Gut, 1970, 11, 688-696
`
`Faecal stasis and diverticular disease in
`ulcerative colitis
`
`K. N. JALAN, R. J. WALKER, R. J. PRESCOTT, S. T. G. BUTTERWORTH,
`A. N. SMITH, AND W. SIRCUS
`From the Gastrointestinal Unit, and the Department of Pathology, Western General Hospital, Edin-
`burgh, and the Computer and Statistics Section, Department of Social Medicine, Univ ersity of Edinburgh
`
`SUMMARY The incidence of faecal stasis and of diverticular disease has been studied in a
`group of 399 patients with ulcerative colitis. Sixty-one patients had faecal stasis and 23 patients
`had diverticular disease. Pathological studies demonstrated an increase in the thickness of
`the inner spiral muscle in colitis patients with faecal stasis. The thickening was not as great
`as that seen in diverticular disease. Preliminary studies on the motility patterns in patients with
`faecal stasis show a higher mean activity in the pelvic colon than in normals but not as great
`as that seen in diverticular disease. Pressure studies in patients with faecal stasis have shown
`hypotonia in the proximal colon associated with dilatation.
`The possible significance of these results is discussed. It is suggested that ulcerative colitis
`may initiate a motility disturbance which leads to muscle thickening similar to that in diverti-
`cular disease. Diverticula associated with ulcerative colitis are usually not involved in the
`mucosal inflammatory process.
`
`It is recognized that constipation may occur
`in patients with proctocolitis (Royal Society of
`Medicine, 1909; Sim and Brooke, 1958; Nefzger
`and Acheson, 1963; Goligher, de Dombal, Watts,
`and Watkinson, 1968), and in up
`to one
`third of patients with proctitis (Lennard-Jones,
`Cooper, Newell, Wilson, and Jones, 1962a).
`Constipation as a prominent disability was
`described in six patients with distal proctocolitis
`all of whom had severe disease with retention of
`faeces in the proximal colon (Lennard-Jones,
`Langman, and Jones, 1962b).
`We have studied this association as part of a
`retrospective survey involving 399 patients with
`ulcerative colitis (Jalan, Prescott, Sircus, Card,
`McManus, Falconer, Small, Smith, and Bruce,
`19o9). In view of the possibility that the cause
`of the constipation could be in disordered motor
`activity of the large bowel, we have examined
`the incidence and possible significance of diverti-
`cular disease when this occurred in association
`with ulcerative colitis. Differences have been
`sought in the clinical and pathological features
`of those colitis patients with constipation, both
`Received for publication 24 December, 1969.
`
`with and without diverticular disease, from those
`of the remainder of the series. Large bowel
`motility was studied in a small number of patients.
`
`Method
`
`The retrospective study covers the period 1950
`to 1967 (inclusive). The primary source of the
`data was the case records, the information being
`transferred to cards and the material analysed
`by Atlas computer.
`The diagnosis of faecal stasis in colitis was
`made when a change of bowel habit occurred
`becoming less frequent than normal and/or
`the need for laxatives. Radiological evidence of
`faeces in the proximal colon was usually obtained.
`Barium often persisted in the right half of the
`colon a week or even a month after a barium
`enema (Figs. 1 and 2). Diverticular disease was
`diagnosed on the presence of one or more diverti-
`cula with or without radiological evidence of
`motor or inflammatory abnormality in the colon.
`In the whole series there were 173 males and 226
`
`MYLAN EXHIBIT - 1049
`Mylan Pharmaceuticals, Inc. v. Bausch Health Ireland, Ltd. - IPR2022-00722
`
`

`

`689
`
`Faecal stasis and diverticular disease in ulcerative colitis
`
`Fig. 1 Barium mass in the ascending colon in a
`patient with faecal stasis one day after barium enema.
`
`Fig. 2 Same patient as in Figure 1. Barium mass
`still present 18 days later.
`
`females. One hundred and ninety-one patients
`were in a first attack of colitis and 208 in relapse.
`
`MOTILITY STUDIES
`Motor activity of the proximal colon was assessed
`in eight patients and four controls using a radio-
`telemetering capsule (Solartron capsule); pressure
`waves were recorded from the frequency change,
``movement activity' from the signal strength,
`and progression from the change in the `edge' of
`the radiomagnetic field (Smith and Ridgway,
`1962).
`Pressure activity in the sigmoid zone and rec-
`tum was examined in five patients with faecal
`stasis, 29 patients with uncomplicated diverticular
`disease, and in 14 control subjects by peranal
`passage of miniature balloons on air-filled poly-
`thene tubes. These were connected by Statham
`to electromanometers within a
`transducers
`photorecording device; basal tone was recorded
`and meals or prostigmine (0.5-1 mg) were used
`as stimuli.
`
`PATHOLOGY
`Histological material from 15 patients with
`faecal stasis was available for study. Studies of
`the colons of 26 patients with ulcerative colitis
`but without faecal stasis served as controls. The
`intact specimens of resected colon were not avail-
`able at the time of this study, but the patho-
`the microscopic
`logists' original reports of
`appearances of these were analysed and considered,
`
`together with a review of the remaining blocks
`and sections from known sites in the colon.
`An eye-piece micrometer was used to measure
`the maximum thickness of the circular muscle
`coat in sections from the descending and sigmoid
`colon.
`
`Results
`
`CLINICAL ASSESSMENT
`
`Incidence
`Faecal stasis was present in 15.8 % of patients
`with ulcerative colitis. In some cases consti-
`pation was the major source of disability and
`such patients correspond to those described by
`Lennard-Jones et al (1962b). Of 79 patients with
`disease confined to the rectum, 21 had stasis.
`This incidence of 26.6 %is similar to that reported
`by Lennard-Jones and his colleagues (1962a) in
`proctitis. It is rare in the young (Fig. 3).
`We also confirmed the commoner incidence
`of faecal stasis in females (Table I). Five out
`of the six cases of stasis described by Lennard-
`Jones et al (1962b) were female.
`
`Previous history
`Twenty per cent of the patients with faecal
`stasis reported constipation before the onset of
`colitis compared with 5.3% of the patients
`without stasis. It is emphasized that a history of
`
`

`

`690
`
`K. N. Jalan, R. J. Walker, R. J. Prescott, S. T. G. Butterworth, A. N. Smith, and W. Sircus
`
`220
`
`200
`
`180
`
`160-
`
`2
`
`80+
`
`60
`
`40
`
`20
`
`Length of History
`(yr)
`
`Faecal Stasis
`
`<1
`1-9
`10+
`
`With
`
`35
`13
`13
`
`Without
`
`159
`123
`56
`
`Table III Length of history in patients with faecal
`stasis'
`
`'x2 = 5-25, df = 2, 0 05 <P <0 .1.
`
`into three grades of severity: mild, moderate, and
`severe (Jalan et al, 1969). The variables used were
`fever, number of bowel movements, and erythro-
`cyte sedimentation rate. A significant relation-
`ship between stasis and severity of disease was
`not established (Table IV). A larger proportion
`
`0 -20
`
`41-60
`21-40
`AGE AT ONSET
`
`I/4
`
`61+
`
`Severity
`
`Faecal Stasis
`
`Fig. 3 Age incidence of faecal stasis (shaded area)
`and diverticular disease (unshaded) associated with
`ulcerative colitis. The total number of patients is
`shown by the black areas.
`
`Mild
`Moderate
`Severe
`
`With
`
`34
`15
`12
`
`Without
`
`156
`83
`109
`
`Table IV Severity of colitis in patients with faecal
`stasis'
`
`Sex
`
`Faecal Stasis
`
`'x' = 3 72, df = 2, 0 10 < P < 0 20.
`
`Male
`Female
`
`With
`
`18
`43
`
`Without
`
`155
`183
`
`Table I Sex incidence in patients with faecal stasis'
`= 4.98, df = 1, 0.025 < P < 0.05.
`
`constipation is subjective. Frequencies shown are
`of visits to the lavatory (Table II). Faeces are not
`always passed on each occasion but often only
`mucus, mucopus, or blood without faeces.
`
`No. of Motions
`
`Faecal Stasis
`
`0-4
`5-8
`9+
`
`With
`
`17
`33
`11
`
`Without'
`
`70
`153
`113
`
`Table II Frequency of bowel motion in patients with
`faecal stasis2
`
`'In two patients bowel frequency was not recorded.
`2x2 = 6-00, df = 2, 0-025 <P <0.05.
`
`Length of history
`Stasis is relatively more common in patients
`with disease of short duration (Table III), and
`incidence is the same in the first attacks as in
`relapses and in colitis of gradual or sudden onset.
`
`Severity, extent, and prognosis
`A scoring procedure was used to classify patients
`
`of patients with faecal stasis had a normal barium
`enema or partial `left-sided' colitis as compared
`with the remaining patients (Table V). Faecal
`stasis was observed in only seven subjects with
`extensive involvement of the colon. Likewise
`the incidence of colonic stricture and of toxic
`
`Extent
`
`Faecal Stasis
`
`Normal
`Partial left'
`Entire
`Not known
`
`With
`
`21
`31
`7
`2
`
`Without
`
`58
`118
`124
`38
`
`Table V Extent of bowel involvement (radiological)
`in patients with faecal stasis2
`
`'Includes 10 patients with right-sided and segmental colitis two
`of which are in the group of patients with faecal stasis.
`'x' = 24.56, df = 3, P = < 0.0005.
`
`dilatation was less than that found in the subjects
`without stasis (Table VI). Not surprisingly, there-
`fore, the outcome in patients with faecal stasis
`is good so that the phenomenon is predominantly
`an expression of the better prognosis of subjects
`with distal involvement regardless of the severity
`of the attack (Table VII). Furthermore a higher
`proportion of patients with stasis show decreasing
`severity with time, and a smaller number exhibit
`continuous disease as compared with the non-
`stasis group.
`
`

`

`691
`
`Faecal stasis and diverticular disease in ulcerative colitis
`
`characteristics in the group of colitics without
`diverticular disease.
`
`PATHOLOGY
`The incidence of pericolitis, submucosal fibrosis,
`and destruction of ganglion cells was the same
`in the two groups of patients with and without
`stasis. As already shown in the clinical assess-
`ment, the proportion of patients with limited or
`distal colitis was much greater in the group of
`patients with faecal stasis and proximal dilata-
`tion of the colon was much commoner. In the
`latter subjects, the mucosa of the proximal colon
`tended to be rather thin, but only in three was
`this a notable feature ( < 0.3 mm); all had
`associated diverticular disease.
`It is of interest that in three patients the
`inflammatory changes of ulcerative colitis were
`slight or absent in the mucosal portion of the
`diverticula (Figs. 4 and 5). Of six patients with
`colitis and with diverticular disease and faecal
`stasis, in only three was the diagnosis of diverti-
`cular disease made by radiology. Only one patient
`had an organic obstruction, a kink in the bowel
`apparently caused by pericolic fibrosis.
`
`. 4s "
`Viro Of
`
`•
`
`• ."
`
`-i:
`4 4° '
`
`) •.* ,
`
`1.1%.-• e,
`- 4L-t's 1-
`I
`
`Faecal Stasis
`
`With
`
`Without
`
`Colonic stricture
`1 V
`No colonic stricture 60
`
`3 1_ 2
`Toxic dilatation
`No toxic dilatation 58
`
`17
`321
`
`52
`286
`
`Table VI Toxic dilatation and colonic
`relation to faecal stasis'
`
`stricture in
`
`> 0 1 (exact test)
`2Xt = 3.93, df = 1, 0.025 < p < 0.05.
`
`Outcome
`
`Faecal Stasis
`
`With
`
`Without
`
`Clinical remission
`Improved
`Surgical survivors'
`Death
`Medical treatment
`After surgery
`Total
`
`53
`3
`5
`
`0
`0
`61
`
`211
`20
`74
`
`16
`17
`338
`
`Table VII Outcome of first referred attack in patients
`with faecal stasis
`
`'All patients undergoing surgery had had previous medical
`treatment.
`
`Twenty-three patients in whom colitis and diverti-
`cular disease coincided were similarly analysed.
`Seven of these had faecal stasis. The incidence
`of faecal stasis in patients with colitis and diverti-
`cular disease is not different from the rest of the
`respect of sex,
`population of colitis. In
`age at onset, previous bowel habit, site of attack,
`onset of colitis, extent of involvement, severity,
`and prognosis, no differences emerge from those
`
`•
`
`•
`
`•
`
`.410.
`•
`lb,
`
`0.
`•
`
`4/ *
`
`-s
`
`so
`
`• re
`
`we
`
`1-7i g. 4
`
`Fig. 5
`Figs. 4 and 5 Diverticulutn (left)Ina case of ulcerative
`colitis. Inflamed mucosa and granulation tissue can be
`seen at the neck, but the inflammation does not extend
`into the compressed diverticular mucosa (x 15,
`haematoxylin and eosin). Magnified (above) view of
`junction of compressed and inflamed areas. (x 75,
`haematoxylin and eosin).
`
`

`

`692
`
`re
`
`re.
`
`M.
`
`.44
`
`K. N. Jalan, R. J. Walker, R. J. Prescott, S. T. G. Butterworth, A. N. Smith, and W. Sircus
`Thickness of muscle layers
`Information on the thickness of the circular
`muscle (Fig. 6) of the colon in colitis patients with
`faecal stasis, in diverticular disease associated
`with faecal stasis, and in two control groups of
`patients with ulcerative colitis without faecal
`stasis and patients with diverticular disease but
`no ulcerative colitis is summarized in Table VIII.
`The last group (diverticular disease) were patients
`operated upon for the disease. No significant
`difference appears in the mean values for cir-
`cular muscle thickness among patients with
`faecal stasis associated with ulcerative colitis
`whether diverticular disease was present or not
`(t = 1.00, 0.3 < P < 0.4) but the patients with
`faecal stasis alone showed a greater variance
`(F = 5.86, 0.01 < P < 0.05). The combined group
`of all patients with faecal stasis in ulcerative
`colitis shows a highly significant increase in
`muscle thickness over the control patients with
`uncomplicated ulcerative colitis. The second
`control group of patients with diverticular disease
`alone show a highly significant increase in
`muscle thickness as compared with that of the
`patients with faecal stasis and colitis. An increased
`variance of muscle thickness was also present
`in this group.
`
`.:•-•-M.V: 4
`
`•1
`
`0:
`
`•
`
`1
`
`MOTILITY
`
`Fig. 6 Descending colon in a case of ulcerative
`colitis and faecal stasis, but without diverticular
`disease, to illustrate the thickness (1.8 mm) of the
`muscular coat (x 40, haematoxylin and eosin).
`
`Group
`
`I (Control) Ulcerative 2 Faecal Stasis with
`Colitis Only
`Ulcerative Colitis'
`
`3 (Control) Diverticular
`Disease Only
`
`15
`
`15
`
`1.63
`0.52
`Group 1 v group 2
`P = 1.69, P > 0.05
`t = 3.07, 0001 < e < 0.005
`
`326
`1.28
`Grow) 3 v grow) 4
`P= 6-11, <0 .01
`4.35, P <0 .001'
`
`t
`
`Table VIII Circular muscle thickness in ulcerative
`colitis in patients with faecal stasis and diverticular
`disease
`
`-
`
`'Including six patients with diverticular disease and faecal stasis.
`Range: 1.1-1.9, msan 1.48, SD 0.26.
`'Welch's modification oft test for different variances applied.
`
`26
`No. of patients
`Muscle thickness (Inn!)
`0.6-2.1
`Range
`1.18
`Mean
`0.40
`SD
`
`Test on variances
`Test on means
`
`Right colon
`Recordings of motility were obtained when the
`capsule reached or was just distal to the ileo-
`caecal junction, which was recognized radiolo-
`gically (Fig. 7), and by the change in the character
`and the frequency of the waves from an ileal
`to a colonic pattern. At the ileocaecal junction
`in normal subjects ileal frequency of waves
`(7-10 per min) falls to the colonic level (2 waves
`per min). In four subjects with faecal stasis
`studied the colonic pressure waves were small
`in three and in the fourth subject were almost
`absent. Fluoroscopic examination of the capsule
`revealed rotational movements but little or no
`pressure change was recorded; records of the
`signal strength showed rapid, irregular falls
`consistent with orientational movements of the
`capsule (Fig. 8). There appeared to be a loss of
`propulsion, with the capsule rotating in the
`faecal stream entering from the terminal ileum.
`In these four cases the capsule took four to five
`days at the minimum to pass this area. (The
`average transit through the right colon in eight
`normal subjects was six and a half hours.)
`In three of the subjects with faecal stasis the
`basal pressure across the ileocaecal junction
`dropped as in normals, but remained lower than
`normal. This contrasted with five patients with
`colitis without faecal stasis who either showed
`patterns similar to those of the normal controls
`or, as in two subjects, revealed a slight rise in
`basal pressures.
`
`

`

`693
`
`Faecal stasis and diverticular disease in ulcerative colitis
`
`• 4 **"
`
`.
`
`MINUTES
`
`50 Cms.H20
`
`Ap
`
`30
`
`10
`
`As
`
`30 Con H2O
`io
`
`AP
`
`As
`
`CRIS H2O
`
`50
`Ap 30
`10
`
`As
`
`\./"
`
`Fig. 7 Telemetering capsule passing from the terminal
`ileum into the caecum faintly outlined by previous
`administration of barium most of which by this
`time had been evacuated.
`
`Left colon
`The mean motility index, defined as the product
`of the mean wave height in millimetres of water
`and the percentage duration of waves occurring
`during the recorded period, was calculated in 14
`control subjects. It was found to be 166 in the
`basal state, 322 for the gastrocolic reflex stimula-
`tion, and 806 after prostigmine injection. In
`five patients with colitis and faecal stasis the mean
`motility index was 204 in the basal state, 668
`after gastrocolic reflex stimulation, and 1,400
`after prostigmine. The mean responses to prostig-
`mine in faecal stasis lay between the values for
`normal subjects given above and for the diverti-
`cular disease cases (prostigmine response = 2,856)
`the
`reported by Attisha and Smith (1969);
`gastrocolic response was much less in both groups
`(mean motility index in faecal stasis 668 and in
`diverticular disease 740).
`
`Discussion
`
`Our findings confirm those of Lennard-Jones
`and his colleagues (1962b). The essential feature
`in these patients is the hold-up of faeces in the
`right half of the colon although all patients pass
`frequent stools consisting in the main of blood
`and mucopus. Plain abdominal films in patients
`in whom the frequency of passage of faeces has
`fallen usually show evidence of stasis in the
`
`Fig. 8 Pressure activity (Pp) and capsule signal
`strength (As) recorded from the right colon. The
`upper set of recordings for pressure and signal
`strength shows little pressure activity and variability
`of the signal strength from which can be deduced
`that there is movement of the capsule. In the subse-
`quent pressure and signal recording underneath
`there is again little pressure change, and at first,
`little alteration in the signal strength, but this later
`becomes irregular showing that there is marked
`capsular positional change. The final set of recordings
`of pressure and signal strength shows a rise in
`basal pressure and marked alteration of signal
`strength indicating rapid movement of the capsule.
`At this point observation by radiological `image-
`intensification' screening showed some movement.
`Marked borborygmi indicated distal small bowel
`activity, and it could be deduced that the capsule
`rotational effects were taking place in the stream
`of chyme being forced to flow into the right colon.
`
`proximal colon. Stasis produces disability deserv-
`ing of treatment in itself. We have found both
`liquid paraffin and oral dioctylsodium sulpha-
`succinate to be helpful.
`In our experience constipation due to stasis
`in proctocolitis is usually a transient affair which
`remits when the inflammation is brought under
`control but tends to recur with each exacerba-
`tion of the disease. In one patient in whom the
`colitis remained active over a long period barium
`was still present in the right half of the colon three
`months after a barium enema.
`The incidence of stasis in our series was
`greatest in patients with limited distal involve-
`ment of the colon. This fits the concept discussed
`by Lennard-Jones et al (1962b) that the cause
`is a functional obstruction to the passage of
`
`

`

`694
`
`K. N. Jalan, R. J. Walker, R. J. Prescott, S. T. G. Butterworth, A. N. Smith, and W. Sircus
`
`PRESSURE
`cm. H2O
`8-
`
`6
`
`4
`
`2
`
`0
`
`o—
`
`—2
`
`X
`
``o,
`
`PASSAGE OF
`ILEOCAECAL VALVE
`
`of diverticular disease to ulcerative colitis could
`explain the constipation or, alternatively, in the
`absence of diverticular disease, it seemed possible
`that ulcerative colitis could bring about a similar
`disordered motility. On this hypothesis muscle
`changes might be expected in colitis, and, similar
`to those seen in early diverticular disease, possibly
`result in the formation of diverticula.
`In the Oxford area the radiological incidence of
`diverticular disease is in the region of 30% in
`subjects over the age of 60 (Manousos, Truelove,
`and Lumsden, 1967) and compares with the 25
`incidence in our patients with ulcerative colitis
`over the age of 60. In the age group 40-59, the
`incidence of diverticular disease in the Oxford
`area was 18.5% compared with 14.3% for our
`ulcerative colitis patients in this age group.
`These figures appear to favour an incidental
`association of the two diseases in our patients
`but there are certain difficulties with this inter-
`pretation. The diagnosis of diverticular disease
`in the presence of ulcerative colitis is not easy
`(Berenbaum, Yaghmai, and Berenbaum, 1965).
`In our six pathological specimens in which the
`2 two diseases coexisted diverticula were demon-
`1
`strated radiologically in only three. It may
`HOURS
`be relevant that before 1958 only one of 103
`of our patients with colitis was recognized to
`have diverticular disease, in the following two
`years nine out of 61 were recognized, and, up to
`the end of the study, 13 out of 235 cases had
`been recognized to have the disease. We feel
`that this is due to more accurate radiological
`diagnosis. The true incidence of diverticular
`disease may be higher than our radiologically
`based overall figure would suggest.
`Although Collins (1961) reported a grave
`prognosis in patients with ulcerative colitis
`complicated by acute diverticulitis, we have not
`encountered this association.
`The pathological study supports the concept
`that a motility disorder similar to that seen in
`diverticular disease accounted for the faecal
`stasis because significant thickening of the inner
`spiral muscle of the colon was demonstrated.
`In diverticular disease this is accompanied by
`marked thickening of the taenia which, it has
`been suggested, causes bunching of the colon
`with an apparent increase in density of all the
`colonic elements (Williams, 1968). In our retro-
`spective study the thickness of the taenia could
`not be measured. Morson (1966) considered the
`characteristic shortening of the bowel in ulcera-
`tive colitis to be due to a muscle abnormality
`and maintains that fibrosis makes little contribu-
`tion to the inflammatory response in colitis. Our
`results confirm the presence of muscle abnormal-
`ity and in only one patient was there a potential
`organic obstruction. The degree of muscle thicken-
`ing in the patients with colitis and faecal stasis
`lay between that in the ordinary oolitic population
`and that found in the group of patients with
`diverticular disease. Functional abnormality of
`
`Fig. 9 The basal pressure has been studied in the
`right colon at the time of a passage of a telemetering
`capsule from the terminal ileum through the ileo-
`caecal valve into the right colon. It was observed
`in four normal subjects (O - - - - O) that the
`pressure falls. This fall was greater in three subjects
`•). In ulcerative
`with faecal stasis (•
`x), the pressure
`colitis, without stasis (x
`varied and either fell as in normals or in two
`instances remained at a high level.
`
`faeces associated with a relatively normal proxi-
`mal colon retaining the capacity to absorb water
`so that hard, scybalous masses are formed. On
`this basis, however, faecal stasis should not occur
`in the presence of extensive involvement of colon
`in which faeces remain liquid. However, in our
`series, seven patients with total involvement of the
`colon had faecal stasis, and examination of the
`specimens resected at operation in six of these
`provided histological confirmation. There was,
`however, a gradient of disease with the most
`severe changes occurring distally.
`The evidence that diverticular disease is based
`(Arfwidsson, 1964;
`on disordered motility
`Painter and Truelove, 1964; Attisha and Smith,
`1969) is convincing. To examine the possibility
`that faecal stasis in colitis had a similar basis,
`we compared patients with diverticular disease
`and those with faecal stasis. Nearly 20% of our
`colitis patients with faecal stasis gave a previous
`history of constipation. Symptoms and signs
`of faecal stasis invariably followed rather than
`preceded each attack of colitis. In some patients,
`the fortuitous addition of the disordered motility
`
`

`

`695
`
`Faecal stasis and diverticular disease in ulcerative colitis
`
`muscle in colitis was suggested by the work of
`Garrett, Sauer, and Moertel (1967), who showed
`significant hyperactivity of the pelvic colon in
`patients with mild or moderate proctocolitis
`after oral administration of 15 minims of tinct.
`opii compared with normal controls.
`Other motility studies have demonstrated
`decreased motor activity in patients with ulcera-
`tive colitis (Spriggs, Code, Bargen, Curtiss, and
`Hightower, 1951; Kern, Almy, Abbot, and
`Bogdonoff, 1951). Kern and his colleagues (1951)
`had shown an inverse relationship between the
`frequency of bowel habit and the total activity
`of the record. Chaudhary and Truelove (1961),
`on the other hand, suggested that the mean
`total activity was greater in patients with severe
`colitis, but Connell (1962), in a discussion of this
`report, pointed out that this was probably a
`false interpretation as the results were signifi-
`cantly affected by one patient with abnormally
`high activity and after excluding this case, the
`mean total activity for the remainder was less
`than normal. There has been great variation in
`the results for individual patients, but in most
`studies there has been no attempt to divide them
`on the basis of bowel frequency, and most of the
`patients studied have had diarrhoea. Kern et al
`(1951) studied the motility of the distal colon
`in non-specific ulcerative colitis, and hyperactive
`records were obtained in four patients, three
`of whom had constipation. Our own finding of
`increased activity, mainly after prostigmine stimu-
`lation in the left colon in ulcerative colitis
`associated with faecal stasis in the right colon,
`is in accord with this, and apparently agrees with
`our pathological study in that the mean total
`activity in the sigmoid colon after cholinergic
`stimulation for these patients fell between that of
`normals and that found in diverticular disease.
`The observation of atony and non-propulsion
`in the proximal colon is in keeping with the
`proximal dilatation observed in resected speci-
`mens and presumably reflects a passive response
`to the distal functional obstruction; the basal
`pressure fell at the ileocaecal junction when a rise
`might have been expected if active obstruction,
`without atony, had been present. The observa-
`tions are taken from patients in whom the orienta-
`tional position of the capsule had not changed
`and in whom the capsule to aerial radio link
`had not varied, as indicated by the stability of
`the strength of the signal received from the capsule.
`An interesting histological finding was that the
`mucosa in many of the diverticula did not share
`in the inflammatory response of the surrounding
`mucosa, but we can offer no explanation for this
`unless disordered motility has some aetiological
`significance in colitis, as diverticula, being largely
`free of muscle, can have little share in the motility
`responses of the rest of the colon.
`Our evidence suggests that when ulcerative
`colitis is associated with faecal stasis a muscular
`abnormality exists which may be indistinguishable
`
`from that seen in prediverticular disease and the
`irritable colon syndrome. It is possible that this
`in some cases leads to the formation of diverti-
`cula but loss of mucosal tissue due to ulceration
`would otherwise limit the process.
`
`We wish to thank Mrs L. Lockerbie and the
`staff of the Computer and Statistics Section of
`the Department of Social Medicine, University
`of Edinburgh, for valuable technical assistance.
`Dr K. N. Jalan was supported for this work
`initially by the Scottish Hospital Endowments
`Research Trust and
`latterly by Pharmacia
`(Great Britain) Ltd during the tenure of a re-
`search fellowship. Dr W. Sircus is an external
`member of the scientific staff of the Medical
`Research Council. Mr A. N. Smith was supported
`by a grant for motility studies by the Scottish
`Hospital Endowments Research Trust. We wish
`to thank Dr Shirley Clarke for assistance with
`the motility studies.
`
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`
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`K. N. Jalan, R. J. Walker, R. J. Prescott, S. T. G. Butterworth, A. N. Smith, and W. Sircus
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`
`The July 1970 issue
`THE JULY 1970 ISSUE CONTAINS THE FOLLOWING PAPERS
`
`Neurological disorders and adult coeliac disease
`JOHN S. MORRIS, A. B. AJDUKIEWICZ, AND A. E.
`READ
`
`The absorption of carbenoxolone administered
`orally as a positioned-release capsule w. E.
`LINDUP, D. V. PARKE, AND D. COLIN-JONES
`
`A controlled trial of glycopyrronium and 1-
`hyoscyamine in the long-term treatment of
`duodenal ulcer MICHAEL D. KAYE, J. RHODES,
`PETER BECK, PETER M. SWEETNAM, G. T. DAVIES,
`AND K. T. EVANS
`
`The effect on jejuna] mucosa of withdrawing and
`adding dietary gluten in cases of idiopathic
`steatorrhoea D. J. POLLOCK, R. E. NAGLE, K. N.
`JEJEEBHOY, AND N. F. COGHILL
`
`Spread of lesions in Crohn's disease of the colon