April 1995 Motility and Nerve-Gut Interactions A699

• ILEAL AND COLONIC BRAKES ARE NOT WORKING IN THE SETTING OF FAST TRANSIT DIARRHEA. G:M. Thomforde, S.B. Saslow, C.T. Van Dyke, J. Rubin, H.C. Pitot, M. Camilleri. Mayo CUnie, Rochester, MN

We have previously shown that, in patients with careinoid diarrhea (CD) unassociated with any resection, small bowel and colonic transit are accelerated. Our hypothesis was that delivery of unabsorbed nutrients by rapid small bowel transit stimulated the ileal and colonic "brakes" to delay gastric emptying. Our aim was to measure regional gastric, small bowel and colonic transit by scintigraphy, 24-hour stool fat and weight, and 24-hour urinaiy 5IKAA in patients with CD. Methods: We used a well-validated seintigraphi¢ method to measure transit of radiolaheled solid pellets incorporated in a standard solid-liquid meal and into a delayed-release capsule coated with the pH-sensitive polymer, methacrylate. Daily intake of fat and calories during the study was standardized. Data from the 7 carcinoid patients were compared with established normal controls from the same laboratories. Transit parameters compared were: k (from power exponential analysis of gastric emptying curve), 10% small bowel transit time (SBTT), and geometric center (GC, weighted average of counts in the colon) at 4 hours. Results: Patients had increased 24-hour stool weight (range 259-663 g, mean 445 g) during the transit study. Small bowel and colonic transit were accelerated in 6 of 7 patients. Gastric emptying was normal in 5 of 7 patients. There were no significant relationships between fecal fat or urinary 5HIAA and transit parameters.

SB Resec- k(xl0 "4) SB1~I " Colonic Fecal Fat Urine Pt tlon (cm) solids (10%)rain GC4hr (% of intake) 5HIAA 1 0 27 240 3.47 9.1 39.9 2 0 14 40 4.56 14.7 284 3 83 61 60 2.09 6.3 59 4 0 77 80 4.67 8.4 151 5 8 74 105 NA 11.3 323 6 32 73 75 3.2A 4.5 289 7 91 65 75 3.65 10.9 194 Control range: 41-66 151-290 0.8-1.3 7% <6 mg Conclusion: Gastric emptying is generally normal despite increased stool weight and accelerated small bowel and colonic transit. This suggests that distal brakes are not operating in earcinoid diarrhea associated with accelerated transit in small bowel and colon.

PNEUMATOSIS COLh A PROPOSED PATHOGENESlS BASED ON STUDY OF 25 CASES. IW Thompsoll, G Gagliardi, MJ Hershman, A Forbes, PR Hawley, IC Talbot*. Depts. of Surgery, Pathology, Medicine and *ICRF Colorectal Cancer Unit, St. Mark's Hospital, London, EC1V 2P5, UK.

Pneumatosis coil is a rare condition characterised by multiple gas-filled cysts within the bowel wall. We present 25 cases treated over the last 30 years. The mean age was 59 years: 15 were female. Presenting symptoms included diarrhea (n=17), mucus discharge (n=17), rectal bleeding (n=15), and constipation (n=12). Pneumatosis usually affected the left colon (96%), and diagnosis was by sigmoidoscopy and biopsy in 18 cases (72%). Pneumatosis coil was associated with psychiatric disorders (36%), chronic lung disease (20%), and colitis (12%). A redundant sigmoid colon was observed in 80% at contrast radiology.

Histology and immunohistochemistry indicate that the cysts are lined by cells of macrophage/monocyte phenotype. Five patients (29%) had mucosal pseudolipomatosis.

Treatment with antidiarrheals and anti-inflammatory drugs in 14 cases resulted in improvement in 9 (64%). Oxygen therapy (n=9) and antibiotics always alleviated symptoms. There was a high recurrence rate, but with further courses of therapy, lasting remission was achieved in 5 patients.

We propose a model of pneumatosis coli which reconciles apparently disparate pathogeneses, associations and therapies. Cyst gas is considered of luminal origin, and the associations with constipation, motility, respiratory end psychiatric disorders, mediated by increased intraluminal pressure, exacerbated by mucosal abnormalities including pseudolipomatosis. Cyst maintenance is accounted for predominantly by intraluminal bacterial gas production. Prolonged responses to (each or all of) laxatives, colitis therapy, antibiotics, and oxygen, can thereby be explained by disruption of otherwise self-sustaining, amplifying mechanisms.

DUODENO-JEJUNAL MANOMETRY (DJM): THE VALUE OF LONG RECORDING SESSIONS. S. Thongsawat, E.E. Soffer. Dept. of Med., Univ. of Iowa college of Medicine, Iowa City, IA

To compare the diagnostic yield of long (L) vs short (S) recording of DJ motility, we reviewed all prolonged ambula- tory DJM studies performed over the last 5 yr, after exclu- sion of short term perfused, and incomplete ambulatory ones. Each ambulatory study consisted of 6-7 hr of fasting fol- lowed by meal (800 Kcal) and then by sleep and was analyzed blindly twice: the first 3 hr of fasting and the first 2 hr of the postprandial period, simulating a short term perfused study, on one occasion, and the full study on another. Fasting and postprandial periods were separately compared and the importance of sleep data assessed. Variables exam- ined were the number of Phase III of the MMC, their configu- ration and migration pattern during fasting and sleep, qui- escence during sleep, the response to meal and the presence of clustered activity, particularly in the postprandial pe- riod. Eighty-one studies were available for review. Results: % %

Both Both same S Nor/ S Abn/ diff Full N Nor % Abn % Dx L Abn % L Nor % Dx study 81 41 50.6 24 29.6 80.2 i0 12.3 6 7.4 19.8 Fast 73 60 82.2 1 1.37 83.6 9 13.7 3 8.2 16.4 Fed 76 45 59.2 24 31.6 90.8 1 1.32 6 7.9 9.2 Nor - Normal; Abn - Abnormal; Fast - Fasting In 1/5 of all patients, L studies were analyzed differently

than S ones. A normal S fed pattern predicts a normal L long one but in i/i0 patients a diagnosis of abnormal fed pattern was changed to normal after review of the L record- ing. On the contrary, in 1/7 patients a normal S fasting period was considered abnormal after review of the L record- ing. In i0 patients the first Phase III was observed only after 3 hr of recording, the most delayed one seen 6 hr af- ter study was initiated (in normal subjects up to 4 hr). Abnormal sleep pattern was observed in 16 patients but in only 2 of them was it the only abnormal period. The sleep period was helpful in the final conclusion when the fasting was considered equivocal. Conclusion: prolonged DJM pro- vides a better diagnostic yield in the study of patients with suspected intestinal dysmotility.

PROLONGED AMBULATORY DUODENO-JEJUNAL MANOMETRY (DJM): NORMAL VALUES IN HEALTHY HUMANS. S. Thonqsaw@t, S. Ellerbroek, E.E. Soffer. Dept. of Med., Univ. of Iowa College of

Medicine, Iowa City, IA

To establish normal values for DJM we performed pro- longed studies, using ambulatory technique, in 24 healthy subjects (15 males, age range 18-55 yrtmedian 23). Record- ing performed with thin catheters (3 mmo.D.) with 5 pres- sure transducers spaced 15 cm apart (Gaeltec), and a solid state datalogger (Synectics, 4 MB memory, 4 Htz sampling rate). Recording lasted for 18.2 • 1.2 hr with 6½-7½ hr of fasting, 4-5 hr of postprandial period (800 kcal meal) and 5-6 hr of sleep. Computer and visual analysis using ANOVA and student's t-test. • ± i SE. Results: Fasting MMC cy- cle duration ranged from 58-226 min, x 118, during the day vs 65-198 min, ~ 96, at night. There were 3.5 ± 1.5 Phase III during fasting (range 1-7), and 3.9 ± 1.2 during the night (range 1-6). Variables of fasting, sleep and post-

prandial motility in Tables 1 and 2. Cont. Mig. Cost.

Table 1 Dur. % of freq. vel. dur. Ampl. Mot. D~ (min.) cycle (#/min) (cm/sec) (sac) (mmHq) index

Phase II 102.6" 60.7 3.5 2.7 21.7 5.0 Phase III 8.0 18.9 10.6 0.07 3.1 30.3 6.7

Niqht Phase II 76.1 60.9 3.3 2.9 22.9 5.1 Phase III 8.5 18.6 10.5 0.06 3.3 30.5 6.9 Cont. - contraction; Mig. - migration; vel. - velocity; dur. - duration; Ampl. - amplitude; Mot. - motility.

• p < 0.05 vs night. Table 2 Fed 1 Fed 2 Fed 3 Fed 4 Fastin q

Cont. freq. (#/min) 7.3 7.0 6.3 5.9 3.1- Ampl. (mmHg) 27.1 24.5 24.0 24.7 22.4

Dur. (min.) 3.0 3.0 3.0 3.0 2.9 Mot. index 6.4 6.2 6.1 6.0 5.0* Fed 1-4, first 4 hr after the meal. * p < 0.01 vs Fed 1-4. Conclusions: There is marked variability in MMC cycle length and number of Phase III during both fasting and sleep. There is marked variability in Phase III duration, configuration and migration pattern. This variability should be considered when reviewing patient's data.