Emmanuel A V, Kamm M A
St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
Gut. 2001 Aug;49(2):214-9. doi: 10.1136/gut.49.2.214.
Although behavioural treatment (biofeedback) successfully treats the pelvic floor abnormalities in patients with idiopathic constipation, many patients also normalise their impaired bowel frequency. We postulated that a response may be associated with altered cerebral outflow via extrinsic autonomic nerves to the gut. We investigated whether treatment changes extrinsic innervation, using mucosal laser Doppler flowmetry, whether autonomic changes are gut specific, and whether it changes gut transit.
Forty nine patients (44 female, mean age 39 years) with idiopathic constipation were studied before and after biofeedback treatment (mean five sessions). Rectal mucosal blood flow was measured by laser Doppler flowmetry to assess direct extrinsic gut nerve autonomic activity. To assess general autonomic activity, RR (interval between successive R waves on the electrocardiogram) variability, Valsalva ratio, orthostatic adjustment ratio, and phase II:IV blood pressure ratio (II:IV) of the Valsalva manoeuvre were measured. All autonomic tests were compared with those of 26 healthy volunteers (19 female, mean age 37 years).
Twenty nine of 49 patients were symptomatically improved. Treatment reduced those with < or =3 bowel actions per week (27 v 9, pre v post), need to strain (26 v 9), and laxative or suppository use (34 v 9). Biofeedback reduced retained markers by 32% in those with slow transit and by 20% in those with normal transit. Twenty two had slow transit before treatment-14 felt symptomatic improvement of whom 13 developed normal transit. There was a significantly greater increase in rectal mucosal blood flow in patients who subjectively improved compared with those who did not (29% v 7%; p<0.03) and in those with improved bowel frequency (33% v 9%, increased v unchanged bowel frequency; p<0.05). Thirty five patients had abnormal RR variability and 33 an abnormal Valsalva ratio; one had an abnormal orthostatic adjustment ratio and one an abnormal II:IV ratio. None of the general cardiorespiratory autonomic reflexes was changed by treatment.
Biofeedback treatment affects more than the pelvic floor. Successful outcome after biofeedback treatment is associated with improved activity of the direct cerebral innervation to the gut and improved gut transit. This effect is gut specific; cardiovascular autonomic reflexes were not altered.
尽管行为治疗（生物反馈）能成功治疗特发性便秘患者的盆底异常，但许多患者受损的排便频率也恢复正常。我们推测，这种反应可能与通过外在自主神经至肠道的脑流出改变有关。我们研究了使用黏膜激光多普勒血流仪治疗是否会改变外在神经支配、自主神经变化是否具有肠道特异性以及是否会改变肠道转运。
对49例（44例女性，平均年龄39岁）特发性便秘患者在生物反馈治疗前后（平均5次治疗）进行研究。通过激光多普勒血流仪测量直肠黏膜血流，以评估直接的外在肠道神经自主神经活动。为评估一般自主神经活动，测量RR（心电图上连续R波之间的间期）变异性、瓦尔萨尔瓦比率、直立位调节比率以及瓦尔萨尔瓦动作的II:IV血压比率（II:IV）。将所有自主神经测试结果与26名健康志愿者（19例女性，平均年龄37岁）的结果进行比较。
49例患者中有29例症状改善。治疗减少了每周排便次数≤3次的患者数量（治疗前27例，治疗后9例）、用力排便的需求（治疗前26例，治疗后9例）以及泻药或栓剂的使用（治疗前34例，治疗后9例）。生物反馈使慢传输型患者的潴留标志物减少32%，正常传输型患者减少20%。治疗前22例为慢传输型，其中14例感觉症状改善，13例排便变为正常。主观改善的患者与未改善的患者相比，直肠黏膜血流增加显著更多（29%对7%；p<0.03），排便频率改善的患者与排便频率未改变的患者相比也是如此（33%对9%，排便频率增加对未改变；p<0.05）。35例患者RR变异性异常，33例瓦尔萨尔瓦比率异常；1例直立位调节比率异常，1例II:IV比率异常。治疗未改变任何一般心肺自主神经反射。
生物反馈治疗的影响不止于盆底。生物反馈治疗成功的结果与至肠道的直接脑支配活动改善及肠道转运改善相关。这种效应具有肠道特异性；心血管自主神经反射未改变。
