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Zhou J, Javadi B, Ho V. Randomized controlled trial of an Internet-of-Medical-Things device for patient-guided anorectal biofeedback therapy. PLoS One 2024; 19:e0311134. [PMID: 39331611 DOI: 10.1371/journal.pone.0311134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 09/10/2024] [Indexed: 09/29/2024] Open
Abstract
Biofeedback therapy is useful for treatment of functional defecation disorders but is not widely available and is labor intensive. We developed an Internet-of-Medical-Things (IoMT) device, enabling self-guided biofeedback therapy. This study assesses the safety and efficacy of self-guided biofeedback therapy using the IoMT device in comparison to standard operator-led therapy. Patients experiencing urge or seepage fecal incontinence (≥1 episode/week) were randomly assigned to either our IoMT system or to the conventional anorectal manometry-based therapy. Both interventions comprised six weekly sessions, focusing on enhancing anal strength, endurance, and coordination. The novel device facilitated self-guided therapy via visual instructions on a companion app. Primary outcomes included safety/tolerability, changes in Vaizey severity scores, and alterations in anorectal pressure profiles. Twenty-five patients (22 females, 3 males) participated, with 13 in the novel device group and 12 in the standard therapy group. Both groups showed significant reductions in symptom severity scores: IoMT device group -4.2 (95% CI: -4.06, -4.34, p = 0.018), and the standard therapy group -4.8 (95% CI: -4.31, -5.29, p = 0.028). Anal sphincter resting pressure and sustained squeeze time improved significantly in both groups, and the novel device group demonstrated an increase in maximum sphincter squeeze pressure. There were no significant differences between the therapy groups. Importantly, the experimental device was well-tolerated compared with standard therapy, with no serious adverse events observed. This study demonstrates the comparable efficacy of self-administered biofeedback using the IoMT device with traditional biofeedback therapy. The results demonstrates the potential of the IoMT device as a safe, self-guided method for FI therapy, offering convenience and effectiveness in fecal incontinence management.
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Affiliation(s)
- Jerry Zhou
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Bahman Javadi
- School of Computer, Data and Mathematical Sciences, Western Sydney University, Parramatta, New South Wales, Australia
| | - Vincent Ho
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
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2
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Shahsavari D, Rao SSC. Review article: advances in the diagnosis and management of anorectal motility disorders. Aliment Pharmacol Ther 2024; 60:701-714. [PMID: 39051556 DOI: 10.1111/apt.18170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field. AIMS To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach. METHODS We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review. RESULTS A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe. CONCLUSIONS Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients.
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Affiliation(s)
- Dariush Shahsavari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
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3
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Gaj F, Lai Q, Gelormini E, Ceci M, Di Saverio S, Quaresima S. Efficacy of surgical treatments for the management of solitary rectal ulcer syndrome: a network meta-analysis. Colorectal Dis 2024; 26:1515-1534. [PMID: 38957108 DOI: 10.1111/codi.17080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/11/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024]
Abstract
AIM Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS. MATERIALS AND METHODS A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing. RESULTS A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14). CONCLUSION Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422).
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Affiliation(s)
- Fabio Gaj
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Quirino Lai
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Enza Gelormini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Marino Ceci
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Salomone Di Saverio
- ASUR Marche, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
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van der Zande JMJ, Koppen IJN, Yacob D, Sanchez RE, Puri NB, Vaz K, Di Lorenzo C, Benninga MA, Lu PL. Current practice in the care of children with functional constipation: What is the hold up? J Pediatr Gastroenterol Nutr 2024; 79:301-308. [PMID: 38924156 DOI: 10.1002/jpn3.12295] [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: 02/12/2024] [Revised: 04/22/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES For children with intractable functional constipation (FC), there are no evidence-based guidelines for subsequent evaluation and treatment. Our objective was to assess the practice patterns of a large, international cohort of pediatric gastroenterologists. METHODS We administered a survey to physicians who attended the 2nd World Congress of Pediatric Neurogastroenterology and Motility held in Columbus, Ohio (USA) in September 2023. The survey included 29 questions on diagnostic testing, nonpharmacological and pharmacological treatment, and surgical options for children with intractable FC. RESULTS Ninety physicians from 18 countries completed the survey. For children with intractable FC, anorectal manometry was the most commonly used diagnostic test. North American responders were more likely than Europeans to use stimulant laxatives (97% vs. 77%, p = 0.032), prosecretory medications (69% vs. 8%, p < 0.001), and antegrade continence enemas (ACE; 83% vs. 46%, p = 0.009) for management. Europeans were more likely than North Americans to require colonic transit testing before surgery (85% vs. 30%, p < 0.001). We found major differences in management practices between Americans and the rest of the world, including use of prosecretory drugs (73% vs. 7%, p < 0.001), anal botulinum toxin injections (81% vs. 58%, p = 0.018), ACE (81% vs. 58% p = 0.018), diverting ileostomies (56% vs. 26%, p = 0.006), and colonic resections (42% vs. 16%, p = 0.012). No differences were found when respondents were compared by years of experience. CONCLUSIONS Practice patterns in the evaluation and treatment of children with intractable FC differ widely among pediatric gastroenterologists from around the world. A clinical guideline regarding diagnostic testing and surgical decision-making is needed.
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Affiliation(s)
- Julia M J van der Zande
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Raul E Sanchez
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Neetu B Puri
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karla Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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van der Zande JMJ, Lu PL. Management of the child with refractory constipation. Aliment Pharmacol Ther 2024; 60 Suppl 1:S42-S53. [PMID: 38923030 DOI: 10.1111/apt.17847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 06/28/2024]
Abstract
BACKGROUND Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely. AIMS To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience. METHODS We performed a literature review on diagnostic tests and treatment options for children with refractory constipation. RESULTS Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed. CONCLUSIONS Recent advances offer hope for children with refractory constipation.
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Affiliation(s)
- Julia M J van der Zande
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter L Lu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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McNevin MS. Evaluation and Management of Rectal Prolapse. Surg Clin North Am 2024; 104:557-564. [PMID: 38677820 DOI: 10.1016/j.suc.2023.12.002] [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] [Indexed: 04/29/2024]
Abstract
Rectal prolapse, or procidentia, is a common pathology for the practicing colorectal surgeon. It is associated with lifestyle limiting symptoms for the patient and frequently co-exists with other types of pelvic prolapse making multidisciplinary management key. It is primarily managed with surgical reconstruction. A number of operative approaches exist, and the optimum procedure is varied dependent upon patient characteristics.
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Affiliation(s)
- Michael Shane McNevin
- GI, Trauma and Endocrine Surgery, Department of Surgery, University of Colorado, Mail Stop C313, Academic Office 1, 12631 East 17th Avenue, Room 6001, Aurora, CO 80045, USA.
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Seo M, Bae JH. Nonpharmacologic Treatment of Chronic Constipation. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:191-196. [PMID: 38783620 DOI: 10.4166/kjg.2024.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Functional constipation is a common clinical diagnosis that affects approximately 14% of the world's population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.
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Affiliation(s)
- Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - June Hwa Bae
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
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8
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Xu D, Kuang M, Liu Y, Jiang H. Diagnostic value of balloon expulsion test and anorectal manometry in patients with constipation: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2024; 36:534-544. [PMID: 38555600 DOI: 10.1097/meg.0000000000002743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
This study aims to compare the diagnostic value of balloon expulsion test and anorectal manometry in patients with constipation through meta-analysis. Databases, encompassing PubMed, EMBASE, Cochrane Library, Web of Science, etc. were searched for all English publications on the diagnosis of constipation using balloon expulsion test and anorectal manometry. The publication date was restricted from the inception of the databases until December 2022. Data analysis was carried out utilizing Stata 15.0 and Meta-Disc 1.4 software. Thirteen studies involving 2171 patients with constipation were included. According to the meta-analysis, the balloon expulsion test showed a pooled sensitivity of 0.75 (95% CI: 0.72-0.77), a pooled specificity (Spe) of 0.67 (95% CI: 0.62-0.72), a pooled positive likelihood ratio (+LR) of 3.24 (95% CI: 1.53-6.88), a pooled negative likelihood ratio (-LR) 0.35 (95% CI: 0.23-0.52) and a pooled diagnostic odds ratio (DOR) of 9.47 (95% CI: 3.27-27.44). For anorectal manometry, the pooled Sen, Spe, +LR, -LR and DOR were 0.74 (95% CI: 0.72-0.76), 0.73 (95% CI: 0.70-0.76), 2.69 (95% CI: 2.18-3.32), 0.35 (95% CI: 0.28-0.43), and 8.3 (95% CI: 5.4-12.75), respectively. The area under the summary receiver operating characteristic curve areas for balloon expulsion test and anorectal manometry were 0.8123 and 0.8088, respectively, with no statistically significant disparity (Z = -0.113, P > 0.05). Both the balloon expulsion test and anorectal manometry demonstrate comparable diagnostic performance, each offering unique advantages. These diagnostic procedures hold significance in the diagnosis of constipation.
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Affiliation(s)
- Dan Xu
- First Clinical Medical College, Shaanxi University of Chinese Medicine, Xi'an, Shaanxi, China
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Triadafilopoulos G, Gardner JD. Relationship of Age and Gender to Motility Test Results and Symptoms in Patients with Chronic Constipation. Dig Dis Sci 2024; 69:1302-1317. [PMID: 38430328 DOI: 10.1007/s10620-024-08314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/23/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND/AIMS Patients with chronic constipation (CC) exhibit symptoms and functional abnormalities upon testing, but their relationship to age and gender is unclear. We assessed age- and gender-related differences in symptoms, colon transit time, and anorectal motility, sensation, and expulsion. PATIENTS AND METHODS Retrospective, post hoc data analysis of patients with CC, who underwent Wireless Motility Capsule (WMC), High-Resolution Anorectal Manometry (HR-ARM), Balloon Expulsion Test (BET) and Rectal Sensory Testing (RST). Clinical assessment was made by questionnaires. Standard WMC criteria for colonic transit time (CTT) and the London classification was used for HR-ARM analyses, and regression plots between age, gender, CTT, HR-HRM, RST and BET were calculated. RESULTS We studied 75 women and 91 men. Abdominal pain, infrequent defecation, incomplete evacuation, defecatory straining, and multiple motility and anorectal function abnormalities were common. Abdominal pain was least frequently, and straining was most frequently associated with a motility abnormality. For each symptom, the highest prevalence was associated with failed BET. There was a significant increase in CTT with age only in men (p = 0.0006). In men, for each year of age there was a CTT increase of 1.02 h. The prevalence of abdominal pain and incomplete evacuation for females was significantly higher than that for males (both P < 0.05). The prevalence of low anal squeeze pressure for females was significantly higher than that for males, and the prevalence of poor rectal sensation for males was significantly higher than that for females (both P < 0.05). A significant decrease in basal anal and squeeze pressures with age occurred in women (p < 0.0001); an increase in age of one year was associated with a decrease in anal base pressure of 1.2 mmHg. Abnormal CTT and HR-ARM tests were associated with increased symptom frequency, but not severity. CONCLUSIONS There are significant age- and gender-related differences in symptoms, CTT, and HR-HRM parameters, rectal sensation, and expulsion, that may influence the multifaceted management of constipation.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA.
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA.
| | - Jerry D Gardner
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA
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Luo Y, Staller K. Starting from the Bottom: Unraveling Obesity's Impact on Anorectal Function. Dig Dis Sci 2024; 69:664-666. [PMID: 38184498 DOI: 10.1007/s10620-023-08244-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 12/12/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Yuying Luo
- Mount Sinai Center for Gastrointestinal Physiology and Motility, New York, NY, USA.
| | - Kyle Staller
- Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA
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Prasad S, Makharia GK. Modifying the Collateral Symptoms in Patients with Parkinson's Disease. Ann Indian Acad Neurol 2024; 27:113-115. [PMID: 38751929 PMCID: PMC11093175 DOI: 10.4103/aian.aian_328_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/18/2024] Open
Affiliation(s)
- Shubham Prasad
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K. Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Allaire C, Yong PJ, Bajzak K, Jarrell J, Lemos N, Miller C, Morin M, Nasr-Esfahani M, Singh SS, Chen I. Directive clinique n o445 : Gestion de la douleur pelvienne chronique. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102284. [PMID: 38341222 DOI: 10.1016/j.jogc.2023.102284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
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13
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Ingemansson A, Walter SA, Jones MP, Sjödahl J. Defecation Symptoms in Relation to Stool Consistency Significantly Reflect the Dyssynergic Pattern in High-resolution Anorectal Manometry in Constipated Patients. J Clin Gastroenterol 2024; 58:57-63. [PMID: 36730549 DOI: 10.1097/mcg.0000000000001794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 10/10/2022] [Indexed: 02/04/2023]
Abstract
GOALS To evaluate the usefulness of a 2-week patient-completed bowel habit and symptom diary as a screening tool for disordered rectoanal coordination (DRC). BACKGROUND DRC is an important subgroup of chronic constipation that benefits from biofeedback treatment. Diagnosis of DRC requires a dyssynergic pattern (DP) of attempted defecation in high-resolution anorectal manometry (HRAM) and at least 1 other positive standardized examination, such as the balloon expulsion test or defecography. However, HRAM is generally limited to tertiary gastroenterology centres and finding tools for selecting patients for referral for further investigations would be of clinical value. STUDY Retrospective data from HRAM and a 2-week patient-completed bowel habit and symptom diary from 99 chronically constipated patients were analyzed. RESULTS Fifty-seven percent of the patients had a DP pattern during HRAM. In the DP group, 76% of bowel movements with loose or normal stool resulted in a sense of incomplete evacuation compared with 55% of the non-DP group ( P =0.004). Straining and sensation of incomplete evacuation with the loose stool were significantly more common in the DP group ( P =0.032). Hard stool was a discriminator for non-DP ( P =0.044). Multiple logistic regression including incomplete evacuation and normal stool predicted DP with a sensitivity of 82% and a specificity of 50%. CONCLUSIONS The sensation of incomplete evacuation with loose or normal stool could be a potential discriminator in favor of DP in chronically constipated patients. The bowel habit and symptom diary may be a useful tool for stratifying constipated patients for further investigation of suspected DRC.
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Affiliation(s)
- Anna Ingemansson
- Department of Gastroenterology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Susanna A Walter
- Department of Gastroenterology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Michael P Jones
- Psychology Department, Macquarie University, North Ryde, NSW, Australia
| | - Jenny Sjödahl
- Department of Gastroenterology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Triadafilopoulos G, Lee M, Neshatian L. High Prevalence of Anorectal Dysfunction in Ambulatory Patients with Chronic Constipation, Regardless of Colon Transit Time. Dig Dis Sci 2024; 69:180-188. [PMID: 37555883 DOI: 10.1007/s10620-023-08072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Classification of chronic constipation (CC) into its three subtypes of slow transit constipation, defecation disorder and normal transit constipation, may improve its multifaceted management. We assessed the merits of the London classification in patients with CC, who were studied by both wireless motility capsule (WMC) and high-resolution anorectal manometry (HR-ARM), examining their relative utilities in decision-making.s PATIENTS AND METHODS: Retrospective, community-based study of prospectively collected data on patients with CC by Rome IV criteria, who underwent WMC and HR-ARM, Balloon Expulsion Test, and Rectal Sensory Testing. Clinical assessment was made by standard questionnaires. On WMC, standard criteria for colonic transit time (CTT) were used (normal CTT < 59 h). The hierarchical London classification was used for HR-ARM analyses. RESULTS Of 1261 patients with CC, 166 (91 M; ages 22-86) received technically satisfactory WMC and HR-ARM, formed the analyzed study cohort, of whom 84 had normal CTT and 82 had prolonged CTT (> 59 h). Patients with slow CTT were significantly older and had longer duration and more severe disease. Using the London classification criteria for disorders of anorectal function, we noted a high prevalence of anorectal dysfunction, regardless of CTT. Except for lower rate of anal hypertonicity in patients with slow CTT, disorders of recto-anal coordination, and rectal sensation were seen at a comparable rate in patients with CC, regardless of CTT. CONCLUSION There is a significant overlap of anorectal disorders in patients with slow CTT. There is questionable specificity and utility of WMC and HR-ARM in assessing patients with CC. More work is needed to demonstrate the value of these studies as surrogate markers of the disease and its response to multifaceted therapy.
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Affiliation(s)
- George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA.
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA.
| | - Megan Lee
- Silicon Valley Neuro-Gastroenterology and Motility Center, 2490 Hospital Drive, Suite 211, Mountain View, CA, 94040, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 420 Broadway Street, Pavilion D, 2nd Floor, Redwood City, CA, 94063, USA
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Allaire C, Yong PJ, Bajzak K, Jarrell J, Lemos N, Miller C, Morin M, Nasr-Esfahani M, Singh SS, Chen I. Guideline No. 445: Management of Chronic Pelvic Pain. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102283. [PMID: 38341225 DOI: 10.1016/j.jogc.2023.102283] [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] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To provide evidence-based recommendations for the management of chronic pelvic pain in females. TARGET POPULATION This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. BENEFITS, HARMS, AND COSTS The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. EVIDENCE Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. TWEETABLE ABSTRACT Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS RECOMMENDATIONS.
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Mego M, Huaman JW, Videla S, Jansana M, Tinoco K, Saperas E. Effectiveness of a high fiber diet in improving constipation in patients with defecatory dyssynergy under treatment with anorrectal biofeedback. Exploratory, randomized clinical trial. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:774-783. [PMID: 36731727 DOI: 10.1016/j.gastrohep.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/03/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Fiber is the initial treatment in chronic functional constipation. However, its role in the group of patients with defecatory dyssynergy is not well established. The objective of the study is to evaluate the efficacy and safety of a high fiber diet in patients with defecatory dyssynergy in the treatment with anorectal biofeedback. PATIENTS AND METHODS An exploratory, randomized (1:1), double-blind, controlled «add-on» clinical trial was carried out in a reference center in Spain in patients with functional constipation and defecatory dyssynergy according to the ROMEIV criteria. CONTROL GROUP treatment with biofeedback and low-fiber diet (15-20g/day). Experimental group: treatment with biofeedback and high fiber diet (25-30g/day). Analyzed: responder (primary endpoint), patient whose defecatory dyssynergy had been corrected (>20% reduction in anal pressure during the defecation maneuver and normal balloon expulsion test); anorectal parameters (anal relaxation, reduced straining); safety (abdominal symptoms: flatulence, pain, borborygmus, bloating). RESULTS A total of 44 patients were randomized: 22 per group. The percentage of responders was 75% (15/20; 95%CI: 53 89%) control group and 70% (14/20; 95%CI: 48-85%) experimental group, P=.225. Differences in favor of the control group were only observed in abdominal symptoms: flatulence (P=.028), abdominal distension (P=.041) and digestive comfort (P=.043). CONCLUSIONS In patients with defecatory dyssynergy, a high-fiber diet not only does not improve the efficacy of anorectal biofeedback but is associated with a loss of improvement in abdominal symptoms.
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Affiliation(s)
- Marianela Mego
- Servicio de Gastroenterología, Hospital Universitari General de Catalunya, Grupo QuirónSalud, Sant Cugat del Vallès, Barcelona, España
| | - José Wálter Huaman
- Servicio de Gastroenterología, Hospital Universitari General de Catalunya, Grupo QuirónSalud, Sant Cugat del Vallès, Barcelona, España; Escuela de Medicina, Universitat Internacional de Catalunya, Barcelona, España.
| | - Sebastian Videla
- Unidad de Soporte a la Investigación Clínica, Departamento de Farmacología Clínica, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Unidad de Farmacología, Departamento de Patología y Terapéutica Experimental, Facultad de Medicina y Ciencias de la Salud, IDIBELL, Universidad de Barcelona, Barcelona, España
| | - Marta Jansana
- Servicio de Endocrinología, Hospital Universitari General de Catalunya, Grupo QuirónSalud, Sant Cugat del Vallès, Barcelona, España
| | - Karen Tinoco
- Servicio de Medicina Interna, Hospital Universitari General de Catalunya, Grupo QuirónSalud, Sant Cugat del Vallès, Barcelona, España
| | - Esteban Saperas
- Servicio de Gastroenterología, Hospital Universitari General de Catalunya, Grupo QuirónSalud, Sant Cugat del Vallès, Barcelona, España; Escuela de Medicina, Universitat Internacional de Catalunya, Barcelona, España
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Zhang YB, Huang ZY, Jin JW, Yuan YP, Xu LY, Jin J. Rectal sensitivity and associated factors in patients with different subtypes of functional defecation disorder. Eur J Gastroenterol Hepatol 2023; 35:1370-1374. [PMID: 37851333 DOI: 10.1097/meg.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE To investigate rectal sensitivity and associated factors in patients with different subtypes of functional defecation disorder (FDD). METHODS We segregated individuals diagnosed with FDD into two groups based on their defecation patterns: those with dyssynergic defecation and those with inadequate defecatory propulsion. We gathered general information through questionnaires and assessed rectal sensitivity using anorectal manometry. The rectal sensitivity performances of the two groups were compared; the factors related to rectal sensitivity were analyzed to determine the factors associated with rectal sensitivity, and the effect of biofeedback therapy on rectal sensitivity was clarified. RESULTS Rectal sensitivity in different subtypes of FDD decreased, and the difference between the two groups was not statistically significant ( P > 0.05). There were no statistically significant differences in the first constant sensation volume, defecatory desire volume, and maximum tolerable volume between the different subtypes of FDD ( P > 0.05). Multi-factor binary logistic regression analysis showed that age, constipation symptom score, and diabetes were all independent risk factors for decreased rectal sensitivity ( P < 0.05). There were no statistically significant differences between the prior- and post-biofeedback therapy in the first constant sensation volume, defecatory desire volume, and maximum tolerable volume ( P > 0.05). CONCLUSION Rectal sensitivity in different subtypes of FDD decreased. Age, constipation symptom score, and diabetes were independent risk factors for decreased rectal sensitivity. Short-term biofeedback therapy did not improve rectal hyposensitivity in patients with FDD.
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Affiliation(s)
- Yi-Bing Zhang
- Department of Gastroenterology, Wenzhou Central Hospital (the Dingli Clinical College of Wenzhou Medical University), Wenzhou, China
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Li J, Sun Y, Zhang C, Thomas K, Lin W, Cheng C, Li H, Zhu Q, Ma S, Hua Q, Shi Q, Zheng X. A randomized, controlled clinical trial of acupoint catgut embedding as an effective control of functional anorectal pain. Medicine (Baltimore) 2023; 102:e35462. [PMID: 37933076 PMCID: PMC10627639 DOI: 10.1097/md.0000000000035462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Patients with functional anorectal pain (FAP) usually feel pain in the anal region, foreign body sensation, and defecation disorders. The pain may radiate to the perineum, thighs, and waist. Conventional biofeedback, local nerve block and surgical treatment have certain limitations. Thread-embedding acupuncture (TEA) is a complementary and alternative therapy, which is widely used in the clinical practice of traditional Chinese medicine to treat functional anorectal pain. This study evaluated the efficacy and safety of the catgut-embedding acupuncture in patients with FAP. METHODS FAP patients were enrolled and randomly divided into a thread-embedding acupuncture group (n = 35) and a sham-embedding acupuncture control group (n = 36). Patients underwent treatment twice monthly for 2 months and were assessed before and after treatments for visual analogue scales (VAS) of anorectal pain, VAS of lumbar pain or soreness, VAS of abdominal distension or pain, anal incontinence index, and SF-36 quality of life. The SF-36 quality of life score included assessment of physical functioning, role-physical, bodily-pain, general health, role-emotional, social functioning, vitality, and mental health. RESULT The total effective rate was 85.71% for the treatment group versus 8.33% of the controls after 2 months (P < .001). The patients' anal rectum VAS score was significantly higher after treatment versus pretreatment (P < .01), while the physical functioning, role-physical, bodily-pain, role-emotional, and mental health in the experimental group and the role-emotional, and mental health in the control group were all significantly improved versus pretreatment (P < .05). The anorectal VAS score, anal incontinence index, and the SF-36 scores of the physical functioning, role-physical, bodily-pain, role-emotional, and mental health were better in the treatment group compared to the control group (P < .05). Most importantly, there were no adverse reactions observed in either group during the treatment. CONCLUSION The thread-embedding acupuncture treatment effectively and safely improved the emotional anxiety and quality of life in FAP patients.
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Affiliation(s)
- Jingjing Li
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
- Maternal and Child Health Hospital of Huadu District, Guangzhou, China
| | - Yuqing Sun
- Anorectal Department of Nanjing Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Cairong Zhang
- Acupuncture Department of Nanjing Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | | | - Wanqi Lin
- Traditional Chinese Medicine Department of Shenshan Medical Center, Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Changcheng Cheng
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Huijia Li
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Qianyang Zhu
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Sufan Ma
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Qixin Hua
- Acupuncture Department of Nanjing Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Qian Shi
- Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Xueping Zheng
- Anorectal Department of Nanjing Hospital of Traditional Chinese Medicine, Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
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Chu CY, Su YC, Hsieh PC, Lin YC. Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis. Toxicon 2023; 235:107311. [PMID: 37816487 DOI: 10.1016/j.toxicon.2023.107311] [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: 07/03/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 10/12/2023]
Abstract
Dyssynergic defecation (DD) is a common cause of chronic constipation. Owing to the lack of a comprehensive synthesis of available data on the effectiveness of botulinum neurotoxin (BoNT) for treating DD, we performed a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane databases from inception to May 9, 2023. The outcomes comprise short-term and long-term symptom improvement, various anorectal function measurements, complications of fecal incontinence, and symptom improvement after repeated BoNT injections. A meta-analysis comparing BoNT injection with either surgery or biofeedback (BFB) therapy in treating DD was also conducted. Subgroup analysis and meta-regression were performed to identify possible moderator effects. We included five randomized controlled trials, seven prospective studies, and two retrospective observational studies. Short-term potential improvement in symptoms (event rate [ER], 66.4%; 95% CI, 0.513 to 0.783) was identified, but in the long-term (>12 months), this effect was decreased (ER, 38.2%; 95% CI, 0.267 to 0.511). Short-term improvements in objective anorectal physiologic parameters were also observed. Repeated BoNT injection was effective for patients with symptom recurrence. Subgroup analysis revealed enhanced long-term symptom improvement with high-dose BoNT, but this treatment also increased the risk of complications and recurrence compared with low doses. The effectiveness, complications, and recurrence of symptoms associated with BoNT injection and surgery did not differ significantly. BoNT injection significantly provided short-term symptom improvement but also heightened the risk of incontinence compared with BFB therapy. Our systematic review and meta-analysis indicated that BoNT could be beneficial for short-term symptom improvement in patients with DD, but this effect tended to decline 12 months after injection. Standardized BoNT intervention protocols remain warranted. Among the several treatments for DD, we concluded that BoNT injection is not inferior to other options considering its effectiveness in relieving symptoms, the associated complication development, and the risk of symptom recurrence.
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Affiliation(s)
- Ching-Yu Chu
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Chun Hsieh
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Aloysius MM, Korsten MA, Radulovic M, Singh K, Lyons BL, Cummings T, Hobson J, Kahal S, Spungen AM, Bauman WA. Lack of improvement in anorectal manometry parameters after implementation of a pelvic floor/anal sphincter biofeedback in persons with motor-incomplete spinal cord injury. Neurogastroenterol Motil 2023; 35:e14667. [PMID: 37743783 DOI: 10.1111/nmo.14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Effect of biofeedback on improving anorectal manometric parameters in incomplete spinal cord injury is unknown. A short-term biofeedback program investigated any effect on anorectal manometric parameters without correlation to bowel symptoms. METHODS This prospective uncontrolled interventional study comprised three study subject groups, Group 1: sensory/motor-complete American Spinal Injury Association Impairment Scale (AIS) A SCI (n = 13); Group 2 (biofeedback group): sensory incomplete AIS B SCI (n = 17) (n = 3), and motor-incomplete AIS C SCI (n = 8), and AIS D SCI (n = 6); and Group 3: able-bodied (AB) controls (n = 12). High-resolution anorectal manometry (HR-ARM) was applied to establish baseline characteristics in all subjects for anorectal pressure, volume, length of pressure zones, and duration of sphincter squeeze pressure. SCI participants with motor-incomplete SCI were enrolled in pelvic floor/anal sphincter bowel biofeedback training (2 × 6-week training periods comprised of two training sessions per week for 30-45 min per session). HR-ARM was also performed after each of the 6-week periods of biofeedback training. RESULTS Compared to motor-complete or motor-incomplete SCI participants, AB subjects had higher mean intra-rectal pressure, maximal sphincteric pressure, residual anal pressure, recto-anal pressure gradient, and duration of squeeze (p < 0.05 for each of the endpoints). No significant difference was evident at baseline between the motor-complete and motor-incomplete SCI groups. In motor-incomplete SCI subjects, the pelvic floor/anal sphincter biofeedback protocol failed to improve HR-ARM parameters. CONCLUSION Biofeedback training program did not improve anal manometric parameters in subjects with motor-incomplete or sensory-incomplete SCI. Biofeedback did not change physiology, and its effects on symptoms are unknown. INFERENCES Utility of biofeedback is limited in patients with incomplete spinal cord injury in terms of improving HR-ARM parameters.
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Affiliation(s)
- Mark M Aloysius
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Mark A Korsten
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miroslav Radulovic
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kamaldeep Singh
- Department of Medicine, College of Medicine, Tucson, Arizona, USA
| | - Brian L Lyons
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | | | - Joshua Hobson
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
| | - Sandeep Kahal
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann M Spungen
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William A Bauman
- National Center for Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, New York, USA
- Medical Service, James J Peters VA Medical Center, Bronx, New York, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Wei DJ, Li HJ, Lyu ZP, Lyu AP, Bian ZX, Ld Zhong L. A clinical pathway for integrative medicine in the treatment of functional constipation in Hong Kong, China. JOURNAL OF INTEGRATIVE MEDICINE 2023; 21:550-560. [PMID: 37989695 DOI: 10.1016/j.joim.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 08/03/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Functional constipation (FC) is a common intestinal disease worldwide. Despite the presence of criteria such as Roman IV, there is no standardized diagnosis and treatment algorithm in Hong Kong that combines both Western and Chinese medicine approaches. This study integrates current effective and safe diagnosis and treatment methods for FC and provides a clear and scientific pathway for clinical professionals and patients. METHODS A systematic search of the PubMed, Cochrane Library, and China National Knowledge Infrastructure databases was performed from their inception to June 30th, 2022, collecting the current evidence about the efficacious integrative management for FC. We organized a meeting of professionals in fields relevant to treatment and management of FC to develop a consensus agreement on clinical pathway process. RESULTS We developed a clinical pathway for the treatment of FC based on the most recent published guidelines and consultation with experts. This pathway includes a hierarchy of recommendations for every step of the clinical process, including clinical intake, diagnostic examination, recommended labs, diagnostic flowchart, and guidance for selection of therapeutic drugs. CONCLUSION This pathway establishes clinical standards for the diagnosis and treatment of FC using Chinese medicine and Western medicine; it will help to provide high-quality medical services in Hong Kong for patients with FC. Please cite this article as: Wei DJ, Li HJ, Lyu ZP, Lyu AP, Bian ZX, Zhong LL. A clinical pathway for integrative medicine in the treatment of functional constipation in Hong Kong, China. J Integr Med. 2023; 21(6): 550-560.
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Affiliation(s)
- Dong-Jue Wei
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Hui-Juan Li
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Zi-Pan Lyu
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China; School of Biological Sciences, Nanyang Technological University, 637551, Singapore
| | - Ai-Ping Lyu
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Zhao-Xiang Bian
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China.
| | - Linda Ld Zhong
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China; School of Biological Sciences, Nanyang Technological University, 637551, Singapore.
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Fan M, Li L, Xu X, Zhou C, Wang P, Yin W, Pei W, Wang S. Psychological status of patients with functional anorectal pain and treatment efficacy of paroxetine in alleviating the symptoms: a retrospective study. Sci Rep 2023; 13:18007. [PMID: 37865675 PMCID: PMC10590436 DOI: 10.1038/s41598-023-45401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/19/2023] [Indexed: 10/23/2023] Open
Abstract
The aim of this study was to investigate the clinical characteristics, psychological status, sleep quality, and quality of life of patients with functional anorectal pain (FAP). The study also assessed the treatment efficacy of paroxetine in alleviating FAP symptoms. A retrospective comparative study of forty-three patients with FAP who were first treated with an anal plug compound glycolate suppository versus paroxetine combined with anal plug compound glycolate suppository between November 2021 and August 2022. Pain, quality of life, depression, anxiety and sleep quality were assessed before and after treatment by the Chinese version of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2), Health-related quality of life scale (The 12-Item Short-Form Health Survey, SF-12), 17-item Hamilton Depression Rating Scale (HDRS), 14-item Hamilton Anxiety Scale (HAMA), and Pittsburgh Sleep Quality Index (PSQI). A total of 46.5% of patients with FAP were found to have anxiety symptoms (HAMA ≥ 7), 37.2% of patients with FAP were found to have depressive symptoms (HDRS ≥ 8). A total of 32.6% of patients with FAP had sleep disorders (PSQI > 10). Within 1 week after drug withdrawal, the short-term efficacy rate of oral paroxetine was 95.5%. After treatment, the symptom pain score (VAS) and sleep score were lower than those before treatment (P < 0.01). In the areas of vitality (VT), Social Functioning (SF), and Mental Health (MH), the difference between the pre-treatment and 8 weeks posttreatment scores of the study group and the control group was statistically significant (P < 0.05). FAP patients have obvious symptoms of anxiety and depression, and the incidence of sleep disturbance is prevalent. Paroxetine, a typical serotonin reuptake inhibitor (SSRI), was able to alleviate depression, anxiety, and pain symptoms in FAP, which might have clinical application prospects.
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Affiliation(s)
- Mingfeng Fan
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Laian Li
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Xiangjun Xu
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Cong Zhou
- Department of Psychology, Affiliated Hospital of Jining Medical University, Jining, China
- School of Mental Health, Jining Medical University, Jining, China
| | - Peng Wang
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Wanbin Yin
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Wenju Pei
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Shuai Wang
- Department of Anorectal Surgery, Affiliated Hospital of Jining Medical University, Jining, China.
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Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Gómez-Escudero O, Amieva-Balmori M, Gómez-Castaños PC, Charúa-Guindic L, Icaza-Chávez ME, López-Colombo A, Morel-Cerda EC, Pérez Y López N, Rodríguez-Leal MC, Salgado-Nesme N, Sánchez-Avila MT, Valdovinos-García LR, Vergara-Fernández O, Villar-Chávez AS. The Mexican consensus on fecal incontinence. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:404-428. [PMID: 38097437 DOI: 10.1016/j.rgmxen.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 01/01/2024]
Abstract
Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City, Mexico
| | - K R García-Zermeño
- Gastroenterología y Motilidad Digestiva, CIGMA, Boca del Río, Veracruz, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles de Puebla, Puebla, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - L Charúa-Guindic
- Práctica privada, Coloproctología del Hospital Ángeles Lomas, Mexico City, Mexico
| | - M E Icaza-Chávez
- Hospital Christus Muguerza Faro del Mayab, Mérida, Yucatán, Mexico
| | - A López-Colombo
- UMAE Hospital de Especialidades, Centro Médico Nacional Manuel Ávila Camacho, IMSS Puebla, Puebla, Mexico
| | - E C Morel-Cerda
- Laboratorio de Motilidad Gastrointestinal, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - M C Rodríguez-Leal
- Hospital Ángeles Valle Oriente, IMSS UMAE 25, Monterrey, Nuevo León, Mexico
| | - N Salgado-Nesme
- Departamento de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City,Mexico
| | - M T Sánchez-Avila
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | - L R Valdovinos-García
- Laboratorio de Motilidad Gastrointestinal Fundación Clínica Médica Sur, Mexico City, Mexico
| | - O Vergara-Fernández
- Departamento de Cirugía Colorrectal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, Mexico
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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25
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Shah ED, Curley MA, Ostler TL, Greeley ARB, Martinez-Camblor P, Chey WD. Empiric Pelvic Rehabilitation Delivered by Pelvic Floor Physical Therapists as an Up-Front Treatment for Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:2415-2417. [PMID: 35934289 DOI: 10.1016/j.cgh.2022.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/30/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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Mazor Y, Schnitzler M, Jones M, Ejova A, Malcolm A. The patient with obstructed defecatory symptoms: Management differs considerably between physicians and surgeons. Neurogastroenterol Motil 2023; 35:e14592. [PMID: 37036403 DOI: 10.1111/nmo.14592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/19/2023] [Accepted: 03/23/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be impacted by this choice of referral. METHODS An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient. KEY RESULTS A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre-treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele. CONCLUSIONS & INFERENCES Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.
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Affiliation(s)
- Yoav Mazor
- Neurogastroenterology Unit, Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Margaret Schnitzler
- Department of Colorectal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Head of Northern Clinical School, University of Sydney, New South Wales, Australia
| | - Michael Jones
- School of Psychological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Anastasia Ejova
- School of Psychological Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
- School of Psychology, University of Adelaide, Adelaide, Australia
| | - Allison Malcolm
- Neurogastroenterology Unit, Department of Gastroenterology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Steurbaut L, Levy EI, De Geyter C, Buyse S, Vandenplas Y. A narrative review on the diagnosis and management of constipation in infants. Expert Rev Gastroenterol Hepatol 2023; 17:769-783. [PMID: 37501219 DOI: 10.1080/17474124.2023.2242255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Functional constipation is one of the common disorders of gut-brain interaction in infancy, and decreases the quality of life of infants and parents. AREAS COVERED Relevant articles up to November 2022 were reviewed. We searched in PubMed, Google Scholar, and MEDLINE for guidelines, position papers, reviews, and randomized controlled trials on infant constipation. EXPERT OPINION Randomized controlled trials in this specific age group are mostly limited to trials with infant formula. The prevalence of infant constipation in formula-fed infants is decreasing, and can be associated with adaptations in formula composition. While the supplementation of infant formula with pro-, pre- and/or synbiotics decreases the prevalence of constipation, their efficacy in constipated infants is disappointing. There is limited evidence to support the addition of magnesium to infant formula to treat constipation. The evidence for the efficacy and safety of polyethylene glycol in children < 2 years has expanded over the past years. The administration of lactulose or polyethylene glycol is the preferred medical management, in case nutritional management does result in insufficient improvement.
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Affiliation(s)
- Laurine Steurbaut
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Elvira Ingrid Levy
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
- Department of Pediatrics, C.H.U. Saint-Pieter, Free University of Brussels, Brussels, Belgium
| | - Charlotte De Geyter
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | | | - Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
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28
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Zhou W, Triadafilopoulos G, Gurland B, Halawi H, Becker L, Garcia P, Nguyen L, Miglis M, Muppidi S, Sinn D, Jaradeh S, Neshatian L. Differential Findings on Anorectal Manometry in Patients with Parkinson's Disease and Defecatory Dysfunction. Mov Disord Clin Pract 2023; 10:1074-1081. [PMID: 37476327 PMCID: PMC10354598 DOI: 10.1002/mdc3.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/22/2023] [Accepted: 04/15/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Gastrointestinal dysfunction, particularly constipation, is among the most common non-motor manifestations in Parkinson's Disease (PD). We aimed to identify high-resolution anorectal manometry (HR-ARM) abnormalities in patients with PD using the London Classification. Methods We conducted a retrospective review of all PD patients at our institution who underwent HR-ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex-specific normal values, HR-ARM recordings were re-analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. Results 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69-74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto-anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Conclusion Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.
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Affiliation(s)
- Wendy Zhou
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - George Triadafilopoulos
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Brooke Gurland
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Houssam Halawi
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Laren Becker
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Patricia Garcia
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Linda Nguyen
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Mitchell Miglis
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Srikanth Muppidi
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Dong‐In Sinn
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Safwan Jaradeh
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Leila Neshatian
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
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29
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Chey WD. Utility of Anorectal Testing to Predict Outcomes With Pelvic Floor Physical Therapy in Chronic Constipation: Pragmatic Trial. Clin Gastroenterol Hepatol 2023; 21:1070-1081. [PMID: 35640864 DOI: 10.1016/j.cgh.2022.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a clinical trial that aimed to inform the clinical utility of anorectal manometry (ARM) and balloon expulsion time (BET) as up-front tests to predict outcomes with community-based pelvic floor physical therapy as the next best step to address chronic constipation after failing an empiric trial of soluble fiber supplementation or osmotic laxatives. METHODS We enrolled 60 treatment-naïve patients with Rome IV functional constipation failing 2 weeks of soluble fiber supplementation or osmotic laxatives. All patients underwent ARM/BET (London protocol) followed by community-based pelvic floor physical therapy. Outcomes were assessed at baseline and 12 weeks. The primary end point was clinical response (Patient Assessment of Constipation-Symptoms instrument). RESULTS Fifty-three patients completed pelvic rehabilitation and the post-treatment questionnaire. Contemporary frameworks define dyssynergia on balloon expulsion time and dyssynergic patterns (ARM), but these parameters did not inform clinical outcomes (area under the curve [AUC], <0.6). Squeeze pressure (>192.5 mm Hg on at least 1 of 3 attempts; sensitivity, 47.6%; specificity, 83.9%) and limited squeeze duration (inability to sustain 50% of squeeze pressure for >20 seconds; sensitivity, 71.4%; specificity, 58.1%) were the strongest predictors of clinical outcomes. Combining BET with squeeze duration (BET greater than 6.5 seconds and limited squeeze duration) improved predictive accuracy (AUC, 0.75; 95% CI, 0.59-0.90). BET poorly predicted outcomes as a single test (AUC, 0.54; 95% CI, 0.38-0.69). CONCLUSIONS Using ARM to evaluate squeeze profiles, rather than dyssynergia, appears useful to screen patients with chronic constipation for up-front pelvic floor physical therapy based on likelihood of response. BET appears noninformative as a single screening test (ClinicalTrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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30
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Oliveira LCC. EVACUATION DISORDERS. CAN WE MAKE A BETTER JOB? ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:161-162. [PMID: 37556740 DOI: 10.1590/s0004-2803.202302000-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Lucia Camara Castro Oliveira
- Director of Anorectal Physiology - CEPEMED - Rio de Janeiro and colorectal surgeon Hospital Casa de Saude São José, Rio de Janeiro. Research fellow of Cleveland Clinic Florida, USA. International fellow of American Society of Colon and Rectal Surgeons. Titular member of Brazilian College of Surgeons and Brazilian Colorectal Society
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31
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Harris A, Siegel CA, Chey WD. An Office-Based, Point-of-Care Test Predicts Treatment Outcomes With Community-Based Pelvic Floor Physical Therapy in Patients With Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:1082-1090. [PMID: 35341952 DOI: 10.1016/j.cgh.2022.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rectal evacuation disorders are common among constipated patients. We aimed to evaluate the accuracy of an investigational point-of-care test (rectal expulsion device [RED]) to predict outcomes with community-based pelvic floor physical therapy. METHODS We enrolled patients meeting Rome IV criteria for functional constipation failing fiber/laxatives for more than 2 weeks. RED was inserted and self-inflated, and then time-to-expel was measured in a left lateral position. All patients underwent empiric community-based pelvic floor physical therapy in routine care with outcomes measured at 12 weeks. The primary end point was global clinical response (Patient Assessment of Constipation Symptoms score reduction, >0.75 vs baseline). Secondary end points included improvement in health-related quality-of-life (Patient Assessment of Constipation Quality of Life score reduction, >1.0) and complete spontaneous bowel movement frequency (Food and Drug Administration complete spontaneous bowel movement responder definition). RESULTS Thirty-nine patients enrolled in a feasibility phase to develop the use-case protocol. Sixty patients enrolled in a blinded validation phase; 52 patients (mean, 46.9 y; 94.2% women) were included in the intention-to-treat analysis. In the left lateral position, RED predicted global clinical response (generalized area under the curve [gAUC], 0.67; 95% CI, 0.58-0.76]), health-related quality-of-life response (gAUC, 0.67; 95% CI, 0.58-0.77; P < .001), and complete spontaneous bowel movement response (gAUC, 0.63; 95% CI, 0.57-0.71; P < .001). As a screening test, a normal RED effectively rules out evacuation disorders (expected clinical response, 8.9%; P = .042). Abnormal RED in the left lateral position (defined as expulsion within 5 seconds or >120 seconds) predicted 48.9% clinical response to physical therapy. A seated maneuver enhanced the likelihood of clinical response (71.1% response with seated RED retained >13 seconds) but likely is unnecessary in most settings. CONCLUSIONS RED offers an opportunity to disrupt the paradigm by offering a personalized approach to managing chronic constipation in the community (Clinicaltrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | | | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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Fawaz SI, Elshatby NM, El-Tawab SS. The effect of spinal magnetic stimulation on the management of functional constipation in adults. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2023. [DOI: 10.1186/s43166-023-00184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Abstract
Background
Functional constipation is a type of functional bowel disorder characterized by difficult defecation with a sense of incomplete evacuation. It is a common disorder with an increasing prevalence, and the underlying cause is poorly identified. Nonpharmacological management of functional constipation includes lifestyle and dietary modification, regular physical activity, advice about toileting posture, and behavioral therapy. Biofeedback training as part of the behavioral training showed great efficacy with long-term results. Spinal magnetic stimulation is the application of extracorporeal magnetic stimuli to the spinal nerves and deep pelvic muscles to enhance bowel evacuation without surgical drawbacks. This study was designed to enhance bowel elimination in functional constipation patients through the dual effect of biofeedback and spinal magnetic stimulation. This work aimed to study the efficacy of spinal magnetic stimulation and biofeedback training versus biofeedback alone in the management of functional constipation.
Results
There was a statistically significant difference between before and after the intervention in both studied groups regarding the mean weekly spontaneous bowel movement, a Numerical Rating Scale for pain assessment, and the Patient Assessment of Constipation Quality of Life questionnaire. When comparing the two groups after the intervention, the spinal magnetic stimulation showed superiority in the mean weekly spontaneous bowel movement and manometric anal pressure at rest.
Conclusions
Spinal magnetic stimulation in addition to biofeedback pelvic floor muscle training could increase the mean weekly complete spontaneous bowel movements and manometric anal pressure at rest in patients with functional constipation. It did not show any additive benefits in improving pain during defecation or patient quality of life.
Trial registration
ClinicalTrials.gov, 0305398. https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BQ0H&selectaction=Edit&uid=U0004JW0&ts=2&cx=-xmnims
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Bae SH. Dyssynergic Defecation in Chronically Constipated Children in Korea. Pediatr Gastroenterol Hepatol Nutr 2023; 26:127-133. [PMID: 36950062 PMCID: PMC10025570 DOI: 10.5223/pghn.2023.26.2.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/07/2022] [Accepted: 02/08/2023] [Indexed: 03/24/2023] Open
Abstract
Purpose Dyssynergic defecation (DSD) is one of the important causes of chronic constipation in children. We aimed to analyze the clinical features, diagnostic test results, and treatments for DSD in children. Methods Children diagnosed with DSD using fluoroscopic defecography were enrolled in this study. Clinical data, including the results of colon transit time (CTT) test and biofeedback (BF) therapy, were collected from medical records retrospectively. Results Nineteen children were enrolled. The median age was 9 years (6-18 years), the median frequency of bowel movement was 1/7 days (1-10 days), the median duration of constipation was 7.0 years (2-18 years), the median age of onset of constipation was 2.5 years (1-11 years). In the CTT test, outlet obstruction type was noted in 10/18 (55.6%), slow transit type in 5/18 (27.8%), and normal transit in 1/18 (5.6%). The median CTT was 52 hours (40-142 hours). Initial medical therapy was performed with the polyethylene glycol 4000, and the response was good in 9/19 (47.4%), fair in 9/19 (47.4%), and poor in 1/19 (5.0%). BF was performed in 8/19, with good results in 6/8 (75.0%) children and failure in 2/8 (25.0%) children. After long-term medical therapy (11/19), 3/5 showed good response with medication alone, 6/8 showed good response with BF and medication combined. Conclusion DSD should be considered as a cause of chronic constipation in children, especially in those with abnormal CTT test results. BF combined with medical therapy is effective even with age-limited cooperation.
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Affiliation(s)
- Sun Hwan Bae
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
- Department of Pediatrics, School of Medicine, Konkuk University, Seoul, Korea
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34
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Atkins M, Burton Murray H, Staller K. Assessment and management of disorders of gut-brain interaction in patients with eating disorders. J Eat Disord 2023; 11:20. [PMID: 36782302 PMCID: PMC9926752 DOI: 10.1186/s40337-022-00731-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/28/2022] [Indexed: 02/15/2023] Open
Abstract
Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).
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Affiliation(s)
- Micaela Atkins
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA. .,Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.
| | - Helen Burton Murray
- Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, 02215, USA
| | - Kyle Staller
- Division of Gastroenterology, Center for Neurointestinal Health, Massachusetts General Hospital, 55 Fruit Street, Wang 5, Boston, MA, 02114, USA.,Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
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Differences in Anorectal Manometry Values Among Women With Fecal Incontinence in a Racially, Ethnically, and Socioeconomically Diverse Population. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:244-251. [PMID: 36735440 DOI: 10.1097/spv.0000000000001324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Anorectal manometry (ARM) is a valuable diagnostic and therapeutic tool that can both aid in identifying mechanisms contributing to fecal incontinence (FI) and inform management strategies. Consensus on standard reference range values has not been established, and women of varying racial and ethnic backgrounds are not well-represented in the current literature. OBJECTIVE We aimed to compare ARM values between women of different racial and ethnic groups with FI. STUDY DESIGN We conducted a retrospective cross-sectional study of women with FI who underwent ARM at a tertiary health system in an urban underserved community between 2016 and 2021. Demographic information and ARM values were collected from the medical record. Socioeconomic status (SES) was represented by the percent of the population living below the poverty line according to zip code using U.S. census data. Anorectal manometry values were compared between racial and ethnic groups, and multivariable logistic regression was conducted to control for patient characteristics. RESULTS Fifty-eight women were included in the analysis: 33% Hispanic, 22% Black, and 45% White. Hispanic and Black women had higher body mass index and higher rates of diabetes and loose stools and were of significantly lower SES compared with White women. Black and Hispanic women had significantly lower thresholds for volume at first sensation and higher mean anal squeeze pressure. Differences were maintained after controlling for body mass index, diabetes, SES, and diarrhea (P = 0.03 and P = 0.01, respectively). Other ARM values were not significantly different between groups. CONCLUSIONS Racial and ethnic differences in ARM values among women with FI exist. Further studies are needed to determine whether these differences have an impact on symptom severity, treatment selection and outcomes, and patient satisfaction.
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Li F, Wang M, Shah SHA, Jiang Y, Lin L, Yu T, Tang Y. Clinical Characteristics of Adult Functional Constipation Patients with Rectoanal Areflexia and Their Response to Biofeedback Therapy. Diagnostics (Basel) 2023; 13:diagnostics13020255. [PMID: 36673065 PMCID: PMC9857652 DOI: 10.3390/diagnostics13020255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Background: The London Classification for anorectal physiological dysfunction specifically proposes rectoanal areflexia (RA), which means the absence of a rectoanal inhibitory reflex (RAIR) based on a manometric diagnosis. Although RA is not observed in healthy people, it can be found in adult patients with functional constipation (FC). This study describes the clinical manifestations of adult patients with FC and RA and their response to biofeedback therapy (BFT). Methods: This retrospective study reviewed the reports of high-resolution anorectal manometry (HR-ARM) and the efficacy of BFT in adult patients with FC. In addition, the Constipation Scoring System (CSS) scale, Patient Assessment of Constipation Symptoms (PAC-SYM) scale, Patient Assessment of Constipation Quality of Life (PAC-QOL) scale, Zung’s Self-Rating Anxiety Scale (SAS), Zung’s Self-Rating Depression Scale (SDS), balloon expulsion test (BET), and the use of laxatives were assessed. Results: A total of 257 adult patients diagnosed with FC were divided into the RA group (n = 89) and the RAIR group (n = 168). In the RA and RAIR groups, 60 (67.4%) and 117 (69.6%) patients, respectively, had dyssynergic defecation (DD) during simulated defecation. Type II pattern of dyssynergia was most frequently observed in both groups. Compared with the RA group, the RAIR group showed a higher CSS score, physical discomfort score, and prevalence of inadequate relaxation of the anal sphincter (p < 0.001, p = 0.036, and p = 0.017, respectively). The anxiety and depression scores were not different between the two groups. The proportion of patients using volumetric and stimulant laxatives and their combination was significantly higher in FC patients with RA, whereas the efficacy of BFT was significantly lower (p = 0.005, p < 0.001, p = 0.045, and p = 0.010, respectively). Conclusion: Adult FC patients with RA may suffer more severe constipation and have a lower efficacy of BFT compared with those with RAIR.
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Affiliation(s)
| | | | | | | | | | - Ting Yu
- Correspondence: (T.Y.); (Y.T.)
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Myofascial Pelvic Pain: Best Orientation and Clinical Practice. Position of the European Association of Urology Guidelines Panel on Chronic Pelvic Pain. Eur Urol Focus 2023; 9:172-177. [PMID: 35945131 DOI: 10.1016/j.euf.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/20/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
CONTEXT Despite the high prevalence of a myofascial pain component in chronic pelvic pain (CPP) syndromes, awareness and management of this component are lacking among health care providers. OBJECTIVE To summarize the current state of the art for the management of myofascial pain in chronic primary pelvic pain syndromes (CPPPS) according to scientific research and input from experts from the European Association of Urology (EAU) guidelines panel on CPP. EVIDENCE ACQUISITION A narrative review was undertaken using three sources: (1) information in the EAU guidelines on CPP; (2) information retrieved from the literature on research published in the past 3 yr on myofascial pelvic pain; and (3) expert opinion from panel members. EVIDENCE SYNTHESIS Studies confirm a high prevalence of a myofascial pain component in CPPPS. Examination of the pelvic floor muscles should follow published recommendations to standardize findings and disseminate the procedure. Treatment of pelvic floor muscle dysfunction and pain in the context of CPP was found to contribute to CPP control and is feasible via different physiotherapy techniques. A multidisciplinary approach is the most effective. CONCLUSIONS Despite its high prevalence, the myofascial component of CPP has been underevaluated and undertreated to date. Myofascial pain must be assessed in all patients with CPPPS. Treatment of the myofascial pain component is relevant for global treatment success. Further studies are imperative to reinforce and better define the role of each physiotherapy technique in CPPPS. PATIENT SUMMARY Pain and inflammation of the body's muscle and soft tissues (myofascial pain) frequently occurs in pelvic pain syndromes. Its presence must be evaluated to optimize management for each patient. If diagnosed, myofascial pain should be treated.
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Lan N, Smukalla STM, Chang S. Fecal Incontinence and Defecatory Disorders in Patients With Ileal Pouch-Anal Anastomosis. Gastroenterol Hepatol (N Y) 2023; 19:41-47. [PMID: 36865815 PMCID: PMC9972658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Functional anorectal disorders are common in patients with ileal pouch-anal anastomosis (IPAA) and often have a debilitating impact on quality of life. The diagnosis of functional anorectal disorders, including fecal incontinence (FI) and defecatory disorders, requires a combination of clinical symptoms and functional testing. Symptoms are generally underdiagnosed and underreported. Commonly utilized tests include anorectal manometry, balloon expulsion test, defecography, electromyography, and pouchoscopy. The treatment for FI begins with lifestyle modifications and medications. Sacral nerve stimulation and tibial nerve stimulation have been trialed on patients with IPAA and FI, resulting in improvement in symptoms. Biofeedback therapy has also been used in patients with FI but is more commonly utilized in defecatory disorders. Early diagnosis of functional anorectal disorders is important because a response to treatment may significantly improve a patient's quality of life. To date, there is limited literature describing the diagnosis and treatment of functional anorectal disorders in patients with IPAA. This article focuses on the clinical presentation, diagnosis, and treatment of FI and defecatory disorders in patients with IPAA.
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Affiliation(s)
- Nan Lan
- 1Department of Gastroenterology, Columbia University Irving Medical Center, New York, New York
| | - Scot t M. Smukalla
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
| | - Shannon Chang
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
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Zhang Z, Cheng Y, Ju J, Shen W, Pan Z, Zhou Y. Analysis of the efficacy of biofeedback for faecal incontinence after surgery for anorectal malformation. Ann Med 2022; 54:2385-2390. [PMID: 36039487 PMCID: PMC9448432 DOI: 10.1080/07853890.2022.2114607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the therapeutic effects of biofeedback in the treatment of faecal incontinence (FI) after surgery for anorectal malformation (ARM). METHODS Clinical data were collected from paediatric patients for postoperative biofeedback due to FI caused by ARM between May 2017 and November 2021. The data included the duration of symptoms, the integrity of the anal sphincter, anorectal manometry parameters, and FI scores. These patients were divided into the low ARM group (group A) and the high ARM group (group B). RESULTS A total of 45 paediatric patients were enrolled in the study. There were 28 cases in group A and 17 cases in group B. The differences in age, gender, and body weight were not statistically significant between the two groups (p > 0.05). The differences in the clinical indicators were also not statistically significant between the two groups at the time of the initial evaluation. The duration of symptoms was 2.21 ± 0.71 years and 4.14 ± 1.89 years in groups A and B. There were 16 cases with an intact anal sphincter in group A and only two cases with an intact anal sphincter in group B. This difference was statistically significant between the two groups (p < .05). The anal resting pressure, initial sensitivity threshold, defaecation sensitivity threshold, defaecation urge threshold, and FI scores were significantly improved in both groups post-treatment compared to pre-treatment (p < .001). Strong impulses improved significantly in group A, while strong impulses did not improve significantly in group B. The multivariate logistic regression analysis with these variables further showed that symptom duration and anal sphincter integrity were the main factors influencing the therapeutic effects of biofeedback. CONCLUSION Biofeedback plays a positive role in the treatment of FI in paediatric patients following surgery for ARM. Symptom duration and anal sphincter integrity were found to be the main factors influencing the therapeutic effect of biofeedback.
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Affiliation(s)
- Zhenqiang Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Yuan Cheng
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Junjun Ju
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Weichen Shen
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Zhubin Pan
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Yuliang Zhou
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
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40
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Rectal Intussusception: Medical management and timing of the decision to operate. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Igualada-Martinez P, Breslin E, Higgins D, Hainsworth A. Physiotherapy management of anorectal dysfunction. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Neshatian L, Karmonik C, Khavari R, Shi Z, Elias S, Boone T, Quigley EMM. Alterations in brain activation patterns in women with functional defecatory disorder: A novel fMRI rectal balloon expulsion study. Neurogastroenterol Motil 2022; 34:e14389. [PMID: 35478218 DOI: 10.1111/nmo.14389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/09/2022] [Accepted: 04/11/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Functional defecatory disorders (FDD) are common among women. Despite the extensive research on peripheral mechanisms involved in FDD, the central-neural contribution to its pathophysiology remains poorly understood. We aimed to delineate specific supra-spinal regions involved in defecation and examine whether their activity, as measured by blood-oxygen-level-dependent (BOLD) signals, is different in FDD. METHODS We performed functional MRI (fMRI) with concurrent rectal manometry in 15 controls and 18 females with ROME III diagnosis of FDD. A block design was used and brain activation maps based on BOLD effect employing the generalized linear model were calculated for each subject. Statistical significance between groups was assessed by a Student t-test with cluster-based multiple comparisons correction (corrected p < 0.01). KEY RESULTS Simulated defecation was associated with activation of regions of primary and supplementary motor (SMA) and somatosensory cortices, homeostatic afferent (thalamus, mid-cingulate cortex, and insula), and emotional arousal networks (hippocampus and prefrontal cortex), occipital and cerebellum along with deactivation of right anterior cingulate cortex (ACC) in controls. Women with FDD had fewer regions engaged in defecation and BOLD activation was much decreased is areas related to executive-cognitive function (insula, parietal, and prefrontal cortices). Patients unlike controls showed activation in right ACC and otherwise had similar brain activation patterns during anal squeeze. CONCLUSIONS & INFERENCES Our results provide evidence that distinct differences exist in supra-spinal control of defecation in key regions of motivational-affective regulation and executive-cognitive function, in patients with FDD as compared to controls.
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Affiliation(s)
- Leila Neshatian
- Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Christof Karmonik
- Translational Imaging Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Zhaoyue Shi
- Translational Imaging Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Saba Elias
- Translational Imaging Center, Houston Methodist Research Institute, Houston, Texas, USA
| | - Timothy Boone
- Department of Urology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
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Diagnosis and Management of Functional Pouch Disorders: A Systematic Review. Dis Colon Rectum 2022; 65:S113-S118. [PMID: 36399771 DOI: 10.1097/dcr.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Functional disorders impart significant morbidity in patients with inflammatory bowel disease who undergo restorative proctocolectomy. OBJECTIVE This systematic review aimed to summarize the management strategies for various functional disorders of the pouch. DATA SOURCES A database search of PubMed was conducted to identify relevant clinical studies assessing the management of various functional disorders in patients who underwent restorative proctocolectomy. STUDY SELECTION Published clinical studies investigating a functional disorder of the pouch in patients who previously underwent a colectomy with ileal pouch-anal anastomosis. INTERVENTIONS Restorative proctocolectomy was completed in patients with inflammatory bowel disease or other indications such as a diagnosis of familial adenomatous polyposis. MAIN OUTCOME MEASURES The primary outcomes described in this review include the prevalence of functional disorders of the pouch in patients undergoing restorative proctocolectomy and the relevant management strategies. RESULTS Ten clinical studies were identified using the predetermined search terms and screened for relevancy to patients with inflammatory bowel disease who previously underwent colectomy with ileal pouch-anal anastomosis. A qualitative summary was developed on the basis of data from these studies and from current guidelines developed for the management of inflammatory bowel disease. LIMITATIONS This systematic review is limited by the small number and low quality of the clinical studies included as well as the nonquantitative summary of the findings. CONCLUSIONS Functional disorders of the pouch are likely underdiagnosed. Although a source of significant morbidity, these diseases require additional clinical studies to better elucidate effective management strategies.
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Lanas A, García-Rayado G. Editorial: Insights in gastroenterology: 2021. Front Med (Lausanne) 2022; 9:1008157. [PMID: 36160135 PMCID: PMC9493470 DOI: 10.3389/fmed.2022.1008157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Angel Lanas
- Department of Medicine, University of Zaragoza, Zaragoza, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain
- Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
| | - Guillermo García-Rayado
- Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, Zaragoza, Spain
- *Correspondence: Guillermo García-Rayado
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Choudhary A, Vollebregt PF, Aziz Q, Scott SM, Fikree A. Rectal hyposensitivity: a common pathophysiological finding in patients with constipation and associated hypermobile Ehlers-Danlos syndrome. Aliment Pharmacol Ther 2022; 56:802-813. [PMID: 35758859 PMCID: PMC9541572 DOI: 10.1111/apt.17104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS To evaluate symptom presentation and underlying pathophysiology of colonic/anorectal dysfunction in females with functional constipation (FC) and hypermobile Ehlers-Danlos syndrome (hEDS)/hypermobility spectrum disorder (HSD) METHODS: Case-control study of 67 consecutive female patients with an established diagnosis of hEDS/HSD referred to a specialist centre for investigation of FC (Rome III criteria), age-matched (1:2 ratio) to 134 female controls with FC scoring 0 on the validated 5-point joint hypermobility questionnaire. Symptoms and results of colonic/anorectal physiology testing were compared. An independent series of 72 consecutive females with hEDS/HSD, referred to a separate hospital for investigation of FC, was used to validate physiological findings. RESULTS Females with hEDS/HSD were more likely to report constipation for ≥ 5 years (76.1% vs. 61.2%, p = 0.035), and a greater proportion had a high Cleveland Clinic constipation score (≥12: 97.0% vs. 87.3%; p = 0.027). The proportions with delayed whole-gut transit were similar between groups (35.3% vs. 41.7%; p = 0.462), as were the proportions with functional or structural abnormalities on defaecography (functional: 47.8% vs. 36.6%; p = 0.127; structural: 65.7% vs. 66.4%; p = 0.916). However, rectal hyposensitivity was more common in those with hEDS/HSD (43.3% vs. 20.1%; p = 0.0006); this was confirmed in the validation cohort (rectal hyposensitivity: 45.8%). CONCLUSIONS Rectal hyposensitivity is a common pathophysiological factor in females with FC and hEDS/HSD as confirmed in two separate cohorts. The rectal hyposensitivity may be due to altered rectal biomechanics/neuronal pathway dysfunction. Management may be better focused on enhancement of sensory perception (e.g., sensory biofeedback).
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Affiliation(s)
- Anisa Choudhary
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK,GI Physiology UnitBarts Health NHS TrustLondonUK
| | - Paul F. Vollebregt
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK,GI Physiology UnitBarts Health NHS TrustLondonUK
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK,The Princess Grace HospitalHCA HealthcareLondonUK
| | - S. Mark Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK,GI Physiology UnitBarts Health NHS TrustLondonUK
| | - Asma Fikree
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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Vollebregt PF, Wiklendt L, Burgell RE, Chaichanavichkij P, Dinning PG, Knowles CH, Scott SM. Abnormal Perception of Urge to Defecate: An Important Pathophysiological Mechanism in Women With Chronic Constipation. Am J Gastroenterol 2022; 117:1125-1136. [PMID: 35435855 DOI: 10.14309/ajg.0000000000001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/13/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although the association of absent or attenuated "call to stool" with constipation is well-recognized, no studies have systematically evaluated the perception of urge to defecate in a well-defined cohort of patients with chronic constipation (CC). METHODS A prospective study of 43 healthy adult women and 140 consecutive adult women attending a tertiary center for investigation of CC. All participants completed a 5-day viscerosensory questionnaire, and all women with CC also underwent anorectal physiologic investigations. Normal urge perception and abnormal urge perception were defined using a Naive Bayes model trained in healthy women (95% having normal urge). RESULTS In total, 181 toilet visits in healthy women and 595 in women with CC were analyzed. Abnormal urge perception occurred in 70 (50.0%) women with CC. In this group, the urge to defecate was more often experienced as abdominal sensation (69.3% vs 41.4%; P < 0.0001), and the viscerosensory referral area was 81% larger (median pixels anterior: 1,849 vs 1,022; P < 0.0001) compared to women with CC and normal urge perception. Abnormal (vs normal) urge in women with CC was associated with more severe constipation (Cleveland Clinic constipation score: 19 vs 15 P < 0.0001), irritable bowel syndrome (45.7% vs 22.9% P < 0.0001), and a functional evacuation disorder on defecography (31.3% vs 14.3% P = 0.023). A distinct pattern of abnormal urge was found in women with CC and rectal hyposensitivity. DISCUSSION Abnormal urge perception was observed in 50% of women with CC and was frequently described as abdominal sensation, supporting the concept that sensory dysfunction makes an important contribution to the pathophysiology of constipation.
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Affiliation(s)
- Paul F Vollebregt
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
| | - Lukasz Wiklendt
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Rebecca E Burgell
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Pam Chaichanavichkij
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, Australia
| | - Charles H Knowles
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
| | - S Mark Scott
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
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Sahid S, Bin Kamarulzaman MY, Mustafa JB, Sahid NA, Bin Mohamed Kamil NA. Biofeedback therapy for anorectal functional disorder: Malaysian colorectal tertiary centre experience. Ann Med Surg (Lond) 2022; 79:103848. [PMID: 35860081 PMCID: PMC9289252 DOI: 10.1016/j.amsu.2022.103848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Anorectal functional disorder encompasses arrays of conditions including Obstructive Defecation Syndrome (ODS) and Fecal Incontinence (FI). Biofeedback Therapy (BFT) serves as first line therapy to re-train pelvic floor coordination, rectal sensation and strengthening pelvic floor muscle. The aim of this study is determining the efficacy of BFT in our centre. Methods This is a retrospective observational cohort study of patients attended biofeedback therapy session from January 2013 to December 2018. Descriptive statistic was used to analyse the data. Result Total 99 patients with mean age of 44.6 ± 18.1 with female 56% (n = 55) and male 44% (n = 44) attended BFT session. Overall, 77 had CC (77%) and 23 (23%) had FI. Mean number of sessions was 11.8. Overall improvement rate 42 (42%), no improvement 32 (32%) and defaulted 26 (26%). In patients with CC, 32 (41.6%) had improvement in symptoms, 23 (29.9%) had no improvements, 22 (28.6%) defaulted BFT. Patients with FI, 7 (30.4%) had Obstetric Sphincter Injury, 7 (30.4%) had traumatic anal injury, 3 (13.0%) has Low Anterior Resection Syndrome, 2 (8.7%) had sphincter injury following anal sepsis, 2 (13.0%) had rectocele repair and 1 (4.3%) were idiopathic. 9 patients (39.1%) had stoma created. Overall response rate was: 10 patients (43.5%) had improvement in symptoms, 9 patients (39.1%) had no improvement, 4 patients (17.4%) defaulted therapy. Conclusion Our outcome rate is lower compared to published due the limited access and logistic restrictions. This issue should be given great consideration such as broadening the service and training. Anorectal functional disorder encompasses arrays of conditions including Obstructive Defecation Syndrome (ODS) and Fecal Incontinence (FI). Biofeedback Therapy (BFT) serves as first line therapy to re-train pelvic floor coordination, rectal sensation and strengthening pelvic floor muscle. The aim of this study is determining the efficacy of BFT in our centre. This is a retrospective observational cohort study of patients attended biofeedback therapy session from January 2013 to December 2018. Total 100 patients with mean age of 44.6 ± 18.1 with female 56% (n = 56) and male 44% (n = 44) attended BFT session. Overall, 77 had CC (77%) and 23 (23%) had FI. Mean number of sessions was 11.8. Overall improvement rate 42 (42%), no improvement 32 (32%) and defaulted 26 (26%). In patients with CC, 32 (41.6%) had improvement in symptoms, 23 (29.9%) had no improvements, 22 (28.6%) defaulted BFT. Patients with FI, 7 (30.4%) had Obstetric Sphincter Injury, 7 (30.4%) had traumatic anal injury, 3 (13.0%) has Low Anterior Resection Syndrome, 2 (8.7%) had sphincter injury following anal sepsis, 2 (13.0%) had rectocele repair and 1 (4.3%) were idiopathic. 9 patients (39.1%) had stoma created. Overall response rate was: 10 patients (43.5%) had improvement in symptoms, 9 patients (39.1%) had no improvement, 4 patients (17.4%) defaulted therapy. Our outcome rate is lower compared to published due the limited access and logistic restrictions. This issue should be given great consideration such as broadening the service and training.
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Jiang Y, Wang Y, Tang Y, Lin L. Clinical value of positive BET and pelvic floor dyssynergia in Chinese patients with functional defecation disorder. Scand J Gastroenterol 2022; 57:775-782. [PMID: 35180039 DOI: 10.1080/00365521.2022.2039282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Functional defecation disorder (FDD) is a common subtype of functional constipation (FC). Balloon expulsion test (BET) and high resolution anorectal manometry (HR-ARM) are significant tools but their results are not always consistent. AIMS To investigate the characteristics of patients with positive BET and pelvic floor dyssynergia (PFD) and explore the value of both positive results in FDD diagnosis. METHODS We retrospectively diagnosed FC subtypes and enrolled FDD patients based on Rome-IV criteria. They underwent HR-ARM, BET and CTT tests. Then they were classified to two groups and further stratified by FDD subtypes. Validated questionnaires were applied to investigate patients' constipation, anxiety/depression and quality of life. RESULTS 335 FDD patients were finally enrolled. They were classified into two groups according to whether BET and PFD were both positive (consistent or not). 84.48% showed consistent results. These patients had significantly higher anal residual pressure, lower anal relaxation rate, manometric defecation index (MDI) and a more negative rectoanal pressure gradient (RAPG) (Ps < .05). The specific distribution of FDD phenotypes in two groups showed significant difference (p = .021). Males suffered a more negative RAPG (p < .001) and age was correlated with anal relaxation rate (p < .001). A subset (177 individuals) was investigated with validated questionnaires. Scores for Defecation Symptoms, Physical Discomfort and GAD-7 score were significantly high in Consistent Group (Ps < .05). GAD-7 score was associated with Defecation Symptoms (p < .001) while anal residual pressure, GAD-7 and Defecation Symptoms score were linked to Physical Discomfort (Ps < .05). The diagnostic specificity and PPV for FDD rose significantly with positive BET and PFD. CONCLUSION FDD patients with positive BET and PFD suffered from severe defecation symptoms, anxiety and impaired QOL. Positive BET and PFD could be an ideal tool for screening FDD.
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Affiliation(s)
- Ya Jiang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yan Wang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yurong Tang
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Lin
- Department of Gastroenterology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Khera AJ, Chase JW, Stillman BC, Salzberg M, Thompson AJV, Basnayake C, Wilson-O'Brien A, Kamm MA. Pelvic floor behavioral treatment for fecal incontinence and constipation in quiescent inflammatory bowel disease. Scand J Gastroenterol 2022; 57:807-813. [PMID: 35188055 DOI: 10.1080/00365521.2022.2039280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Refractory bowel symptoms in quiescent inflammatory bowel disease (IBD) are common but evidence for effective management is limited. We aimed to determine whether behavioral treatment, including pelvic floor muscle training, decreases the severity of functional bowel symptoms in patients with quiescent IBD. Secondary aims were to evaluate the treatment effect on quality of life, psychological well-being and pelvic floor muscle function. METHODS This prospective study included IBD patients in remission with persistent symptoms of fecal incontinence or constipation who received up to six sessions of behavioral treatment at monthly intervals. The primary outcome was patient-rated symptom improvement on a 7-point Likert scale (1 = substantially worse, 7 = substantially better). Secondary outcomes included validated symptom scores, quality-of-life, psychological measures, and transperineal ultrasound assessment of pelvic floor muscle activity. RESULTS Thirty-four patients (median age 38 years; 24 females; 18 ulcerative colitis, 13 Crohn's disease, 3 ileo-anal pouch) were included. Twenty-one of the 29 (72%) patients who completed treatment, or 21 of all 34 (62%) patients, reported moderate or substantial improvement (patient rating of 6 or 7). Symptom scores (p < .001), IBD-specific quality of life (p = .008) and illness perception scores (p = .003) significantly improved. General quality of life, and anxiety and depression scores, did not change significantly. Transperineal ultrasound pelvic floor measures did not correlate with patient-rating of symptom improvement. CONCLUSION Significant symptomatic improvement occurred in a majority of patients with quiescent IBD. Behavioral treatment should be considered for patients with quiescent IBD and ongoing functional bowel symptoms of fecal incontinence, fecal urgency, or constipation.
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Affiliation(s)
- Angela J Khera
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Janet W Chase
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia
| | - Barry C Stillman
- School of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Michael Salzberg
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Alexander J V Thompson
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Chamara Basnayake
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Amy Wilson-O'Brien
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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van Reijn-Baggen DA, Elzevier HW, Putter H, Pelger RCM, Han-Geurts IJM. Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Tech Coloproctol 2022; 26:571-582. [PMID: 35511322 PMCID: PMC9069957 DOI: 10.1007/s10151-022-02618-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/16/2022] [Indexed: 12/12/2022]
Abstract
Background A chronic anal fissure is a common, painful condition with great impact on daily life. The exact pathogenesis has not been fully elucidated and treatment varies. A large percentage of patients experience pelvic floor dysfunction (dyssynergia and increased pelvic floor muscle tone). The aim of our study was to investigate the effect of pelvic floor physical therapy in patients with chronic anal fissure. Methods Between December 2018 and July 2021, at the Proctos Clinic in the Netherlands, patients with chronic anal fissure and pelvic floor dysfunction were randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy including electromyographic biofeedback or assigned to a control group receiving postponed pelvic floor physical therapy. The primary outcome was muscle tone at rest during electromyographic registration of the pelvic floor before and after pelvic floor physical therapy. Secondary outcomes contained healing of the fissure, pain ratings, improvement of pelvic floor function, and complaint reduction measured with a proctology-specific patient-reported outcome measurement. Endpoints were measured at 8- and 20-week follow-up. Results One hundred forty patients were included in the study, 68 men (48.6%) and 72 women (51.4%) with a mean age of 44.5 ± 11.1 (range 19–79) years. Mean resting electromyographic values of the pelvic floor in the intervention group significantly improved from pre- to post-treatment (p < 0.001) and relative to controls (mean estimated difference between groups − 1.88 µV; 95% CI, − 2.49 to − 1.27 (p < 0.001) at first follow-up and remained significant from baseline at 20-week follow-up (p < 0.001). The intervention group performed better compared to the control group on all secondary outcomes, i.e., healing of the fissure (55.7% of the patients vs 21.4% in control, pain ratings (p < 0.001), diminished dyssynergia (p < 0.001), complaint reduction (p < 0.001), and decrease of pelvic floor muscle tone (p < 0.05) at first follow-up. Conclusions The findings of this study provide strong evidence that pelvic floor physical therapy is effective in patients with chronic anal fissure and pelvic floor dysfunction and supports its recommendation as adjuvant treatment besides regular conservative treatment.
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Affiliation(s)
- Daniëlle A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands. .,Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Henk W Elzevier
- Department of Urology and Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Putter
- Department of Biomedical Data Science, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rob C M Pelger
- Department of Urology, Leiden University Medical Centre, Leiden, The Netherlands
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