Ableton Forum

Ableton Live is a loop-based software music sequencer and DAW for Mac OS and Windows by Ableton. The latest major release of Live, Version 8, was released in April 2009. In contrast to many other software sequencers, Live is designed to be an instrument for live performances as well as a tool for composing and arranging. It is also used for mixing of tracks by DJs, as it offers a suite of controls for beatmatching, crossfading, and other effects used by turntablists, and was one of the first music applications to automatically beat match songs. It does not support traditional musical notation.[1] Rob Jones produced a new set of training courses for Ableton Live in 2010 Ableton Courses website
Contents [hide]
1 History
2 Features
2.1 Views
2.2 Instruments
2.2.1 Built-In
2.3 Dedicated Hardware Instruments
2.3.1 Add-On
2.4 Effects
2.5 Working with audio clips
2.6 Envelopes
3 Versions
3.1 Live Intro and Live LE
3.2 Live 8
4 See also
5 References
6 External links
[edit]History

Ableton Live is written in C++, with the first version released in 2001 as commercial software. Contrary to popular belief, Live was not prototyped in Max/MSP, although it was used to model some of the audio devices. The German Company "Ableton AG" is run by Gerhard Behles (CEO), formerly a member of Monolake, and Bernd Roggendorf (CTO), its original founders, and Jan Bohl (COO/CFO). [2]
Artists who use Ableton Live in the creation of their music include Spinundrum, Monolake, Roberto Paci Dalò, Moguai, Coldcut, Daft Punk, Dirty Vegas, Nine Inch Nails, Scanner, Meat Beat Manifesto, Farben, Akufen, Jan Jelinek, El-P, Telefon Tel Aviv, Steve Stoll, Rennie Pilgrem, The Dust Brothers, Armin van Buuren, Richard Devine, Richie Hawtin, Sasha, Pete Tong, Dj Sasha, DJ Hyper, Robert Henke, Evil Nine, Surgeon, Debasser, Vernon Reid, Eivind Aarset, Fussible, Sound Tribe Sector 9, Praful, Matthew Dear, Gabriel & Dresden, Jeff Rona, Charlie Clouser, Darren Price, Tom Salta, Brazilian Girls, Wakal, Carmen Rizzo, Shinichi Osawa, Vate, Vakero, Kid Beyond, avi bortnick, DJ Cutlass Supreme, Sabrepulse, Balkan Beat Box, Went, Berliner Ensemble, Gaiser, Ambor Grieko, Billy Bush, Adrian Carter, KraftiM, Jerome and Sylvie, Macadamia, Kilvo, Blockhead , Felixdroid, Avell, le visage, Electromagnetic Impulses, Latent Image, Solid Electro, ongoingprocess, DJ Krush, DJ DIABETES, and Deadmau5.
Major Releases
Version Date
Live 1 30 Oct 2001 [3]
Live 1.5 28 Apr 2002 [4]
Live 2 22 Dec 2002 [5]
Live 2.1 24 Jul 2003 [6]
Live 3 10 Oct 2003 [7]
Live 4 28 Jul 2004 [8]
Live 5 24 Jul 2005 [9]
Live 5.2 10 Apr 2006 [10]
Live 6 29 Sep 2006 [11]
Live 7 29 Nov 2007 [12]
Live 8 02 Apr 2009 [13]
[edit]Features

Much of Live's interface comes from being designed for use in live performance as well as for production.[14] As such the interface is more compact than most sequencers and clearly designed for use on a single screen. There are few pop up messages or dialogs. Portions of the interface are hidden and shown based on arrows which may be clicked to show or hide a certain segment (e.g. to hide the instrument/effect list or to show or hide the help box).
[edit]Views
Live is composed of two 'views' – the arrangement view and the session view. The session view is primarily used to organize and trigger sets of MIDI and audio called clips. These clips can be arranged into scenes which can then be triggered as a unit. For instance a drum, bass and guitar track might comprise a single scene. When moving on to the next scene, which may feature a synth bassline, the artist will trigger the scene, activating the clips for that scene. As of Live 6, "device racks" have been implemented which allow the user to easily group instruments and effects, as well as map their controls to a set of 'macro' controls.
The other view is the arrangement view, which is used for recording tracks from the session view and further manipulating their arrangement and effects. It is also used for manual MIDI sequencing, something for which a classical composer would have a greater affinity. This view is fairly similar to a traditional software sequencer interface.
Clips may either be an audio sample or MIDI sequence. MIDI triggers notes on Live's built in instruments, as well as third party VST instruments or external hardware.
[edit]Instruments
[edit]Built-In
By default, Live comes with two instruments – Impulse and Simpler.
Impulse is a traditional drum triggering instrument which allows the user to define a kit of up to eight drum sounds, each based on a single sample. There are a number of effects available such as basic equalization, attack, decay, pitch shift, etc. Once the kit is defined, rhythms and beats are created through Live's MIDI sequencer.
Simpler is a relatively easy-to-use sampling instrument. It works using a single sample, applying some simple effects, envelopes, and timing, and then applying pitch transformations. In this case, incoming MIDI does not trigger drums as it does in Impulse, but selects the final pitch of the sample, with C3 playing the sample at its original pitch.

[edit]Dedicated Hardware Instruments
Akai Professional announced the release of the APC40, a MIDI controller dedicated to work solely with Ableton. The APC20 was also just released and will be coming out in 2010. Though there are hundreds of MIDI controllers compatible with Ableton, these designed by Akai are meant to take the virtual interface and give it a hardware face for an easier and more fluid workflow. Novation Digital Music Systems created the "Launchpad" which is a also a pad device that has been designed for use only with Ableton.
[edit]Add-On
There are a number of additional instruments which may be purchased separately or as part of the Ableton Suite. [15]
Sampler is an enhanced sampler.
Operator is an FM synthesizer.
Electric is an electric piano instrument.
Tension is a string physical modelling synthesizer.
Collision is a mallet percussion physical modelling synthesizer.
Analog simulates an analog synthesizer.
Drum Machines is a collection of emulators for classic drum machines.
Session Drums is a collection of sampled drum kits.
Latin Percussion is a collection of sampled latin percussion hits and loops.
Essential Instruments Collection is a large collection of acoustic and electric instrument samples.
Orchestral Instrument Collection is a collection of four different orchestral libraries, which can be purchased individually or as a bundle. They are as follows: Orchestral Strings, Orchestral Brass, Orchestral Woodwinds and Orchestral Percussion. The Orchestral Instrument Collection is not included in Live Suite.
[edit]Effects
Most of Live's effects are already common effects in the digital signal processing world which have been adapted to fit Live's interface. They are, however, tailored to suit Live's target audience – electronic musicians and DJs – and would not typically be used for other recording tasks such as post-processing a guitar rig. [citation needed]
Audio Effects MIDI Effects
Auto Filter
Auto Pan
Beat Repeat
Chorus
Compressor
Corpus
Dynamic Tube
EQ Eight
EQ Three
Erosion
Filter Delay
Flanger
Frequency Shifter
Gate
Grain Delay
Limiter
Looper
Multiband Dynamics
Overdrive
Phaser
Ping Pong Delay
Redux
Resonators
Reverb
Saturator
Simple Delay
Spectrum
Utility
Vinyl Distortion
Vocoder
Arpeggiator
Chord
Note Length
Pitch
Random
Scale
Velocity
Live is also able to host VST plugins and, on the Macintosh version, Audio Unit plug-ins.
[edit]Working with audio clips


Sasha performing using Ableton Live.
In addition to the instruments mentioned above, Live can work with samples. Live attempts to do beat analysis of the samples to find their meter, number of bars and the number of beats per minute. This makes it possible for Live to shift these samples to fit into loops that are tied into the piece's global tempo.
Additionally Live's Time Warp feature can be used to either correct or adjust beat positions in the sample. By setting warp markers to a specific point in the sample, arbitrary points in the sample can be pegged to positions in the measure. For instance a drum beat that fell 250 ms after the midpoint in measure may be adjusted so that it will be played back precisely at the midpoint.
Some artists and online stores, such as The Covert Operators and Puremagnetik, now make available sample packs that are pre-adjusted, with tempo information and warp markers added. The audio files are accompanied with an "analysis file" in Live's native format.[16] [17]
[edit]Envelopes
Almost all of the parameters in Live can be automated by envelopes which may be drawn either on clips, in which case they will be used in every performance of that clip, or on the entire arrangement. The most obvious examples are volume or track panning, but envelopes are also used in Live to control parameters such as the root note of a resonator or, more commonly, a filter's cutoff frequency. Clip envelopes may also be mapped to MIDI controls.
[edit]Versions

[edit]Live Intro and Live LE
As of version 6, Ableton also offers a stripped-down version of Live targeted at the non-professional market. It has limitations on the number of audio channels and effects and does not feature some of the synchronization (MIDI Clock, ReWire) utilities the full version has to offer. The current Live LE version is 7.0.18.[18]
Part of the Able10 celebrations, Ableton introduced Live Intro. That and Ableton Live Lite effectively have replaced LE. Registered users of Live LE can now receive a free upgrade to Live Intro.[19] The current version is 8.0.9.
[edit]Live 8
On January 17, 2009, Ableton announced version 8 of Live. Live 8 includes a wealth of new features, including an integrated Max/MSP platform, internet collaboration features, and many new effects and workflow enhancements, as well as a refined piracy protection system. Also announced was a dedicated hardware controller developed in collaboration with Akai, called the APC40. Live 8 was released on April 2nd of 2009[20]. Max for Live was released on November 23rd of 2009[21].
[edit]See also

Music portal
Category:Ableton Live users
Pro Tools
FL Studio
Reason
Renoise
Steinberg Cubase
REAPER
Mainstage
[edit]References

^ "Ableton - Ableton Live 7".
^ http://www.ableton.com/forum/viewtopic. ... 887#280887 Live prototyping explained by Live co-creator Robert Henke
^ http://news.harmony-central.com/Product ... Ships.html
^ http://news.harmony-central.com/Product ... ve-15.html
^ http://news.harmony-central.com/Product ... -Card.html
^ http://news.harmony-central.com/Product ... eased.html
^ http://aes.harmony-central.com/115AES/a ... eased.html
^ http://namm.harmony-central.com/SNAMM04 ... Ships.html
^ http://namm.harmony-central.com/SNAMM05 ... eased.html
^ http://news.harmony-central.com/Product ... e-5.2.html
^ http://news.harmony-central.com/Product ... Ships.html
^ http://news.harmony-central.com/Product ... ments.html
^ http://news.harmony-central.com/Product ... nd-Suite-8
^ Tusa, Scott. "Getting Started with Ableton Live". O'Reilly Digital Media. Retrieved 2009-04-19. "This user-friendly program was designed for live performances by musicians who wanted to use the recording studio like a musical instrument. As performers and recording engineers, they felt stymied by the non-real-time nature of typical audio programs, so they wrote their own."
^ Ableton - Ableton Suite
^ "The Covert Operators - Ableton Live Packs". Retrieved 2008-12-17.
^ "Puremagnetik". Retrieved 2008-12-17.
^ Ableton - Live 7 LE Features
^ [1]
^ http://www.ableton.com/live-8-whats-new Ableton - Live 8 - What's New
^ http://www.ableton.com/maxforlive Max for Live
[edit]External links

Ableton's Official Website
Lastfm Website
Ableton Live Training website
Categories: Ableton Live | Digital audio workstation software | C++ software | Mac OS X music creation software | Mac OS X software | Music software | Windows software

tldr

#1
Set the two bed rails down on the part of the floor where you want the bed to go.

#2
If your metal frame has headboard brackets, connect them to the top end of each bed rail using bolts or screws.

#3
Lock the cross arms together or attach the cross rails using bolts or screws. There should usually be at least three cross rails: one at either end (forming the frame) and a third in the center (to stabilize the assembly). If your metal bed frame involves cross wires, pull them diagonally across the space between the two bed rails and affix them to their appropriate slots. Test the bed's sturdiness by stressing the points where the cross rails meet the bed rails. Lock in place, and check for bending or wriggling.

#4
Measure the frame with a tape measure to make sure the mattress will fit comfortably inside the rails. If the measurements are off, this is the time to make corrections.

#5
Snap the casters, wheels or glides into their appropriate brackets. The specifics will vary depending on the particular type of bed you have, but they all should be securely locked to the brackets.

#6
Secure the brackets to the four ends of the bed rails using bolts or screws. Test them by placing stress on the contact points, to ensure they will support the weight of the mattress.

#7
Attach the headboard to the headboard brackets, if appropriate.

#8
Place the end caps on the ends of the bed rails. They will keep the sheets from snagging on the metal.

#9
Place the mattress on top of the assembled frame.

The history of the potato has its roots in the windswept Andes Mountains of South America. It is an austere region plagued by fluctuating temperatures and poor soil conditions. Yet the tough and durable potato evolved in its thin air (elevations up to 15,000 feet), climbing ever higher like the people who first settled the region.

The tough pre-Columbian farmers first discovered and cultivated the potato some 7,000 years ago. They were impressed by its ruggedness, storage quality and its nutritional value. Western man did not come in contact with the potato until as late as 1537 when the Conquistadors tramped through Peru. And it was even later, about 1570, that the first potato made its way across the Atlantic to make a start on the continent of Europe.

Though the tuber was productive and hardy, the Spanish put it to very limited use. In the Spanish Colonies potatoes were considered food for the underclasses; when brought to the Old World they would be used primarily to feed hospital inmates.

It would take three decades for the potato to spread to the rest of Europe. Even so the potato was cultivated primarily as a curiosity by amateur botanists. Resistance was due to ingrained eating habits, the tuber's reputation as a food for the underpriveleged and perhaps most importantly its relationship to poisonous plants.

The potato is a member of the nightshade family and its leaves are, indeed, poisonous. A potato left too long in the light will begin to turn green. The green skin contains a substance called solanine which can cause the potato to taste bitter and even cause illness in humans. Such drawbacks were understood in Europe, but the advantages, generally, were not.

Europe would wait until the 1780's before the potato gained prominence anywhere. About 1780 the people of Ireland adopted the rugged food crop. The primary reason for its acceptance in Ireland was its ability to produce abundant, nutritious food. Unlike any other major crop, potatoes contain most of the vitamins needed for sustenance. Perhaps more importantly, potatoes can provide this sustenance to nearly 10 people on an acre of land. This would be one of the prime factors causing a population explosion in the early 1800s. Of course, by the mid-1800's the Irish would become so dependent upon this crop that its failure would provoke a famine.

While in Ireland the potato gained acceptance from the bottom up, in France the potato was imposed upon society by an intellectual. Antoine Augustine Parmentier saw that the nutritional benefits of the crop combined with its productive capacity could be a boon to the French farmer. He was a pharmacist, chemist and employee of Louis XV. Parmentier discovered the benefits of the potato while held prisoner by the Prussians during the Seven Years War. He was so enamored by the potato that he determined that it should become a staple of the French diet. After failing by conventional means to convince Frenchmen of its advantages, he determined upon a surreptitious means of making his point.

Parmentier acquired a miserable and unproductive spot of ground on the outskirts of Paris. There, he planted 50 acres of potatoes. During the day, he set a guard over it. This drew considerable attention in the neighborhood. In the evening the guard was relaxed and the locals came to see what all the fuss was about. Believing this plant must be valuable, many peasants "acquired" some of the potatoes from the plot, and soon were growing the root in their own garden plots. Their resistance was overcome by their curiosity and desire to better their lot with the obviously valuable new produce.

Soon the potato would gain wide acceptance across Europe and eventually make its way back over the Atlantic to North America. As time passed, the potato would become one of the major food stuffs of the world. But not without a few bumps in the road. The 1840's saw disastrous potato blight. This terrible disease was caused by a fungus known as Phytophthora infestans. With the devastation of potato crops throughout Europe came the destruction and dislocation of many of the populations that had become dependent upon it. The Potato Famine in Ireland would cut the population by half (through both starvation and emigration). An effective fungicide was not found until 1883 by the French botanist, Alexandre Millardet.

Today, the potato is so common, plentiful and pervasive in the Western diet that it is taken for granted. We forget that it has only been with us for a few hundred years. For a new appreciation of the potato, check out our sections on its cultivation and preparation.

The toilet is of the standard zero-gravity type. Depending on requirements, System A and/or System B can be used, details of which are clearly marked in the toilet compartment. When operating System A, depress lever and a plastic dalkron eliminator will be dispensed through the slot immediately underneath. When you have fastened the adhesive lip, attach connection marked by the large "X" outlet hose. Twist the silver coloured ring one inch below the connection point until you feel it lock.

The toilet is now ready for use. The Sonovac cleanser is activated by the small switch on the lip. When securing, twist the ring back to its initial-condition, so that the two orange line meet. Disconnect. Place the dalkron eliminator in the vacuum receptacle to the rear. Activate by pressing the blue button.

The controls for System B are located on the opposite wall. The red release switch places the uroliminator into position; it can be adjusted manually up or down by pressing the blue manual release button. The opening is self adjusting. To secure after use, press the green button which simultaneously activates the evaporator and returns the uroliminator to its storage position.

You may leave the lavatory if the green exit light is on over the door. If the red light is illuminated, one of the lavatory facilities is not properly secured. Press the "Stewardess" call button on the right of the door. She will secure all facilities from her controll panel outside. When gren exit light goes on you may open the door and leave. Please close the door behind you.

To use the Sonoshower, first undress and place all your clothes in the clothes rack. Put on the velcro slippers located in the cabinet immediately below. Enter the shower. On the control panel to your upper right upon entering you will see a "Shower seal" button. Press to activate. A green light will then be illuminated immediately below. On the intensity knob select the desired setting. Now depress the Sonovac activation lever. Bathe normally.

The Sonovac will automatically go off after three minutes unless you activate the "Manual off" over-ride switch by flipping it up. When you are ready to leave, press the blue "Shower seal" release button. The door will open and you may leave. Please remove the velcro slippers and place them in their container.

If the red light above this panel is on, the toilet is in use. When the green light is illuminated you may enter. However, you must carefully follow all instructions when using the facilities duting coasting (Zero G) flight. Inside there are three facilities: (1) the Sonowasher, (2) the Sonoshower, (3) the toilet. All three are designed to be used under weightless conditions. Please observe the sequence of operations for each individual facility.

Two modes for Sonowashing your face and hands are available, the "moist-towel" mode and the "Sonovac" ultrasonic cleaner mode. You may select either mode by moving the appropriate lever to the "Activate" position.

If you choose the "moist-towel" mode, depress the indicated yellow button and withdraw item. When you have finished, discard the towel in the vacuum dispenser, holding the indicated lever in the "active" position until the green light goes on...showing that the rollers have passed the towel completely into the dispenser. If you desire an additional towel, press the yellow button and repeat the cycle.

If you prefer the "Sonovac" ultrasonic cleaning mode, press the indicated blue button. When the twin panels open, pull forward by rings A & B. For cleaning the hands, use in this position. Set the timer to positions 10, 20, 30 or 40...indicative of the number of seconds required. The knob to the left, just below the blue light, has three settings, low, medium or high. For normal use, the medium setting is suggested.

After these settings have been made, you can activate the device by switching to the "ON" position the clearly marked red switch. If during the washing operation, you wish to change the settings, place the "manual off" over-ride switch in the "OFF" position. you may now make the change and repeat the cycle.

Anal warts, also known as condyloma, are growths found on the skin around the anus (rectal opening), in the anal canal, or in the lower rectum.

Back to Top

What Causes Anal Warts?

Anal warts are caused by the human papilloma virus, which is usually transmitted through sexual contact but not necessarily through anal intercourse. The same type of warts may occur on the penis, scrotum, vagina or labia. The time from exposure to the virus and growth of the warts is commonly from one to six months, but it can be longer. During that time the virus remains in the tissues but is inactive. There are many types of human papilloma virus; some cause warts on the hands and feet and others cause genital and anal warts.

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What are the Symptoms of Anal Warts?

Many patients with anal warts have no symptoms. Some patients may notice small growths in the anal area. Others have minor complaints of itching, occasional bleeding, or moisture in the anal area.

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How are Anal Warts Diagnosed?

Diagnosis is made by the doctor, who inspects the skin around the anus and checks the anal canal with an anoscope (a short instrument inserted into the anus).

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How are Anal Warts Treated?

There are several ways anal warts can be treated, depending on the location, number, and size of the warts. If the warts are small, they can be treated with podophyllin or bichloracetic acid, which are solutions applied directly to the warts intended to cause exfoliation of the warts. This is an office procedure that takes just a few minutes. Another form of treatment is cauterization. The area is numbed with local anesthesia before the warts are burned off. If there are numerous warts, the doctor may choose to remove them surgically. This is done as a same-day procedure in a hospital or day surgery center.

Back to Top

Will a Single Treatment Cure Anal Warts?

In most cases, a single treatment will not cure anal warts. Close follow-up is critical because the virus may continue to be present and cause new anal warts to form. Even after there are no visible warts, the virus may remain in the tissue. Small warts that reappear are easily treated in the office. Follow-up visits are necessary even after there are no visible warts. Visits may be necessary for up to six months. There is a possibility of serious problems if the warts are left untreated. On rare occasions, these warts can become cancerous, so it is important to keep the follow-up appointments the doctor suggests.

How Can the Spread of Anal Warts be Prevented? There are several ways to prevent this virus from spreading:

Sexual partners should be checked.
Refrain from sexual activity until treatment is completed.
Use condoms. They offer some, but not complete, protection. Because anal warts are highly contagious, you will lessen your chance of recurrence if these suggestions are followed.

You put your right foot in,
You put your right foot out,
You put your right foot in
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your left foot in,
You put your left foot out,
You put your left foot in,
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your right hand in,
You put your right hand out,
You put your right hand in
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your left hand in,
You put your left hand out,
You put your left hand in,
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your right shoulder in,
You put your right shoulder out,
You put your right shoulder in,
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your left shoulder in,
You put your left shoulder out,
You put your left shoulder in,
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your right hip in,
You put your right hip out,
You put your right hip in
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your left hip in,
You put your left hip out,
You put your left hip in,
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

You put your whole self in,
You put your whole self out,
You put your whole self in
And you shake it all about.
You do the Hokey Pokey
And you turn yourself around,
That's what it's all about.

Rectal Prolapse
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Rectal prolapse is the protrusion of either the rectal mucosa or the entire wall of the rectum. Partial prolapse involves only the mucosa and usually only protrudes by a few centimetres. Complete prolapse involves all layers of the rectal wall.

* May occur with bowel movements or independently. In the elderly, rectal prolapse initially only occurs with defaecation and then retracts spontaneously.
* Later may occur merely on standing thus interfering with patient's quality of life.1

Epidemiology

* Uncommon, but the true incidence is unknown because of under-reporting, especially in the elderly population.
* Mainly occurs in the elderly and in young children.
* Complete prolapse in adults is most common in elderly females.2
* In children, rectal prolapse occurs most often in patients younger than 3 years, and especially in the first year of life.2

Risk factors2

* Increased intra-abdominal pressure, e.g. constipation, diarrhoea, benign prostatic hypertrophy, pregnancy, severe or chronic cough (e.g. chronic obstructive pulmonary disease, cystic fibrosis, whooping cough)
* Previous surgery
* Pelvic floor dysfunction
* Parasitic infections, e.g. amoebiasis, schistosomiasis
* Neurological disease, e.g. previous lower back or pelvic trauma, lumbar disc disease, cauda equina syndrome, spinal tumours, multiple sclerosis
* Psychiatric disease

In children rectal prolapse may be associated with cystic fibrosis, Ehlers-Danlos syndrome, Hirschsprung's disease, congenital megacolon, malnutrition and polyps.
Presentation

* Mass protruding through the anus:
o Initially only after a bowel movement and usually retracts when the patient stands up.
o Later the mass protrudes more often, especially with straining and Valsalva manoeuvres such as sneezing or coughing.
o Finally, the rectum prolapses with daily activities such as walking and may progress to continual prolapse.
o Patients may have to manually replace it.
* Pain, constipation, faecal incontinence, mucus discharge or rectal bleeding may occur.
* If seen on examination, the protruding mass should show concentric rings of mucosa, which are classic signs of rectal prolapse.
Examination may also reveal a rectal ulcer and decreased anal sphincter tone.

Differential diagnosis

* Rectal prolapse must be differentiated from prolapse of an intussusception or a rectal polyp.
* Can usually differentiate a rectal prolapse from a haemorrhoid by the presence of symmetrical circumferential folds occurring with a rectal prolapse.

Investigations

* Barium enema: Evaluate the entire colon prior to surgery for rectal prolapse to exclude any other colonic lesions that should be simultaneously addressed. Evaluation can be accomplished by colonoscopy or barium enema. Barium enema is a better indicator of the redundancy of the colon.
* Other investigations to assess underlying conditions include stool microscopy and cultures for gastrointestinal infection and sweat test for cystic fibrosis.
* In cases of small prolapse, it is sometimes difficult to distinguish between mucosal and full-thickness rectal prolapse. If these cannot be clinically distinguished, a defaecogram may be of help in differentiating these two conditions.
* A defaecogram is unnecessary in the presence of an obvious rectal prolapse.
* Anal rectal manometry is sometimes used to evaluate the anal sphincter muscles. In almost all patients, the results show a decrease in resting pressure in the internal sphincter and an absence of the anorectal inhibitory reflex. The significance of these results is unclear, and most surgeons do not use this test.
* Rigid proctosigmoidoscopy should be performed to assess the rectum for additional lesions, especially solitary rectal ulcers. These ulcers are present in about 10-25% of patients with either internal or full-thickness prolapse.

Associated diseases

* Affected adult women may also have uterine or bladder prolapse, or an associated cystocoele.

Management

* Rectal prolapse can usually be reduced with gentle digital pressure. Sedation and local perianal anaesthesia may help the reduction.
* Contributing factors, such as constipation and diarrhoea, should be treated.
* Prompt surgical referral is recommended for an irreducible prolapse and for strangulation or gangrene of the prolapsed tissue.2
* Partial prolapse often responds to conservative measures but occasionally requires excision of prolapsed mucosa.
* Emergency rectosigmoidectomy is required if the prolapsed tissue is incarcerated and found to be non-viable.2
* If occurs on standing or incontinence develops, most common surgical repair is Delorne's operation which involves excision of the rectum and sigmoid colon via the perineum together with anastomosis of the colon to the anus.3 Altemeier's procedure is an alternative perineal procedure popular in the USA.4
* Two abdominal operations are suture fixation rectopexy and resection rectopexy. In these the rectum is mobilised and the mesorectum sutured to the sacral promontory and the presacral fascia. In resection rectopexy, a sigmoid colectomy is also performed. Laparoscopic repair is currently under study.5

Non-drug

* Children: gently replace using water-soluble lubricant. Advise parents on need for high fibre diet and inadvisability of straining on stool. A mild laxative may be required, and very occasionally a submucosal injection of a sclerosant.
* Elderly: often well tolerated and concealed with patient manually reducing prolapse. In those unfit for surgery, a subcutaneous circumanal rubber ring may be fitted. However, this often fails either because it is too tight or too loose resulting in constipation or recurrent prolapse.

Surgical6

* Abdominal procedures: usually performed in younger, healthier patients whose life expectancy is longer:
o Anterior resection (not often performed):
+ Patients with rectal prolapse and constipation often have a redundant colon, and resection of it is thought to improve constipation and cure rectal prolapse.
+ The rectum is mobilised to the level of the lateral ligaments, and the redundant sigmoid colon is resected.
+ The left colon is then anastomosed to the top of the rectum so that the rectum is held in place and can no longer prolapse.
o Marlex rectopexy (Ripstein procedure):
+ The entire rectum is mobilised.
+ A non-absorbable material, e.g. Marlex mesh or an Ivalon sponge, is then fixed to the presacral fascia.
+ The rectum is then placed on tension and the material is partially wrapped around the rectum to keep it in position.
+ The anterior wall of the rectum is not covered with the sponge or mesh in order to prevent a circumferential obstruction.
+ The Marlex mesh or sponge causes an inflammatory reaction that scars and fixes the rectum into place.
+ This procedure should not be performed on patients who have a large component of constipation or a very redundant sigmoid colon because the symptoms are likely to worsen.
o Suture rectopexy:
+ Essentially the same as a Marlex rectopexy except that the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge.
o Resection rectopexy (Frykman Goldberg procedure):
+ Is a combination of the anterior resection and the Marlex rectopexy and is a good option for patients with a significant component of constipation.
+ The rectum is completely mobilised.
+ The redundant sigmoid colon is then resected and the remaining colon is anastomosed to the top of the rectum.
+ The lateral ligaments or the rectal fascia are then sutured to the presacral fascia with the rectum on tension, which keeps the rectum in place and prevents further rectal prolapse.
+ The rectopexy is accomplished with suture instead of non-absorbable mesh because the bowel is opened for the anastomosis and the mesh may become contaminated.
* Perineal procedures; have a higher recurrence rate but a lower morbidity rate and are often performed in the elderly or in patients who have a contraindication to general anaesthetic:
o Anal encirclement (Thiersch wire):
+ A non-absorbable band is placed subcutaneously around the anus. The purpose of this procedure is to keep the rectum from prolapsing by restricting the size of the anal lumen.
+ The therapy is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder.
+ Complications from the procedure include obstruction with faecal impaction and erosion of the material leading to infection.
+ This procedure is no longer commonly performed and is usually reserved for patients with the highest surgical risks.
o Delorme mucosal sleeve resection:
+ A circumferential incision is made through the mucosa of the prolapsed rectum near the dentate line.
+ Using electrocautery, the mucosa is stripped from the rectum to the apex of the prolapse and excised.
+ The denuded prolapsed muscle is then pleated with a suture. The transected edges of the mucosa are then sutured together.
+ This procedure is often used for small prolapses but may also be used for large ones.
o Altemeier perineal rectosigmoidectomy:
+ A full-thickness circumferential incision is made in the prolapsed rectum at about 1-2 cm from the dentate line.
+ The hernia sac is then entered, and the prolapse is delivered.
+ The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down.
+ The bowel is transected and hand sewn to the distal anal canal or stapled using a stapler.
+ Plication of the levator ani muscles anteriorly may help improve continence.
* Surgery for mucosal prolapse:
o Mucosal prolapse is treated with a haemorrhoidectomy.

Surgical treatment for children7

* Surgical intervention is usually reserved for failed conservative management in children younger than 4 years who have tried non-surgical management for longer than 1 year.
* Surgery may also be used in cases of complicated rectal prolapse, e.g. recurrent rectal prolapse that requires manual reduction, painful prolapse, ulceration, and rectal bleeding.
* There are many different operations used, including:
o Circumferential injection procedures (90-100% success rate); injection procedures use a sclerosant to promote adhesion formation, which stabilises the rectum.
o Thiersch operation (90% success rate); synthetic materials are used to create a perianal sling to support the rectum.
o Lockhart-Mummery operation (approximately 100% success rate); mesh gauze packing is placed temporarily in the retrorectal space to promote adhesions that stabilise the rectum.
o Cauterisation treatment (approximately 80% success rate); the prolapsed rectum is cauterised to produce inflammation and scarring that prevents prolapse.
o Abdominal rectopexy (75% success rate); endoscopic or open approach. The perirectal tissues are attached to the presacral area to assure correct anatomical positioning and tissue adherence.
o Ekehorn rectopexy (100% success rate); a suture is placed in the rectal ampulla through the lowest part of the sacrum to induce inflammation and adhesions between the rectal wall and perirectal wall.

Complications2

* Mucosal ulceration.
* Necrosis of rectal wall.
* The most common postoperative complications are bleeding and dehiscence at the anastomosis.
* Postoperative recurrence rate can be as high as 15%, regardless of operative procedure.

Prognosis

* The prognosis for elderly patients presenting with rectal prolapse is variable and depends on the nature of any underlying or associated problems and the age and general well-being of the patient.
* Approximately 10% of patients who experience rectal prolapse as children continue to experience it in their adult lives.
* Spontaneous resolution usually occurs in children.
* Of the children with rectal prolapse who are aged 9 months to 3 years, 90% will need only conservative treatment.2
* For children older than 4 years who first experience prolapse, a much lower rate of spontaneous resolution exists.

Document references

1. Burkitt HG, Quick CRG; Essential Surgery 3rd Ed Churchill Livingstone
2. LK Flowers; Rectal Prolapse. eMedicine, August 2007.
3. Watkins BP, Landercasper J, Belzer GE, et al; Long-term follow-up of the modified Delorme procedure for rectal prolapse. Arch Surg. 2003 May;138(5):498-502; discussion 502-3. [abstract]
4. Kairaluoma MV, Viljakka MT, Kellokumpu IH; Open vs. laparoscopic surgery for rectal prolapse: a case-controlled study assessing short-term outcome. Dis Colon Rectum. 2003 Mar;46(3):353-60. [abstract]
5. Kimmins MH, Evetts BK, Isler J, et al; The Altemeier repair: outpatient treatment of rectal prolapse. Dis Colon Rectum. 2001 Apr;44(4):565-70. [abstract]
6. Poritz LS; Rectal Proloapse. eMedicine, August 2006.
7. Friedlander JA; Rectal prolpase. eMedicine, March 2007.

Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 573
Document Version: 21
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Last Updated: 10 Jun 2008
Review Date: 10 Jun 2010

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liveISlife wrote:

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liveISlife wrote:

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