RevistÄ de MedicinÄ Åi Farmacie - Clujul Medical - Iuliu HaÅ£ieganu

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Patologie digestivă HOW TO ASSESS GASTROINTESTINAL MOTILITY JUERGEN BARNERT 3. Med. Klinik, Klinikum Augsburg, Germany Abstract Motility is a property of the gastrointestinal tract and represents one of its most important functions. Motility may have large variety in physiological and pathological conditions. Therefore measuring gastrointestinal motility is an important aim of the gastroenterologists, despite the fact that this field of neurogastroenterology is neglected by many specialists. This is an overview of major techniques for assessing gastrointestinal motility. The large interobserver and intraobserver variability and also the lack of some standardized techniques make this field still difficult to know and interpret. Keywords: Function, gastrointestinal physiology, manometry, motility. EVALUAREA MOTILITĂȚII GASTROINTESTINALE Rezumat Motilitatea este o proprietate a tractului gastrointestinal și reprezintă una din funcțiile sale cele mai importante. Motilitatea poate prezenta o varietate mare de stări fiziologice și patologice. Deci măsurarea motilității gatrointestinale este un obiectiv important al gastroenterologiștilor, în ciuda faptului că acest domeniu al neurogastroenterologiei este neglijat de mulți specialiști. Articolul conține o trecere în revistă a principalelor tehnici pentru evaluarea motilității gastrointestinale. Varietatea mare, atât intra-, cât și extraobservațională, precum și lipsa unor anumite tehnici standardizate, fac acest domeniu încă dificil de cunoscut și de interpretat. Cuvinte cheie: funcție, fiziologie gastrointestinală, manometrie, motilitate. 314 Essentials of gastrointestinal (GI) motility Although the morphology of the alimentary tract can simplistically be described as a muscular tube extending from the mouth to the anus the motility of the gastrointestinal tract is organized in a complex way. The diameter of the tube is not the same throughout its length. There are widenings and narrowings so that different compartments are formed, which are more or less separate from each other. The contractions of the gastrointestinal tract can be divided into two types. Tonic contractions are long lasting. Tone is a state of stable and protracted contraction of the smooth muscle. Tonic contractions form sphincters and haustral indentations of the colon. They are prominent in the proximal stomach and the gallbladder. Phasic contractions are short and (more and less) rhythmic. They predominate in the tubular esophagus, the distal stomach and the small intestine. Peristaltic phasic contractions transport a bolus aborally, simultaneous contractions mix and grind the intestinal content, and for example in Articol intrat la redacţie în data de: 08.07.2009 Acceptat în data de: 10.07.2009 Adresa pentru corespondenţă: juergen.barnert@t-online.de Clujul Medical 2009 Vol. LXXXII - nr. 3 the colon retropulsive contractions even propagate orad. Apart from recording contractions motility can be tested by measuring the transport of a marker in the alimentary tract. Gastric emptying studies are performed in this way as well as measurements of transport in the small or large intestine. Motility studies are not only done in scientific research but are also useful in assessing patients and guiding their treatment. Measurement of gastrointestinal motility needs not to be complicated but it is sometimes difficult in the clinical setting to choose the appropriate test and to interpret its results. Combined measurement of contractions and passage Radiology Radiography is the oldest method of examining the movements of many parts of the gastrointestinal tract. The first observations of gastric and colonic motility were done using radiography with barium contrast. But radiology has a major disadvantage especially in humans: The dose of radiation it delivers makes prolonged observations impossible. In addition the contrast media are not
Articole de orientare physically and chemically comparable to food which often provokes the patient’s symptoms. Nowadays radiography is performed only in a special dynamic technique called cineradiography [1-3] in patients with swallowing or defecation disorders. Defecography makes the defecation process visible. The rectum is filled with a barium paste which should have the same viscosity as normal feces. The patient sits on a radiolucent commode following the rectal injection of the contrast medium. The radiological examination is done by taking the lateral pelvic view at rest, during straining and during defecation. A slow motion film is recorded and afterwards analyzed. Attention is paid to the anorectal angle, the lowering of the pelvic floor, anatomical changes like a rectocele, a prolapse or an intussusception, the opening of the anal canal and the expulsion of the contrast medium. Deglutition disorders can also be analyzed by means of slow motion or frame-by-frame analysis of cinefluorographic or videotape recordings (Fig.1). This method is a helpful clinical tool especially for patients with oropharyngeal dysphagia and dyskinesia of the upper esophageal sphincter. Esophagograms are performed using either a semi-solid barium suspension or a solid barium-containing marshmallow. Cineradiography can identify altered patters of deglutition, defective closure of the laryngeal vestibule, immobility of the epiglottis and cricopharyngeal dysfunction but also defective peristaltic motor function of the esophageal body, dilation of the esophageal lumen and ineffective relaxation of the lower esophageal sphincter. At the same time other causes of dysphagia like malignancy, peptic stricture, rings, webs or Zenker’s diverticulum can be excluded. Abdominal radiographs reveal in these patients marked dilatations of the small intestinal loops filled with air and fluid, and a variable degree of colonic distension. The presence of large amounts of air throughout the whole gastrointestinal tract distinguishes this motility problem from an obstructive ileus and helps to avoid an unnecessary laparotomy. A plain film of the abdomen may also be used to assess the degree of fecal accumulation in the colon in patients suffering from constipation. The speed of passage through the alimentary tract can be measured by having the patient swallowed radio-opaque pellets or tiny rings which can then be seen on X-ray pictures. The mouth to anus time is normally 1-3 days whereas the passage from mouth to the large bowel accounts only for 1-6 hours. In practice the measured passage time is mainly determined by the colonic transit time of the markers. The radio-opaque markers can be ingested either as a bolus or on a daily basis followed by interval radiography of the abdomen [4,5]. A number of methods has been described. The method preferred in our institution is to give 20 pellets daily for six days and to carry out a plain film of the abdomen on the seventh day. Using this method the counted number of the markers on the X-ray picture (Fig. 2) has to multiplied by 1.2 to obtain the hours of total colonic transit time. Values exceeding 60 hours confirm objectively the diagnosis of constipation. Radioopaque markers can also be used to study gastric emptying. In the method proposed by Feldman [6], small pieces of gastric tubing were ingested together with a test meal. After 6 hours all markers should have emptied from the stomach. Changes in the rate of emptying of pellets according to the composition of the meal suggest that the emptying of the marker reflects emptying of the meal and not emptying of the marker alone. But it must be emphasized that in contrast to studies using barium swallows or enemas pellet tests can give no information about contractions. Fig. 1 Cineradiography: Normal radiological sequence of deglutition. From the onset of swallowing (a) to the passage of the upper esophageal sphincter (f), every detail of the deglutition can be visualized. E=epiglottis, K= pharyngeal contraction, D=small Zenker’s diverticulum, C= cricopahryngeal muscle (upper esophageal sphincter). Plain films of the abdomen may also be helpful especially in patients with suspected pseudoobstruction. Fig. 2 Colonic transit time: The X-ray picture shows a large amount of radio-opaque markers retained in the colon of a patient with constipation. Lines are drawn to enable calculation of segmental transit times of the right hemicolon, the left hemicolon and the rectosigmoid. Clujul Medical 2009 Vol. LXXXII - nr. 3 315
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