Anorectal manometry with and without ketamine for evaluation of defecation disorders in children

Impact of anesthesia drugs on digestive motility measurements in humans: A systematic review

BACKGROUND AND PURPOSE

Measurement of gastro-intestinal motility is increasingly performed under general anesthesia during endoscopic or surgical procedures. The aim of the present study was to review the impact of different anesthetic agents on digestive motility measurements in humans.

METHODS

This systematic review was performed using the Medline-Pubmed and Web of Science databases. All articles published until October 2023 were screened by identification of key words. Studies were reviewed if patients had an assessment of digestive motility using conventional perfused manometry, high-resolution manometry, electronic barostat or functional lumen impedance planimetry with the use of inhaled or intravenous anesthetic anesthetic agents (propofol, ketamine, halogens, nitrous oxide, opioids, and neuromuscular blockades).

RESULTS

Four hundred and eighty-eight unique citations were identified, of which 42 studies met the inclusion criteria and were included in the present review. The impact of anesthetics was mostly studied in patients who underwent esophageal manometry. There was a heterogeneity in both the dose and timing of administration of anesthetics among the studies. Remifentanil analgesia was the most studied anesthetic drug in the literature, showing a decrease in both distal latency and lower esophageal sphincter pressure after its administration, but the impact on Chicago classification was not studied. Inhaled anesthetics administration elicited a decrease in lower esophageal sphincter pressure, but contradictory findings were shown on esophageal motility following propofol or neuromuscular blocking agents administration.

CONCLUSION

Studies of the impact of anesthetics on digestive motility remain scarce in the literature, although some agents have been reported to profoundly affect gastro-intestinal motility.

High-resolution anorectal manometry in children

Anorectal manometry is one of the motility tests in children performed by pediatric gastroenterologist. It evaluates the motility function of anorectal tract. It is helpful for diagnosing children with constipation, rectal hypersensitivity, fecal incontinence, Hirschsprung disease, anal achalasia, and anorectal malformations. The most common indication to perform anorectal manometry is to diagnose Hirschsprung disease. It is a safe procedure. This paper discusses recent advances and reviews on anorectal motility disorders in children.

State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation

BACKGROUND

Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC.

METHODS

A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years.

RESULTS

The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test.

CONCLUSION

Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.

Accuracy of Anorectal Manometry to Detect the Rectoanal Inhibitory Reflex in Children: Awake Versus Under General Anesthesia

OBJECTIVES

Our objective was to investigate if there is a difference in the detection of the rectoanal inhibitory reflex (RAIR) when an anorectal manometry (ARM) is performed awake or under general anesthesia.

METHODS

A retrospective review of ARM studies was performed to identify children who had undergone ARMs both while awake and under general anesthesia. We compared ARM outcomes including the detection of the RAIR and anal canal resting pressure.

RESULTS

Thirty-four children had received ARMs both while awake and under general anesthesia (53% female, median age at first ARM 7.5 years [range 3-18 years]). In 9 of 34 (26%) children the RAIR was solely identified during ARM under general anesthesia and not during ARM while awake. In 6 of 9 (66%) this was unrelated to the balloon volumes used during balloon inflations. In 4 of 34 (12%) children, assessment of the RAIR was inconclusive during ARM under general anesthesia due to too low, or loss of anal canal pressure. In 2 of those children, ARMs while awake showed presence of a RAIR. Anal canal resting pressures were higher during ARM while awake versus ARM under general anesthesia (median 70 [interquartile range, IQR 59-85] vs 46 mmHg [IQR 36-65] respectively, P < 0.001).

CONCLUSIONS

General anesthesia may affect the detection of a RAIR in 2 ways. On the one hand, it may facilitate better visualization in children in whom a RAIR could not be visualized while awake. On the other hand, it may cause a loss of anal canal pressure resulting in an inconclusive test result.

Can Propofol Be Used to Assess the Presence of the Rectoanal Inhibitory Reflex During Anorectal Manometry Studies?

OBJECTIVES

To study changes in intra-anal pressure (IAP) and characteristics of the rectoanal inhibitory reflex (RAIR) during anorectal manometry (ARM) in patients undergoing anesthesia induction with propofol.

METHODS

Prospective study in which ARM was performed at baseline while patients were awake and repeated after propofol-induced anesthesia. We studied IAP and the presence and characteristics of the RAIR before and after propofol.

RESULTS

A total of 27 patients were included (63% male; 9.2 years). Three patients had obstructive symptoms after Hirschsprung disease repair (HSCR), and 24 had intractable constipation. At baseline, the RAIR was present on 21 of 27 patients and absent on 6 of 27. Of the six patients with an absent RAIR, it remained absent in four of six (three known HSCR, and one new diagnosis of IAS achalasia), and two of six had a normal RAIR during propofol. Therefore, RAIR was present in all patients with constipation. The mean resting IAP was significantly lower after propofol. The percentage of IAS relaxation after lower balloon volume inflations was significantly higher during propofol (P < 0.05). No difference was observed over the latency time or the total relaxation time after propofol.

CONCLUSIONS

Propofol can be used to assess the presence of the RAIR during ARM in children who are uncooperative and undergoing other procedures under anesthesia. On the other hand, propofol significantly reduces the resting IAP and increases the percentage of internal anal sphincter relaxation after balloon distention. These findings may impact the interpretation to decide if an intervention is needed, or if there is a possible spinal neuropathy.

Diagnosis analysis of rectal function through using ensemble empirical mode decomposition-deep belief networks algorithm

The rectal motility function can reflect a person's rectal health status. To diagnose the rectal motility function after artificial anal sphincter implantation, this paper proposes a rectal function diagnosis model based on ensemble empirical mode decomposition-deep belief networks (EEMD-DBNs). Because of the rectal pressure signals that are unstable and subjected to noise interferences, an EEMD framework based on EMD, which can reduce the effect of signal modal mixing, is proposed. EMD and EEMD were used to decompose the analog signal, respectively, and it was found that EEMD can significantly reduce the effect of mode aliasing. During the rectal pressure signal decomposition experiment, by analyzing the intrinsic mode functions generated by the signals from normal people and diseased patients, the rectal signals at these two different conditions can be well distinguished. Additionally, the DBN was introduced to perform deep learning to extract the multi-dimensional features of rectal signals and then output the classification results via using the top-level classifier, which can overcome the difficulties in extracting the rectal signal features. The results showed that, following the principle of balancing the diagnosis accuracy and model running speed, the best diagnosis performance was achieved when three restricted Boltzmann machines and five layers of DBN model were set, with the diagnosis rate of 85%. The diagnostic model used in this study can distinguish the signals between normal and abnormal rectal functions with accurate performance, thus providing the technical support for the recovery of the rectal motility function of artificial anal sphincter implanters.

Anorectal Manometry on Children: A Moroccan Series and Literature Review

Introduction and objectives: Anorectal manometry is a test that evaluates the function of the rectum,but also the anus. It is useful for the diagnosis of several conditions like fecal incontinence and constipation.In children these tests are being increasingly used for all ages.The aim of this study was to determine the benefit of anorectal manometry in children and to report our experience. Material and Methods:Over a period of four years, 273children that underwent anorectal manometry were included in the study,their data and tests results were analyzed. Results:Out of 273 patients included,68,5% were boys and 31,5% were girls.The mean age was 9 years.154patients(51,6%) had Fecal incontinence(Group1),75children(27,5%) had chronic constipation(Group2),and both of them(Group3) were reported in 37children(13,6%).An awake manometry was  performed in 248children(91%) however this test under sedation allowed us the exclusion of Hirschsprung’s disease in 21children(84%).In group1, 25%patients had bad anal contraction.In groupe3, 21,6%children had bad anal contraction.The statistical analysis showed a significant difference in age(p=0.022) and resting pressure(p=0.050) between the three groups.Children with fecal incontinence had a higher rate of dyssynergy,80.2% and 83.8% in groups 1 and 3 respectively compared to 60.4% in patients with chronic constipation(p=0,852) Conclusion:The gold standard for the exploration of children’s terminal constipation and encopresis is the anorectal manometry.It is an important tool to establish diagnosis.In our study, this test allow the exclusion of Hirschsprung’s disease in infants with constipation,  in other hand we found a higher rate of dyssynergy in children with fecal incontinence(80%) which had allow us to propose a biofeedback therapy.

Anorectal manometry in pediatric settings: A systematic review of 227 studies

BACKGROUND

There is wide variation in the clinical use of diagnostic tools for children with chronic constipation and functional/structural fecal incontinence (CCFSFI). Anorectal manometry (ARM) is a well-recognized technique to assess the function of the anorectum.

PURPOSE

Our aim was to perform an up-to-date review on ARM in pediatric patients with CCFSFI, with specific focus on the indication of use and protocol. Variation of its use in pediatrics will be explored.

METHODS

A systematic search was conducted for empirical studies utilizing ARM with a pediatric sample. A keyword search of literature published in English before July 2018 was conducted and updated to October 2019. Data on demographics, clinical information, study aims, ARM parameters and use of sedation/anesthesia were collected.

KEY RESULTS

A total of 227 studies were included in this systematic review. The age of study participants at the time of ARM ranged from birth to 18 years. ARM was most commonly used in patients with organic conditions (65%) compared to functional constipation (41%). In almost half [108/227 (48%)] of the studies, ARM was performed awake. The ARM parameters most frequently assessed were the rectoanal inhibitory reflex, which was evaluated in 198/227 studies (87%) and the anal resting pressure [166/227 studies (73%)].

CONCLUSIONS AND INFERENCES

This systematic review has highlighted the vast variation of ARM use within pediatrics and the need to strive toward standardization and use of consensus guidelines. We anticipate this will further advance our understanding of the pathophysiological mechanisms involved in children with defecation disorders.

Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement

Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.

Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence

PURPOSE

There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children's Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI.

METHODS

Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS).

RESULTS

Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung's disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05).

CONCLUSIONS

Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.

Effects of a Psychological Preparation Intervention on Anxiety Associated with Pediatric Anorectal Manometry

Background and Aims

High-resolution anorectal manometry (HRM) is associated with significant patient and parent anxiety, which can impact the success and efficiency of the procedure. The nature of HRM necessitates cooperation of an alert child. This study examined effects of psychoeducation intervention on decreasing procedural distress in both pediatric patients and their parents.

Methods

A prospective randomized study of children aged 3–12 years, undergoing HRM, was performed utilizing child-centric educational video. Patients received either psychological preparation intervention or treatment-as-usual. Distress was assessed through self-reported and parent-reported anxiety measures (STAIC-S; STAI-S), physiological arousal measurements, and an observational scale of procedural distress (PBCL).

Results

A total of 63 children, aged 3–12 yrs (6.7 ± 2.5), completed the study. Measures of observed and reported distress and anxiety (PBCL; STAIC-S) were significantly less in children receiving intervention. Parents of children in the intervention group also reported significantly less preprocedural anxiety (STAI-S). Effects on physiological arousal were mixed, with significant preprocedural decrease in systolic blood pressure but no difference in heart rate from baseline.

Conclusions

Preprocedural psychological preparation was effective in decreasing pediatric patient and parental self-reported anxiety associated with HRM. Intervention decreased physician time necessary to successfully complete the study and significantly decreased the number of times patients had to endure balloon inflation.

Manometric findings in relation to functional outcomes in different types of anorectal malformations

AIMS

To compare anorectal manometry (AM) in patients with different types of anorectal malformations (ARMs) in relation to functional outcomes.

METHODS

A single-institution, cross-sectional study. After ethical approval, all patients ≥7years old treated for anterior anus (AA), perineal fistula (PF), vestibular fistula (VF), or rectourethral fistula (RUF) from 1983 onwards were invited to answer the Rintala bowel function score (BFS) questionnaire and to attend anorectal manometry (AM). Patients with mild ARMs (AA females and PF males) had been treated with minimally invasive perineal procedures. Females with VF/PF and males with RUF had undergone internal-sphincter saving sagittal repairs.

RESULTS

55 of 132 respondents (42%; median age 12 (7-29) years; 42% male) underwent AM. Patients with mild ARMs displayed good anorectal function after minimally invasive treatments. The median anal resting and squeeze pressures among patients with mild ARMs (60 cm H2O and 116 cm H2O respectively) were significantly higher than among patients with more severe ARMs (50 cm H2O, and 80cm H2O respectively; p≤0.002). The rectoanal inhibitory reflex was preserved in 100% of mild ARMs and 83% of patients with more severe malformations after IAS-saving sagittal repair. The functional outcome was poor in 4/5 patients with an absent RAIR (BFS≤11 or antegrade continence enema-dependence). Rectal sensation correlated significantly with the BFS.

CONCLUSIONS

Our findings support the appropriateness of our minimally invasive approaches to the management of mild ARMs, and IAS-saving anatomical repairs for patients with more severe malformations.

LEVEL OF EVIDENCE

III.

An ANMS-NASPGHAN consensus document on anorectal and colonic manometry in children

BACKGROUND

Over the last few years, the study of the colon and anorectal function has experienced great technical advances that have facilitated the performance of the tests and have allowed a more detailed characterization of reflexes and motor patterns. As a result, we have achieved a much better understanding of the pathophysiology of children with defecation problems. Anorectal and colonic manometry are now commonly used in all major pediatric referral centers as diagnostic tools and to guide the management of children with intractable constipation and fecal incontinence, particularly when a surgical intervention is being considered.

PURPOSE

This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).