Background: Anal Intraepithelial Neoplasia (AIM), a pre-cursor of anal squamous carcinoma, is increasingly detected in individuals with impaired immune function. However, choices for effective, low morbidity treatment are limited. Photodynamic Therapy (PDT) is promising as it is known to ablate more proximal gastrointestinal mucosa with safe healing, without damage to underlying muscle. It can also ablate skin with safe healing and minimal scarring.Methods: Pharmacokinetics: Normal rats were sensitised with 200 mg/kg 5-aminolaevulinic acid (ALA) and killed 1-8 h later. Anal tissues were examined by fluorescence microscopy to quantify the concentration of PPIX (protoporphyrin IX, the active derivative of ALA) in anal mucosa and in the underlying sphincter.PDT: Normal rats were sensitised similarly 3 h later, laser light (635 nm) was delivered. Anal canal: 50-150 J/cm using 1 cm diffuser fibre; for peri-anal skin, 50-200 J/cm(2), using microlens fibre. In each group, 2 rats were killed 3, 7, 14 and 28 days later and the anal region removed for histological examination.Results: Pharmacokinetics: Peak concentration of PPIX in mucosa was at 3 h, peak ratio mucosa: muscle, 6, seen at same time.PDT. Anal canal 50 J/cm: complete mucosal ablation by 3 days, complete regeneration by 28 days. Higher energies caused muscle damage with scarring. Peni-anal skin: 200 J/cm(2); complete ablation of skin, including appendages, complete healing by 28 days. Minimal effect with lower energy.Conclusion: ALA-PDT can ablate anal mucosa and pen-anal skin with safe healing and no underlying damage. However, over treatment can damage the sphincters. This technique is ready to undergo clinical trials. (C) 2013 Elsevier B.V. All rights reserved.

OBJECTIVES:The aim of this study was to apply qualitative techniques to assimilate data on patient experience and attitudes during MR colonography (MRC) and colonoscopy (CC).METHODS:18 patients (11 male, 8 female, median age 40.5 years), 10 of whom had known colonic inflammatory bowel disease (IBD) and 8 who were under investigation for suspected colonic neoplasia (non-IBD), underwent MRC and conventional CC. Semi-structured interviews were performed to assimilate test experiences and preferences, and themes were extracted using thematic analysis.RESULTS:Thematic analysis identified three main themes: (i) physical experience, (ii) information provision and (iii) overall preference. Patients expressed mixed views about the physical experience of MRC but specifically identified water filling, breath holding and lying still as problematic. Anxiety was expressed regarding potential incontinence. Scanner noise interfered with the understanding of instructions, particularly amongst non-IBD patients. Non-IBD patients expressed greater anxiety over the delay in receiving the MRC report than IBD patients. In general MRI was considered as the more informative and safer investigation. Patients reported more physical discomfort during CC (notably IBD patients) related to air insufflation and colonoscopic manipulation but were more satisfied with the feedback they received. 10 patients (56%) stated an overall preference for MRC and 5 (28%) preferred CC. Reasons for preferences stated by the patients included discomfort, speed of the test, safety, perceived diagnostic ability and the ability to take biopsies.CONCLUSION:Experiences of MRC and CC are complex and influenced by clinical indication. Individuals place different weightings on the relative importance of test attributes including discomfort, noise, immobility, feedback, safety and fear of incontinence and this defines overall preference.

OBJECTIVES Abnormal contrast enhancement on MRI is advocated as a biomarker for inflammation in colitis, although the enhancement kinetics of normal colon are poorly described. Our purpose was to quantitatively assess mural enhancement in normal colon and test for intersegmental differences. METHODS Eight patients without prior history of inflammatory bowel disease underwent standard MRI colonography followed by normal same-day colonoscopy. Acquired sequences included a volumetric interpolated breath-hold examination (VIBE) to encompass the whole colonic volume, performed at 5°, 10° and 35° flip angles for T(1) quantitation and then at a fixed 35° flip angle three times prior to and every 30 s following intravenous gadoterate meglumine for 220 s. Ascending colon, descending colon and rectal R(1) (1/T(1)) was plotted against time. Mean pre-contrast R(1), initial change of R(1) (ΔR(1)), early and late "plateau phase" enhancement and the area under the R(1)-time (AUC-R(1)) curve were compared between segments using the Student's paired t-test. RESULTS There was no significant difference of pre-contrast R(1) between segments (p=0.49 to 0.62). ΔR(1) was higher for ascending colon compared with descending colon (0.0023±0.0012 ms(-1) vs 0.0010±0.0011 ms(-1), p=0.03). There was no significant difference for early or late plateau phase R(1) between colonic segments (p=0.08 to 1.00). AUC-R(1) was greater for ascending than descending colon (0.54±0.19 vs 0.30±0.14, p=0.03). CONCLUSIONS Intersegmental differences in colonic enhancement are present and should be considered when interpreting differential segmental enhancement.

IntroductionBowel dysfunction (BD) affects two thirds of patients with Multiple Sclerosis (MS), with constipation and incontinence often co-existing. Management is largely empirical; however, Peristeen transanal irrigation (PTAI) has been successfully employed in patients with spinal cord injury and spina bifida. We evaluated the effectiveness of PTAI in MS and examined possible predictors of success.MethodsThirty consecutive consenting patients (26 female, age 48.2 ± 10.8) with MS who failed maximal medical treatment and Biofeedback for BD were entered in the study. They all undertook a one-to-one training session on how to use the device. Primary outcome measures, the Wexner-Constipation and Wexner-Incontinence scores, were prospectively compared pre- and post-treatment. Standard ano-rectal physiology and measurement of rectal compliance with barostat were performed at baseline. Patients post-treatment were classified as Responders or non-Responders on the basis of reduction to below 10 in the relevant Wexner score, and baseline tests and scores were compared between groups to identify predictors of successful treatment.ResultsAt 12 months follow-up Wexner-Constipation (12 ± 5.5 vs 4.8 ± 5.5, p = 0.001) and Wex-Incontinence (11.1 ± 6.3 vs 5.9 ± 9.1) improved. Sixteen patients (54%) were classified as Responders. Age, disease duration and disability status were not different to non-Responders. At baseline, Responders had higher Wexner-Incontinence scores compared to non-Responders (13.3 ± 5.7 vs 8.4 ± 6.1 p = 0.037, respectively). Wexner-Constipation scores were similar in both Responders and non-Responders. Physiology parameters were similar in the 2 groups, except that Responders had a higher Maximum tolerated volume to rectal balloon distension (Resp 272 ± 62 vs non-Resp 205 ± 96 mls, p = 0.0296) and Rectal Compliance (Resp 15.5 ± 3.3 vs non-Resp 10 ± 4.6 ml/mmHg p = 0.003).ConclusionPTAI helps over 50% of MS who have failed to respond to maximal medical treatment for bowel dysfunction. It appears that a more compliant and capacious rectum and higher baseline incontinence scores predict successful treatment.

Aim Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure.Method Fifty-seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50-ml distensions (n = 35) or isobaric 4-mmHg distensions (n = 22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure.Results The distension-induced squeeze increment was calculated as the maximum percentage increase in maxi-mum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean +/- standard deviation (range) increase of 32.8 +/- 24.1 (-5.5 to 97.7)%. The mean +/- standard deviation (range) distension-induced squeeze increment in male subjects was 36.1 +/- 25.7 (-5.5 to 97.7)% and in female subjects was 28.1 +/- 20.1 (-3.8 to 70.2)%. There was no significant difference between the sexes (P = 0.194).Conclusion Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.

Introduction Bowel dysfunction in multiple sclerosis (MS) and spinal cord injury (SCI) is common, affecting up to 2/3 of patients, with constipation and incontinence often co-existing. In MS we have shown that spinal cord involvement by the disease predicts bowel dysfunction. Spinal disease burden is easily measured clinically by EDSS (expanded disability status scale, 0–4.5 = mild disability, 5–10 = high disability). In supraconal-SCI the autonomic dysfunction underlying bowel symptoms causes increased rectal compliance (RC). We hypothesised that spinal cord involvement by MS is responsible for the autonomic dysfunction affecting the rectum, hence compared RC between MS, supraconal-SCI patients and normal controls. Methods Forty-five MS patients with bowel symptoms were divided in two groups according to EDSS: MS-A (EDSS < 5, n = 25) and MS-B (EDSS > 5, n = 20). Rectal compliance and Wexner constipation and incontinence scores were compared with 19 Supraconal-SCI patients and 25 normal controls. Age, gender and parity were well-matched between groups. Results Rectal compliance (ml/mmHg) post-hoc analysis in table 1. Wexner-Incontinence: MS-A (6.12 ± 4.72) vs MS-B (9.8 ± 6.4) p = 0.96 MS-A (6.12 ± 4.72) vs Spinal(10.8 ± 5.3)p = 0.033 MS-B (9.8 ± 6.4) vs Spinal(10.8 ± 5.3) p = 0.883. Wexner-Constipation: MS-A (10.8 ± 5.3) vs MS-B (11.3 ± 4.3) p = 0.951 MS-A (10.8 ± 5.3) vs Spinal (15.4 ± 5.8) p = 0.025 MS-B (11.3 ± 4.3) vs Spinal (15.4 ± 5.8) p = 0.065. In the MS group there was a strong relationship between EDSS and RC (r = 0.438, p = 0.003; β = 0.487, p = 0.001). Conclusion Rectal compliance is increased similarly in both MS patients with high disability and supraconal-SCI patients, suggesting that similar autonomic dysfunction underlies bowel symptoms in both groups. Bowel dysfunction in MS is multifactorial, but spinal cord involvement by MS seems critical to development of both constipation and incontinence.

Introduction: Active inflammation in acute colitis may resolve with medical therapy, whilst failure to respond often necessitates surgery with removal of the large bowel. Currently, assessment of response to drug treatment is based on a combination of clinical (e.g. stool frequency, temperature) and biochemical markers (C-reactive protein [CRP]) of inflammation, imaging (abdominal radiograph, computed tomography) and endoscopy [1,2]. Despite these measures, assessment of response is often problematic; CRP maybe elevated in other pathologies and repeated conventional imaging imparts a subtstantial dose of ionising radiation to a predominantly young patient group. T2 weighted and contrast enhanced MR imaging has been used to assess inflammation within the small bowel, providing excellent depiction of both mural and extra-mural tissue [3]. High mural T2 signal intensity is related to inflammatory activity and likely caused by mural oedema [4], but to date no study has assessed mural MR diffusion changes. Diffusion weighted imaging is known to be extremely sensitive to changes in intracellular and extracellular water in neuroimaging, and increased Apparent Diffusion Coefficient (ADC) is seen with oedema [5]. The purpose of this study was to investigate whether a similar relationship exists between colonic mural ADC and inflammation.

loss of stool" as their sole reason, contradicting their answer on the e-PAQ -PF.The most frequently cited reasons for not discussing FI were "other health problems more important to discuss"(n=9), "able to manage symptoms on my own"(n=7), and "thought leakage was a normal part of aging"(n=4).17 women indicated a most important reason; "other health problems more important"(n=4) and "normal part of aging"(n=3) were the most frequently chosen.No one chose embarrassment as the most important reason.Conclusion: Consistent with other reports, participants who had discussed FI in the past had more severe FI than those who had not.Some women who indicated FI in the past 4 weeks, did not consider themselves to have the problem for unclear reasons.Higher prioritization of other health problems, perception that they are able to manage FI on their own, and belief that FI is a normal part of aging were the most common reasons for not discussing FI with clinicians.

relating to social process (family, friends) more than IBD/HC (F=7.52,p<0.05).Personal concern dimensions (job, occupation, achievement) varied among the groups (F=4.99,p<0.05) with IBD using these categories more regularly than IBS/HC.IBD subjects also used causative language (because, effect) at a higher rate (F=4.01,p<0.05).Reference to death was significantly (F=3.38,p<0.05) higher in the IBS/IBD groups.Notably, there was no difference in somatic references between the groups (χ2=1.44,p=0.49).CONCLUSIONS: Qualitative language analysis of experiences on 9/11 demonstrated high negative affect amongst patients with IBS in comparison to IBD/HC.In contrast to prior research, IBS patients did not utilize more first-person singular pronouns (indicative of self-involvement) or illness-specific language within their narratives.Both illness groups referenced death more often than controls.IBS patients are thought to employ maladaptive cognitive processes amenable to cognitive therapy-our study supports this finding at a qualitative level.