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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1513_Библиотеки_им_академика_М_И_Перельмана.pdf
Anal Ultra Slow Wave: A Mysterious Manometric Finding…
165
Figure 1. Pressure fluctuations of the anal canal. Three kinds of pressure fluctuations are
presented, namely, small pulsating waves (p) reflecting vascular pressure, slow waves
(SW) with a frequency of 10 – 20/min and ultraslow waves (USW).
2. ULTRA SLOW WAVES OF THE ANAL CANAL
There are three kinds of pressure fluctuations in the anal canal, i.e., small
pulsating waves reflecting vascular pressure, slow waves with a frequency of 10 –
20/min and USW (Figure 1). Ultra slow waves are rhythmical pressure
fluctuations with a frequency less than 2/min and an amplitude greater than 25 cm
H
2
O [3]. It is recommended that the physician make sure that these giant waves
are lacking synchronicity with rectal contractions and that they have persistent
slow waves at their nadir [20] because repeated recto-anal inhibitory reflex caused
by rectal contractions resembles USW in shape. The prevalence rate of USW in
patients with hemorrhoids has been reported in more than 10 reports to date
(Table 2). The prevalence rate of USW in these reports varies with a range of 8 –
100% in patients and 0 – 10% in controls. In total, 125 of 323 (38.7%) patients
with hemorrhoids and 17 of 345 (4.9%) controls were positive for USW.
Furthermore, anal pressure in subjects with USW was significantly higher than
that in subjects without USW [2, 9, 13, 16, 19, 20].
Table 2 Prevalence of USW
Reference
Method
USW
Subjects with hemorrhoids
Controls
Positive/Total
%
Positive/Total
%
Hancock BD et al. (1975)
2)
Balloon
22/56
39,0
3/40
7,5
Hancock BD (1976)
3)
Balloon
17/40
42,0
4/84
5,0
Read MG et al. (1982)
18)
Perfused open tip
7/24
29,2
NA
NA
El-Gendi MA-F et al. (1986)
7)
Perfused open tip
4/30
13,3
0/20
0,0
Roe AM et al. (1987)
10)
Balloon
16/40
40,0
0/19
0,0
Champigneulle B et al. (1989)
12)
Perfused open tip
15/25
60,0
2/22
9,1
Schouten WR et al. (1992)
13)
Microtransducer
29/58
50,0
2/20
10,0
Faurouk R et al. (1994)
15)
Microtransducer
10/22
45,5
2/33
6,1
Eckardt V et al. (1997)
16)
Perfused open tip
2/25
8,0
0/25
0,0
Yoshino H et al. (2007)
19)
Perfused open tip
NA
NA
0/32
0,0
Yoshino H et al. (2007)
20)
Perfused open tip
3/3
100,0
4/50
4,1
Total
125/323
38,7
17/345
4,9
Anal Ultra Slow Wave: A Mysterious Manometric Finding…
167
That is why USWs are thought to represent hyperactivity of the internal anal
sphincter. Induction of anesthesia or complete paralysis of the external anal
sphincter has no effect on USW [21], while lateral internal sphincterotomy or
forced dilatation of the anal canal may cause disappearance of USW [2, 13]. The
underlying mechanism of UWS and high anal pressure has yet to be elucidated.
The hypothesis that peristaltic activity of the internal anal sphincter generates
USW [10] does not explain the emergence of UWS in several other conditions
such as chronic constipation and megacolon
20)
and in normal subjects.
Figure 2. Abdominal X-ray films of an infant with USWs.
Marked intestinal gas and the remnant of contrast enema is seen. (lt: supine position, A-P view,
rt: upright-lateral view).
III. USW-RELATED CLINICAL CONDITIONS
Ultra slow wave of the anal canal is not a specific manometric finding for
hemorrhoids. Since USW accompanies hyperactivity of the internal anal sphincter
and high anal pressure, patients with USW tend to share a common problem,
namely, difficulty in defecation. Excessive straining at stool is a frequent
complaint of these patients. Fecoflowmetric evaluation of the ability to pass stool
Hiroyuki Kayaba
168
in these patients showed intermittent excretion from the rectum with a low flow
rate and long excretion time [19]. During the early infantile period, they exhibit
marked abdominal distension (Figure 2), vomiting, and constipation, mimicking
Hirschsprung‘s disease. It is not uncommon for patients with UWS to fail to show
typical recto-anal inhibitory reflex, which makes exclusion of Hirschsprung‘s
disease difficult with a manometric study. In addition to chronic constipation and
hemorrhoids, megacolon was a typical clinical presentation in our adult cases.
Some of these patients had undergone surgery for dilated colonic loop with
unsatisfactory long-term results before their first visit to our clinic [20].
Furthermore, a high incidence of accompanying neurological disorders may
warrant attention. In our adult series [20], three of 10 patients with USW had
concomitant central nervous system disorders, and of four pediatric cases, one girl
with severe chronic constipation developed epilepsy at the age of 10 years, two
years after her first visit [19]. Disappearance of USW during sleep [15] may
suggest the influence of the central nervous system on development of USW.
4. NATURAL HISTORY OF PATIENTS WITH USW
No study has ever published on the natural history of patients with USW
because our report published in 2007 [19] was the first in pediatric cases, and the
follow-up period is still too short. At least in infantile cases, symptoms are well
controlled with conservative treatment such as laxatives and temporal use of
suppository or glycerin enema. There is little information available to answer
whether or not these pediatric cases will become adult patients with chronic
constipation, hemorrhoids and/or megacolon in the future.
5. PATHOLOGICAL FINDINGS
Of our 14 cases, pathological examination was carried out in two pediatric
cases in their infantile period and one adult case. Suction biopsy of the rectal wall
in one infant revealed increased acetylcholinesterase activity and ganglion cells,
while there was no abnormality was noted ininfant. A 74-year-old woman with
megacolon and chronic constipation, who lacked recto-anal inhibitory reflex, had
hyperplastic ganglion cells in her rectal wall (Figure 3).
Anal Ultra Slow Wave: A Mysterious Manometric Finding…
169
Figure 3.
6. TREATMENT
To relieve hyperactivity of the internal anal sphincter, lateral internal
sphincterotomy or forceful dilatation of the anal canal is proposed as surgical
treatment [2, 5, 22]. Since glyceryl trinitrate, acting as an NO donor, decreases
internal anal sphincter tone with disappearance of USW [23], topical use of
glyceryl trinitrate ointment is proposed as the medical treatment of choice in
recent years [24, 25].
7. CONCLUSION
USW is a manometric finding frequently seen in patients with hemorrhoids;
however, it is not specific to hemorrhoids. USW represents hyperactivity of the
internal anal sphincter and, as a result, may be seen in several conditions caused
by tonic internal anal sphincter. As was shown in this commentary, USW-
presenting conditions such as chronic constipation, hemorrhoids, and megacolon
in adults and marked abdominal distension mimicking Hirschsprung‘s disease in
Hiroyuki Kayaba
170
infants may share a common physiopathology; however, there remain questions to
be investigated.
ACKNOWLEDGEMENTS
Our works on USW were supported by the Mitsubishi Foundation Research
Grants and Assocation for Technical Aids Research Grants.
REFERENCES
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Br. J. Surg. 81:946-954, 1994
[2] Hancock BD et al., The internal sphincter and Lord‘s procedure for
haemorrhoids Br J Surg 62:833-836, 1975
[3] Hancock BD, Measurement of anal pressure and motility, Gut 17:645-651,
1976.
[4] Arabi Y et a。l, Anal pressures in hemorrhoids and anal fissure Am. J. Surg.
134:608-610, 1977.
[5] Creve U et a。l, The effect of Lord‘s procedure on anal pressure, Dis.
Colon. Rectum. 22:483-485, 1979
[6] Hiltunen KM et al., Anal manometric findings in symptomatic hemorrhoids,
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[7] El-Gendi MA-F et al., Anorectal pressure in patients with symptomatic
hemorrhoids, Dis .Clon. Rectum. 29:388-391, 1986
[8] Schouten WR et al., Lateral internal sphincterotomy in the treatment of
hemorrhoids. A clinical and manometric study.Dis. Colon. Rectum. 29:869-
872, 1986
[9] Deutch AA et al., Anal pressure measurements in the study of hemorrhoid
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[10] Roe AM et al., Submucosal versus ligation excision haemorrhoidectomy: a
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pain and function, Br. J. Surg .74:948-951, 1987
[11] Lin JK, Anal manometric studies in hemorrhoids and anal fissures, Dis
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456, 1989
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[20] Yoshino H et al., Megacolon hemorrhoids and constipation: multiple
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[21] Wankling WJ et al., Basal electrical activity in the anal canal in man,
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[22] Shouten WR et al., Lateral internal sphincterotomy in the treatment of
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[23] Bassotti G et al., Double-blind manometric assessment of two topical
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Liver Dis. 32:699-702, 2000
[24] Bhardwaj R, Neuromyogenic properties of the internal anal sphincter:
therapeutic rationale for anal fissures, Gut 46:861-868, 2000
[25] Tjandra JJ et al., Rectogesic
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(glyceryl trinitrate 0.2%) ointment relieves
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INDEX
A
acetylcholinesterase, 168
acid, 150
active feedback, 14
acute, 13, 15, 22, 27, 43, 46, 68, 72, 109
administration, 42
adrenaline, 71, 102
adult, 168
adults, 169
adverse event, 71
aetiology, 17, 73, 170
age, 2, 18, 58, 59, 150, 168
ageing, 33
agent, 28, 47
agents, 6, 15, 25, 27
aid, 28, 41
air, 103
alcohol, 27
allergic reaction, 6
alternative, 8, 12, 19, 21, 26, 30, 32, 45, 50,
55, 57, 122, 156, 158, 159
aluminum, 28
amplitude, 165
anaemia, 85
anaesthesia, 58, 63, 68, 73, 86, 110, 111, 150,
155, 156
anal fissures, 109, 119, 170, 171
anal inhibitory reflex, 165, 168
analgesia, 15, 96, 104, 155, 156
analgesic, 10, 12, 15, 108, 110, 111, 113, 116,
117, 155
analgesics, 7, 12, 70, 80, 108, 110, 113, 117,
125
analog, 113
anastomoses, 83, 84
anastomosis, 26, 38, 69, 103
anatomy, 2, 3, 20, 63, 74, 82, 97, 157
anemia, 4, 18
anesthetics, 28
anorectal abscess, 5
anoscope, 7, 8, 41, 88, 89, 90, 93, 102, 121,
122, 123, 124, 125, 146, 147, 155, 156
anoscopy, 5
antibiotic, 43, 58, 72
antibiotics, 12, 43, 59, 103
anticoagulant, 153
anticoagulation, 105
anus, 2, 16, 84, 88, 97, 162
arteries, 8, 26, 33, 38, 83, 151, 153, 155, 156,
157, 159
artery, 8, 19, 33, 49, 80, 83, 84, 93, 150, 151,
156, 157, 158, 159
aspiration, 155
assessment, 5, 14, 51, 113, 171
asymmetry, 90
asymptomatic, 26, 153
atrophy, 6
attacks, 27, 46
avoidance, 42, 158
Index
174
B
back
, 10, 121, 123, 124, 128, 129, 133, 139,
145
bacterial, 109, 115
barium, 5
barium enema, 5
baths, 6, 114, 119
beneficial effect, 27
benefits, 46, 114
benign, 22, 52, 79, 80
biopsies, 117
biopsy, 168
bipolar, 14, 19, 21, 29, 33, 42, 47, 49
birth, 83
bladder, 102
blood, 2, 15, 27, 43, 61, 80, 83, 84, 86, 93, 96,
108, 109, 115, 117, 119, 162
blood flow, 15, 83, 108, 109, 115, 117, 119
blood supply, 80, 93
blood transfusion, 61
blood transfusions, 61
blood vessels, 2, 27, 43, 162
body temperature, 56, 59
botulinum, 119
bowel, 4, 5, 6, 12, 42, 72, 100, 103, 162
burning, 15
C
Ca
2+
, 64, 69
calcium, 22, 27, 46, 50, 51, 63, 68, 119
calcium channel blocker, 22, 50, 63, 68, 119
cancer, 5, 18
cancer screening, 18
candidates, 1, 7
capillary, 27, 83
carbon, 11
carbon dioxide, 11
carcinomas, 5, 6
catheter, 102, 104
catheterization, 12, 60
causation, 4
cauterization, 25
CCR, 151
central nervous system, 168
cephalosporin, 58, 86
channel blocker, 22, 50, 63, 68, 73, 116, 119
channels, 90, 91, 95
charring, 14
chemical agents, 9
childhood, 171
children, 161
chronic pain, 56, 59, 61, 63, 69, 73
classical, 80, 100, 101
clinical presentation, 168, 171
clinical trial, 10, 20, 21, 50, 52, 53, 78, 105,
118, 119, 146
clinical trials, 10
clinically significant, 115
closure, 4, 25, 26, 72, 79, 81, 124, 155, 156
CO2, 30
coagulation, 8, 20, 29, 47, 48, 85, 93, 110,
149, 155
coagulopathy, 16
Cochrane, 13, 14, 18, 22, 49, 118
Cochrane Database of Systematic Reviews, 49
cohort, 57
collagen, 14, 83
collateral, 14, 108, 113
collateral damage, 108, 113
colonisation, 109
colonization, 115
colonoscopy, 5, 15, 18
colorectal cancer, 5
colorectal surgeon, 5, 9, 58
colostomy, 102
compliance, 44
components, 26, 109
composition, 17
computed tomography, 68, 103
confidence, 59
congress, 21
connective tissue, 2, 14, 83, 151
consensus, 21, 72, 77, 82, 84, 85, 86, 105
constipation, 4, 6, 27, 83, 86, 161, 167, 168,
169, 171
contractions, 165
contracts, 84