Investigation of anal function in patients with systemic sclerosis

Fecal incontinence and scleroderma: Pathogenesis and unmet needs

Scleroderma is a chronic autoimmune disorder involving multiple organs and very commonly the gastrointestinal (GI) system; nevertheless, data on the involvement of the anal sphincter and consequent faecal incontinence (FI) are inadequate. FI in scleroderma was first reported in 1994 by Engel and colleagues, but its impact of added health care costs and declining quality of life (QoL) is poorly determined. Up to 40% of patients with GI involvement complain of FI, however, the quality of data available is poor owing to majority of the studies being retrospective and case reports or series of small study size. A direct involvement of internal anal sphincter muscularis propria has been demonstrated on anorectal ultrasound imaging suggesting a thin, atrophic or scarred internal sphincter. Treatment guidelines for incontinence in scleroderma are mainly symptomatic, with radical surgeries burdened by poor outcomes. Sacral neuromodulation is being used with good outcomes in a subgroup of patients, but larger, controlled studies are required to assess its efficacy on symptoms and prognosis.

FUNCTIONAL AND ANATOMICAL ANALYSIS OF THE ANORECTUM OF FEMALE SCLERODERMA PATIENTS AT A CENTER FOR PELVIC FLOOR DISORDERS

ABSTRACT BACKGROUND: Scleroderma or progressive systemic sclerosis is characterized by a chronic inflammatory process with proliferation of fibrous connective tissue and excessive deposition of collagen and extracellular matrix in the skin, smooth muscle, and viscera. The smooth muscle most involved in scleroderma is that of the esophagus, and dysphagia is the most commonly reported symptom. However, the internal anal sphincter may also be impaired by degeneration and fibrosis, leading to concomitant anal incontinence in scleroderma patients. These patients may neglect to complain about it, except when actively questioned. OBJECTIVE: To assess anorectal function and anatomy of female scleroderma patients with symptoms of anal incontinence through Cleveland Clinic Florida Fecal Incontinence Score (CCFIS), anorectal manometry and endoanal ultrasound at the outpatient clinic of colorectal and anal physiology, Clinics Hospital, University of São Paulo Medical School (HC-FMUSP). METHODS: Female scleroderma patients were prospectively assessed and questioned as to symptoms of anal incontinence. The anorectal manometry and endoanal ultrasound results were correlated with clinical data and symptoms. RESULTS: In total, 13 women were evaluated. Their mean age was 55.77 years (±16.14; 27-72 years) and their mean disease duration was 10.23 years (±6.23; 2-23 years). All had symptoms of fecal incontinence ranging from 1 to 15. Seven (53.8%) patients had fecal incontinence score no higher than 7; three (23.1%) between 8 and 13; and three (23.1%) 14 or higher, corresponding to mild, moderate, and severe incontinence, respectively. Ten (76.92%) patients had hypotonia of the internal anal sphincter. Three-dimensional endoanal ultrasound showed tapering associated with muscle atrophy of the internal sphincter in six cases and previous muscle defects in three cases. CONCLUSION: A functional and anatomical impairment of the sphincter is an important factor to assess in patients with progressive systemic sclerosis and it should not be underestimated.

Physiological and structural anorectal abnormalities in patients with systemic sclerosis and fecal incontinence

OBJECTIVE

Fecal incontinence is common in systemic sclerosis (SSc), but the underlying mechanisms are not fully understood. The objectives of this study were to characterize anorectal physiological and morphological defects in SSc patients and to correlate the results with incontinence symptoms.

MATERIALS AND METHODS

Twenty-five SSc patients underwent anorectal neurophysiological investigations, anal manometry, and ultrasound.

RESULTS

Eleven patients (44%) reported incontinence to solid or liquid feces, but no patient reported diarrhea. Increased fiber density (FD) was recorded in 78% of patients with and in 86% of patients without fecal incontinence not significant (NS). Incontinent patients had lower squeeze pressure (SP; median 49.5 mm Hg) in the high-pressure zone (HPZ) than continent patients (median 72 mm Hg; p = 0.01). In two of the incontinent patients, sonographic abnormalities of the internal anal sphincter (IAS) and the external anal sphincter (EAS) were present, whereas in another two patients isolated IAS abnormalities were seen. These four individuals had lower resting pressure at 1 cm and in the HPZ, and lower SP at 2 cm than patients with normal anorectal sonographic findings (p < 0.05).

CONCLUSION

Lower voluntary SP in incontinent patients and EAS sonographic abnormalities only in patients with incontinence suggest that the EAS is more important in maintaining fecal continence in SSc patients than has previously been reported. The finding of increased FD in most patients further supports involvement of the EAS function in SSc and could indicate previous nerve injury with consequent incomplete reinnervation.

Vascular events are risk factors for anal incontinence in systemic sclerosis: a study of morphology and functional properties measured by anal endosonography and manometry

OBJECTIVES

To study anal sphincter morphology, anal sphincter pressure, and rectoanal inhibitory reflex (RAIR) in patients with systemic sclerosis (SSc) complicated by anal incontinence (AI) and to investigate possible risk factors for AI in SSc.

METHOD

Nineteen SSc patients with severe AI were investigated using anal endosonography, anal manometry, and rectal manovolumetry. To determine risk factors for AI, disease characteristics of SSc patients with AI were compared with those of 95 SSc patients without AI; there were five matched SSc patients without AI for each SSc patient with AI.

RESULTS

The mean (SD) internal sphincter thickness was 1.3 (0.46) mm in patients with AI, which was thinner (p < 0.001) than reference data from healthy individuals whose internal sphincter measured 2.2 (0.45) mm, whereas the external sphincter thickness did not differ. The mean (SD) resting pressure in AI patients was lower than the reference data from healthy individuals [60 (22) vs. 94 (29) mmHg, p < 0.002] whereas the squeeze pressure did not differ. Centromeric antibodies and features of vascular disease [i.e. the presence of pulmonary arterial hypertension (PAH), digital ulcers, pitting scars, or the need for iloprost infusions] were associated with AI whereas fibrotic manifestations [i.e. modified Rodnan skin score (mRss), the diffuse cutaneous SSc (dcSSc) subset, or low vital capacity (VC)] were not.

CONCLUSIONS

SSc patients with AI have a thin internal anal sphincter and a low resting pressure. Risk factors for AI among SSc patients are centromeric antibodies and vascular disease, which supports the hypothesis that gastrointestinal involvement in SSc is in part a vascular manifestation of the disease.

Evidence for oesophageal and anorectal involvement in very early systemic sclerosis (VEDOSS): report from a single VEDOSS/EUSTAR centre

BACKGROUND

The oesophagus is the first gastrointestinal (GI) tract involved in systemic sclerosis (SSc), followed by the anorectum.

OBJECTIVE

Evaluation of oesophageal and anorectal involvement and their correlations in patients with very early diagnosis of SSc (VEDOSS).

PATIENTS AND METHODS

59 patients with VEDOSS, evaluated with oesophageal and anorectal manometry and investigated with lung function tests and chest HRCT. Demographic data, oesophageal and anorectal symptoms, Raynaud's phenomenon, autoantibodies, videocapillaroscopy patterns, puffy fingers and digital ulcers were recorded for all patients.

RESULTS

In 4 patients oesophageal manometry and in 17 patients anorectal manometry was not performed because of scarce tolerance. Oesophageal peristalsis was absent in 14 patients; its pressure and speed were significantly lower in 41 patients (p<0.001 and p=0.005, respectively). The maximum pressure and mean pressure (Pmax and Pm) of lower oesophageal sphincter were significantly lower (p=0.012 and p=0.024, respectively). Patients with a diffusing capacity of the lung for carbon monoxide<80% presented a hypotonic lower oesophageal sphincter (p=0.008) and an abnormal peristalsis (p<0.001); patients with a diffusing capacity of the lung for carbon monoxide>80% showed only an abnormal peristalsis (<0.001). The anal resting pressure (ARP) at 4.3 cm and 2 cm from anal edge and the anal canal Pm were significantly decreased (p<0.001 and p=0.010, respectively). The maximum voluntary contraction was significantly abnormal in its Pmax and Pm (p=0.017 and p=0.005) and in its duration (p=0.001). In patients with a positive HRCT, the ARP and the canal Pmax and Pm were significantly lower; patients with negative HRCT presented only an abnormal ARP.

CONCLUSIONS

In patients with VEDOSS, oesophageal and anorectal disorders are frequently detected, showing that very early SSc is characterised by GI involvement.

Distensibility of the anal canal in patients with systemic sclerosis: a study with the functional lumen imaging probe

AIM

Systemic sclerosis (SSc) is a generalized connective tissue disease that affects smooth muscle cells. Patients with SSc often have faecal incontinence caused by fibrotic degeneration of the internal anal sphincter (IAS). The functional lumen imaging probe (FLIP) is a novel method that allows the segmental biomechanical properties of the anal canal to be dynamically evaluated. The aim of the present study was to compare the segmental biomechanical properties of the anal canal in incontinent SSc patients and healthy controls. We hypothesized that the FLIP would reveal weaknesses of the IAS in the SSc patients.

METHOD

We performed FLIP distensions, endoanal ultrasonography and standard anal manometry on 14 incontinent SSc patients [11 women, median age 60 years (range 35-80)] and 15 healthy volunteers [12 women, median age 54 years (range 33-67)]. The anal canal was divided into three parts for the biomechanical analysis: upper (surrounded by the IAS and the puborectalis), middle (IAS and external anal sphincter) and lower (external sphincter only).

RESULTS

The middle anal canal was the segment most resistant to distension in all of the subjects, but it was less resistant in the SSc patients than in the controls (P < 0.01). Correspondingly, the endoanal ultrasonography showed that the IAS of the SSc patients was thinner than normal (P < 0.05), and the anal resting and squeeze pressures were lower (P < 0.05). Only minor distensibility differences were found in the upper anal canal. No changes were found in the lower anal canal.

CONCLUSION

Faecal incontinence in SSc patients is associated with poor IAS function, causing increased distensibility of the middle anal canal.

Anorectal motility and sensation abnormalities and its correlation with anorectal symptoms in patients with systemic sclerosis: a preliminary study

Gastrointestinal (GI) hypomotility and symptoms are common in Scleroderma (SSc) patients yet so far uncorrelated. Eight SSc patients and matched controls were queried about their GI dysmotility symptoms and quality of life (QoL) and underwent anorectal motility and sensory tests. Specific scoring systems were developed for anorectal symptoms and anorectal dysmotility. We found that (1) the SSc patients showed low QoL and marked overall GI symptoms. The most common anorectal symptom was incomplete bowel movement (50%). (2) Compared to normal controls, SSc patients showed impaired anorectal pressures, sensations, and rectal compliance (P ≤ .01 for each). (3) The anorectal motility/sensation abnormality score was robustly correlated with the total anorectal symptom score (r_s = .78, P = .02). In conclusion, scleroderma patients have impaired anorectal motor and sensory functions, and the abnormality score of these anorectal functions is correlated with the total anorectal symptoms score. These scoring systems may assist clinicians in predicting dysmotility based on patient symptoms.

Anal canal vector volume manometry

BACKGROUND

Anal manometry is routinely used in the assessment of the anal sphincters in patients with fecal incontinence or suspected sphincter injury. Such physiological information is complementary to the anatomical assessment provided by anal endosonography. The evolution of 3-dimensional anal endosonography provides more diagnostically useful information in complex cases. Vector volume manometry has been developed to give a 3-dimensional view of the anal sphincters.

OBJECTIVE

We reviewed the published literature on this technique, with the intention of deriving a system of standardization based on the published literature and to summarize the derivation and physiological meaning of the parameters measurable by vector volume studies, as well.

DATA SOURCES

We undertook a MEDLINE search using the terms "vector volume" or "vector manometry" and "anal canal." We also reviewed further publications found from references cited in the original articles identified from the above search.

STUDY SELECTION

Only English language articles of studies performed on humans were reviewed.

INTERVENTION

Anal canal vector volume manometry was the intervention.

RESULTS

With the development of automated puller systems and associated software, parameters such as total vector volume, maximum pressure, mean pressure, anal canal symmetry, anal canal length, and the length of the high-pressure zone can be readily calculated.

LIMITATIONS

There are conflicting studies related to the clinical value of both anal manometry and vector volume manometry, in part, because of the lack of standardization of equipment and technique.

CONCLUSIONS

The vector volume parameters have been shown to correlate with both imaging results and incontinence scores with automated puller systems. The clinical utility of vector volume manometry would be improved further by the standardization of equipment and technique. The main clinical utility may lie in the treatment selection and preoperative assessment of patients awaiting surgery for anal pathology that has yet to be evaluated.

The internal anal sphincter in systemic sclerosis

PURPOSE

Fecal incontinence in systemic sclerosis can occur secondary to fibrous replacement of the internal sphincter or ischemic myopathy of internal anal sphincter from vasculitis. Both lead to morphologic changes of the internal anal sphincter on endoanal ultrasound. This study documents the morphologic changes that can occur.

METHODS

A retrospective study of consecutive patients with systemic sclerosis and fecal incontinence was performed. Endoanal ultrasound was performed by using a 10 MHz Bruel and Kjaer endoprobe. Internal anal sphincter thickness and echogenecity were assessed at mid anal canal using prospectively collected images. Sphincter thicknesses were measured at 3, 6, 9, and 12 o'clock positions and averaged. Sphincter quality was assessed as homogeneous or heterogeneous and hyperechoic or hypoechoic by an experienced colorectal surgeon. Sphincter thickness was compared with sex- and age-matched controls by using Wilcoxon's signed-rank test.

RESULTS

There were 11 patients (all women). Two distinct morphologic changes were observed where patients had a thickened, homogeneous, and hypoechoic internal anal sphincter, or a thinned, difficult to discern, and hyperechoic internal anal sphincter. Average sphincter thickness was 1.6 (range, 0.8-4) mm, which was significantly different from control subjects (P = 0.028).

CONCLUSIONS

Available literature suggest that internal anal sphincter in systemic sclerosis is invariably thinned and hyperechoic. This series suggests that two distinct morphologic changes are possible.

Systematic review: pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma)

Gastrointestinal dysmotility in systemic sclerosis (scleroderma) is prevalent in 90% of patients, increasing morbidity and in some cases mortality. The resultant gastrointestinal complications are usually extensive, involving many regions of the gut from the oesophagus to the anus. Collagen replacement of vascular and enteric smooth muscle results in hypomotility, lumen dilatation, tensile rigidity and eventual loss of organ functions. The aim of this paper is to provide an overview of systemic sclerosis-related gastrointestinal dysmotility and available/potential therapeutic options. We evaluated published data on the pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis patients using the MEDLINE database for English and non-English articles from 1966 to July 2005. Based on this systematic review, lifestyle and medical therapy approaches are preferred as they often improve and/or ameliorate symptoms. Surgery is only recommended with serious, rare complications such as bowel perforation or ischaemia. Alternative therapies such as acupuncture-based therapies are well tolerated, with clinical improvement and may be of potential therapeutic benefit for systemic sclerosis gastrointestinal dysmotility. Further elucidation of initiating and persistent mechanisms of systemic sclerosis-related gastrointestinal dysmotility will optimize the development of a multidisciplinary and more directed treatment regimen.

Impaired rectoanal inhibitory response in scleroderma (systemic sclerosis): an association with fecal incontinence

Gastrointestinal abnormalities in systemic sclerosis (SSc) involve both myogenic and neural mechanisms. The aims of this study were to evaluate the rectoanal inhibitory response (RAIR) in SSc patients and to correlate RAIR with duration and subtype of disease, antibody status, and lower gastrointestinal symptoms. Thirty-five patients with SSc completed a questionnaire and underwent anorectal manometry (ARM). Forty-five patients without SSc served as controls. In the 35 SSc patients, 62.3% reported diarrhea, 57.1% reported constipation, and 37.1% reported fecal incontinence. Twenty-five of the 35 scleroderma patients (71.4%) demonstrated an impaired or absent RAIR, compared with none of the 45 controls (P < 0.001). Eleven of 13 incontinent SSc patients (84%) had an impaired RAIR. No correlation was found between RAIR and duration or subtype of SSc, antibody status, or presence of diarrhea or constipation. Impaired RAIR was closely correlated with fecal incontinence, suggesting a possible neural mechanism for maintenance of continence.

Subtotal colectomy and cecosigmoid anastomosis for colonic systemic sclerosis: report of a case and review of the literature

PURPOSE

We report a case of subtotal colonic involvement of systemic sclerosis, successfully managed by subtotal colectomy and cecosigmoid anastomosis, and review the literature on surgical management.

METHODS

A patient had profound slow transit constipation and severe colonic involvement on nuclear transit study. Surgery was conservative, with preservation of distal sigmoid colon and the ileocecal valve. A literature search regarding management of colonic systemic sclerosis was conducted.

RESULTS

The surgery was uncomplicated and near normal bowel function was restored. The literature indicates that colonic involvement is common in systemic sclerosis and that surgery is sometimes required for severe disease or the development of complications.

CONCLUSIONS

If surgery is required for colonic involvement in systemic sclerosis, it should be directed at the segmental distribution of the disease, preserving the colon if possible and considering the possibility of concurrent small-bowel involvement. Nuclear colonic transit study is helpful in guiding the extent of surgery.

Bowel problems in patients with systemic sclerosis

BACKGROUND

The impact of systemic sclerosis on bowel function is still unknown. The aim of this study was therefore to assess the frequency and severity of colorectal problems among patients with systemic sclerosis and to determine whether these problems are associated with age, gender, type of systemic sclerosis, or time since diagnosis.

METHODS

A detailed questionnaire describing diarrhoea, constipation, obstructed defecation, faecal incontinence, bowel habits, social activities, and quality of life was sent to 96 consecutive patients with systemic sclerosis.

RESULTS

Among 83 respondents (86%) 16% did not have a normal desire to defecate, 18% regularly needed digital stimulation or evacuation of the rectum, and 38% had faecal incontinence. Most patients (79%) had episodes of diarrhoea, and 38% had this once or more each month. Overall, 20% reported that colorectal dysfunction caused some or a major restriction of social activities or the quality of life.

CONCLUSIONS

Colorectal dysfunction is very common among patients with systemic sclerosis, often restricting social activities and the quality of life. Therefore, further studies of colorectal pathophysiology in patients with systemic sclerosis are needed.