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Vollebregt PF, Heitmann PT, Damon H, Garcia-Zermeño K, Daniel Garcia F, Baker J, Schloithe A, Moshiree B, Remes-Troche JM, Mion F, Dinning PG, Knowles CH, Scott SM. Prevalence and Clinical Impact of the London Classification: A Prospective, International, Multicenter Study From the Lower Gastrointestinal International Consortium (LoGIC). Am J Gastroenterol 2025:00000434-990000000-01553. [PMID: 39819766 DOI: 10.14309/ajg.0000000000003320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Accepted: 12/23/2024] [Indexed: 01/19/2025]
Abstract
INTRODUCTION The London classification provides standardization for characterization of disorders of anorectal function, although prevalences and clinical impact of these disorders are unclear. METHODS An international research consortium was established, including 5 specialist centers. Prospective data were collected in consecutive adults referred for refractory chronic constipation (CC), fecal incontinence (FI), or coexistent CC/FI over 18 months. Patients completed a standardized clinical questionnaire and underwent anorectal physiology tests, which were performed and interpreted using uniform methodology. The prevalence of the London classification was compared between symptom groups (CC, FI, and coexistent CC/FI), equipment types, and sites. Clinical impact was assessed using Cleveland Clinic Constipation and St. Marks Incontinence Scores. RESULTS Of 1,012 included patients (85.6% women), 30.5% had self-reported CC, 33.2% had FI, and 36.3% had coexistent CC/FI. Rectoanal areflexia was uncommon (3.1%). Disorders of anal tone/contractility (CC: 45.0%; FI: 68.5%; coexistent CC/FI: 63.8%; P < 0.0001) and disorders of rectal sensation (major findings: rectal hyposensitivity, CC: 10.0%; FI: 5.0%; coexistent CC/FI: 11.1%; P = 0.018; rectal hypersensitivity, CC: 3.8%; FI: 9.0%; coexistent CC/FI: 4.9%; P = 0.025) varied between the symptom groups and were associated with symptom severity. Most disorders of rectoanal coordination were found in similar proportions across the symptom groups and were not associated with the severity of CC (median Cleveland Clinic Constipation Score 10-14 in all groups). Prevalences of some disorders differed between equipment types (specifically balloon expulsion test). DISCUSSION This prospective multicenter study provides information on the prevalence and clinical impact of the London classification and will guide refinement of the current London classification.
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Affiliation(s)
- Paul F Vollebregt
- Queen Mary University London, London, UK
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Paul T Heitmann
- Flinders Medical Centre/College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Henri Damon
- Université de Lyon et Hospices Civils de Lyon, Lyon, France
| | | | | | - Jason Baker
- Atrium Health Wake Forest Medical University, Charlotte, North Carolina, USA
| | - Ann Schloithe
- Flinders Medical Centre/College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Baharak Moshiree
- Atrium Health Wake Forest Medical University, Charlotte, North Carolina, USA
| | - Jose M Remes-Troche
- Medical Biological Research Institute, University of Veracruz, Veracruz, Mexico
| | - François Mion
- Université de Lyon et Hospices Civils de Lyon, Lyon, France
| | - Phil G Dinning
- Flinders Medical Centre/College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Shahsavari D, Rao SSC. Review article: advances in the diagnosis and management of anorectal motility disorders. Aliment Pharmacol Ther 2024; 60:701-714. [PMID: 39051556 DOI: 10.1111/apt.18170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field. AIMS To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach. METHODS We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review. RESULTS A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe. CONCLUSIONS Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients.
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Affiliation(s)
- Dariush Shahsavari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
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Chiarioni G, Lambiase C, Whitehead WE, Rettura F, Morganti R, Popa SL, Bellini M. Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests. Dig Liver Dis 2024; 56:429-435. [PMID: 37394370 DOI: 10.1016/j.dld.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND AND AIMS Defecation Disorders (DD) are a frequent cause of refractory chronic constipation. DD diagnosis requires anorectal physiology testing. Our aim was to evaluate the accuracy and Odds Ratio (OR) of a straining question (SQ) and a digital rectal examination (DRE) augmented by abdomen palpation on predicting a DD diagnosis in refractory CC patients. METHODS Two hundred and thirty-eight constipated patients were enrolled. Patients underwent SQ, augmented DRE and balloon evacuation test before entering the study and after a 30-day fiber/laxative trial. All patients underwent anorectal manometry. OR and accuracy were calculated for SQ and augmented DRE for both dyssynergic defecation and inadequate propulsion. RESULTS "Anal Muscles" response was associated to both dyssynergic defecation and inadequate propulsion, with an OR of 13.6 and 5.85 and an accuracy of 78.5% and 66.4%, respectively. "Failed anal relaxation" on augmented DRE was associated with dyssynergic defecation, with an OR of 21.4 and an accuracy of 73.1%. "Failed abdominal contraction" on augmented DRE was associated with inadequate propulsion with an OR >100 and an accuracy of 97.1%. CONCLUSIONS Our data support screening constipated patients for DD by SQ and augmented DRE to improve management and appropriateness of referral to biofeedback.
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Affiliation(s)
- Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy; UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Christian Lambiase
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy.
| | - William E Whitehead
- UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Francesco Rettura
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
| | - Riccardo Morganti
- Clinical Trial Statistical Support Unit, Azienda Ospedaliero Universitaria Pisana, 56010 Pisa, Italy
| | - Stefan Lucian Popa
- 2nd Medical Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
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Sun D, Lo KM, Chen SC, Leung WW, Wong C, Mak T, Ng S, Futaba K, Gregersen H. The rectum, anal sphincter and puborectalis muscle show different contraction wave forms during prolonged measurement with a simulated feces. Sci Rep 2024; 14:432. [PMID: 38172283 PMCID: PMC10764324 DOI: 10.1038/s41598-023-50655-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
Contractile patterns in rectum, puborectalis muscle and anal sphincter must be studied to understand defecation. Six subjects had contractile waveforms studied with Fecobionics. Symptom questionnaires, balloon expulsion test and anorectal manometry were done for reference. The Fecobionics bag was filled in rectum to urge-to-defecate volume and measurements were done for 4 h before the subjects attempted to evacuate the device. Pressures and bend angle (BA) variations were analyzed with Fast Fourier Transformation. Four normal subjects exhibited low frequency waves (< 0.06 Hz) for pressures and BA. The waves were uncoordinated between recordings, except for rear and bag pressures. Peak wave amplitudes occurred at 0.02-0.04 Hz. Pressures and the BA differed for peak 1 (p < 0.001) and peak 2 amplitudes (p < 0.005). The front pressure amplitude was bigger than the others (rear and BA, p < 0.05; bag, p < 0.005) for peak 1, and bigger than bag pressure (p < 0.005) and BA (p < 0.05) for peak 2. One subject was considered constipated with lower front pressure amplitudes compared to normal subjects and increased amplitudes for other parameters. The sixth subject was hyperreactive and differed from the other subjects. In conclusion, the rectum, anal sphincter and puborectalis muscle showed different contraction waves during prolonged measurements. The data call for larger studies to better understand normal defecation, feces-withholding patterns, and the implications on anorectal disorders.
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Affiliation(s)
- Daming Sun
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing University of Posts and Telecommunications, Chongqing, China
| | - Kar Man Lo
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
| | - Ssu-Chi Chen
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kaori Futaba
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA.
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Bokova E, Svetanoff WJ, Rosen JM, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1078. [PMID: 37371309 DOI: 10.3390/children10061078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC. METHODS A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years. RESULTS The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test. CONCLUSION Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Nojkov B, Baker JR, Chey WD, Saad R, Watts L, Armstrong M, Collins K, Ezell G, Phillips C, Menees S. Age- and Gender-Based Differences in Anorectal Function, Gastrointestinal Symptoms, and Constipation-Specific Quality of Life in Patients with Chronic Constipation. Dig Dis Sci 2023; 68:1403-1410. [PMID: 36173584 DOI: 10.1007/s10620-022-07709-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/21/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC. METHODS This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET. RESULTS 2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6%) and Caucasian (82%). 73% were < 60 years old (mean = 41) vs. 27% ≥ 60 years old (mean = 69). The prevalence of impaired anal sphincter relaxation on ARM, abnormal BET, and DD in patients with CC was 48%, 42.1%, and 22.9%, respectively. Patients who were older and male were significantly more frequently diagnosed with DD and more frequently had impaired anal sphincter relaxation on ARM, compared to patients who were younger and female (p < 0.05). Conversely, CC patients who were younger and female reported greater constipation symptoms severity and more impaired QoL (p ≤ 0.004). CONCLUSION Among patients with CC referred for anorectal function testing, men and those older than 60 are more likely to have dyssynergic defecation, but women and patients younger than 60 experience worse constipation symptoms and QoL.
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Affiliation(s)
- Borko Nojkov
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA.
| | - Jason R Baker
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - William D Chey
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Richard Saad
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Lydia Watts
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Moira Armstrong
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Kristen Collins
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Gabrielle Ezell
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Cari Phillips
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Stacy Menees
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
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Prichard DO, Fetzer J. Recto-anal Pressures in Constipated Men and Women Undergoing High-Resolution Anorectal Manometry. Dig Dis Sci 2023; 68:922-930. [PMID: 35727425 DOI: 10.1007/s10620-022-07590-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND In constipated individuals, high-resolution anorectal manometry (HRM) may suggest the presence of a defecatory disorder. Despite known physiological differences between men and women, our understanding of functional anorectal pathophysiology is based upon predominantly female cohorts. Results are generalized to men. AIMS To evaluate whether recto-anal pressure patterns in constipated men are similar to those in constipated women. METHODS The electronic health records at Mayo Clinic, Rochester were used to identify constipated adult patients, without organic anorectal disease, who had undergone HRM and balloon expulsion testing (BET) in 2018, 2019, and 2020. Comparative analyses were performed. RESULTS Among 3,298 constipated adult patients (2,633 women, 665 men), anal and rectal pressures were higher in men. Women more likely to have HRM findings suggestive of a defecatory disorder (39% versus 20%, P < 0.001). Women were more likely to exhibit a type 4 pattern (27% versus 14%, P < 0.001), and less likely to exhibit a type 1 pattern (14% versus 38%, P < 0.001), of dyssynergia. Men were more likely to have an abnormal balloon expulsion test (BET, 34% versus 29%, P = 0.006). Nominal logistic regression demonstrates that male sex, age over 50 years, reduced recto-anal gradient during simulated evacuation, and types 2 and 4 dyssynergia are associated with an abnormal BET. CONCLUSIONS In this large retrospective study, constipated men and women exhibited different patterns of dyssynergia both in the presence and absence of an abnormal BET. These findings were independent of sex-specific baseline physiological differences.
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Affiliation(s)
- David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Jeffrey Fetzer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
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Sadeghi A, Akbarpour E, Majidirad F, Bor S, Forootan M, Hadian MR, Adibi P. Dyssynergic Defecation: A Comprehensive Review on Diagnosis and Management. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2023; 34:182-195. [PMID: 36919830 PMCID: PMC10152153 DOI: 10.5152/tjg.2023.22148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 12/22/2022] [Indexed: 03/15/2023]
Abstract
About one-third of chronically constipated patients have an evacuation disorder, and dyssynergic defecation is a common cause of the evacuation disorder. In dyssynergic defecation, the coordination between abdominal and pelvic floor muscles during defecation is disrupted and patients cannot produce a normal bowel movement. The etiology of dyssynergic defecation is still unknown. Although a detailed history taking and a careful examination including digital rectal examination could be useful, other modalities such as anorectal manometry and balloon expulsion test are necessary for the diagnosis. Biofeedback therapy is one of the most effective and safe treatments. Here, we provide an overview of dyssynergic defecation as well as how to diagnose and manage this condition.
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Affiliation(s)
- Anahita Sadeghi
- Digestive Disease Research Institute (DDRI), Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Akbarpour
- Digestive Disease Research Institute (DDRI), Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Majidirad
- Physical Therapy Department, Tehran University of Medical Sciences Faculty of Rehabilitation Sciences, Tehran, Iran
| | - Serhat Bor
- Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Hadian
- Department of Physical Therapy, Brain & Spinal Cord Injury Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences (TUMS) Faculty of Rehabilitation Sciences, Tehran, Iran
| | - Peyman Adibi
- Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Dawra S, Behl P, Srivastava S, Manrai M, Chandra A, Kumar A, Kumar A, Tevatia MS. Non-neoplastic disorders in an aging gut: concise review. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023; 35:7. [DOI: 10.1186/s43162-023-00189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/15/2023] [Indexed: 01/31/2023] Open
Abstract
AbstractThe spectrum of gastrointestinal (GI) issues in the older population varies from common physiological age-related changes to devastating, less common sinister pathological illness. GI system has direct exposure to external environment. Thus, it is modeled to embrace the pathophysiological changes that occur due to interaction with external factors. Gastrointestinal tract (GIT) per se is more resilient to aging as compared to other organ systems. On the other hand, elderly may present with a large plethora of GI symptoms. This presents a challenge to all echelons of medical consultation for accurate attribution for the aging process or pathophysiological causation of GI symptoms. This dichotomy leads to hindrance in adequate and appropriate treatment of GI ailments. In GI system, non-neoplastic disorders are far more common than neoplastic disorders. Hence, it becomes imperative to understand the aging evolution of the GI system and management of GI disorders in the older population.
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Blackett JW, Gautam M, Mishra R, Oblizajek NR, Kathavarayan Ramu S, Bailey KR, Bharucha AE. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology 2022; 163:1582-1592.e2. [PMID: 35995074 PMCID: PMC9691522 DOI: 10.1053/j.gastro.2022.08.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The utility of high-resolution anorectal manometry (HR-ARM) for diagnosing defecatory disorders (DDs) is unclear because healthy people may have features of dyssynergia. We aimed to identify objective diagnostic criteria for DD and to ascertain the utility of HR-ARM for diagnosing DD. METHODS Constipated patients were assessed with HR-ARM and rectal balloon expulsion time (BET), and a subset underwent defecography. Normal values were established by assessing 184 sex-matched healthy individuals. Logistic regression models evaluated the association of abnormal HR-ARM findings with prolonged BET and reduced rectal evacuation (determined by defecography). RESULTS A total of 474 constipated individuals (420 women) underwent HR-ARM and BET, and 158 underwent defecography. BET was prolonged, suggesting a DD, for 152 patients (32%). Rectal evacuation was lower for patients with prolonged vs normal BET. A lower rectoanal gradient during evacuation, reduced anal squeeze increment, and reduced rectal sensation were independently associated with abnormal BETs; the rectoanal gradient was 36% sensitive and 85% specific for prolonged BET. A lower rectoanal gradient and prolonged BET were independently associated with reduced evacuation. Among constipated patients, the probability of reduced rectal evacuation was 14% when the gradient and BET were both normal, 45% when either was abnormal, and 75% when both variables were abnormal. CONCLUSIONS HR-ARM, BET, and defecography findings were concordant for constipated patients, and reduced rectoanal gradient was the best HR-ARM predictor of prolonged BET or reduced rectal evacuation. Prolonged BET, reduced gradient, and reduced evacuation each independently supported a diagnosis of DD in constipated patients. We propose the terms probable DD for patients with an isolated abnormal gradient or BET and definite DD for patients with abnormal results from both tests.
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Affiliation(s)
- John W Blackett
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Misha Gautam
- Enteric Physiology and Imaging Facility, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shivabalan Kathavarayan Ramu
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Gregersen H, Wang Y, Field F, Wang M, Lo KM, Guo X, Combs W, Kassab GS. Anorectal volume-pressure relations, contraction work, and flow during defecation. Biomech Model Mechanobiol 2022; 21:1613-1621. [PMID: 35908095 PMCID: PMC9633562 DOI: 10.1007/s10237-022-01610-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022]
Abstract
Fecobionics is an integrated device that has shown promise for assessment of anorectal function. We used a wireless Fecobionics prototype to visualize defecatory patterns and to compute volume-pressure, contraction work, and flow. Twelve normal subjects were studied. The probe was 10 cm-long and contained pressure sensors and electrodes for impedance planimetry. Pressures, diameters, and volume data during defecation were analyzed. The bag was distended inside rectum to the urge-to-defecate level where after the subjects were asked to evacuate. The contraction work and defecatory flow were computed from the volume changes during expulsion. The minimum anal diameter during the evacuation was 17.6 ± 1.5 mm. The middle diameter recording was 10-20% lower than the front diameter channels and 10-20% bigger than the rear channels. The bag volume at urge correlated with the minimum diameter (r = 0.63). The diameter-pressure and volume-pressure loops were counterclockwise with phases of bag filling, isometric contraction, ejection and anal passage. The defecatory contraction work was 3520 ± 480 mL × cmH2O. The maximum flow during defecation was 302 ± 33 mL/s. The flow was associated with the anal diameter (r = 0.84) but not with the rectoanal pressure gradient (r = 0.14). Volume-pressure loops have a tremendous impact on the understanding of cardiopulmonary pathophysiology. Future studies will shed light on potential clinical impact in defecatory pathophysiology.
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Affiliation(s)
- Hans Gregersen
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA.
| | - Yanmin Wang
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
| | | | | | - Kar Man Lo
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
| | - Xiaomei Guo
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
| | | | - Ghassan S Kassab
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA
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12
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Bharucha AE, Basilisco G, Malcolm A, Lee TH, Hoy MB, Scott SM, Rao SSC. Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test. Neurogastroenterol Motil 2022; 34:e14335. [PMID: 35220645 PMCID: PMC9418387 DOI: 10.1111/nmo.14335] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. PURPOSE This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guido Basilisco
- UO Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Tae Hee Lee
- Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Matthew B Hoy
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, USA
| | - S Mark Scott
- National Bowel Research Centre, Queen Mary University of London, London, UK
| | - Satish S C Rao
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
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13
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Khanna L, Zeydan B, Kantarci OH, Camilleri M. Gastrointestinal motility disorders in patients with multiple sclerosis: A single-center study. Neurogastroenterol Motil 2022; 34:e14326. [PMID: 35112759 PMCID: PMC9338921 DOI: 10.1111/nmo.14326] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/12/2022] [Accepted: 01/22/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Most prevalent gastrointestinal symptoms in multiple sclerosis (MS) relate to lower bowel dysfunction, often in association with bladder manifestations. OBJECTIVE To assess clinical and objective gastrointestinal motor dysfunctions in patients with MS. METHODS This was a single-center, retrospective study of 166 patients evaluated between 1996 and 2020. We reviewed characterization of the MS, gastrointestinal and neurological symptoms, measurements of gastrointestinal and colonic transit, and anorectal manometry. KEY RESULTS At the time of the gastrointestinal evaluations of the 166 patients with MS (138 women; 83%), 111 were in the relapsing-remitting phase and 52 were in the progressive phase. In 3 patients, disease phase was not assigned due to insufficient data. Constipation was identified in 82% (136/166) of patients. Most [103/116 (88%)] patients with bladder symptoms also had constipation or fecal incontinence. Delayed gastric emptying at 4 h and colonic transit at 24 h was identified in 16% and 7% of the cohort, respectively; 22% had accelerated gastric emptying. On anorectal manometry, resting anal sphincter pressure >90 mm Hg and rectoanal pressure differential below -50mm Hg suggested evacuation disorder in patients with constipation. CONCLUSIONS AND INFERENCES In addition to slow colonic transit and anorectal dysfunction leading to constipation in MS, 22% of patients had accelerated gastric emptying.
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Affiliation(s)
- Lehar Khanna
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Division of Gastroenterology and Hepatology Rochester MN USA
| | - Burcu Zeydan
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology Mayo Clinic Rochester MN USA
| | - Orhun H. Kantarci
- Department of Neurology and Center for Multiple Sclerosis and Autoimmune Neurology Mayo Clinic Rochester MN USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Division of Gastroenterology and Hepatology Rochester MN USA
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14
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White BA, Linder BJ, Szarka LA, Prichard DO. Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation. Dig Dis Sci 2022; 67:3036-3044. [PMID: 34292471 DOI: 10.1007/s10620-021-07167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS. METHODS We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction. RESULTS A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]). CONCLUSIONS Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.
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Affiliation(s)
- Bradley A White
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Lawrence A Szarka
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David O Prichard
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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15
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Jiang Y, Wang Y, Tang Y, Lin L. Clinical value of positive BET and pelvic floor dyssynergia in Chinese patients with functional defecation disorder. Scand J Gastroenterol 2022; 57:775-782. [PMID: 35180039 DOI: 10.1080/00365521.2022.2039282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Functional defecation disorder (FDD) is a common subtype of functional constipation (FC). Balloon expulsion test (BET) and high resolution anorectal manometry (HR-ARM) are significant tools but their results are not always consistent. AIMS To investigate the characteristics of patients with positive BET and pelvic floor dyssynergia (PFD) and explore the value of both positive results in FDD diagnosis. METHODS We retrospectively diagnosed FC subtypes and enrolled FDD patients based on Rome-IV criteria. They underwent HR-ARM, BET and CTT tests. Then they were classified to two groups and further stratified by FDD subtypes. Validated questionnaires were applied to investigate patients' constipation, anxiety/depression and quality of life. RESULTS 335 FDD patients were finally enrolled. They were classified into two groups according to whether BET and PFD were both positive (consistent or not). 84.48% showed consistent results. These patients had significantly higher anal residual pressure, lower anal relaxation rate, manometric defecation index (MDI) and a more negative rectoanal pressure gradient (RAPG) (Ps < .05). The specific distribution of FDD phenotypes in two groups showed significant difference (p = .021). Males suffered a more negative RAPG (p < .001) and age was correlated with anal relaxation rate (p < .001). A subset (177 individuals) was investigated with validated questionnaires. Scores for Defecation Symptoms, Physical Discomfort and GAD-7 score were significantly high in Consistent Group (Ps < .05). GAD-7 score was associated with Defecation Symptoms (p < .001) while anal residual pressure, GAD-7 and Defecation Symptoms score were linked to Physical Discomfort (Ps < .05). The diagnostic specificity and PPV for FDD rose significantly with positive BET and PFD. CONCLUSION FDD patients with positive BET and PFD suffered from severe defecation symptoms, anxiety and impaired QOL. Positive BET and PFD could be an ideal tool for screening FDD.
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Affiliation(s)
- Ya Jiang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yan Wang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yurong Tang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Lin
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Futaba K, Chen SC, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Fecobionics characterization of female patients with fecal incontinence. Sci Rep 2022; 12:10602. [PMID: 35732729 PMCID: PMC9218093 DOI: 10.1038/s41598-022-14919-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/15/2022] [Indexed: 12/12/2022] Open
Abstract
Defecatory disorders including fecal incontinence (FI) are diagnosed on the symptom pattern supplemented by anorectal manometry (ARM), the balloon expulsion test (BET), and endo-anal ultrasonography. In this study, we used a simulated stool named Fecobionics to study distinct defecation patterns in FI patients using preload-afterload diagrams and to provide comparative data on defecation indices (DIs) between passive and urge incontinent patients. All subjects had Fecobionics, endo-anal ultrasonography and ARM-BET done. The Fecobionics bag was distended in rectum until urge in 37 female patients (64.1 ± 1.5 yrs) and a group of normal subjects (NS, 12F, age 64.8 ± 2.8 yrs). Rear-front pressure (preload-afterload) diagrams and DIs were compared between groups. The FISI score in the patients was 8.6 ± 0.6. The NS did not report FI-related symptoms. All patients and NS defecated Fecobionics and ARM-BET within 2 min. The urge volume was 46.1 ± 3.6 and 35.3 ± 5.9 mL in the FI and normal groups (P > 0.1). The expulsion duration was 14.8 ± 2.4 and 19.8 ± 5.1 s for the two groups (P > 0.1). The preload-afterload diagrams demonstrated clockwise loops that clearly differed between the FI subtypes and NS. The DIs showed profound difference between patients and NS. Fecobionics data showed higher correlation with symptoms in FI patients than ARM-BET. Fecobionics obtained novel pressure signatures in subtypes of FI patients and NS. Fecobionics provides DI data that cannot be obtained with ARM-BET.
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Affiliation(s)
- Kaori Futaba
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong.
- California Medical Innovations Institute, 11107 Roselle St., San Diego, CA, 92121, USA.
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Gregersen H, Wang Y, Field F, Wang M, Lo KM, Guo X, Combs W, Kassab GS. Feasibility study of defecation studied with a wireless Fecobionics probe in normal subjects. Physiol Rep 2022; 10:e15338. [PMID: 35656707 PMCID: PMC9163794 DOI: 10.14814/phy2.15338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 06/15/2023] Open
Abstract
Several technologies have been developed for assessing anorectal function including the act of defecation. We used a new prototype of the Fecobionics technology, a multi-sensor simulated feces, to visualize defecatory patterns and introduced new metrics for anorectal physiology assessment in normal subjects. Fourteen subjects with normal fecal incontinence and constipation questionnaire scores were studied. The 10-cm-long Fecobionics device provided measurements of axial pressures, orientation, bending, and shape. The Fecobionics bag was distended to the urge-to-defecate level inside rectum where after the subjects were asked to evacuate. Physiological evacuation parameters were assessed. Special attention was paid to the Fecobionics rectoanal pressure gradient (F-RAPG) during evacuation. Anorectal manometry (ARM) and balloon expulsion test (BET) were done as references. The user interface displayed the fine coordination between pressures, orientation, bending angle, and shape. The pressures showed that Fecobionics was expelled in 11.5 s (quartiles 7.5 and 18.8s), which was shorter than the subjectively reported expulsion time of the BET balloon. Six subjects did not expel the BET balloon within 2 min. The F-RAPG was 101 (79-131) cmH2 O, whereas the ARM-RAPG was -28 (-5 to -47) cmH2 0 (p < 0.001). There was no association between the two RAPGs (r2 = 0.19). Fecobionics showed paradoxical contractions in one subject (7%) compared to 12 subjects with ARM (86%). Fecobionics obtained novel physiological data. Defecatory patterns and data are reported and can be used to guide larger-scale studies in normal subjects and patients with defecatory disorders. In accordance with other studies, this Fecobionics study questions the value of the ARM-RAPG.
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Affiliation(s)
- Hans Gregersen
- California Medical Innovations InstituteSan DiegoCaliforniaUSA
| | - Yanmin Wang
- California Medical Innovations InstituteSan DiegoCaliforniaUSA
| | | | | | - Kar Man Lo
- California Medical Innovations InstituteSan DiegoCaliforniaUSA
| | - Xiaomei Guo
- California Medical Innovations InstituteSan DiegoCaliforniaUSA
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18
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Futaba K, Chen SC, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Fecobionics Evaluation of Biofeedback Therapy in Patients With Fecal Incontinence. Clin Transl Gastroenterol 2022; 13:e00491. [PMID: 35363631 PMCID: PMC9132520 DOI: 10.14309/ctg.0000000000000491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Biofeedback therapy (BFT) is a well-known treatment for functional anorectal disorders. The effect of BFT was monitored in fecal incontinence (FI) patients with the Fecobionics test and with the conventional technologies, anorectal manometry (ARM) and balloon expulsion test (BET). METHODS Studies were performed in 12 patients before and after 8 weeks of biofeedback training. The Fecal Incontinence Severity Index (FISI) score was obtained. Anal resting and squeeze pressures were measured before the bag was distended in the rectum until urge to defecate. Pressure recordings were made during Fecobionics evacuation. RESULTS BFT resulted in 24% reduction in FISI scores (P < 0.01). Seven patients were characterized as responders. Anal pressures, the urge-to-defecate volume, and defecatory parameters did not change significantly during BFT. For ARM-BET, the maximum anal squeeze pressure, the urge-to-defecate volume, and the expulsion time were lower after BFT compared with those before BFT (P < 0.05). For Fecobionics, the change in urge volume (r = 0.74, P < 0.05) and the change in defecation index (r = 0.79, P < 0.01) were associated with the change in FISI score. None of the ARM-BET parameters were associated with the change in FISI score. It was studied whether any pre-BFT data could predict treatment success. The Fecobionics expulsion duration and the defecation index predicted the outcome (P < 0.05). The defecation index had a sensitivity of 100% and a specificity of 72%. None of the ARM-BET parameters predicted the outcome (all P > 0.2). DISCUSSION Fecobionics was used as a tool to monitor the effect of BFT and proved better than conventional technologies for monitoring and predicting the outcome in the FISI score.
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Affiliation(s)
- Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
- California Medical Innovations Institute, San Diego, California, USA
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19
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Pathipati MP, Silvernale CJ, Barshop KG, Ha JB, Richter JM, Staller KD. Rectal Evacuation Disorders are Associated With Poor Bowel Preparation in Patients With Chronic Constipation: Results From Two Centers. J Clin Gastroenterol 2022; 56:438-443. [PMID: 34334764 DOI: 10.1097/mcg.0000000000001593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/15/2021] [Indexed: 12/10/2022]
Abstract
INTRODUCTION We evaluated factors that can predict the adequacy of bowel preparation in patients with chronic constipation undergoing colonoscopy. MATERIALS AND METHODS We identified patients with chronic constipation who underwent anorectal manometry and at least 1 colonoscopy at 2 tertiary referral centers from 2003 to 2019. We also identified a subgroup of patients who underwent colonic transit testing through radiopaque marker testing. We determined demographic, medical, and constipation-related factors associated with poor bowel preparation and their effect on standardized quality metrics using univariate and multivariate analyses. RESULTS We identified 274 patients with chronic constipation who underwent anorectal manometry testing. Both outlet dysfunction (prolonged balloon expulsion) and slow-transit constipation were associated with suboptimal bowel preparation. Outlet dysfunction was also associated with decreased cecal intubation rates, adenoma detection rates, and sessile serrated polyp detection rates. In multivariable analyses controlling for demographics and known factors associated with poor bowel preparation, outlet dysfunction was associated with an almost 3-fold odds of suboptimal bowel preparation [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.6-5.1] and a 3-fold reduction in cecal intubation rates (OR: 0.3; 95% CI: 0.1-0.8). Among those with radiopaque marker colonic transit testing available, slow-transit constipation was associated with a >2-fold odds of suboptimal bowel preparation (OR: 2.2; 95% CI: 1.1-4.4). CONCLUSIONS Among a cohort of patients with chronic constipation undergoing colonoscopy, outlet dysfunction was associated with suboptimal bowel preparation and other quality metrics. Constipated patients with a rectal evacuation disorder may represent a subgroup of patients that could benefit from individualized strategies for better bowel preparation.
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Affiliation(s)
- Mythili P Pathipati
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Casey J Silvernale
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Kenneth G Barshop
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jasmine B Ha
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Kyle D Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
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20
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Bellini M, Lambiase C, Chiarioni G. Innovative Balloon Expulsion Testing for Defecation Disorders: Look Before Leaping the Old Path. Am J Gastroenterol 2022; 117:809. [PMID: 35139048 DOI: 10.14309/ajg.0000000000001647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Massimo Bellini
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Christian Lambiase
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy
- UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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PASSOS MDCF, ALVARIZ RC, ANDRÉ EA, BARBUTI RC, FILLMANN HS, MURAD-REGADAS SM, REZENDE FILHO J, PERROTTI M, GUEDES L. DIAGNOSIS AND MANAGEMENT OF CHRONIC IDIOPATHIC CONSTIPATION: A NARRATIVE REVIEW FROM A BRAZILIAN EXPERT TASK FORCE. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:137-144. [DOI: 10.1590/s0004-2803.202200001-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
ABSTRACT Background Chronic idiopathic constipation (CIC) is a condition that widely affects the global population, represents relevant healthcare resource utilization and costs, and impacts the individual’s well-being. Objective To review the consensus of expert societies and published guidelines on the diagnosis and treatment of CIC in adults, seeking to assist reasoning and decision-making for medical management of patients with CIC and provide a practical reference material. Methods A Brazilian medical task force searched the scientific literature in the following electronic databases: MEDLINE/PubMed, SciELO, EMBASE and Cochrane, using the following descriptors: chronic constipation, diagnosis, management of chronic constipation. In addition, a review of articles on the mechanism of action, safety, and efficacy of therapeutic options available in Brazil was carried out. Results The diagnostic approach and the understanding of the pathophysiology present in CIC are essential items to indicate the appropriate therapy and to understand the ecosystem of the patient’s needs. Conclusion CIC is a common condition in adults, occurring more frequently in the elderly and in women. Proper management is defined by detailed medical history and physical examination, together with appropriate therapeutics, regardless pharmacological or not, and depending on the best moment of indication. This way, the impact on quality of life is also optimized.
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22
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Sharma A, Herekar A, Yan Y, Karunaratne T, Rao SSC. Dyssynergic Defecation and Other Evacuation Disorders. Gastroenterol Clin North Am 2022; 51:55-69. [PMID: 35135665 DOI: 10.1016/j.gtc.2021.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.
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Affiliation(s)
- Amol Sharma
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA.
| | - Anam Herekar
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tennekoon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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23
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Bharucha AE, Coss-Adame E. Diagnostic Strategy and Tools for Identifying Defecatory Disorders. Gastroenterol Clin North Am 2022; 51:39-53. [PMID: 35135664 PMCID: PMC8829054 DOI: 10.1016/j.gtc.2021.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
This article reviews the indications, techniques, interpretation, strengths, and weaknesses of tests (anal manometry, anal surface electromyography, rectal balloon expulsion test, barium and MRI defecography, assessment of rectal compliance and sensation, and colonic transit) that are used diagnose defecatory disorders in constipated patients. The selection of tests and the sequence in which they are performed should be individualized to and interpreted in the context of the clinical features. Because anorectal functions are affected by age, results should be interpreted with reference to age- and sex-matched normal values for the same technique.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905
| | - Enrique Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, México City, México
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24
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Woo M, Pandey A, Gill H, Li D, Buresi M, Nasser Y, Sawhney S, Andrews CN. Manometric parameters, when measured with the 3-dimensional high-definition anorectal manometry probe, poorly predict prolonged balloon expulsion time. Neurogastroenterol Motil 2022; 34:e14180. [PMID: 34125464 DOI: 10.1111/nmo.14180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/07/2021] [Accepted: 05/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are little data evaluating the performance of the 3-dimensional high-definition anorectal manometry (3D-HDAM) system in the diagnosis of dyssynergic defecation. Physical properties of the thicker, rigid, 3D-HDAM probe may have implications on the measurements of anorectal pressures. AIM Our aim was to compare 3D-HDAM to balloon expulsion test and magnetic resonance (MR) defecography. METHODS Consecutive constipated patients referred for anorectal function testing at the Calgary Gut Motility Centre (Calgary, Canada) between 2014 and 2019 were assessed. All patients underwent anorectal manometry with the 3D-HDAM probe, and a subset underwent BET or MR defecography. Anorectal manometric variables were compared between patients who had normal and abnormal BET. RESULTS Over the study period, 81 patients underwent both 3D-HDAM and BET for symptoms of constipation. 52 patients expelled the balloon within 3 minutes. Patients with abnormal BET had significantly lower rectoanal pressure differential (RAPD) (-61 vs. -31 mmHg for normal BET, p = 0.03) and defecation index (0.29 vs. 0.56, p = 0.03). On logistic regression analysis, RAPD (OR: 0.99, 95% CI: 0.97-0.99, p = 0.03) remained a negative predictor of abnormal BET. On ROC analysis, RAPD had an AUC of 0.65. There was good agreement between dyssynergic patterns on 3D-HDAM and defecographic evidence of dyssynergia (sensitivity 80%, specificity 90%, PLR 9, NLR 0.22, accuracy 85%). CONCLUSIONS Manometric parameters, when measured with the 3D-HDAM probe, poorly predict prolonged balloon expulsion time. RAPD remains the best predictor of prolonged balloon expulsion time. The 3D-HDAM probe may not be the ideal tool to diagnose functional defecatory disorders.
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Affiliation(s)
- Matthew Woo
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Armaan Pandey
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Harman Gill
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Dorothy Li
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Michelle Buresi
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Yasmin Nasser
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Summit Sawhney
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Christopher N Andrews
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
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25
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Song EM, Lee HJ, Jung KW, Kim MJ, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Choe J, Yang SK, Rao SSC, Myung SJ. Long-Term Risks of Parkinson's Disease, Surgery, and Colorectal Cancer in Patients With Slow-Transit Constipation. Clin Gastroenterol Hepatol 2021; 19:2577-2586.e6. [PMID: 32882425 DOI: 10.1016/j.cgh.2020.08.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Long-term outcomes of constipation have not been evaluated fully. We investigated the incidence of Parkinson's disease, constipation-related surgery, and colorectal cancer (CRC) in patients with constipation and slow-transit constipation (STC), followed up for up to 20 years. METHODS We collected data from 2165 patients (33.1% men; median patient age, 54 y; median symptom duration, 5.0 y) with a diagnosis of constipation (based on Rome II criteria) who underwent an anorectal function test and a colonic transit time study, from 2000 through 2010, at a tertiary university hospital in Seoul, South Korea. The presence of STC was determined from colonic transit time. We used the Kaplan-Meier method to analyze and compare cumulative probabilities of a new diagnosis of Parkinson's disease or CRC according to the presence of STC. The patients were followed up until the end of 2019. RESULTS During a median follow-up period of 4.7 years (interquartile range, 0.7-8.3 y), 10 patients underwent constipation-related surgery. The cumulative probabilities of constipation-related surgery were 0.7% at 5 years and 0.8% at 10 years after a diagnosis of constipation. Twenty-nine patients (1.3%) developed Parkinson's disease; the cumulative probabilities were 0.4% at 1 year, 1.0% at 5 years, and 2.6% at 10 years after a diagnosis of constipation. At 10 years, 1.3% of patients with STC required constipation-related surgery and 3.5% of patients with STC developed Parkinson's disease; in contrast, none of the patients without STC required constipation-related surgery (P = .003), and 1.5% developed Parkinson's disease (P = .019). In multivariate analysis, patient age of 65 years or older at the diagnosis of constipation (hazard ratio, 4.834; 95% CI, 2.088-11.190) and the presence of STC (hazard ratio, 2.477; 95% CI, 1.046-5.866) were associated independently with the development of Parkinson's disease. Only 5 patients had a new diagnosis of CRC during the follow-up period. The risk of CRC did not differ significantly between patients with vs without STC (P = .575). CONCLUSIONS In a long-term follow-up study of patients with constipation in Korea, most patients had no severe complications. However, patients older than age 65 years with a new diagnosis of STC might be considered for Parkinson's disease screening.
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Affiliation(s)
- Eun Mi Song
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hyo Jeong Lee
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Mi Jung Kim
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jaewon Choe
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Augusta, Augusta, Georgia
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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26
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Abstract
Normal defecation is a complex and coordinated physiologic process that involves the rectum, anus, anal sphincter complex, and pelvic floor muscles. Any alteration of this process can be considered defecatory dysfunction, a term that covers a broad range of disorders, including slow-transit constipation, functional constipation, and functional or anatomic outlet obstruction. Evaluation should include history, physical, and consideration of additional testing such as colonoscopy, colonic transit studies, defecography, and/or anorectal manometry. Depending on the etiology, management options can include conservative measures such as dietary or lifestyle modifications, medications, pelvic floor physical therapy, or surgical repair.
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28
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Allemeyer E, Müssig K. Chronische Obstipation und Diabetes mellitus. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1320-9358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sharma A, Rao SSC, Kearns K, Orleck KD, Waldman SA. Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders. Aliment Pharmacol Ther 2021; 53:1250-1267. [PMID: 33909919 PMCID: PMC8252518 DOI: 10.1111/apt.16369] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/24/2020] [Accepted: 03/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders. AIM To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic-based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation. METHODS Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices. RESULTS Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects. CONCLUSIONS Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence-based treatments by a gastroenterology provider.
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Affiliation(s)
- Amol Sharma
- Division of Gastroenterology/HepatologyMedical College of GeorgiaAugusta UniversityAugustaGAUSA
| | - Satish S. C. Rao
- Division of Gastroenterology/HepatologyMedical College of GeorgiaAugusta UniversityAugustaGAUSA
| | | | | | - Scott A. Waldman
- Department of Pharmacology and Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPAUSA
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30
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Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil 2021; 33:e14050. [PMID: 33263938 DOI: 10.1111/nmo.14050] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting. PURPOSE This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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Affiliation(s)
- S Mark Scott
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam D Farmer
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Institute of Applied Clinical Science, University of Keele, Keele, UK
| | - Philip G Dinning
- College of Medicine and Public Health, Flinders Medical Centre, Flinders University & Discipline of Gastroenterology, Adelaide, SA, Australia
| | - Emma V Carrington
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Gastroenterology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karen Nugent
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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31
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Gregersen H, Chen SC, Leung WW, Wong C, Mak T, Ng S, Daming S, Futaba K. Characterization of Patients With Obstructed Defecation and Slow Transit Constipation With a Simulated Stool. Clin Transl Gastroenterol 2021; 12:e00354. [PMID: 33949343 PMCID: PMC8099406 DOI: 10.14309/ctg.0000000000000354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Defecatory disorders including obstructed defecation (OD) are currently diagnosed using specialized investigations including anorectal manometry and the balloon expulsion test. Recently, we developed a simulated stool named Fecobionics that provides a novel type of pressure measurements and analysis. The aim was to study OD phenotypes compared with slow transit constipation (STC) patients and normal subjects (NS). METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics device contained pressure sensors at the front, rear, and inside a bag. All constipation patients had colon transit study, defecography, anorectal manometry, and balloon expulsion test performed. The Fecobionics bag was distended in the rectum until desire-to-defecate in 26 OD compared with 8 STC patients and 10 NS. Rear-front pressures (preload-afterload parameters) and defecation indices (DIs) were compared between groups. RESULTS The Wexner constipation scoring system score was 13.8 ± 0.9 and 14.6 ± 1.5 in the OD and STC patients (P > 0.5). The median desire-to-defecate volume was 80 (quartiles 56-80), 60 (54-80), and 45 (23-60) mL in OD, STC, and NS, respectively (P < 0.01). The median expulsion duration was 37 (quartiles 15-120), 6 (3-11), and 11 (8-11) seconds for the 3 groups (P < 0.03). Fecobionics rear-front pressure diagrams demonstrated clockwise loops with distinct phenotype differences between OD and the other groups. Most DIs differed between OD and the other groups, especially those based on the anal afterload reflecting the nature of OD constipation. Several OD subtypes were identified. DISCUSSION Fecobionics obtained novel pressure phenotypes in OD patients. DIs showed pronounced differences between groups. Larger studies are needed on OD subtyping.
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Affiliation(s)
- Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sun Daming
- School of Microelectronics and Communication Engineering, Chongqing University, Shapingba, China
| | - Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
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32
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Milosavljevic T, Popovic DD, Mijac DD, Milovanovic T, Krstic S, Krstic MN. Chronic Constipation: Gastroenterohepatologist's Approach. Dig Dis 2021; 40:175-180. [PMID: 33946065 DOI: 10.1159/000516976] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Constipation is a common problem in gastroenterological practice. The prevalence of constipation is about 16%. Constipation can be primary or secondary. SUMMARY The diagnostic and therapeutic approach to patients with constipation begins with a detailed history and physical examination. In selected cases, the use of additional diagnostic procedures is very important. This includes the use of laboratory, endoscopic, and radiological examinations, as well as advanced physiological testing (anorectal manometry, balloon expulsion test, colonic transit studies, and defecography). Constipation therapy can be both nonoperative and operative. Nonoperative therapy includes the application of a lifestyle measures, pharmacotherapy and biofeedback therapy. Key Messages: Two key things when taking a medical history and physical examination are to rule out the existence of alarm symptoms/signs and to rule out secondary constipation (primarily drug-induced). Therapy begins with lifestyle modification, and in case of failure, bulk or osmotic laxatives are used. In case of failure, the use of lubiprostone is indicated, as well as linaclotide. Surgical treatment of constipation is reserved for cases of refractory constipation, with delayed intestinal transit.
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Affiliation(s)
| | - Dusan D Popovic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Danilo Mijac
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tamara Milovanovic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Krstic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Emergency Centre, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Miodrag N Krstic
- Clinic for Gastroenterohepatology, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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33
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Lalwani N, El Sayed RF, Kamath A, Lewis S, Arif H, Chernyak V. Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography. Abdom Radiol (NY) 2021; 46:1323-1333. [PMID: 31332501 DOI: 10.1007/s00261-019-02142-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.
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34
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Abstract
Chronic constipation is one of the five most common symptoms seen by gastroenterologist. In the absence of alarm symptoms, a confident symptom-based diagnosis can often be made using the Rome criteria. Three different subtypes have been identified to date: normal transit constipation, defaecatory disorders and slow transit constipation. Differentiation between these subtypes can be made through functional testing using tests such as anorectal manometry with balloon expulsion and a radio-opaque marker test. In general, patients are initially advised to increase their fluid and fibre intake. When these general lifestyle recommendations do not improve patients' symptoms, a step-wise and add-on treatment approach should be applied. This review summarises the diagnostic criteria to differentiate functional constipation from other causes of chronic constipation. In addition, current drug treatment options, including discussion of new therapeutic targets are discussed. Further, practical treatment approaches (choice and dosing), include discussion of combination/augmentation, treatment failure (adherence/expectations), and relapse prevention are mentioned. Finally, treatment and management of pain and bloating aspects are included.
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Affiliation(s)
- Jasper Pannemans
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium
| | - Imke Masuy
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium
| | - Jan Tack
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium.
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35
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Martos Vizcaíno E, Ciriza de Los Ríos C, Canga Rodríguez-Valcárcel F. Diagnostic and therapeutic challenges in the management of obstructive defecation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:619. [PMID: 33397119 DOI: 10.17235/reed.2021.7587/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Chronic constipation is a very common disease in daily clinical practice with a significant deterioration in quality of life that increases when associated with obstructive defecation. For this reason, we believe that the case presented here can improve our knowledge of these problems.
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36
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Abstract
Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.
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Affiliation(s)
- David B Snell
- Division of Gastroenterology & Hepatology, Department of Medicine, New York University, 550 First Avenue, New York, NY 10016, USA.
| | - Saamia Faruqui
- Division of Gastroenterology & Hepatology, Department of Medicine, New York University, 550 First Avenue, New York, NY 10016, USA
| | - Brian P Bosworth
- Department of Medicine, New York University, 550 First Avenue, HCC 3-15, New York, NY 10016, USA
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37
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Affiliation(s)
- Kyle Staller
- Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts, USA
| | - Brooks D Cash
- Division of Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center at Houston/McGovern Medical School, Houston, Texas, USA
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Caetano AC, Costa D, Gonçalves R, Correia-Pinto J, Rolanda C. Does sequential balloon expulsion test improve the screening of defecation disorders? BMC Gastroenterol 2020; 20:338. [PMID: 33054847 PMCID: PMC7559767 DOI: 10.1186/s12876-020-01490-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/07/2020] [Indexed: 12/30/2022] Open
Abstract
Background A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three “low-cost” tools to evaluate DD—a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as separate or combined tests for DD screening. Methods This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Department of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. Results From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18–25.14, revealing to be the most significant predictor for DD screening. Conclusion The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting.
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Affiliation(s)
- A C Caetano
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal. .,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. .,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal.
| | - D Costa
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - R Gonçalves
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal
| | - J Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - C Rolanda
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
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Brandler J, Camilleri M. Pretest and Post-test Probabilities of Diagnoses of Rectal Evacuation Disorders Based on Symptoms, Rectal Exam, and Basic Tests: a Systematic Review. Clin Gastroenterol Hepatol 2020; 18:2479-2490. [PMID: 31811949 PMCID: PMC7269802 DOI: 10.1016/j.cgh.2019.11.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/15/2019] [Accepted: 11/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the utility of symptoms, examination, and tests for diagnosis of rectal evacuation disorders (REDs) or slow-transit constipation (STC). We aimed to ascertain the pooled prevalence, sensitivity, specificity, and likelihood ratios for clinical parameters to determine pretest and post-test probabilities of diagnoses of RED and STC without RED. METHODS We searched the MEDLINE and PUBMED databases since 1999 for studies that used binary data to calculate sensitivity, specificity, and likelihood ratios to determine the diagnostic utility of history, symptoms, and tests for RED and STC. RED and STC were defined based on confirmation by at least 1 objective anorectal test or colonic transit test. Controls had normal test results based on the specific protocol in each study. RESULTS We reviewed 100 articles; 63 studies of RED and 61 studies of STC met the inclusion criteria. Among 3364 patients with chronic constipation, objective tests demonstrated RED alone, 27.2%; normal transit constipation alone, 37.2%; STC alone, 19.0%; and RED with STC, 16.6%. To diagnose RED, discriminant features were urinary symptoms (specificity, 100%; likelihood ratio, above 10; 58 patients), less than 2 findings of dyssynergia in a digital rectal exam (sensitivity, 83.2%; negative likelihood ratio, 0.2; 462 patients) and rectoanal pressure gradient below -40 mm Hg with high anal pressure during straining (specificity, 100%; likelihood ratio, above 10; 101 patients). The features most strongly associated with STC alone were call to stool (specificity, 91.5%; likelihood ratio, 10.5; 75 patients) and absence of abdominal distension, fullness, or bloating (sensitivity, 92.9%; negative likelihood ratio, 0.1; 93 patients). CONCLUSIONS In a systematic review, we found specific symptoms, lack of dyssynergia in a digital rectal exam, and findings on anorectal manometry to be highly informative and critical in evaluation of RED and STC.
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Affiliation(s)
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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40
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Curtin B, Jimenez E, Rao SSC. Clinical Evaluation of a Patient With Symptoms of Colonic or Anorectal Motility Disorders. J Neurogastroenterol Motil 2020; 26:423-436. [PMID: 32989182 PMCID: PMC7547199 DOI: 10.5056/jnm20012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 08/11/2020] [Accepted: 08/16/2020] [Indexed: 12/13/2022] Open
Abstract
Constipation, irritable bowel syndrome, fecal incontinence, abdominal pain, and anorectal pain are problems that affect 40% of the population. They commonly present with overlapping symptoms indicating that their pathophysiology affects multiple segments of the gut as well as brain and gut interactions. Clinically, although some conditions are readily recognized, dyssynergic defecation, fecal incontinence, and anorectal pain are often missed or misdiagnosed. Consequently, the assessment of lower gastrointestinal symptoms in patients with suspected colonic or anorectal motility disorder(s) remains challenging for most clinicians. A detailed history, use of the Bristol stool form scale, prospective stool diaries, ideally through a phone App, digital rectal examination, and judicious use of complementary diagnostic tests are essential. Additionally, it is important to evaluate the impact of these problems on quality of life and psychosocial issues, because they are intricately linked with these disorders. The Rome IV diagnostic questionnaire for functional gastrointestinal disorders can provide additional information often missed during history taking. Here, we discuss a systematic approach for the clinical evaluation of patients with suspected lower gastrointestinal problems, grouped under 4 common diagnostic categories. We describe how to take a detailed history, perform meticulous digital rectal examination, and use validated tools to supplement clinical evaluation, including assessments of quality of life and scoring systems for disease severity and digital Apps. These tools could facilitate a comprehensive plan for clinical management including diagnostic tests, and translate the patients' complaints into definable, diagnostic categories.
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Affiliation(s)
- Bryan Curtin
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
| | - Enoe Jimenez
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Medical College of Georgia, Augusta, GA, USA
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41
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Kaplan JA, Simianu VV. Pelvic Floor Nonrelaxation: Approach to Evaluation and Treatment. Clin Colon Rectal Surg 2020; 34:49-55. [PMID: 33536849 DOI: 10.1055/s-0040-1714286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Dyssynergic defecation can be a complex, burdensome condition. A multidisciplinary approach to these patients is often indicated based on concomitant pathology or symptomatology across the pelvic organs. Escalating treatment options should be based on shared decision making and include medical and lifestyle optimization, pelvic floor physical therapy with biofeedback, Botox injection, sacral neuromodulation, rectal irrigation, and surgical diversion.
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Jiang AC, Panara A, Yan Y, Rao SSC. Assessing Anorectal Function in Constipation and Fecal Incontinence. Gastroenterol Clin North Am 2020; 49:589-606. [PMID: 32718572 DOI: 10.1016/j.gtc.2020.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.
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Affiliation(s)
- Alice C Jiang
- Division of Gastroenterology, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Chicago, IL 60612, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard M. Miller School of Medicine, 1601 NW 12th Ave, Miami, FL, USA
| | - Yun Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University Medical Center, 1120 15th Street, AD 2226, Augusta, GA 30912, USA.
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Ambartsumyan L, Khlevner J, Nurko S, Rosen R, Kaul A, Pandolfino JE, Ratcliffe E, Yacob D, Li BU, Punati J, Sood M, Rao SSC, Levitt MA, Cocjin J, Rodriguez L, Flores A, Rosen JM, Belkind-Gerson J, Saps M, Garza JM, Fortunato J, Schroedl RL, Keefer L, Friedlander J, Heuckeroth RO, Rao M, El-Chammas K, Vaz K, Chumpitazi BP, Sanghavi R, Matta S, Danialifar T, Di Lorenzo C, Darbari A. Proceedings of the 2018 Advances In Motility and In NeuroGastroenterology: AIMING for the Future Single Topic Symposium. J Pediatr Gastroenterol Nutr 2020; 71:e59-e67. [PMID: 32287151 PMCID: PMC8451965 DOI: 10.1097/mpg.0000000000002720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Motility and functional disorders are common in children and often debilitating, yet these disorders remain challenging to treat effectively. At the 2018 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Neurogastroenterology and Motility Committee held a full day symposium entitled, 2018 Advances In Motility and In NeuroGastroenterology - AIMING for the future. The symposium aimed to explore clinical paradigms in pediatric gastrointestinal motility disorders and provided a foundation for advancing new scientific and therapeutic research strategies. METHODS The symposium brought together leading experts throughout North America to review the state of the art in the diagnosis and management of motility and functional disorders in children. Presentations were divided into esophageal, antral duodenal, and colorectal modules. Each module included oral presentations by experts in the respective fields, leading to thought-provoking discussions. There were 2 breakout sessions with small group discussions on select topics, focusing on defining scientific insights into the diagnosis and management of pediatric functional gastrointestinal and motility disorders in a systematic, segment-based approach. CONCLUSIONS The field of neurogastroenterology has made remarkable progress in the last decade. The current report summarizes the major learning points from the symposium highlighting the diagnosis and promising therapies on the horizon for pediatric neurogastrointestinal and motility disorders.
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Affiliation(s)
| | - Julie Khlevner
- Division of Gastroenterology, Hepatology and Nutrition, Columbia University College of Physicians and Surgeons, New York, NY
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | | | - Desale Yacob
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - B U.K. Li
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Jaya Punati
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Manu Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Satish SC Rao
- Division of Gastroenterology, Department of Medicine, Augusta University Medical Center, Augusta, GA
| | - Marc A Levitt
- Division of Colorectal Surgery, Children’s National Hospital, Washington, DC
| | - Jose Cocjin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Alejandro Flores
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Jaime Belkind-Gerson
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Colorado, Aurora, CO
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, University of Miami, Miami, FL
| | - Jose M Garza
- Children’s Center for Digestive Health Care, Atlanta, GA
| | - John Fortunato
- Division of Gastroenterology, Ann & Robert H Lurie Children’s Hospital, Chicago, IL
| | - Rose L Schroedl
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Laurie Keefer
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joel Friedlander
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Robert O. Heuckeroth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia - Research Institute, Philadelphia, PA
| | - Meenakshi Rao
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Khalil El-Chammas
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Karla Vaz
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | | | - Rina Sanghavi
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center Dallas, TX
| | - Sravan Matta
- Pediatric Gastroenterology and Nutrition, Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Tanaz Danialifar
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Anil Darbari
- Division of Pediatric Gastroenterology and Nutrition, Children’s National Hospital, Washington, DC
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Lee TH, Lee JS, Kim J, Kim JO, Kim HG, Jeon SR, Hong SJ, Cho YS, Park S. Spontaneous Internal Anal Sphincter Relaxation During High-resolution Anorectal Manometry Is Associated With Peripheral Neuropathy and Higher Charlson Comorbidity Scores in Patients With Defecatory Disorders. J Neurogastroenterol Motil 2020; 26:362-369. [PMID: 32403904 PMCID: PMC7329158 DOI: 10.5056/jnm19129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/12/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims We aimed to evaluate associations between comorbidities, peripheral neuropathy, and spontaneous internal anal sphincter relaxation (SAR) in patients with defecatory disorders. Methods A patient was considered to exhibit SAR during high-resolution anorectal manometry (HR-ARM) when the nadir pressure is < 15 mmHg and the time from onset to relaxation was ≥ 15 seconds in the resting pressure frame. A case-control study was performed using HR-ARM data collected from 880 patients from January 2010 to May 2015. We identified 23 cases with SAR (median age 75 years; 15 females; 12 fecal incontinence and 11 constipation). We compared HR-ARM values, Charlson index comorbidity scores, neuropathy, and the prevalence of diseases that potentially cause neuropathy between controls and SAR patients. Each SAR case was compared to 3 controls. Controls were selected to match the age, gender, and examination year of each SAR case. Results Compared to controls (26.1%), SAR patients (52.2%) exhibited a significantly higher frequency of fecal incontinence. SAR patients also had higher Charlson index scores (5 vs 4, P = 0.028). Nine of 23 SAR patients (39.1%) exhibited peripheral neuropathy— this frequency was higher than that for the control group (11.6%; P = 0.003). Diseases that potentially cause neuropathy were observed in 17 of 23 SAR cases and 32 of 69 controls (P = 0.022). Conclusions SAR develops in patients with constipation and fecal incontinence but is more common in patients with fecal incontinence. Our controlled observational study implies that SAR is associated with peripheral neuropathy and more severe comorbidities.
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Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Joon Seong Lee
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeeyeon Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun Gun Kim
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research, Digestive Disease Center Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi-do, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Suyeon Park
- Department of biostatistics, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Jain M, Singh S, Baijal R. Diagnostic value of the balloon expulsion test compared with anorectal manometry in Indian patients with dyssynergic defecation. PRZEGLAD GASTROENTEROLOGICZNY 2020; 15:151-155. [PMID: 32550948 PMCID: PMC7294974 DOI: 10.5114/pg.2020.95558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Digital rectal examination (DRE) and balloon expulsion test (BET) are simple tests to diagnose dyssynergic defecation (DD). AIM To determine differences in symptoms and manometry findings in patients with abnormal BET and normal BET. The secondary objective was to ascertain the sensitivity and specificity of BET and DRE + BET for the diagnosis of DD in an Indian setting using ARM findings as the gold standard. MATERIAL AND METHODS Retrospective analysis of patients with chronic constipation referred for anorectal manometry (ARM) between December 2012 and March 2019. DD was diagnosed using ARM. Findings on BET and, in a subset of cases, on DRE + BET were compared with ARM findings. The data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Agreement of BET and DRE + BET with ARM was calculated using Cohen's κ coefficient. A p-value of < 0.05 was considered significant. RESULTS A total of 1006 cases (734 males, 73%) formed the study cohort. Patients with abnormal BET more frequently reported digitation, bleeding per rectum, and straining (p < 0.00001). Moreover, they had a significantly higher median basal pressure compared to those with normal BET (80 vs. 67, p = 0.03). DD was significantly more common in those with abnormal BET. The sensitivity, specificity, PPV, and NPV of BET in detecting DD were 28.29%, 97.15%, 81.13%, and 75.78%, respectively. The percentage of agreement was 76.34%, and there was fair degree of correlation between the two tests. In a smaller subset of cases (166), DRE and BET findings were both available for analysis. We noted that the sensitivity, specificity, PPV, and NPV of combined DRE + BET were 57.63%, 88.79%, 73.91%, and 79.17%, respectively. The Cohen's κ correlation coefficient was 0.49, suggesting moderate agreement. CONCLUSIONS Patients with abnormal BET more frequently report digitation, straining, and bleeding per rectum, and have higher resting anal pressure. BET is a good screening test for DD in an Indian setting.
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Affiliation(s)
- Mayank Jain
- Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, India
| | - Saransh Singh
- Department of Gastroenterology, Pushpavati Singhania Hospital and Research Centre, New Delhi, India
| | - Rajiv Baijal
- Department of Gastroenterology, Pushpavati Singhania Hospital and Research Centre, New Delhi, India
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Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology 2020; 158:1232-1249.e3. [PMID: 31945360 PMCID: PMC7573977 DOI: 10.1053/j.gastro.2019.12.034] [Citation(s) in RCA: 317] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Abstract
With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy
- UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK
- The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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48
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 244] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Oblizajek NR, Gandhi S, Sharma M, Chakraborty S, Muthyala A, Prichard D, Feuerhak K, Bharucha AE. Anorectal pressures measured with high-resolution manometry in healthy people-Normal values and asymptomatic pelvic floor dysfunction. Neurogastroenterol Motil 2019; 31:e13597. [PMID: 30957382 PMCID: PMC6559859 DOI: 10.1111/nmo.13597] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/27/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND High-resolution manometry (HRM) is used to measure rectoanal pressures in defecatory disorders and fecal incontinence. This study sought to define normal values for rectoanal HRM, ascertain the effects of age and BMI on rectoanal pressures, and compare pressures in asymptomatic women with normal and prolonged balloon expulsion time (BET). METHODS High-resolution manometry pressures and BET were measured in 163 asymptomatic healthy participants. Women (96) and men (47) with normal BET were used to estimate normal values and the effects of age/BMI on pressures using a Medtronic 4.2-mm-diameter rectoanal catheter. KEY RESULTS Age is associated with lower resting pressure, higher rectal pressure during evacuation, and a higher rectoanal gradient during evacuation in women and men. In women, the BET is also inversely correlated with age while the BMI is correlated with a higher threshold volume for discomfort and a longer BET. The anal squeeze pressure increment, squeeze duration, and HPZ length are higher in men than women. The rectoanal gradient during evacuation is also lower (ie, more negative) in asymptomatic women with an abnormal than a normal BET. CONCLUSIONS & INFERENCES These findings provide an expanded database of normal values for anorectal HRM in men and women. Age and sex affect anal resting and squeeze pressures, respectively; rectal pressure during evacuation is also higher in older people. Less than 15% of asymptomatic people have BET >60 seconds, which is associated with manometry features of impaired evacuation.
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Affiliation(s)
| | - Sangeetha Gandhi
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
| | | | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
| | - David Prichard
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Division of Internal Medicine
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50
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Zhao Y, Ren X, Qiao W, Dong L, He S, Yin Y. High-resolution Anorectal Manometry in the Diagnosis of Functional Defecation Disorder in Patients With Functional Constipation: A Retrospective Cohort Study. J Neurogastroenterol Motil 2019; 25:250-257. [PMID: 30982241 PMCID: PMC6474701 DOI: 10.5056/jnm18032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 01/25/2019] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background/Aims High-resolution anorectal manometry (HRAM) has been considered a first-line diagnostic tool for functional defecation disorder. However, clinical studies on HRAM used in constipation patients are very limited and few studies have reported the characteristics of anorectal pressure in Chinese patients. The aim of this study is to investigate the characteristics of motility data in a cohort of Chinese patients with functional constipation. Methods A total of 82 consecutive patients with functional constipation who underwent a standardized HRAM were retrospectively enrolled in this study. The functional defecation disorder was classified into Rao’s types. Results The mean age of 82 patients was 51 years (range, 16–83 years). Indications for anorectal manometry were functional constipation for all patients. The mean resting pressure was 69.2 ± 21.2 mmHg (range, 24.5–126.9 mmHg). The mean maximum squeezing pressure was 198.4 ± 75.6 mmHg (range, 54.2–476.9 mmHg). The mean length of the anal high pressure zone was 3.4 ± 1.0 cm (range, 0.6–4.9 cm). Sixty (73.2%) patients were diagnosed as functional defecation disorder. In attempted defecation, type I was most common (n = 24), followed by type II (n = 12), type III (n = 11), and type IV (n = 13) that were present on HRAM according to Rao’s classification. In all 60 patients with functional defecation disorder, 37 were women and 23 were men. Men were significantly more likely than women to have functional defecation disorder (92.0% vs 64.9%, P = 0.014). Conclusion HRAM could be used as a test for the diagnosis of functional defecation disorder and functional defecation disorder is common in Chinese patients with functional constipation.
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Affiliation(s)
- Yan Zhao
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Xiaoyang Ren
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Wen Qiao
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Lei Dong
- Department of Gastroenterology, Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Shuixiang He
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Yan Yin
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
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