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Gastroparesis is a disorder of gastric motility that results in delayed gastric emptying. Common symptoms include early satiety, postprandial fullness, epigastric pain, nausea, vomiting, and weight loss. The underlying etiologies of gastroparesis are many and include diabetes, prior gastric surgery, collagen vascular disorders, and a previous viral illness. Up to one third of cases are classified as idiopathic. Treatment typically consists of a change in diet to small volume, frequent meals and the use of the prokinetic agents metoclopramide, cisapride, erythromycin, or domperidone. Botulinum toxin has recently been shown to be effective in treating disorders of smooth muscle hypertonicity in the GI tract. This case report describes three patients with severe gastroparesis whose symptoms persisted despite dietary changes and the use of high dose prokinetic agents. All three were treated with intrasphincteric injection of the pylorus with botulinum toxin and all had significant symptomatic improvement afterwards. Possible mechanisms of action of botulinum toxin on the pylorus and its effects in patients with gastroparesis are discussed.

Objective: Abdominal pain has not been reported generally as a significant feature of the clinical presentation of patients with gastroparesis., Methods: Using a standardized questionnaire, we analyzed the clinical features of 28 consecutive patients referred with established or suspected gastroparesis over a 4-yr period. The diagnosis of gastroparesis was supported by abnormalities in gastric emptying studies (GES), electrogastrography (EGG), or upper endoscopy (EGD). Diagnostic tests were reviewed., Results: A total of 12 male (mean age 39.5 yr) and 18 female patients (mean age 39.6 yr) were included in this study. These patients had been symptomatic for an average of 37.8 months before their referral to our center. Seven of these patients had insulin-dependent diabetes. Idiopathic gastroparesis was present in more than half of the patients. The symptom profile of the 28 patients was as follows: nausea, 92.9%; abdominal pain, 89.3%; early satiety, 85.7%; and vomiting, 67.9%. The pain was described as burning, vague, or crampy in nature. Only 36% localized to the upper abdomen. In all, 60% of patients complained of postprandial pain, whereas 80% complained of nocturnal pain that interfered with their normal sleeping pattern. In general, pain responded poorly or not at all to prokinetic agents., Conclusions: Nausea and abdominal pain are the most common complaints of patients with gastroparesis. In 80% of patients, GES and EGG correlated positively.

Cyclic vomiting is a rare syndrome that over the years has variously been ascribed to psychogenic causes, sensory seizures, abdominal migraine, and more recently, to mechanical or electrical disturbances in gastric physiology. We describe the case of a 65-year-old white diabetic female with a 10-yr history of recurrent episodes of nausea and vomiting, occurring every 10-12 days and lasting approximately 1-3 days at a time. These episodes were accompanied by edema, mild temperature elevations, and remarkable elevations in blood pressure. In between these episodes, the patient remained asymptomatic. Initial screening tests were also negative except for moderate gastroparesis. However, antral motility was found to be normal, as was an electrogastrogram. Detailed neurological and psychiatric evaluations were negative. Trials of erythromycin, metoclopramide, naloxone, ondansetron, and amitryptiline were unsuccessful. Serial endocrinological testing revealed that an episode of vomiting was always preceded by an abnormal elevation in at least one of the following: serum adrenocorticotropic hormone, serum cortisol, or urinary cortisol. In the midst of an episode, all three values were exceedingly high (e.g., > 10-fold increases in 24-hr urinary cortisol levels). Fluctuations of a milder degree, though still abnormally high, were also noted in between cycles at times when the patient was completely asymptomatic. High-dose dexamethasone suppressed these hormonal surges completely but not the clinical symptoms, which continued undisturbed. The patient was finally given a trial of intramuscular ketorolac during one of her episodes, which produced prompt and sustained relief. During the next few weeks, she was given this drug each time her symptoms commenced, and each time it appeared that her cycle had been aborted. She has since been able to terminate her episodes promptly and completely by self-administration of ketorolac. We speculate that her syndrome is caused by a poorly characterized disorder of endogenous prostaglandin release, resulting not only in derangements in the hypothalamic pituitary system but also in nausea and vomiting.

Objectives: Chronic intestinal pseudoobstruction (CIP) is difficult to differentiate from true mechanical obstruction, so many patients undergo multiple operations before the diagnosis is established. This is because of a lack of easily identifiable signs and symptoms that can differentiate true intestinal obstruction from pseudoobstruction. The digital arch is the least common (10%) of the three patterns of fingerprints (arches, loops, and whorls) found in primates. Digital arches have also been reported in association with mitral valve prolapse, which in turn is associated with joint laxity. Fingerprints and mitral valve prolapse are congenital features and are influenced by heredity, so we evaluated CIP patients for coexistence of these clinical markers., Methods: Fingerprints were examined in 1566 consecutive gastrointestinal specialty referrals. In 43 patients, the initial diagnosis of CIP was confirmed by subsequent testing. Because of the clinical impression that four features were present with increased frequency in CIP patients, these signs and symptoms were recorded prospectively: 1) number of digital arches (DA); 2) presence of mitral valve prolapse (MVP), 3) presence of joint laxity (JL), and 4) onset of constipation before age 10 (C < 10)., Results: Forty-three CIP patients (39 female, four male, ages 18-62) were seen. Using the test for significance of differences in proportions, the presence of DA, MVP, JL, and C < 10 proved significantly higher (p < 0.001) in CIP patients than in age- and sex-matched controls and the general population., Conclusions: We conclude that: 1) CIP may be a heritable syndrome because it is associated with heritable congenital markers (DA, MVP, JL, and C < 10; 2) these markers are identified with higher frequency in CIP patients than in the general population and in age- and sex-matched patients with other gastrointestinal disorders; 3) all four markers are easily detectable, and their recognition could lead to earlier diagnosis of the disorder.

Objective: Total abdominal colectomy (TAC) for intractable constipation has a variable reported success rate that decreases to 50% beyond 2 yr. We hypothesize that this inconsistent outcome can be explained by a more extensive intestinal involvement in some patients., Design: A consecutive sample of patients with intractable constipation had preoperative evaluations that included both upper and lower GI studies. Stool frequency, constipation, diarrhea, abdominal pain, and laxative or enema requirements were compared before and after operation. The study took place in an academic referral center and included 37 consecutive referred patients with severe intractable constipation and colonic dysmotility documented by radiopaque marker studies., Interventions: TAC, with ileoproctostomy in 34 patients and ileostomy in three., Main Outcome Measures: Patients with motility abnormalities only of the lower GI tract were diagnosed as having colonic inertia (CI). Those with motility disorders of both the upper and the lower GI tracts were considered to have generalized intestinal dysmotility (GID) with colon predominance., Results: Twenty-one patients had CI, and 16 had GID. Ninety percent of CI patients undergoing TAC had a successful outcome with a mean of 23 bowel movements (BMs)/wk at a mean follow-up of 7.5 yr. Although 88% of GID patients had initial improvement, with a mean of 19 BMs/wk at 6 months, only 13% had prolonged relief. After 2 yr, nine of the GID patients had recurrent constipation, and three had severe diarrhea., Conclusions: This study has identified two distinct types of colonic dysmotility, CI and GID. It has demonstrated the long-term success of TAC for CI and the importance of upper GI physiological studies to identify colon-predominant GID, which has a poor long-term response to TAC.

Objectives: The aim of this study was to characterize the frequency and severity of gastrointestinal symptoms in bulimic patients and to determine their response to treatment of the eating disorder., Methods: Forty-three consecutive bulimic patients admitted to the inpatient Eating Disorders Unit of the Psychiatry Service were asked to fill out a gastrointestinal symptoms questionnaire, an Eating Disorders Inventory, and a Zung Depression Inventory on admission and discharge. Thirty-two age- and sex-matched healthy volunteers completed the same questionnaire., Results: In bulimic patients, the most commonly reported gastrointestinal symptoms were bloating (74.4%), flatulence (74.4%), constipation (62.8%), decreased appetite (51.2%), abdominal pain (48.8%), borborygmi (48.8%), and nausea (46.5%). The average symptom score (sum of severity ratings) on the gastrointestinal symptoms questionnaire decreased from 20.6 +/- 10.8 (mean +/- SD) on admission to 13.46 +/- 10.5 (t(27) = 3.31, p < 0.01) on discharge but remained significantly higher than that of the control group (4.4 +/- 6.2, t(43) = 4.02, p < 0.001). However, the severity of reported gastrointestinal symptoms was correlated with the severity of depression (r = 0.43, p < 0.05), and when the possible mediating effects of depression on gastrointestinal symptoms were controlled statistically (analysis of covariance), the effects of treatment on gastrointestinal symptoms were not statistically significant., Conclusion: Gastrointestinal symptoms in bulimics are common, multiple, and often severe and they improve with treatment. However, the most important determinant of gastrointestinal symptoms appears to be depression.

Objectives: The relationship between menstrual and bowel symptoms, the overlap between the diagnoses of dysmenorrhea (DYS) and functional bowel disorder (FBD), and markers that may be useful in discriminating functional bowel disorders from DYS were studied in 383 women (20-40 yr of age)., Methods: All women completed the NEO Personality Inventory at intake and completed the Moos' Menstrual Distress Questionnaire and a bowel symptom inventory every 3 months for 12 months. Prostaglandin levels were measured in vaginal dialysate on the first day of menses., Results: DYS was diagnosed in 19.8% of the total sample. Functional bowel disorder, defined as abdominal pain with altered bowel function, was diagnosed in 61% of the DYS group compared with 20% of controls (p < 0.05). Neuroticism scores were significantly higher in subjects with functional bowel disorder with or without DYS. However, bowel symptoms were significantly correlated with menstrual symptoms even after statistically controlling for the effects of neuroticism. Painful menses and water retention distinguished the DYS group from the functional bowel disorder group. Prostaglandin levels were elevated in women with DYS, but did not consistently differentiate the diagnostic groups., Conclusions: The strong covariation of menstrual and bowel symptoms, along with the overlap in diagnoses of DYS and function bowel disorder, suggest a common physiological basis.

Patients with functional bowel disorders frequently complain of bloating and abdominal pain, but no practical method is available to measure intestinal gas objectively. To evaluate a new technique, we evaluated 54 abdominal radiographs from 19 patients. A gastroenterologist and a radiologist independently outlined the intestinal gas bubbles in these films. Areas of gas bubbles were measured with a computer digitizing board. Bowel gas was also measured in 24 healthy controls, and in five emergency room patients, supine and erect radiographs were compared to evaluate the effects of position on bowel gas patterns. The two evaluators agreed well on the measured areas of bowel gas (r = 0.96), showing that this is a reliable method. Bowel gas was significantly greater in patients than in controls but did not correlate with symptoms. Bowel gas was significantly greater in supine than upright films, showing that the position of the patient must be standardized.

Because of reports suggesting the efficacy of metronidazole therapy in the healing of perianal fistulae in Crohn's disease, the effect of metronidazole on symptoms of Crohn's disease and associated perianal fistulae were evaluated in eight consecutive patients. The criterion for entry into the study was the presence of resistant fistulae in patients with Crohn's disease. The duration of intestinal Crohn's ranged from 1/2-30 years and fistulae from 1-14 years. All patients had ileocolitis or pancolitis. Two had enteroenteric fistulae in addition to perianal fistulae. All had had previous surgery, half for fistulae and half for intestinal complications, usually obstruction. All had been on Prednisone. All but one had received multiple other drugs including Azathioprine, Azulfidine, antibiotics, and rectal steroids. Patients were placed on metronidazole 1000 to 1500 mg/day orally in divided doses. The number of draining fistulae was reduced 20-fold and the number of detectable fistulous openings by 50%. All patients had relief of fistula-associated pain; general Crohn's disease symptoms improved as well. Complete resolution of all symptoms occurred in half the patients. All patients experienced side effects, six had numbness of toes and five had metallic taste. Resolution of side effects occurred on discontinuation of metronidazole after 1-3 wk off the drug in all except one patient. All patients noted continued improvement in Crohn's symptoms during 6 months of follow-up after cessation of their therapy. Other side effects that have been reported with metronidazole therapy were not seen in our patients.

Chest pain is a major symptom of patients diagnosed with esophageal motility abnormalities. Motility disorders of the esophagus are also associated with elevated scores on measures of somatic anxiety and depression. In spite of this relationship between psychological characteristics and esophageal motility disturbances, few attempts have been made to treat complaints of chest pain in patients with esophageal motility disorders using psychological methods. This report describes the successful use of a behavioral pain management program for the treatment of persistent chest pain in a patient diagnosed with vigorous achalasia who was previously treated with pneumatic dilatation and a long Heller myotomy. This is the first report on the use of psychotherapy in treating chest pain associated with vigorous achalasia, and suggests that, in the etiology and treatment of chest pain in patients with esophageal motility disturbances, psychological influences may be more important than has generally been recognized. No long-term relationship between esophageal motility disturbances and complaints of chest pain was found.

The anatomy and physiology of the external anal sphincter, puborectalis muscle, internal anal sphincter, and rectum are described. Measurement techniques are reviewed emphasizing those which can be carried out by the gastroenterologist in independent office practice, and the range of normal values for each test is given. A protocol for diagnostic evaluation of anorectal disorders is recommended which includes testing for rectal prolapse and for descent of the perineum by having the patient strain while seated on a commode chair, evaluating the external and internal anal sphincters by recording EMG with an anal plug, or recording pressures with a perfused catheter or balloon probe, using a rectal balloon to evaluate the maximum tolerable volume of rectal distension and the minimum (threshold) volume of a bolus injection which can be subjectively perceived, and arranging with a radiologist to perform a proctogram--a radiograph of the rectum and anal canal during rest and when the patient strains to defecate--in order to evaluate the anorectal angle (puborectalis muscle) and to detect rectocele and intussusception. These objective tests should be supplemented by a careful clinical history and physical examination.

The relationship between abdominal pain and bowel gas from bacterial fermentation of undigested carbohydrate was investigated in nine patients with irritable bowel syndrome (IBS), six lactose malabsorbers, and 11 asymptomatic controls. All subjects took breath samples and marked analog scales for abdominal pain, bloating, and psychological stress hourly during all waking hours for 7 days. Breath samples were analyzed for hydrogen concentration within 3 days, and the concentration was corrected for storage time. Symptoms of pain and bloating were significantly more common in IBS patients than in lactose malabsorbers or normal controls, and pain was significantly correlated with bloating in IBS patients. Breath hydrogen concentration was similar in all three groups, and breath hydrogen was not correlated with pain ratings in IBS patients. Thus, abdominal pain may be related to bloating from gastrointestinal gas, but bacterial fermentation cannot be the cause of such gas. The most likely source is swallowed air. This study also demonstrates the feasibility of monitoring hydrogen production in the bowel in field studies by having subjects collect hourly breath samples.