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O'Connor A, Liao D, Drewes AM, Sharma A, Vasant DH, McLaughlin J, Kiff E, Telford K. A comparison of function lumen imaging probe measurements of anal sphincter function in fecal incontinence. Neurogastroenterol Motil 2024; 36:e14791. [PMID: 38587047 DOI: 10.1111/nmo.14791] [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: 12/22/2023] [Revised: 02/14/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) is a test of anal sphincter distensibility under evaluation by specialist centers. Two measurement protocols termed "stepwise" and "ramp" are used, risking a lack of standardization. This study aims to compare the performance of these protocols to establish if there are differences between them. METHODS Patients with fecal incontinence were recruited and underwent measurement with both protocols at a tertiary pelvic floor referral unit. Differences in minimum diameter, FLIP bag pressure, and distensibility index (DI) at rest and during squeeze were calculated at various FLIP bag volumes. KEY RESULTS Twenty patients (19 female, mean age 61 [range: 38-78]) were included. The resting minimum diameter at 30 and 40 mL bag volumes were less in the stepwise protocol (mean bias: -0.55 mm and -1.18 mm, p < 0.05) along with the DI at the same bag volumes (mean bias: -0.37 mm2/mmHg and -0.55 mm2/mmHg, p < 0.05). There was also a trend towards greater bag pressures at 30 mL (mean bias: +2.08 mmHg, p = 0.114) and 40 mL (mean bias: +2.81 mmHg, p = 0.129) volumes in the stepwise protocol. There were no differences between protocols in measurements of minimum diameter, maximum bag pressure, or DI during voluntary squeeze (p > 0.05). CONCLUSION AND INFERENCES There are differences between the two commonly described FLIP measurement protocols at rest, although there are no differences in the assessment of squeeze function. Consensus agreement is required to agree the most appropriate FLIP measurement protocol in assessing anal sphincter function.
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Affiliation(s)
- Alexander O'Connor
- Department of General Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Donghua Liao
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Abhiram Sharma
- Department of General Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Dipesh H Vasant
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Edward Kiff
- Department of General Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karen Telford
- Department of General Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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2
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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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3
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Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [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] [Indexed: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Evans-Barns HME, Tien MY, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-Operative Anorectal Manometry in Children following Anorectal Malformation Repair: A Systematic Review. J Clin Med 2023; 12:jcm12072543. [PMID: 37048627 PMCID: PMC10094903 DOI: 10.3390/jcm12072543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Despite surgical correction, children with anorectal malformations may experience long-term bowel dysfunction, including fecal incontinence and/or disorders of evacuation. Anorectal manometry is the most widely used test of anorectal function. Although considerable attention has been devoted to its application in the anorectal malformation cohort, there have been few attempts to consolidate the findings obtained. This systematic review aimed to (1) synthesize and evaluate the existing data regarding anorectal manometry results in children following anorectal malformation repair, and (2) evaluate the manometry protocols utilized, including equipment, assessment approach, and interpretation. We reviewed four databases (Embase, MEDLINE, the Cochrane Library, and PubMed) for relevant articles published between 1 January 1985 and 10 March 2022. Studies reporting post-operative anorectal manometry in children (<18 years) following anorectal malformation repair were evaluated for eligibility. Sixty-three studies were eligible for inclusion. Of the combined total cohort of 2155 patients, anorectal manometry results were reported for 1755 children following repair of anorectal malformations. Reduced resting pressure was consistently identified in children with anorectal malformations, particularly in those with more complex malformation types and/or fecal incontinence. Significant variability was identified in relation to manometry equipment, protocols, and interpretation. Few studies provided adequate cohort medical characteristics to facilitate interpretation of anorectal manometry findings within the context of the broader continence mechanism. This review highlights a widespread lack of standardization in the anorectal manometry procedure used to assess anorectal function in children following anorectal malformation repair. Consequently, interpretation and comparison of findings, both within and between institutions, is exceedingly challenging, if not impossible. Standardized manometry protocols, accompanied by a consistent approach to analysis, including definitions of normality and abnormality, are essential to enhance the comparability and clinical relevance of results.
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5
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Keshtgar AS, Selim IM. Role of 3D high resolution anorectal manometry compared to conventional technique in management of constipation and fecal incontinence in children. J Pediatr Surg 2023; 58:251-257. [PMID: 36414477 DOI: 10.1016/j.jpedsurg.2022.10.018] [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: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Anorectal manometry is a valuable tool for objective assessment of motility motor and sensory function of the anorectum. The aim of this study was to investigate role of water-perfused (WP) three dimensional high-resolution anorectal manometry (3D-HRARM) compared to WP conventional manometry (CM) in the management of chronic idiopathic constipation (CIC) and faecal incontinence (FI) in children. METHODS This was a retrospective review of 122 consecutive children, who had WP 8-channel CM or 24 channel 3D-HRARM and endosonography under ketamine anaesthesia from September 2012 to February 2019. All patients had a validated symptom severity score questionnaire ranging from 0 (best) to 65 (worst). Mann-Whitney-U test and Spearman rank test were used and p<0.05 was considered significant. RESULTS Subjects were divided according to investigation: CM group (n = 75) and 3D-HRAM (n = 47), who were otherwise comparable. Median anal resting pressure was 50 mmHg and rectoanal inhibitory reflex (RAIR) threshold volume was 10mls across the entire cohort. There were no significant differences in resting pressure or RAIR threshold when using conventional or 3D-HRARM. Rectal capacity was significantly higher in the CM group (p = 0.002). Rectal capacity and internal anal sphincter (IAS) thickness positively correlated with symptom severity, duration and patient age. 3D-HRARM provided a more detailed depiction of the anorectal pressure profile. Botulinum toxin was injected into the external anal sphincter (EAS) muscle (n = 75, 61%) and an anterograde colonic enema (ACE) stoma was needed subsequently in 19 (16%) to treat recurrent constipation and soiling symptoms. Rectal biopsy was done in 43(35%) patients, if RAIR was absent or inconclusive. CONCLUSION CM and 3D-HRARM are comparable in terms of resting pressure and RAIR threshold. 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and faecal incontinence in children and plan further treatment. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Alireza S Keshtgar
- Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Kings College London, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Iman M Selim
- Kings College London, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
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6
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Blackett JW, Gautam M, Mishra R, Oblizajek NR, Kathavarayan Ramu S, Bailey KR, Bharucha AE. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders. Gastroenterology 2022; 163:1582-1592.e2. [PMID: 35995074 PMCID: PMC9691522 DOI: 10.1053/j.gastro.2022.08.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The utility of high-resolution anorectal manometry (HR-ARM) for diagnosing defecatory disorders (DDs) is unclear because healthy people may have features of dyssynergia. We aimed to identify objective diagnostic criteria for DD and to ascertain the utility of HR-ARM for diagnosing DD. METHODS Constipated patients were assessed with HR-ARM and rectal balloon expulsion time (BET), and a subset underwent defecography. Normal values were established by assessing 184 sex-matched healthy individuals. Logistic regression models evaluated the association of abnormal HR-ARM findings with prolonged BET and reduced rectal evacuation (determined by defecography). RESULTS A total of 474 constipated individuals (420 women) underwent HR-ARM and BET, and 158 underwent defecography. BET was prolonged, suggesting a DD, for 152 patients (32%). Rectal evacuation was lower for patients with prolonged vs normal BET. A lower rectoanal gradient during evacuation, reduced anal squeeze increment, and reduced rectal sensation were independently associated with abnormal BETs; the rectoanal gradient was 36% sensitive and 85% specific for prolonged BET. A lower rectoanal gradient and prolonged BET were independently associated with reduced evacuation. Among constipated patients, the probability of reduced rectal evacuation was 14% when the gradient and BET were both normal, 45% when either was abnormal, and 75% when both variables were abnormal. CONCLUSIONS HR-ARM, BET, and defecography findings were concordant for constipated patients, and reduced rectoanal gradient was the best HR-ARM predictor of prolonged BET or reduced rectal evacuation. Prolonged BET, reduced gradient, and reduced evacuation each independently supported a diagnosis of DD in constipated patients. We propose the terms probable DD for patients with an isolated abnormal gradient or BET and definite DD for patients with abnormal results from both tests.
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Affiliation(s)
- John W Blackett
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Misha Gautam
- Enteric Physiology and Imaging Facility, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shivabalan Kathavarayan Ramu
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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7
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Video-Based Deep Learning to Detect Dyssynergic Defecation with 3D High-Definition Anorectal Manometry. Dig Dis Sci 2022; 68:2015-2022. [PMID: 36401758 DOI: 10.1007/s10620-022-07759-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 11/03/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND We developed a deep learning algorithm to evaluate defecatory patterns to identify dyssynergic defecation using 3-dimensional high definition anal manometry (3D-HDAM). AIMS We developed a 3D-HDAM deep learning algorithm to evaluate for dyssynergia. METHODS Spatial-temporal data were extracted from consecutive 3D-HDAM studies performed between 2018 and 2020 at Dartmouth-Hitchcock Health. The technical procedure and gold standard definition of dyssynergia were based on the London consensus, adapted to the needs of 3D-HDAM technology. Three machine learning models were generated: (1) traditional machine learning informed by conventional anorectal function metrics, (2) deep learning, and (3) a hybrid approach. Diagnostic accuracy was evaluated using bootstrap sampling to calculate area-under-the-curve (AUC). To evaluate overfitting, models were validated by adding 502 simulated defecation maneuvers with diagnostic ambiguity. RESULTS 302 3D-HDAM studies representing 1208 simulated defecation maneuvers were included (average age 55.2 years; 80.5% women). The deep learning model had comparable diagnostic accuracy [AUC 0.91 (95% confidence interval 0.89-0.93)] to traditional [AUC 0.93(0.92-0.95)] and hybrid [AUC 0.96(0.94-0.97)] predictive models in training cohorts. However, the deep learning model handled ambiguous tests more cautiously than other models; the deep learning model was more likely to designate an ambiguous test as inconclusive [odds ratio 4.21(2.78-6.38)] versus traditional/hybrid approaches. CONCLUSIONS Deep learning is capable of considering complex spatial-temporal information on 3D-HDAM technology. Future studies are needed to evaluate the clinical context of these preliminary findings.
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8
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O'Connor A, Byrne CM, Vasant DH, Sharma A, Liao D, Klarskov N, Kiff ES, Telford K. Current and future perspectives on the utility of provocative tests of anal sphincter function: A state-of-the-art summary. Neurogastroenterol Motil 2022:e14496. [PMID: 36377815 DOI: 10.1111/nmo.14496] [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: 09/15/2022] [Revised: 10/18/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The maintenance of fecal continence depends upon coordinated interactions between the pelvic floor, anorectum, and anal sphincter complex orchestrated by central and peripheral neural activities. The current techniques to objectively measure anorectal function rely on fixed diameter catheters placed inside the anal canal with a rectal balloon to obtain measurements of anal resting and squeeze function, and rectal compliance. Until recently it had not been possible to measure the distensibility of the anal canal, or in other words its ability to resist opening against an increasing pressure, which has been proposed as the main determinant of a biological sphincter's function. Anal acoustic reflectometry (AAR) and the functional lumen imaging probe (FLIP) are two novel, provocative techniques that dynamically assess the anal sphincter complex under volume-controlled distension. In doing so, both provide information on the viscoelastic properties of the anal canal and offer new insights into its function. PURPOSE This review details the current and potential future applications of AAR and FLIP and highlights the unanswered questions relevant to these new technologies.
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Affiliation(s)
- Alexander O'Connor
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK.,Department of Colorectal Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Caroline M Byrne
- Department of Colorectal Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Diabetes, Endocrinology and Gastroenterology, The University of Manchester, Manchester, UK
| | - Abhiram Sharma
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK.,Department of Colorectal Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Donghua Liao
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Klarskov
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Edward S Kiff
- Department of Colorectal Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karen Telford
- Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK.,Department of Colorectal Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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9
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Oblizajek NR, Deb B, Ramu S(SK, Chunawala Z, Feuerhak K, Bailey KR, Bharucha AE. Optimizing techniques for measuring anal resting and squeeze pressures with high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14383. [PMID: 35468247 PMCID: PMC9529769 DOI: 10.1111/nmo.14383] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/17/2022] [Accepted: 03/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal methods for measuring and analyzing anal resting and squeeze pressure with high-resolution manometry (HRM) are unclear. METHODS Anal resting and squeeze pressures were measured with HRM in 90 healthy women, 35 women with defecatory disorders (DD), and 85 with fecal incontinence (FI). Pressures were analyzed with Manoview™ software and a customized approach. Resting pressures measured for 20, 60, and 300 s were compared. During the squeeze period, (3 maneuvers, 20 s each), the squeeze increment, which was averaged over 5, 10, 15, and 20 s, and squeeze duration were evaluated. RESULTS Compared to healthy women, the anal resting pressure, squeeze pressure increment, and squeeze duration were lower in FI (p ≤ 0.04) but not in DD. The 20, 60, and 300 s resting pressures were strongly correlated (concordance correlation coefficients = 0.96-0.99) in healthy and DD women. The 5 s squeeze increment was the greatest; 10, 15, and 20 s values were progressively lower (p < 0.001). The squeeze pressure increment and duration differed (p < 0.01) among the three maneuvers in healthy and DD women but not in FI women. The upper 95th percentile limit for squeeze duration was 19.5 s in controls, 19.9 s in DD, and 19.3 s in FI. Adjusted for age, resting pressure, and squeeze duration, a greater squeeze increment was associated with a lower risk of FI versus health (OR, 0.96; 95% CI, 0.94-0.97). CONCLUSIONS These findings suggest that anal resting and squeeze pressures can be accurately measured over 20 s. In most patients, one squeeze maneuver is probably sufficient.
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Affiliation(s)
| | - Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | | | - Zainali Chunawala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Kent R. Bailey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
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10
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Bharucha AE, Basilisco G, Malcolm A, Lee TH, Hoy MB, Scott SM, Rao SSC. Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test. Neurogastroenterol Motil 2022; 34:e14335. [PMID: 35220645 PMCID: PMC9418387 DOI: 10.1111/nmo.14335] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. PURPOSE This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guido Basilisco
- UO Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Tae Hee Lee
- Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Matthew B Hoy
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, USA
| | - S Mark Scott
- National Bowel Research Centre, Queen Mary University of London, London, UK
| | - Satish S C Rao
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
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11
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Bharucha AE, Knowles CH, Mack I, Malcolm A, Oblizajek N, Rao S, Scott SM, Shin A, Enck P. Faecal incontinence in adults. Nat Rev Dis Primers 2022; 8:53. [PMID: 35948559 DOI: 10.1038/s41572-022-00381-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/09/2022]
Abstract
Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Charles H Knowles
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Isabelle Mack
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Satish Rao
- Department of Gastroenterology, University of Georgia, Augusta, GA, USA
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Paul Enck
- University Hospital, Department of Psychosomatic Medicine, Tübingen, Germany.
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12
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Evans-Barns HME, Swannjo JB, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-operative anorectal manometry in children with Hirschsprung disease: A systematic review. Neurogastroenterol Motil 2022; 34:e14311. [PMID: 34964199 DOI: 10.1111/nmo.14311] [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: 09/13/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hirschsprung disease is commonly encountered by pediatric surgeons. Despite advances in the surgical management, these children may experience symptoms of bowel dysfunction throughout adulthood. Anorectal manometry may be used to assess post-operative anorectal structure and function. This review aimed to consolidate and evaluate the literature pertaining to post-operative findings of anorectal manometry in children with Hirschsprung disease. PURPOSE (1) Synthesize the available data regarding anorectal motility patterns in children following repair of Hirschsprung disease. (2) Evaluate the reported anorectal manometry protocols. DATA SOURCES We performed a systematic review of four databases: Embase, MEDLINE, the Cochrane Library, and PubMed. STUDY SELECTION This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting results of post-operative anorectal manometry in children with Hirschsprung disease were evaluated for inclusion. RESULTS Twenty-three studies satisfied inclusion criteria, with a combined cohort of 939 patients. Post-operative anorectal manometry results were reported for 682 children. The majority of included studies were assessed as "poor quality." Disparate manometry protocols, heterogeneous cohorts, and lack of standardized outcome assessments introduced a risk of outcome reporting bias, limited the comparability of results, and impeded clinical translation of findings. CONCLUSIONS This systematic review demonstrated the lack of high-quality evidence underlying the current understanding of post-operative anorectal motility in children with HD. There was little consistency in reported manometry outcomes between studies. In future work, emphasis must be placed on the application of standardized manometry protocols, cohort reporting, and patient outcome assessments.
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Affiliation(s)
- Hannah M E Evans-Barns
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Justina B Swannjo
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Misel Trajanovska
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mark Safe
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John M Hutson
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Phil G Dinning
- Department of Surgery, College of Medicine and Public Health, The Flinders University and Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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13
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Prevalence of double incontinence in patients with fecal incontinence undergoing anorectal manometry and discriminating factors. Acta Gastroenterol Belg 2022; 85:277-281. [DOI: 10.51821/85.2.9697] [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: 11/11/2022]
Abstract
Background: Double incontinence (DI) is the concomitant presence of incontinence for urine and stool. Aim of this study is to assess prevalence of DI in patients with fecal incontinence (FI) undergoing Ano-Rectal Manometry (ARM) in a tertiary care center and to identify factors discriminating between both.
Methods: Medical records of consecutive patients referred for ARM for FI during 2 years at University Hospital Brussels were retrospectively reviewed. Results from ARM, presence of diarrhea, diseases from recto-anal or peri-anal region, prior abdominal, proctological or urological surgery and neurological comorbidities were recorded.
Results: Of 101 enrolled patients, 77% suffered from solitary FI and 23% from DI. Diarrhea was more common in DI vs. FI (43,5% vs. 15,4%, P=.008), as was the presence of neurological comorbidities (34.8% vs. 10.3%, P=.009) and urological interventions (21.7% vs. 1.3%, P=.002). In respect to women only, more urological interventions were performed (20% vs. 0%, P=.006) and more diseases from recto-anal or peri-anal region were encountered in DI vs. FI (35.0 % vs. 12.5 %, P= .045). In men, neurological disorders were significantly more common in DI (100.0% vs. 3.3%, P=.002).
Conclusions: This study identified gender-specific patterns of comorbidities in FI and DI. ARM had no distinctive value between FI and DI in men and women. A prospective study should provide more information on patients at risk for incontinence and help to identify distinct features between FI and DI in men and women.
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14
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Bellini M, Chiarioni G. Staying in HRAM's Way: Tweaking the London Classification for Disorders of Anorectal Function. Dig Dis Sci 2022; 67:748-749. [PMID: 33939155 DOI: 10.1007/s10620-021-06995-3] [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] [Accepted: 04/07/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Massimo Bellini
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, AOUI Verona, Verona, Italy.
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Divisione di Gastroenterologia B, Ospedale Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy.
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15
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Redundancy in the International Anorectal Physiology Working Group Manometry Protocol: A Diagnostic Accuracy Study in Fecal Incontinence. Dig Dis Sci 2022; 67:964-970. [PMID: 33939154 DOI: 10.1007/s10620-021-06994-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anorectal manometry (ARM) is essential for identifying sphincteric dysfunction. The International Anorectal Physiology Working Group (IAPWG) protocol and London Classification provide a standardized format for performing and interpreting ARM. However, there is scant evidence to support timing and number of constituent maneuvers. AIMS To assess the impact of protocol modification on diagnostic accuracy in patients with fecal incontinence. METHODS Retrospective analysis of high-resolution ARM recordings from consecutive patients based on the current IAPWG protocol and modifications thereof: (1) baseline rest period (60 vs. 30 vs. 10 s); (2) number of abnormal short squeezes (SS) out of 3 (SS1/SS2/SS3) based on maximal incremental squeeze pressures over 5 s; (3) resting anal pressures (reflecting recovery) at 25-30 versus 15-20 s after SS1. RESULTS One hundred patients (86 F, median age 55 [IQR: 39-65]; median St. Mark's incontinence score 14 [10-17]) were studied. 26% and 8% had anal hypotonia and hypertonia, respectively. Compared with 60-s resting pressure, measurements had perfect correlation (κ = 1.0) over 30 s, and substantial correlation (κ = 0.85) over 10 s. After SS1, SS2, and SS3, 43%, 49%, and 46% had anal hypocontractility, respectively. Correlation was substantial between SS1 and SS2 (κ = 0.799) and almost perfect between SS2 and SS3 (κ = 0.9). Compared to resting pressure of 5 s before SS1, pressure recordings at 25-30 and 15-20 s after SS1 were significantly correlated. CONCLUSIONS A 30-s resting anal pressure, analysis of 2 short-squeezes with a 20-s between-maneuver recovery optimizes study duration without compromising diagnostic accuracy. These findings indicate the IAPWG protocol has redundancy.
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Volumetric Rectal Perception Testing: Is It Clinically Relevant? Results From a Large Patient Cohort. Am J Gastroenterol 2021; 116:2419-2429. [PMID: 34608885 DOI: 10.14309/ajg.0000000000001526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Rectal perception testing is a recommended component of anorectal physiology testing. Although recent consensus (London) guidelines suggested criteria for categorizing hyporectal and hyper-rectal sensitivity, these were based on scant evidence. Moreover, data regarding diagnostic capabilities and clinical utility of rectal perception testing are lacking. The aims of this study were to determine the association between rectal perception testing and both clinical and physiological variables to enhance the analysis and interpretation of real-life test results. METHODS Prospectively documented data from 1,618 (92% female) patients referred for anorectal physiology testing were analyzed for 3 rectal perception thresholds (first, urge, and maximal tolerated). Normal values derived from healthy female subjects were used to categorize each threshold into hyposensitive and hypersensitive to examine the clinical relevance of this categorization. RESULTS There was poor to moderate agreement between the 3 thresholds. Older age, male sex, and constipation were associated with higher perception thresholds, whereas irritable bowel syndrome, fecal incontinence, connective tissue disease, and pelvic radiation were associated with lower perception thresholds to some, but not all, thresholds (P < 0.01 on multivariate analysis for all). The clinical utility and limitations of categorizing thresholds into "hypersensitivity" and "hyposensitivity" were determined. DISCUSSION Commonly practiced rectal perception testing is correlated with several disease states and thus has clinical relevance. However, most disease states were correlated with 2 or even only 1 abnormal threshold, and agreement between thresholds was limited. This may suggest each threshold measures different pathophysiological pathways. We suggest all 3 thresholds be measured and reported separately in routine clinical testing.
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17
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Knowles CH, Booth L, Brown SR, Cross S, Eldridge S, Emmett C, Grossi U, Jordan M, Lacy-Colson J, Mason J, McLaughlin J, Moss-Morris R, Norton C, Scott SM, Stevens N, Taheri S, Yiannakou Y. Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background
Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.
Objectives
(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.
Design
The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).
Setting
Specialist hospital centres across England, with a mix of urban and rural referral bases.
Participants
The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.
Interventions
CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks’ (n = 10) and after 24 weeks’ (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively).
Main outcome measures
The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.
Results
A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.
Conclusions
Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.
Limitations
All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome.
Trial registration
Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Charles H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Steve R Brown
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Samantha Cross
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ugo Grossi
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mary Jordan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jon Lacy-Colson
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Christine Norton
- Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - S Mark Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shiva Taheri
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yan Yiannakou
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
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Cohen DL, Richter V, Malikov I, Bermont A, Shirin H. The Effect of a Didactic Course on Gastroenterology Nurses' Knowledge and Interest in Anorectal Manometry. Gastroenterol Nurs 2021; 44:412-417. [PMID: 34690296 DOI: 10.1097/sga.0000000000000636] [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: 04/19/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022] Open
Abstract
Anorectal manometry may be performed by a nurse or physician, yet little has been written about what training is needed. Additionally, many gastroenterology nurses receive little exposure to motility studies such as anorectal manometry, limiting their ability to learn these procedures. We therefore sought to evaluate whether a short didactic course on anorectal manometry would increase nurses' knowledge about the procedure and stimulate their interest in becoming trained to perform it. To accomplish this, gastroenterology nurses attended a series of three lectures on anorectal manometry. A 15-question quiz was given as a pre-test and again as a post-test after completing the course. Thirteen nurses participated (11 female, mean age 46). None had experience performing anorectal manometry. Due to the course, test scores increased from a mean of 8.4 (55.9%) correct to 13.3 (88.7%) (p < .001), with improvements noted in 12 of 13 participants (92.3%). All of the nurses felt that the course increased their knowledge of anorectal manometry and reported that they would recommend it to other nurses. Most (61.5%) also expressed an interest in becoming trained to perform anorectal manometry. In conclusion, a short didactic course has been shown to increase nurses' knowledge and interest in performing anorectal manometry.
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Affiliation(s)
- Daniel L Cohen
- Daniel L. Cohen, MD, is Gastroenterologist and Head of the GI Motility Laboratory at Shamir Medical Center, Zerifin, Israel
- Vered Richter, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Irena Malikov, MA, Head of GI Nursing at Shamir Medical Center, Zerifin, Israel
- Anton Bermont, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Haim Shirin, MD, is Director of the Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin, Israel, and Professor of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- Daniel L. Cohen, MD, is Gastroenterologist and Head of the GI Motility Laboratory at Shamir Medical Center, Zerifin, Israel
- Vered Richter, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Irena Malikov, MA, Head of GI Nursing at Shamir Medical Center, Zerifin, Israel
- Anton Bermont, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Haim Shirin, MD, is Director of the Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin, Israel, and Professor of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irena Malikov
- Daniel L. Cohen, MD, is Gastroenterologist and Head of the GI Motility Laboratory at Shamir Medical Center, Zerifin, Israel
- Vered Richter, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Irena Malikov, MA, Head of GI Nursing at Shamir Medical Center, Zerifin, Israel
- Anton Bermont, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Haim Shirin, MD, is Director of the Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin, Israel, and Professor of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anton Bermont
- Daniel L. Cohen, MD, is Gastroenterologist and Head of the GI Motility Laboratory at Shamir Medical Center, Zerifin, Israel
- Vered Richter, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Irena Malikov, MA, Head of GI Nursing at Shamir Medical Center, Zerifin, Israel
- Anton Bermont, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Haim Shirin, MD, is Director of the Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin, Israel, and Professor of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Shirin
- Daniel L. Cohen, MD, is Gastroenterologist and Head of the GI Motility Laboratory at Shamir Medical Center, Zerifin, Israel
- Vered Richter, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Irena Malikov, MA, Head of GI Nursing at Shamir Medical Center, Zerifin, Israel
- Anton Bermont, MD, is Gastroenterologist at Shamir Medical Center, Zerifin, Israel
- Haim Shirin, MD, is Director of the Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir Medical Center, Zerifin, Israel, and Professor of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Ortengren AR, Ramkissoon RA, Chey WD, Baker JR, Staller K, Iturrino J, Shah ED. Anorectal manometry to diagnose dyssynergic defecation: Systematic review and meta-analysis of diagnostic test accuracy. Neurogastroenterol Motil 2021; 33:e14137. [PMID: 33772969 PMCID: PMC10091423 DOI: 10.1111/nmo.14137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic constipation is a common condition, and dyssynergic defecation underlies up to 40% of cases. Anorectal manometry is recommended to assess for dyssynergic defecation among chronically constipated patients but remains poorly standardized. We aimed to evaluate the diagnostic accuracy of anorectal manometry and determine optimal testing parameters. METHODS We performed a systematic review with meta-analysis of diagnostic test accuracy including cohort studies of chronically constipated patients and case-control studies of patients with dyssynergic defecation or healthy controls. Meta-analysis was performed to determine summary sensitivity, specificity, and area under the curve (AUC) with 95% confidence intervals (CI). KEY RESULTS A total of 15 studies comprising 2140 patients were included. Including all studies (estimating optimal diagnostic accuracy), the AUC was 0.78 [95% CI 0.72-0.82], summary sensitivity was 79% [61%-90%], and summary specificity was 64% [44%-79%] to diagnose dyssynergic defecation. In cohort studies only (estimating real-world diagnostic accuracy), the AUC was 0.72 [0.66-0.77], summary sensitivity was 86% [64%-95%], and summary specificity was 49% [30%-68%]. Employing three consecutive simulated defecation attempts improved sensitivity to 94%. A fourth simulated defecation maneuver with air insufflation may improve accuracy. Measuring anorectal pressures to identify complex dyssynergic patterns did not improve real-world diagnostic accuracy estimates over anal pressure measurement alone. Choice of manometry system did not impact diagnostic accuracy. CONCLUSIONS & INFERENCES Following the current iteration of the London consensus protocol (three simulated defecation attempts measuring anal relaxation), the role of anorectal manometry in evaluating dyssynergic defecation appears limited. Future iterations of this protocol may improve diagnostic accuracy.
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Affiliation(s)
- Alexandra R. Ortengren
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Resham A. Ramkissoon
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Jason R. Baker
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachussetts General Hospital, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
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20
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Pinto RA, Correa-Neto IJF, Bustamante-Lopez LA, Nahas CSR, Marques CFS, Sobrado-Junior CW, Cecconello I, Nahas SC. ANORECTAL MANOMETRY STANDARD OF A BRAZILIAN POPULATION AT PRODUCTIVE AGE WITHOUT PELVIC FLOOR DISORDERS: A PROSPECTIVE VOLUNTEERED STUDY. ACTA ACUST UNITED AC 2021; 34:e1580. [PMID: 34133527 PMCID: PMC8195462 DOI: 10.1590/0102-672020210001e1580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022]
Abstract
Background: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities.
Aim: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female.
Methods: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders.
Results: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003).
Conclusions: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal
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Affiliation(s)
- Rodrigo Ambar Pinto
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Isaac José Felippe Correa-Neto
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | | | - Caio Sergio R Nahas
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Carlos Frederico S Marques
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Carlos Walter Sobrado-Junior
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Ivan Cecconello
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Sergio Carlos Nahas
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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21
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Sharma M, Lowry AC, Rao SS, Whitehead WE, Szarka LA, Hamilton FA, Bharucha AE. A multicenter study of anorectal pressures and rectal sensation measured with portable manometry in healthy women and men. Neurogastroenterol Motil 2021; 33:e14067. [PMID: 33462889 PMCID: PMC8169521 DOI: 10.1111/nmo.14067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The equipment and methods for performing anorectal manometry and biofeedback therapy are different and not standardized. Normal values are influenced by age and sex. Our aims were to generate reference values, examine effects of gender and age, and compare anorectal pressures measured with diagnostic and biofeedback catheters and a portable manometry system. METHODS In this multicenter study, anorectal pressures at rest, during squeeze, and evacuation were measured with diagnostic and biofeedback catheters using Mcompass™ portable device in healthy subjects. Balloon expulsion time and rectal sensation were evaluated. The effects of age and gender were assessed. RESULTS The final dataset comprised 108 (74 women) of 124 participants with normal rectal balloon expulsion time (less than 60 s). During squeeze, anal resting pressure increased by approximately twofold in women and threefold in men. During evacuation, anal pressure exceeded rectal pressure in 87 participants (diagnostic catheter). The specific rectoanal pressures (e.g., resting pressure) were significantly correlated and not different between diagnostic and biofeedback catheters. With the diagnostic catheter, the anal squeeze pressure and rectal pressure during evacuation were greater in men than women (p ≤ 0.02). Among women, women aged 50 years and older had lower anal resting pressure; rectal pressure and the rectoanal gradient during evacuation were greater in older than younger women (p ≤ 0.01). CONCLUSIONS Anal and rectal pressures measured with diagnostic and biofeedback manometry catheters were correlated and not significantly different. Pressures were influenced by age and sex, providing reference values in men and women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | | | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
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22
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Yates G, Friedmacher F, Cleeve S, Athanasakos E. Anorectal manometry in pediatric settings: A systematic review of 227 studies. Neurogastroenterol Motil 2021; 33:e14006. [PMID: 33118295 DOI: 10.1111/nmo.14006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/03/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is wide variation in the clinical use of diagnostic tools for children with chronic constipation and functional/structural fecal incontinence (CCFSFI). Anorectal manometry (ARM) is a well-recognized technique to assess the function of the anorectum. PURPOSE Our aim was to perform an up-to-date review on ARM in pediatric patients with CCFSFI, with specific focus on the indication of use and protocol. Variation of its use in pediatrics will be explored. METHODS A systematic search was conducted for empirical studies utilizing ARM with a pediatric sample. A keyword search of literature published in English before July 2018 was conducted and updated to October 2019. Data on demographics, clinical information, study aims, ARM parameters and use of sedation/anesthesia were collected. KEY RESULTS A total of 227 studies were included in this systematic review. The age of study participants at the time of ARM ranged from birth to 18 years. ARM was most commonly used in patients with organic conditions (65%) compared to functional constipation (41%). In almost half [108/227 (48%)] of the studies, ARM was performed awake. The ARM parameters most frequently assessed were the rectoanal inhibitory reflex, which was evaluated in 198/227 studies (87%) and the anal resting pressure [166/227 studies (73%)]. CONCLUSIONS AND INFERENCES This systematic review has highlighted the vast variation of ARM use within pediatrics and the need to strive toward standardization and use of consensus guidelines. We anticipate this will further advance our understanding of the pathophysiological mechanisms involved in children with defecation disorders.
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Affiliation(s)
- Gregory Yates
- Department of Paediatric Surgery, The Royal London Hospital, London, UK.,Barts and The London, School of Medicine and Dentistry, London, UK
| | - Florian Friedmacher
- Department of Paediatric Surgery, The Royal London Hospital, London, UK.,Barts and The London, School of Medicine and Dentistry, London, UK.,Department of Pediatric Surgery, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, UK
| | - Stewart Cleeve
- Department of Paediatric Surgery, The Royal London Hospital, London, UK.,Barts and The London, School of Medicine and Dentistry, London, UK
| | - Eleni Athanasakos
- Department of Paediatric Surgery, The Royal London Hospital, London, UK.,Barts and The London, School of Medicine and Dentistry, London, UK
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23
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Rasijeff AMP, Garcia-Zermeno K, Carrington EV, Knowles C, Scott SM. Systematic evaluation of cough-anorectal pressure responses in health and in fecal incontinence: A high-resolution anorectal manometry study. Neurogastroenterol Motil 2021; 33:e13999. [PMID: 33150700 DOI: 10.1111/nmo.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/31/2020] [Accepted: 09/07/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anorectal manometry is the most commonly performed test of anorectal function. The cough-anorectal response is frequently assessed as part of a routine manometric investigation but has not previously been the subject of detailed analysis. This study systematically examined anorectal pressure responses to cough in health and evaluated the impact of parity and symptoms of fecal incontinence (FI) on measurements. METHODS High-resolution anorectal manometry (HR-ARM) traces from nulliparous (n = 25) and parous (n = 25) healthy volunteers (HV: aged 41, range 18-64), and 57 parous patients with FI (age 47, range 28-72) were retrospectively reviewed. Cough-anorectal pressure responses were analyzed between groups by qualitative and quantitative approaches. KEY RESULTS In health, traditional anal pressure measurements ("rest" and "squeeze") were similar between nulliparous and parous women. In contrast, incremental anal-rectal pressure difference during cough significantly differed: nulliparous 42 mm Hg (95% CI: 21-64) vs. parous 6 mm Hg (-14-25), P < 0.036). This measure also differed significantly between nulliparous HVs and patients with FI (-2 mm Hg (95% CI: -15-12), P < 0.001), but not between parous HVs and FI. Qualitatively, a color-contour trace resembling a "spear" in the upper anal canal was observed uniquely in FI. Of 25 patients with normal anal function by traditional measures, cough parameters were abnormal in 52%. CONCLUSIONS AND INFERENCES Novel HR-ARM measures during coughing revealed differences in anal function between nulliparous and parous HV, and patients with FI, which were not detected by traditional measures. Cough-anorectal measurements may improve manometric yield, though clinical utility would require assessment by longitudinal studies.
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Affiliation(s)
- Annika M P Rasijeff
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Karla Garcia-Zermeno
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - Emma V Carrington
- Colorectal Unit, Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Charles Knowles
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & 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 & Trauma, Queen Mary University of London, London, UK
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24
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Fomenko OY, Morozov SV, Scott S, Knowles H, Morozov DA, Shelygin YA, Maev IV, Nikityuk DB, Shkoda AS, Kashnikov VN, Bordin DS, Isakov VA, Biryukov OM, Belousova SV, Pimenova ES, Rumiantsev AS, Fedorov ED, Gvozdev MY, Trukhmanov AS, Storonova OA, Indeykina LH, Biryukova MG, Andreev DN, Kucheryavyy YA, Achkasov SI. [Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]. TERAPEVT ARKH 2020; 92:105-119. [PMID: 33720582 DOI: 10.26442/00403660.2020.12.200472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/07/2021] [Indexed: 02/07/2023]
Abstract
This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.
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Affiliation(s)
- O Y Fomenko
- Ryzhikh National Medical Research Centre for Coloproctology
| | - S V Morozov
- Federal Research Center of Nutrition and Biotechnology
| | - S Scott
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - H Knowles
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - D A Morozov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - Y A Shelygin
- Ryzhikh National Medical Research Centre for Coloproctology
| | - I V Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D B Nikityuk
- Federal Research Center of Nutrition and Biotechnology
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - V N Kashnikov
- Ryzhikh National Medical Research Centre for Coloproctology
| | - D S Bordin
- Yevdokimov Moscow State University of Medicine and Dentistry
- Loginov Moscow Clinical Research Center
- Tver State Medical University
| | - V A Isakov
- Federal Research Center of Nutrition and Biotechnology
| | - O M Biryukov
- Ryzhikh National Medical Research Centre for Coloproctology
| | - S V Belousova
- Ryzhikh National Medical Research Centre for Coloproctology
| | - E S Pimenova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - E D Fedorov
- Pirogov Russian National Research Medical University
| | - M Y Gvozdev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - A S Trukhmanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Storonova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - L H Indeykina
- Loginov Moscow Clinical Research Center
- Research Institute of Health Care Organization and Medical Management
| | - M G Biryukova
- Federal Research Center of Nutrition and Biotechnology
| | - D N Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - Y A Kucheryavyy
- Yevdokimov Moscow State University of Medicine and Dentistry
- Ilyinsky Hospital
| | - S I Achkasov
- Ryzhikh National Medical Research Centre for Coloproctology
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25
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Heitmann PT, Rabbitt P, Schloithe AC, Wattchow DA, Scott SM, Dinning PG. The relationships between the results of contemporary tests of anorectal structure and sensorimotor function and the severity of fecal incontinence. Neurogastroenterol Motil 2020; 32:e13946. [PMID: 32683767 DOI: 10.1111/nmo.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnostic investigations for fecal incontinence (FI) assess the structure and sensorimotor function of the anorectum. Investigations include anorectal manometry, anorectal sensory testing, pudendal nerve terminal motor latencies (PNTML), and endoanal sonography. The severity of FI and results of investigations are often discordant and the rate of symptom resolution following treatment remains <40%. High-resolution anorectal manometry (HRAM) and three-dimensional endoanal ultrasound (3D-US) have been introduced during the last decade. This study aims to assess the strength of relationships between contemporary investigation results and FI severity. METHODS Adults presenting for investigation of FI were assessed using the St Mark's FI severity score (SMIS), HRAM, anorectal sensory testing, PNTML, and 3D-US. KEY RESULTS 246 patients were included. There were significant relationships between the SMIS and HRAM (resting pressure rs = -0.23, 95% CI = (-0.34, -0.11), P < .001; squeeze pressure (rs = -0.26, 95% CI = (-0.37, -0.14), P < .001) and 3D-US (anterior EAS length rs = -0.22, 95% CI = (-0.34, -0.09), P = .001). The relationships between SMIS and HRAM had a greater effect size in those with urge-predominant symptoms (resting pressure: rs = -0.40, 95% CI = (-0.57, -0.20), P < .001, squeeze pressure: rs = -0.34, 95% CI = (-0.52, -0.12), P = .003). Overall, the variance in SMIS accounted for by anorectal investigations was 8.6% (R2 = 0.098, adjusted R2 = 0.086, P < .001). CONCLUSIONS AND INFERENCES Anorectal investigations are not strong predictors of FI severity. These findings may reflect the multifactorial, heterogeneous pathophysiology of FI, the limitations of the SMIS and anorectal investigations, and contributing factors extrinsic to the anorectum.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Philippa Rabbitt
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Ann C Schloithe
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Queen Mary University, London, UK
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
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26
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Brandler J, Camilleri M. Pretest and Post-test Probabilities of Diagnoses of Rectal Evacuation Disorders Based on Symptoms, Rectal Exam, and Basic Tests: a Systematic Review. Clin Gastroenterol Hepatol 2020; 18:2479-2490. [PMID: 31811949 PMCID: PMC7269802 DOI: 10.1016/j.cgh.2019.11.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/15/2019] [Accepted: 11/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the utility of symptoms, examination, and tests for diagnosis of rectal evacuation disorders (REDs) or slow-transit constipation (STC). We aimed to ascertain the pooled prevalence, sensitivity, specificity, and likelihood ratios for clinical parameters to determine pretest and post-test probabilities of diagnoses of RED and STC without RED. METHODS We searched the MEDLINE and PUBMED databases since 1999 for studies that used binary data to calculate sensitivity, specificity, and likelihood ratios to determine the diagnostic utility of history, symptoms, and tests for RED and STC. RED and STC were defined based on confirmation by at least 1 objective anorectal test or colonic transit test. Controls had normal test results based on the specific protocol in each study. RESULTS We reviewed 100 articles; 63 studies of RED and 61 studies of STC met the inclusion criteria. Among 3364 patients with chronic constipation, objective tests demonstrated RED alone, 27.2%; normal transit constipation alone, 37.2%; STC alone, 19.0%; and RED with STC, 16.6%. To diagnose RED, discriminant features were urinary symptoms (specificity, 100%; likelihood ratio, above 10; 58 patients), less than 2 findings of dyssynergia in a digital rectal exam (sensitivity, 83.2%; negative likelihood ratio, 0.2; 462 patients) and rectoanal pressure gradient below -40 mm Hg with high anal pressure during straining (specificity, 100%; likelihood ratio, above 10; 101 patients). The features most strongly associated with STC alone were call to stool (specificity, 91.5%; likelihood ratio, 10.5; 75 patients) and absence of abdominal distension, fullness, or bloating (sensitivity, 92.9%; negative likelihood ratio, 0.1; 93 patients). CONCLUSIONS In a systematic review, we found specific symptoms, lack of dyssynergia in a digital rectal exam, and findings on anorectal manometry to be highly informative and critical in evaluation of RED and STC.
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Affiliation(s)
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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28
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Scott SM, Carrington EV. The London Classification: Improving Characterization and Classification of Anorectal Function with Anorectal Manometry. Curr Gastroenterol Rep 2020; 22:55. [PMID: 32935278 PMCID: PMC7497505 DOI: 10.1007/s11894-020-00793-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice. RECENT FINDINGS This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.
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Affiliation(s)
- S Mark Scott
- Neurogastroenterology Group and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University London, London, UK.
| | - Emma V Carrington
- Neurogastroenterology Group and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University London, London, UK
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
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29
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Jiang AC, Panara A, Yan Y, Rao SSC. Assessing Anorectal Function in Constipation and Fecal Incontinence. Gastroenterol Clin North Am 2020; 49:589-606. [PMID: 32718572 DOI: 10.1016/j.gtc.2020.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.
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Affiliation(s)
- Alice C Jiang
- Division of Gastroenterology, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Chicago, IL 60612, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard M. Miller School of Medicine, 1601 NW 12th Ave, Miami, FL, USA
| | - Yun Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University Medical Center, 1120 15th Street, AD 2226, Augusta, GA 30912, USA.
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Alessandrella A, Turco R, Russo M, Poziello A, Miele E, Staiano A. High-resolution anorectal manometry in children with functional constipation with or without fecal incontinence. Neurogastroenterol Motil 2020; 32:e13882. [PMID: 32476213 DOI: 10.1111/nmo.13882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/29/2020] [Accepted: 04/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND High-resolution anorectal manometry (HR-ARM) is expected to be better than conventional manometry. Our aim was to characterize HR-ARM pressures in children with functional constipation (FC), with or without fecal incontinence (FI). METHODS Children with diagnosis of FC, with or without FI, according to Rome-IV criteria, were enrolled. All patients underwent HR-ARM using 24-channel water-perfused catheter. RESULTS Twenty-nine consecutive children (M/F: 21/8; mean age ± SD: 9.5 ± 3.1 years; range 4-15), of whom 21 affected by FC without FI (mean age ± SD: 9.3 ± 3.23 years) and 8 affected by FC with FI (mean age ± SD: 10.2 ± 3.08 years), were enrolled. No significant differences were found regard to gender and age. The analysis of HR-ARM 3D plots demonstrated asymmetry of the anal canal, with higher pressures in distal halves. Comparing pressures between the two groups, we found lower values in FC with FI than in FC without FI group, with a statistically significance for maximum and mean resting pressures (P = .032 and P = .008, respectively). When evaluating our study population respect to asymptomatic children, we found lower resting pressures, lower maximum squeeze pressure, and higher rectoanal inhibitory reflex (RAIR) values. CONCLUSIONS Our data demonstrate that HR-ARM pressures at rest and during squeezing in FC with FI children are lower than FC without FI subjects, particularly in anteroposterior quadrants. Compared to children without lower gastrointestinal symptoms, children with FC with or without FI show lower pressures and higher values of RAIR.
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Affiliation(s)
- Annalisa Alessandrella
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
| | - Rossella Turco
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
| | - Marina Russo
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
| | - Antonio Poziello
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
| | - Erasmo Miele
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
| | - Annamaria Staiano
- Section of Pediatrics, Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy
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Athanasakos E, Cleeve S, Thapar N, Lindley K, Perring S, Cronin H, Borrelli O, Mutalib M. Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement. Neurogastroenterol Motil 2020; 32:e13797. [PMID: 31989766 DOI: 10.1111/nmo.13797] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.
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Affiliation(s)
| | | | - Nikhil Thapar
- Gastroenterology, Great Ormond Street Hospital, London, UK.,UCL Great Ormond Street Institute of Child Health Library, London, UK
| | - Keith Lindley
- Department of Paediatric Gastroenterology, Division of Paediatric Neurogastroenterology and Motility, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Steve Perring
- Medical Physics, Poole Hospital NHS Trust, Poole, UK
| | - Hannah Cronin
- Department of Paediatric Gastroenterology, Division of Paediatric Neurogastroenterology and Motility, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Division of Paediatric Neurogastroenterology and Motility, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Mohamed Mutalib
- Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
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Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence. Pediatr Surg Int 2020; 36:295-303. [PMID: 31844977 DOI: 10.1007/s00383-019-04605-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children's Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI. METHODS Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS). RESULTS Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung's disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05). CONCLUSIONS Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy.,UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK.,The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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Relationships between the results of anorectal investigations and symptom severity in patients with faecal incontinence. Int J Colorectal Dis 2019; 34:1445-1454. [PMID: 31280351 DOI: 10.1007/s00384-019-03331-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Anorectal dysfunction is the focus of diagnostic investigations for faecal incontinence. However, severity of incontinence and anorectal investigation results can be discordant. The aim of this study was to define the relationships between anorectal investigation results and incontinence severity to determine which measures, if any, were predictive of incontinence severity. METHODS Patients presenting for investigation of faecal incontinence completed a symptom questionnaire, anorectal manometry, rectal sensation, pudendal nerve terminal motor latency, and endoanal ultrasound. Bivariate analyses were conducted between the Jorge-Wexner score and investigation results. Subgroup analyses were performed for gender and symptom subtypes (urge, passive, mixed). A multiple regression analysis was performed. RESULTS Five hundred and thirty-eight patients were included. There were weak correlations between the Jorge-Wexner score and maximal squeeze pressure [r = - 0.24, 95%CI(- 0.31, - 0.16), p < 0.001], and resting pressure [r = - 0.18, (95%CI(- 0.26, - 0.10), p < 0.001]. In men only, there were significant associations between the Jorge-Wexner score and endoanal sonography [IAS defects: t(113) = - 2.26, p = 0.03, d = 0.58, 95%CI(- 4.38, - 0.29)] and rectal sensation (MTV: rs = - 0.24, 95%CI(- 0.41, - 0.06), p = 0.01). No substantial differences were observed in the urge/passive/mixed subgroup analyses. Multiple regression analysis included three variables: age (β = 0.02, p = 0.17), maximal resting pressure (β = - 0.01, p = 0.28), and maximal squeeze pressure (β = - 0.01, p < 0.01). The variance in the Jorge-Wexner score accounted for by this model was < 10%, (R2 = 0.07, p = < 0.01, adjusted R2 = 0.06). CONCLUSION Anorectal investigations cannot predict the severity of faecal incontinence. This may be due to limitations of diagnostic modalities, the heterogeneity of anorectal dysfunction in these patients, or contributing factors which are extrinsic to the anorectum.
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Grossi U, Di Tanna GL, Heinrich H, Taylor SA, Knowles CH, Scott SM. Letter: limitations of defecography among patients with refractory constipation. Authors' reply. Aliment Pharmacol Ther 2019; 50:112-113. [PMID: 31184395 DOI: 10.1111/apt.15309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Ugo Grossi
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gian Luca Di Tanna
- Statistics Division, The George Institute for Global Health, UNSW, Sydney, Australia
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Charles H Knowles
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Mark Scott
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Kamal AN, Garcia P, Clarke JO. Under Pressure: Do Volume-Based Measurements Define Rectal Hyposensitivity in Clinical Practice? Dig Dis Sci 2019; 64:1062-1063. [PMID: 30963367 DOI: 10.1007/s10620-019-05613-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.
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Mazor Y, Prott G, Jones M, Kellow J, Ejova A, Malcolm A. Anorectal physiology in health: A randomized trial to determine the optimum catheter for the balloon expulsion test. Neurogastroenterol Motil 2019; 31:e13552. [PMID: 30703851 DOI: 10.1111/nmo.13552] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/18/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anorectal manometry (ARM) and balloon expulsion test (BET) are pivotal in investigation of anorectal disorders. There is controversy, however, about normal values and optimum methodology for performing these tests. Our aims were to compare BET using three different balloons and to establish normal values for ARM and BET in health. METHODS Forty-four female healthy subjects (mean age 56 ± 12 years) underwent ARM, followed by BET which was performed in a private toilet using three different catheters (party balloon, Foley catheter and a commercially available catheter) in a single-blinded randomized order. Outcome measures were time to balloon expulsion and comprehensive measures of anal sphincter function, the push maneuver and rectal sensation. KEY RESULTS The Foley catheter took longer to expel compared to both party and commercial balloons (both pairwise P < 0.001) with a wider distribution of results (P < 0.001). Ten of 40 healthy subjects could not expel the Foley catheter within 120 seconds. On ARM, older age was associated with lower resting anal sphincter pressure (ρ = -0.3, P = 0.05) and lower anal squeeze pressure (ρ = -0.3, P = 0.05). Having at least one vaginal delivery (compared to none) was associated with lower anal squeeze pressures (P = 0.03) and a smaller difference between cough and squeeze pressures (P = 0.03). CONCLUSIONS & INFERENCES A commercial balloon exhibited superior results in vivo compared to the Foley catheter without the concerns of latex allergy and quality control present with the use of a party balloon. Normal values for high-resolution water-perfused manometry have been established and an effect seen for age and parity.
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Affiliation(s)
- Yoav Mazor
- Department of Gastroenterology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Gillian Prott
- Department of Gastroenterology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mike Jones
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - John Kellow
- Department of Gastroenterology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Anastasia Ejova
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
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Vollebregt PF, Rasijeff AMP, Pares D, Grossi U, Carrington EV, Knowles CH, Scott SM. Functional anal canal length measurement using high-resolution anorectal manometry to investigate anal sphincter dysfunction in patients with fecal incontinence or constipation. Neurogastroenterol Motil 2019; 31:e13532. [PMID: 30637863 DOI: 10.1111/nmo.13532] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/23/2018] [Accepted: 11/28/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Using high-resolution anorectal manometry, we aimed to evaluate the: (a) optimal threshold to measure functional anal canal length (FACL) with intra- and inter-observer variability; (b) relationship between abnormal FACL and other phenotypic findings; and (c) utility of FACL measurement to discriminate between healthy volunteers (HV) and patients with fecal incontinence (FI) or chronic constipation (CC). METHODS Consecutive patients referred for investigation of FI or CC in isolation were included. FACL was calculated at 5, 10, 20, 30, and 50 mm Hg above rectal pressure. 5th-95th percentile in HV defined limits of normality. KEY RESULTS FACL was analyzed in 192 patients with FI (154 females), 204 patients with CC (175 females), and 134 HV (101 females). The optimal threshold for measurement of FACL was 20 mm Hg. Using this threshold, observer reproducibility was very high (ICC 0.99, P < 0.0001). FACL was shorter in females with FI and longer in females with CC compared to HV (2.3 vs 2.9 cm; and 3.4 cm vs 2.9 cm; both P < 0.0001). Twenty percent of females and 13% males with FI had a short FACL, associated with older age, anal hypotonia or hypocontractility, and a atrophic internal anal sphincter. However, abnormal FACL in isolation was only found in 1/190 FI (0.5%) and 2/201 CC (1%) patients; all other patients had other abnormal manometric findings. CONCLUSIONS AND INFERENCES Considering overlap with other routinely evaluated manometric parameters, FACL measurement does not provide additional information in the diagnostic assessment of FI or CC.
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Affiliation(s)
- Paul F Vollebregt
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
| | - Annika M P Rasijeff
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
| | - David Pares
- Hospital Germans Trías i Pujol, Barcelona, Spain
| | - Ugo Grossi
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
| | - Emma V Carrington
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
| | - Charles H Knowles
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
| | - S Mark Scott
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Surgery & Trauma, Queen Mary University of London, London, UK
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Carrington EV, Knowles CH, Grossi U, Scott SM. High-resolution Anorectal Manometry Measures Are More Accurate Than Conventional Measures in Detecting Anal Hypocontractility in Women With Fecal Incontinence. Clin Gastroenterol Hepatol 2019; 17:477-485.e9. [PMID: 29966707 DOI: 10.1016/j.cgh.2018.06.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 06/08/2018] [Accepted: 06/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry is a common test of anal tone and contractility. However, existing measures are often criticized for their poor ability to detect functional differences between individuals with presumably normal sphincter function and individuals with fecal incontinence. We investigated whether new measures, derived from high-resolution anal manometry (HR-ARM), more accurately identify incontinent women with abnormal sphincter function than measures from conventional anal manometry (C-ARM). METHODS We performed a prospective HR-ARM study of 85 healthy female volunteers (median age 41 years; range 18-68 years) and 403 women with fecal incontinence (median age 55; range 18-91 years) from June 2013 through December 2015. We compared the diagnostic accuracy of conventional measurements of contractility (C-ARM squeeze increment) and tone (C-ARM resting pressure) (the reference standards), with HR-ARM measures (HR-ARM squeeze increment, HR-ARM contractile integral, HR-ARM resting average, HR-ARM rest integral). We also investigated associations between symptom severity and structural sphincter integrity. RESULTS We identified anal hypocontractility in 129 women with fecal incontinence using the C-ARM squeeze increment (32% sensitivity; likelihood ratio, 6.4), in 189 women using the HR-ARM squeeze increment (47% sensitivity; likelihood ratio, 9.4), and in 220 women using the HR-ARM contractile integral (55% sensitivity; likelihood ratio, 11.0). In contrast, HR-ARM measures of anal tone did not particularly outperform conventional measures (31% sensitivity for HR-ARM resting average vs 28% for C-ARM resting pressure). Ninety-eight of the 206 patients with fecal incontinence who were classified as having normal anal function, based on C-ARM measures, were reclassified as having abnormal function based on HR-ARM measures. CONCLUSION In a prospective study of healthy women and women with fecal incontinence, we demonstrated that the newly developed HR-ARM contractile integral increased the sensitivity of detection of anal hypocontractility, from 32% to 55%, compared with conventional measurements of squeeze.
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Affiliation(s)
- Emma V Carrington
- National Bowel Research Centre and GI Physiology Unit, Queen Mary University of London, London, United Kingdom.
| | - Charles H Knowles
- National Bowel Research Centre and GI Physiology Unit, Queen Mary University of London, London, United Kingdom
| | - Ugo Grossi
- National Bowel Research Centre and GI Physiology Unit, Queen Mary University of London, London, United Kingdom
| | - S Mark Scott
- National Bowel Research Centre and GI Physiology Unit, Queen Mary University of London, London, United Kingdom
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Verkuijl SJ, Trzpis M, Broens PMA. Normal Rectal Filling Sensations in Patients with an Enlarged Rectum. Dig Dis Sci 2019; 64:1312-1319. [PMID: 30003387 PMCID: PMC6548060 DOI: 10.1007/s10620-018-5201-6] [Citation(s) in RCA: 5] [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: 03/14/2018] [Accepted: 07/05/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND Increased rectal volume is believed to be associated with diminished rectal sensation, i.e., rectal hyposensitivity. AIMS To demonstrate that patients with increased rectal volumes do not automatically have diminished rectal filling sensations. METHODS We, retrospectively, observed 100 adult patients with defecation problems, and 44 healthy controls who had undergone anorectal function tests. Using the balloon retention test, we analyzed the distribution of rectal volumes and pressures at different rectal filling sensation levels. RESULTS We found variance in the distribution of rectal volumes at all levels, while rectal pressures showed a normal distribution. We found no correlation between rectal volumes and pressures (constant sensation, r = 0.140, P = 0.163, urge sensation, r = - 0.090, P = 0.375, and maximum tolerable volumes, r = - 0.091, P = 0.366), or when taking age and sex into account. The findings for the patient group were congruent with those for the control group. CONCLUSIONS Participants with increased rectal volumes do not experience increased rectal pressures at any sensation level. This finding, combined with the knowledge that rectal pressure triggers rectal filling sensation, indicates that rectal filling sensations in patients with increased rectal volumes are not diminished. Therefore, "rectal hyposensitivity" should be reserved for patients with increased rectal pressure thresholds, and not for "abnormally" increased rectal volume thresholds.
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Affiliation(s)
- Sanne J. Verkuijl
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Monika Trzpis
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M. A. Broens
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,0000 0000 9558 4598grid.4494.dDepartment of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Seo M, Joo S, Jung KW, Song EM, Rao SSC, Myung SJ. New Metrics in High-Resolution and High-Definition Anorectal Manometry. Curr Gastroenterol Rep 2018; 20:57. [PMID: 30397834 DOI: 10.1007/s11894-018-0662-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques. RECENT FINDINGS The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence. HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.
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Affiliation(s)
- Myeongsook Seo
- Department of Internal Medicine, Konkuk University Chungju Hospital, Chungju, South Korea
| | - Segyeong Joo
- Department of Biomedical Engineering, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Eun Mi Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, Augusta, GA, USA
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Schawkat K, Pfister B, Parker H, Heinrich H, Barth BK, Weishaupt D, Fox M, Reiner CS. Dynamic MRI of the pelvic floor: comparison of performance in supine vs left lateral body position. Br J Radiol 2018; 91:20180393. [PMID: 30160176 DOI: 10.1259/bjr.20180393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE: To investigate the performance of MR-defecography (MRD) in lateral body position as an alternative to supine position. METHODS: 22 consecutive patients (16 females; mean age 51 ± 19.4) with obstructed defecation and 20 healthy volunteers (11 females; mean age 33.4 ± 11.5) underwent MRD in a closed-configuration 3T-MRI in supine and lateral position. MRD included T2 weighted images at rest and during defecation after filling the rectum with 250 ml water-based gel. Measurements were performed in reference to the pubococcygeal line and grade of evacuation was assessed. Image quality (IQ) was rated on a 5-point-scale (5 = excellent). RESULTS: In patients grades of middle and posterior compartment descent were similar in both body positions (p > 0.05). Grades of anterior compartment descent were significantly higher in lateral position (21/22 vs 17/22 patients with normal or small descent, p < 0.034). In volunteers grades of descent were similar for all compartments in supine and lateral position (p > 0.05). When attempting to defecate in supine position 6/22 (27%) patients showed no evacuation, while in lateral position only 3/22 (14%) were not able to evacuate. IQ in patients was equal at rest (4.4 ± 0.5 and 4.7 ± 0.6, p > 0.05) and slightly better in supine compared to the lateral position during defecation (4.5 ± 0.4 vs 3.9 ± 0.9, p < 0.017). IQ in volunteers was equal in supine and lateral position (p > 0.05). CONCLUSION: In lateral position, more patients were able to evacuate with similar grades of pelvic floor descent compared to supine position. MRD in lateral position may be a valuable alternative for patients unable to defecate in supine position. ADVANCES IN KNOWLEDGE: In lateral position, more patients were able to evacuate during MRD. MRD in lateral position may be an alternative for patients unable to defecate in supine position.
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Affiliation(s)
- Khoschy Schawkat
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Bettina Pfister
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Helen Parker
- 2 University Zurich , Zurich , Switzerland.,3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,4 Institute of Health and Society, Newcastle University , Newcastle upon Tyne , UK
| | - Henriette Heinrich
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Borna K Barth
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Dominik Weishaupt
- 6 Department of Radiology, Stadtspital Triemli , Zurich , Switzerland
| | - Mark Fox
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Caecilia S Reiner
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
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Viebig RG, Franco JTY, Araujo SV, Gualberto D. WATER-PERFUSED HIGH-RESOLUTION ANORECTAL MANOMETRY (HRAM-WP): THE FIRST BRAZILIAN STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:41-46. [PMID: 30088530 DOI: 10.1590/s0004-2803.201800000-38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND High resolution anorectal manometry (HRAM-WP) allows more simplified, objective, and uniform data acquisition and interpretation of the test results. OBJECTIVE To validate a HRAM under water perfusion (Alacer Biomédica) with a 24-channel probe and to compare the results of anorectal manometry with other systems. METHODS Individuals without critical evacuation disorders were selected. Patients with incontinence, anal surgery, dyssynergia or sphincter injury were excluded. The test was performed with an Alacer Biomédica 24 channel manometry system under water perfusion, with a probe configured with 6 levels of 4 radial channels, separated from each other by 0.8 mm. The mean pressures for the functional channel were determined, in states of rest (RMP), contention effort (CMP) and evacuation effort (EEMP). The pressure extension of the sphincter was also tabulated in cm. The results were compared with those available in recent literature. RESULTS Fifty patients were studied (20 men; 30 women). Overall, the following results were obtained: the RMP was 76.9±3.0 mmHg, the CMP was 194.2±9.4 mmHg, and EEMP was 88.2±3.7 mmHg. When classified according to the gender, for men: RMP was 72.2±3.0 mmHg, CMP was 229.5±17 mmHg, and EEMP was 91.4±7.0. For women, RMP was 79.8±4.0 mmHg, CMP was 170.7±8, and EEMP was 86.1±4.3 mmHg. The sphincter gauge extension for both genders was 3.1±0.09 cm (men 3.3±0.1; women 3.0±0.1). DISCUSSION Studying HRAM-WP has become much easier. Non-mobilization of the sensor causes less discomfort and artefacts with a lower assessment time. In this study, small differential values between both sexes during rest were observed, highlighting a greater containment force in men. No difference in sphincter extension was noted. The results of this study are consistent with that of existing reports and with those obtained using solid state probes. CONCLUSION The perfusion system yielded results similar to that of solid state systems. Further studies to evaluate parameters with respect to pelvic dyssynergia and incontinence need to be conducted. Additionally, to determine if the vector volume can furnish new information in terms of functional and anatomical aspects.
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Affiliation(s)
- Ricardo Guilherme Viebig
- Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades (IBEPEGE), São Paulo, SP, Brasil.,Motilidade Digestiva e Neurogastroenterologia (MoDiNe), São Paulo, SP, Brasil
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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Heinrich H, Misselwitz B. High-Resolution Anorectal Manometry - New Insights in the Diagnostic Assessment of Functional Anorectal Disorders. Visc Med 2018; 34:134-139. [PMID: 29888243 PMCID: PMC5981680 DOI: 10.1159/000488611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.
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Affiliation(s)
- Henriette Heinrich
- Abdominal Center: Gastroenterology, St. Claraspital Basel, Basel, Switzerland
- Department of Gastroenterology and Hepatology, Universitätsspital Zürich, Zurich, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology and Hepatology, Universitätsspital Zürich, Zurich, Switzerland
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight current and newer therapeutic approaches to treat fecal incontinence in patients who do not respond to conservative measures. RECENT FINDINGS Neurostimulation techniques, injection of bulking agents, and radiofrequency energy delivery to the anal canal have been proposed and tested for fecal incontinence over the last decade. Sacral stimulation is both effective and durable and is now the most popular of the invasive techniques whereas percutaneous tibial stimulation, radiofrequency energy, and bulking agents are either less effective or their evaluation has been handicapped by suboptimal study designs. The precise indications for the new vaginal control device and anal plugs remain to be established. The magnetic anal sphincter is disappointing. Stem cell therapy is a potentially exciting approach, which is in its infancy. There continues to be an unmet need for innovative approaches to patients with fecal incontinence who do not respond to conservative measures. The efficacy of current and future therapies should be assessed using criteria more stringent than has been used in the past to provide a more realistic assessment of meaningful efficacy.
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Lin KY, Denehy L, Granger CL, Frawley HC. Pelvic floor outcomes in patients who have undergone general rehabilitation following surgery for colorectal cancer: A pilot study. Physiother Theory Pract 2018; 35:206-218. [PMID: 29498563 DOI: 10.1080/09593985.2018.1443184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is a paucity of evidence on changes in pelvic floor outcomes in patients with colorectal cancer (CRC) following general oncology rehabilitation. OBJECTIVE In patients following surgery for CRC, to explore changes in pelvic floor muscle function before and after a general oncology rehabilitation program; and to compare pelvic floor symptoms in patients undergoing the rehabilitation program to a matched control group. METHODS This pilot study was conducted as an observational study nested within a prospective study evaluating the feasibility of a general oncology rehabilitation program for patients following surgery for abdomino-pelvic cancer. In this nested study, pelvic floor muscle function was measured in 10 participants with CRC (rehabilitation group) before and immediately after the 8-week rehabilitation program and at 6-month follow-up. Data of 10 matched participants from the prospective study who completed questionnaires only at the same assessment time points were used as a control group. Symptom measurement tools were the Australian Pelvic Floor Questionnaire (APFQ) and the International Consultation on Incontinence Questionnaire-Bowel module (ICIQ-B). Descriptive statistics were used to summarize data on pelvic floor muscle function of the rehabilitation group, and repeated measures analysis of variance was used to assess within- and between-group changes in pelvic floor symptom scores over time in the rehabilitation group and control group matched for gender and level of tumor. RESULTS Scores in the bowel domain of the APFQ (p = 0.037) and bowel control domain of the ICIQ-B (p = 0.026) improved in the rehabilitation group only and the improvement in ICIQ-B was sustained at 6-month follow-up. There were no significant differences in bladder and bowel symptoms between the rehabilitation and matched control groups (p > 0.05) at any assessment time-point. CONCLUSIONS Patients undergoing a general rehabilitation program following surgery for CRC demonstrated improved bowel symptoms from pre- to post-rehabilitation program; however, there were no differences when compared with matched controls who did not undertake rehabilitation. Further studies with larger sample sizes and longer-term follow-up are needed confirm these findings.
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Affiliation(s)
- Kuan-Yin Lin
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,b Cabrini Health , Melbourne , Australia.,c Department of Physiotherapy, School of Primary and Allied Health Care , Monash University , Melbourne , Australia
| | - Linda Denehy
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,e Institute for Breathing and Sleep , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,d Department of Physiotherapy , Melbourne Health , Melbourne , Australia.,e Institute for Breathing and Sleep , Melbourne , Victoria , Australia
| | - Helena C Frawley
- b Cabrini Health , Melbourne , Australia.,c Department of Physiotherapy, School of Primary and Allied Health Care , Monash University , Melbourne , Australia
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Sweis R, Heinrich H, Fox M. Variation in esophageal physiology testing in clinical practice: Results from an international survey. Neurogastroenterol Motil 2018; 30. [PMID: 28948708 DOI: 10.1111/nmo.13215] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Advances in clinical measurement of esophageal motility and function have improved the assessment of swallowing disorders and reflux symptoms. Variation in data acquisition, analysis, and reporting exists and impacts on diagnosis and management. AIMS AND METHODS This study examined variation in esophageal manometry methodology between institutions to establish the status in current practice. A structured survey was distributed through international NGM societies using an Internet-based platform. Questions explored infrastructure, technology, analysis, and reporting. KEY RESULTS Responses were received from 91 centers from 29 countries. Eighteen (20%) centers used "conventional" manometry, 75 (82%) high-resolution manometry, and 53 (58%) HR impedance manometry. All centers documented motility for single water swallows. The Chicago Classification was applied by 65 (71.4%) centers. In contrast, analysis of EGJ morphology varied widely. Adjunctive testing was often applied: multiple rapid swallows (77%), rapid drink challenge (77%), single solid swallows (63%), and a standard test meal (18%). Of 86 (94.5%) units that offered pH impedance (pH-Z) studies, approximately half (53.5%) performed tests on acid-suppressant medication in patients with a high pretest probability (eg, erosive esophagitis). Most (75.6%) centers manually reviewed every reflux event. Others examined pH-Z data only prior to symptoms. To assess symptom association with reflux events, 73.6% centers analyzed each symptom separately, whereas 29.7% centers pooled symptoms. CONCLUSIONS AND INFERENCES There is marked variation in the data acquisition, analysis, and reporting of esophageal manometry studies. Further efforts to improve quality and uniformity in testing and reporting are required. This survey provides information upon which best-practice guidelines can be developed.
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Affiliation(s)
- R Sweis
- GI Services, University College London Hospital, London, UK
| | - H Heinrich
- National Bowel Research Centre & GI Physiology Unit, Queen Mary University of London, London, UK.,Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - M Fox
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
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Rasijeff AMP, Withers M, Burke JM, Jackson W, Scott SM. High-resolution anorectal manometry: A comparison of solid-state and water-perfused catheters. Neurogastroenterol Motil 2017. [PMID: 28639425 DOI: 10.1111/nmo.13124] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal manometry is the most commonly performed investigation for assessment of anorectal dysfunction. Findings from previous studies comparing water-perfused (WP) and solid-state (SS) techniques in the anorectum are conflicting. We compared anal sphincter pressure at rest and during dynamic maneuvers (squeezing and coughing) in healthy volunteers using SS and WP high-resolution anorectal manometry (HR-ARM) employing equivalent catheter configurations, a standardized protocol, and identical data acquisition and analysis software. METHODS Sixty healthy volunteers (40F; median age: 40; range: 18-74) underwent WP and SS HR-ARM in randomized order. Anal resting pressure, and squeeze and cough increments were measured. Median pressure and 5th and 95th percentiles were calculated for each maneuver and compared using Wilcoxon signed-rank test. Bland and Altman plots were used to assess agreement between the systems. The impact of gender and parity was also explored. KEY RESULTS Anal sphincter pressure measurements during squeeze (P<.001) and cough (P<.001) were significantly higher using SS HR-ARM than WP HR-ARM. No differences were seen at rest between the two types of catheter (nulliparous: P=.304; parous: P=.390; males: P=.167). Normal ranges for SS and WP manometry from this small group of healthy volunteers are presented. CONCLUSIONS & INFERENCES Greater sensitivity to rapid pressure change is one of the advantages associated with SS HR-ARM. This is reflected in the differences observed during dynamic maneuvers performed during this study. Catheter type should be taken into consideration when selecting normal ranges for comparison to disease states.
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Affiliation(s)
- A M P Rasijeff
- Department of Gastrointestinal Physiology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK.,The Centre for Trauma and Surgery and GI Physiology Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M Withers
- Department of Gastrointestinal Physiology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - J M Burke
- Department of Gastrointestinal Physiology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - W Jackson
- Department of Gastrointestinal Physiology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - S M Scott
- The Centre for Trauma and Surgery and GI Physiology Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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