Orthotopic liver transplantation improves small bowel motility disorders in cirrhotic patients

Altered small intestinal motility has been observed in patients with liver cirrhosis. Its pathophysiology remains to be defined. Our aim was to investigate the effect of orthotopic liver transplantation on small intestinal dysmotility in patients with liver disease. Two patients were studied both before and after orthotopic liver transplantation. Abnormal migrating motor complex activity and prominent clustered contractions present preoperatively normalized within 6 months after the surgical procedure. This finding might represent an additional benefit of liver transplantation considering that altered motility may be involved in bacterial overgrowth and infections observed in these patients.     

Intestinal motility after massive small bowel resection

To evaluate intestinal motility after 80% massive distal small bowel resection (MSBR), we continuously monitored interdigestive and postprandial bowel motility using bipolar electrodes and/or contractile strain gage force transducers in conscious beagle dogs before, and at 0-4 weeks and 8-13 months after the surgery. Fasting duodenal migrating myoelectric (or motor) complexes (MMCs) occurred at longer intervals in the short-term after 80% MSBR than in controls, and were simulated in long-term that in controls. MMCs arising from the duodenum were often migrated to the proximal jejunum, the jejunum above the anastomosis, and to the terminal ileum beyond the anastomosis. The velocity of duodenal MMC propagation was slowed in every intestinal segment in the short-term, and had not recovered even long after the operation. The duration of the postprandial period without duodenal MMCs was prolonged significantly in the short-term, and still remained longer in the long-term than in controls. These findings suggest that changes in gut motility after MSBR tend to compensate for the shorter intestine and maintain small bowel absorption early postoperatively, and adaptations of motility would occur over the long-term to increased intestinal absorption.     

Severe late radiation enteropathy is characterized by impaired motility of proximal small intestine

Late radiation enteropathy (LRE) is a serious disorder, and therapeutic progress has thus far been hampered by insufficient understanding of the pathogenesis. This prospective study addresses whether alterations in proximal intestinal motility can predict the clinical severity of this disorder. Forty-one consecutive patients with chronic abdominal complaints after radiotherapy for gynecological cancer were examined by prolonged ambulatory manometry. Twenty-seven healthy adults served as controls. Impaired fasting motility was found in 12 of 41 patients (29%), and attenuated postprandial motor response after a liquid-solid meal was seen in 10 of 41 patients (24%). Postprandial delay of the migrating motor complex (MMC) was a good predictor of the degree of malnutrition (Cox regression, P < 0.01), and intensity of the MMC and postprandial motility index explained 69% (P < 0.001, multiple regression) of the variability in degree of malnutrition, assessed by weight loss and serum albumin level. The typical presentation of severe LRE was clinical symptoms suggesting intestinal pseudoobstruction, malnutrition, failure of a liquid-solid meal to induce postprandial motility, and delayed initiation and reduced intensity of MMC during nocturnal fasting. Prolonged ambulatory manometry was useful for detection of dysmotility in patients with symptoms of LRE and impaired motility of proximal small intestine seems to be a key factor in the pathogenesis of severe LRE.     

Effect of ageing on pancreatic hyperplasia after 90% proximal small bowel resection

PURPOSE: A longitudinal study to ascertain the attitudes toward, and habits of, substance use among a single class of medical students. METHOD: A single class from a northeastern medical school was surveyed in both its first year (February 1991, 176 students) and its third year (May 1993, 170 students). The students were asked to report how frequently during the prior year they had used drugs or alcohol, and whether their use of each substance had increased, decreased, or remained the same since entering medical school; to identify any family members with histories of alcohol or drug problems; and to report any incidence during the prior year of ten behaviors associated with substance dependence. The students were also asked to indicate their agreement or disagreement with 11 attitudinal statements. Additional attitudinal items asked the students to identify three major deterrents to the abuse of drugs and alcohol, and what they had done if they had become aware of a classmate with a drug or alcohol problem. Chi-square analysis and two-tailed t-tests were used to compare data from the two surveys. RESULTS: The response rates in the first and second surveys were 96.9% and 81.8%, respectively. Use of licit and illicit substances was comparable to that of chronological peers and prior national studies of medical trainees. Most of the students admitted to using alcohol at least once in the prior year (91.8% and 95%, respectively). In both years marijuana was the illicit drug used most often. Although there was a slight increase over time in the use of benzodiazepines (2.4% to 5.8%) and a decrease in the use of marijuana (29.4% to 21.7%), these changes were not significant. Few of the students in their third year reported using any substance other than alcohol more than once a month. In general, a greater percentage of the students reported a decrease rather than an increase in the use of a substance since entering medical school; the primary exception was for wine. As they progressed in their training, the students became less concerned about the effect of substance use on their performance and more likely to be embarrassed about admitting to an addiction. Although in each year a few of the students appeared to be at risk for substance dependence (8.9% and 3.5%, respectively), no student came to the attention of the administration because of problems related to substance use. While most of the students were unaware of any classmate who had a problem, half of those who were aware had done nothing, and the balance had rarely sought assistance from the faculty or administration. CONCLUSION: Although there was no evidence that substance use was a major problem, a few of the students appeared to be at risk for drug or alcohol dependence. Appropriate intervention, support, and referral systems should be identified for the few who may be at risk, and increased educational efforts are needed to help all students address this issue with their peers and, ultimately, with their patients.     

Impact of corticotropin-releasing hormone on gastrointestinal motility and adrenocorticotropic hormone in normal controls and patients with irritable bowel syndrome

The present study adopted a prospective design to explore relationships among various types of social support and depression. Four types of social support, namely network support, instrumental enacted support, socio-emotional enacted support, and perceived support, were assessed in a sample of Chinese adolescents. Results revealed that perceived support was related to a reduction of subsequent depression for both male and female adolescents. In addition, instrumental enacted support was a significant predictor of subsequent depression for male adolescents, whereas socioemotional enacted support was a significant predictor of subsequent depression for female adolescents. Functional differences in the types of social support for Chinese male and female adolescents, as well as implications for clinical intervention, are discussed.     

Plasma selenium in patients with cirrhosis

S100B(betabeta) is a dimeric Ca2+-binding protein that is known to inhibit the protein kinase C (PKC)-dependent phosphorylation of several proteins. To further characterize this inhibition, we synthesized peptides based on the PKC phosphorylation domains of p53 (residues 367-388), neuromodulin (residues 37-53), and the regulatory domain of PKC (residues 19-31), and tested them as substrates for PKC. All three peptides were shown to be good substrates for the catalytic domain of PKC. As for full-length p53 (Baudier J, Delphin C, Grunwald D, Khochbin S, Lawrence JJ. 1992. Proc Natl Acad Sci USA 89:11627-11631), S100B(betabeta) binds the p53 peptide and inhibits its PKC-dependent phosphorylation (IC50 = 10 +/- 7 microM) in a Ca2+-dependent manner. Similarly, phosphorylation of the neuromodulin peptide and the PKC regulatory domain peptide were inhibited by S100B(betabeta) in the presence of Ca2+ (IC50 = 17 +/- 5 microM; IC50 = 1 +/- 0.5 microM, respectively). At a minimum, the C-terminal EF-hand Ca2+-binding domain (residues 61-72) of each S100beta subunit must be saturated to inhibit phosphorylation of the p53 peptide as determined by comparing the Ca2+ dependence of inhibition ([Ca]IC50 = 29.3 +/- 17.6 microM) to the dissociation of Ca2+ from the C-terminal EF-hand Ca2+-binding domain of S100B(betabeta).     

Abnormal gastric motility in liver cirrhosis: roles of secretin

Cutaneous electrogastrography (EGG) revealed that the power ratio, an indicator of rhythmicity of EGG waveforms was significantly less in liver cirrhosis (power ratio: 28.2+/-14.5%) than in normal subjects (power ratio: 45.6+/-16.2%) (P < 0.01), thus demonstrating dysrhythmic EGG waveforms for liver cirrhosis. Gastric emptying time (T1/2), calculated from the half-life of retained radioisotope (RI) in the region of interest (ROI) in the stomach following the ingestion of RI containing test meal was significantly prolonged in patients with liver cirrhosis compared to the control (liver cirrhosis vs controls 43.2+/-20.3 min vs 24.8+/-9.6 min, P < 0.01). Of the five gastrointestinal hormones-gastrin, secretin, motilin, cholecystokinin (CCK), and glucagon-serum secretin was significantly higher in liver cirrhosis than the control (P < 0.05) and negatively correlated with the power ratio (r = 0.51, P < 0.01). Normal, regular EGG waveforms (power ratio: 47.1+/-10.2%) became dysrhythmic in normal volunteers (power ratio: 34.1+/-12.4%), when their serum secretin was experimentally increased to essentially that in liver cirrhosis and possible roles of hypersecretinemia in abnormal gastric motility in liver cirrhosis are proposed.     

Oesophageal motility disorders in patients with psychiatric disease

Clinical and experimental observations indicate that the motility of the oesophagus may be affected by emotional stimuli. The aim of this study was to evaluate the incidence of oesophageal contractility impairment in patients suffering from a psychiatric disorder. Fifty-one patients admitted to the psychiatric department were submitted to an oesophageal transit study by means of krypton-81m. All patients with an abnormal oesophageal transit underwent manometry and endoscopy. The level of depression and anxiety was evaluated by the treating psychiatrist, using the Hamilton Depression and Anxiety Rating Scales. The oesophageal transit was abnormal in 13 patients. Two of these 13 patients refused manometric investigation. In ten of the 11 remaining patients, the manometry revealed functional motor abnormalities. Endoscopy, performed in all these ten patients, was normal. In conclusion, a high percentage of oesophageal contractility disturbances was found in psychiatric patients complaining of anxiety and/or depression. These abnormalities were detected by scintigraphy as well as by manometry. Owing to the normal endoscopic findings, these contraction abnormalities are likely to reflect a functional motor impairment.     

Urinary endothelin-like immunoreactivity in patients with cirrhosis

BACKGROUND/AIMS: To investigate a possible relationship between the renal production of endothelin and the presence of renal dysfunction and activation of vasoactive systems in cirrhosis, the urinary excretion and the circulating plasma levels of immunoreactive endothelin (irET) and the plasma levels of vasoactive hormones were measured in 19 healthy subjects, 12 cirrhotic patients without ascites and 39 patients with ascites and different degrees of renal dysfunction. METHODS: The urinary excretion and the circulating levels of irET were assessed after 5 days on a 40 mEq sodium diet and off diuretics. Renal function parameters and the plasma levels of vasoactive hormones were also measured. RESULTS: Patients with and without ascites had similar values of urinary irET as compared with healthy subjects (30+/-3, 31+/-3 and 29+/-2 ng/day, respectively, p>0.10). By contrast, patients with ascites had higher circulating levels of irET (15+/-1.2 pg/ml) than patients without ascites and healthy subjects (11+/-1.6 and 5+/-0.4 pg/ml, p<0.01). In patients with cirrhosis, no correlation was found between urinary irET and circulating irET. Moreover, urinary irET did not correlate with liver tests, serum and urine sodium, glomerular filtration rate or vasoactive substances. Patients with hepatorenal syndrome had similar urinary irET to patients with ascites without hepatorenal syndrome. CONCLUSIONS: Urinary excretion of irET is not increased in cirrhotic patients with ascites and does not correlate with abnormalities in renal function.     

Diffusion disorders in patients with liver cirrhosis

In 17 patients with cirrhosis of theliver and in 11 controls the pulmonary diffusing capacity for CO (DLCO) was determined at three different levels of alveolar oxygen tensions. The diffusing capacity of the alveolar membrane (DMCO) and the intra-pulmonary capillary volume (VC) were calculated following the formula given by Roughton and Forster. The following results were obtained: 1) Both DLCO and DMCO were lower (p less than 0,01) in the patient group than in the controls. 2) VC showed larger variations in thepatient group than in the controls (p less than 0,01). The mean values did not differ, however. 3) There was a significant linear correlation (p less than 0,001) between DM and 1/VC in the patient group (DM and VC in % of the predicted value). The results suggest, that a change in the configuration of the capillary bed may be responsible for the transfer defect found in cirrhosis.     

Laparoscopic approach in acute small bowel obstruction. A review of 68 patients

BACKGROUND/AIMS: Laparoscopic management of acute small bowel obstruction has potential advantages over classical laparotomy. The aims of this study were to assess the feasibility and the safety of this technique, as well as to find any predictive success factors. METHODOLOGY: A laparoscopic approach was undertaken in 68 out of 150 patients admitted between 1991 and 1997 for acute small bowel obstruction. RESULTS: The cause of obstruction was bands or adhesions in 80% of the patients. A correct laparoscopic diagnosis was established in 66% of the cases. A laparoscopic treatment was performed successfully in 31 patients (46%), and was assisted by minilaparotomy in 4 patients (6%), and by open herniorraphy in 2 patients (3%). Thirty-one patients (46%) needed a conversion to laparotomy. There were 6 bowel injuries (9%), all recognized during laparoscopy. There were 2 deaths in converted patients and 2 early reoperations for persisting ileus in patients treated by laparoscopy alone or by assisted laparoscopy. CONCLUSION: Acute small bowel obstruction can be treated by laparoscopy alone, or assisted by minilaparotomy or open herniorraphy with advantages for the patient and few complications despite a high rate of conversion. There were no pre-operative predictive factors for successful laparoscopy, except for an isolated previous scar from an appendectomy. Pre-operative predictive success factors were parietal intestinal adhesions, as the only cause of obstruction. Multiple adhesions will mostly require conversion to laparotomy.     

The small bowel enema: experience with 150 examination

Clinical application of the small bowel enema has received waxing and waning enthusiasm since it was first described in 1929. Our experiences with 150 small bowel enema studies is presented. The Sellink method was used for patients without ileostomy, (140), and retrograde studies for those with ileostomy. The merits of the small bowel enema compared to the conventional technique are discussed. The small bowel enema is the preferred method for radiologic assessment of the small bowel in patients whose clinical picture suggests small bowel disease.     

Community experience with small bowel bypass for morbid obesity

A comparison of small bowel bypass performed at university centers and by private practitioners in a large metropolitan area demonstrates definite stmilarities in terms of patient selection, mortality and morbidity, and weight loss results. The only aspect of small bowel bypass in the private sector that could be criticized would be the adequacy of follow-up. An operation with as many known and probably other unknown long-term complications as jejunoileal bypass necessitates prolonged careful patient follow-up. We belive the person most qualified to provide such follow-up is the surgeon who performed by bypass procedure.