We have investigated the effect of loperamide (4 mg tds) on the continence to a standard volume of rectally infused saline and anorectal manometry in 26 patients complaining of chronic diarrhea complicated by fecal incontinence and severe urgency. Each patient was treated for one week with loperamide (4 mg tds) and for one week with an identical placebo in a double-blind cross-over trial. Our results showed that as well as its established effects of improving stool consistency and reducing stool weight, frequency and episodes of incontinence and severe urgency, loperamide also significantly improved continence to a standard volume of rectally infused saline. This action was associated with an increase in the maximum basal sphincter pressure, an increase in the rectal volume required to abolish recovery of the rectoanal inhibitory reflex, and a reduction in rectal compliance. These results suggest that loperamide may have a specific action on the anal sphincter, which may aid continence in patients who complain of diarrhea and fecal incontinence.
'THE anal region in man (circumanal skin and anal canal) is extremely sensitive, yet a search of the literature reveals that little work, histological or experimental, has been done on its sensory innervation. The histological investigations of Ottaviani (1940) were mainly on small animals and mostly concerned with the rectum. However, he did note that there were nerve-plexuses made up of thick and thin fibres beneath the columnar epithelium of the rectal columns. No mention was made of organized sensory nerve-endings. In work on human adult and embryonic material Seto (I940), using his own modification of the Bielschowsky-Gros method, described intra-epithelial free endings in the anal canal and illustrated them by means of diagrams. His study was concerned particularly with the nerves crf the epithelium and no organized endings were described. Using a Cajal silver technique Sotelo (1954) demonstrated nerve-fibres at the anal canal ducts in human fetuses, although no organized endings were described. The nerve-fibres apparently supplied both endings in the skin and other endings in the glandular epithelial surface. Using Seto's method, Izumi (1955), one of his pupils, described organized endings in the anal region of man and illustrated them by drawings. He noted large and small end-formations which he believed to be two types of genital bodies. He also described and illustrated branching nerve-fibres which were thought to be simple or complex terminations according to the number of subdivisions involved in the termination. In addition, in the subcutaneous fat he found Pacinian corpuscles which he thought were rather smaller than those usually found elsewhere. He emphasized that the nerves and endings diminished markedly in number in the zona columnaris. In a study on human sigmoid colon and rectum Wang Wei Fan (1955) found myelinated fibres and branching non-myelinated fibres to which he attributed a sensory function. No end-formations were shown in connexion with these fibres. However, he noted some tangled glomerular endings lying close to the basal membrane of the epidermis at the mucocutaneous junction. These he considered to resemble genital corpuscles. Two types of ending have been described by Kantner (1957) in connexion with a deep and superficial network of fibres in the 38 submucosa at the mucocutaneous junction. He remarked on the presence of occasional Pacinian corpuscles near the anal sphincters. The rectum he found to lack organized endings and networks and to have submucosal nerve-fibres the branches of which were in close relationship to blood-vessels near the epithelium.The present study was undertaken to investigate the sensory nerve-endings in the perianal skin, the anal canal, and the adjoining rectal mucosa. A preliminary report of the findings has already been published (Duthie and Gairns, 1958). M T E R I A L AND METHODSHistological.-Material for the investigation was obtained from ten human beings whose ages ranged from 34 to 70 years. Three of the specimens were from early autopsies...
SUMMARY The myoelectrical activity of human colon and rectum has been studied by three types of electrode in man-intraluminal (suction), serosal and cutaneous. The patterns obtained indicate a high degree of consistency between the methods and the value of surface electrodes is emphasized.Gradients along the large bowel of both frequency and percentage electrical activity have been observed and possible physiological roles are postulated for them. By correlating the features of regular electrical and corresponding regular motor waves an alteration in the myoelectrical pattern is observed in the region of the rectosigmoid junction.The main electrical wave form detected in the smooth muscle of the stomach and small bowel is known as the slow wave or basic electrical rhythm and is present all the time. Slow waves are thought to coordinate gastrointestinal motility and their characteristics have been described both in vivo and in vitro (Daniel, Wachter, Honour, and Bogoch, 1960;Bass, Code, and Lambert, 1961; Duthie, Brown, Robertson-Dunn, Kwong, Whittaker, and . The situation in the colon and rectum is more complex. In a previous study of the rectosigmoid region in man we described long periods of electrical silence, particularly in the lower sigmoid region, although in the lower rectum slow waves were more constant and regular (Taylor, Duthie, Smallwood, Brown, and Linkens, 1974). These observations agree with other work (Provenzale and Pisano, 1971). In addition two distinct rhythms of slow waves were recognized in this region: a predominant higher frequency one (6-10 c/m), and a less commonly observed lower frequency one (2.5-4 c/m) with a greater amplitude. We have now extended these initial studies to the more proximal large bowel. MethodsElectrical slow waves of the smooth muscle of the colon and rectum were recorded in 108 subjects with no known pathology in this area, using three types of electrodes-intraluminal, serosal and cutaneous.
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