Functional anorectal disorders

Diagnostic value of pelvic floor surface electromyography in functional anorectal pain

AIM: To assess the diagnostic value of pelvic floor surface electromyography (sEMG) in functional anorectal pain (FARP) using receiver operating characteristic (ROC) curve analysis.

METHODS: The parameters of pelvic floor sEMG in 118 patients with FARP and 103 normal controls were measured according to the Glazer protocol. Parameters included amplitude (AVG), coefficient of variance (CV), onset time and median frequency (MF). The ROC curve was plotted to assess the diagnostic value of pelvic floor sEMG.

RESULTS: Compared with the control group, the FARP group had a lower AVG (23.81 ± 13.75 vs 30.55 ± 16.14, P < 0.05) and a higher CV (0.43 ± 0.12 vs 0.30 ± 0.07, P < 0.05) during the tonic phase and a higher CV during the endurance phase (0.40 ± 0.15 vs 0.28 ± 0.09, P < 0.05). The critical value of CV during the tonic and endurance phases were 0.35 and 0.31, respectively, and the areas under ROC curve were 0.813 and 0.761.

CONCLUSION: CV during the tonic and endurance phases has better diagnostic value in FARP.

Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence

CONTEXT

Biofeedback has been used successfully in the treatment of fecal incontinence, working mainly on rehabilitation of the sphincter muscle. However, there are few studies presenting objective results of biofeedback, in terms of functional results and those related to the quality of life.

OBJECTIVES

The aims of this study was to evaluate the immediate results of biofeedback in the treatment of fecal incontinence and its impact on the quality of life of patients by using validated questionnaires, correlating the results with those related to functional parameters of quality of life and clinical variables.

METHODS

We analyzed and compared the results of biofeedback in 52 patients with fecal incontinence before the start of the sessions and immediately after the end of them, by applying validated questionnaires assessing the degree of intensity of fecal incontinence (FISI - Fecal Incontinence Severity Index) and evaluation of quality of life related to fecal incontinence (FIQL - Faecal Incontinence Quality of Life Scale) as compared to clinical variables (age, onset of symptoms, etiology of the fecal incontinence, number of sessions of biofeedback and number and types of deliveries).

RESULTS

The evaluation of the results of FISI showed a significant increase in the number of individuals who had low severity scores of symptoms before and after the biofeedback (from 48.1 to 65.4%) with P = 0.004. There was significant improvements in domains of the FIQL, behavior (P = 0.008), depression (P = 0.006) and embarrassment (P = 0.008) after biofeedback. There was no significant correlation between the improvement of functional parameters evaluated by FISI and the improvement of quality of life. Positive correlation was found between the improvements of the domains of FIQL. There was no significant correlation between the results obtained using the FISI and FIQL with clinical variables assessed.

CONCLUSIONS

Biofeedback has proven to be an effective therapy in the treatment of fecal incontinence, improving symptoms and/or quality of life for most patients, regardless of clinical presentation of this functional disorder.

Normal values for high-resolution anorectal manometry/topography in a healthy Korean population and the effects of gender and body mass index

BACKGROUND

High-resolution manometry (HRM) based on spatiotemporal plots is increasingly being used. The aim this study was to evaluate, for the first time, the influence of gender, with adjustment for age, body mass index (BMI), and vaginal delivery, on anorectal functions in asymptomatic adults.

METHODS

Fifty-four asymptomatic healthy subjects (M : F = 27 : 27; age = 20-67 years) who were matched by age and gender were enrolled prospectively. We evaluated anorectal pressures, rectal sensation using a HRM probe, and balloon expulsion time. Multivariate linear regression analysis was performed to identify the independent effects of each factor.

KEY RESULTS

Anal resting pressure (median [IQR]; 32 [18] vs 46 [17] mmHg, p < 0.001), anal squeeze pressure (75 [28] vs 178 [72] mmHg, p < 0.001), rectal pressure (33 [16] vs 53 [46] mmHg, p = 0.009) and anal pressure (16 [17] vs 30 [36] mmHg, p = 0.019) during simulated evacuation with rectal distention, and the threshold for the desire to defecate (60 [20] vs 80 [60] mL, p = 0.020) were significantly lower in women than in men. BMI was positively correlated with anal resting pressure (95% CI: 0.598-2.947) and negatively correlated with the threshold for first sensation (95% CI: -0.099 to -0.015). Vaginal delivery did not affect any of the anorectal HRM parameters.

CONCLUSIONS & INFERENCES

HRM parameters may be associated with gender and BMI. Therefore, gender and BMI should be taken into consideration when interpreting HRM results.

What's New in the Toolbox for Constipation and Fecal Incontinence?

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.

Treatment of chronic anorectal pain by acupuncture

Chronic anorectal pain is a common functional anorectal disease. Currently, there are still some difficulties in diagnosing and treating this disease. Acupuncture has advantages in treating chronic anorectal pain. This article will summarize the progress in treatment of chronic anorectal pain by acupuncture.

Patients with irritable bowel syndrome and constipation are more depressed than patients with functional constipation

BACKGROUND

Psychosocial factors, such as depression, have been shown to be associated with gastrointestinal disorders like constipation.

METHODS

We retrospectively compared the depression and anxiety profiles of patients with irritable bowel syndrome with constipation versus those of patients with functional constipation using validated questionnaires. Subjects rated the intensity of digestive symptoms experienced during the previous month using visual analogue scales. Colonic transit time measurements and anorectal manometry were performed.

RESULTS

Of the 128 consecutive, constipated patients included (84% females, mean age 49.7 ± 15.5 years) 66 suffered from irritable bowel syndrome with constipation and 62 from functional constipation. Demographic and physiological traits were similar in the two groups. Patients suffering from irritable bowel syndrome with constipation reported higher depression scores (18.8 ± 1.4 vs 12.7 ± 1.3, P=0.002) and higher symptom intensity scores for constipation (6.2 ± 0.3 vs 4.3 ± 0.4, P<0.001), bloating (6.7 ± 0.3 vs 3.3 ± 0.4, P<0.001) and abdominal pain (6.0 ± 0.3 vs 2.7 ± 0.4, P<0.001) than patients with functional constipation. Multiple linear regression showed positive correlations between symptom intensity and depression and anxiety scores for functionally constipated patients only.

CONCLUSIONS

Our results support the integration of a psychosocial component to the traditional treatment of constipated patients; however, further research exploring causality between psychosocial factors and specific gastrointestinal disorders would contribute to developing a tailored therapeutic approach.

Clinical parameters and symptom severity in males with fecal leakage and incontinence

BACKGROUND

Despite the commonality of fecal incontinence (FI) in men, few studies have been carried out in this patient group. The aim of the study was to determine the contributions of clinical and physiological factors to symptom severity in males with fecal leakage (FL) and FI.

METHODS

The records of all male patients referred for evaluation of FI and FL over a 6-year period were analyzed. For each male case, the records of three age-matched female controls with FI or FL were retrieved. All patients completed symptom assessment questionnaires (Vaizey score) and standard anorectal manometry testing.

KEY RESULTS

A total of 100 males and 300 age-matched female controls were included. Vaizey scores were similar between sexes. For all Vaizey strata, males had normal maximal resting pressures (MRP) as well as normal maximal squeeze pressure (MSP). Females had a significantly reduced MRP and MSP across all Vaizey strata. In the FL subgroup, males had higher MRP and MSP than females. A multivariable linear regression analysis in males did not identify any clinical factors predictive of symptoms severity. For females, increased symptom duration, abnormal Bristol score, and reduced MSP were associated with worsening in Vaizey score.

CONCLUSIONS & INFERENCES

For females, FL represents one end of the severity spectrum of FI while in males FL has a distinct pathophysiology. Contributing factors to symptoms in males with FL are not identified by routine clinical tests; however, anorectal manometry may identify a subgroup of FL males with low anal sphincter pressures that may respond to targeted interventions.

Feedback control of TET system with variable coupling coefficients for a novel artificial anal sphincter

For treating severe faecal incontinence, the authors developed an intelligent artificial anal sphincter system (AASS) equipped with a feedback sensor that utilized a transcutaneous energy transfer system (TETS). To deliver the correct amount of power (i.e. to match the load demand under variable coupling conditions caused by changes in positioning between the coils due to fitting and changes in posture), a regulating method to stabilize output voltage with a closed loop variable-frequency controller was developed in this paper. The method via which the voltage gain characteristics of a voltage-fed series-tuned TETS were derived is also described. The theoretical analysis was verified by the results of the experiment. A numerical analysis method was used as a control rule with respect to the relationship between operating frequency and output voltage. To validate the feedback control rules, a prototype of the TET charging system was constructed, and its performance was validated with the coupling variation between 0.12-0.42. The results show that the output voltage of the secondary side can be maintained at a constant 7 V across the whole coupling coefficient range, with a switching frequency regulation range of 271.4-320.5 kHz, and the proposed controller has reached a maximal end-to-end power efficiency of 67.5% at 1 W.

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit

INTRODUCTION

Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service.

MATERIAL AND METHODS

We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011.

RESULTS

We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments.

CONCLUSION

Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

Dyssynergic defecation: a treatable cause of persistent symptoms when inflammatory bowel disease is in remission

BACKGROUND

Introduction of biologic agents in inflammatory bowel disease (IBD) has increased the likelihood of disease remission. Despite resolution of active inflammation, a subset of IBD patients report persistent defecatory symptoms.

AIM

To evaluate a group of patients with inflammatory bowel disease with suspected functional defecatory disorders, by use of anorectal manometric testing and subsequent biofeedback therapy.

METHODS

A group of IBD patients with persistent defecatory problems despite clinical improvement were included in this study. These patients had no evidence of left-sided disease. Endoscopic and radiographic study findings and timing in relation to the manometry study were recorded. Anorectal manometry was performed by the standard protocol and included rectal sensory assessment, ability to expel a balloon, and pressure dynamics with simulated defecation.

RESULTS

Thirty IBD patients (Crohn's 23 patients; ulcerative colitis six patients) presented with defecatory disorders including constipation (67%) increased stooling (10%), and rectal urgency and/or incontinence and rectal pain (6%). All but one patient had anorectal manometric criteria of dyssynergia (presence of anismus motor pattern and inability to expel the balloon). Of the patients who completed biofeedback therapy, 30% had a clinically significant (≥7-point) improvement in SIBDQ score, with a reduction in health-care utilization after a six-month period (p=0.02).

CONCLUSIONS

Despite remission, some inflammatory bowel disease patients have persistent defecatory symptoms. Defecatory symptoms may not be predictive of an underlying inflammatory disorder. Lack of inflammatory activity and absence of left-sided disease should prompt investigation of functional disorders. Anorectal manometric testing and biofeedback therapy for patients with a diagnosis of dyssynergia may be a useful therapy.

Functional disorders of the gastrointestinal tract: Cost effectiveness review

BACKGROUND

The project aim was to review current cost-effectiveness research for each functional gastrointestinal disorder, as defined by the Rome III classification system.

METHODS

Biomedical databases were searched for articles with the functional gastrointestinal disorders and their pseudonyms included in the title, abstract, or medical subject headings, plus the terms benefit, cost, effectiveness, outcomes, test, utility, or utilization in any search field.

RESULTS

Highly prevalent conditions such as dyspepsia and irritable bowel syndrome have advanced cost-effectiveness analyses including cost-utility studies that have helped support current management guidelines. The rarer functional gastrointestinal disorders have few or no published cost-effectiveness analyses, but the Rome III classification system provides a framework for identifying the specific cost data or outcomes measures available or needed for future research.

CONCLUSIONS

The Rome process has provided a useful system for defining the functional gastrointestinal disorders and identifying specific clinical questions to be examined using cost-effectiveness analysis techniques.

Comparison of rectal balloon expulsion test in seated and left lateral positions

BACKGROUND

Defecatory disorders can be diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions, respectively. The aims of this study were to compare BE in the LL and seated positions and to compare anorectal manometric parameters to BE performed in the seated and LL positions.

METHODS

220 women [healthy (62), chronic constipation (158)] had anorectal high-resolution manometry and BE, summarized by time required (seated position, normal ≤60 s) or external traction to facilitate expulsion (LL position, normal ≤100 g).

KEY RESULTS

Balloon expulsion results in both positions were either concordant [normal (141) or abnormal (32)] or discordant [only LL abnormal (30), only seated abnormal (17)]. There was modest agreement [κ = 0.44 (95% CI 0.30-0.57)] between seated and LL BE. Compared with subjects with normal BE in both positions, anal pressure during simulated evacuation (SE) was higher, and the rectoanal gradient (rectal-anal pressure) during SE was more negative in the other 3 categories (i.e., abnormal LL only, abnormal seated only, and both abnormal). High anal pressure during SE (OR = 1.02, 95% CI 1.00-1.04) and high rectal sensory threshold for desire to defecate (OR = 1.01, 95% CI 1.00-1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR = 0.96, 95% CI 0.93-0.98) was associated with lower risk.

CONCLUSIONS & INFERENCES

There is modest agreement between rectal BE in LL and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, high resolution manometry findings suggest that even some patients with abnormal BE in the LL position have pelvic floor dysfunction.

Stercoral perforation of the colon in sigmoid colostomy patients: Two case reports

INTRODUCTION

Stercoral perforation of the colon has rarely been reported. Only 3 cases of stercoral perforation of the colon proximal to an end colostomy have been reported. We present two cases of stercoral perforation of the colon in end colostomy patients.

PRESENTATION OF CASE

A 70-year-old man who had undergone abdomino-perineal excision for anal cancer was referred for left lower quadrant pain and fever. Stercoral perforation was discovered along the distal descending colon, proximal to the end sigmoid colostomy. The patient underwent segmental resection of the colon and revision of the stoma and was discharged on postoperative day 32. A 71-year-old woman who had undergone abdomino-perineal excision for distal rectal cancer with preoperative chemoradiation presented fever with 2 days of low abdominal pain. The patient had sacral bone and lung metastases from rectal cancer and suffered from chronic constipation. Stercoral perforation was found around the sigmoid colon, just proximal to the end sigmoid colostomy. The patient underwent simple repair of the perforated colon through the parastomal incision. On postoperative day 8, leakage occurred at the repair site. Segmental resection of the colon and revision of the stoma were performed. She was discharged 44 days after the initial surgery.

DISCUSSION

Segmental resection of the perforated colon, rather than simple repair, appears to improve postoperative outcomes.

CONCLUSION

As the number of cancer survivors increases, appropriate management of constipation is important to prevent stercoral perforation during follow-up.

Anxiety and depression as markers of multiplicity of sites of functional gastrointestinal disorders: a gender issue?

BACKGROUND

Anxiety and depression are frequently present in patients with different types of functional gastrointestinal disorders (FGID), and seem to play a major part in both the perception of symptoms and the outcome of treatment.

AIMS

The aim of the present study was therefore to evaluate levels of anxiety and depression in adult patients according to the extent and the type of FGID.

METHODS

Three hundred and eighty-five consecutive patients (72% female) were evaluated. Each patient filled a standard clinical questionnaire based on diagnostic questions for uro-genital complaints and for FGID according to the Rome III criteria. In addition, they indicated on a 10-cm visual analog scale (VAS) the intensity of constipation, diarrhea, bloating, and abdominal pain, and stool description using the Bristol Stool Form Scale. Anxiety and depression were evaluated using Beck Depression Inventory and Anxiety State and Trait Anxiety Inventory.

RESULTS

In FGID patients, levels of depression, state and trait anxiety are higher in patients with several sites of complaint. Females are more depressed than males, regardless of the level of FGID. Females tend to react emotionally to stress with a lot of anxiety ("state" anxiety), as well as in the long run ("trait" anxiety). VAS parameters for constipation, bloating and abdominal pain were related to psychological scores in contrast to VAS diarrhea and stool form. In males, the extent of sites of FGID was strongly related to trait anxiety. In females, it was strongly related to depression.

CONCLUSION

Different types of FGID are associated with depression and anxiety according to the number of sites of complaints linked to gender and psychological parameters, as well as the magnitude of complaint expressed by the VAS.

Attributes and barriers to care of pelvic pain in university women

STUDY OBJECTIVE

To describe rates of pelvic pain in university women ages 18 and older and to explore the barriers to adequate health care for pelvic pain in this population.

DESIGN

A cross-sectional study (Canadian Task Force classification II-2).

SETTING

University of Florida, Gainesville, FL.

PATIENTS

A total of 2000 female students at the University of Florida were randomly selected for participation.

INTERVENTIONS

The 2000 sample members were sent a questionnaire to be completed online.

MEASUREMENTS AND MAIN RESULTS

The online questionnaire was hosted through the REDCap electronic data capture tool hosted at the University of Florida. This questionnaire included demographic items, general health and health behavior questions, measures to assess different types of pelvic pain (e.g., dysmenorrheal; dyspareunia; urinary, bowel, and vulvar pain), items regarding barriers to care for pelvic pain problems, and quality of life measures. Data were exported to SAS software (SAS Institute Inc., Cary, NC) for analysis. Of the 2000 subjects who received the questionnaire invitation, 390 filled out the questionnaire, yielding a response rate of 19.5%. Respondents' ages ranged from 18 to 62 with a mean of 23 years. A total of 72.8% of respondents reported experiencing pelvic pain over the past 12 months. Dysmenorrhea was reported by nearly 80% of participants, over one third of participants noted deep dyspareunia, and a significant proportion of participants reported symptoms related to bowel movements. Vulvar symptoms, including superficial dyspareunia, were reported by 21.5% of participants. Most participants with pelvic pain (78.8%) have not received any diagnosis for their pain, whereas 73.6% reported not yet having visited a doctor. Significant barriers to receiving adequate medical care were reported, including difficulty with insurance coverage and physicians' lack of time and knowledge or interest in chronic pelvic pain conditions.

CONCLUSION

Pelvic pain in younger women is a critical public health issue experienced by a significant portion of the population. Significant awareness deficits and barriers to care exist. Careful study of the barriers to receiving adequate medical care reported by these women will allow researchers to describe how best to improve care for these syndromes.

Magnetic resonance imaging of pelvic floor dysfunction

Pelvic floor dysfunction is largely a complex problem of multiparous and postmenopausal women and is associated with pelvic floor or organ descent. Physical examination can underestimate the extent of the dysfunction and misdiagnose the disorders. Functional magnetic resonance (MR) imaging is emerging as a promising tool to evaluate the dynamics of the pelvic floor and use for surgical triage and operative planning. This article reviews the anatomy and pathology of pelvic floor dysfunction, typical imaging findings, and the current role of functional MR imaging.

Abdominal pain localization is associated with non-diarrheic Rome III functional gastrointestinal disorders

BACKGROUND

Abdominal pain is common in patients with functional bowel disorders (FBDs). The aim of this study was to characterize the predominant sites of abdominal pain associated with FBD subtypes, as defined by the Rome III criteria.

METHODS

A total of 584 consecutive patients attending FBD consultations in a tertiary center participated in the study. Stool form, abdominal pain location (nine abdominal segments), and pain intensity (10-point Likert scale) during the previous week were recorded. Logistic regression analysis was used to characterize the association of abdominal pain sites with specific FBD subtypes.

KEY RESULTS

FBDs were associated with predominant pain sites. Irritable bowel syndrome (IBS) with constipation was associated with pain in the left flank and patients were less likely to report pain in the right hypochondrium. Patients with functional constipation reported pain in the right hypochondrium and were less likely to report pain in the left flank and left iliac site. IBS with alternating constipation and diarrhea was associated with pain in the right flank, and unsubtyped IBS with pain in the hypogastrium Patients with functional abdominal pain syndrome reported the lower right flank as predominant pain site. Patients with unspecified FBDs were least likely to report pain in the hypogastrium. Patients with functional diarrhea, IBS with diarrhea, or functional bloating did not report specific pain sites.

CONCLUSIONS & INFERENCES

The results from this study provide the basis for developing new criteria allowing for the identification of homogeneous groups of patients with non-diarrheic FBDs based on characteristic sites of pain.

Advances in motility testing--current and novel approaches

Disorders of gastrointestinal motility are frequently seen in clinical practice. Apart from motility disorders, factors leading to lowered visceroperception thresholds are recognized as commonly involved in the pathogenesis of functional gastrointestinal disorders. The wide array of gastrointestinal motility and viscerosensitivity tests available is in contrast with the relatively limited number of tests used universally in clinical practice. The main reason for this discrepancy is that the outcome of a test only becomes truly important when it carries clinical consequences. The main goal of this Review is to assess the place of the presently available gastrointestinal motility and sensitivity tests in the clinical armamentarium of the gastroenterologist.

Faecal soiling: pathophysiology of postdefaecatory incontinence

AIM

Passive postdefaecatory incontinence is poorly understood and yet is an important clinical problem. The aim of this study was to characterize the pathophysiology of postdefaecatory incontinence in patients affected by faecal soiling.

METHOD

Seventy-two patients (30 women, age range 49-79 years; 42 men, age range, 53-75 years) affected by faecal passive incontinence with faecal soiling were included in the study. Two patient groups were identified: Group 1 comprised 42 patients with postdefaecatory incontinence and Group 2 had 30 patients without incontinence after bowel movements. After a preliminary clinical evaluation, including the Faecal Incontinence Severity Index (FISI) score and the obstructed defaecation syndrome (ODS) score, all patients of Groups 1 and 2 were studied by means of endoanal ultrasound and anorectal manometry. The results were compared with those from 20 healthy control subjects.

RESULTS

A significantly higher ODS score was found in Group 1 (P < 0.001). Endoanal ultrasound revealed a significantly diffuse thinning of the internal anal sphincter (IAS) in Group 2 (P < 0.02) with a linear relationship between signs of IAS atrophy and the FISI score (ρs 0.78; P < 0.03). Anal resting pressure (Pmax and Pm ) was significantly lower in Group 2 (P < 0.04). The straining test was considered positive in 30 (71.4%) patients in Group 1, significantly greater than in Group 2 (P < 0.01). A significantly higher conscious rectal sensitivity threshold (CRST) was found in Group 1 patients (P < 0.01).

CONCLUSION

The ODS score, a positive straining test and high CRST values suggest that postdefaecatory incontinence is secondary to impaired defaecation.

Biofeedback therapy combined with traditional chinese medicine prescription improves the symptoms, surface myoelectricity, and anal canal pressure of the patients with spleen deficiency constipation

In order to observe the clinical therapeutic effects of Yiqi Kaimi Prescription and biofeedback therapy on treating constipation with deficiency of spleen qi, the 30 cases in the control group were given oral administration of Yiqi Kaimi Prescription, in combination with anus-lifting exercise; the 30 cases in the treatment group were given biofeedback therapy on the basis of the afore mentioned methods for the control group. The TCM symptom scores and anorectal pressures before and after treatment were observed and evaluated. There were significant differences in TCM symptom scores, anorectal pressure, and clinical recovery rate before and after treatment. In the treatment group, the total recovery rate was 86.66%, while in the control group it was 50%; there were significant differences between the two groups (P < 0.01). Yiqi Kaimi Prescription coupled with biofeedback therapy is clinically effective for treating constipation with deficiency of spleen qi, and thus this method is applicable for functional constipation with deficiency of spleen qi.

Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis

BACKGROUND

Dyssynergic defecation (DD) results from inadequate relaxation of the pelvic floor on attempted defecation. The prevalence of DD in patients with chronic constipation (CC) is not certain. Aims of this study are to estimate the prevalence of abnormal findings associated with DD across testing modalities in patients referred for physiological testing for CC.

METHODS

Systematic search of MEDLINE, EMBASE and PUBMED databases were conducted. We included full manuscripts reporting DD prevalence in CC, and specific findings at pelvic floor diagnostic tests. Random effects models were used to calculate pooled DD prevalences (with 95% CI) according to individual tests and specific findings.

KEY RESULTS

A total of 79 studies on 7581 CC patients were included. The median prevalence of any single abnormal finding associated with DD was 37.2%, ranging from 14.9% (95% CI 7.9-26.3) for absent opening of the anorectal angle (ARA) on defecography to 52.9% (95% CI 44.3-61.3) for a dyssynergic pattern on ultrasound. The prevalence of a dyssynergic pattern on manometry was 47.7% (95% CI 39.5-56.1). The prevalence of DD was similar across specialty and geographic area as well as when restricting to studies using Rome criteria to define constipation.

CONCLUSIONS & INFERENCES

Dyssynergic defecation is highly prevalent in CC and is commonly detected across testing modalities, type of patient referred, and geographical regions. We believe that the lower prevalence of findings associated with DD by defecography supports use of manometry and balloon expulsion testing as an initial evaluation for CC.

Interpretation of overall colonic transit in defecation disorders in males and females

BACKGROUND

There is little information regarding gender-specific measurements of colonic transit and anorectal function in patients with defecation disorders (DD). To compare overall colonic transit by gender in DD.

METHODS

In 407 patients with constipation due to DD diagnosed by a single gastroenterologist (1994-2012), DD was characterized by anorectal manometry, balloon expulsion test, and colonic transit by scintigraphy. The primary endpoint was overall colonic transit (geometric center, GC) at 24 h (GC24). Effects of gender in DD on colonic transit, and comparison with transit in 208 healthy controls were assessed by Mann-Whitney rank sum test. Secondary endpoints were maximum anal resting (ARP) and squeeze (ASP) pressures. We also tested association of the physiological endpoints among DD females by pregnancy history and among DD patients by colectomy history.

KEY RESULTS

The DD patients were 67 males (M) and 340 females (F). Significant differences by gender in DD patients were observed in GC24 (median: M: 2.2; F: 1.8; P = 0.01), ARP (median: M: 87.8 mmHg; F: 82.4 mmHg; P = 0.04), and ASP (median: M: 182.4 mmHg; F: 128.7 mmHg; P < 0.001). GC24 was slower in DD compared with same-gender healthy controls. GC24 did not differ among DD females by pregnancy history. Anorectal functions and upper GI transit did not differ among DD patients by colectomy history.

CONCLUSIONS & INFERENCES

Patients with DD have slower colonic transit compared with gender-matched controls. Among DD patients, males have higher ARP and ASP, and females have slower colonic transit. Although the clinical significance of these differences may be unclear, findings suggest that interpretation of these tests in suspected DD should be based on same-gender control data.

The association between prucalopride efficacy and constipation type

BACKGROUND

Prucalopride is a selective serotonin receptor agonist with prokinetic activity, indicated for women with chronic constipation in whom laxatives have failed to provide adequate relief. Data suggests an improvement in about 50 % of such patients but whether the therapeutic effect is on patients with slow transit constipation (STC) and/or obstructed defaecation syndrome (ODS), or even those with constipation-predominant irritable bowel syndrome (IBS-C) is unknown. We therefore assessed whether there is any association between prucalopride efficacy and constipation type.

METHODS

All patients receiving prucalopride between June 2010 and April 2012 at our institution were identified, and data analysed following a 4-week "test" period. Patients were sub-grouped as those suffering with ODS, STC, mixed (ODS and STC) or IBS-C based on symptomatology and investigations. Subjective assessment of patient satisfaction and continuation of medication were taken as positive outcomes and analysed for each sub-type along with any side effects.

RESULTS

Sixty-nine patients met our criteria. Data were available for 59 women (median age 46 years, range 17-79 years). Sixty-five per cent of prescriptions came from colorectal surgeons. Overall, 25 out of 59 (42 %) patients improved, according to our criteria, after the 4-week trial period. Seventeen patients (29 %) had ODS, 26 (44 %) had STC, 7 (12 %) had mixed symptoms and 9 (15 %) had IBS-C. At 4 weeks, 10 out of 17 patients (59 %) with ODS had improved compared with 4 out of 9 patients (44 %) with IBS-C, 3 out of 7 patients (43 %) with mixed symptoms and 8 out of 26 (31 %) patients with STC. The underlying disorder did not predict whether or not a patient responded to the 4-week trial period (p = 0.32). Nine patients (15 %) experienced side effects that precluded further use.

CONCLUSIONS

Patients with all categories of constipation may respond to prucalopride. A trial regime may be indicated regardless of the aetiology of the constipation.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Significance of defecographic parameters in diagnosing pelvic floor dyssynergia

PURPOSE

Defecography is known to be a sensitive and specific measurement of pelvic floor dyssynergia (PFD). However, its standardized parameter for diagnostic analysis is still incomplete. We attempted to determine which defecographic findings are most significant for PFD, and how closely they match other physiologic tests and clinical symptoms of functional pelvic outlet obstruction.

METHODS

Ninety-six patients with constipation who completed work-up of their symptoms with defecography, anorectal manometry and electromyography (EMG) were included in the study. Internal consistency of defecographic findings, and agreements between defecographic findings and results of other tests were statistically analyzed (Crohnbach's α, Cohen's κ, respectively).

RESULTS

Of the 96 patients evaluated, obstructive symptoms of constipation were obvious in 35 (36.5%) by obstructive symptom score. As known defecographic findings for PFD, poor opening of the anal canal was found in 33 (34.4%), persistent posterior angulation of the rectum in 33 (34.4%), and poor emptying of the rectum in 61 (63.5%). Manometric defecation index, manometric evacuation index, and EMG findings compatible with PFD were in 81 (84.4%), 72 (75%), and 73 (76%), respectively. Internal consistency of three defecographic findings was good (α = 0.78). Agreements between each defecographic findings and each result of other tests were all poor.

CONCLUSION

Among known defecographic findings for PFD, one specific finding cannot be considered more important than the others for its diagnosis. It is hard to expect consistent results of various diagnostic tests and to predict the presence of defecographic PFD by use of anorectal manometry, EMG, or even by clinical symptoms.

Longitudinal study of bowel function in children with anorectal malformations

PURPOSE

Longitudinal follow-up of changes in bowel function in children with anorectal malformations (ARMs) with or without spinal cord pathology and neurogenic bladder dysfunction (NBD) as they grow. Another purpose was to identify predictors influencing bowel functional outcome.

MATERIAL AND METHODS

The study included 41 patients with ARM, excluding perineal fistula (21 boys and 20 girls). Bowel function was evaluated at ages 5, 10 and 15 years using a structured questionnaire and a three-week registration of number and time of bowel movements, episodes of fecal leakage and soiling. Additional bowel treatment with enemas and stool softeners and use of diapers were recorded. A group of 52 healthy boys and girls was used as control.

RESULTS

A successive improvement in functional outcome with age in children with ARM and normal spinal cord was seen with respect to continence, soiling and constipation. Continence was achieved earlier in girls than in boys (at 10 years: girls 80%, boys 36%). Soiling and constipation decreased with age both in grade and frequency (at 10 years low grade soiling: girls 53%, boys 64%). Boys with spinal cord malformation with NBD in combination with prostatic/bladder neck fistula (PRF/BNF) and sacral agenesis had the worst functional outcome with minimal possibility of improvement over time. Functional outcome in girls with NBD and tethered cord did not differ significantly from those without NBD and with a normal spinal cord. Psychosocial co-morbidity, neuropsychiatric disorders, developmental delay and megarectosigmoid were also risk factors impeding the functional outcome.

CONCLUSION

In the present study there was a successive improvement in bowel function during childhood and adolescence in ARM children, but they did not achieve the level of healthy children. NBD, spinal cord malformation, sacral malformation and PRF all were negative predictive factors for bowel score at 5 years.

Manometric evaluation of evacuatory difficulty (dyschezia) in ileal pouch patients

BACKGROUND

Dyschezia occurs in patients with ileal pouch-anal anastomosis. There are limited data on the mechanisms of this condition. We hypothesized that paradoxical contractions may contribute to dyschezia in those patients with mechanical or inflammatory pouch conditions. This study was aimed to evaluate the underlying manometric abnormalities in this population.

METHODS

In this retrospective analysis, we screened our Pouchitis Registry for patients with dyschezia and underlying inflammatory bowel disease. Patients having undergone anopouch manometry were considered eligible and included. Patients without inflammatory or structural diseases of the pouch (the functional pouch disorder [FPD] group) were compared with those with inflammatory or structural diseases (the inflammatory/structural pouch disorder [ISPD] group). Demographic, clinical, manometric, and laboratory variables were analyzed.

RESULTS

A total of 45 patients were included; of which, 21 (46.7%) were female. The median age of patients in the FPD group (n = 10) and ISPD group (n = 35) were 41 (interquartile range =32.5-56) years and 40 (interquartile range = 28-49) years, respectively (P = 0.469). There were no differences in the demographic, clinical, and laboratory variables between the 2 groups, with the exception of the modified Pouch Disease Activity Index. For manometric evaluations, paradoxical contractions and failure of balloon expulsion occurred in 50.0% and 60.0%, respectively, of the FPD group and in 17.1% and 20.0%, respectively, of the ISPD group (P = 0.048 and 0.043, respectively).

CONCLUSIONS

In this cohort, manometric evaluation demonstrated that paradoxical contractions occurred more frequently in patients with FPD than in those with inflammatory/structural conditions. This suggests that the underlying physiologic mechanisms of dyschezia in these patients differ.

Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry

BACKGROUND & AIMS

Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry.

METHODS

We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry.

RESULTS

Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times.

CONCLUSIONS

Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.

Factors associated with symptom severity in women presenting with fecal incontinence

BACKGROUND

Fecal incontinence (FI) affects 2-12% of the US population. Identification of factors associated with worsening symptoms has important implications for prevention and treatment.

OBJECTIVE

The aim of our study is to assess factors associated with symptom severity in women presenting with FI.

DATA SOURCES

This was a prospective survey study.

STUDY SELECTION

Patients presenting to the Michigan Bowel Control Program Clinic for FI were prospectively enrolled between May 2005 and May 2009.

MAIN OUTCOME MEASURES

Factors associated with fecal incontinence severity.

RESULTS

Data on 231 women was analyzed with a mean age of 59.2 years (SD = 14.2) and mean BMI of 30.0 (SD = 8.6); 92% were white. Mean FISI score was 32.4 (SD = 15.3). Two-thirds of patients had a type 1-4 stool on the Bristol stool scale. Forty-one percent of subjects complained of urinary incontinence, 56.2% had an episiotomy, 29% had an operative delivery, and 15.1% reported a severe laceration with childbirth. The majority of patients (86.1%) reported FI for greater than 1 year, and 65.4% had previously sought care for FI. Bivariate analysis revealed that diabetes, IBS, urinary incontinence, history of operative delivery or severe laceration, fecal urgency, longer history of symptoms, previous health care for FI, and belief in treatment were positively associated with worse FISI score. In multiple linear regression analysis, increased FI symptom severity was shown to be associated with fecal urgency (0.0004), history of episiotomy (0.04), urinary incontinence (0.02), and diabetes mellitus (0.004).

LIMITATIONS

This was a cross-sectional survey study performed at a Tertiary care center.

CONCLUSION

Patients with a history of episiotomy, diabetes, urinary incontinence, and fecal urgency have increased FI symptom severity. Proactive screening of patients with these medical histories is needed.

Interferential therapy: a new treatment for slow transit constipation. a pilot study in adults

AIM

The study aimed to assess, for the first time, the effectiveness of interferential therapy (IFT) in the treatment of slow transit constipation in adults and its impact on the quality of life.

METHOD

All consecutive patients with slow transit constipation diagnosed by symptomology and a colonic transit time (CTT) of > 100 h measured with radiopaque markers were included in this prospective study. IFT was performed for 1 h/day over 3 months. Clinical improvement was based on the stool diary and the Knowles-Eccersley-Scott Symptom and Cleveland Clinic Constipation Scores. Quality of life was assessed with the Gastrointestinal Quality of Life Index questionnaire.

RESULTS

Eleven patients with a median age of 51 years were included. At the end of the follow-up period, seven (63.6%) had significantly improved after IFT with a median of 0.66 stools per week [interquartile range (IQR) 0.33-0.66] before treatment and 1.66 (IQR 1.33-1.66) after (P = 0.007). The Knowles-Eccersley-Scott Symptom score changed from 30 (IQR 27-33) before treatment to 19 (IQR 17-26) after treatment (P = 0.005) and the Cleveland Clinic Constipation Score from 26 (IQR 25-28) to 17 (IQR 13-24; P = 0.005). The CTT improved from 103 h (IQR 101-113) to 98 h (IQR 94-107; P = 0.02). The Gastrointestinal Quality of Life Index score improved from 60 (IQR 57-63) to 95 (IQR 68-100; P = 0.005).

CONCLUSION

IFT is a new non-invasive treatment for slow transit constipation. Further studies to confirm these results with longer follow-up are necessary.

[Anorectal diagnostics for proctological diseases]

The majority of proctological diseases can be defined by a structured evaluation of the symptoms and a physical examination. Magnetic resonance imaging (MRI) and anal endosonography can detect complex anal fistulas with a high accuracy but MRI should be preferred because of its objective visualization. Functional anorectal disorders are multifactorial and show morphological and functional irregularities in different compartments of the pelvic floor which is why MR defecography is now one of the most important methods in diagnostic algorithms. Interpreting the results of anal endosonography, anal manometry and neurophysiological testing is highly demanding because of large interindividual variability. Scores are used for objective measurement of symptom severity and quality of life. In clinical practice, well validated scores evaluated in large patient groups with predetermined circumstances are needed. Bringing together morphological results with scores based on subjective perception is required to optimize diagnostics and therapy evaluation in proctology.

Rectal hyposensitivity

Impaired or blunted rectal sensation, termed rectal hyposensitivity (RH), which is defined clinically as elevated sensory thresholds to rectal balloon distension, is associated with disorders of hindgut function, characterised primarily by symptoms of constipation and fecal incontinence. However, its role in symptom generation and the pathogenetic mechanisms underlying the sensory dysfunction remain incompletely understood, although there is evidence that RH may be due to 'primary' disruption of the afferent pathway, 'secondary' to abnormal rectal biomechanics, or to both. Nevertheless, correction of RH by various interventions (behavioural, neuromodulation, surgical) is associated with, and may be responsible for, symptomatic improvement. This review provides a contemporary overview of RH, focusing on diagnosis, clinical associations, pathophysiology, and treatment paradigms.

Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient

OBJECTIVES

High-resolution manometry (HRM) is used to measure anal pressures in clinical practice but normal values have not been available. Although rectal evacuation is assessed by the rectoanal gradient during simulated evacuation, there is substantial overlap between healthy people and defecatory disorders, and the effects of age are unknown. We evaluated the effects of age on anorectal pressures and rectal balloon expulsion in healthy women.

METHODS

Anorectal pressures (HRM), rectal sensation, and balloon expulsion time (BET) were evaluated in 62 asymptomatic women ranging in age from 21 to 80 years (median age 44 years) without risk factors for anorectal trauma. In total, 30 women were aged <50 years.

RESULTS

Age is associated with lower (r=-0.47, P<0.01) anal resting (63 (5) (≥50 years), 88 (3) (<50 years), mean (s.e.m.)) but not squeeze pressures; higher rectal pressure and rectoanal gradient during simulated evacuation (r=0.3, P<0.05); and a shorter (r=-0.4, P<0.01) rectal BET (17 (9) s (≥50 years) vs. 31 (10) s (<50 years)). Only 5 women had a prolonged (>60 s) rectal BET but 52 had higher anal than rectal pressures (i.e., negative gradient) during simulated evacuation. The gradient was more negative in younger (-41 (6) mm Hg) than older (-12 (6) mm Hg) women and negatively (r=-0.51, P<0.0001) correlated with rectal BET but only explained 16% of the variation in rectal BET.

CONCLUSIONS

These observations provide normal values for anorectal pressures by HRM. Increasing age is associated with lower anal resting pressure, a more positive rectoanal gradient during simulated evacuation, and a shorter BET in asymptomatic women. Although the rectoanal gradient is negatively correlated with rectal BET, this gradient is negative even in a majority of asymptomatic women, undermining the utility of a negative gradient for diagnosing defecatory disorders by HRM.

Semi-automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence

BACKGROUND

Inter-observer variability limits the reproducibility of pelvic floor motion measured by magnetic resonance imaging (MRI). Our aim was to develop a semi-automated program measuring pelvic floor motion in a reproducible and refined manner.

METHODS

Pelvic floor anatomy and motion during voluntary contraction (squeeze) and rectal evacuation were assessed by MRI in 64 women with fecal incontinence (FI) and 64 age-matched controls. A radiologist measured anorectal angles and anorectal junction motion. A semi-automated program did the same and also dissected anorectal motion into perpendicular vectors representing the puborectalis and other pelvic floor muscles, assessed the pubococcygeal angle, and evaluated pelvic rotation.

KEY RESULTS

Manual and semi-automated measurements of anorectal junction motion (r = 0.70; P < 0.0001) during squeeze and evacuation were correlated, as were anorectal angles at rest, squeeze, and evacuation; angle change during squeeze or evacuation was less so. Semi-automated measurements of anorectal and pelvic bony motion were also reproducible within subjects. During squeeze, puborectalis injury was associated (P ≤ 0.01) with smaller puborectalis but not pelvic floor motion vectors, reflecting impaired puborectalis function. The pubococcygeal angle, reflecting posterior pelvic floor motion, was smaller during squeeze and larger during evacuation. However, pubococcygeal angles and pelvic rotation during squeeze and evacuation did not differ significantly between FI and controls.

CONCLUSION & INFERENCES

This semi-automated program provides a reproducible, efficient, and refined analysis of pelvic floor motion by MRI. Puborectalis injury is independently associated with impaired motion of puborectalis, not other pelvic floor muscles in controls and women with FI.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Dynamic transperineal ultrasound in the workup of men with obstructed defecation: a pilot study

BACKGROUND

Dynamic transperineal ultrasound has been used in women for the noninvasive investigation of functional disorders of the posterior pelvic floor, but its use in men has been limited by technical difficulties related to the consistency of the male perineum.

OBJECTIVES

The aim of this study was to explore the efficacy of dynamic transperineal ultrasound in diagnosing posterior pelvic floor dysfunction in men.

DESIGN

This is a study of diagnostic accuracy.

SETTINGS

This study was performed at a public hospital.

PATIENTS

Forty-six men with symptoms of obstructed defecation were included.

INTERVENTIONS

All patients underwent dynamic transperineal ultrasound 1 week after standard defecography with manometric confirmation when rectoanal dyssynergy was observed.

MAIN OUTCOME MEASURES

Images were obtained, and anorectal angles were measured under resting conditions and during maximal strain. The accuracy of the sonographic method in diagnosing pelvic floor alterations was assessed against defecography (reference method).

RESULTS

: Anorectal angles measured with ultrasound and defecography were not significantly different under resting conditions or maximum strain. Sonographic and reference method findings were concordant in 41 (89.1%) of the cases (25 with rectoanal intussusceptions, 7 with rectorectal intussusceptions, 8 with rectoanal dyssynergy, and 1 with rectorectal intussusception and dyssynergy). In 1 patient with rectoanal intussusception, dynamic transperineal ultrasound was nondiagnostic (low image quality probably due to dehydration of perineal tissues). Discordant dynamic transperineal ultrasound findings included normal findings in another patient with rectoanal intussusception, diagnosis of rectoanal intussusception in 2 men with rectorectal intussusception, and failure to detect dyssynergy in a second patient with rectorectal intussusception and dyssynergy. The sensitivity, specificity, and Cohen κ indices for dynamic transperineal ultrasound were 92.6%, 90.5%, and 82% (rectoanal intussusception); 81.8%, 100%, and 87% (rectorectal intussusception); 90%, 100%, and 93% (rectoanal dyssynergy).

LIMITATIONS

This study was limited by its small size and by the absence of patients with other morphofunctional disorders associated with obstructed defecation.

CONCLUSIONS

Dynamic transperineal ultrasound is potentially useful for diagnosis and follow-up of posterior pelvic floor dysfunction in men.

Psychiatric, somatic and other functional gastrointestinal disorders in patients with irritable bowel syndrome at a tertiary care center

BACKGROUND/AIMS

To study the prevalence of somatic and psychiatric co-morbidities in the patients of irritable bowel syndrome (IBS) and to assess the quality of life (QOL) of these patients.

METHODS

One hundred and eighty-four IBS patients and 198 controls were included. Diagnosis of IBS, its sub-classification and assessment of other functional gastrointestinal disorders (FGIDs) was made on basis of Rome III criteria. Severity of IBS was assessed using IBS severity scoring system. Psychiatric evaluation was done using Patient Heath Questionnaire. QOL was evaluated using WHO QOL-BREF.

RESULTS

One hundred and forty-seven (79.9%) and 158 (85.9%) patients with IBS had at least one other FGID or at least one somatic co-morbidity, respectively. Higher number of patients had at least one psychiatric co-morbidity compared to controls (79.9% vs 34.3%; P < 0.001). Major depressive syndrome (47.3% vs 5.1%; P < 0.001), somatoform disorder (50% vs 14.6%; P < 0.001) and panic syndrome (44% vs 11.6%; P < 0.001) were more common in IBS than controls. Only 14 (7.6%) patients were receiving drug treatment for their psychiatric illness. Severe IBS symptoms were present in significantly higher number of patients with constipation predominant IBS than diarrhea predominant IBS. Those with severe disease had higher prevalence of psychiatric (95.1%) and somatic (96.7%) co-morbidities compared with mild disease. QOL of IBS patients was significantly lower in all four domains compared to controls. Presence of at least one other FGID was significantly associated with presence of one or more psychiatric co-morbidity (P < 0.001).

CONCLUSIONS

Majority of IBS patients presenting to a tertiary care center had associated psychiatric, somatic co-morbidities and reduced QOL. Very few of them received specific psychiatric treatment.

A cross-sectional survey of the relationship between fecal incontinence and constipation

INTRODUCTION AND HYPOTHESIS

We compared the prevalence of fecal incontinence between constipated and nonconstipated women and correlated its prevalence with the number of Rome III constipation symptoms.

METHODS

We performed a cross-sectional survey to evaluate the prevalence of fecal incontinence and constipation among women who presented to two gynecologic clinics for routine care over a 24-month period. Fecal incontinence was defined as loss of well-formed and/or loose stool beyond the patient's control that occurred at least once in the last 4 weeks, was bothersome, had been present for the past 3 or more months, and had affected the person's activities, relationships, or feelings. Constipation was diagnosed using the Rome III criteria. Our study was exempt from institutional review board approval because it was a survey and did not ask for information that could be used to identify the participant.

RESULTS

Mean age of the 2,319 participants was 50.1 ± 15 years and mean body mass index (BMI) was 28.7 ± 7. Seven hundred and twenty-five (31 %) women had constipation, and 233 (10 %) had fecal incontinence. One hundred and one (43 %) incontinent women had coexisting constipation. Logistic regression analysis identified white race (p = .013), menopause (p = .010), and constipation (p = .004) as risk factors for fecal incontinence. After controlling for these risk factors, constipated women were more likely to have fecal incontinence than nonconstipated women [relative risk (RR) 1.60, 95 % confidence interval (CI) 1.26-2.05]. In addition, the prevalence of fecal incontinence was strongly associated with the number of Rome III constipation symptoms (p < .001).

CONCLUSION

Constipation is an important risk factor for fecal incontinence.

The physiology of human defecation

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.

Prevalence and co-occurrence of upper and lower functional gastrointestinal symptoms in patients eligible for bariatric surgery

BACKGROUND

Obesity is considered as a risk factor for many functional digestive disorders. The aim of the present study was to evaluate the prevalence and the association of functional digestive symptoms affecting the upper and the lower digestive tract in patients eligible for bariatric surgery.

METHODS

Before surgery, 120 consecutive patients with normal upper endoscopy (7.5% males, mean BMI 44 ± 6 m/kg(2)) have filled a standard questionnaire in order to evaluate the presence of depressive symptoms and functional digestive disorders according to the Rome criteria. The major symptoms (esophageal, gastroduodenal, anorectal, and abdominal pain) were coded as dichotomous variables. Data analysis was performed using multivariate logistic regression with a backwards selection procedure adjusted only for the variables that were significant in univariate analysis (p < 0.05).

RESULTS

Functional symptoms were present in 89% of the subjects (2.5 functional digestive symptoms/subject). Depression symptoms were found in 43% of the patients. Esophageal symptoms were independent predictors for the presence of gastric, bowel, and anorectal symptoms. Functional abdominal pain and bowel symptoms were present, respectively, in 19% and 84% of the patients. Approximately half of the patients have specific functional bowel disorders (28.6% constipation, 18% irritable bowel syndrome, 18% diarrhea, 1% bloating) and 35.7% have non-specific bowel disorders. Anorectal symptoms were found in 40% of the patients: difficult defecation in 32% and fecal incontinence in 9.8% of the patients. Depression was an independent predictor for anorectal symptoms.

CONCLUSIONS

This study shows the high prevalence of functional bowel symptoms in patients complaining of morbid obesity.

Functional studies of the gastrointestinal tract in adult surgical clinics: when do they help?

Gut motility and visceral sensation are two important components of normal gastrointestinal (GI) tract function. Disordered gut motility and sensation can cause significant symptoms which not only pose a health burden to patients, but may also mimic structural diseases and may generate many surgical referrals from primary care. Unfortunately, diagnostic testing for disorders of function lags well behind that for structural disease. In this article we review common presentations of functional disorders in surgical clinics, and relevant testing modalities.

Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Obstructed defaecation: what is the role of rehabilitation?

AIM

The study was designed to evaluate the results of rehabilitative treatment in patients suffering from obstructed defaecation.

METHOD

Between January 2008 and July 2010, 39 patients (37 women, age range 25-73 years; and two men, aged 57 and 67 years) affected by obstructed defaecation were included in the study. After a preliminary clinical evaluation, including the Obstructed Defaecation Syndrome (ODS) score, defaecography and anorectal manometry were performed. All 39 patients underwent rehabilitative treatment according to the 'multimodal rehabilitative programme' for obstructive defaecation. At the end of the programme, all 39 patients were reassessed by clinical evaluation and anorectal manometry. Postrehabilition ODS scores were used to categorize patients arbitrarily into three classes, as follows: class I, good (score ≤ 4); class II, fair (score > 4 to ≤ 8); and class III, poor (score > 8).

RESULTS

After rehabilitation, there was significant improvement in the overall mean ODS score (P < 0.001). Thirty (76.9%) patients were included as class I (good results), of whom eight (20.5%) were symptom free. Five (12.8%) patients were considered class III. A significant postrehabilitative direct correlation was found between ODS score and pelvic surgery (ρ(s) = 0.54; P < 0.05). Significant differences were found between pre- and postrehabilitative manometric data from the straining test (P < 0.001), duration of maximal voluntary contraction (P < 0.001) and conscious rectal sensitivity threshold (P < 0.02).

CONCLUSION

After rehabilitation, some patients become symptom free and many had an improved ODS score.

[Acupuncture combined with Chinese herbal medicine Plantain and Senna Granule in treatment of functional constipation: a randomized, controlled trial]

BACKGROUND

Functional constipation is one of the most common gastrointestinal diseases. Currently, there is no effective Western medical therapy for functional constipation and it significantly impacts the quality of life of the patients. Integrated traditional Chinese and Western medicine therapies were reported to have better therapeutic effects than routine Western medicine therapies.

OBJECTIVE

To explore the efficacy of acupuncture combined with Chinese herbal medicine Plantain and Senna Granule in the treatment of functional constipation.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

A total of 390 patients with confirmed functional constipation enrolled from the Department of Gastroenterology, the First Affiliated Hospital of Xinxiang Medical College in China from February 2008 to January 2010 were randomly divided into three groups, with 130 cases in each group. Acupuncture group was treated with puncture of point Tianshu (ST25), Shangjuxu (ST37), Zusanli (ST36), Dachangyu (BL25) and Zhigou (SJ6) twice daily for four weeks, while Plantain and Senna Granule group was treated with 5 g of Plantain and Senna Granule once daily, and the combination group was given above-mentioned acupuncture and Plantain and Senna Granule.

MAIN OUTCOME MEASURES

The defecation cycle, stool property, constipation symptom, accompanying symptoms, gastrointestinal transit time, including total gastrointestinal transit time, mouth-intestine transit time, colonic transit time, right colonic transit time, left colonic transit time and rectosigmoid colonic transit time, and adverse reactions of the three groups were evaluated before treatment, at the end of treatment and 64 weeks after treatment, respectively.

RESULTS

Compared with before treatment, the scores of defecation cycle, stool property, constipation symptoms and accompanying symptoms, and gastrointestinal transit time all decreased significantly at the end of treatment in each group (P<0.01), and the combination group showed better results than the other groups (P<0.05). Compared with the end of treatment, the above-mentioned indexes recurred insignificantly in the combination group and acupuncture group after 64 weeks of follow-up (P>0.05), but all recurred significantly in the Plantain and Senna Granule group (P>0.05). Both short- and long-term total response rates of the combination group showed significant differences compared with those of the other two groups (P<0.05 or P<0.01). No serious adverse reactions occurred in all the three groups.

CONCLUSION

Acupuncture plus Plantain and Senna Granule can significantly decrease gastrointestinal transit time and defecation cycle in patients with functional constipation; it can also change stool property and alleviate constipation symptom and accompanying symptoms, with good security and tolerance.

Recognition and management of nonrelaxing pelvic floor dysfunction

Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction, (2) educating patients, (3) performing selective tests when needed to confirm the diagnosis, and (4) providing early referral for physical therapy.

Functional bowel disorders in adults

BACKGROUND

Chronic abdominal pain, bloating, constipation, diarrhea, and stool irregularity are common symptoms in primary care and gastroenterology. A routine diagnostic evaluation fails to reveal any underlying somatic condition in about half of the affected patients, who are therefore said to have a functional bowel disorder. Physicians are often unsure how extensive the work-up must be to exclude a somatic cause.

METHODS

This review is based on a selective review of the literature, including published guidelines from Germany and abroad.

RESULTS

Functional bowel disorders are diagnosed on the basis of a typical constellation of symptoms and the absence of pathological findings that would adequately explain them (exclusive criteria). The basic diagnostic assessment, consisting of a physical examination, basic laboratory tests, abdominal ultrasonography, and (in women) a gynecological examination, is supplemented by further testing that depends on the patient's symptoms. Colonoscopy is obligatory to rule out underlying pathological abnormalities. By communicating the diagnosis of irritable bowel syndrome to the patient, the physician shows that the patient's symptoms and concerns have been taken seriously. The mainstays of treatment are patient education on the benign course of the disease and the encouragement of a salubrious lifestyle. Further treatment options include dietary measures, time-limited symptomatic treatment with drugs, and psychotherapy.

CONCLUSION

The diagnosis of a functional bowel disorder is based on a thorough history (positive criteria) and a small battery of diagnostic tests to exclude somatic disease. Both the diagnostic assessment and the treatment should be carried out in accordance with published guidelines.