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The effects of sennosides on colonic motility were investigated in eight conscious dogs chronically fitted with two strain gauge transducers in the proximal colon, an intracolonic silicone catheter and a polyethylene catheter implanted in a branch of the right colonic artery. Oral sennosides (30 mg/kg) inhibited colonic motility for 12 to 18 h after a three to six hours delay, and associated with giant contractions and diarrhoea. The minimal oral dose of sennosides to produce such changes varied from 5 to 15 mg/kg. Intracolonic sennosides at the minimal effective dose and at 30 mg/kg reproduced the effects of oral sennosides, but with a shorter latency (0.5-1.5 h). Intracolonic PGE2 (100 micrograms/kg) in viscous gel medium or intra-arterial PGE2 (10 micrograms/h) inhibited colonic motility and induced giant contractions often associated with defecation. The colonic motor changes induced by intracolonic sennosides at the minimal effective dose, but not those induced by intracolonic PGE2, were blocked by intra-arterial indomethacin (10 micrograms/h) or piroxicam (5 micrograms/h). These results suggest that colonic motor actions of sennosides are mediated through a local prostaglandins synthesis, as they were blocked by cyclooxygenase inhibitor and reproduced by PGE2. [ABSTRACT FROM PUBLISHER]

Aim: In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab., Methods: This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities., Results: Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000)., Conclusions: Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution., (© 2021 Association of Coloproctology of Great Britain and Ireland.)

Aim: To establish consensual definitions of anoperineal lesions of Crohn's (APLOC) disease and assess interobserver agreement on their diagnosis between experts., Methods: A database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Française de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss's kappa test or descriptive statistics., Results: Terms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration (entity, depth, extension), anal skin tags (entity, inflammatory activity, ulcerated aspect), fistula (complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions (abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association's guidelines definitions. The diagnosis of ulceration (κ = 0.70), fistulae (κ = 0.75), inflammatory activity of external fistula openings (86.6% agreement), abscesses (84.6% agreement) and erythema (100% agreement) achieved a substantial degree of interobserver reproducibility., Conclusion: This study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions., Competing Interests: Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.

Background: Constipation has a significant impact on quality of life. Aim of this study was to evaluate the safety and the efficacy for relieving dyschezia symptoms of a CO2-releasing suppository in a randomized, placebo-controlled, clinical trial., Methods: Fifty-three office-based primary care physicians and 24 gastroenterologists conducted the study in France, between November 2010 and January 2012. Patients (aged 18-75 years) with dyschezia were eligible. Patients were randomly allocated a once-a-day suppository (CO2-releasing suppository or placebo) for 21 days. Primary endpoint was the change, from Day 0 to Day 21, in the intensity of discomfort related to dyschezia based on a self-assessed 0-100 visual analogue scale., Results: A total of 323 patients were randomized, i.e. 166 into the intervention group and 157 into the placebo group. Co-variance analysis showed a greater reduction in discomfort visual analogue scale score in the intervention group (-34.5mm; standard error of the mean: 1.8mm) than in the placebo group (-26.2mm; standard error of the mean: 1.9 mm; p<0.001). The greater efficacy of the CO2-releasing suppository was confirmed for all secondary efficacy parameters. No significant side effects for either treatment were observed., Conclusion: A CO2-releasing suppository is more effective than a placebo for the relief of symptoms of dyschezia. This efficacy is associated with a good safety profile., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Only three non-surgical treatments of haemorrhoids are clearly validated: infrared coagulation, injection sclerotherapy and rubber band ligation. Those procedures are only indicated for painless symptoms related to internal haemorrhoids, i.e. bleeding at defecation or spontaneously reducible prolapse. Their main interest is to be possible on the outpatient clinic, with a simple anuscope, without enema or anaesthesia, since they are applied to non-sensitive area on the top of internal haemorrhoids. The aim of all these treatments is to create local fibrosis, which reduces vascular tissue and hold rectal mucosa to underlying muscle. Short-dated efficiency of all techniques is similar on bleeding. After one and three years, rubber band ligation is clearly more efficient than other techniques, especially on prolapse. Secondary effects are non-constant and usually minor, as transient pain or tenesmus, and mild bleeding for few days. Infrequent complications may occur, only after haemorrhoidal banding and sclerotherapy, as thrombosis, massive delayed bleeding or local abscess. Exceptional life-threatening pelvic cellulitis cases have been reported., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Epidermoid carcinoma of the anus is a rare cancer, and conventionally affects elderly women. Its incidence is on the increase, at a younger age of onset, particularly within the male homosexual population. Main predisposing factors are sexually transmitted diseases and particularly human papillomavirus (HPV) infection, variety of sexual partners, smoking, homosexuality, history of uterine cervix cancer, and immunodepression. Warning signs of anal cancer are often non-specific. Therefore any atypical lesion should be systematically biopsied for histology. The evaluation assessment should include lung X-ray, abdominal CT scan, and often pelvis MNR or anal endosonography. Key prognostic factors are infiltration of the initial tumour and presence of lymph node metastasis. First-line treament of anal epidermoid carcinoma is radiotherapy, combined with chemotherapy for extensive forms.

Aims: The perception patients consulting for primary care have of anorectal disorders has never been evaluated. Our aim was to analyze proctological complaints among outpatients consulting general practitioners., Patients and Methods: Among 1484 physicians who responded to a nationwide mailing in France, 161 enrolled 437 females and 358 males consulting between October 2004 and December 2005., Results: Females were younger than males (46 +/- 15 vs 51 +/- 13 years) (p<0.0001). Intermediate and upper social-occupational categories were overrepresented as compared with the general population. Symptoms were pain (48%), bleeding (37%), swelling (26%) and pruritus (24%). For 76%, these symptoms persisted for less than one month and 58% mentioned earlier visits or prior treatment. The first manifestation was correlated with a pregnancy in 31% of women. Present symptoms were secondary to acute constipation (52%), stress (33%), ingestion of spices (29%) or alcohol (20%), and diarrhea (8%). Symptoms were considered important in 61% or a cause of anxiety in 33% of patients. Treatment was prescribed for all patients: ointments (90%), phlebotonics (66%) or suppositories (51%), in combination for 75% of prescriptions. Patients preferred oral medicines (41%), ointments (30%) and suppositories (7%)., Conclusion: Proctological complaints are a reason for repeated visits to the general practitioner and lead to repeated prescriptions. Patients appreciate anti-hemorrhoidal treatments variably.

Chronic perineal pain, too easily considered in the past as psychogenic, has undergone significant reshapings in recent years because of a better understanding of pathophysiology. Progress in functional investigations, especially electrophysiological tests, has allowed to define new clinical entities such as pudendal neuralgia or pain linked to pelvic floor disorders. Treatments have been improved, but remain empirical outside these well defined entities. In practice, clinical examination is the main diagnostic step, which allows to exclude common anorectal or pelviperineal lesions, and to consider additional investigations. However diagnosis may remain entirely clinical in some typical presentations.

Respiratory impairments occurring as systemic manifestations of ulcerative colitis are often misinterpreted. We report a case of chronic productive bronchitis associated with ulcerative colitis; symptoms appeared after colectomy. Clinical features distinguished it from common chronic bronchitis: it occurred in a woman without respiratory disease or smoking history, a chronic productive cough without bronchiectasis, negative infectious investigations, severe endoscopic and histologic lesions, and above all remarkable steroid efficacy. Systematic research and early treatment of these manifestations avoids aggravating pulmonary disease, especially secondary bronchiectasis. Though less frequent, other respiratory manifestations of ulcerative colitis have been described, such as asphyxiating tracheal stenosis, pneumonia or interstitial pulmonary diseases, pleurisy or pleuro-pericarditis.

Effects of octreotide (1.25 micrograms/kg subcutaneously) on colonic tone and visceral perception were evaluated in 10 IBS patients, using a barostat and compared to placebo in a double-blind crossover study. Colonic sensory thresholds were also studied in healthy controls for comparison with IBS patients. Colonic tone was reflected by variations in volume of the barostat balloon. Baseline volume was 117 +/- 38 ml and was not modified by placebo (122 +/- 40 ml) or octreotide (106 +/- 42 ml). After the meal, maximal decrease in balloon volume was 75 +/- 4% following placebo (P < 0.001) beginning after 9 +/- 3 min and lasting 136 +/- 17 min. Following octreotide, the maximal decrease was 69 +/- 16% (NS vs placebo), after 10 +/- 3 min and lasting 140 +/- 22 min. In the second part, discomfort and pain thresholds were evaluated during isobaric distensions (4 mm Hg increments, 5-min duration, 5-min interval with return to pressure 0 between each). The pressure inducing discomfort was 21.2 +/- 5.9 mm Hg following placebo vs 29.6 +/- 6.6 mm Hg following octreotide (P < 0.01). The pressure inducing pain was 24.8 +/- 7.3 mm Hg following placebo vs 33.2 +/- 7.3 mm Hg following octreotide (P < 0.01). In healthy subjects, discomfort and pain were induced by colonic distensions at a mean intraballoon pressure of 32.7 +/- 5.8 mm Hg and 36.7 +/- 3.9 mm Hg, respectively. Compliance curves were not different following placebo and octreotide. Octreotide significantly increases thresholds for visceral perception in IBS patients without modifying compliance during distension nor colonic tone.

Using an intraluminal probe with six pairs of annular electrodes, the myoelectric activity of the proximal jejunum was recorded during 48-hr sessions in 16 healthy volunteers receiving evening and noon meals (1000 kcal) and breakfast (400 kcal). In 10 subjects receiving no drug, the characteristics of the migrating motor complexes (period, duration of each phase, velocity of propagation of phase 3, duration of the postprandial disruption) varied markedly between subjects but were relatively constant from the first to the second day of recording. Single spike bursts propagated at a rate of 2-5 cm/sec, clusters of 3-10 spike bursts propagated at a rate of 0.5-1 cm/sec, and similar clusters recurring repetitively each 1.5-2 min were observed after the meals and very rarely in the fasted state during phase 2 of nocturnal migrating motor complexes. In six subjects, oral administration of codeine (50 mg) 1 hr before a meal induced migrating motor complexes in the postprandial state, with characteristics similar to that observed in the fasted state except a longer duration of phase 2. Single spike bursts and isolated and repetitive clusters of spike bursts were observed during phase 2 of the codeine-induced migrating motor complexes and after meals preceded by placebo, but very rarely during the phase 2 of nocturnal (fasted state) migrating motor complexes. It is concluded that the patterns of jejunal contractions consisting of propagated single spike bursts and isolated or repetitive spike bursts characterize the postprandial state in healthy humans and are dependent upon digesta flow.

The importance of colonic motor disorders during the irritable bowel syndrome is recognized, but, paradoxically, their description has yet to be perfected. Among the fundamental questions that remain unanswered, three are of prime importance: a) are there one or more specific disturbances in basal colonic motility? b) can specific motor disorders be induced by certain situations, for instance, during stress? c) is there any real relationship between clinical symptoms and coexisting motor disorders? The answers to these questions are full of ambiguities; this may be explained by the difficulty with which methods of investigation are performed as well as the heterogeneous character of the disorders. Presently, recording colonic myoelectric activity over a 24 hour period or more might prove to be useful in increasing our knowledge on motor disorders. It is not at all certain that a specific basal abnormality exists and the results of the effects of stress vary according to the methods used. Segmental hyperactivity in painful constipation, abnormal colonic response to alimentation in the case of painful bloating, and propulsive hyperactivity with absence or decrease in the "sigmoid brake" during painless diarrhea have been noted on basal motor activity recordings during sleep and after meals. Myoelectric disorders, however, are seen in only two-thirds of patients with intestinal functional disorders. "Sensitivity", personality, or other disorders, and particularly, intestinal disorders, can contribute to explain the pathophysiology of "irritable bowels" in which the role of colonic disorders has yet to be shown.

The effects of sennosides on colonic myoelectrical activity were investigated in man. Spiking activity of the left and sigmoid colons was continuously recorded in seven constipated patients during two sessions from 5:00 PM to 9:00 AM. Each patient received orally at 7:00 PM on two consecutive days 30 mg of sennosides one day (sequence S) and placebo on the other (sequence P) in a random fashion. A significant (P less than 0.05) increase of peristaltic activity (migrating long spike bursts or MLSBs) after sennosides was observed between 1:00 and 7:00 AM, and a corresponding decrease between 7:00 and 9:00 AM. No change was noted in total short spike burst (SSB) activity or in SSBs characteristic of the rectosigmoid area. This study indicates that the main modification of colonic motility induced by sennosides was a stimulation of propulsive activity (MLSBs), which occurred between 6-12 hr after oral administration, the delay required for orocecal transit and metabolism of the drug.