Clinical utility of balloon expulsion test for functional defecation disorders

Clinical Characteristics of Different Primary Constipation Subtypes in a Chinese Population

GOAL

To investigate the clinical characteristics of different primary constipation subtypes, including symptom clusters, psychological problems, quality of life (QOL), and to explore the role of constipation symptoms and the mental state in the QOL of constipation subtypes.

BACKGROUND

Patients with chronic constipation (CC) may be unsatisfied with their therapy and suffer recurrent symptoms. Different constipation subtypes require different treatments; therefore, it is important to identify the features of different constipation subtypes.

STUDY

CC patients (n=206) visiting our gastroenterology clinic were studied. CC subtypes were diagnosed using the Rome-IV criteria. We used validated questionnaires to investigate the symptom severity, mental state, and QOL of patients. QOL was assessed with the Patient Assessment of Constipation Quality of Life (PAC-QOL) and SF-36 questionnaire. Results of symptom, mental and QOL scores are expressed as means with 95% confidence interval.

RESULTS

Three groups of CC patients differed in their constipation scoring system and the Patient Assessment of Constipation Symptoms (PAC-SYM) total scores, and both were significantly higher in the functional defecation disorder (FDD) group compared with that in the normal transit constipation (NTC) group. FDD patients tended to have more severe "abdominal symptoms," "rectal symptoms" than NTC group. No significant difference in General Anxiety Disorder 7-item or Patient Health Questionnaire-9 results was found among the 3 groups. Significantly more patients with FDD suffered more "physical discomfort" and had poorer QOL in the "physical function" dimension of SF-36. FDD and NTC patients mainly showed associations between CC-related QOL and constipation severity, while slow transit constipation patients' QOL was significantly associated with anxiety and depression.

CONCLUSION

Patients with FDD suffer more severe constipation symptoms and have a lower QOL than patients in other CC subgroups. FDD and NTC patients' QOL is mainly linked to constipation symptoms, while that of slow transit constipation is mainly related to mental states such as anxiety and depression.

Anorectal physiology in health: A randomized trial to determine the optimum catheter for the balloon expulsion test

BACKGROUND

Anorectal manometry (ARM) and balloon expulsion test (BET) are pivotal in investigation of anorectal disorders. There is controversy, however, about normal values and optimum methodology for performing these tests. Our aims were to compare BET using three different balloons and to establish normal values for ARM and BET in health.

METHODS

Forty-four female healthy subjects (mean age 56 ± 12 years) underwent ARM, followed by BET which was performed in a private toilet using three different catheters (party balloon, Foley catheter and a commercially available catheter) in a single-blinded randomized order. Outcome measures were time to balloon expulsion and comprehensive measures of anal sphincter function, the push maneuver and rectal sensation.

KEY RESULTS

The Foley catheter took longer to expel compared to both party and commercial balloons (both pairwise P < 0.001) with a wider distribution of results (P < 0.001). Ten of 40 healthy subjects could not expel the Foley catheter within 120 seconds. On ARM, older age was associated with lower resting anal sphincter pressure (ρ = -0.3, P = 0.05) and lower anal squeeze pressure (ρ = -0.3, P = 0.05). Having at least one vaginal delivery (compared to none) was associated with lower anal squeeze pressures (P = 0.03) and a smaller difference between cough and squeeze pressures (P = 0.03).

CONCLUSIONS & INFERENCES

A commercial balloon exhibited superior results in vivo compared to the Foley catheter without the concerns of latex allergy and quality control present with the use of a party balloon. Normal values for high-resolution water-perfused manometry have been established and an effect seen for age and parity.

The assessment and management of defecatory dysfunction: a critical appraisal

PURPOSE OF REVIEW

To summarize the advances in diagnostic modalities and management options for defecatory dysfunction and highlight the areas in need of further research.

RECENT FINDINGS

The diagnostic utility of high-resolution anorectal manometry (ARM), which has emerged as a promising tool for the diagnosis of defecatory dysfunction, appears to be questionable in differentiating disease from normal physiology. There also seems to be discrepancy between results of various tests of anorectal function in the diagnosis of defecatory dysfunction. New revisions in diagnostic criteria for defecatory dysfunction by Rome IV consortium, may enhance its diagnostic yield. Biofeedback remains to be the most effective evidence-based treatment option for patients with defecatory dysfunction. Anorectal pressure profile cannot predict or mediate the success of biofeedback. Biofeedback may improve the symptoms through central effects.

SUMMARY

Despite the advances in the ARM and defecography techniques, no one test has been able to be considered as the 'gold standard' for diagnosis of defecatory dysfunction. The mechanism of action of biofeedback in defecatory dysfunction remains poorly understood.