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Chiarioni G, Lambiase C, Whitehead WE, Rettura F, Morganti R, Popa SL, Bellini M. Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests. Dig Liver Dis 2024; 56:429-435. [PMID: 37394370 DOI: 10.1016/j.dld.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND AND AIMS Defecation Disorders (DD) are a frequent cause of refractory chronic constipation. DD diagnosis requires anorectal physiology testing. Our aim was to evaluate the accuracy and Odds Ratio (OR) of a straining question (SQ) and a digital rectal examination (DRE) augmented by abdomen palpation on predicting a DD diagnosis in refractory CC patients. METHODS Two hundred and thirty-eight constipated patients were enrolled. Patients underwent SQ, augmented DRE and balloon evacuation test before entering the study and after a 30-day fiber/laxative trial. All patients underwent anorectal manometry. OR and accuracy were calculated for SQ and augmented DRE for both dyssynergic defecation and inadequate propulsion. RESULTS "Anal Muscles" response was associated to both dyssynergic defecation and inadequate propulsion, with an OR of 13.6 and 5.85 and an accuracy of 78.5% and 66.4%, respectively. "Failed anal relaxation" on augmented DRE was associated with dyssynergic defecation, with an OR of 21.4 and an accuracy of 73.1%. "Failed abdominal contraction" on augmented DRE was associated with inadequate propulsion with an OR >100 and an accuracy of 97.1%. CONCLUSIONS Our data support screening constipated patients for DD by SQ and augmented DRE to improve management and appropriateness of referral to biofeedback.
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Affiliation(s)
- Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy; UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Christian Lambiase
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy.
| | - William E Whitehead
- UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Francesco Rettura
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
| | - Riccardo Morganti
- Clinical Trial Statistical Support Unit, Azienda Ospedaliero Universitaria Pisana, 56010 Pisa, Italy
| | - Stefan Lucian Popa
- 2nd Medical Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
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2
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Yan Y, Erdogan A, Adame EC, Rao SSC. Pathoetiology of Levator Ani Syndrome and Its Treatment With Translumbosacral Neuromodulation Therapy. Am J Gastroenterol 2023; 118:2242-2246. [PMID: 37410923 PMCID: PMC10834850 DOI: 10.14309/ajg.0000000000002394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION The pathoetiology and treatment of levator ani syndrome (LAS) remain unclear. METHODS We evaluated pathophysiology using translumbosacral motor-evoked potentials and anorectal manometry in patients with LAS and compared with healthy controls. A cohort underwent translumbosacral neuromodulation therapy (TNT). RESULTS Lumbar and sacral motor-evoked potential latencies were prolonged in 32 patients with LAS compared with 31 controls ( P < 0.013), with higher prevalence of anal neuropathy ( P = 0.026). TNT improved anorectal pain ( P = 0.003) and neuropathy ( P < 0.02) in 13 patients with LAS. DISCUSSION Patients with LAS demonstrate significant lumbosacral neuropathy that may cause anorectal pain. TNT improved anorectal pain and neuropathy, providing a novel therapeutic option.
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Affiliation(s)
- Yun Yan
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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3
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Andresen V, Becker G, Frieling T, Goebel-Stengel M, Gundling F, Herold A, Karaus M, Keller J, Kim M, Klose P, Krammer H, Kreis ME, Kuhlbusch-Zicklam R, Langhorst J, Layer P, Lenzen-Großimlinghaus R, Madisch A, Mönnikes H, Müller-Lissner S, Rubin D, Schemann M, Schwille-Kiuntke J, Stengel A, Storr M, van der Voort I, Voderholzer W, Wedel T, Wirz S, Witzigmann H, Pehl C. Aktualisierte S2k-Leitlinie chronische Obstipation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie & Motilität (DGNM) – April 2022 – AWMF-Registriernummer: 021–019. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1528-1572. [PMID: 36223785 DOI: 10.1055/a-1880-1928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - G Becker
- Klinik für Palliativmedizin, Freiburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios-Klinikum Krefeld, Krefeld, Deutschland
| | | | - F Gundling
- Medizinische Klinik II (Gastroenterologie, Gastroenterologische Onkologie, Hepatologie, Diabetologie, Stoffwechsel, Infektiologie), Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Herold
- Sozialstiftung Bamberg, End- und Dickdarm-Zentrum Mannheim, Mannheim, Deutschland
| | - M Karaus
- Abt. Innere Medizin, Evang. Krankenhaus Göttingen-Weende, Göttingen, Deutschland
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M Kim
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie (Chirurgische Klinik I) des Universitätsklinikums, Zentrum Operative Medizin (ZOM), Würzburg, Deutschland
| | - P Klose
- Universität Duisburg-Essen, Medizinische Fakultät, Essen, Deutschland
| | - H Krammer
- Sozialstiftung Bamberg, End- und Dickdarm-Zentrum Mannheim, Mannheim, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Knappschafts-Krankenhaus, Essen, Deutschland
| | - P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | | | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah-Oststadt-Heidehaus, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - D Rubin
- Klinik für Innere Medizin Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Mitte, Berlin, Deutschland.,Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, Vivantes Klinikum Spandau, Spandau, Deutschland
| | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Freising, Deutschland
| | - J Schwille-Kiuntke
- Innere Medizin VI Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - A Stengel
- Medizinische Klinik mit Schwerpunkt Psychosomatik, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Starnberg, Deutschland
| | - I van der Voort
- Klinik für Innere Medizin Gastroenterologie und Diabetologie, Jüdisches Krankenhaus Berlin, Berlin, Deutschland
| | | | - T Wedel
- Anatomisches Institut, Universität Kiel, Kiel, Deutschland
| | - S Wirz
- Cura Krankenhaus Bad Honnef, Bad Honnef, Deutschland
| | - H Witzigmann
- Klinik für Allgemein- und Viszeralchirurgie, Krankenhaus Dresden-Friedrichstadt, Dresden, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
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Khatri G, Bhosale PR, Robbins JB, Akin EA, Ascher SM, Brook OR, Dassel M, Glanc P, Henrichsen TL, Learman LA, Sadowski EA, Saphier CJ, Wasnik AP, Maturen KE. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol 2022; 19:S137-S155. [PMID: 35550798 DOI: 10.1016/j.jacr.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Gaurav Khatri
- Division Chief, Body MRI; Associate Division Chief, Abdominal Imaging, UT Southwestern Medical Center, Dallas, Texas; Program Director, Body MRI Fellowship.
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Section Chief of Abdominal Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Director Endometriosis and Chronic Pelvic Pain, Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Lee A Learman
- Dean, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Elizabeth A Sadowski
- University of Wisconsin, Madison, Wisconsin; and ACR O-RADS MRI Education Subcommittee Chair
| | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | - Ashish P Wasnik
- Division Chief, Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Katherine E Maturen
- Associate Chair for Ambulatory Care and Specialty Chair, University of Michigan, Ann Arbor, Michigan
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Lucente G, Corral J, Rodríguez-Esparragoza L, Castañer S, Ortiz H, Piqueras A, Broto J, Hernández-Pérez M, Domenech S, Martinez-Piñeiro A, Serra J, Almendrote M, Parés D, Millán M. Current Incidence and Risk Factors of Fecal Incontinence After Acute Stroke Affecting Functionally Independent People. Front Neurol 2021; 12:755432. [PMID: 34790163 PMCID: PMC8591097 DOI: 10.3389/fneur.2021.755432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Previously published retrospective series show a high prevalence of fecal incontinence (FI) in stroke patients. We aimed to analyze in a prospective series the current incidence of FI in acute stroke in functionally independent patients and its evolution over time and the patient characteristics associated with the appearance of FI in acute stroke. Methods: We included consecutive patients with acute stroke admitted in our stroke unit who fulfilled the following inclusion criteria: a first episode of stroke, aged >18 years, with no previous functional dependency [modified Rankin Scale (mRS) ≤ 2] and without previous known FI. FI was assessed by a multidisciplinary trained team using dedicated questionnaires at 72 ± 24 h (acute phase) and at 90 ± 15 days (chronic phase). Demographic, medical history, clinical and stroke features, mortality, and mRS at 7 days were collected. Results: Three hundred fifty-nine (48.3%) of 749 patients (mean age 65.9 ± 10, 64% male, 84.1% ischemic) fulfilled the inclusion criteria and were prospectively included during a 20-month period. FI was identified in 23 patients (6.4%) at 72 ± 24 h and in 7 (1.9%) at 90 days ± 15 days after stroke onset. FI was more frequent in hemorrhagic strokes (18 vs. 5%, p 0.007) and in more severe strokes [median National Institute of Health Stroke Scale (NIHSS) 18 (14-22) vs. 5 (3-13), p < 0.0001]. No differences were found regarding age, sex, vascular risk factors, or other comorbidities, or affected hemisphere. Patients with NIHSS ≥12 (AUC 0.81, 95% CI 0.71 to 0.89) had a 17-fold increase for the risk of FI (OR 16.9, IC 95% 4.7-60.1) adjusted for covariates. Conclusions: At present, the incidence of FI in acute stroke patients without previous functional dependency is lower than expected, with an association of a more severe and hemorrhagic stroke. Due to its impact on the quality of life, it is necessary to deepen the knowledge of the underlying mechanisms to address therapeutic strategies.
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Affiliation(s)
- Giuseppe Lucente
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Javier Corral
- General Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Luis Rodríguez-Esparragoza
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Sara Castañer
- Institut de Diagnostic per Imatge (IDI), Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Hector Ortiz
- Department of Project and Construction Engineering (EPC), Universitat Politècnica de Catalunya, Barcelona, Spain
- Department of Engineering Design, Universitat Politècnica de Barcelona, Barcelona, Spain
| | - Anna Piqueras
- General Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Joaquim Broto
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - María Hernández-Pérez
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Sira Domenech
- Institut de Diagnostic per Imatge (IDI), Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Alicia Martinez-Piñeiro
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Miriam Almendrote
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - David Parés
- General Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Mònica Millán
- Neurology Service, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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6
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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7
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Kosmadakis G, Albaret J, Da Costa Correia E, Somda F, Aguilera D. Constipation in Peritoneal Dialysis Patients. Perit Dial Int 2019; 39:399-404. [DOI: 10.3747/pdi.2018.00169] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/28/2018] [Indexed: 12/13/2022] Open
Abstract
Constipation in peritoneal dialysis (PD) is an infrequent but potentially serious condition affecting the mechanical properties of dialysis techniques and predisposing to bacterial intestinal translocation and eventual enteric peritonitis. Despite the importance of the problem, published literature is scarce, consisting mostly of uncontrolled single-center trials. This inconsistency may be attributed to the large number of clinical, radiological, and endoscopic tools that have been used in the studies with a lack of generally accepted core primary outcomes. The current narrative review discusses the pathophysiological associations between chronic kidney disease, PD, and constipation with related complication.
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Affiliation(s)
- George Kosmadakis
- Metabolic Pole and Nephrology Department, Jacques Lacarin Vichy General Hospital, Vichy, France
| | - Julie Albaret
- Metabolic Pole and Nephrology Department, Jacques Lacarin Vichy General Hospital, Vichy, France
| | | | - Frederic Somda
- Metabolic Pole and Nephrology Department, Jacques Lacarin Vichy General Hospital, Vichy, France
| | - Didier Aguilera
- Metabolic Pole and Nephrology Department, Jacques Lacarin Vichy General Hospital, Vichy, France
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Parés D, Abcarian H. Management of Common Benign Anorectal Disease: What All Physicians Need to Know. Am J Med 2018; 131:745-751. [PMID: 29499172 DOI: 10.1016/j.amjmed.2018.01.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 12/15/2022]
Abstract
Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.
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Affiliation(s)
- David Parés
- Department of Colon and Rectal Surgery, Hospital Germans Trias i Pujol, School of Medicine, Universitat Autónoma de Barcelona, Badalona, Spain.
| | - Herand Abcarian
- Division of Colon and Rectal Surgery, University of Illinois at Chicago
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Zheng S, Yao J. Expert consensus on the assessment and treatment of chronic constipation in the elderly. Aging Med (Milton) 2018; 1:8-17. [PMID: 31942474 PMCID: PMC6880707 DOI: 10.1002/agm2.12013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 03/07/2018] [Indexed: 12/11/2022] Open
Abstract
It is of significant importance to scientifically assess and efficiently address chronic constipation in the elderly population. Therefore, organizing some domestic experts of geriatrics and gastroenterology, we have formulated this consensus to reference for clinical staff.
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:168-189. [PMID: 29555103 DOI: 10.1016/j.rgmx.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/08/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología. AIMS To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence. METHODS Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus. RESULTS AND CONCLUSIONS The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.
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Davies D, Bailey J. Diagnosis and Management of Anorectal Disorders in the Primary Care Setting. Prim Care 2017; 44:709-720. [PMID: 29132530 DOI: 10.1016/j.pop.2017.07.012] [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] [Indexed: 12/19/2022]
Abstract
Anorectal disorders are very common among a wide population of patients. Because patients may be embarrassed about the anatomic location of their symptoms, they may present to care late in the course of their illness. Care should be taken to validate patient concerns and normalize fears. This article discusses the diagnoses and management of common anorectal disorders among patients presenting to a primary care physician.
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Affiliation(s)
- Danielle Davies
- Department of Family Medicine, University of Washington, Seattle, WA 98195, USA; Department of Family Medicine, Family Medicine Residency of Idaho, 777 North Raymond Street, Boise, ID 83702, USA.
| | - Justin Bailey
- Department of Family Medicine, Family Medicine Residency of Idaho, 777 North Raymond Street, Boise, ID 83702, USA; Department of Family Medicine, University of Washington School of Medicine, 331 North East Thornton Place, Seattle, WA 98125, USA
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13
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Mastragostino P, Lee AD, Battaglia PJ. Perianal abscess mimicking levator ani syndrome: a case report and approach to the differential diagnosis of anorectal pain. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2017; 61:145-152. [PMID: 28928497 PMCID: PMC5596975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To present the clinical management and comprehensive differential diagnosis of a patient with anorectal pain from a perianal abscess. CLINICAL FEATURES A 41-year-old woman presented with pain localized to her perianal and gluteal region, accompanied by internal and external rectal pain. Prior to presentation, the patient had received a working diagnosis of levator ani syndrome. INTERVENTION AND OUTCOME An interdisciplinary management approach was utilized. Diagnostic imaging confirmed the clinical suspicion of a perianal abscess and the patient underwent surgical drainage. SUMMARY Anorectal pain is complex and multifactorial and a diagnosis such as an abscess should not be overlooked. This case emphasized that practitioners must be diligent in their evaluation and management of patients with anorectal pain, including recognizing situations that require further imaging and interdisciplinary management.
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Affiliation(s)
- Paul Mastragostino
- Department of Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON
| | - Alexander D. Lee
- Clinical Faculty, Canadian Memorial Chiropractic College, Toronto, ON
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Wu GJ, Xu F, Lin L, Pasricha PJ, Chen JDZ. Anorectal manometry: Should it be performed in a seated position? Neurogastroenterol Motil 2017; 29. [PMID: 27910245 DOI: 10.1111/nmo.12997] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anorectal manometry (ARM) is typically preformed in a lateral position. This non-physiological testing position has produced an unexpected negative rectoanal pressure gradient (RAPG, i.e. difference between rectal and anal pressure) with normal defecation. This study was designed (i) to study differences in ARM parameters between water-perfused and solid-state sensors and between lateral and seated positions and (ii) to investigate the roles of ARM parameters in predicting balloon expulsion. METHODS ARM was performed in 18 healthy volunteers (HV) and 60 patients with functional constipation (FC) under three randomized conditions: water-perfused in lateral position, solid-state in lateral position, and solid-state in seated position, followed by a balloon expulsion test in seated position. KEY RESULTS i) Under the same lateral position, solid-state sensors produced higher rectal resting pressure and RAPG than water-perfused sensors. ii) Using the solid-state sensors, ARM in the seated position revealed higher resting rectal pressure (34.9 vs 10.9 mmHg in HV, 30.9 vs 10.6 mmHg in FC, both P<.001) and higher RAPG (22.6 vs -6.2 mmHg in HV, 17.1 vs -8.1 mmHg in FC, both P<.001) than the lateral position. iii) When ARM was performed using solid-state sensors in seated position, RAPG was predictive of balloon expulsion; using 10 mmHg as a threshold, RAPG could predict balloon expulsion with specificity of 82% and sensitivity 77%. CONCLUSIONS AND INFERENCE ARM performed in a seated position using solid-state sensors seems more accurate in assessing rectal pressure, and the RAPG measured under these conditions is predictive of balloon expulsion in FC patients.
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Affiliation(s)
- G-J Wu
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Division of Gastroenterology, Wuxi No.2 Hospital affiliated to Nanjing Medical University, Wuxi, China.,Ningbo Pace Translational Medical Research Center, Ningbo, China
| | - F Xu
- Division of Gastroenterology, Ningbo Yinzhou People's Hospital, Ningbo, China
| | - L Lin
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - J D Z Chen
- Ningbo Pace Translational Medical Research Center, Ningbo, China.,Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
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15
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Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:332-63. [PMID: 27230827 DOI: 10.17235/reed.2016.4389/2016] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.
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Affiliation(s)
| | - Constanza Ciriza
- Aparato Digestivo, Hospital Universitario Doce de Octubre, España
| | | | - Enrique Rey
- Aparato Digestivo, Hospital Clínico San Carlos, España
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16
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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)]. Aten Primaria 2017; 49:42-55. [PMID: 28027792 PMCID: PMC6875955 DOI: 10.1016/j.aprim.2016.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/01/2016] [Indexed: 12/15/2022] Open
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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17
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Prasad VGM, Abraham P. Management of chronic constipation in patients with diabetes mellitus. Indian J Gastroenterol 2017; 36:11-22. [PMID: 27987136 DOI: 10.1007/s12664-016-0724-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/27/2016] [Indexed: 02/04/2023]
Abstract
AIM The aim of this review is to provide an overview of the clinical assessment and evidence-based treatment options for managing diabetes-associated chronic constipation. METHODS A literature search of published medical reports in English language was performed using the OVID Portal, from PUBMED and the Cochrane Database of Systematic Reviews, from inception to October 2015. A total of 145 abstracts were identified; duplicate publications were removed and 95 relevant full-text articles were retrieved for potential inclusion. RESULTS Chronic constipation is one of the most common gastrointestinal symptoms in patients with diabetes, and occurs more frequently than in healthy individuals. Treatment goals include improving symptoms and restoring bowel function by accelerating colonic transit and facilitating defecation. Based on guidelines and data from published literature, food and dietary change with exercise and lifestyle change should be the first step in management. For patients recalcitrant to these changes, laxatives should be the next step of treatment. Treatment should begin with bulking agents such as psyllium, bran or methylcellulose followed by osmotic laxatives if response is poor. Lactulose, polyethylene glycol and lactitol are the most frequently prescribed osmotic agents. Lactulose has a prebiotic effect and a carry-over effect (continued laxative effect for at least 6 to 7 days, post cessation of treatment). Stimulants such as bisacodyl, sodium picosulphate and senna are indicated if osmotic laxatives are not effective. Newer agents such as chloride-channel activators and 5-HT4 agonist can be considered for severe or resistant cases. CONCLUSION The primary aim of intervention in diabetic patients with chronic constipation is to better manage the diabetes along with management of constipation. The physician should explain the rationale for prescribing laxatives and educate patients about the potential drawbacks of long-term use of laxatives. They should contact their physician if short-term use of prescribed laxative fails to provide relief.
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Affiliation(s)
- V G M Prasad
- VGM Hospital, 2100, Trichy Road, Coimbatore, 641 005, India.
| | - Philip Abraham
- P D Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, 400 016, India
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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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Abstract
Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Tae Hee Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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20
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Ihnát P, Kozáková R, Rudinská LI, Peteja M, Vávra P, Zonča P. Fecal incontinence among nursing home residents: Is it still a problem? Arch Gerontol Geriatr 2016; 65:79-84. [DOI: 10.1016/j.archger.2016.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 03/09/2016] [Accepted: 03/11/2016] [Indexed: 10/22/2022]
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21
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Chu H, Hou X. Understanding of Constipation Symptoms and the Diagnosis and Management of Constipation in Chinese Physicians. PLoS One 2016; 11:e0152801. [PMID: 27031865 PMCID: PMC4816533 DOI: 10.1371/journal.pone.0152801] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/18/2016] [Indexed: 01/03/2023] Open
Abstract
Background and Aims Although a range of guidelines for the diagnosis and treatment of chronic constipation has been carried out, there was very little information about the understanding on constipation. The aim of the present study was to estimate the understanding of constipation symptoms and the diagnosis and management of constipation by clinical physicians in China. Methods Participants were physicians and researchers in the field of gastroenterology in China who were scheduled to attend the National Conference on gastrointestinal motility(Constipation). Based on the recommendation of the Rome Foundation Board, the self-reported questionnaire was constructed. Findings Although most of the opinions on symptoms of constipation were consistent, there were still some differences. Opinions on the Bristol stool form during constipation were discordant, 34% of the doctors thought that it was type 1 and type 2, while 46%of the doctors suggested that type 3 should also be considered constipation. There was no significant difference between them(P = 0.05); We investigated the interpretation on the duration of defecation prolonged, 27% of the doctors suggested it should be longer than 10 minutes, 22% of the doctors suggested it should be longer than 20 minutes, and other 22% of the doctors suggested it should be time of defecation became longer compared to previously bowel habits, there was no significant difference among them(P = 0.38).Only 36% of the doctors thought that psychotherapy was most important in the treatment of severe constipation, while 37% of the doctors thought that medication treatment was most important in the treatment of severe constipation, there was no significant difference between them(P = 0.895). Conclusion We were able to obtain valuable information about current views on symptoms of constipation and the diagnosis and treatment of constipation among Chinese doctors. Although most of the opinions were consistent there were still some differences. This study indicated that in practice in China there was a need for further study on the role of constipation symptoms and there may also be a need for better establishment of consensus guidelines for constipation.
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Affiliation(s)
- Huikuan Chu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, China
- * E-mail:
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22
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Prichard D, Harvey DM, Fletcher JG, Zinsmeister AR, Bharucha AE. Relationship Among Anal Sphincter Injury, Patulous Anal Canal, and Anal Pressures in Patients With Anorectal Disorders. Clin Gastroenterol Hepatol 2015; 13:1793-1800.e1. [PMID: 25869638 PMCID: PMC4575824 DOI: 10.1016/j.cgh.2015.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/04/2015] [Accepted: 03/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The anal sphincters and puborectalis are imaged routinely with an endoanal magnetic resonance imaging (MRI) coil, which does not assess co-aptation of the anal canal at rest. By using a MRI torso coil, we identified a patulous anal canal in some patients with anorectal disorders. We aimed to evaluate the relationship between anal sphincter and puborectalis injury, a patulous anal canal, and anal pressures. METHODS We performed a retrospective analysis of data from 119 patients who underwent MRI and manometry analysis of anal anatomy and pressures, respectively, from February 2011 through March 2013 at the Mayo Clinic. Anal pressures were determined by high-resolution manometry, anal sphincter and puborectalis injury was determined by endoanal MRI, and anal canal integrity was determined by torso MRI. Associations between manometric and anatomic parameters were evaluated with univariate and multivariate analyses. RESULTS Fecal incontinence (55 patients; 46%) and constipation (36 patients; 30%) were the main indications for testing; 49 patients (41%) had a patulous anal canal, which was associated with injury to more than 1 muscle (all P ≤ .001), and internal sphincter (P < .01), but not puborectalis (P = .09) or external sphincter (P = .06), injury. Internal (P < .01) and external sphincter injury (P = .02) and a patulous canal (P < .001), but not puborectalis injury, predicted anal resting pressure. A patulous anal canal was the only significant predictor (P < .01) of the anal squeeze pressure increment. CONCLUSIONS Patients with anorectal disorders commonly have a patulous anal canal, which is associated with more severe anal injury and independently predicted anal resting pressure and squeeze pressure increment. It therefore is important to identify a patulous anal canal because it appears to be a marker of not only anal sphincter injury but disturbances beyond sphincter injury, such as damage to the anal cushions or anal denervation.
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Pucciani F, Altomare DF, Dodi G, Falletto E, Frasson A, Giani I, Martellucci J, Naldini G, Piloni V, Sciaudone G, Bove A, Bocchini R, Bellini M, Alduini P, Battaglia E, Galeazzi F, Rossitti P, Usai Satta P. Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2015; 47:628-45. [PMID: 25937624 DOI: 10.1016/j.dld.2015.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/28/2015] [Indexed: 02/06/2023]
Abstract
Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.
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Affiliation(s)
| | - Filippo Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Giuseppe Dodi
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ezio Falletto
- I Division of Surgical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Alvise Frasson
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Iacopo Giani
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | - Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | | | - Guido Sciaudone
- General and Geriatric Surgery Unit, School of Medicine, Second University of Naples, Italy
| | | | - Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology - AORN "A. Cardarelli", Naples, Italy
| | - Renato Bocchini
- Gastrointestinal Physiopathology, Gastroenterology Department, Malatesta Novello Private Hospital, Cesena, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Gastroenterology, University of Pisa, Italy
| | - Pietro Alduini
- Digestive Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | | | - Piera Rossitti
- Gastroenterology Unit, S.M. della Misericordia University Hospital, Udine, Italy
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Abdominal Symptoms Are Common and Benefit from Biofeedback Therapy in Patients with Dyssynergic Defecation. Clin Transl Gastroenterol 2015. [PMID: 26225863 PMCID: PMC4816253 DOI: 10.1038/ctg.2015.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objectives: Dyssynergic defecation (DD) is a subtype of chronic constipation that responds to biofeedback therapy (BFT). Abdominal, anorectal, and stool symptoms are commonly reported by DD patients, but limited data exist to demonstrate the improvement of these associated symptoms to BFT. Aims to prospectively study the response of constipation and associated abdominal, rectal, and stool symptoms to biofeedback in a population with dyssynergia. Methods: Patients with DD as determined by anorectal manometry and balloon expulsion testing were included into the study. All patients completed a validated survey, the Personal Assessment of Constipation Symptom (PAC-SYM) questionnaire, before and following BFT. The PAC-SYM is a clinical tool to assess constipation-related symptom frequency and severity. Results: Seventy-seven dyssynergic patients fulfilled the study requirements. Abdominal symptoms were present in up to 74% of patients with dyssynergia. PAC-SYM summation scores improved following completion of biofeedback by 48%, from 22.08 to 11.48 (P<0.001). The proportion of patients with at least moderate symptoms decreased in all 12 questionnaire items, including all abdominal symptoms, after completing BFT (46.8% to 14.3%, P<0.001). Conclusions: Abdominal symptoms are common in patients with dyssynergia. BFT improves both anorectal-related constipation symptoms and associated abdominal symptoms in patients with DD. Limitations of this study are observational design, lack of control group, and lack of long-term follow-up.
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Jodorkovsky D, Macura KJ, Gearhart SL, Dunbar KB, Stein EM, Clarke JO. High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies. J Gastroenterol Hepatol 2015; 30:71-4. [PMID: 25088015 DOI: 10.1111/jgh.12697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI. METHODS This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test. RESULTS Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM. CONCLUSION We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.
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Affiliation(s)
- Daniela Jodorkovsky
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Prichard D, Bharucha AE. Management of pelvic floor disorders: biofeedback and more. ACTA ACUST UNITED AC 2014; 12:456-67. [PMID: 25267107 DOI: 10.1007/s11938-014-0033-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Defecatory disorders (DD) and fecal incontinence (FI) are common conditions. DD are primarily attributable to impaired rectoanal function during defecation or structural defects. FI is caused by one or more disturbances of anorectal continence mechanisms. Altered stool consistency may be the primary cause or may unmask anorectal deficits in both conditions. Diagnosis and management requires a systematic approach beginning with a thorough clinical assessment. Symptoms do not reliably differentiate a DD from other causes of constipation such as slow or normal transit constipation. Therefore, all constipated patients who do not adequately respond to medical therapy should be considered for anorectal testing to identify a DD. Preferably, two tests indicating impaired defecation are required to diagnose a DD. Patients with DD, or those for whom testing is not available and the clinical suspicion is high, should be referred for biofeedback-based pelvic floor physical therapy. Patients with FI should be managed with lifestyle modifications, pharmacotherapy for bowel disturbances, and management of local anorectal problems (e.g., hemorrhoids). When these measures are not beneficial, anorectal testing and pelvic floor retraining with biofeedback therapy should be considered. Sacral nerve stimulation or perianal bulking could be considered in patients who have persistent symptoms despite optimal management of bowel disturbances and pelvic floor retraining.
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Affiliation(s)
- David Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA,
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Symptom improvement in women after fecal incontinence treatments: a multicenter cohort study of the pelvic floor disorders network. Female Pelvic Med Reconstr Surg 2014; 21:46-52. [PMID: 25185613 DOI: 10.1097/spv.0000000000000099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The study aims were to characterize women with fecal incontinence (FI) and measure changes in FI severity and quality of life 3 and 12 months after treatment. METHODS This study is a secondary analysis of a multicenter study measuring adaptive behaviors among women with FI. Women included had a primary complaint of at least monthly FI over 3 consecutive months and planned FI treatment. Demographic and medical history data were obtained at baseline. Data were collected at baseline, 3 months, and 12 months after clinically selected, nonstandardized treatment. Validated questionnaires were as follows: Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire, Pelvic Floor Disorders Inventory's Colorectal and Anal Distress Inventory, Pelvic Floor Impact Questionnaire's Colorectal and Anal Impact Questionnaire, and Medical Outcomes Study Short Form. Questionnaire score changes from baseline were compared using paired t tests at 3 and 12 months after treatment. RESULTS Of the 133 women enrolled, 90 women had treatment data at 3 months and 77 at 12 months. Nonsurgical therapies were the most common (78%) with anal sphincter repair in 22%. Fecal Incontinence Severity Index scores and Modified Manchester Health Questionnaire scores significantly improved 3 months after nonsurgical and surgical treatments (-8.8 ± 12.0 and -12.6 ± 19.2, respectively, P < 0.001), as did Colorectal-Anal Distress Inventory and Colorectal-Anal Impact Questionnaire scores (-52.7 ± 70.0 and -60.6 ± 70.0, respectively, P < 0.001) and Medical Outcomes Study Short Form mental health scores (4.2 ± 9.4, P = 0.001). Improvement persisted 12 months posttreatment. CONCLUSIONS In women seeking care for FI, symptom severity and condition-specific quality of life significantly improve within the first 3 months after FI treatment and are maintained up to 12 months.
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ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol 2014; 109:1141-57; (Quiz) 1058. [PMID: 25022811 DOI: 10.1038/ajg.2014.190] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 06/05/2014] [Indexed: 02/07/2023]
Abstract
These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials.
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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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Lam TJ, Visscher AP, Meurs-Szojda MM, Felt-Bersma RJF. Clinical response and sustainability of treatment with temperature-controlled radiofrequency energy (Secca) in patients with faecal incontinence: 3 years follow-up. Int J Colorectal Dis 2014; 29:755-61. [PMID: 24805249 DOI: 10.1007/s00384-014-1882-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Controlled delivery of radio frequent energy (Secca) has been suggested as treatment for faecal incontinence (FI). OBJECTIVE The objective of the study is to evaluate clinical response and sustainability of Secca for FI. DESIGN This is a prospective cohort study. PATIENTS This study involved patients who had failed full conservative management for FI. INTERVENTIONS This study was performed between 2005 and 2010. MAIN OUTCOME MEASURES FI was scored using the Vaizey score (VS). A clinically significant response to Secca was defined as ≥50 % reduction in incontinence score. Impact of FI on quality of life (QOL) was measured using the FIQL. Data was obtained at baseline, at 6 months and at 1 and 3 years. Anal endosonography and anal manometry were performed at 3 months and compared to baseline. RESULTS Thirty-one patients received Secca. During follow-up, 5/31 (16 %), 3/31 (10 %) and 2/31 (6 %) of patients maintained a clinically significant response after the Secca procedure. Mean VS of all patients was 18 (SD 3), 14 (SD 4), 14 (SD 4) and 15 (SD 4), at baseline, 6 months and 1 and 3 years. No increases in anorectal pressures or improvements in rectal compliance were found. Coping improved between baseline and t = 6 months. No predictive factors for success were found. LIMITATIONS This is a non-randomised study design. CONCLUSION This prospective non-randomised trial showed disappointing outcomes of the Secca procedure for the treatment of FI. The far minority of patients reported a clinically significant response of seemingly temporary nature. Secca might be valuable in combination with other interventions for FI, but this should be tested in strictly controlled randomised trials.
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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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Bassotti G, Blandizzi C. Understanding and treating refractory constipation. World J Gastrointest Pharmacol Ther 2014; 5:77-85. [PMID: 24868488 PMCID: PMC4023327 DOI: 10.4292/wjgpt.v5.i2.77] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/20/2014] [Accepted: 02/19/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.
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Effects of clonidine in women with fecal incontinence. Clin Gastroenterol Hepatol 2014; 12:843-851.e2; quiz e44. [PMID: 23891925 PMCID: PMC3900592 DOI: 10.1016/j.cgh.2013.06.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/14/2013] [Accepted: 06/29/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some women with urge-predominant fecal incontinence (FI) have diarrhea-predominant irritable bowel syndrome and a stiffer and hypersensitive rectum. We evaluated the effects of the α2-adrenergic agonist clonidine on symptoms and anorectal functions in women with FI in a prospective, placebo-controlled trial. METHODS We assessed bowel symptoms and anorectal functions (anal pressures, rectal compliance, and sensation) in 43 women (age, 58 ± 2 y) with urge-predominant FI, randomly assigned to groups given oral clonidine (0.1 mg, twice daily) or placebo for 4 weeks. Before and after administration of the medication, anal pressures were evaluated by manometry, and rectal compliance and sensation were measured using a barostat. Anal sphincter injury was evaluated by endoanal magnetic resonance imaging. Bowel symptoms were recorded in daily and weekly diaries. The primary end point was the FI and Constipation Assessment symptom severity score. RESULTS FI scores decreased from 9.1 ± 0.3 to 7.6 ± 0.5 among subjects given placebo and from 8.1 ± 0.4 to 6.5 ± 0.6 among patients given clonidine. Clonidine did not affect FI symptom severity, bowel symptoms (stool consistency or frequency), anal pressures, rectal compliance, or sensation compared with placebo. However, when baseline data were used to categorize subjects as those with or without diarrhea, clonidine reduced the proportion of loose stools in patients with diarrhea only (P = .018). Clonidine also reduced the proportion of days with FI in patients with diarrhea (P = .0825). CONCLUSIONS Overall, clonidine did not affect bowel symptoms, fecal continence, or anorectal functions, compared with placebo, in women with urge-predominant FI. Among patients with diarrhea, clonidine increased stool consistency, with a borderline significant improvement in fecal continence. ClinicalTrials.gov, Number NCT00884832.
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Felt-Bersma RJF. Temperature-controlled radiofrequency energy in patients with anal incontinence: an interim analysis of worldwide data. Gastroenterol Rep (Oxf) 2014; 2:121-5. [PMID: 24759350 PMCID: PMC4020122 DOI: 10.1093/gastro/gou016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Controlled delivery of radiofrequency energy (SECCA procedure) as treatment for anal incontinence (AI) was introduced 15 years ago. Since then, several clinical studies have emerged. This article evaluates the clinical response and sustainability of SECCA for patients with AI. METHODS Only original clinical studies retrieved from PubMed and Medline were included. The outcome measures, faecal incontinence scores, definition of response, clinical results and anorectal evaluation were analysed. RESULTS Ten studies were included, which involved 150 original patients. Three studies reported a long-term follow-up. The one-year follow-up shows a moderate effect, which declines somewhat over time. Only minor temporary side-effects are reported and none of the patients declined treatment. CONCLUSION SECCA is a safe and well-tolerated procedure that is easy to perform without any serious short- or long-term complications, but with only a moderate clinical effect that declines over time. Results of randomized, sham-controlled controlled trials are awaited.
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Affiliation(s)
- Richelle J F Felt-Bersma
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, Netherlands
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Woodward S, Norton C, Chiarelli P. Biofeedback for treatment of chronic idiopathic constipation in adults. Cochrane Database Syst Rev 2014; 2014:CD008486. [PMID: 24668156 PMCID: PMC10618629 DOI: 10.1002/14651858.cd008486.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Biofeedback therapy has been used to treat the symptoms of people with chronic constipation referred to specialist services within secondary and tertiary care settings. However, different methods of biofeedback are used within different centres and the magnitude of suggested benefits and comparable effectiveness of different methods of biofeedback has yet to be established. OBJECTIVES To determine the efficacy and safety of biofeedback for the treatment of chronic idiopathic (functional) constipation in adults. SEARCH METHODS We searched the following databases from inception to 16 December 2013: CENTRAL, the Cochrane Complementary Medicine Field, the Cochrane IBD/FBD Review Group Specialized Register, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsychINFO. Hand searching of conference proceedings and the reference lists of relevant articles was also undertaken. SELECTION CRITERIA All randomised trials evaluating biofeedback in adults with chronic idiopathic constipation were considered for inclusion. DATA COLLECTION AND ANALYSIS The primary outcome was global or clinical improvement as defined by the included studies. Secondary outcomes included quality of life, and adverse events as defined by the included studies. Where possible, we calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the mean difference (MD) and 95% CI for continuous outcomes. We assessed the methodological quality of included studies using the Cochrane risk of bias tool. The overall quality of the evidence supporting each outcome was assessed using the GRADE criteria. MAIN RESULTS Seventeen eligible studies were identified with a total of 931 participants. Most participants had chronic constipation and dyssynergic defecation. Sixteen of the trials were at high risk of bias for blinding. Attrition bias (4 trials) and other potential bias (5 trials) was also noted. Due to differences between study populations, the heterogeneity of the different samples and large range of different outcome measures, meta-analysis was not possible. Different effect sizes were reported ranging from 40 to 100% of patients who received biofeedback improving following the intervention. While electromyograph (EMG) biofeedback was the most commonly used, there is a lack of evidence as to whether any one method of biofeedback is more effective than any other method of biofeedback. We found low or very low quality evidence that biofeedback is superior to oral diazepam, sham biofeedback and laxatives. One study (n = 60) found EMG biofeedback to be superior to oral diazepam. Seventy per cent (21/30) of biofeedback patients had improved constipation at three month follow-up compared to 23% (7/30) of diazepam patients (RR 3.00, 95% CI 1.51 to 5.98). One study compared manometry biofeedback to sham biofeedback or standard therapy consisting of diet, exercise and laxatives. The mean number of complete spontaneous bowel movements (CSBM) per week at three months was 4.6 in the biofeedback group compared to 2.8 in the sham biofeedback group (MD 1.80, 95% CI 1.25 to 2.35; 52 patients). The mean number of CSBM per week at three months was 4.6 in the biofeedback group compared to 1.9 in the standard care group (MD 2.70, 95% CI 1.99 to 3.41; 49 patients). Another study (n = 109) compared EMG biofeedback to conventional treatment with laxatives and dietary and lifestyle advice. This study found that at both 6 and 12 months 80% (43/54) of biofeedback patients reported clinical improvement compared to 22% (12/55) laxative-treated patients (RR 3.65, 95% CI 2.17 to 6.13). Some surgical procedures (partial division of puborectalis and stapled transanal rectal resection (STARR)) were reported to be superior to biofeedback, although with a high risk of adverse events in the surgical groups (wound infection, faecal incontinence, pain, and bleeding that required further surgical intervention). Successful treatment, defined as a decrease in the obstructed defecation score of > 50% at one year was reported in 33% (3/39) of EMG biofeedback patients compared to 82% (44/54) of STARR patients (RR 0.41, 95% CI 0.26 to 0.65). For the other study the mean constipation score at one year was 16.1 in the balloon sensory biofeedback group compared to 10.5 in the partial division of puborectalis surgery group (MD 5.60, 95% CI 4.67 to 6.53; 40 patients). Another study (n = 60) found no significant difference in efficacy did not demonstrate the superiority of a surgical intervention (posterior myomectomy of internal anal sphincter and puborectalis) over biofeedback. Conflicting results were found regarding the comparative effectiveness of biofeedback and botulinum toxin-A. One small study (48 participants) suggested that botulinum toxin-A injection may have short term benefits over biofeedback, but the relative effects of treatments were uncertain at one year follow-up. No adverse events were reported for biofeedback, although this was not specifically reported in the majority of studies. The results of all of these studies need to be interpreted with caution as GRADE analyses rated the overall quality of the evidence for the primary outcomes (i.e. clinical or global improvement as defined by the studies) as low or very low due to high risk of bias (i.e. open label studies, self-selection bias, incomplete outcome data, and baseline imbalance) and imprecision (i.e. sparse data). AUTHORS' CONCLUSIONS Currently there is insufficient evidence to allow any firm conclusions regarding the efficacy and safety of biofeedback for the management of people with chronic constipation. We found low or very low quality evidence from single studies to support the effectiveness of biofeedback for the management of people with chronic constipation and dyssynergic defecation. However, the majority of trials are of poor methodological quality and subject to bias. Further well-designed randomised controlled trials with adequate sample sizes, validated outcome measures (especially patient reported outcome measures) and long-term follow-up are required to allow definitive conclusions to be drawn.
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Affiliation(s)
- Sue Woodward
- King's College London57 Waterloo RoadLondonUKSE1 8WA
| | | | - Pauline Chiarelli
- University of NewcastleSchool of Health SciencesCallaghan DriveCallaghanNSWAustralia2308
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Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. Gastroenterology 2014; 146:37-45.e2. [PMID: 24211860 PMCID: PMC3913170 DOI: 10.1053/j.gastro.2013.10.062] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 01/13/2023]
Abstract
Gastroenterologists frequently encounter pelvic floor disorders, which affect 10% to 15% of the population. The anorectum is a complex organ that collaborates with the pelvic floor muscles to preserve fecal continence and enable defecation. A careful clinical assessment is critical for the diagnosis and management of defecatory disorders and fecal incontinence. Newer diagnostic tools (eg, high-resolution manometry and magnetic resonance defecography) provide a refined understanding of anorectal dysfunctions and identify phenotypes in defecatory disorders and fecal incontinence. Conservative approaches, including biofeedback therapy, are the mainstay for managing these disorders; new minimally invasive approaches may benefit a subset of patients with fecal incontinence, but more controlled studies are needed. This mini-review highlights advances, current concepts, and controversies in the area.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Satish S C Rao
- Section of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Georgia Regents University, Augusta, Georgia.
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Ratuapli S, Bharucha AE, Harvey D, Zinsmeister AR. Comparison of rectal balloon expulsion test in seated and left lateral positions. Neurogastroenterol Motil 2013; 25:e813-20. [PMID: 23952111 PMCID: PMC3836851 DOI: 10.1111/nmo.12208] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 07/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Defecatory disorders can be diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions, respectively. The aims of this study were to compare BE in the LL and seated positions and to compare anorectal manometric parameters to BE performed in the seated and LL positions. METHODS 220 women [healthy (62), chronic constipation (158)] had anorectal high-resolution manometry and BE, summarized by time required (seated position, normal ≤60 s) or external traction to facilitate expulsion (LL position, normal ≤100 g). KEY RESULTS Balloon expulsion results in both positions were either concordant [normal (141) or abnormal (32)] or discordant [only LL abnormal (30), only seated abnormal (17)]. There was modest agreement [κ = 0.44 (95% CI 0.30-0.57)] between seated and LL BE. Compared with subjects with normal BE in both positions, anal pressure during simulated evacuation (SE) was higher, and the rectoanal gradient (rectal-anal pressure) during SE was more negative in the other 3 categories (i.e., abnormal LL only, abnormal seated only, and both abnormal). High anal pressure during SE (OR = 1.02, 95% CI 1.00-1.04) and high rectal sensory threshold for desire to defecate (OR = 1.01, 95% CI 1.00-1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR = 0.96, 95% CI 0.93-0.98) was associated with lower risk. CONCLUSIONS & INFERENCES There is modest agreement between rectal BE in LL and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, high resolution manometry findings suggest that even some patients with abnormal BE in the LL position have pelvic floor dysfunction.
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Affiliation(s)
- Shiva Ratuapli
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Rochester, Minnesota
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Rochester, Minnesota
| | - Doris Harvey
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Rochester, Minnesota
| | - Alan R. Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
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Mearin F. [Impact of chronic constipation on quality of life: Much more important than it seems]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:467-72. [PMID: 23769426 DOI: 10.1016/j.gastrohep.2012.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/30/2012] [Indexed: 11/27/2022]
Abstract
Chronic constipation is highly frequent in the general population (a prevalence of 14%). An underlying organic cause is usually absent, this type of constipation being known as chronic idiopathic constipation (CIC). Although usually considered banal, this disorder has a substantial personal, social and healthcare impact. Several studies have associated CIC with high rates of absenteeism in the workplace and disruption of routine activities. All these factors lead to high direct and indirect healthcare expenditure. Physically, the impact on patients with CIC, who require specialized care, is higher than that of ulcerative colitis or stable Crohn's disease. The psychological impact exceeds that caused by rheumatoid arthritis or hemodialysis. Appropriate treatment can improve HRQL in affected individuals. Recently, prucalopride, a highly selective 5-HT4 receptor agonist has been shown to improve the symptoms of CIC and to have a beneficial effect on HRQL.
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Affiliation(s)
- Fermín Mearin
- Servicio de Aparato Digestivo, Instituto de Trastornos Funcionales y Motores Digestivos, Centro Médico Teknon, Barcelona, España.
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Bharucha AE, Low P, Camilleri M, Veil E, Burton D, Kudva Y, Shah P, Gehrking T, Zinsmeister AR. A randomised controlled study of the effect of cholinesterase inhibition on colon function in patients with diabetes mellitus and constipation. Gut 2013; 62:708-15. [PMID: 22677718 PMCID: PMC3924965 DOI: 10.1136/gutjnl-2012-302483] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Chronic constipation in diabetes mellitus is associated with colonic motor dysfunction and is managed with laxatives. Cholinesterase inhibitors increase colonic motility. This study evaluated the effects of a cholinesterase inhibitor on gastrointestinal and colonic transit and bowel function in diabetic patients with constipation. DESIGN After a 9-day baseline period, 30 patients (mean ± SEM age 50 ± 2 years) with diabetes mellitus (18 type 1, 12 type 2) and chronic constipation without defaecatory disorder were randomised to oral placebo or pyridostigmine, starting with 60 mg three times a day, increasing by 60 mg every third day up to the maximum tolerated dose or 120 mg three times a day; this dose was maintained for 7 days. Gastrointestinal and colonic transit (assessed by scintigraphy) and bowel function were evaluated at baseline and the final 3 and 7 days of treatment, respectively. Treatment effects were compared using analysis of covariance, with gender, body mass index and baseline colonic transit as covariates. RESULTS 19 patients (63%) had moderate or severe autonomic dysfunction; 16 (53%) had diabetic retinopathy. 14 of 16 patients randomised to pyridostigmine tolerated 360 mg daily; two patients took 180 mg daily. Compared with placebo (mean ± SEM 1.98 ± 0.17 (baseline), 1.84 ± 0.16 (treatment)), pyridostigmine accelerated (1.96 ± 0.18 (baseline), 2.45 ± 0.2 units (treatment), p<0.01) overall colonic transit at 24 h, but not gastric emptying or small-intestinal transit. Treatment effects on stool frequency, consistency and ease of passage were significant (p ≤ 0.04). Cholinergic side effects were somewhat more common with pyridostigmine (p=0.14) than with placebo. CONCLUSIONS Cholinesterase inhibition with oral pyridostigmine accelerates colonic transit and improves bowel function in diabetic patients with chronic constipation.
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Affiliation(s)
- Adil E Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Krol R, Smeenk RJ, van Lin ENJT, Hopman WPM. Impact of late anorectal dysfunction on quality of life after pelvic radiotherapy. Int J Colorectal Dis 2013; 28:519-26. [PMID: 23080344 DOI: 10.1007/s00384-012-1593-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Anorectal dysfunction is common after pelvic radiotherapy. This study aims to explore the relationship of subjective and objective anorectal function with quality of life (QoL) and their relative impact in patients irradiated for prostate cancer. METHODS Patients underwent anal manometry, rectal barostat measurement, and completed validated questionnaires, at least 1 year after prostate radiotherapy (range 1-7 years). QoL was measured by the Fecal Incontinence Quality of Life scale (FIQL) and the Expanded Prostate Cancer Index Composite Bowel domain (EPICB)-bother subscale. Severity of symptoms was rated by the EPICB function subscale. RESULTS Anorectal function was evaluated in 85 men. Sixty-three percent suffered from one or more anorectal symptoms. Correlations of individual symptoms ranged from r = 0.23 to r = 0.53 with FIQL domains and from r = 0.36 to r = 0.73 with EPICB bother scores. They were strongest for fecal incontinence and urgency. Correlations of anal sphincter pressures, rectal capacity, and sensory thresholds ranged from r = 0.00 to r = 0.42 with FIQL domains and from r = 0.15 to r = 0.31 with EPICB bother scores. Anal resting pressure correlated most strongly. Standardized regression coefficients for QoL outcomes were largest for incontinence, urgency, and anal resting pressure. Regression models with subjective parameters explained a larger amount (range 26-92 %) of variation in QoL outcome than objective parameters (range 10-22 %). CONCLUSIONS Fecal incontinence and rectal urgency are the symptoms with the largest influence on QoL. Impaired anal resting pressure is the objective function parameter with the largest influence. Therefore, sparing the structures responsible for an adequate fecal continence is important in radiotherapy planning.
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Affiliation(s)
- Robin Krol
- 455 Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Zeitoun JD, de Parades V. [Chronic constipation in adults]. Presse Med 2013; 42:1176-85. [PMID: 23453994 DOI: 10.1016/j.lpm.2012.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 09/14/2012] [Accepted: 09/27/2012] [Indexed: 02/07/2023] Open
Abstract
Chronic constipation is a very common condition, which is responsible for a major socioeconomic burden. Primary management must rule out secondary constipation before recognizing chronic idiopathic constipation, which is the most common diagnosis. Initial treatment frequently associates simple lifestyle modifications, whose efficacy is limited, with osmotic laxatives or bulking agents. If those measures do not relieve symptoms, a switch of laxatives or a combination must be proposed. Pharmacological treatments of constipation represent a new alternative approach in case of failure of previously mentioned measures. In case of chronic constipation reluctant to all conservative therapies, specific tests are required before considering biofeedback intervention or exceptionally a surgical option.
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Affiliation(s)
- Jean-David Zeitoun
- Hôpital Saint-Antoine, service de gastroentérologie et nutrition, 75012 Paris, France; Centre hospitalier Diaconesses-Croix Saint-Simon, service de proctologie médico-interventionnelle, 75012 Paris, France.
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41
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RATUAPLI SHIVAK, BHARUCHA ADILE, NOELTING JESSICA, HARVEY DORISM, ZINSMEISTER ALANR. Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry. Gastroenterology 2013; 144:314-322.e2. [PMID: 23142135 PMCID: PMC3681888 DOI: 10.1053/j.gastro.2012.10.049] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 10/23/2012] [Accepted: 10/28/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry. METHODS We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry. RESULTS Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times. CONCLUSIONS Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.
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Affiliation(s)
- SHIVA K. RATUAPLI
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
,Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - ADIL E. BHARUCHA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
,Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - JESSICA NOELTING
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - DORIS M. HARVEY
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
,Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - ALAN R. ZINSMEISTER
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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Abstract
Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.
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Affiliation(s)
- Catherine L C Bryant
- Academic Surgical Unit, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Wong RK, Drossman DA, Bharucha AE, Rao SS, Wald A, Morris CB, Oxentenko AS, Ravi K, Van Handel DM, Edwards H, Hu Y, Bangdiwala S. The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns. Am J Gastroenterol 2012; 107:1157-63. [PMID: 22858996 DOI: 10.1038/ajg.2012.23] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization. METHODS A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs. RESULTS On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually. CONCLUSIONS The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.
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Affiliation(s)
- Reuben K Wong
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, USA.
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Relationship among bacterial virulence, bladder dysfunction, vesicoureteral reflux and patterns of urinary tract infection in children. J Urol 2012; 188:236-41. [PMID: 22595065 DOI: 10.1016/j.juro.2012.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Indexed: 11/22/2022]
Abstract
PURPOSE We hypothesized that virulence levels of Escherichia coli isolates causing pediatric urinary tract infections differ according to severity of infection and also among various uropathies known to contribute to pediatric urinary tract infections. We evaluated these relationships using in vitro cytokine interleukin-6 elicitation. MATERIALS AND METHODS E. coli isolates were cultured from children presenting with urinary tract infections. In vitro cytokine (interleukin-6) elicitation was quantified for each isolate and the bacteria were grouped according to type of infection and underlying uropathy (neurogenic bladder, nonneurogenic bowel and bladder dysfunction, primary vesicoureteral reflux, no underlying etiology). RESULTS A total of 40 E. coli isolates were collected from children with a mean age of 61.5 months (range 1 to 204). Mean level of in vitro cytokine elicitation from febrile urinary tract infection producing E. coli was significantly lower than for nonfebrile strains (p = 0.01). The interleukin-6 response to E. coli in the neurogenic bladder group was also significantly higher than in the vesicoureteral reflux (p = 0.01) and no underlying etiology groups (p = 0.02). CONCLUSIONS In vitro interleukin-6 elicitation, an established marker to determine bacterial virulence, correlates inversely with clinical urinary tract infection severity. Less virulent, high cytokine producing E. coli were more likely to cause cystitis and were more commonly found in patients with neurogenic bladder and nonneurogenic bowel and bladder dysfunction, whereas higher virulence isolates were more likely to produce febrile urinary tract infections and to affect children with primary vesicoureteral reflux and no underlying etiology. These findings suggest that bacteria of different virulence levels may be responsible for differences in severity of pediatric urinary tract infections and may vary among different underlying uropathies.
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Lam TJ, Kuik DJ, Felt-Bersma RJF. Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients. Colorectal Dis 2012; 14:214-23. [PMID: 21689265 DOI: 10.1111/j.1463-1318.2011.02548.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. METHOD Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. RESULTS Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC-curve was 0.84 (P < 0.001; 95% confidence interval, 0.80-0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. CONCLUSION Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands.
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Lam TJ, Mulder CJJ, Felt-Bersma RJF. Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment. Int J Colorectal Dis 2012; 27:931-7. [PMID: 22350189 PMCID: PMC3378831 DOI: 10.1007/s00384-012-1415-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2012] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Anorectal function tests are often performed in patients with faecal incontinence who have failed conservative treatment. This study was aimed to establish the additive value of performing anorectal function tests in these patients in selecting them for surgery. PATIENTS AND METHODS Between 2003 and 2009, all referred patients with faecal incontinence were assessed by a questionnaire, anorectal manometry and anal endosonography. Patients with diarrhea, inflammatory bowel disease, pouches or rectal carcinoma were excluded. RESULTS In total, 218 patients were evaluated. Of these, 107 (49%) patients had no sphincter defects, 71 (33%) had small defects and 40 (18%) had large defects. Anorectal manometry could not differentiate between patients with and without sphincter defects. Patients with sphincter defects were only found to have a significantly shorter sphincter length and reduced rectal capacity compared to patients without sphincter defects. Forty-three patients (20%) had a normal anal pressures ≥ 40 mmHg. Seventeen patients (8%) had also a dyssynergic pelvic floor both on clinical examination and anorectal manometry. Fifteen patients (7%) had a reduced rectal capacity between 65 and 100 ml. There was no difference in anal pressures or the presence of sphincter defects in these patients compared to patients with a rectal capacity >150 ml. There was no correlation between anorectal manometry, endosonography and faecal incontinence severity scores. CONCLUSION In patients with faecal incontinence who have failed conservative treatment, only anal endosonography can reveal sphincter defects. Anorectal manometry should be reserved for patients eligible for surgery to exclude those with suspected dyssynergic floor or reduced rectal capacity.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW To highlight observations that have suggested the need for changing the conventional approach to the evaluation and management of urinary tract infections (UTIs) and vesicoureteral reflux in children and examine new alternative approaches to prevention of UTI and renal scarring based on research into host-pathogen interaction. RECENT FINDINGS Recent studies have questioned the traditional approach of using prophylactic antibiotics to prevent recurrence of UTI and development of renal scarring in children with vesicoureteral reflux. Ongoing research on host-pathogen interactions reveals a promising capability to analyze virulence factors in bacteria causing UTIs in children, identify highly virulent bacteria capable of causing pyelonephritis and renal injury, and to selectively target the gastrointestinal reservoirs of these bacteria for elimination using probiotics. SUMMARY Promising experimental studies correlating bacterial virulence with pattern of UTI and identification and characterization of a newly available probiotic capable of eradicating uropathogenic bacteria make targeted probiotic prevention of renal injury-inducing UTIs a potential therapeutic reality.
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48
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Abstract
Defecatory disorders are a common cause of chronic constipation and should be managed by biofeedback-guided pelvic floor retraining. While anorectal tests are necessary to diagnose defecatory disorders, recent studies highlight the utility of a careful digital rectal examination. While obstetric anal injury can cause fecal incontinence (FI), diarrhea is a more important risk factor for FI among women in the community, who typically develop FI after age 40. Initial management of fecal incontinence should focus on bowel disturbances. Pelvic floor retraining with biofeedback therapy is beneficial for patients who do not respond to bowel management. Sacral nerve stimulation should be considered in patients who do not respond to conservative therapy.
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Affiliation(s)
- Adil E Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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49
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Tack J, Müller-Lissner S, Stanghellini V, Boeckxstaens G, Kamm MA, Simren M, Galmiche JP, Fried M. Diagnosis and treatment of chronic constipation--a European perspective. Neurogastroenterol Motil 2011; 23:697-710. [PMID: 21605282 PMCID: PMC3170709 DOI: 10.1111/j.1365-2982.2011.01709.x] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although constipation can be a chronic and severe problem, it is largely treated empirically. Evidence for the efficacy of some of the older laxatives from well-designed trials is limited. Patients often report high levels of dissatisfaction with their treatment, which is attributed to a lack of efficacy or unpleasant side-effects. Management guidelines and recommendations are limited and are not sufficiently current to include treatments that became available more recently, such as prokinetic agents in Europe. PURPOSE We present an overview of the pathophysiology, diagnosis, current management and available guidelines for the treatment of chronic constipation, and include recent data on the efficacy and potential clinical use of the more newly available therapeutic agents. Based on published algorithms and guidelines on the management of chronic constipation, secondary pathologies and causes are first excluded and then diet, lifestyle, and, if available, behavioral measures adopted. If these fail, bulk-forming, osmotic, and stimulant laxatives can be used. If symptoms are not satisfactorily resolved, a prokinetic agent such as prucalopride can be prescribed. Biofeedback is recommended as a treatment for chronic constipation in patients with disordered defecation. Surgery should only be considered once all other treatment options have been exhausted.
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Affiliation(s)
- J Tack
- Division of Gastroenterology, University Hospital LeuvenLeuven, Belgium
| | - S Müller-Lissner
- Department of Internal MedicinePark-Klinik Weissensee, Berlin, Germany
| | - V Stanghellini
- Department of Clinical Medicine, University of BolognaBologna, Italy
| | - G Boeckxstaens
- Division of Gastroenterology, University Hospital LeuvenLeuven, Belgium
| | - M A Kamm
- Departments of Medicine and Gastroenterology, St Vincent's HospitalMelbourne, Australia and Imperial CollegeLondon, UK
| | - M Simren
- Department of Internal Medicine, Sahlgrenska University HospitalGöteborg, Sweden
| | - J-P Galmiche
- Department of Liver and Gastroenterology, Institute of Diseases of the Digestive System NantesCHU Nantes, France
| | - M Fried
- Division of Gastroenterology and Hepatology, University Hospital ZurichZurich, Switzerland
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50
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Tack J, Müller-Lissner S, Stanghellini V, Boeckxstaens G, Kamm MA, Simren M, Galmiche JP, Fried M. Diagnosis and treatment of chronic constipation--a European perspective. Neurogastroenterol Motil 2011. [PMID: 21605282 DOI: 10.111/j.1365-2982.2011.01709.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although constipation can be a chronic and severe problem, it is largely treated empirically. Evidence for the efficacy of some of the older laxatives from well-designed trials is limited. Patients often report high levels of dissatisfaction with their treatment, which is attributed to a lack of efficacy or unpleasant side-effects. Management guidelines and recommendations are limited and are not sufficiently current to include treatments that became available more recently, such as prokinetic agents in Europe. PURPOSE We present an overview of the pathophysiology, diagnosis, current management and available guidelines for the treatment of chronic constipation, and include recent data on the efficacy and potential clinical use of the more newly available therapeutic agents. Based on published algorithms and guidelines on the management of chronic constipation, secondary pathologies and causes are first excluded and then diet, lifestyle, and, if available, behavioral measures adopted. If these fail, bulk-forming, osmotic, and stimulant laxatives can be used. If symptoms are not satisfactorily resolved, a prokinetic agent such as prucalopride can be prescribed. Biofeedback is recommended as a treatment for chronic constipation in patients with disordered defecation. Surgery should only be considered once all other treatment options have been exhausted.
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Affiliation(s)
- J Tack
- Division of Gastroenterology, University Hospital Leuven, Leuven, Belgium.
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