Study On Anorectal Motility, Rectal Sensory And Autonomic Nerve Function After Stroke With Constipation

Part Ⅰ Anorectal motility,rectal sensation and autonomic function in patients with post-stroke constipationBackground and aims The incidence of post-stroke constipation(PSC)is very high.Constipation does great harm to stroke patients.However,there are few studies on the mechanisms of PSC.A few of studies reported prolonged colon transit time in post-stroke patients with constipation.However,there has been no published research on anorectal function in PSC patients.Some studies have found that autonomic nervous dysfunction may be involved in the development of PSC.At present,heart rate variability(HRV)is the main method to evaluate autonomic nerve function,but it lacks unified normal value.The aims of our study were as follows:1)to evaluate anorectal motility and rectal sensation in PSC patients using anorectal manometry(ARM);2).to detect the autonomic function with HRV in order to explore the potential mechanisms of anorectal dysfunction in PSC patients.Methods 1.From November 2017 to June 2018,a total of 24 healthy controls(HC)and 71 stroke patients(constipation group: 34;non-constipation group: 37)referred to the Clinical Gastrointestinal Motility Lab at Ningbo Yinzhou People’s Hospital were recruited into this study(Written consent was obtained)2.Relevant questionnaires and data were collected,such as general information,spontaneous bowel movements(SBMs)in the past one week,Bristol score,modified Patient Assessment of Constipation Symptom(PAC-SYM)and modified Patient Assessment of Constipation Quality of Life(PAC-QOL),Barthel index(BI)and the NIH Stroke Scale(NIHSS).3.The HRV test was performed in all subjects to assess autonomic nervous function.4.The ARM test was performed in all subjects to evaluate the function of anorectal motility and rectal sensation.Results 1.Impaired rectal sensation in patients with post-stroke constipation 1)Constipation patients exhibited increased rectal sensation thresholds(first sensation,desire of defecation and urge of defecation),compared with stroke patients without constipation or healthy controls(all P<0.05).2)Clinical characteristics of constipation,including spontaneous bowel movements,time spent in toilet per defecation,Bristol stool form,laxative use,modified PACSYM and modified PAC-Qo L were correlated with rectal sensation thresholds(P<0.05 or P<0.001).3)Almost no significant difference was detected in anorectal motility parameters among these three groups.2.Stroke patients with brainstem lesions tended to suffer from constipation,compared to patients without brainstem lesions(87.5% vs.41.0%,P<0.05).Moreover,they had an increased threshold volume for first sensation,compared to the latter group(46.9±17.7 vs.32.5±15.6,P<0.05).3.There was a positive correlation between sympathetic activity and stroke severity,and a negative one between vagal activity and stroke severity(r=0.323,P=0.006;r=-0.322,P=0.006 respectively).The threshold volumes for desire of defecation,urge of defecation and maximum tolerance were all positively correlated with sympathetic activity but negatively with vagal activity(all P<0.05).4.The physical activity and the threshold volume for desire of defecation were independent risk factors for development of post-stroke constipation(OR=0.992,P=0.021;OR=1.074,P=0.049 respectively).Conclusions 1.Post-stroke constipation is characterized by elevated thresholds for rectal sensation,rather than dysfunctions of anorectal motility.2.Patients with brainstem lesions are predisposed to constipation,possibly due to the disruption of afferent pathway from the rectum to the cerebral cortex.3.The physical activity level and the threshold for desire of defecation are factors independently associated with post-stroke constipation.Part Ⅱ A combined noninvasive multiple gastric and autonomic functional test to evaluate the pathophysiological mechanisms of functional dyspepsiaBackground and aims The pathophysiological mechanisms of functional dyspepsia(FD)are complicated,involving many factors,and studies have found that the pathophysiological mechanisms of each subgroup of FD are not consistent.There were few researches on pathophysiological mechanisms of different FD subgroups according to Roman Ⅳ criteria.Meanwhile,the assessment of these pathophysiological mechanisms requires multiple independent examinations,which are time-consuming and laborious,and some of them are invasive,affecting patients’ acceptance.Therefore,the aims of our study were as follows:1)A combined,noninvasive examination was designed to evaluate multiple pathophysiological mechanisms of FD(anxiety and depression,gastric accommodation,visceral sensitivity,gastric electrical activity,and autonomic nervous function)at one time.2)The Roman Ⅳ criteria and subgroup analysis were utilized to evaluate the differences in pathophysiological mechanisms among different FD subgroups.Methods 1.From November 2017 to September 2018,a total of 47 healthy controls(HC)and 190 FD patients referred to the Clinical Gastrointestinal Motility Lab at Ningbo Yinzhou People’s Hospital and the Department of gastroenterology at Wuhan First Hospital were recruited into this study(Written consent was obtained).According to FD Roman Ⅳ criteria,the included 190 FD patients were classified into three subgroups: 16 patients with epigastric pain syndrome(EPS),86 patients with postprandial distress syndrome(PDS),86 patients with overlapping symptoms.2.All subjects completed FD symptom score,anxiety and depression score.3.Then,4-channel electrogastrogram(EGG)and HRV were simultaneously recorded for 30 min in fasting state and for 30 min after a nutrient drink(evaluating gastric accommodation).Meanwhile,visceral sensitivity was determined using visual analogue scale(VAS).Results 1.Compared to HC,all three subgroups of patients showed elevated anxiety and depression scores(P<0.01),and there was a significant correlation between the severity of FD symptoms and the anxiety/depression score(r=0.362,P<0.001;r=0.360,P<0.001 respectively)2.FD patients with postprandial distress syndrome(PDS)and overlapping symptoms but not epigastric pain syndrome(EPS)showed reduced most tolerated volume(MTV)in comparison with HC(789.9±189.0,759.4±195.0,826.9±212.3 vs.917.7±191.9;P<0.001,P<0.001,P>0.05 respectively).Overall,the severity of FD symptoms was negatively correlated with MTV(r=-0.251,P<0.001).3.All three sub-groups of FD patients showed an increased fullness score during the 30 min after the nutrient drinking.The severity of FD symptoms was positively correlated with the post-drinking fullness VAS score at 30min(r=0.183,P=0.019).4.Patients with PDS or overlapping symptoms but not EPS showed decreased percentage of gastric slow waves in both fasting and fed states.5.The maximal amount of liquid nutrient intake impairs gastric slow waves in both HC and FD patients(all subgroups),however,the distribution of EGG channels was not consistent.6.Before meals,autonomic functions showed no difference in any subgroup of FD patients in comparison with HC.After meals,the vagal activity of the overlapping group was higher than that of EPS,PDS and HC,while the sympathetic activity was lower.Conclusions: 1.The multiple combined examination of gastric function is simple,non-invasive and highly acceptable.2.This set of tests are able to distinguish different subgroups of FD: PDS and patients with overlapping symptoms(not EPS)have impaired gastric accommodation and gastric slow waves.The autonomic dysfunction due to feeding is only found in FD patients with overlapping symptoms.