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Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. [Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]. Semergen 2016; 43:43-56. [PMID: 27810257 DOI: 10.1016/j.semerg.2016.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 12/19/2022]
Abstract
In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.
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Affiliation(s)
- F Mearin
- Coordinación de la guía de práctica clínica (GPC), Comité Roma de Trastornos Funcionales Intestinales, Asociación Española de Gastroenterología (AEG), Centro Médico Teknon, Barcelona, España
| | - C Ciriza
- Grupo de Trastornos Funcionales, Sociedad Española de Patología Digestiva (SEPD), Hospital Universitario Doce de Octubre, Madrid, España
| | - M Mínguez
- AEG y SEPD, Hospital Clínico Universitario, Universitat de Valencia, Valencia, España
| | - E Rey
- SEPD Hospital Clínico Universitario San Carlos, Madrid, España
| | - J J Mascort
- Secretaría Científica, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), España
| | - E Peña
- Coordinación de Digestivo, Sociedad Española de Médicos de Atención Primaria (SEMERGEN), España.
| | - P Cañones
- Coordinación de Digestivo, Sociedad Española de Médicos Generales y de Familia (SEMG), España
| | - J Júdez
- Departamento de Gestión del Conocimiento, SEPD, España
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- Sociedad Española de Patología Digestiva (SEPD), Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Sociedad Española de Médicos Generales y de Familia (SEMG)
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Caetano AC, Santa-Cruz A, Rolanda C. Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests? Can J Gastroenterol Hepatol 2016; 2016:8654314. [PMID: 27847802 PMCID: PMC5101368 DOI: 10.1155/2016/8654314] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/22/2016] [Indexed: 01/29/2023] Open
Abstract
Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and time-consuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests of DD. Methods. We performed a systematic search in PUBMED and MEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (I2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to perform better when a cut-off time of 2 minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.
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Affiliation(s)
- Ana C. Caetano
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - André Santa-Cruz
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
- Department of Internal Medicine, Braga Hospital, Braga, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
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Palit S, Thin N, Knowles CH, Lunniss PJ, Bharucha AE, Scott SM. Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients. Neurogastroenterol Motil 2016; 28:1589-98. [PMID: 27154577 DOI: 10.1111/nmo.12859] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Evacuatory dysfunction (ED) is a common cause of constipation and may be sub-classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for 'functional' defecatory disorders (FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED. METHODS One hundred consecutive patients fulfilling Rome III criteria for functional constipation underwent four tests: expulsion of a rectal balloon distended to 50 mL (BE50 ) or until patients experienced the desire to defecate (BEDDV ), evacuation proctography (EP) and anorectal manometry. Yields and agreements between tests for the diagnosis of ED and FDD were assessed. KEY RESULTS Positive diagnostic yields for ED were: BEDDV 18%, BE50 31%, EP 38% and anorectal manometry (ARM) 68%. Agreement was substantial between the two balloon tests (k = 0.66), only fair between proctography and BE50 (k = 0.27), poor between manometry and proctography (k = 0.01), and there was no agreement between the balloon tests and manometry (k = -0.07 for both BE50 and BEDDV ). For the diagnosis of FDD, there was only fair agreement between ARM and EP (k = 0.23), ARM ± BE50 and EP (k = 0.18), ARM and EP ± BE50 (k = 0.30) and ARM ± BE50 and EP ± BE50 (k = 0.23). CONCLUSIONS & INFERENCES There is considerable disagreement between the results of various tests used to diagnose ED and FDD. This highlights the need for a reappraisal of both diagnostic criteria, and what represents the 'gold standard' investigation.
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Affiliation(s)
- S Palit
- National Centre for Bowel Research and Surgical Innovation (NCBRSI) and GI Physiology Unit (GIPU), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Thin
- National Centre for Bowel Research and Surgical Innovation (NCBRSI) and GI Physiology Unit (GIPU), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C H Knowles
- National Centre for Bowel Research and Surgical Innovation (NCBRSI) and GI Physiology Unit (GIPU), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - P J Lunniss
- National Centre for Bowel Research and Surgical Innovation (NCBRSI) and GI Physiology Unit (GIPU), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A E Bharucha
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
| | - S M Scott
- National Centre for Bowel Research and Surgical Innovation (NCBRSI) and GI Physiology Unit (GIPU), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Abstract
Chronic constipation is a common health condition representing a substantial proportion of primary care visits and referrals to specialist providers. Chronic constipation can have a significant negative effect on health-related quality of life and has been associated with psychological distress in severely affected patients. It has the potential to cause patients to curtail work, school, and social activities. While different pathophysiological mechanisms have been implicated in the development of chronic constipation, in some instances, the causes of chronic constipation are not easily determined. Expenditures for the evaluation and management of chronic constipation represent a significant burden on patients and payers, and it is important for clinicians to have a clear understanding of the different pathophysiological mechanisms associated with constipation, understand the different testing modalities and treatments that are available including their appropriateness and limitations, and tailor that knowledge to the management of individual patients.
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Affiliation(s)
- Hani Sbahi
- Division of Gastroenterology, University of South Alabama, 75 University Boulevard S, Suite 6000-B, Mobile, Al, 36688, USA.
| | - Brooks D Cash
- Division of Gastroenterology, University of South Alabama, 75 University Boulevard S, Suite 6000-B, Mobile, Al, 36688, USA.
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Clark K, Lam LT, Talley NJ, Quinn J, Blight A, Byfieldt N, Currow DC. Assessing the Presence and Severity of Constipation with Plain Radiographs in Constipated Palliative Care Patients. J Palliat Med 2016; 19:617-21. [DOI: 10.1089/jpm.2015.0451] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Katherine Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Lawrence T. Lam
- Discipline of Paediatrics and Child Health, The Sydney Medical School, The University of Sydney, Sydney, Australia
- Department of Health and Physical Education, The Hong Kong Institute of Education, Hong Kong, China
| | - Nicholas J. Talley
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jessica Quinn
- School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Alison Blight
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
| | - Naomi Byfieldt
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
| | - David C. Currow
- Palliative and Supportive Services, Flinders University, Adelaide, Australia
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Lu L, Yan G, Zhao K, Xu F. Analysis of the Chaotic Characteristics of Human Colonic Activities and Comparison of Healthy Participants to Costive Subjects. IEEE J Biomed Health Inform 2016; 20:231-9. [DOI: 10.1109/jbhi.2014.2371073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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A study of human colonic motility in healthy and constipated subjects using the wireless capsule. Comput Biol Med 2015; 65:269-78. [PMID: 26238703 DOI: 10.1016/j.compbiomed.2015.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/13/2015] [Accepted: 07/14/2015] [Indexed: 02/07/2023]
Abstract
Constipation is a common and distressing condition that has been linked to major morbidity, burdens the health care system, and impacts patients׳ quality of life. However, there is no perfect method for diagnosing and treating constipation. The purpose of this paper is to develop an automatic algorithm to identify patients with constipation from healthy subjects. Data from 12 healthy subjects and 10 patients with constipation were analyzed. The key challenges for data processing were data filtering, feature extraction, information evaluation, and providing the reference conclusion; these were resolved by employing the phase space reconstruction (PSR), independent component analysis (ICA), dynamic feature extraction algorithm, and the Wilcoxon rank sum test. The contractile frequency (Fr), motility index per unit time (MIU), average peak of peristaltic wave (Pave) and variance (Var) were extracted as dynamic parameters and analyzed. Results between groups were compared with the Wilcoxon rank sum test. There were statistically significant differences between healthy subjects and patients with constipation for Fr and MIU (P<0.05), whereas there was no statistically difference for Var. Moreover, the Fr and MIU of patients with normal transit constipation (NTC) are significantly lower compared to healthy subjects, whereas patients with slow transit constipation (STC) did not show significant differences. The proposed algorithms were able to differentiate between healthy subjects and patients with constipation based on the colonic motility profiles.
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Bodmer NA, Thakrar KH. Evaluating the Patient with Left Lower Quadrant Abdominal Pain. Radiol Clin North Am 2015; 53:1171-88. [PMID: 26526432 DOI: 10.1016/j.rcl.2015.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Left lower quadrant pain is a frequent indication for imaging in the emergency department. Most causes of pain originate from the colon, including diverticulitis, colitis, fecal impaction, and epiploic appendagitis. Left-sided urolithiasis and spontaneous hemorrhage in the retroperitoneum or rectus sheath are additional causes of pain. Computed tomography is the preferred imaging modality in the emergent setting for all of these pathologic conditions. Gynecologic, testicular, and neoplastic pathology may also cause left lower quadrant pain but are not discussed in this article.
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Affiliation(s)
- Nicholas A Bodmer
- Department of Radiology, Advocate Good Samaritan Hospital, 3815 Highland Avenue, Downers Grove, IL 60515, USA.
| | - Kiran H Thakrar
- Department of Radiology, Evanston NorthShore University, 2650 Ridge Avenue, Evanston, IL 60201, USA
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Dimitriou N, Shah V, Stark D, Mathew R, Miller AS, Yeung JMC. Defecating Disorders: A Common Cause of Constipation in Women. WOMENS HEALTH 2015; 11:485-500. [DOI: 10.2217/whe.15.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.
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Affiliation(s)
- Nikoletta Dimitriou
- 1st Department of Surgery, University of Athens, Medical School, Laiko Hospital, Athens, Greece
| | - Vikas Shah
- Department of Radiology, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Diane Stark
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Ronnie Mathew
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Andrew S Miller
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Justin MC Yeung
- Pelvic Floor Unit, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
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Coss-Adame E, Rao SSC, Valestin J, Ali-Azamar A, Remes-Troche JM. Accuracy and Reproducibility of High-definition Anorectal Manometry and Pressure Topography Analyses in Healthy Subjects. Clin Gastroenterol Hepatol 2015; 13:1143-50.e1. [PMID: 25616028 PMCID: PMC4442034 DOI: 10.1016/j.cgh.2014.12.034] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 12/22/2014] [Accepted: 12/27/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS High-definition anorectal manometry (HDAM-3D) provides a topographic and 3-dimensional profile of anorectal pressure. We assessed anorectal sensorimotor function and the reproducibility of measurements made with HDAM-3D in healthy adults, and the accuracy of data analysis by its software. METHODS Anal sphincter pressures and rectal sensory thresholds were measured in 78 healthy subjects via placement of a 10-mm rigid probe, with 256 circumferentially arrayed pressure sensors, and a balloon in the rectum. The bearing down maneuver was assessed in a subset of 18 subjects. We compared data analyzed by an expert with findings from automated software analysis. Measurements made in a subset of 16 subjects, 2 weeks apart, were compared to determine reproducibility. RESULTS Resting, squeezing, and sustained squeezing pressures were significantly higher in men than in women (P < .05); other parameters were similar. Desire and urgency to defecate were similar between men and women, but the maximal tolerable volume was significantly lower in women (P < .05). Older women (>50 years) had significantly lower resting (P < .01) and sustained squeeze pressures (P < .04). Dyssynergic patterns of defecation were observed in 12 of 18 subjects (67%) who attempted to defecate without the 60-mL rectal balloon distention and in 6 of 18 subjects (33%) with the 60-mL rectal balloon distention. Test-retest values correlated (r = 0.81), as did analyses made by an expert vs software analyses of data (r = 0.99). CONCLUSIONS On the basis of HDAM-3D measurements in healthy adults, anal sphincter pressures are higher in men than in women, but sensory and other parameters are similar; older subjects have weaker sphincters. Many people were found to have dyssynergic patterns of defecation, which could be related to the probe or other technical issues, so this technique may not be suitable for assessing defecation patterns. Measurements made by HDAM-3D are reproducible, and data can be accurately analyzed by its software.
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Affiliation(s)
| | - Satish S C Rao
- Digestive Health Center, Georgia Regents University, Augusta, Georgia; University of Iowa Hospitals and Clinics, Iowa City, Iowa.
| | | | - Amyra Ali-Azamar
- Biological and Medical Research Institute, University of Veracruz, Veracruz, Mexico
| | - Jose M Remes-Troche
- Biological and Medical Research Institute, University of Veracruz, Veracruz, Mexico
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Abstract
PURPOSE Slow transit constipation (STC) and functional fecal retention (FFR) are two forms of severe intractable constipation in childhood diagnosed by nuclear transit studies (NTS). This retrospective study aims to identify the predicting factors for STC and FFR by looking at the association with neuropsychiatric disorders (NPD), obesity, family history of constipation and atopic disease. PATIENTS AND METHODS A retrospective chart review was conducted on children with intractable constipation referred for NTS between 1st April 2003 and 1st April 2014. Comparisons were made between STC, FFR and normal transit patients with regards to NPD, obesity (BMI z score >95th percentile), family history of constipation in first and second-degree relatives and atopic disease which included food allergy, asthma and eczema. RESULTS Between 2003 and 2014, 97 patients were referred for a NTS. Out of 36 patients with NPD, 21 (58.3 %) had STC and 13 (36.1 %) had FFR (p < 0.05). 15.8 % of patients with constipation were obese, compared to 6.4 % in the general Australian paediatric population (p < 0.05). There was no significant association between constipation and atopic disease or family history. CONCLUSION Neuropsychiatric disorders, in particular autism, are useful predictors of STC and FFR in children. Obesity may be associated with a higher risk of developing chronic constipation.
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Affiliation(s)
- Zainab Ridha
- The Australian National University, Canberra, Australia
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Xinias I, Mavroudi A. Constipation in Childhood. An update on evaluation and management. Hippokratia 2015; 19:11-19. [PMID: 26435640 PMCID: PMC4574579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Constipation is a frequent problitalic in childhood and may be defined as delay or difficulty in defecation that persists for longer than two weeks. It is one of the ten most frequent pathological conditions that a general paediatrician deals with. The aim of this review is to provide the general paediatrician an overview of constipation in children discussing the etiology, differential diagnosis, signs and symptoms and patient evaluation. METHODS We provide an overview on the pathogenesis, the diagnostic approach and the managitalicent of constipation based on electronic literature searches using the best available evidence from PubMed, Medline, Google Scholar, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). RESULTS The most common type of constipation is functional accounting for 90-95% of all cases. In a small percentage of children, who may have an organic cause of constipation, an appropriate laboratory investigation and imagine studying is warranted. CONCLUSIONS Functional constipation ritalicains a frequent problitalic in childhood. Treatment options differ between infants and children. italicphasis on recommended regimens for maintenance and how to reduce medication will help to improve the long-term outcome. Moreover, it is of great importance to follow constipated children closely and restart medication promptly. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. Hippokratia 2015, 19 (1): 11-19.
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Affiliation(s)
- I Xinias
- 3 Pediatric Department, Hippokratio Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Mavroudi
- 3 Pediatric Department, Hippokratio Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Lee BE, Kim GH. How to perform and interpret balloon expulsion test. J Neurogastroenterol Motil 2014; 20:407-9. [PMID: 24948132 PMCID: PMC4102152 DOI: 10.5056/jnm14068] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/04/2014] [Accepted: 06/05/2014] [Indexed: 11/20/2022] Open
Abstract
The balloon expulsion test is a simple and useful method for investigating a defecatory disorder assessing the subject's ability to evacuate a simulated stool. However, there is no standard methodology and varying interpretations have been reported. This review discusses the techniques, interpretation and clinical utility of the balloon expulsion test.
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Affiliation(s)
- Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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Jung KW, Joo S, Yang DH, Yoon IJ, Seo SY, Kim SO, Lee J, Lee HJ, Kim KJ, Ye BD, Byeon JS, Jung HY, Yang SK, Kim JH, Myung SJ. A novel high-resolution anorectal manometry parameter based on a three-dimensional integrated pressurized volume of a spatiotemporal plot, for predicting balloon expulsion in asymptomatic normal individuals. Neurogastroenterol Motil 2014; 26:937-49. [PMID: 24758370 DOI: 10.1111/nmo.12347] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 03/25/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anorectal manometry with simulated evacuation (SE) has limited applicability in predicting balloon expulsion (BE) test results. The newly developed high-resolution anorectal manometry (HRAM) technique can yield spatiotemporal plots with three-dimensional pressurization. We aimed to define new parameters based on three-dimensional integrated pressurized volume (IPV) for predicting the BE test results in asymptomatic normal individuals. METHODS Fifty-four asymptomatic healthy individuals were prospectively enrolled. BE tests were performed using 50 mL of water, and a requirement of more than 1 min was considered as delayed BE. HRAM profiles were converted into ASCII files and analyzed using a MATLAB program. A three-dimensional IPV was plotted after transforming the data to a cubic spline interpolation followed by resampling the manometry position at 0.1-cm intervals. KEY RESULTS Eight of the 54 (15%) individuals demonstrated delayed BE. Conventional manometric profiles did not differ significantly between cases of early and delayed BE. Receiver-operator characteristic curve analysis revealed that the ratio of the IPVs of the upper 1 cm to the lower 4 cm of the anorectal canal with balloon distension was more predictable of the BE results (area under curve, 0.73: 95% confidence interval, 0.53-0.92; p = 0.04) than the other IPVs or their ratios. CONCLUSIONS & INFERENCES The newly developed IPV methods could predict delayed BE tests during SE better than the conventional parameters defined on the basis of linear waves. Well-designed prospective trials on a large number of subjects are warranted to validate the clinical application of this novel parameter.
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Affiliation(s)
- Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hall KA, Ward SM, Cobine CA, Keef KD. Spatial organization and coordination of slow waves in the mouse anorectum. J Physiol 2014; 592:3813-29. [PMID: 24951622 DOI: 10.1113/jphysiol.2014.272542] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The internal anal sphincter (IAS) develops tone and is important for maintaining a high anal pressure while tone in the rectum is less. The mechanisms responsible for tone generation in the IAS are still uncertain. The present study addressed this question by comparing the electrical properties and morphology of the mouse IAS and distal rectum. The amplitude of tone and the frequency of phasic contractions was greater in the IAS than in rectum while membrane potential (Em) was less negative in the IAS than in rectum. Slow waves (SWs) were of greatest amplitude and frequency at the distal end of the IAS, declining in the oral direction. Dual microelectrode recordings revealed that SWs were coordinated over a much greater distance in the circumferential direction than in the oral direction. The circular muscle layer of the IAS was divided into five to eight 'minibundles' separated by connective tissue septa whereas few septa were present in the rectum. The limited coordination of SWs in the oral direction suggests that the activity in adjacent minibundles is not coordinated. Intramuscular interstitial cells of Cajal and platelet-derived growth factor receptor alpha-positive cells were present in each minibundle suggesting a role for one or both of these cells in SW generation. In summary, three important properties distinguish the IAS from the distal rectum: (1) a more depolarized Em; (2) larger and higher frequency SWs; and (3) the multiunit configuration of the muscle. All of these characteristics may contribute to greater tone generation in the IAS than in the distal rectum.
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Affiliation(s)
- K A Hall
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, NV 89557, USA
| | - S M Ward
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, NV 89557, USA
| | - C A Cobine
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, NV 89557, USA
| | - K D Keef
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, NV 89557, USA
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Mapel DW. Functional disorders of the gastrointestinal tract: Cost effectiveness review. Best Pract Res Clin Gastroenterol 2013; 27:913-31. [PMID: 24182611 DOI: 10.1016/j.bpg.2013.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 09/10/2013] [Accepted: 09/17/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The project aim was to review current cost-effectiveness research for each functional gastrointestinal disorder, as defined by the Rome III classification system. METHODS Biomedical databases were searched for articles with the functional gastrointestinal disorders and their pseudonyms included in the title, abstract, or medical subject headings, plus the terms benefit, cost, effectiveness, outcomes, test, utility, or utilization in any search field. RESULTS Highly prevalent conditions such as dyspepsia and irritable bowel syndrome have advanced cost-effectiveness analyses including cost-utility studies that have helped support current management guidelines. The rarer functional gastrointestinal disorders have few or no published cost-effectiveness analyses, but the Rome III classification system provides a framework for identifying the specific cost data or outcomes measures available or needed for future research. CONCLUSIONS The Rome process has provided a useful system for defining the functional gastrointestinal disorders and identifying specific clinical questions to be examined using cost-effectiveness analysis techniques.
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Affiliation(s)
- Douglas W Mapel
- Health Services Research Division, Lovelace Clinic Foundation, 2309 Renard Place SE, Suite 103, Albuquerque, NM 87106-4264, United States.
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Abstract
A good understanding of anorectal physiology is essential for the diagnosis and appropriate treatment of various anorectal disorders, such as fecal incontinence, constipation, and pain. This article reviews the physiology of the anorectum and details the various investigations used to diagnose anorectal physiology disorders. These anatomic and functional tests include anal manometry, endoanal ultrasound, defecography, balloon expulsion test, magnetic resonance imaging, pudendal nerve terminal motor latency, electromyography, and colonic transit studies. Indications for investigations, steps in performing the tests, and interpretation of results are discussed.
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Affiliation(s)
- Julie Ann M Van Koughnett
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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Burgers RE, Mugie SM, Chase J, Cooper CS, von Gontard A, Rittig CS, Homsy Y, Bauer SB, Benninga MA. Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society. J Urol 2013; 190:29-36. [PMID: 23313210 DOI: 10.1016/j.juro.2013.01.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 01/19/2023]
Abstract
PURPOSE We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms. MATERIALS AND METHODS Discussions were held by the board of the ICCS and a multidisciplinary core group of authors was appointed. The draft document review process was open to all ICCS members via the website. Feedback was considered by the core authors and, by agreement, amendments were made as necessary. RESULTS Guidelines on the assessment, and pharmacological and nonpharmacological management of functional constipation in children with lower urinary tract symptoms are outlined. CONCLUSIONS The final document is not a systematic literature review. It includes relevant research when available, as well as expert opinion on the current understanding of functional constipation in children with lower urinary tract symptoms. The document is intended to be clinically useful in primary, secondary and tertiary care settings.
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Affiliation(s)
- Rosa E Burgers
- Department of Pediatric Gastroenterology, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
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70
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Lam TJ, Felt-Bersma RJF. Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation. Int Urogynecol J 2012; 24:67-72. [PMID: 22618205 PMCID: PMC3536997 DOI: 10.1007/s00192-012-1796-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/11/2012] [Indexed: 01/27/2023]
Abstract
Introduction and hypothesis Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions. Methods Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography. Results One hundred and thirteen women were referred and classified as having idiopathic constipation (n = 100), neurological disorder (n = 8), or others (n = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P = 0.002) and had no rectoceles identified (P = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia. Conclusion Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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71
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Bashashati M, Andrews CN. Functional studies of the gastrointestinal tract in adult surgical clinics: when do they help? Int J Surg 2012; 10:280-4. [PMID: 22561737 DOI: 10.1016/j.ijsu.2012.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 04/27/2012] [Indexed: 02/08/2023]
Abstract
Gut motility and visceral sensation are two important components of normal gastrointestinal (GI) tract function. Disordered gut motility and sensation can cause significant symptoms which not only pose a health burden to patients, but may also mimic structural diseases and may generate many surgical referrals from primary care. Unfortunately, diagnostic testing for disorders of function lags well behind that for structural disease. In this article we review common presentations of functional disorders in surgical clinics, and relevant testing modalities.
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Bove A, Pucciani F, Bellini M, Battaglia E, Bocchini R, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V, Gambaccini D, Bove V. Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis). World J Gastroenterol 2012; 18:1555-64. [PMID: 22529683 PMCID: PMC3325520 DOI: 10.3748/wjg.v18.i14.1555] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/21/2011] [Accepted: 03/10/2012] [Indexed: 02/06/2023] Open
Abstract
Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.
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Lee TH, Lee JS. High-resolution Anorectal Manometry for Acquired Megarectum in a Patient With Parkinson's Disease. J Neurogastroenterol Motil 2012; 18:218-9. [PMID: 22523733 PMCID: PMC3325309 DOI: 10.5056/jnm.2012.18.2.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/06/2012] [Accepted: 01/15/2012] [Indexed: 01/29/2023] Open
Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
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Abstract
Constipation in children is an often long-lasting pediatric functional gastrointestinal disorder with a worldwide prevalence varying between 0.7% and 29.6%, and estimated health-care costs of US$3.9 billion per year in the USA alone. The pathophysiology of childhood constipation is multifactorial and remains incompletely understood; however, withholding of stools, starting after an experience of a hard, painful, or frightening bowel movement is the most common cause found in children. A thorough medical history and physical examination, including a rectal examination in combination with a bowel diary, is sufficient in the majority of cases to diagnose constipation. The current standard treatment consists of education, toilet training, disimpaction, maintenance therapy and long-term follow-up. In the past decade, well-designed treatment trials in the pediatric population have emerged and long-term outcome studies have been completed. This Review summarizes the current knowledge of the clinical aspects of childhood constipation, including pathogenesis, diagnosis and treatment, with particular emphasis on the latest available data.
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Chronic constipation: no more idiopathic, but a true neuropathological entity. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2011; 4:109-15. [PMID: 24834167 PMCID: PMC4017417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 06/11/2011] [Indexed: 11/25/2022]
Abstract
Chronic constipation is still considered a functional or idiopathic disorder. However, in recent years there is evidence that its pathopysiological grounds may be actually due to a complex system of abnormalities of the enteric nervous system of these patients. In particular, as reported in this review, the enteric glial cells seem to be constantly involved in constipated patients, suggesting that (at least some forms of) constipation should be considered as true neuro-gliopathies.
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