Background An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer. Aim The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry. Methods Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2). Results Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p = 0.007). Surgery determined a significantly decrease of the resting pressure (p = 0.001), of the maximum squeeze pressure (p = 0.001) and of the volume threshold for urgency (p = 0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively. Conclusions CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.

Conversely, the IBS subjects experienced decreased compliance with LPD (-1.3±0.9 ml/ mmHg; p=0.4) and nominal increases in compliance with HPD (0.6 ±0.7 ml/mmHg; p= 0.17).Between groups, these differences in barostat acclimation were significant for HPD (p=0.03) but not LPD (p =0.28).Rectal compliance did not correlate with subjective discomfort ratings of LPD or HPD in either group; however, lower mean rectal compliance with HPDs trended toward predicting more severe IBS symptoms (p=0.07) and higher symptomatic days (p=0.08).CONCLUSIONS: IBS patients have decreased dynamic rectal compliance with both low pressure and high pressure rectal distensions.While healthy individuals acclimate to a series of distensions by increasing rectal compliance, IBS patients experience minimal increases, or even losses in rectal compliance with subsequent distensions.These observations appear to relate to IBS symptom severity and frequency, and advance our understanding of the relevance of rectal compliance to IBS pathophysiology.

recruited.Patients with unexpected rectal cancer were excluded.Self-reported fecal incontinence was measured using the COREFO questionnaire.Rectoanal manometry was performed prior to and 6 months after treatment to assess anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), rectoanal inhibitory reflex (RAIR), rectal distension-related sensation levels (first sense (FS), first urge (FU), maximum tolerable volume (MTV)) and rectal compliance (RC).Results.Of 26 enrolled patients, 4 were excluded because of unexpected cancer.Of the remaining 22 (EMR/TEM 10/12), 17 were male and mean age was 62.4 ± (standard deviation) 9.4 years.Mean adenoma size was 48 ± 17 mm and median distance from the dentate line was 3 cm (range 0-14).Prior to treatment, incontinence for solid feces, liquid feces, flatus and soiling were reported by 14%, 41%, 68% and 55%, respectively.Mean ARP, SP and SE were 66 ± 18 mmHg, 205 ± 101 mmHg and 21 ± 10 s (SE ≥ 30 s in 8 patients (36%)).RAIR was present in 16 patients (73%).Median levels of FS, FU and MTV were 85 mL (25-300), 120 mL (55-340) and 223 (150-500).In 3 patients, the MTV was not reached.RC was 6.7 ± 2.7 mL/mmHg.Follow-up data were available for 9 patients (EMR/TEM 6/3).Six months after treatment, incontinence for solid, liquid feces, flatus and soiling were reported by 0%, 0%, 67% and 44%, respectively.Mean ARP, SP and SE after 6 months were 55 ± 14 mmHg, 193 ± 56 mmHg and 27 ± 7s (SE ≥ 30 s in 6 patients (67%)).In paired analyses, ARP was significantly lower compared to preoperative values (p=.038).SP was comparable, with longer SE (p=.023).RAIR was present in 7 patients (78%).Median levels of FS, FU and MTV after 6 months were 100 mL (10-350), 120 mL (60-350) and 230 (115-350); in 2 patients, FS and FU were not reached, respectively.Distension-related sensation levels were comparable to preoperative values.RC was also comparable to preoperative assessment (5.8 ± 2.7 mL/mmHg, p=.355).Discussion.Rectoanal functional complaints in patients with large rectal adenomas may be caused by increased distension-related sensitivity levels as well as increased rectal mucus production in comparison with healthy adults.Although endoscopic or surgical adenoma resection may cause a decrease in ARP, the short-term effects of EMR and TEM on rectoanal function seem limited.

To the Editor: Treatment of ulcerative proctitis with local administration of corticosteroids is a common practice. Beclomethasone dipropionate (BDP) is a poorly absorbed corticosteroid endowed wit...

Purpose: Active ulcerative proctitis is usually treated with local administration of either mesalamine or corticosteroids. Cessation of rectal bleeding can be already observed within a couple of weeks, but occasionally patients do no respond to standard local therapy. Purpose of our analysis was to establish the therapeutic role of enemas combining mesalamine and beclomethasone dipropionate in patients resistant to rectal administration of beclomethasone dipropionate alone Methods: We re-examined retrospectively 34 outpatients with rectal localization of ulcerative colitis treated in our Unit during the last four years. The subjects, aged 29–47 years, had experienced a clinical flare-up of the disease during oral maintenance with mesalamine 1600 mg daily and had been treated with rectal beclomethasone diproprionate 3 g/100 ml at bedtime for up to 15 days with persistence of rectal bleeding. Sixteen patients continued the ongoing local treatment with beclomethasone enemas for further two weeks and increased the oral dose of mesalamine to 3.200 mg daily (group A). The remaining eighteen subjects maintained oral mesalamine 1.600 mg daily and were treated for two weeks at bedtime with a rectal enema where beclomethasone 3 g/100 was mixed with a powder containing 1.5 g of mesalamine (group B). Results: In group A, five patients reported no more bleeding at the end of the treatment period, whereas eleven patients with persistent bleeding at two weeks were switched to oral corticosteroids. In group B sixteen of the eighteen subjects experienced disappearance of rectal bleeding. The difference between the two treatment groups is statistically significant: P= 0.002 by chi-square test Conclusion: Our preliminary, retrospective analysis suggests that: 1) rectal administration of a mixture of beclomethasone and mesalamine is effective in patients refractory to rectal beclomethasone alone; 2) adding rectal mesalamine to the beclomethasone enema is more effective than increasing the dose of oral mesalamine.

Background. A target-controlled infusion system automatically adjusts the rate of infusion of propofol to maintain a desired (target) concentration. The aim of this study was to determine whether administration of propofol with a target-controlled infusion system could improve the sedation of patients undergoing ERCP.Methods: A total of 205 consecutive patients undergoing ERCP were sedated by using a propofol target-controlled infusion system by an anesthesiologist. The target plasma concentration of propofol ranged from 2 to 5 mug/mL. A bolus dose of fentanyl (50-100 mcg) was administered if signs of insufficient analgesia were observed at the maximum target concentration of propofol allowed. The technical difficulty of ERCP was graded on a scale from 1 (least difficult) to 5 (most difficult).Results: The mean dosages of propofol and fentanyl administered were 465 (245) mg and 59 (23) mcg, respectively. The total dose of propofol administered and the mean duration of ERCP were related to the degree of difficulty of the procedure. No severe complication was observed; mean time to discharge was 31 (12) minutes. Time to discharge was not influenced by the difficulty of ERCP or by the total dose of propofol administered.Conclusions: A target-controlled infusion system for administration of propofol provides safe and effective sedation during ERCP. Further studies are needed to determine the cost-effectiveness and the safety profile for infusion of propofol with a target-controlled infusion system by a nonanesthesiologist during ERCP.

BACKGROUND:The role of enteric flora in the pathogenesis of inflammatory bowel disease constitutes the rationale for the use of antibiotics as adjuvant agents in the treatment of ulcerative colitis (UC) and Crohn's disease.OBJECTIVE:The aim of this study was to assess, in a preliminary fashion, the efficacy of the nonabsorbable antibiotic rifaximin in the treatment of exacerbation of UC in patients with a history of poor corticosteroid tolerance.METHODS:This open label pilot study was conducted in the Gastroenterology Unit, S. Raffaele University Hospital (Milan, Italy). Male and female patients aged 18 to 65 years with an established diagnosis of left-sided UC who were experiencing a clinical relapse during maintenance treatment with mesalamine and with a history of poor tolerance to corticosteroid therapy were included in the study. They received rifaximin 400 mg BID for 4 weeks while continuing to receive mesalamine 2.4 g/d. Disease activity before and after treatment was assessed using Rachmilewitz's Activity Index (RAI). A final RAI score <6 was considered clinical remission.RESULTS:Ten patients (9 men, 1 woman; mean [sd]age, 48.1 [12.3] years [range, 23-64 years]) participated in the study. The RAI decreased in all patients. Rifaximin treatment induced clinical remission in 7 patients (70%). No adverse effects were reported.CONCLUSIONS:Due to our study design, no definitive Conclusions can be drawn. However, our preliminary data suggest that rifaximin may be beneficial in the treatment of active UC, obviating corticosteroid therapy in most cases.

OBJECTIVES:Probiotics can be useful in the treatment of inflammatory bowel disease. In a previous report, the non-pathogenic yeast Saccharomyces boulardii was found to be beneficial in the maintenance treatment of Crohn's disease. The aim of this study was to assess the efficacy of S. boulardii in ulcerative colitis patients.METHODS:A group of 25 patients with a mild to moderate clinical flare-up of ulcerative colitis received additional treatment with S. boulardii 250 mg three times a day for 4 weeks during maintenance treatment with mesalazine. These patients were unsuitable for steroid therapy. Before and after treatment, Rachmilewitz's clinical activity index was calculated. The probiotic treatment was considered a therapeutic success only when the final score was lower than 6.RESULTS:Of the 24 patients who completed the study, 17 attained clinical remission; this was confirmed endoscopically.CONCLUSIONS:Our preliminary results suggest that S. boulardii can be effective in the treatment of ulcerative colitis. Controlled studies with this probiotic agent are warranted.