Rectal motility in patients with idiopathic fecal incontinence: a study with impedance planimetry

Esophageal distensibility measurement: impact on clinical management and procedure length

Luminal distensibility measurement has demonstrated relevance to various disease processes, though its effects on clinical decision-making have been less well understood. This study aims to characterize the clinical impact of impedance planimetry measurement as well as the learning curve associated with its use in the esophagus. A single provider performed distensibility measurement in conjunction with upper endoscopy for a variety of clinical indications with the functional lumen imaging probe (FLIP) over a period of 21 months. Procedural data were prospectively collected and, along with medical records, retrospectively reviewed. Seventy-three procedures (70 patients) underwent esophageal distensibility measurement over the timeline of this study. The most common procedural indications were known or suspected achalasia (32.9%), dysphagia with connective tissue disease (13.7%), eosinophilic esophagitis (12.3%), and dysphagia with prior fundoplication (9.6%). FLIP results independently led to a change in management in 29 (39.7%) cases and supported a change in management in an additional 15 (20.5%) cases. The most common change in management was a new or amended therapeutic procedure (79.5%). Procedural time added by distensibility measurement was greater among earlier cases than among later cases. The median time added overall was 5 minutes and 46 seconds. Procedural time added varied significantly by procedural indication, but changes in management did not. Distensibility measurement added meaningful diagnostic information that impacted therapeutic decision-making in the majority of cases in which it was performed. Procedural time added by this modality is typically modest and decreases with experience.

Pyloric Therapies for Gastroparesis

OPINION STATEMENT

Gastroparesis is a syndrome that can be difficult to treat effectively and likely represents the common clinical presentation of multiple underlying mechanisms. One of these presumed mechanisms involves pyloric dysfunction, tied perhaps to spasm or fibrosis, manifesting as functional gastric outlet obstruction. Various diagnostic modalities have been used to better characterize this hypothesized abnormality, including most recently antroduodenal manometry and impedance planimetry. A variety of therapeutic interventions specific to the pylorus have also been proposed in the last several years, including intrapyloric injections of botulinum toxin, transpyloric stenting, surgical pyloroplasty, and endoscopic pyloromyotomy. The clinical application of these maneuvers has been mostly empiric thus far, but efforts are ongoing to identify the subset of patients whose physiology best positions them to benefit from such therapy. Early results for many of these interventions have been promising and will serve as the basis for larger and more systematic research frameworks moving forward.

Rectal tone and compliance affected in patients with fecal incontinence after fistulotomy

AIM: To investigate the anal sphincter and rectal factors that may be involved in fecal incontinence that develops following fistulotomy (FIAF).

METHODS: Eleven patients with FIAF were compared with 11 patients with idiopathic fecal incontinence and with 11 asymptomatic healthy subjects (HS). All of the study participants underwent anorectal manometry and a barostat study (rectal sensitivity, tone, compliance and capacity). The mean time since surgery was 28 ± 26 mo. The postoperative continence score was 14 ± 2.5 (95%CI: 12.4-15.5, St Mark’s fecal incontinence grading system).

RESULTS: Compared with the HS, the FIAF patients showed increased rectal tone (42.63 ± 27.69 vs 103.5 ± 51.13, P = 0.002) and less rectal compliance (4.95 ± 3.43 vs 11.77 ± 6.9, P = 0.009). No significant differences were found between the FIAF patients and the HS with respect to the rectal capacity; thresholds for the non-noxious stimuli of first sensation, gas sensation and urge-to-defecate sensation or the noxious stimulus of pain; anal resting pressure or squeeze pressure; or the frequency or percentage of relaxation of the rectoanal inhibitory reflex. No significant differences were found between the FIAF patients and the patients with idiopathic fecal incontinence.

CONCLUSION: In patients with FIAF, normal motor anal sphincter function and rectal sensitivity are preserved, but rectal tone and compliance are impaired. The results suggest that FIAF is not due to alterations in rectal sensitivity and that the rectum is more involved than the anal sphincters in the genesis of FIAF.

Rectal motility in pediatric constipation

OBJECTIVES

Constipation is a common disorder in children, but little is known about its etiology. Rectal impedance planimetry determines segmental rectal cross-sectional area (CSA) and pressure, allowing detailed description of rectal motility. The aim of the present study was to compare rectal motility in healthy and constipated children.

METHODS

We analyzed data from 10 children (1 girl) with constipation according to the Rome III criteria, mean age 8.8 years (standard deviation ± 1.2), and 10 healthy children (5 girls), mean age 9.9 years (standard deviation ± 1.5). CSA was determined at 3 levels (4, 5.5, and 7 cm from the anal verge). The resting rectal motility was recorded for 30 minutes followed by a distension protocol to assess compliance. Runs of phasic rectal contractions were defined as changes of >10% from baseline CSA and lasting at least 2 minutes. Rectal dimensions were expressed as mean CSA.

RESULTS

A low-amplitude contraction pattern (3%-5% of baseline CSA) with a frequency of 6 to 8/minute was present in all of the children. There was significantly more time with phasic rectal contractions in constipated children (median 38%, range [0-100]) compared with healthy children (median 8.8%, range [0-57]) (P < 0.05). The rectal CSA was higher in constipated children (median 1802 mm [range 1106-2948]) compared with healthy children (1375 mm [range 437-1861]) (P < 0.05), but compliance did not differ (constipated: median 38 mm/H2O [range 12-86] vs healthy 33 mm/H2O [range 10-63]) (P = 30).

CONCLUSIONS

In children with constipation, we found phasic rectal contractions for a significantly longer period compared with healthy children, and their rectum is larger than normal.

The acute effect of dorsal genital nerve stimulation on rectal wall properties in patients with idiopathic faecal incontinence

AIM

Faecal continence depends on several factors, including rectal wall properties. Stimulation of the dorsal genital nerve (DGN) can suppress bladder contraction and similar effects are anticipated for the rectum. In this study, the acute effect of DGN stimulation on the rectal cross-sectional area is investigated.

METHOD

Ten female patients (median age 60 years) with idiopathic faecal incontinence were included in the study. Stimulation was applied via plaster electrodes with the maximum tolerable amplitude (pulse width was 200 μs at a pulse rate of 20 Hz). Three series of pressure-controlled phasic (10, 20 and 30 cm H(2) O) and stepwise (5-30 cm H(2) O in steps of 5 cm H(2) O) rectal distensions were conducted (unstimulated, stimulated, unstimulated), and the rectal cross-sectional area (CSA) was measured with impedance planimetry.

RESULTS

All patients completed the investigation. The median stimulation amplitude was 21 (8.5-27) mA. Comparing stimulated with unstimulated phasic distension, there was no significant difference in the median rectal CSA. Comparing stimulated with unstimulated stepwise distension, there was no significant difference in the median rectal CSA. Neither the rectal pressure-CSA relationship (CSA/P(R) ) nor the rectal wall tension changed during stimulation.

CONCLUSION

No acute effect on rectal CSA during pressure-controlled distension was demonstrated during DGN stimulation.