Colonic Motor Activity and Bowel Function

Gut: first published as 10.1136/gut.9.4.442 on 1 August 1968. Downloaded from Gut, 1968, 9, 442-456 Colonic motor activity and bowel function Part I Normal movement of contents J. A. RITCHIE From the Motility Unit of the Nuffield Department of Clinical Medicine, The Radcliffle Infirmary, Oxford, and the Nuffield Institute for Medical Research, Oxford There have been few detailed accounts of human and descending colon by x-ray cinematography colonic movements since the original radiological during periods of up to two and a half minutes. He observations on animals by Cannon (1901). described the movement of haustral contents as Holzknecht (1909) described as a 'mass peristalsis' being slow, intermittent and circular within the a wave of contraction that moved down a narrowed haustrum, with no sign of directional intention. section of colon from which the interhaustral folds Ritchie, Ardran, and Truelove (1962) observed the had temporarily disappeared. The remains of a secondary contraction of individual haustra in the bismuth meal were propelled in this way in seconds pelvic colon some four to eight seconds after their from the transverse colon to the pelvic colon, leaving distension by injected liquid, and distinguished what the gut empty behind it. Holzknecht saw no other appeared to be longitudinal and circular components changes in the outline of the gut wall and concluded of such contractions. Serial contraction of liquid- that the activity of the normal colon was limited .o and gas-filled haustra produced a segmental propul- such sudden, brief and occasional movements, sive movement away from the site of introduction of occurring perhaps three times in a day. the liquid at widely varying speeds up to 4 in./sec. Schwarz (1911) made repeated tracings of the The mass propulsions originally described by http://gut.bmj.com/ outline of the colon on a fluoroscopic screen after a Holzknecht and by Hertz and Newton seem to have bismuth meal and showed that its haustration was since come to be regarded as identical and, by some slowly changing for much of the time. Haustral observers, as synonymous with peristalsis. However, movements were most common in the proximal half peristalsis is not usually associated with the tubular of the colon, and travelled a little way backwards appearance that precedes mass activity. The classical and forwards along the bowel. description of Bayliss and Starling (1900) makes it Hertz and Newton (1913) described small rapid clear that they regarded peristalsis as essentially a on September 26, 2021 by guest. Protected copyright. movements in the haustra of the caecum and progressive wave of contraction preceded by a wave ascending colon. In addition, they observed a of relaxation. Peristalsis within this strict definition, propulsive movement which, though it also involved though called a 'stripping wave', has recently been ingested bismuth and was associated with a transient described in detail by Williams (1967) as a feature of tubular appearance of the colon, was otherwise the evacuation of barium enemata to which 2% of different from that of Holzknecht. It occurred when Dulcolax had been added. These 'actuated' waves some of the contents of a distended section near the propelled liquid bowel contents at varying speeds hepatic flexure were transported almost instantane- between the slowest visible advance and about 3 in. ously to the splenic flexure without emptying the (8 cm)/sec, and the relaxation ahead of them was original section. Hertz and Newton considered that sufficient to relieve the spastic structures associated such a movement of the contents could only have with diverticulitis. Barclay (1936) expressed the been effected by a uniform circular contraction of the opinion that propulsion at a greater speed than this distended section of colonic wall. Hertz (1909) had was likely to be abnormal. The only peristaltic already noted that colonic contents observed over movement observed by Ritchie et al (1962), which long periods appeared to travel farther during the was probably transporting semisolid bowel contents, dinner hour than during any other four-hour period. travelled at a maximum speed equivalent to less than Barclay (1912) also observed mass movements in 6 in. (15 cm)/min. the human colon, and later (1935) was able to In view of the scarce and sometimes contradictory demonstrate haustral movements in the transverse nature of these observations, a study was made of 442 Gut: first published as 10.1136/gut.9.4.442 on 1 August 1968. Downloaded from Colonic motor activity and bowelfunction 443 the radiological appearances of ingested barium in incidence, and probably the speed, of colonic activity the human colon. It was undertaken in the first place but there was no evidence that they changed its character to examine the character and to establish the in any way. Some of the more extensive movements of colonic contents were relatively uncommon under resting frequency of the movements of normal contents in conditions and, because of superimposition by barium the bowel. In Part II of this study, the distribution of in other sections of gut, were often unsuitable for the different movements within the colon and their reproduction as illustrations. When necessary, the cor- relationship to its function will be examined in more responding movements seen in stimulated patients have detail. been used instead. The illustrations were all taken from different subjects. TECHNIQUE AND APPARATUS INTERPRETATION Each of the 193 subjects examined had been given barium sulphate suspension by mouth and between 12 The displacement of normal colonic contents is unlikely and 24 hours later the colon was observed in the supine to have any other propulsive source than the contractions position to avoid compressing the bowel. The barium of the bowel wall surrounding them. However, it must be was first located briefly by means of television fluoroscopy bome in mind that it is only the barium-impregnated and the subject was positioned to ensure that maximum contents themselves that can be seen with certainty in advantage was taken of the whole field of the 121-inch these fluorographic studies, and that gut movements which Cinelix electron-optical image intensifier. No other are envisaged to explain changes in their outline can only monitoring was attempted; experiment showed that on be deduced. average five seconds of fluoroscopy represented the same exposure to radiation as 13 frames of cinefluorography. RESULTS The 35 mm time-lapse cinefluorography was maintained for one hour at a rate of one frame per minute. In this The normal appearance of the mass of colonic way the almost imperceptible movements of the normal contents at rest varied colon could be accelerated several hundred times. Details widely between those that of the rapid movements involving gas or liquids, as seen were relatively narrow and almost ribbon-like, and in barium enema examinations, tended to become others that were broad and had a deeply indented unrecognizable. However, the transport of gas was outline. In some colons the haustral barium masses outside the scope of this study and even fresh ileal were unconnected by contrast medium. Occasionally contents on entry to the colon were rarely seen to cause a section of six or eight inches of segmented bowel such rapid changes of outline. contents might become smooth-edged one minute http://gut.bmj.com/ Each colon was observed without any subject receiving and then revert to its former haustral pattern, or to a more than 775 R cm2 to an area of about 450 cm2. different one, in the next. Over the whole series, the mean irradiation was less than half this figure, 295 R cm2, a skin exposure of about 075 R. NON-PROPULSIVE SEGMENTAL MOVEMENTS The cine- fluorograms showed that over the period of observ- CLINICAL MATERIAL ation there was almost always movement of some kind somewhere in the colon. Only in one subject on September 26, 2021 by guest. Protected copyright. The subjects included in the present study were con- did the whole bowel appear to remain immobile valescent volunteers from among the ward patients of the throughout the hour, and even then there may have Radcliffe Infirmary, Oxford. They offered to help after been some movement of gas in the intervals between the purpose of the work and the possible dangers of the radiographs. small amount of radiation involved had been fully The commonest explained to them. Their ages ranged from 22 to 87 years movement of colonic contents although, as a general rule, women of childbearing age consisted of a change in the outline of the barium were excluded. Nineteen (10%) of the subjects were mass where some degree ofcontinuity existed between known to have colonic disease. One hundred and one of adjoining segments. These changes were of great the subjects were observed for the whole hour under variety. The simplest took the form of a reduction in resting conditions, 63 were given their ordinary ward the dimensions of the haustral barium mass, chiefly lunch to eat at the start of the period of observation, and affecting its diameter at right angles to the long axis 29 were given an intramuscular injection of 0 25 mg of of the gut, with displacement of a proportion of its carbachol instead. The interval before the earliest barium into neighbouring haustra. Such a change recognizable gastrointestinal response to carbachol, which was usually an increase in ileal outflow, varied sometimes reduced the volume of the mass even to from three minutes to more than 40 minutes (mean 11 complete obliteration in from less than a minute to minutes). In about 10% no ileal response was visible. about five minutes, and lasted for less than a minute Any increase of colonic propulsion that occurred usually or up to half an hour.

Load more