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The relationship between cardiovascular autonomic neuropathy (CVAN) and oesophageal dysfunction in diabetes mellitus has not been well established because reports are contradictory. The aim of this study was to assess oesophageal function and its correlation with CVAN in type 1 diabetic patients without oesophageal symptoms. Forty-six type 1 diabetic patients without oesophageal symptoms (DG) and 34 healthy volunteers (CG) were studied. Both groups underwent CVAN tests and oesophageal manometry and pH-metry. Differences between groups regarding results of cardiovascular autonomic tests and oesophageal studies were statistically analysed. Compared with the CG, the DG group showed insufficient lower oesophageal sphincter (LOS) relaxation and a higher percentage of simultaneous waves (P0.01). Patients with CVAN (n = 22) showed a higher prevalence of pathological simultaneous contractions (10%), and the prevalence of simultaneous waves related to the degree of autonomic neuropathy was: 9% of patients without CVAN, 7% of those suspected to have it and 50% of patients with CVAN (P0.001). Factors associated with the presence of pathological simultaneous waves (10%) were the presence of CVAN and duration of diabetes (P0.05, logistic regression analysis). Increase in simultaneous waves and impaired relaxation of LOS are more frequent in diabetic patients with CVAN.

The recent study by Noble et al ( Gut 2005; 54 :1416–20) did not find an association of the DLG5 G113A polymorphism with either inflammatory bowel disease (IBD) or Crohn’s disease (CD). Previous studies in other European populations had reported an increase in 113A allele frequency in IBD and CD patients1,2 but, in striking contrast, Noble et al reported a trend towards decreased carrier frequency for the 113A allele in IBD (p = 0.069) and CD (p = 0.057) patients. We believe there is reason to re-examine the genotype data used in the report of Noble et al . Firstly, there was a significant difference in the proportion of missing genotypes between the IBD patients and controls (p

Endorectal advancement flap repair is a well-recognized method for the treatment of complex anorectal fistula. The purpose of this study was to prospectively assess the clinical and functional results of endorectal advancement flaps for complex anorectal fistula and to identify factors that affect outcome.A prospective study of 56 patients was performed. Clinical and functional results were studied using the Wexner continence scale and anal manometry before and after surgery. Factors associated with recurrence and incontinence were analyzed by univariate and multivariate regression analysis.Sixty endorectal flaps were constructed in 56 patients. Mean age was 49 years (range 24-74). The fistula was of cryptoglandular origin in 91.1% cases. Mean follow-up was 43.8 months. The technique was repeated in four patients because of recurrence (7.1%), with subsequent healing in all cases. There were significant reductions in maximum resting pressure 3 months after surgery (83.6+/-33.2 vs 45.6+/-18.3, p0.001) and maximum squeeze pressure (208.8+/-91.5 vs 169.5+/-75, p0.001). Before surgery, five patients (8.9%) reported incontinence symptoms. After surgery, 78.6% patients had normal continence, seven patients (12.5%) complained of minor incontinence, and five (9%) had major continence disturbances. None of the variables studied (age, sex, previous fistula surgery, rectovaginal fistula, and Crohn's disease) affected the outcome of the procedure in multivariate analysis.Endorectal advancement flap repair is an effective technique for complex anal fistula, with a low recurrence rate (7.1%). Patients (21.4%) reported disturbed anal continence. It is still not possible to identify factors that are predictive of failure or incontinence.

OBJECTIVES To study the prevalence of fecal (FI) and urinary incontinence (UI) in women from Teruel (Spain), as well as the clinical conditions associated with these disorders. METHODS We studied prospectively women with an age range of 20-64 years who were randomly selected from the population seen in a primary care center because of medical disorders not related to incontinence. Patients with functional or cognitive impairment were excluded. Medical and obstetric antecedents, as well as the type and frequency of incontinence symptoms were collected in a questionnaire. RESULTS Out of 115 women, 103 completed the study (mean age: 41+/-12 years range 20-64). UI was present in 34.9% (stress 33%, urge 14%, mixed 47%), FI in 14 (13.6%) (flatus 57%, liquid stools 43%), and 10 (9.7%) displayed both disorders. Age > 42 years and body mass index more or equal of 25 were associated with FI and UI; pregnancy was only associated with UI, but the group of women with more or equal of 2 vaginal deliveries showed a higher frequency of FI (p < 0.05, Chi squared test). In the multivariate analysis, only the presence of UI was associated with FI (OR 6.0; CI 95% 1.7-21). Association of FI and UI was more frequent in women older than 42 years (OR 16.7, CI 95% 1.9-141). No statistical differences were found when smoking, exercise, and type of childbirth were compared between the presence/absence of FI or UI. CONCLUSIONS Urinary and fecal incontinence are frequent in women, and the coexistence of both disorders is not uncommon. Age, overweight and parity are associated with the presence of fecal and/or urinary incontinence.

Objectives: To assess the salivary flow rate, pH, and buffer capacity of healthy volunteers, and their relationships with age, gender, obesity, smoking, and alcohol consumption, and to establish the lower-end value of normal salivary flow (oligosialia). Methods: A prospective study was conducted in 159 healthy volunteers (age > 18 years, absence of medical conditions that could decrease salivary flow). Unstimulated whole saliva was collected during ten minutes, and salivary flow rate (ml/min), pH, and bicarbonate concentration (mmol/l) were measured using a Radiometer ABL 520. The 5 percentile of salivary flow rate and bicarbonate concentration was considered the lower limit of normality. Results: Median salivary flow rate was 0.48 ml/min (range: 0.1-2 ml/min). Age younger than 44 years was associated with higher flow rates (OR 2.10). Compared with women, men presented a higher flow rate (OR 3.19) and buffer capacity (OR 2.81). Bicarbonate concentration correlated with salivary flow rate. The lower-end values of normal flow rate and bicarbonate concentration were 0.15 ml/min and 1.800 mmol/l, respectively. The presence of obesity, smoking, and alcohol consumption did not influence salivary parameters. Conclusions: In healthy volunteers, salivary flow rate depends on age and gender, and correlates with buffer capacity. Obesity, smoking, and alcohol use do not influence salivary secretion.

Background: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. Methods: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). Conclusion: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.

Dental erosion has been considered an extraesophageal manifestation of gastro-oesophageal reflux disease, but few reports have studied the relationship between this disease and other periodontal or dental lesions. The aim of this study was to investigate the prevalence of dental and periodontal lesions in patients with gastro-oesophageal reflux disease.A total of 253 subjects were prospectively studied between April 1998 and May 2000. Two study groups were established: 181 patients with gastro-oesophageal reflux disease and 72 healthy volunteers. Clinical assessment, including body mass index and consumption of tobacco and alcohol, was performed in all subjects, as well as a dental and periodontal examination performed by a dentist physician, blind as to the diagnosis of subjects. Parameters evaluated were: (a) presence and number of dental erosion, location and severity, according to the Eccles and Jenkins index [Prosthet Dent 1979;42:649-53], modified by Hattab [Int J Prosthes 2000;13:101-71; (b) assessment of dental condition by means of the CAO index; and (c) periodontal status analysed by the plaque index, the haemorrhage index, and gingival recessions.Clinical parameters were similar in both groups (p0.05). Age was statistically associated with the CAO index, presence of dental erosion, and gingival recession (p0.001, Student's t-test). Compared with the control group, the percentage of dental erosion was significantly higher in the gastro-oesophageal reflux disease group (12.5 vs. 47.5%, p0.001, chi2-test), as was the number and severity of dental erosions (p0.001, Student's t-test). Location of dental erosion was significantly different between groups. Age was not statistically related to either the amount or severity of dental erosion. CAO and periodontal indices were similarly distributed between groups.Dental erosion may even be considered as an extraesophageal manifestation of gastro-oesophageal reflux disease. The fact that the prevalence of caries and periodontal lesions is similar in patients with gastro-oesophageal reflux disease and in healthy volunteers suggests a lack of relationship with gastro-oesophageal reflux disease.

Background & Aims: Botulinum toxin is an effective treatment in idiopathic chronic anal fissure, but the long-term outcome after healing is not well documented. We analyzed the long-term outcome of patients in whom an anal fissure had healed after botulinum toxin injection and the factors contributing to recurrence. Methods: Fifty-seven patients who had completely healed 6 months after injection of botulinum toxin were reassessed every 6 months. The follow-up was 42 months in all patients. Clinical and manometric differences between the permanently healed and the relapsed group were statistically analyzed. Results: Four patients were lost to follow-up. A fissure recurrence was shown in 22 patients (41.5%). Statistical differences between the permanently healed and the relapsed group were detected when analyzing the anterior location of the fissure (6% vs. 45%), a longer duration of the disease (38% vs. 68%), the need for reinjection (26% vs. 59%), a higher total dose injected to achieve definitive healing (13% vs. 45%), and the percentage decrease of maximum squeeze pressure after injection (−28% vs. −13%; P Conclusions: The late recurrence rate of chronic anal fissure is high when the effect of botulinum toxin disappears. The highest risk of recurrence is associated with anterior location of the anal fissure, prolonged illness, the need for reinjection and for high doses to achieve healing, and a lower decrease of maximum squeeze pressure after treatment. GASTROENTEROLOGY 2002;123:112-117

OBJECTIVE: Eotaxin is a recently characterized chemokine with potent and selective chemotactic activity for eosinophils. Previous studies indicating that eosinophils accumulate and become activated in inflammatory bowel disease (IBD) led us to hypothesize that eotaxin is potentially involved in the pathophysiology of IBD and, therefore, that eotaxin would be increased in the serum of patients with IBD. The objective of this study was to test those assumptions. METHODS: We investigated 72 patients with IBD, 35 with ulcerative colitis, and 37 with Crohn’s disease. A total of 27 patients had active and 45 inactive disease; 26 were receiving corticosteroids. Eotaxin serum levels were determined by solid phase sandwich ELISA. Lymphocytes, monocytes, and granulocyte subpopulations were determined in fresh blood samples with an automated autoanalyzer. RESULTS: Serum eotaxin levels were significantly higher in patients with Crohn’s disease and in those with ulcerative colitis than in the control subjects (p < 0.0001). Patients with inactive Crohn’s disease had significantly higher levels of eotaxin than patients with inactive ulcerative colitis (p < 0.05). We did not find significant differences for activity or inactivity of disease, nor for treatment with prednisone. A negative correlation (p < 0.05) was found between eotaxin serum level and eosinophil counts in peripheral blood in patients with Crohn’s disease. CONCLUSIONS: There is an increased expression of eotaxin in IBD patients, suggesting that eotaxin may be involved in the pathogenesis of IBD. This increase is more accentuated in Crohn’s disease and negatively correlates with the eosinophil number in peripheral blood. Our data support the increasing evidence that eosinophil are functionally involved in the pathophysiology of IBD.

The aim of this study was to evaluate with colour Doppler ultrasound the vascular changes in the wall of the loops affected by Crohn's disease, and to establish whether these changes reflects clinical or biochemical activity of Crohn's disease. Seventy-nine patients with Crohn's disease (44 with active disease and 35 inactive patients) were studied with frequency- and amplitude-encoded duplex Doppler sonography. A group of 35 healthy volunteers were also included. The exam consisted of the search for colour signals in the walls of the loops affected by Crohn's disease, classifying the degree of vascularity with a simple scoring system into three groups: absence of colour signal (score of 0); weak or scattered colour signals (score of 1); and multiple colour signals or clear identification of vessels in the loops walls (score of 2). Doppler curves were obtained of the detected vessels with measurement of the resistive index (RI). There was a visible increase in the gut walls' vascularity in the active patients compared with those with inactive disease. The mean RI was statistically significantly lower in the gut wall vessels of the patients with active illness than that obtained in the inactive patients. Colour Doppler ultrasound is a useful tool in the assessment of activity in Crohn's disease.

Antecedentes El examen de la Latencia Motora Terminal de Nervios Pudendos (LMTNP) se utiliza habitualmente para valorar la existencia o no de Neuropatia Pudenda (NP). Sin embargo, la utilidad de esta tecnica es motivo de controversia dado que unicamente evalua las fibras nerviosas de conduccion rapida. Objetivos Establecer la prevalencia de NP medida mediante la LMTNP en pacientes con Incontinencia anal (IA) y evaluar la relacion existente entre NP y funcion ano-rectal en estos pacientes. Metodos Se revisaron un total de 380 pacientes con IA, 348 (91,6%) mujeres, con edad media de 59 anos (rango 15–84 anos). Todos ellos fueron estudiados mediante ecografia endoanal, manometria ano- rectal, estudio de sensibilidad rectal, test de retencion intra-rectal de liquidos (1500 ml), asi como LMTNP. Ademas, un subgrupo de 121 pacientes completaron tratamiento con biofeedback (BF). Los datos obtenidos fueron analizados mediante el test t de Student para dos muestras independientes asi como el estadistico chi-cuadrado. Resultados Para un punto de corte menor de 2,2 ms como valor normal del estudio de LMTNP, 150 pacientes (39,5%) presentaron NP, siendo esta bilateral en 82 pacientes (21,6%). La NP, sea unilateral (unilateral vs no NP) o bilateral (bilateral vs no NP), no se asocia a una disminucion de la presion media de reposo, presion media de contraccion voluntaria o del indice de gravedad de la incontinencia (score de Miller). Tampoco se objetiva asociacion significativa entre la existencia de NP y anormalidades en la sensibilidad rectal ni con un menor porcentaje de retencion en el test de perfusion intra-rectal de liquidos (ver tabla adjunta). De los 107 pacientes que en ecografia endoanal presentaban un aparato esfinteriano anal intacto, un 35% mostraban un alargamiento de la LMTNP de forma unilateral, y un 20% bilateralmente, porcentajes similares a los encontrados en pacientes con lesion esfinteriana. Tampoco se ha observado relacion entre la existencia de NP y resultados clinicos tras tratamiento con BF. Se han obtenido resultados similares, al aplicar en el test de LMTNP un valor de corte de normalidad de menos de 2,4 ms. Conclusiones La NP evaluada mediante el test de LMTNP es una alteracion frecuente en individuos con IA y su presencia no se asocia con descensos en las presiones del canal anal, existencia de sensibilidad rectal patologica ni con disminucion del porcentaje de retencion intra-rectal de liquidos. Los hallazgos del estudio de LMTNP no son predictores de los resultados obtenidos con BF. Por todo ello, la LMTNP no puede ser recomendada para la evaluacion de pacientes con IA. PNTML resultados Presion basal (mmHg) Presion Contraccion Voluntaria (mmHg) Sensibilidad Rectal (ml) Retencion Liquidos (%) Bilateral ⩾ 2.2 ms (n=82) 52±28 105±52 35±19 47±27 Normal 51±26 104±54 34±21 49±28 Unilateral ⩾ 2.2 ms (n=150) 50±25 107±48 35±18 47±29

Introduccion El estrenimiento es un sintoma relatado por el paciente y el medico verifica que cumple los criterios consensuados para sentar el diagnostico de ECF. Para algunos autores el TTC seria el metodo objetivo para la definicion de estrenimiento. Objetivos Relacionar los datos clinicos recogidos mediante diario de 30 dias con el TTC determinado por marcadores radioopacos en pacientes con ECF. Material y metodos Grupo de estudio constituido por 220 pacientes diagnosticados de ECF (Roma II) de edad media 38,3±15 anos (IC95% 36,3–40,3, mediana 37 anos), integrado por 204 mujeres (38,4±15,2, IC95% 36,3–40,5, mediana 37) y 16 hombres (36,1±12,9, IC95% 29,2–43, mediana 31,5 anos). Se han recogido los datos sobre habito intestinal (frecuencia, consistencia de las heces, sintomas defecatorios, uso y tipo de laxantes) mediante diario de 30 dias y se ha determinado tiempo de transito colonico (TTC) con marcadores radioopacos; como valores de normalidad se han tomado los referidos por el Grupo Espanol de Motilidad Digestiva (GEMD) (transito lento > IC95%), ajustados por sexo. La comparacion de variables cualitativas se ha realizado mediante el estadistico chi-cuadrado y las variables cuantitativas por la t de Student para muestras independientes; se ha tomado como limite de significatividad estadistica una p Resultados El TTC medio es de 76,6±54,4 horas (IC95% 69,4–83,7, mediana 69,6 horas); superior en las mujeres (78,5±53,5) respecto a los hombres (51,9±47,1), sin alcanzar significatividad estadistica (p=0,055). Solo en el 32,7% de los pacientes se objetiva un TTC superior al IC95% del grupo de sujetos sanos (64,4 horas en hombres y 92,5 horas en mujeres) (GEMD): 33,8% en mujeres y 31,5% en hombres. En nuestro grupo de estudio, el sexo y la edad (cuartiles) no se relacionan con un TTC alargado (p=1.000 y p=0,652, respectivamente). En la Tabla se especifican las relaciones entre los datos recogidos en el diario (30 dias) y el resultado del TTC (normal/lento). Datos diario 30 dias TTC TTC > IC95% (n. 74) P Toma laxantes 84,9% 87,8% 0,425 Deposiciones/semana 5,90±3,79 4,53±2,10 0,005 Numero dias sin deposicion 10,43±6,62 14,49±6,17 0,000 % dias sin deposicion 36,97±22,74 51,39±21,39 0,000 % deposiciones bolas/duras 45,58±33,84 48,87±34,05 0,952 % deposiciones normales/blandas 51,39±33,52 51,23±30,07 0,974 % esfuerzo defecatorio 62,68±30,53 65,43±35,19 0,556 % evacuacion incompleta 47,32±37,62 41,99±39,60 0,337 % dolor anal con deposicion 35,34±35,29 35,85±40,13 0,925 % dolor abdominal con deposicion 30,08±34,64 42,56±39,91 0,026 Conclusiones El TTC aisladamente no puede utilizarse para la definicion de ECF en pacientes que cumplen criterios clinicos segun Roma II. Solo se observa relacion del TTC lento con la frecuencia defecatoria y dolor abdominal, pero no con las caracteristicas de las heces y sintomas defecatorios.

Late Recurrence Of Anal Fissure ARer Conservative Therapy With Botufinum Toxin Miguel Minguez, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain; Alejandro Espi, Dept of Surg, Univ Clio Hosp, Valencia Spain; Vicente Sanchiz, Isabel Pascual, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain; Eduardo Garcia-Granero, Dept of Surg, Univ Clin Hosp, Valencia Spain; Andres Pena, Francisco Mora, Pedro Almela, Vicente Hernandez, Paloma Lluch, Cirilo Amoros, Adolfo Benages, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain