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Ramu SK, Oblizajek NR, Savica R, Chunawala ZS, Deb B, Bharucha AE. Defecatory disorders are a common cause of chronic constipation in Parkinson disease. Neurogastroenterol Motil 2024; 36:e14767. [PMID: 38376243 PMCID: PMC11061800 DOI: 10.1111/nmo.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND AIMS Up to 50% of patients with Parkinson disease have constipation (PD-C), but the prevalence of defecatory disorders caused by rectoanal dyscoordination in PD-C is unknown. We aimed to compare anorectal function of patients with PD-C versus idiopathic chronic constipation (CC). METHODS Anorectal pressures, rectal sensation, and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry (HR-ARM) in patients with PD-C and control patients with CC, matched for age and sex. RESULTS We identified 97 patients with PD-C and 173 control patients. Eighty-six patients with PD-C (89%) had early PD, and 39 (40%) had a defecatory disorder, manifest by a prolonged rectal balloon expulsion time (37 patients) or a lower rectoanal pressure difference during evacuation (2 patients). PD-C patients with a prolonged BET had a greater anal resting pressure (p = 0.02), a lower rectal pressure increment (p = 0.005), greater anal pressure (p = 0.047), and a lower rectoanal pressure difference during evacuation (p < 0.001). Rectal sensory thresholds were greater in patients with abnormal BET. In the multivariate model comparing CC and PD-C (AUROC = 0.76), PD-C was associated with a lower anal squeeze increment (odds ratio [OR] for PD-C, 0.93 [95% CI, 0.91-0.95]), longer squeeze duration (OR, 1.05 [95% CI, 1.03-1.08]), lower rectal pressure increment (OR per 10 mm Hg, 0.72 [95% CI, 0.66-0.79]), and negative rectoanal gradient during evacuation (OR per 10 mm Hg, 1.16 [95% CI, 1.08-1.26]). CONCLUSIONS Compared with CC, PD-C was characterized by impaired squeeze pressure, longer squeeze duration, lower increase in rectal pressure, and a more negative rectoanal gradient during evacuation.
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Affiliation(s)
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rodolfo Savica
- Division of Movement Disorders, Mayo Clinic, Rochester, Minnesota, USA
| | - Zainali S Chunawala
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Brototo Deb
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Varma R, Chakraborty S, Burton DD, Bailey KR, Bharucha AE. Small intestinal bacterial overgrowth in diabetic gastroenteropathy. Neurogastroenterol Motil 2024:e14798. [PMID: 38651669 DOI: 10.1111/nmo.14798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/06/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Although diabetic gastroenteropathy (DGE) is associated with small intestinal bacterial overgrowth (SIBO), most studies have evaluated SIBO with a hydrogen breath test, which may be affected by altered transit in DGE. The risk factors for the consequences of SIBO in DGE are poorly understood. We aimed to evaluate the prevalence of, risk factors for, and gastrointestinal symptoms associated with SIBO in patients with DGE. METHODS In 75 patients with DGE and dyspepsia, we tested for SIBO (≥105 colony forming units /mL of aerobic and/or anaerobic bacteria in a duodenal aspirate) and assessed gastric emptying (GE) of solids, symptoms during a GE study and during an enteral lipid challenge (300 kcal/2 h), and daily symptoms with a Gastroparesis Cardinal Symptom Index diary for 2 weeks. Symptoms and GE were compared in patients with versus without SIBO. KEY RESULTS Of 75 patients, 34 (45%) had SIBO, which was not associated with the use of proton pump inhibitors, daily symptoms, GE, or symptoms during a GE study. During enteral lipid challenge, severe nausea (p = 0.006), fullness (p = 0.02) and bloating (p = 0.009) were each associated with SIBO. Twenty patients (59%) with versus 13 (32%) without SIBO had at least one severe symptom during the lipid challenge (p = 0.006). CONCLUSIONS & INFERENCES Among patients with DGE 45% had SIBO, which was associated with symptoms during enteral lipid challenge but not with delayed GE, symptoms during a GE study, or daily symptoms. Perhaps bacterial products and even fatty acids are recognized by and activate mast cells that drive the increased lipid sensitivity in SIBO.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Duane D Burton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Mack I, Hahn H, Gödel C, Enck P, Bharucha AE. Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:712-731.e8. [PMID: 37734583 PMCID: PMC10948379 DOI: 10.1016/j.cgh.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND & AIMS Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age. METHODS We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI. RESULTS Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age. CONCLUSIONS Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.
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Affiliation(s)
- Isabelle Mack
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Tübingen, Germany
| | - Heiko Hahn
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Tübingen, Germany
| | - Celina Gödel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Tübingen, Germany
| | - Paul Enck
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital, Tübingen, Germany
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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4
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Varma R, Staab JP, Matey ET, Wright JA, Deb B, Lazaridis KN, Szarka LA, Bailey KR, Bharucha AE. Most patients with disorders of gut-brain interaction receive pharmacotherapy with major or moderate drug-gene interactions. Neurogastroenterol Motil 2024; 36:e14722. [PMID: 38072827 DOI: 10.1111/nmo.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND How variations predicted by pharmacogenomic testing to alter drug metabolism and therapeutic response affect outcomes for patients with disorders of gut- brain interaction is unclear. AIMS To assess the prevalence of pharmacogenomics-predicted drug-gene interactions and symptom outcomes for patients with disorders of gut-brain interaction. METHODS Patients who were treated in our clinical practice for functional dyspepsia/bowel disorder underwent pharmacogenomic testing. The change in symptoms from baseline to 6 months was compared for patients with variations in CYP2D6 and CYP2C19, which metabolize neuromodulators, and SLC6A4, which encodes the sodium- dependent serotonin transporter. RESULTS At baseline, 79 of 94 participants (84%) had at least one predicted major drug- gene interaction, and all 94 (100%) had at least one predicted moderate interaction. For the 44 participants who completed a survey of their symptoms at 6 months, the mean (SD) irritable bowel syndrome-symptom severity score decreased from 284 (71) at baseline to 231 (95) at 6 months (p < 0.001). Among patients taking selective serotonin reuptake inhibitors, the decrease in symptom severity (p = 0.03) and pain (p = 0.002) scores from baseline to 6 months was greater for patients with a homozygous SLC6A4 long/long genotype (n = 30) (ie, increased serotonin transporter activity) than for patients with homozygous short/short or heterozygous long/short genotypes (n = 64). Symptom outcomes were not affected by CYP2D6 or CYP2C19 variations. CONCLUSIONS The homozygous SLC6A4 long/long genotype confers better symptom resolution for patients with disorders of gut-brain interaction who take selective serotonin reuptake inhibitors than do the homozygous short/short or heterozygous long/short genotypes.
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Affiliation(s)
- Revati Varma
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric T Matey
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Brototo Deb
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Varma R, Feuerhak KJ, Mishra R, Chakraborty S, Oblizajek NR, Bailey KR, Bharucha AE. A randomized double-blind trial of clonidine and colesevelam for women with fecal incontinence. Neurogastroenterol Motil 2024; 36:e14697. [PMID: 37890049 PMCID: PMC10842236 DOI: 10.1111/nmo.14697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/11/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Diarrhea and rectal urgency are risk factors for fecal incontinence (FI). The effectiveness of bowel modifiers for improving FI is unclear. METHODS In this double-blind, parallel-group, randomized trial, women with urge FI were randomly assigned in a 1:1 ratio to a combination of oral clonidine (0.1 mg twice daily) with colesevelam (1875 mg twice daily) or two inert tablets for 4 weeks. The primary outcome was a ≥50% decrease in number of weekly FI episodes. KEY RESULTS Fifty-six participants were randomly assigned to clonidine-colesevelam (n = 24) or placebo (n = 32); 51 (91%) completed 4 weeks of treatment. At baseline, participants had a mean (SD) of 7.5 (8.2) FI episodes weekly. The primary outcome was met for 13 of 24 participants (54%) treated with clonidine-colesevelam versus 17 of 32 (53%) treated with placebo (p = 0.85). The Bristol stool form score decreased significantly, reflecting more formed stools with clonidine-colesevelam treatment (mean [SD], 4.5 [1.5] to 3.2 [1.5]; p = 0.02) but not with placebo (4.2 [1.9] to 4.1 [1.9]; p = 0.47). The proportion of FI episodes for semiformed stools decreased significantly from a mean (SD) of 76% (8%) to 61% (10%) in the clonidine-colesevelam group (p = 0.007) but not the placebo group (61% [8%] to 67% [8%]; p = 0.76). However, these treatment effects did not differ significantly between groups. Overall, clonidine-colesevelam was well tolerated. CONCLUSIONS AND INFERENCES Compared with placebo, clonidine-colesevelam did not significantly improve FI despite being associated with more formed stools and fewer FI episodes for semiformed stools.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly J Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Gao F, Hayashi Y, Saravanaperumal SA, Gajdos GB, Syed SA, Bhagwate AV, Ye Z, Zhong J, Zhang Y, Choi EL, Kvasha SM, Kaur J, Paradise BD, Cheng L, Simone BW, Wright AM, Kellogg TA, Kendrick ML, McKenzie TJ, Sun Z, Yan H, Yu C, Bharucha AE, Linden DR, Lee JH, Ordog T. Hypoxia-Inducible Factor 1α Stabilization Restores Epigenetic Control of Nitric Oxide Synthase 1 Expression and Reverses Gastroparesis in Female Diabetic Mice. Gastroenterology 2023; 165:1458-1474. [PMID: 37597632 PMCID: PMC10840755 DOI: 10.1053/j.gastro.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND & AIMS Although depletion of neuronal nitric oxide synthase (NOS1)-expressing neurons contributes to gastroparesis, stimulating nitrergic signaling is not an effective therapy. We investigated whether hypoxia-inducible factor 1α (HIF1A), which is activated by high O2 consumption in central neurons, is a Nos1 transcription factor in enteric neurons and whether stabilizing HIF1A reverses gastroparesis. METHODS Mice with streptozotocin-induced diabetes, human and mouse tissues, NOS1+ mouse neuroblastoma cells, and isolated nitrergic neurons were studied. Gastric emptying of solids and volumes were determined by breath test and single-photon emission computed tomography, respectively. Gene expression was analyzed by RNA-sequencing, microarrays, immunoblotting, and immunofluorescence. Epigenetic assays included chromatin immunoprecipitation sequencing (13 targets), chromosome conformation capture sequencing, and reporter assays. Mechanistic studies used Cre-mediated recombination, RNA interference, and clustered regularly interspaced short palindromic repeats (CRISPR)-CRISPR-associated protein 9 (Cas9)-mediated epigenome editing. RESULTS HIF1A signaling from physiological intracellular hypoxia was active in mouse and human NOS1+ myenteric neurons but reduced in diabetes. Deleting Hif1a in Nos1-expressing neurons reduced NOS1 protein by 50% to 92% and delayed gastric emptying of solids in female but not male mice. Stabilizing HIF1A with roxadustat (FG-4592), which is approved for human use, restored NOS1 and reversed gastroparesis in female diabetic mice. In nitrergic neurons, HIF1A up-regulated Nos1 transcription by binding and activating proximal and distal cis-regulatory elements, including newly discovered super-enhancers, facilitating RNA polymerase loading and pause-release, and by recruiting cohesin to loop anchors to alter chromosome topology. CONCLUSIONS Pharmacologic HIF1A stabilization is a novel, translatable approach to restoring nitrergic signaling and treating diabetic gastroparesis. The newly recognized effects of HIF1A on chromosome topology may provide insights into physioxia- and ischemia-related organ function.
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Affiliation(s)
- Fei Gao
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Gastroenterology, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yujiro Hayashi
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Siva Arumugam Saravanaperumal
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gabriella B Gajdos
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sabriya A Syed
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota
| | - Aditya V Bhagwate
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Zhenqing Ye
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jian Zhong
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yuebo Zhang
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Egan L Choi
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sergiy M Kvasha
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jagneet Kaur
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brooke D Paradise
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota
| | - Liang Cheng
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Brandon W Simone
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota
| | - Alec M Wright
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Todd A Kellogg
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Zhifu Sun
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota; Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Huihuang Yan
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota; Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chuanhe Yu
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Linden
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Jeong-Heon Lee
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota; Division of Experimental Pathology and Laboratory Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Tamas Ordog
- Enteric NeuroScience Program and Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota.
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7
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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8
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Am J Gastroenterol 2023; 118:936-954. [PMID: 37204227 PMCID: PMC10544839 DOI: 10.14309/ajg.0000000000002227] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - William D. Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Christopher V. Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Katarina B. Greer
- Cleveland VA Healthcare System, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lucinda A. Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC, USA
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Eric D. Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
- Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire, USA
| | - Anthony J. Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, USA
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
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Vargas EJ, Rizk M, Gomez-Villa J, Edwards PK, Jaruvongvanich V, Storm AC, Acosta A, Lake D, Fidler J, Bharucha AE, Camilleri M, Abu Dayyeh BK. Effect of endoscopic sleeve gastroplasty on gastric emptying, motility and hormones: a comparative prospective study. Gut 2023; 72:1073-1080. [PMID: 36241388 PMCID: PMC10102256 DOI: 10.1136/gutjnl-2022-327816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/30/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG. DESIGN A priori-designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss. RESULTS 36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG. CONCLUSION ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity. TRIAL REGISTRATION NUMBER NCT03406975.
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Affiliation(s)
- Eric J Vargas
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Monika Rizk
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jacky Gomez-Villa
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Phillip K Edwards
- Biomedical Engineering and Physiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Veeravich Jaruvongvanich
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andrew C Storm
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Andres Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - David Lake
- Biomedical Engineering and Physiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeff Fidler
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R), Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Chang L, Chey WD, Imdad A, Almario CV, Bharucha AE, Diem S, Greer KB, Hanson B, Harris LA, Ko C, Murad MH, Patel A, Shah ED, Lembo AJ, Sultan S. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Gastroenterology 2023; 164:1086-1106. [PMID: 37211380 PMCID: PMC10542656 DOI: 10.1053/j.gastro.2023.03.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.
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Affiliation(s)
- Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - William D Chey
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Aamer Imdad
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
| | - Christopher V Almario
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Diem
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Katarina B Greer
- Cleveland VA Healthcare System, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Brian Hanson
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lucinda A Harris
- Division of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Cynthia Ko
- Division of Gastroenterology & Hepatology, University of Washington, Washington, DC
| | | | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Eric D Shah
- Division of Gastroenterology & Hepatology, Michigan Medicine, Ann Arbor, Michigan; Division of Gastroenterology & Hepatology, Department of Medicine, DartMouth Health, Lebanon, New Hampshire
| | - Anthony J Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio
| | - Shahnaz Sultan
- Minneapolis VA Healthcare System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
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Xiao AH, Kathavarayan Ramu S, Gautam M, Bharucha AE. Defecatory disorders in patients with type 1 diabetes and chronic constipation. Neurogastroenterol Motil 2023:e14599. [PMID: 37052404 DOI: 10.1111/nmo.14599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/07/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Chronic constipation (CC) may be caused by defecatory disorders (DDs) and associated with reduced rectal sensation. Among patients with type 1 diabetes (T1D) and CC (T1DCC patients), the prevalence of DDs and reduced rectal sensation is unknown. We sought to compare complications of T1D, anorectal dysfunction, and CC symptoms, among T1DCC patients with versus without a DD. METHODS Anorectal pressures at rest and during squeeze and evacuation, as well as rectal sensation and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry in 114 consecutive T1DCC patients. RESULTS Thirty-seven patients (32%) had prolonged BET, suggestive of a DD. Complications of T1D included peripheral neuropathy (n = 67, 59%), retinopathy (n = 42, 37%), and nephropathy (n = 26, 23%). Among these complications, only retinopathy was associated with, that is, more prevalent in patients with normal (45%) than prolonged BET (19%). Compared with patients with normal BET, patients with prolonged BET had a lower rectal pressure (mean [SD], 32 [23] mm Hg vs. 23 [19] mm Hg, p = 0.03), greater anal pressure (91 [23] mm Hg vs. 68 [36] mm Hg, p < 0.001), and lower rectoanal gradient (-67 [30] mm Hg vs. -36 [32] mm Hg, p < 0.0001) during evacuation. Anal resting pressure and anal squeeze increment were below normal in 14 (13%) and 32 (29%) of patients and one or more rectal sensory thresholds were above normal in 34 (30%) patients; these abnormalities affected similar proportions in the normal and prolonged BET cohorts. CONCLUSIONS Among T1DCC patients, 37 (32%) had prolonged BET, which was associated with anorectal pressures indicative of a DD but was not associated with reduced rectal sensation, suggesting that DDs are more likely explained by abdomino-anal dyscoordination than visceral disturbance.
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Affiliation(s)
- Alexander H Xiao
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | | | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, United States
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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12
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Camerucci E, Mullan AF, Bower JH, Bharucha AE, Turcano P, Stang CD, Benarroch EE, Boeve BF, Ahlskog JE, Savica R. Lifelong constipation in Parkinson's disease and other clinically defined alpha-synucleinopathies: A population-based study in Southeast Minnesota. Parkinsonism Relat Disord 2023; 107:105244. [PMID: 36630736 PMCID: PMC10262204 DOI: 10.1016/j.parkreldis.2022.105244] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Epidemiological studies show correlations between constipation and development of Parkinson's disease (PD); however, few studies have explored the association between constipation and dementia with Lewy bodies (DLB), Parkinson's disease dementia (PDD), and multiple system atrophy (MSA). We sought to explore the lifelong association of constipation and PD, DLB, PDD, and MSA (α-Synucleinopathies), compared to age- and sex-matched controls. METHODS Using the Rochester Epidemiology Project (REP), we established an incident cohort of clinically defined α-synucleinopathies. A movement-disorder specialist reviewed all medical charts to establish clinical diagnoses. RESULTS We identified 453 incident cases of clinically diagnosed α-synucleinopathies and an identical number of age- and sex-matched controls in Olmsted County (MN), 1991-2010. There were 303 cases of PD; 80, DLB; 54, PDD; and 16, MSA. Approximately 50% of α-synucleinopathies of all types reported constipation, compared to 27% in controls. The earliest pre-motor onset constipation was in DLB (median, 3.76 years prior to α-synucleinopathies motor-symptom onset); latest onset post-motor constipation was in PD (median, 5.15 years after motor-symptom onset). PD also had the highest longstanding constipation rate (18.2%). All α-synucleinopathies had higher odds of constipation compared to controls, except for MSA (p = 0.09), likely due to a limited sample size. CONCLUSION PD, DLB, and PDD had higher odds of constipation compared to controls; PD had the most widespread onset of lifelong constipation, both longstanding and pre- or post-motor onset symptoms. Our results indicate that constipation rates do not differ among α-synucleinopathies but do differ in terms of temporal onset compared to disease onset.
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Affiliation(s)
- Emanuele Camerucci
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Neurology, University of Kansas Medical Center (KUMC), Kansas City, MO, USA
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - James H Bower
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Cole D Stang
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; University of Minnesota Medical School, Duluth, MN, USA
| | | | | | - J Eric Ahlskog
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
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Bharucha AE. When to Order Anorectal Function Testing. Gastroenterol Hepatol (N Y) 2023; 19:59-61. [PMID: 36865821 PMCID: PMC9972655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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Blackett JW, Gautam M, Mishra R, Oblizajek NR, Kathavarayan Ramu S, Bailey KR, Bharucha AE. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology 2022; 163:1582-1592.e2. [PMID: 35995074 PMCID: PMC9691522 DOI: 10.1053/j.gastro.2022.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The utility of high-resolution anorectal manometry (HR-ARM) for diagnosing defecatory disorders (DDs) is unclear because healthy people may have features of dyssynergia. We aimed to identify objective diagnostic criteria for DD and to ascertain the utility of HR-ARM for diagnosing DD. METHODS Constipated patients were assessed with HR-ARM and rectal balloon expulsion time (BET), and a subset underwent defecography. Normal values were established by assessing 184 sex-matched healthy individuals. Logistic regression models evaluated the association of abnormal HR-ARM findings with prolonged BET and reduced rectal evacuation (determined by defecography). RESULTS A total of 474 constipated individuals (420 women) underwent HR-ARM and BET, and 158 underwent defecography. BET was prolonged, suggesting a DD, for 152 patients (32%). Rectal evacuation was lower for patients with prolonged vs normal BET. A lower rectoanal gradient during evacuation, reduced anal squeeze increment, and reduced rectal sensation were independently associated with abnormal BETs; the rectoanal gradient was 36% sensitive and 85% specific for prolonged BET. A lower rectoanal gradient and prolonged BET were independently associated with reduced evacuation. Among constipated patients, the probability of reduced rectal evacuation was 14% when the gradient and BET were both normal, 45% when either was abnormal, and 75% when both variables were abnormal. CONCLUSIONS HR-ARM, BET, and defecography findings were concordant for constipated patients, and reduced rectoanal gradient was the best HR-ARM predictor of prolonged BET or reduced rectal evacuation. Prolonged BET, reduced gradient, and reduced evacuation each independently supported a diagnosis of DD in constipated patients. We propose the terms probable DD for patients with an isolated abnormal gradient or BET and definite DD for patients with abnormal results from both tests.
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Affiliation(s)
- John W Blackett
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Misha Gautam
- Enteric Physiology and Imaging Facility, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shivabalan Kathavarayan Ramu
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Mishra R, Gautam M, Oblizajek NR, Bharucha AE. Reproducibility of high-resolution manometry among healthy and constipated persons. Neurogastroenterol Motil 2022; 34:e14438. [PMID: 36017816 PMCID: PMC9722563 DOI: 10.1111/nmo.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/30/2022] [Accepted: 07/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although high-resolution manometry (HR_ARM) is commonly used to diagnose defecatory disorders, its intraindividual day-to-day reproducibility is unknown. Since these measurements entail voluntary effort, this study aimed to evaluate the intraindividual day-to-day reproducibility of HR_ARM. METHODS In 22 healthy women (35 years [14] mean [SD]) and 53 constipated patients (42 years [13], 46 women), the rectal balloon expulsion time (BET), and anorectal pressures were measured with HR_ARM on 2 days separated by a median (interquartile range) of 15 days (11-53) in healthy and 40 days (8-75) in constipated patients. Anorectal pressures were evaluated at rest (20 s), during squeeze, and during evacuation. Rectal sensation was also evaluated in constipated patients. The agreement between both measurements was evaluated with Lin's concordance correlation coefficient (CCC) and other tests. RESULTS Among constipated patients, the anal resting (mean CCC [95%CI] 0.62 [0.43-0.76]) and squeeze pressures (CCC 0.65 [0.47-0.79]), rectoanal gradient during evacuation (CCC 0.42 [0.17-0.62]), and rectal sensory thresholds (CCC for urgency 0.72 [0.52-0.84]) were concordant. Between days 1 and 2, one or more outcomes, characterized as normal or abnormal, differed in 79% of constipated patients, i.e., anal resting and squeeze pressures, the gradient, and the rectal BET differed in, respectively, 25%, 19%, 36%, and 10% of constipated patients. The rectal BET was prolonged in three healthy persons (both days) and either on 1 day (six patients) or 2 days (33 patients) in constipated patients. CONCLUSIONS While HR_ARM variables and the BET are reproducible within healthy and constipated persons, the outcome on repeat testing differed in 79% of constipated patients.
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Affiliation(s)
- Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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16
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ElWazir M, Gautam M, Mishra R, Oblizajek NR, Blackett JW(W, Bharucha AE. Automated extraction of anorectal pressures from high-resolution manometry reports. Neurogastroenterol Motil 2022; 34:e14411. [PMID: 35593217 PMCID: PMC9588692 DOI: 10.1111/nmo.14411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND During high-resolution anorectal manometry (HR_ARM), the raw data are converted into software-derived summary variables (e.g., rectoanal gradient during evacuation) that capture only a snapshot of the data collected during HR_ARM and are less useful than newer indices, which are also derived from the raw data, for diagnosing defecatory disorders (DD). However, it is cumbersome and time-consuming to extract raw data from the program and calculate such indices. This study aimed to devise a user-friendly approach to extract anorectal pressures measured with HR_ARM. METHODS Anorectal pressures at rest, during anal squeeze, and evacuation were measured with HR_ARM in 180 women, among whom 60 each were healthy, had DD, or fecal incontinence. A reverse engineering approach extracted pressure values from color images in HR_ARM reports. The summary variables generated by the software and a reverse engineering approach were compared with Lin's concordance correlation coefficient (CCC), paired t-tests, and Bland-Altman's tests. RESULTS Anorectal pressures summarized by the software and a reverse engineering method were highly concordant for anal resting (CCC [95% CI], 0.98 [0.97, 0.99]) and squeeze pressures (0.99 [0.99, 0.99) and the rectoanal gradient during evacuation with an empty (0.98 [0.97, 0.98]) and a filled balloon (0.99 [0.99, 0.99]). For most variables, the paired t and Bland-Altman comparisons were not significant. CONCLUSIONS Anorectal pressures can be accurately determined from pressure topography images in HR_ARM reports. In future, this reverse engineering approach can be harnessed to compile large HR_ARM datasets across centers and to uncover newer, potentially more useful summary rectoanal pressure variables.
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Affiliation(s)
- Mohamed ElWazir
- Department of Cardiovascular Medicine, Suez Canal University, Ismailia, Egypt
| | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Bharucha AE, Knowles CH. Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era. Neurogastroenterol Motil 2022; 34:e14453. [PMID: 36102693 PMCID: PMC9887546 DOI: 10.1111/nmo.14453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/06/2022] [Accepted: 08/17/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles H Knowles
- Blizard Institute (Knowles), Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
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18
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Nehra AK, Sheedy SP, Johnson CD, Flicek KT, Venkatesh SK, Heiken JP, Wells ML, Ehman EC, Barlow JM, Fletcher JG, Olson MC, Bharucha AE, Katzka DA, Fidler JL. Imaging Review of Gastrointestinal Motility Disorders. Radiographics 2022; 42:2014-2036. [PMID: 36206184 DOI: 10.1148/rg.220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The motor function of the gastrointestinal tract relies on the enteric nervous system, which includes neurons spanning from the esophagus to the internal anal sphincter. Disorders of gastrointestinal motility arise as a result of disease within the affected portion of the enteric nervous system and may be caused by a wide array of underlying diseases. The etiology of motility disorders may be primary or due to secondary causes related to infection or inflammation, congenital abnormalities, metabolic disturbances, systemic illness, or medication-related side effects. The symptoms of gastrointestinal dysmotility tend to be nonspecific and may cause diagnostic difficulty. Therefore, evaluation of motility disorders requires a combination of clinical, radiologic, and endoscopic or manometric testing. Radiologic studies including fluoroscopy, CT, MRI, and nuclear scintigraphy allow exclusion of alternative pathologic conditions and serve as adjuncts to endoscopy and manometry to determine the appropriate diagnosis. Additionally, radiologist understanding of clinical evaluation of motility disorders is necessary for guiding referring clinicians and appropriately imaging patients. New developments and advances in imaging techniques have allowed improved assessment and diagnosis of motility disorders, which will continue to improve patient treatment options. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Avinash K Nehra
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Shannon P Sheedy
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - C Daniel Johnson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Kristina T Flicek
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Sudhakar K Venkatesh
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jay P Heiken
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael L Wells
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Eric C Ehman
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - John M Barlow
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Joel G Fletcher
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael C Olson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Adil E Bharucha
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - David A Katzka
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jeff L Fidler
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
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19
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Oblizajek NR, Deb B, Ramu S(SK, Chunawala Z, Feuerhak K, Bailey KR, Bharucha AE. Optimizing techniques for measuring anal resting and squeeze pressures with high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14383. [PMID: 35468247 PMCID: PMC9529769 DOI: 10.1111/nmo.14383] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/17/2022] [Accepted: 03/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal methods for measuring and analyzing anal resting and squeeze pressure with high-resolution manometry (HRM) are unclear. METHODS Anal resting and squeeze pressures were measured with HRM in 90 healthy women, 35 women with defecatory disorders (DD), and 85 with fecal incontinence (FI). Pressures were analyzed with Manoview™ software and a customized approach. Resting pressures measured for 20, 60, and 300 s were compared. During the squeeze period, (3 maneuvers, 20 s each), the squeeze increment, which was averaged over 5, 10, 15, and 20 s, and squeeze duration were evaluated. RESULTS Compared to healthy women, the anal resting pressure, squeeze pressure increment, and squeeze duration were lower in FI (p ≤ 0.04) but not in DD. The 20, 60, and 300 s resting pressures were strongly correlated (concordance correlation coefficients = 0.96-0.99) in healthy and DD women. The 5 s squeeze increment was the greatest; 10, 15, and 20 s values were progressively lower (p < 0.001). The squeeze pressure increment and duration differed (p < 0.01) among the three maneuvers in healthy and DD women but not in FI women. The upper 95th percentile limit for squeeze duration was 19.5 s in controls, 19.9 s in DD, and 19.3 s in FI. Adjusted for age, resting pressure, and squeeze duration, a greater squeeze increment was associated with a lower risk of FI versus health (OR, 0.96; 95% CI, 0.94-0.97). CONCLUSIONS These findings suggest that anal resting and squeeze pressures can be accurately measured over 20 s. In most patients, one squeeze maneuver is probably sufficient.
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Affiliation(s)
| | - Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | | | - Zainali Chunawala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kent R. Bailey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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20
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Puthanmadhom Narayanan S, Grover M, Bharucha AE. Reply. Clin Gastroenterol Hepatol 2022; 20:2413. [PMID: 34902569 DOI: 10.1016/j.cgh.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/04/2021] [Indexed: 02/07/2023]
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21
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Caldera F, Farraye FA, Necela BM, Cogen D, Saha S, Wald A, Daoud ND, Chun K, Grimes I, Lutz M, Van Helden SR, Swift MD, Virk A, Bharucha AE, Patel TC, Gores GJ, Chumsri S, Hayney MS, Knutson KL. Higher Cell-Mediated Immune Responses in Patients With Inflammatory Bowel Disease on Anti-TNF Therapy After COVID-19 Vaccination. Inflamm Bowel Dis 2022:6697965. [PMID: 36103273 PMCID: PMC9494450 DOI: 10.1093/ibd/izac193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Some patients with inflammatory bowel disease (IBD) on immunosuppressive therapies may have a blunted response to certain vaccines, including the messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccines. However, few studies have evaluated the cell-mediated immune response (CMIR), which is critical to host defense after COVID-19 infection. The aim of this study was to evaluate the humoral immune response and CMIR after mRNA COVID-19 vaccination in patients with IBD. METHODS This prospective study (HERCULES [HumoRal and CellULar initial and Sustained immunogenicity in patients with IBD] study) evaluated humoral immune response and CMIR after completion of 2 doses of mRNA COVID-19 vaccines in 158 IBD patients and 20 healthy control (HC) subjects. The primary outcome was the CMIR to mRNA COVID-19 vaccines in patients with IBD. The secondary outcomes were a comparison of (1) the CMIR in patients with IBD and HC subjects, (2) CMIR and humoral immune response in all participants, and (3) correlation between CMIR and humoral immune response. RESULTS The majority (89%) of patients with IBD developed a CMIR, which was not different vs HC subjects (94%) (P = .6667). There was no significant difference (P = .5488) in CMIR between immunocompetent (median 255 [interquartile range, 146-958] spike T cells per million peripheral blood mononuclear cells) and immunosuppressed patients (median 377 [interquartile range, 123-1440]). There was no correlation between humoral and cell-mediated immunity after vaccination (P = .5215). In univariable analysis, anti-tumor necrosis factor therapy was associated with a higher CMIRs (P = .02) and confirmed in a multivariable model (P = .02). No other variables were associated with CMIR. CONCLUSIONS Most patients with IBD achieved CMIR to a COVID-19 vaccine. Future studies are needed evaluating sustained CMIR and clinical outcomes.
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Affiliation(s)
- Freddy Caldera
- Address correspondence to: Freddy Caldera, DO, MS, 1685 Highland Avenue, Madison, WI, 53705-2281, USA ()
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Brian M Necela
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Davitte Cogen
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Sumona Saha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arnold Wald
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nader D Daoud
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Kelly Chun
- R&D and Specialty Medicine, LabCorp, Calabasas, CA, USA
| | - Ian Grimes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Megan Lutz
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sean R Van Helden
- School of Pharmacy, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Melanie D Swift
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abinash Virk
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tushar C Patel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Saranya Chumsri
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Mary S Hayney
- School of Pharmacy, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
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22
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Bharucha AE, Basilisco G, Malcolm A, Lee TH, Hoy MB, Scott SM, Rao SSC. Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test. Neurogastroenterol Motil 2022; 34:e14335. [PMID: 35220645 PMCID: PMC9418387 DOI: 10.1111/nmo.14335] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. PURPOSE This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guido Basilisco
- UO Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Tae Hee Lee
- Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Matthew B Hoy
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, USA
| | - S Mark Scott
- National Bowel Research Centre, Queen Mary University of London, London, UK
| | - Satish S C Rao
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
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23
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Srinivasan SG, Muthyala A, Sharma M, Feuerhak K, Boon A, Bailey KR, Bharucha AE. Abdomino-anal Dyscoordination in Defecatory Disorders. Clin Gastroenterol Hepatol 2022; 20:2091-2101.e5. [PMID: 34896282 PMCID: PMC9174349 DOI: 10.1016/j.cgh.2021.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/19/2021] [Accepted: 11/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The contribution of the abdominal muscles to normal defecation and disturbances thereof in defecatory disorders (DDs) are unknown. METHODS In 30 healthy and 60 constipated women with normal rectal balloon expulsion time (BET) (n = 26) or prolonged BET (ie, DD; n = 34), seated anorectal pressures (manometry) and thickness (ultrasound) of the external and internal oblique and transversus abdominis muscles were measured simultaneously at rest, during hollowing, squeeze, evacuation, and a Valsalva maneuver. RESULTS Compared with healthy women with a normal BET, DD women had a lower rectal and greater anal pressure increase during evacuation (P ≤ .05), and more activation of the internal oblique and the transversus abdominis muscles during squeeze (P < .05). The change in transversus abdominis thickness during a Valsalva maneuver vs hollowing (rho = 0.5; P = .002) and separately vs evacuation (rho = 0.7; P < .0001) were correlated in DD but not in healthy women with a normal BET. A principal component (PC) analysis of anorectal pressures and muscle thicknesses during evacuation uncovered a PC (PC3) that was associated with a prolonged BET. Higher PC3 scores were associated with low rectal and high anal pressures at rest and during evacuation, thinner external oblique muscle, and thicker internal oblique muscle during evacuation. A greater PC3 score was associated with increased odds for DD vs health (odds ratio, 1.84; 95% CI, 1.05-3.23), and separately vs constipation with a normal BET (odds ratio, 3.64; 95% CI, 1.73-7.69). CONCLUSIONS Taken together, these findings show 3, possibly inter-related, disturbances suggestive of dyscoordination in DD: aberrant activation of abdominal muscles during squeeze in DD, dyscoordination of the abdominal muscles during various tasks in constipated women, and abdomino-anal dyscoordination.
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Affiliation(s)
| | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota
| | - Andrea Boon
- Department of Neurology, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Statistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota.
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24
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Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
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25
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Deb B, O’Brien DR, Chunawala ZS, Bharucha AE. Duodenal Mucosal Expression of COVID-19-Related Genes in Health, Diabetic Gastroenteropathy, and Functional Dyspepsia. J Clin Endocrinol Metab 2022; 107:e2600-e2609. [PMID: 35090021 PMCID: PMC8807322 DOI: 10.1210/clinem/dgac038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT SARS-CoV-2 infects the gastrointestinal tract and may be associated with symptoms that resemble diabetic gastroparesis. Why patients with diabetes who contract COVID-19 are more likely to have severe disease is unknown. OBJECTIVE We aimed to compare the duodenal mucosal expression of SARS-CoV-2 and inflammation-related genes in diabetes gastroenteropathy (DGE), functional dyspepsia (FD), and healthy controls. METHODS Gastrointestinal transit, and duodenal mucosal mRNA expression of selected genes were compared in 21 controls, 39 DGE patients, and 37 FD patients from a tertiary referral center. Pathway analyses were performed. RESULTS Patients had normal, delayed (5 FD [13%] and 13 DGE patients [33%]; P = 0.03 vs controls), or rapid (5 FD [12%] and 5 DGE [12%]) gastric emptying (GE). Compared with control participants, 100 SARS-CoV-2-related genes were increased in DGE (FDR < 0.05) vs 13 genes in FD; 71 of these 100 genes were differentially expressed in DGE vs FD but only 3 between DGE patients with normal vs delayed GE. Upregulated genes in DGE include the SARS-CoV2 viral entry genes CTSL (|Fold change [FC]|=1.16; FDR < 0.05) and CTSB (|FC|=1.24; FDR < 0.05) and selected genes involved in viral replication (eg, EIF2 pathways) and inflammation (CCR2, CXCL2, and LCN2, but not other inflammation-related pathways eg, IL-2 and IL-6 signaling). CONCLUSION Several SARS-CoV-2-related genes were differentially expressed between DGE vs healthy controls and vs FD but not between DGE patients with normal vs delayed GE, suggesting that the differential expression is related to diabetes per se. The upregulation of CTSL and CTSB and replication genes may predispose to SARS-CoV2 infection of the gastrointestinal tract in diabetes.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel R O’Brien
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Zainali S Chunawala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Deb B, Sharma M, Fletcher JG, Srinivasan SG, Chronopoulou A, Chen J, Bailey KR, Feuerhak KJ, Bharucha AE. Inadequate Rectal Pressure and Insufficient Relaxation and Abdominopelvic Coordination in Defecatory Disorders. Gastroenterology 2022; 162:1111-1122.e2. [PMID: 34951994 PMCID: PMC8934280 DOI: 10.1053/j.gastro.2021.12.257] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Diagnostic tests for defecatory disorders (DDs) asynchronously measure anorectal pressures and evacuation and show limited agreement; thus, abdominopelvic-rectoanal coordination in normal defecation and DDs is poorly characterized. We aimed to investigate anorectal pressures, anorectal and abdominal motion, and evacuation simultaneously in healthy and constipated women. METHODS Abdominal wall and anorectal motion, anorectal pressures, and rectal evacuation were measured simultaneously with supine magnetic resonance defecography and anorectal manometry. Evacuators were defined as those who attained at least 25% rectal evacuation. Supervised (logistic regression and random forest algorithm) and unsupervised (k-means cluster) analyses identified abdominal and anorectal variables that predicted evacuation. RESULTS We evaluated 28 healthy and 26 constipated women (evacuators comprised 19 healthy participants and 8 patients). Defecation was initiated by abdominal wall expansion that was coordinated with anorectal descent, increased rectal and anal pressure, and then anal relaxation and rectal evacuation. Compared with evacuators, nonevacuators had lower anal diameters during simulated defecation, rectal pressure, anorectal junction descent, and abdominopelvic-rectoanal coordination (P < .05). Unsupervised cluster analysis identified 3 clusters that were associated with evacuator status (P < .01), that is, 10 evacuators (83%), 16 evacuators (73%), and 1 evacuator (5%) in clusters 1, 2, and 3, respectively. Each cluster had distinct characteristics (eg, maximum abdominosacral distance, rectal pressure, anorectal junction descent, anal diameter) and correlates that were more (clusters 1-2) or less (cluster 3) conducive to evacuation. Cluster 2 had 16 evacuators (73%) and intermediate characteristics (eg, lower anal resting pressure and relaxation during evacuation; P < .05). CONCLUSIONS Women with DDs and a modest proportion of healthy women had specific patterns of anorectal dysfunction, including inadequate rectal pressurization, anal relaxation, and abdominopelvic-rectoanal coordination. These observations may guide individualized therapy for DDs in the future.
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Abstract
This article reviews the indications, techniques, interpretation, strengths, and weaknesses of tests (anal manometry, anal surface electromyography, rectal balloon expulsion test, barium and MRI defecography, assessment of rectal compliance and sensation, and colonic transit) that are used diagnose defecatory disorders in constipated patients. The selection of tests and the sequence in which they are performed should be individualized to and interpreted in the context of the clinical features. Because anorectal functions are affected by age, results should be interpreted with reference to age- and sex-matched normal values for the same technique.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905
| | - Enrique Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, México City, México
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Chumsri S, Advani PP, Pai TS, Li Z, Mummareddy A, Acampora M, Reynolds GA, Wylie N, Boyle AW, Lou Y, Mody K, Moreno-Aspitia A, Swift MD, Virk A, Bharucha AE, Marquez CP, Patel TC, Gores GJ, Knutson KL. Humoral Responses After SARS-CoV-2 mRNA Vaccination and Breakthrough Infection in Cancer Patients. Mayo Clin Proc Innov Qual Outcomes 2021; 6:120-125. [PMID: 34926993 PMCID: PMC8666324 DOI: 10.1016/j.mayocpiqo.2021.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate the magnitude of humoral response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger RNA (mRNA) vaccines in patients with cancer receiving active therapies. PATIENTS AND METHODS Patients 18 years or older in whom SARS-CoV-2 spike antibody (anti-S Ab) levels were measured after 2 doses of SARS-CoV-2 mRNA vaccines were included. Patients with prior coronavirus disease 2019 (COVID-19) infection or receiving other immunosuppressive therapy were excluded. RESULTS Among 201 patients who met the criteria, 61 were immunocompetent, 91 had a hematologic malignancy, and 49 had a solid malignancy while receiving treatments associated with cytopenia, including chemotherapy or cyclin-dependent kinase 4 and 6 inhibitors. A significantly greater proportion of immunocompetent patients (96.7% [59 of 61]) had anti-S Ab titers of 500 U/mL or greater compared to patients with hematologic (7.7% [7 of 91) and solid (55.1% [27 of 49]) malignancy (P<.001). Despite 2 doses of SARS-CoV-2 mRNA vaccines, 52.7% of patients with hematologic malignancy (48 of 91) and 8.2% of those with solid malignancy (4 of 49) receiving cytopenic therapy had no seroconversion (spike antibody titers <0.8 U/mL). Two patients subsequently had development of breakthrough COVID-19 infection after full vaccination. CONCLUSION A substantial proportion of patients with hematologic and solid malignancies receiving chemotherapies and CDK4/6i had poor humoral responses after SARS-CoV-2 mRNA vaccination. Our study adds to a growing body of literature suggesting that immunosuppressed patients have a suboptimal humoral response to COVID-19 vaccination. Our study also underscores the importance of assessing antibody response after COVID-19 vaccines in these vulnerable patients.
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Affiliation(s)
- Saranya Chumsri
- Division of Hematology and Medical Oncology,Correspondence: Address to Saranya Chumsri, MD, Division of Hematology and Medical Oncology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224.
| | | | | | - Zhuo Li
- Department of Quantitative Health Sciences
| | | | | | | | | | | | - Yanyan Lou
- Division of Hematology and Medical Oncology
| | - Kabir Mody
- Division of Hematology and Medical Oncology
| | | | | | | | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Keith L. Knutson
- Departments of Immunology and Cancer Biology, Mayo Clinic, Jacksonville, FL
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Kuwelker S, Prichard DO, Bailey K, Bharucha AE. Relationship between symptoms during a gastric emptying study, daily symptoms and quality of life in patients with diabetes mellitus. Neurogastroenterol Motil 2021; 33:e14154. [PMID: 33830588 PMCID: PMC8822501 DOI: 10.1111/nmo.14154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 02/27/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
AIMS Gastric emptying is of limited utility for predicting the severity of symptoms in patients with diabetes mellitus and gastrointestinal symptoms. We evaluated the extent to which symptoms recorded during a 13 C-spirulina-based gastric emptying breath test (GEBT) or scintigraphy predicting the severity of daily symptoms in diabetes mellitus. METHODS Gastric emptying, symptoms during a gastric emptying study, either scintigraphy (n = 38) or GEBT (n = 111), and daily gastrointestinal symptoms were evaluated in 149 patients with diabetes mellitus and variably severe gastrointestinal symptoms. KEY RESULTS Gastric emptying was normal, delayed, and rapid in 37%, 52%, and 9% measured with the GEBT and 55%, 34%, and 11% of patients measured with scintigraphy; differences between GEBT and scintigraphy were not significant. Daily symptoms were moderately severe or more intense in 58% and 21% of patients undergoing scintigraphy and GEBT (P < 0.0001). Symptoms during the GEBT (46%) and emptying thalf (3%) explained 50% of the variance in daily symptoms in the GEBT group. In the scintigraphy group, symptoms explained 29% of this variance; the thalf was insignificant. Patients who reported that one or more symptoms were more severe than the others during the GE study were more likely (OR 3.98, 95% CI 2.16, 7.33) to report the same symptom(s) as being the most severe in the daily diary. CONCLUSIONS Symptoms during a GEBT and to a lesser extent during scintigraphy, but not gastric emptying predict the severity of daily symptoms and may serve as a biomarker in patients with diabetes mellitus.
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Affiliation(s)
- Saatchi Kuwelker
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - David O. Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kent Bailey
- Division of Biostatistics, Mayo Clinic, Rochester, MN 55905
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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Levy AD, Liu PS, Kim DH, Fowler KJ, Bharucha AE, Chang KJ, Cilenti E, Gage KL, Garcia EM, Kambadakone AR, Korngold EK, Marin D, Moreno C, Pietryga JA, Santillan CS, Weinstein S, Wexner SD, Carucci LR. ACR Appropriateness Criteria® Anorectal Disease. J Am Coll Radiol 2021; 18:S268-S282. [PMID: 34794588 DOI: 10.1016/j.jacr.2021.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 01/06/2023]
Abstract
This review summarizes the relevant literature for the selection of the initial imaging in 4 clinical scenarios in patients with suspected inflammatory disease or postoperative complication of the anorectum. These clinical scenarios include suspected perianal fistula or abscess; rectovesicular or rectovaginal fistula; proctitis or pouchitis; and suspected complication following proctectomy, coloproctectomy, or colectomy with a pouch or other anastomosis. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of anorectal disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia.
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California; and Founder, Advisory Board Quantix Bio
| | - Adil E Bharucha
- Chair of the Neurogastroenterology Section, Chair of Research Compliance Subcommittee, and Medical Director, Office of Clinical Trials, Mayo Clinic Rochester, Minnesota; and American Gastroenterological Association
| | - Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts
| | - Elizabeth Cilenti
- Medstar Georgetown University Hospital, Washington, District of Columbia, Primary care physician
| | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; SECJNMMI Member-at-Large
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Avinash R Kambadakone
- Massachusetts General Hospital, Boston, Massachusetts; Taubman Museum of Art Board Member; and Past-President VA Rad Society
| | - Elena K Korngold
- Section Chief, Abdominal Imaging, Oregon Health and Science University, Portland, Oregon
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Courtney Moreno
- Emory University, Atlanta, Georgia; Chair ACR CTC Registry Committee; and Executive Council American Roentgen Ray Society
| | - Jason A Pietryga
- University of Alabama at Birmingham, Birmingham, Alabama; Associate Editor Hollow Organ GI
| | - Cynthia S Santillan
- Chief, Body Imaging Division and Vice-Chair, Clinical Operations for Radiology, University of California San Diego, San Diego, California
| | | | - Steven D Wexner
- Cleveland Clinic Florida, Weston, Florida; Editor-in-Chief, Surgery Journal; American College of Surgeons PAC Board; and Managing Member, Unique Surgical Innovations
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia; Director of CT and MRI at VCU, Section Chief, Abdominal Imaging at VCU
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Srinivasan SG, Sharma M, Feuerhak K, Bailey KR, Bharucha AE. A comparison of rectoanal pressures during Valsalva maneuver and evacuation uncovers rectoanal discoordination in defecatory disorders. Neurogastroenterol Motil 2021; 33:e14126. [PMID: 33797175 PMCID: PMC8486876 DOI: 10.1111/nmo.14126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 01/31/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is suggested that patients with defecation disorders (DD) strain excessively or do a Valsalva maneuver (VM) during evacuation, resulting in rectoanal discoordination, which hinders rectal evacuation. However, definitive data are lacking. METHODS Rectoanal pressures during evacuation and a VM were measured with seated high-resolution manometry (HRM) in 64 healthy and 136 constipated women with a normal (84 women, C-normal) or prolonged (52 women, C-abnormal) balloon expulsion time (BET). The number of abnormal rectoanal parameters during evacuation and the joint distribution of pressures during evacuation and a VM were used to discriminate between controls and C-abnormal BET patients. KEY RESULTS The peak anal pressure (5 s) during a VM accounted for 0%, 26%, and 49% of the variance in anal pressure during evacuation in healthy women, C-normal BET, and C-abnormal BET. The association between anal pressure during a VM and evacuation was stronger in C-abnormal BET than in healthy women and C-normal BET (p for interaction <0.001). Fifty-eight of 64 controls and 33 of 52 C-abnormal BET patients had no or one abnormal parameter during evacuation; hence, the probability of C-abnormal BET was 33/91 (36%). In patients with no or one abnormal parameter during evacuation, a logistic model based on anal pressures during evacuation and a VM discriminated between controls and patients with C-abnormal BET with a sensitivity and a specificity of 67% and 75%. CONCLUSIONS Assessment of rectoanal pressures during evacuation and a VM uncovers rectaoanal discoordination and facilitates the diagnosis of DD in selected patients.
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Affiliation(s)
- Sushmitha Grama Srinivasan
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Kent R Bailey
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
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Bharucha AE, Rhodes CT, Boos CM, Keller DA, Dispenzieri A, Oldenburg RP. Increased Utilization of Virtual Visits and Electronic Approaches in Clinical Research During the COVID-19 Pandemic and Thereafter. Mayo Clin Proc 2021; 96:2332-2341. [PMID: 34481597 PMCID: PMC8255101 DOI: 10.1016/j.mayocp.2021.06.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the impact of the COVID-19 pandemic on clinical research and the use of electronic approaches to mitigate this impact. METHODS We compared the utilization of electronic consenting, remote visits, and remote monitoring by study monitors in all research studies conducted at Mayo Clinic sites (Arizona, Florida, and Minnesota) before and during the COVID-19 pandemic (ie, between May 1, 2019 and December 31, 2020). Participants are consented through a participant-tracking system linked to the electronic health record. RESULTS Between May 2019, and December 2020, there were 130,800 new consents across every modality (electronic and paper) to participate in a non-trial (107,176 [82%]) or a clinical trial (23,624 [18%]). New consents declined from 5741 in February 2020 to 913 in April 2020 but increased to 11,864 in November 2020. The mean (standard deviation [SD]) proportion of electronic consent increased from 22 (2%) before to 45 (20%) during the pandemic (P=.001). Mean (SD) remote electronic consenting increased from 0.3 (0.5%) to 29 (21%) (P<.001). The mean (SD) number of patients with virtual visits increased from 3.5 (2.4%) to 172 (135%) (P=.003) per month between pre-COVID (July 2019 to February 2020) and post-COVID (March to December 2020) periods. Virtual visits used telemedicine (68%) or video (32%). Requests for remote monitor access to complete visits increased from 44 (17%) per month between May 2019 and February 2020 to 111 (74%) per month between March and December 2020 (P=.10). CONCLUSION After a sharp early decline, the enrollment of new participants and ongoing study visits recovered during the COVID-19 pandemic. This recovery was accompanied by the increased use of electronic tools.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - Cathi T Rhodes
- Research Systems Operations, Mayo Clinic, Scottsdale, AZ
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Bharucha AE, Gantz MG, Rao SS, Lowry AC, Chua H, Karunaratne T, Wu J, Hamilton FA, Whitehead WE. Comparative effectiveness of biofeedback and injectable bulking agents for treatment of fecal incontinence: Design and methods. Contemp Clin Trials 2021; 107:106464. [PMID: 34139357 PMCID: PMC8429255 DOI: 10.1016/j.cct.2021.106464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/08/2021] [Accepted: 05/30/2021] [Indexed: 12/13/2022]
Abstract
Fecal incontinence (FI), the involuntary passage of stool, is common and can markedly impair the quality of life. Among patients who fail initial options (pads or protective devices, bowel modifying agents, and pelvic floor exercises), the options are pelvic floor biofeedback (BIO), perianal injection with bulking agents (INJ), and sacral nerve electrical stimulation (SNS), which have not been subjected to head-to-head comparisons. This study will compare the safety and efficacy of BIO and INJ for managing FI. The impact of these approaches on quality-of-life and psychological distress, cost effectiveness, and predictors of response to therapy will also be evaluated. Six centers in the United States will enroll approximately 285 patients with moderate to severe FI. Patients who have 4 or more FI episodes over 2 weeks proceed to a 4-week trial of enhanced medical management (EMM) (ie, education, bowel management, and pelvic floor exercises). Thereafter, 194 non-responders as defined by a less than 75% reduction in the frequency of FI will be randomized to BIO or INJ. Three months later, the efficacy, safety, and cost of therapy will be assessed; non-responders will be invited to choose to add the other treatment or SNS for the remainder of the study. Early EMM responders will be re-evaluated 3 months later and non-responders randomized to BIO or INJ. Standardized, and where appropriate validated approaches will be used for study procedures, which will be performed by trained personnel. Prospectively collected data on care costs and resource utilization will be used for cost effectiveness analyses.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Heidi Chua
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | | | - Jennifer Wu
- Division of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
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Sharma M, Lowry AC, Rao SS, Whitehead WE, Szarka LA, Hamilton FA, Bharucha AE. A multicenter study of anorectal pressures and rectal sensation measured with portable manometry in healthy women and men. Neurogastroenterol Motil 2021; 33:e14067. [PMID: 33462889 PMCID: PMC8169521 DOI: 10.1111/nmo.14067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The equipment and methods for performing anorectal manometry and biofeedback therapy are different and not standardized. Normal values are influenced by age and sex. Our aims were to generate reference values, examine effects of gender and age, and compare anorectal pressures measured with diagnostic and biofeedback catheters and a portable manometry system. METHODS In this multicenter study, anorectal pressures at rest, during squeeze, and evacuation were measured with diagnostic and biofeedback catheters using Mcompass™ portable device in healthy subjects. Balloon expulsion time and rectal sensation were evaluated. The effects of age and gender were assessed. RESULTS The final dataset comprised 108 (74 women) of 124 participants with normal rectal balloon expulsion time (less than 60 s). During squeeze, anal resting pressure increased by approximately twofold in women and threefold in men. During evacuation, anal pressure exceeded rectal pressure in 87 participants (diagnostic catheter). The specific rectoanal pressures (e.g., resting pressure) were significantly correlated and not different between diagnostic and biofeedback catheters. With the diagnostic catheter, the anal squeeze pressure and rectal pressure during evacuation were greater in men than women (p ≤ 0.02). Among women, women aged 50 years and older had lower anal resting pressure; rectal pressure and the rectoanal gradient during evacuation were greater in older than younger women (p ≤ 0.01). CONCLUSIONS Anal and rectal pressures measured with diagnostic and biofeedback manometry catheters were correlated and not significantly different. Pressures were influenced by age and sex, providing reference values in men and women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | | | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
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Shah VH, Bharucha AE, Katzka DA, Gores GJ. Presentation of the Julius M. Friedenwald Medal to Michael Camilleri, MD, AGAF. Gastroenterology 2021; 160:2563-2571. [PMID: 34051987 DOI: 10.1053/j.gastro.2021.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Narayanan SP, Anderson B, Bharucha AE. Sex- and Gender-Related Differences in Common Functional Gastroenterologic Disorders. Mayo Clin Proc 2021; 96:1071-1089. [PMID: 33814075 PMCID: PMC8075061 DOI: 10.1016/j.mayocp.2020.10.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/07/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022]
Abstract
Functional gastrointestinal (GI) disorders (FGIDs) result from central and peripheral mechanisms, cause chronic remitting-relapsing symptoms, and are associated with comorbid conditions and impaired quality of life. This article reviews sex- and gender-based differences in the prevalence, pathophysiologic factors, clinical characteristics, and management of functional dyspepsia (FD) and irritable bowel syndrome (IBS) that together affect approximately 1 in 4 people in the United States. These conditions are more common in women. Among patients with IBS, women are more likely to have severe symptoms and coexistent anxiety or depression; constipation or bloating and diarrhea are more common in women and men, respectively, perhaps partly because defecatory disorders, which cause constipation, are more common in women. Current concepts suggest that biological disturbances (eg, persistent mucosal inflammation after acute gastroenteritis) interact with other environmental factors (eg, abuse) and psychological stressors, which influence the brain and gut to alter GI tract motility or sensation, thereby causing symptoms. By comparison to a considerable understanding of sex-based differences in the pathogenesis of visceral hypersensitivity in animal models, we know less about the contribution of these differences to FGID in humans. Slow gastric emptying and colon transit are more common in healthy women than in men, but effects of gonadal hormones on colon transit are less important than in rodents. Although increased visceral sensation partly explains symptoms, the effects of sex on visceral sensation, colonic permeability, and the gut microbiome are less prominent in humans than rodents. Whether sex or gender affects response to medications or behavioral therapy in FD or IBS is unclear because most patients in these studies are women.
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Affiliation(s)
| | | | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Sharma M, Feuerhak K, Corner SM, Manduca A, Bharucha AE. A new method for assessing anal distensibility with a barostat and magnetic resonance imaging in healthy and constipated women. Neurogastroenterol Motil 2021; 33:e13972. [PMID: 32815246 PMCID: PMC7864861 DOI: 10.1111/nmo.13972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/08/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Defecation requires relaxation of the internal and external anal sphincters. High anal resting pressure is associated with painful constipation, defecatory disorders, and increased healthcare utilization in constipated patients; the mechanisms are unclear. Perhaps patients with a high anal resting pressure have a less distensible canal, which impedes defecation. METHODS In 50 of 64 participants (33 healthy and 17 constipated women), anal pressures and distensibility were measured, respectively, with manometry and balloon distention combined with magnetic resonance imaging; rectal balloon expulsion time (BET) was also studied. RESULTS The BET (P = .006) was longer, and the mean (SD) rectoanal pressure gradient (-58[40] vs -34[26] mm Hg, P = .03) was more negative in constipated than healthy women; anal resting pressure was not different. During anal distention, the balloon expanded rapidly at an opening pressure of 49 (18) mm Hg, which was lower (P < .0001) than resting pressure (90 [25] mm Hg). The resting pressure was correlated with the opening pressure (r = 0.57, P < .0001) and inversely (r = -0.38, P = .007) with maximum volume but not with anal distensibility (volume-pressure slope). In healthy women, the difference (opening-resting pressure) was correlated with anal relaxation during evacuation (r = 0.35, P = .04). Anal distensibility and sensory thresholds were not different between constipated and healthy women. CONCLUSIONS Among healthy and constipated women, a greater anal resting pressure is correlated with greater opening pressure and lower maximum volume during distention, and, hence, provides a surrogate marker of anal distensibility. The difference (opening-resting pressure), which reflects anal relaxation during distention, is correlated with anal relaxation during evacuation. Anal resting pressure and distensibility were comparable in healthy and constipated women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Armando Manduca
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Puthanmadhom Narayanan S, O'Brien D, Sharma M, Miller K, Adams P, Passos JF, Eirin A, Ordog T, Bharucha AE. Duodenal mucosal mitochondrial gene expression is associated with delayed gastric emptying in diabetic gastroenteropathy. JCI Insight 2021; 6:143596. [PMID: 33491664 PMCID: PMC7934845 DOI: 10.1172/jci.insight.143596] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
Hindered by a limited understanding of the mechanisms responsible for diabetic gastroenteropathy (DGE), management is symptomatic. We investigated the duodenal mucosal expression of protein-coding genes and microRNAs (miRNA) in DGE and related them to clinical features. The diabetic phenotype, gastric emptying, mRNA, and miRNA expression and ultrastructure of duodenal mucosal biopsies were compared in 39 DGE patients and 21 controls. Among 3175 differentially expressed genes (FDR < 0.05), several mitochondrial DNA–encoded (mtDNA-encoded) genes (12 of 13 protein coding genes involved in oxidative phosphorylation [OXPHOS], both rRNAs and 9 of 22 transfer RNAs) were downregulated; conversely, nuclear DNA–encoded (nDNA-encoded) mitochondrial genes (OXPHOS) were upregulated in DGE. The promoters of differentially expressed genes were enriched in motifs for transcription factors (e.g., NRF1), which regulate mitochondrial biogenesis. Seventeen of 30 differentially expressed miRNAs targeted differentially expressed mitochondrial genes. Mitochondrial density was reduced and correlated with expression of 9 mtDNA OXPHOS genes. Uncovered by principal component (PC) analysis of 70 OXPHOS genes, PC1 was associated with neuropathy (P = 0.01) and delayed gastric emptying (P < 0.05). In DGE, mtDNA- and nDNA-encoded mitochondrial genes are reduced and increased — associated with reduced mitochondrial density, neuropathy, and delayed gastric emptying — and correlated with cognate miRNAs. These findings suggest that mitochondrial disturbances may contribute to delayed gastric emptying in DGE.
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Affiliation(s)
| | - Daniel O'Brien
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl Miller
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, California, USA
| | - Peter Adams
- Sanford Burnham Prebys Medical Discovery Institute, San Diego, California, USA
| | - João F Passos
- Department of Physiology and Biomedical Engineering and
| | - Alfonso Eirin
- Division of Nephrology & Hypertension Research, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tamas Ordog
- Department of Physiology and Biomedical Engineering and
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Bharucha AE, Oblizajek NR. Translumbosacral Neuromodulation Therapy Is a Promising Option for Fecal Incontinence. Am J Gastroenterol 2021; 116:80-81. [PMID: 33273260 PMCID: PMC7775327 DOI: 10.14309/ajg.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
ABSTRACT Fecal incontinence is a common symptom that can significantly impair quality of life. The treatment options range from conservative measures (e.g., Kegel exercises, pelvic floor biofeedback therapy, fiber supplementation, or medications) to noninvasive nerve stimulation (e.g., posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation), implanted neurostimulation (i.e., sacral nerve stimulation), perianal injection of dextranomer, and anal sphincteroplasty. In this issue of the journal, a promising, uncontrolled study suggests that noninvasive, repetitive magnetic stimulation of the lumbosacral nerves significantly improved symptoms, increased anal squeeze pressure, and increased rectal compliance in patients with fecal continence. Sham-controlled studies are necessary to confirm these findings.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Sharma M, Muthyala A, Feuerhak K, Puthanmadhom Narayanan S, Bailey KR, Bharucha AE. Improving the utility of high-resolution manometry for the diagnosis of defecatory disorders in women with chronic constipation. Neurogastroenterol Motil 2020; 32:e13910. [PMID: 32613711 PMCID: PMC7529936 DOI: 10.1111/nmo.13910] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We compared the utility of existing and modified versions of high-resolution manometry for diagnosing defecatory disorders (DD). METHODS In 64 healthy and 136 constipated women, we compared left lateral (LL) and seated manometry, and analyzed with existing (ManoView™) and new methods, for discriminating between constipated patients with normal and prolonged rectal balloon expulsion time (BET). In both positions, the rectoanal gradient (RAG) and, for the new analysis, the pressure topography pattern during evacuation were used to discriminate between constipated patients without and with DD. KEY RESULTS The BET was prolonged, suggestive of a DD, in 52 patients (38%). During evacuation, rectoanal pressures and the RAG were greater in the seated than the LL position (P≤.001). The new analysis identified 4 rectoanal pressure patterns. In the seated position, the BET was associated with the pattern (P=.0001), being prolonged in, respectively, 45%, 15%, 53%, and 0% of patients with minimal change, anal relaxation, paradoxical contraction, and transmission. Within each pattern, the RAG was greater (ie, less negative, P<.0001) in patients with a normal than a prolonged BET. Compared to the ManoView™ RAG in the LL position, the integrated analysis (ie, pattern and new RAG) in the LL position (P<.01) and the seated ManoView™ gradient (P=.02) were more effective for discriminating between constipated patients without and with DD. CONCLUSIONS & INFERENCES Anorectal HRM ideally should be performed in the more physiological seated position and analyzed by a two-tier approach, which incorporates the overall pattern followed by the rectoanal gradient. These findings reinforce the utility of manometry for diagnosing DD.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Anjani Muthyala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Kent R Bailey
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Puthanmadhom Narayanan S, Linden DR, Peters SA, Desai A, Kuwelker S, O’Brien D, Smyrk TJ, Graham RP, Grover M, Bharucha AE. Duodenal mucosal secretory disturbances in functional dyspepsia. Neurogastroenterol Motil 2020; 33:e13955. [PMID: 32776463 PMCID: PMC7772227 DOI: 10.1111/nmo.13955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/31/2020] [Accepted: 07/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is increased recognition of duodenal disturbances (inflammation, altered mucosal protein expression, and chemosensitivity) in functional dyspepsia (FD). Besides sensorimotor functions, enteric submucosal neurons also regulate epithelial ion transport. We hypothesized that duodenal mucosal ion transport and expression of associated genes are altered in FD. METHODS Duodenal mucosal ion transport (basal and acetylcholine- and glucose-evoked changes in short-circuit current [Isc]) and expression of associated genes and regulatory miRNAs were evaluated in 40 FD patients and 24 healthy controls. RESULTS Basal Isc (FD: 88.2 [52.6] μA/cm2 vs healthy: 20.3 [50.2] μA/cm2 ; P ≤ .0001), acetylcholine-evoked Isc (FD: Emax 50.4 [35.8] μA/cm2 vs healthy: 16.6 [15] μA/cm2 ; P ≤ .001), and glucose-evoked Isc responses (FD: Emax 69.8 [42.1] μA/cm2 vs healthy: 40.3 [24.6] μA/cm2 ; P = .02) were greater in FD than in controls. The Emax for glucose was greater in FD patients on selective serotonin reuptake inhibitors. In FD, the mRNA expression of SLC4A7 and SLC4A4, which transport bicarbonate into cells at the basolateral surface, and the apical anion exchanger SLC26A3 were reduced (false discovery rate <0.05), the serotonin receptor HTR4 was increased, and the serotonin transporter SLC6A4 was decreased. Selected miRNAs (hsa-miR-590-3p, hsa-miR-32-5p) that target genes associated with ionic transport were upregulated in FD. CONCLUSIONS Compared to controls, FD patients had greater baseline and agonist-evoked duodenal mucosal secretory responses. These findings may be explained by reduced gene expression, which would be anticipated to reduce luminal bicarbonate secretion. The upregulated miRNAs may partly explain the downregulation of these genes in FD.
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Affiliation(s)
| | - David R. Linden
- Department of Physiology and Biomedical Engineering Mayo Clinic Rochester MN USA
| | - Stephanie A. Peters
- Department of Physiology and Biomedical Engineering Mayo Clinic Rochester MN USA
| | - Anshuman Desai
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
| | - Saatchi Kuwelker
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
| | - Daniel O’Brien
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN USA
| | - Thomas J. Smyrk
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester MN USA
| | - Rondell P. Graham
- Department of Laboratory Medicine and Pathology Mayo Clinic Rochester MN USA
| | - Madhusudan Grover
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
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Affiliation(s)
- Karen M Meagher
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Nathan W Cummins
- Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Andrew D Badley
- Division of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Linda L Chlan
- Department of Nursing, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - R Scott Wright
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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Kuwelker S, Muthyala A, O’Connor M, Bharucha AE. Clinical features and disturbances of gastrointestinal transit in patients with rapid gastric emptying. Neurogastroenterol Motil 2020; 32:e13779. [PMID: 31960554 PMCID: PMC7085445 DOI: 10.1111/nmo.13779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 12/15/2022]
Abstract
AIMS Some patients with upper gastrointestinal symptoms have rapid gastric emptying (GE). We aimed to compare patients with normal and rapid GE and to identify phenotypes among patients with rapid GE. METHODS Among 2798 patients who underwent GE scintigraphy, we compared patients with normal and rapid GE and separately, patients with rapid GE at 1 hour (GE1), 2 hours (GE2), or both (GE12). RESULTS In 2798 patients, GE was normal (74%), delayed (18%), or rapid (8%). Among 211 patients with rapid GE, patterns were rapid GE1 (48%), 2 hours (17%), or 1 and 2 hours (35%); 42 (20%) had diseases that explain rapid GE. A combination of upper and lower gastrointestinal symptoms (54%) was more common that isolated upper (17%) or lower (28%) gastrointestinal symptoms (P < .001). Constipation was more prevalent in patients with rapid GE 2 (72%) than rapid GE 1 (47%) or rapid GE12 hours (67%) (P < .05). Among 179 diabetes mellitus (DM) patients, 15% had rapid GE, which was not associated with the DM phenotype. By multivariable analysis, insulin therapy (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.15-0.88), and weight loss (OR, 0.10; 95% CI, 0.01-0.78) were associated with a lower risk of rapid than normal GE in DM. CONCLUSIONS Eight percent of patients undergoing scintigraphy had rapid GE, which is most frequently associated with upper and lower gastrointestinal symptoms; constipation is common. Insulin therapy and weight loss were associated with a lower risk of rapid than normal GE in DM patients.
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Affiliation(s)
- Saatchi Kuwelker
- Clinical Enteric Neuroscience Translational and
Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota
| | - Anjani Muthyala
- Clinical Enteric Neuroscience Translational and
Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota
| | | | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and
Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota
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Abstract
With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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Desai A, Low PA, Camilleri M, Singer W, Burton D, Chakraborty S, Bharucha AE. Utility of the plasma pancreatic polypeptide response to modified sham feeding in diabetic gastroenteropathy and non-ulcer dyspepsia. Neurogastroenterol Motil 2020; 32:e13744. [PMID: 31642143 PMCID: PMC6994387 DOI: 10.1111/nmo.13744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/31/2019] [Accepted: 09/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The relationship between cardiovascular and gastrointestinal (ie, plasma pancreatic polypeptide [PP] response to modified sham feeding [MSF]) indices of vagal function is unclear. Hyperglycemia inhibits PP secretion via vagally mediated mechanisms. Our aims were to (a) compare the PP response, (b) its relationship with glycemia, and (c) the relationship between PP response to MSF, gastric emptying (GE) of solids, and symptoms during GE study in healthy controls, patients with diabetic gastroenteropathy (DM), and non-ulcer dyspepsia (NUD). METHODS In 24 healthy controls, 40 DM, and 40 NUD patients, we measured plasma PP concentrations during MSF, cardiovagal functions, GE, and symptoms during a GE study. KEY RESULTS Baseline PP concentrations were higher in DM than in controls and NUD (P = .01), and in type 2 than in type 1 DM patients (P < .01). The PP increment during MSF was normal (≥20 pg/mL) in 70% of controls, 54% of DM, and 47% of NUD patients. Overall, the PP response and cardiovagal tests were concordant (P = .01). Among patients with a reduced PP increment with MSF, 7/10 of T1DM and 1/7 of T2DM patients had moderate or severe cardiovagal dysfunctions (P < .05). The PP response to MSF was not associated with GE. CONCLUSIONS & INFERENCES Up to 30% of healthy controls have a reduced PP increment during MSF, limiting the utility of this test to detect vagal injury. The PP response is more useful when it is normal than abnormal. A reduced PP response is more likely to be associated with cardiovagal dysfunctions in T1DM than in T2DM.
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Affiliation(s)
- Anshuman Desai
- Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and
Hepatology
| | - Phillip A. Low
- Department of Neurology, College of Medicine, Mayo Clinic,
Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and
Hepatology
| | - Wolfgang Singer
- Department of Neurology, College of Medicine, Mayo Clinic,
Rochester, Minnesota, USA
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and
Hepatology
| | - Subhankar Chakraborty
- Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and
Hepatology
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and
Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and
Hepatology
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Anderson B, Carlson P, Laurenti M, Vella A, Camilleri M, Desai A, Feuerhak K, Bharucha AE. Association between allelic variants in the glucagon-like peptide 1 and cholecystokinin receptor genes with gastric emptying and glucose tolerance. Neurogastroenterol Motil 2020; 32:e13724. [PMID: 31691451 PMCID: PMC6923543 DOI: 10.1111/nmo.13724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/06/2019] [Accepted: 08/28/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nutrient-mediated release of cholecystokinin and glucagon-like peptide-1 (GLP-1) regulates gastric emptying (GE) via duodenogastric feedback mechanisms; GLP-1 also regulates postprandial insulin secretion. Some patients with functional upper gastrointestinal symptoms have impaired glucose tolerance during enteral dextrose infusion. Our hypothesis was that variants in CCK, GLP-1, and TCF7L2 (transcription factor 7-like 2 locus), which is associated with greatest genetic risk for development of type 2 diabetes mellitus, are associated with GE and independently with glucose tolerance. Our aims were to evaluate the associations between these GE, glucose tolerance, and these single nucleotide polymorphisms (SNPs). METHODS Genetic variants, scintigraphic GE of solids, plasma glucose, insulin, and GLP-1 during enteral dextrose infusion (75gm over 2 hours) were measured. GE and enteral dextrose infusion were, respectively, evaluated in 44 (27 controls and 17 patients with functional dyspepsia or nausea) and 42 (28 controls, 14 patients) participants; of these, 51 participants consented to assessment of SNPs. Four functional SNPs were studied: rs6923761 and rs1042044 at GLP-1 receptor, rs7903146 (TCF7L2), and rs1800857 (CCK receptor). KEY RESULTS Gastric emptying was normal in 38, rapid in 4, and delayed in two participants; 38 had normal, and four had impaired glucose tolerance. The T allele at rs7903146 (TCF7L2) was non-significantly associated (P = .14) with faster GE. The associations between SNPs and demographic variables, GE thalf , glucose tolerance and plasma GLP1 levels were not significant. CONCLUSIONS & INFERENCES There is a trend toward an association between faster GE and the diabetes-associated allele at rs7903146 in TCF7L2. However, these SNPs were not associated with plasma glucose or GLP1 concentrations during enteral dextrose infusion.
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Affiliation(s)
| | | | - Marcello Laurenti
- Mayo School of Graduate Medical Education, Division of Internal Medicine
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Carrington EV, Heinrich H, Knowles CH, Fox M, Rao S, Altomare DF, Bharucha AE, Burgell R, Chey WD, Chiarioni G, Dinning P, Emmanuel A, Farouk R, Felt‐Bersma RJF, Jung KW, Lembo A, Malcolm A, Mittal RK, Mion F, Myung S, O’Connell PR, Pehl C, Remes‐Troche JM, Reveille RM, Vaizey CJ, Vitton V, Whitehead WE, Wong RK, Scott SM. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil 2020; 32:e13679. [PMID: 31407463 PMCID: PMC6923590 DOI: 10.1111/nmo.13679] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. METHODS Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018. KEY RECOMMENDATIONS The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia. CONCLUSIONS AND INFERENCES This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.
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Affiliation(s)
| | | | | | - Mark Fox
- University of ZürichZürichSwitzerland
| | - Satish Rao
- Medical College of GeorgiaAugustaGeorgiaUSA
| | | | | | - Rebecca Burgell
- Monash University and Alfred HealthMelbourneVictoriaAustralia
| | | | | | | | | | - Ridzuan Farouk
- National University Hospital SingaporeSingapore CitySingapore
| | | | | | | | - Allison Malcolm
- University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | | | - Franҫois Mion
- Université de Lyon et Hospices Civils de LyonLyonFrance
| | | | | | - Christian Pehl
- Krankenhaus Vilsbiburg and Technical University MunichMunichGermany
| | | | | | | | | | | | - Reuben K. Wong
- National University Hospital SingaporeSingapore CitySingapore
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Abstract
Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Arnold Wald
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison
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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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