variety of symptoms having the following manometric diagnoses: normal manometry (125), achalasia (24), scleroderma (4), ineffective esophageal motility (IEM) (71), distal esophageal spasm (DES) (33), nutcracker esophagus (30), hypertensive lower esophageal sphincter (LES) (25), hypotensive LES (5), and poorly relaxing LES (33). None of the patients with achalasia and scleroderma had normal bolus transit. Fifty-one percent of patients with IEM and 55% of patients with DES had normal bolus transit while almost all (more than 95%) patients with normal esophageal manometry, nutcracker esophagus, poorly relaxing LES, hypertensive LES, and hypotensive LES had normal bolus transit. Dysphagia occurred most often in patients with incomplete bolus transit on MII testing. CONCLUSION: Esophageal body pressures primarily determine bolus transit with isolated LES abnormalities appearing to have little effect on esophageal function. MII clarifies functional abnormalities in patients with abnormal manometric studies.

Sperandio M, Tutuian R, Gideon RM, Katz PO, Castell DO.

Department of Medicine, Graduate Hospital, Philadelphia, Pennsylvania, USA.

Dig Dis Sci. 2003 Jul;48(7):1380-4.

Diffuse esophageal spasm is an uncommon motility disorder that is found in less than 5% of patients undergoing esophageal motility testing for dysphagia. It is defined manometrically by the presence of 20% or more simultaneous contractions in the distal esophageal body with normal peristalsis. This motility abnormality has been traditionally identified as occurring primarily in the smooth muscle portion of the distal esophagus yet, the term "diffuse" persists in the medical literature to identify DES. The aim of our study was to assess the diffuse or limited nature of this entity by evaluating the prevalence of simultaneous contractions in both proximal and distal esophagus in patients with DES. We reviewed esophageal motility tracings of 53 consecutive patients (32 F, 21 M) with DES and compared them with 53 age-matched patients with manometric normal studies. In the distal esophagus we found 195 simultaneous contractions (37% of swallows) with a median of 3 and range of 2-7 per patient. Of the 53 patients with DES a total of 13 simultaneous contractions (2% of swallows) occurred in the proximal esophagus with only 3 (5.6%) of the 53 patients having 2 or more simultaneous contractions in 10 swallows. None of the patients with normal manometry showed more than one simultaneous contraction in either proximal or distal esophagus. In conclusion, these findings suggest that the term diffuse esophageal spasm is a misnomer and the DES is more appropriately described as "distal" esophageal spasm.

Shay S, Tutuian R, Sifrim D, Vela M, Wise J, Balaji N, Zhang X, Adhami T, Murray J, Peters J, Castell D.

Department of Gastroenterology, Cleveland Clinic Foundation, OH 44195, USA.

Am J Gastroenterol. 2004 Jun;99(6):1037-43.

OBJECTIVES: Impedance monitoring is a new diagnostic method for gastroesophageal reflux disease (GERD) where multiple impedance electrode pairs are placed on a standard pH catheter. It detects reflux of a liquid and/or gas bolus into the esophagus, as well as its distribution, composition, and clearing. The aim of this collaborative study is to define normal values for 24-h ambulatory simultaneous impedance and pH monitoring (24-h Imp-pH), and compare bolus parameters by impedance monitoring to changes in [H(+)] measured by pH monitoring. METHODS: Sixty normal volunteers without GER symptoms underwent 24-h Imp-pH with impedance measured at six sites (centered at 3, 5, 7, 9, 15, and 17 cm above lower esophageal sphincter) and pH 5 cm above the LES. Reflux detected by impedance was characterized by the pH probe as either acid, weakly acidic, nonacid, or superimposed acid reflux. Proximal reflux was defined as reflux that reached the impedance site 15 cm above the LES. RESULTS: Reflux frequency was common upright (median-27, 25th and 75th quartile-16, 42), but rare recumbent (median-1; 0, 4). A median of 34% (14%, 49%) of upright reflux reached the proximal esophagus. There was a similar number of mixed composition (liquid + gas; 49%) and liquid-only reflux (51%). Acid reflux was two-fold more common than weakly acidic reflux (p < 0.001). Superimposed acid reflux and nonacid reflux were rare. Acid neutralization to pH 4 took twice as long as volume clearance measured by impedance. CONCLUSIONS: Combining impedance and pH monitoring improves the detection and characterization of GER. This study characterizes the frequency, duration, and extent of reflux in health and provides normal values for 24-h Imp-pH for future comparison with GERD patients.

Zaslavsky C, De Barros SG, Gruber AC, MacIel AC, Da Silveira TR.

Gastroenterology Post Graduate Program, School of Medicine, Universidade Federal do Rio Grande do Sul and the Gastroenterology Service, Hospital de Clinicas de Porto Alegre (HCPA), Ramiro Barcelos 910/1003 Porto Alegre, RS, Brazil. carlos.zaslavsky@hmv.org.br

J Adolesc Health. 2004 Jun;34(6):517-22.

OBJECTIVE: To evaluate the clinical findings and colonic transit time in adolescents with chronic functional constipation. METHODS: Forty-eight consecutive adolescents with chronic functional constipation referred to the Gastroenterology Service at the Hospital de Clinicas de Porto Alegre, Brazil were studied. Clinical parameters were assessed using a questionnaire. Total and segmental colonic transit time were measured with radiopaque markers. RESULTS: Mean age at first visit was 14 +/- 2 years, and age at onset of constipation was 6 +/- 4 years; 90% of patients depended on laxatives, and 86% on intermittent enemas; 76% had a family history of constipation. There was no statistical difference in the amount of daily fiber ingested by patients and controls. Measurements of colonic transit time revealed that 60% of patients had slow transit constipation, 13% had pelvic floor dysfunction, 10% had slow transit constipation associated with pelvic floor dysfunction, and 17% had a normal colonic transit time. Decreased frequency of evacuation and palpable abdominal fecal mass were significantly associated with slow transit constipation. CONCLUSIONS: Functional constipation in adolescence consists of a heterogeneous group of colonic functional disorders. The identification of these different functional disorders in adolescents will guide specific treatment, which may prevent the progression of this symptom into adult life.

Zaslavsky C, Loening-Baucke V.

Hospital da Crianca Santo Antonio and Hospital Materno Infantil Presidente Vargas, Porto Alegre, Brazil; carlos.zaslavsky@hmv.org.br

J Pediatr Surg. 2003 Feb;38(2):191-53.

BACKGROUND: Little is known about anorectal function in patients after surgery for Hirschsprung's disease. Therefore, the authors evaluated anorectal sphincter function after corrective surgery. METHODS: Thirty-five patients were studied after corrective surgery for Hirschsprung's disease. Sixteen of them had anorectal manometry performed also before surgery. The clinical outcome, the highest anal resting pressure, the presence of the rectosphincteric reflex (RSR), and of high amplitude propulsive waves were evaluated. RESULTS: A total of 89% were doing poorly. Three had a fair and only one had a good outcome at the time of manometry 4.4 years after corrective surgery. RSR was absent in 33 and abnormal in 2 patients. The preoperative anal resting pressure was 45 +/- 14 mm Hg and postoperatively 45 +/- 13 mm Hg (P >.3). The anal resting pressure was 44 +/- 16 mm Hg in the 19 patients evaluated only postoperatively. Propulsive waves > or =50 mm Hg were present in 60% of patients. CONCLUSIONS: Four years postsurgery, patients had a persistent absence of RSR regardless of the type of surgery. There was no significant difference in anal resting pressure between patients with and without sphincterotomy or between different surgical procedures. The presence of propulsive waves was not a prognostic indicator for achieving bowel control. Copyright 2003, Elsevier Science (USA). All rights reserved.

No dia 29 de maio (Dia Mundial da Saúde Digestiva), o Brasil recebeu a campanha nacional de conscientização “Nutrição para Saúde Digestiva”. A iniciativa faz parte da ação global da Organização Mundial de Gastroenterologia (WGO), com apoio no Brasil da Federação Brasileira de Gastroenterologia (FBG) e parceria mundial da Danone para marcar a data, celebrada pela primeira vez no País.

Na data também foi lançado o mapa mundial das desordens e doenças digestivas, com dados epidemiológicos de 50 países. Para ampliar o alcance da iniciativa, a campanha contará com um hotsite (www.saudedigestiva.com.br), que reunirá informações sobre a saúde e os distúrbios digestivos, dicas de alimentação, pesquisas sobre o tema, teste de avaliação do funcionamento do intestino, entre outros dados.

A Campanha foi realizada simultaneante, em três capitais brasileiras (São Paulo, Belo Horizonte e Porto Alegre), com objetivo de disseminar informações sobre os distúrbios digestivos, e o impacto da nutrição na saúde.

:: EVENTOS

Saiba onde serão os próximos Eventos Nacionais e Eventos Internacionais sobre Motilidade Digestiva!


IX SEMANA BRASILEIRA DO APARELHO DIGESTIVO


Dias: 21, 22, 23, 24 e 25 de Novembro de 2010
Local: Florianópolis - SC

:: LANÇAMENTO

FISIOLOGIA ANORETAL é lançamento da Editora Rubio que leva assinatura da Dra. Lucia Camara Castro Oliveira, que apresenta com diversos conteúdos para o especialista do aparelho digestivo. Organizados por temas específicos a obra destaca a motilidade como um todo com a cobertura dos principais assuntos da fisiologia anoretal.

:: RESUMO DE TESES

PROSPECTIVE RANDOMIZED TRIAL COMPARING PENUMATIC DILATATION AND LAPAROSCOPIC MYOTOMY IN IDIOPATHIC ACHALASIA – PRELIMINARY RESULTS. Saiba mais.

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