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Sarofim M, Slaar A, Dermout S, den Boer F, Engel A. Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries. Colorectal Dis 2024; 26:508-514. [PMID: 38229253 DOI: 10.1111/codi.16862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
AIM Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV). METHOD A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria. RESULTS There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores. CONCLUSION OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.
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Affiliation(s)
- Mina Sarofim
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Annelie Slaar
- Department of Radiology Dirksland Ziekenhuis, Hoorn, The Netherlands
| | - Sylvia Dermout
- Department of Gynaecology and Obstetrics, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Frank den Boer
- Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Alexander Engel
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
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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Comparison of Patient Impact and Clinical Characteristics Between Urgency and Passive Fecal Incontinence Phenotypes. Female Pelvic Med Reconstr Surg 2021; 26:570-574. [PMID: 29979355 DOI: 10.1097/spv.0000000000000603] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine if categorizing fecal incontinence (FI) as urgency or passive FI is clinically meaningful, we compared clinical severity, quality of life, physical examination findings, and functional and anatomic deficits between women with urgency and passive FI. METHODS This study is a prospective cross-sectional study of women with at least monthly FI. All women completed the St Mark's Vaizey and the Fecal Incontinence Quality of Life questionnaires and underwent anorectal manometry and endoanal ultrasound. We compared women with urgency FI to women with passive FI. RESULTS Forty-six women were enrolled, 21 (46%) with urgency FI and 25 (54%) with passive FI. Clinical severity by Vaizey score did not differ between groups (urgency 11.7 ± 1.6 vs passive 11.0 ± 1.0, P = 0.51). Women with urgency FI had worse median (range) lifestyle and coping scores than passive FI (Fecal Incontinence Quality of Life: lifestyle domain 2.5 [1, 4] vs 3.8 [1, 4], P = 0.04; coping domain 1.7 [1, 3] vs 2.4 [0.9, 4], P < 0.01). Women with urgency FI had higher anal resting and squeeze pressure than passive FI (60 ± 4 mm Hg vs 49 ± 3 mm Hg, P = 0.03; 78 [48, 150] mm Hg vs 60 [40, 103], P = 0.05). Internal anal sphincter defects were more common in women with passive FI (41.7% vs 30.0%, P = 0.53) and external anal sphincter defects more common in women with urgency FI (25% vs 16.7%, P = 0.71), but this did not reach statistical significance. CONCLUSIONS We identified functional and anatomic differences between women with urgency FI and passive FI. Pheonotyping women with FI into these subtypes is clinically meaningful.
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Andromanakos N, Filippou D, Karandreas N, Kostakis A. Puborectalis muscle and External Anal Sphincter: a functional unit? TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:342-343. [PMID: 32412905 DOI: 10.5152/tjg.2020.19208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Nikolaos Andromanakos
- Department of General Surgery, Athens General Hospital "Evagelismos-Athens Eye Hospital-Polykliniki", Athens, Greece
| | - Dimitrios Filippou
- Department of Anatomy and Surgical Anatomy, Athens University Medical School, Athens, Greece
| | - Nikolaos Karandreas
- First Department of Neurology, Athens University Medical School, Hospital "Eginitio", Athens, Greece
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Lunniss PJ, Gladman MA, Hetzer FH, Williams NS, Scott SM. Risk Factors in Acquired Faecal Incontinence. J R Soc Med 2017; 97:111-6. [PMID: 14996955 PMCID: PMC1079318 DOI: 10.1177/014107680409700303] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acquired faecal incontinence arising in the non-elderly population is a common and often devastating condition. We conducted a retrospective cohort analysis in 629 patients (475 female) referred to a tertiary centre, to determine the relative importance of individual risk factors in the development of faecal incontinence, as demonstrated by abnormal results on physiological testing. Potential risk factors were identified in all but 6% of patients (7 female, 32 male). In women, the principal risk factor was childbirth (91%), and in most cases at least one vaginal delivery had met with complications such as perineal injury or the need for forceps delivery. Of the males, half had undergone anal surgery and this was the only identified risk factor in 59%. In many instances, assignment of cause was hampered by a long interval between the supposed precipitating event and the development of symptoms. Abnormalities of anorectal physiology were identified in 76% of males and 96% of females (in whom they were more commonly multiple). These findings add to evidence that occult damage to the continence mechanism, especially through vaginal delivery and anal surgery, can result in subsequent faecal incontinence, sometimes after an interval of many years.
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Affiliation(s)
- Peter J Lunniss
- Centre for Academic Surgery, Gastrointestinal Physiology Unit, Queen Mary's School of Medicine and Dentistry, Royal London Hospital, Whitechapel, London E1 1BB, UK
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Kadam-Halani PK, Arya LA, Andy UU. Clinical anatomy of fecal incontinence in women. Clin Anat 2017; 30:901-911. [PMID: 28699286 DOI: 10.1002/ca.22951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/10/2017] [Indexed: 12/17/2022]
Abstract
Fecal incontinence is a devastating condition that has a severe impact on quality of life. This condition disproportionately affects women and its incidence is increasing with the aging United States population. Fecal continence is maintained by coordination of a functioning anal sphincter complex, intact sensation of the anorectum, rectal compliance, and the ability to consciously control defecation. Particularly important are the puborectalis sling of the levator ani muscle complex and intact innervation of the central and peripheral nervous systems. An understanding of the intricate anatomy required to maintain continence and regulate defecation will help clinicians to provide appropriate medical and surgical management and diminish the negative impact of fecal incontinence. In this article, we describe the anatomic and neural basis of fecal continence and normal defecation as well as changes that occur with fecal incontinence in women. Clin. Anat. 30:901-911, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Priyanka K Kadam-Halani
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lily A Arya
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Uduak U Andy
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
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Koo BI, Bang TS, Kim SY, Ko SH, Kim W, Ko HY. Anorectal Manometric and Urodynamic Parameters According to the Spinal Cord Injury Lesion. Ann Rehabil Med 2016; 40:528-33. [PMID: 27446791 PMCID: PMC4951373 DOI: 10.5535/arm.2016.40.3.528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/19/2015] [Indexed: 11/21/2022] Open
Abstract
Objective To assess the correlation between the anorectal function and bladder detrusor function in patients with complete spinal cord injury (SCI) according to the type of lesion. Methods Medical records of twenty-eight patients with SCI were included in this study. We compared the anorectal manometric and urodynamic (UD) parameters in total subjects. We analyzed the anorectal manometric and UD parameters between the two groups: upper motor neuron (UMN) lesion and lower motor neuron (LMN) lesion. In addition, we reclassified the total subjects into two groups according to the bladder detrusor function: overactive and non-overactive. Results In the group with LMN lesion, the mean value of maximal anal squeeze pressure (MSP) was slightly higher than that in the group with UMN lesion, and the ratio of MSP to maximal anal resting pressure (MRP) was statistically significant different between the two groups. In addition, although the mean value of MSP was slightly higher in the group with non-overactive detrusor function, there was no statistical correlation of anorectal manometric parameters between the groups with overactive and non-overactive detrusor function. Conclusion The MSP and the ratio of MSP to MRP were higher in the group with LMN lesion. In this study, we could not identify the correlation between bladder and bowel function in total subjects. We conclude that the results of UD study alone cannot predict the outcome of anorectal manometry in patients with SCI. Therefore, it is recommended to perform assessment of anorectal function with anorectal manometry in patients with SCI.
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Affiliation(s)
- Bon Il Koo
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Sik Bang
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo-Yeon Kim
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sung Hwa Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wan Kim
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun-Yoon Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Yangsan, Korea.; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options. Eur J Gastroenterol Hepatol 2015; 27:204-14. [PMID: 25629565 DOI: 10.1097/meg.0000000000000288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.
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Abstract
Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.
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McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma MG. Pathophysiology of constipation in the older adult. World J Gastroenterol 2008; 14:2631-8. [PMID: 18461648 PMCID: PMC2709058 DOI: 10.3748/wjg.14.2631] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This review provides information on the definition of constipation, normal continence and defecation and a description of the pathophysiologic mechanisms of constipation. In addition, changes in the anatomy and physiology of the lower gastrointestinal tract associated with aging that may contribute to constipation are described. MEDLINE (1966-2007) and CINAHL (1980-2007) were searched. The following MeSH terms were used: constipation/etiology OR constipation/physiology OR constipation/physiopathology) AND (age factors OR aged OR older OR 80 and over OR middle age). Constipation is not well defined in the literature. While self-reported constipation increases with age, findings from a limited number of clinical studies that utilized objective measures do not support this association. Dysmotility and pelvic floor dysfunction are important mechanisms associated with constipation. Changes in GI function associated with aging appear to be relatively subtle based on a limited amount of conflicting data. Additional research is warranted on the effects of aging on GI function, as well as on the timing of these changes.
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Youssef NN. Childhood and adolescent constipation: Review and advances in management. ACTA ACUST UNITED AC 2007; 10:401-11. [PMID: 17897578 DOI: 10.1007/s11938-007-0040-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Constipation is a common symptom throughout all ages in the pediatric population, both sexes, and all educational and socioeconomic levels. It is estimated that 12% to 30% of the general population suffers from functional constipation. A practical overview of pathogenic mechanisms contributing to constipation is presented, with emphasis on evaluation and management options available to the treating practitioner. The evaluation of constipation requires careful history taking and interpretation. Diagnostic tests such as manometry and colonic scintigraphy are reserved for those severely affected. Constipation can be challenging to treat, especially if pain and discomfort are predominant features. Therapy requires early recognition of the problem; support by physicians and family members; identification and explanation of contributing factors; and the providing of medications, including osmotic and/or stimulant laxatives. When constipation becomes refractory to standard medical treatment, more novel considerations may include probiotics, botulinum toxin, mind-body interventions, electrical stimulation of the intestine, and surgery.
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Affiliation(s)
- Nader N Youssef
- Nader N. Youssef, Center for Pediatric Irritable Bowel and Motility Disorders, Goryeb Children’s Hospital at Atlantic Health, University of Medicine and Dentistry of New Jersey, 100 Madison Avenue, Internal Box 82, Morristown, NJ 07962, USA.
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Iannelli A, Piche T, Dainese R, Fabiani P, Tran A, Mouiel J, Gugenheim J. Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia. World J Gastroenterol 2007; 13:2590-5. [PMID: 17552007 PMCID: PMC4146820 DOI: 10.3748/wjg.v13.i18.2590] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the results of sub total colectomy with cecorectal anastomosis (STC-CRA) for isolated colonic inertia (CI).
METHODS: Fourteen patients (mean age 57.5 ± 16.5 year) underwent surgery for isolated CI between January 1986 and December 2002. The mean frequency of bowel motions with the aid of laxatives was 1.2 ± 0.6 per week. All subjects underwent colonoscopy, anorectal manometry, cinedefaecography and colonic transit time (CTT). CI was defined as diffuse markers delay on CTT without evidence of pelvic floor dysfunction. All patients underwent STC-CRA. Long-term follow-up was obtained prospectively by clinical visits between October 2005 and February 2006 at a mean of 10.5 ± 3.6 years (range 5-16 years) during which we considered the number of stool emissions, the presence of abdominal pain or digitations, the use of pain killers, laxatives and/or fibers. Patients were also asked if they were satisfied with the surgery.
RESULTS: There was no postoperative mortality. Postoperative complications occurred in 21.4% (3/14). At the end of follow-up, bowel frequency was significantly (P < 0.05) increased to a mean of 4.8 ± 7.5 per day (range 1-30). One patient reported disabling diarrhea. Two patients used laxatives less than three times per month without complaining of what they called constipation. Overall, 78.5% of patients would have chosen surgery again if necessary.
CONCLUSION: STC-CRA is feasible and safe in patients with CI achieving 79% of success at a mean follow-up of 10.5 years. A prospective controlled evaluation is warranted to verify the advantages of this surgical approach in patients with CI.
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Affiliation(s)
- Antonio Iannelli
- Service de Chirurgie Digestive, Université de Nice-Sophia-Antipolis, Faculté de Médicine, Nice, France
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Andromanakos N, Skandalakis P, Troupis T, Filippou D. Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management. J Gastroenterol Hepatol 2006; 21:638-46. [PMID: 16677147 DOI: 10.1111/j.1440-1746.2006.04333.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.
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Affiliation(s)
- Nikolaos Andromanakos
- Second Department of Propedeutic Surgery, Athens University Medical School, Laiko General Hospital, Athens, Greece
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Bassotti G, de Roberto G, Castellani D, Sediari L, Morelli A. Normal aspects of colorectal motility and abnormalities in slow transit constipation. World J Gastroenterol 2005; 11:2691-6. [PMID: 15884105 PMCID: PMC4305899 DOI: 10.3748/wjg.v11.i18.2691] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Human colonic motility is a relatively difficult topic to investigate. However, the refinement of manometric techniques in recent years enabled us to study both the proximal and distal segments of the viscus. The present paper reviews our knowledge about normal aspects of colorectal motility in man and the abnormalities found in slow transit constipation (STC), one of the most frequent and difficult to treat subtypes of constipation. An internet-based search strategy of the Medline and Science Citation Index was performed using the keywords colon, colonic, colorectal, constipation, slow transit, motility, rectal, rectum in various combinations with the Boolean operators AND, OR and NOT. Only articles related to human studies were used, and manual cross-referencing was also performed. Most of colonic motor activity is represented by single nonpropagated contractions, rarely organized in bursts; this activity is maximal during the day, especially after waking and following meals. In addition, a specialized propagated activity with propulsive features is detectable, represented by high- and low-amplitude propagated contractions. In the severe form of constipation represented by the slow transit type, the above motor activity is completely deranged. In fact, both basal segmental activity (especially in response to meals) and propagated activity (especially that of high amplitude) are usually decreased, and this may represent a physiologic marker of this disorder. Human colonic motor activity is quite a complex issue, still only partly understood and investigated, due to anatomic and physiological difficulties. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, although only in part, some pathophysiological mechanisms of chronic constipation, and especially of the STC subtype.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology and Hepatology Section, Dept. of Clinical and Experimental Medicine, University of Perugia Medical School, Strada del Cimitero 2/a, 06131 San Marco, Perugia, Italy.
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Di Giorgio A, Biacchi D, Sibio S, Accarpio F, Sinibaldi G, Petrella L, Cappiello FR, Sammartino P. Abdominal rectopexy for complete rectal prolapse: preliminary results of a new technique. Int J Colorectal Dis 2005; 20:180-9. [PMID: 15688100 DOI: 10.1007/s00384-004-0650-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2004] [Indexed: 02/04/2023]
Abstract
PURPOSE Although the technique for the surgical repair of rectal prolapse has advanced over the years, no ideal procedure has been found. We aim to test a new surgical procedure for abdominal rectopexy that uses the greater omentum to support the rectum below the rectopexy, to reconstruct the anorectal angle and dispense with the need for synthetic mesh, thus reducing the risk of infection. METHODS A series of ten patients, all young and medically fit, underwent repair surgery for rectal prolapse with the new rectopexy technique. Some patients had concomitant sigmoidectomy. Preoperative and postoperative assessment included a clinical examination, anal manometry and defecography. RESULTS Follow-up lasted a mean of 56.4 months. None of the patients had recurrent rectal prolapse or infection. Postoperative assessment at 24 months disclosed significant improvements in all the bowel and sphincter variables assessed. The 8 patients who had severe incontinence preoperatively had notably improved and 4 were fully continent, 3 moderately incontinent, and only 1 patient had persistently high levels of incontinence. In only 1 patient who initially had severe incontinence, continence completely regressed and severe constipation developed. Maximal basal pressure values increased significantly after surgery (p=0.0025), although they increased slightly less evidently in patients in whom marked incontinence persisted at postoperative follow-up. Maximal voluntary contraction pressure also increased significantly after surgery (p=0.0054), although the values changed less than those for basal pressure. During rest, squeeze and straining, and in all the patients who regained continence, even those who recovered it only partly, surgery substantially reduced the anorectal angle. The reduction during rest was statistically significant (p=0.0062). CONCLUSIONS The rectopexy technique we tested in patients with rectal prolapse avoids the need for synthetic mesh, and provides good results in terms of bowel and sphincter function, without infection or recurrence.
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Affiliation(s)
- Angelo Di Giorgio
- Department of Surgery Pietro Valdoni, University of Rome La Sapienza, Rome, Italy
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Lunniss PJ, Gladman MA, Hetzer FH, Williams NS, Scott SM. Risk factors in acquired faecal incontinence. J R Soc Med 2004. [PMID: 14996955 DOI: 10.1258/jrsm.97.3.111] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acquired faecal incontinence arising in the non-elderly population is a common and often devastating condition. We conducted a retrospective cohort analysis in 629 patients (475 female) referred to a tertiary centre, to determine the relative importance of individual risk factors in the development of faecal incontinence, as demonstrated by abnormal results on physiological testing. Potential risk factors were identified in all but 6% of patients (7 female, 32 male). In women, the principal risk factor was childbirth (91%), and in most cases at least one vaginal delivery had met with complications such as perineal injury or the need for forceps delivery. Of the males, half had undergone anal surgery and this was the only identified risk factor in 59%. In many instances, assignment of cause was hampered by a long interval between the supposed precipitating event and the development of symptoms. Abnormalities of anorectal physiology were identified in 76% of males and 96% of females (in whom they were more commonly multiple). These findings add to evidence that occult damage to the continence mechanism, especially through vaginal delivery and anal surgery, can result in subsequent faecal incontinence, sometimes after an interval of many years.
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Affiliation(s)
- Peter J Lunniss
- Centre for Academic Surgery, Gastrointestinal Physiology Unit, Queen Mary's School of Medicine and Dentistry, Royal London Hospital, Whitechapel, London E1 1BB, UK
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de Carvalho LP, Corleta OC, Mallmann ACM, Koshimizu RT, Spolavori A. [Pudendal neuropathy: correlation with demographic data, severity index and pressoric parameters in patients with fecal incontinence]. ARQUIVOS DE GASTROENTEROLOGIA 2002; 39:139-46. [PMID: 12778304 DOI: 10.1590/s0004-28032002000300002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fecal incontinence stands for inability in maintaining the control of defecation to a socially acceptable and adequate time and place, resulting in unwanted release of gas, liquid or solid stool. The diagnosis needs multiple exams. Anorectal manometry is mandatory for this study. The correlation between manometry with electophysiological studies and symptoms is not yet clear in the literature. AIMS Correlate values of anal manometry, pudental nerve terminal motor latency and co morbidity in fecal incontinence patients. METHODOLOGY AND PATIENTS Patients with clinical fecal incontinence, who attended the outpatient department of "Hospital Nossa Senhora da Concei o", Porto Alegre, RS, Brazil, between March 1997 and June 2000, were studied prospectively. Every single patient has undergone a general investigation, incontinence score, anal manometry, bilateral pudendal nerve terminal motor latency and physical examination. For statistical purposes the patients were separated in groups according to the results of the anal manometry, pudendal neuropathy, for age and sex. RESULTS/CONCLUSION Thirty-nine patients were studied, 85,6% female, average age 60,1 years (+/- 12,89). The average index of the fecal incontinence was of 9,30 (+/- 4,93). In the anorectal manometry 23 patients showed low pressure. The pressures were significantly higher among males. The nerve terminal motor latency and pudental nerve (neuropathy) time was greater in 14 patients (35,9%). The age and the time of pudental nerve terminal motor were significantly co related. The other co relations were not statistically significant.
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Chan CL, Scott SM, Knowles CH, Lunniss PJ. Exaggerated rectal adaptation - another cause of outlet obstruction. Colorectal Dis 2001; 3:141-2. [PMID: 12791009 DOI: 10.1046/j.1463-1318.2001.00222.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
PURPOSE Fecal incontinence is a socially devastating disorder which affects at least 2.2 percent of community dwelling adults and 45 percent of nursing home residents. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. The aim of this study was to develop a consensus on treatment options by convening a conference of surgeons, gastroenterologists, nurses, psychologists, and patient advocates. METHOD A 1-1/2 day conference was held in April, 1999. Experts from different disciplines gave overviews, followed by extended discussions. Consensus statements were developed at the end of the conference. This summary statement was drafted, circulated to all participants, and revised based on their input. CONCLUSIONS 1) Diarrhea is the most common aggravating factor for fecal incontinence, and antidiarrheal medications such as loperamide and diphenoxylate or bile acid binders may help. Fecal impaction, a common cause of fecal incontinence in children and elderly patients, responds to combinations of laxatives, education, and habit training in approximately 60 percent. These causes of fecal incontinence can usually be identified by history and physical examination alone. 2) In patients who fail medical management or have evidence of sphincter weakness, anorectal manometry and endoanal ultrasound are recommended as helpful in differentiating simple morphologic defects from afferent and efferent nerve injuries and from combined structural and neurologic injuries. 3) Biofeedback is a harmless and inexpensive treatment which benefits approximately 75 percent of patients but cures only about 50 percent. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects. 4) External anal sphincter plication with or without pelvic floor repair is indicated when there is a known, repairable structural defect without significant neurologic injury. It is effective in approximately 68 percent. 5) Salvage operations are reserved for patients who can not benefit from biofeedback or levator-sphincteroplasty. These include electrically stimulated gracilis muscle transpositions and colostomy. 6) Antegrade enemas delivered through stomas in the cecum or descending colon reduce or eliminate soiling in approximately 78 percent of children with myelomeningocele; this operation may come to be more widely applied. 7) Investigational treatments include implanted nerve stimulators, artificial sphincters, and anal plugs. 8) Patient characteristics which influence choice of treatment include mental status, mobility impairment, and typical bowel habits. 9) Additional research is needed to better define the mechanisms responsible for fecal incontinence, to assess the efficacy of these treatments, to develop better treatments for nursing home residents, and to identify predictors of outcome.
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Affiliation(s)
- W E Whitehead
- UNC Center for Functional Gastrointestinal & Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Locke GR, Pemberton JH, Phillips SF. AGA technical review on constipation. American Gastroenterological Association. Gastroenterology 2000; 119:1766-78. [PMID: 11113099 DOI: 10.1053/gast.2000.20392] [Citation(s) in RCA: 235] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on March 4, 2000, and by the AGA Governing Board on May 21, 2000.
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Affiliation(s)
- G R Locke
- Division of Gastroenterology, Mayo Clinic and Mayo Medical School, Rochester, Minnesota, USA
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Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. Following external review, the paper was approved by the committee on May 17, 1998.
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Affiliation(s)
- N E Diamant
- AGA National Office, 7910 Woodmont Avenue, 7th floor, Bethesda, MD 20814, USA
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Harewood GC, Coulie B, Camilleri M, Rath-Harvey D, Pemberton JH. Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol 1999; 94:126-30. [PMID: 9934742 DOI: 10.1111/j.1572-0241.1999.00782.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our aim was to retrospectively analyze the Mayo Clinic experience of descending perineum syndrome from 1987-1997. METHODS Clinical records were abstracted for demographic features, risk factors, results of anorectal and defecation tests, and a mailed questionnaire evaluated outcome and current symptoms. RESULTS All results are mean +/- SD. Clinically, 39 patients (38 women, one man), mean age 53+/-14 yr, presented with constipation (97%), incomplete rectal evacuation (92%), excessive straining (97%), digital rectal evacuation (38%), and fecal incontinence (15%). Laboratory tests showed anal sphincter resting pressure was 54+/-26 mm Hg, and squeeze pressure was 96+/-35 mm Hg; expulsion from the rectum of a 50-ml balloon required > 200 g added weight in 27%; perineal descent was 4.4+/-1 cm (normal < 4 cm) by scintigraphy. Scintigraphic evacuation, rectoanal angle change during defecation, and perineal descent were abnormal in 23%, 57%, and 78% of the patients, respectively. Associated features included female gender (96%), multiparity with vaginal delivery (55%), hysterectomy or cystocele/rectocele repair (74%). On follow-up, 64% responded; 17 of these 25 responders underwent pelvic floor retraining. At 2-yr median follow-up (range, 1-6 yr), 12 still experienced constipation or excessive straining; their perineal descent was greater than in patients who responded to retraining (p = 0.005). CONCLUSIONS Descending perineum syndrome is identifiable by clinical history and examination, and the most prevalent abnormality on testing is perineal descent > 4 cm; rectal balloon expulsion is an insensitive screening test for descending perineum syndrome. Pelvic floor retraining is a suboptimal treatment for this chronic disorder of rectal evacuation; the extent of perineal descent appears to be a useful predictor of response to retraining.
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Affiliation(s)
- G C Harewood
- Gastroenterology Research Unit, Mayo Clinic, Rochester, Minnesota 55905, USA
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Lazorthes F, Gamagami R, Cabarrot P, Muhammad S. Is rectal intussusception a cause of idiopathic incontinence? Dis Colon Rectum 1998; 41:602-5. [PMID: 9593243 DOI: 10.1007/bf02235267] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.
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Affiliation(s)
- F Lazorthes
- Department of General and Digestive Surgery, University of Toulouse III, Purpan Hospital, France
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Kreis ME, Jehle EC, Starlinger MJ, Cuypers P, Herranz M, Wiesel P, Blum AL. The Favre system for anorectal manometry: comparison with other manometry systems in vitro and in healthy volunteers. Scand J Gastroenterol 1997; 32:888-93. [PMID: 9299666 DOI: 10.3109/00365529709011197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Favre system operates with airflow in a semi-closed circuit to transmit pressure. We aimed to evaluate the Favre system in comparison with other commonly used manometry systems. METHODS The Favre, Arndorfer, Arhan, and Synectics systems were evaluated in vitro and in 14 volunteers. RESULTS In vitro testing showed no relevant differences for latency, precision, or retest stability. In vivo, maximum resting pressure differed among all probes (P < 0.01) except for Arhan versus Arndorfer (NS). Maximum squeeze pressures differed among all probes (P < 0.01). Decrease of resting pressure during rectoanal inhibitory reflex was similar for Favre versus Arndorfer and Arhan versus Synectics (NS). Retest stability was higher with Favre than with Arndorfer (P < 0.05) and Synectics (P < 0.05) with regard to maximum resting pressure; it was higher with Favre than with Arhan (P < 0.01) and Arndorfer (P < 0.05) with regard to maximum squeeze pressure. Favre caused less discomfort than Synectics (P < 0.05) or Arndorfer (P < 0.05). CONCLUSION The Favre probe is an excellent and cost-efficient system for routine anorectal manometry.
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Affiliation(s)
- M E Kreis
- University Hospital Tübingen, Dept. of General Surgery, Germany
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