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Ramu SK, Oblizajek NR, Savica R, Chunawala ZS, Deb B, Bharucha AE. Defecatory disorders are a common cause of chronic constipation in Parkinson disease. Neurogastroenterol Motil 2024; 36:e14767. [PMID: 38376243 PMCID: PMC11061800 DOI: 10.1111/nmo.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND AIMS Up to 50% of patients with Parkinson disease have constipation (PD-C), but the prevalence of defecatory disorders caused by rectoanal dyscoordination in PD-C is unknown. We aimed to compare anorectal function of patients with PD-C versus idiopathic chronic constipation (CC). METHODS Anorectal pressures, rectal sensation, and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry (HR-ARM) in patients with PD-C and control patients with CC, matched for age and sex. RESULTS We identified 97 patients with PD-C and 173 control patients. Eighty-six patients with PD-C (89%) had early PD, and 39 (40%) had a defecatory disorder, manifest by a prolonged rectal balloon expulsion time (37 patients) or a lower rectoanal pressure difference during evacuation (2 patients). PD-C patients with a prolonged BET had a greater anal resting pressure (p = 0.02), a lower rectal pressure increment (p = 0.005), greater anal pressure (p = 0.047), and a lower rectoanal pressure difference during evacuation (p < 0.001). Rectal sensory thresholds were greater in patients with abnormal BET. In the multivariate model comparing CC and PD-C (AUROC = 0.76), PD-C was associated with a lower anal squeeze increment (odds ratio [OR] for PD-C, 0.93 [95% CI, 0.91-0.95]), longer squeeze duration (OR, 1.05 [95% CI, 1.03-1.08]), lower rectal pressure increment (OR per 10 mm Hg, 0.72 [95% CI, 0.66-0.79]), and negative rectoanal gradient during evacuation (OR per 10 mm Hg, 1.16 [95% CI, 1.08-1.26]). CONCLUSIONS Compared with CC, PD-C was characterized by impaired squeeze pressure, longer squeeze duration, lower increase in rectal pressure, and a more negative rectoanal gradient during evacuation.
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Affiliation(s)
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rodolfo Savica
- Division of Movement Disorders, Mayo Clinic, Rochester, Minnesota, USA
| | - Zainali S Chunawala
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Brototo Deb
- Research Fellow in the Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Xu D, Kuang M, Liu Y, Jiang H. Diagnostic value of balloon expulsion test and anorectal manometry in patients with constipation: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2024; 36:534-544. [PMID: 38555600 DOI: 10.1097/meg.0000000000002743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
This study aims to compare the diagnostic value of balloon expulsion test and anorectal manometry in patients with constipation through meta-analysis. Databases, encompassing PubMed, EMBASE, Cochrane Library, Web of Science, etc. were searched for all English publications on the diagnosis of constipation using balloon expulsion test and anorectal manometry. The publication date was restricted from the inception of the databases until December 2022. Data analysis was carried out utilizing Stata 15.0 and Meta-Disc 1.4 software. Thirteen studies involving 2171 patients with constipation were included. According to the meta-analysis, the balloon expulsion test showed a pooled sensitivity of 0.75 (95% CI: 0.72-0.77), a pooled specificity (Spe) of 0.67 (95% CI: 0.62-0.72), a pooled positive likelihood ratio (+LR) of 3.24 (95% CI: 1.53-6.88), a pooled negative likelihood ratio (-LR) 0.35 (95% CI: 0.23-0.52) and a pooled diagnostic odds ratio (DOR) of 9.47 (95% CI: 3.27-27.44). For anorectal manometry, the pooled Sen, Spe, +LR, -LR and DOR were 0.74 (95% CI: 0.72-0.76), 0.73 (95% CI: 0.70-0.76), 2.69 (95% CI: 2.18-3.32), 0.35 (95% CI: 0.28-0.43), and 8.3 (95% CI: 5.4-12.75), respectively. The area under the summary receiver operating characteristic curve areas for balloon expulsion test and anorectal manometry were 0.8123 and 0.8088, respectively, with no statistically significant disparity (Z = -0.113, P > 0.05). Both the balloon expulsion test and anorectal manometry demonstrate comparable diagnostic performance, each offering unique advantages. These diagnostic procedures hold significance in the diagnosis of constipation.
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Affiliation(s)
- Dan Xu
- First Clinical Medical College, Shaanxi University of Chinese Medicine, Xi'an, Shaanxi, China
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Wattchow DA, Brookes SJ, Spencer NJ, Heitmann PT, De Giorgio R, Costa M, Dinning PG. From the organ bath to the whole person: a review of human colonic motility. ANZ J Surg 2024; 94:320-326. [PMID: 37974532 DOI: 10.1111/ans.18779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
Motor function of the colon is essential for health. Our current understanding of the mechanisms that underlie colonic motility are based upon a range of experimental techniques, including molecular biology, single cell studies, recordings from muscle strips, analysis of part or whole organ ex vivo through to in vivo human recordings. For the surgeon involved in the clinical management of colonic conditions this amounts to a formidable volume of material. Here, we synthesize the key findings from these various experimental approaches so that surgeons can be better armed to deal with the complexities of the colon.
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Affiliation(s)
- David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon J Brookes
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Nick J Spencer
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Marcello Costa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
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Basilisco G, Marchi M, Coletta M. Chronic intestinal pseudo-obstruction in adults: A practical guide to identify patient subgroups that are suitable for more specific treatments. Neurogastroenterol Motil 2024; 36:e14715. [PMID: 37994282 DOI: 10.1111/nmo.14715] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/24/2023]
Abstract
Chronic intestinal pseudo-obstruction is a rare and heterogeneous syndrome characterized by recurrent symptoms of intestinal obstruction with radiological features of dilated small or large intestine with air/fluid levels in the absence of any mechanical occlusive lesion. Several diseases may be associated with chronic intestinal pseudo-obstruction and in these cases, the prognosis and treatment are related to the underlying disease. Also, in its "primary or idiopathic" form, two subgroups of patients should be determined as they require a more specific therapeutic approach: patients whose chronic intestinal pseudo-obstruction is due to sporadic autoimmune/inflammatory mechanisms and patients whose neuromuscular changes are genetically determined. In a context of a widely heterogeneous adult population presenting chronic intestinal pseudo-obstruction, this review aims to summarize a practical diagnostic workup for identifying definite subgroups of patients who might benefit from more specific treatments, based on the etiology of their underlying condition.
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Affiliation(s)
- Guido Basilisco
- Gastroenterology and Endoscopic Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Margherita Marchi
- Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Marina Coletta
- Gastroenterology and Endoscopic Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Lv CL, Song GQ, Liu J, Wang W, Huang YZ, Wang B, Tian JS, Yin MQ, Yu Y. Colorectal motility patterns and psychiatric traits in functional constipation and constipation-predominant irritable bowel syndrome: A study from China. World J Gastroenterol 2023; 29:5657-5667. [PMID: 38077156 PMCID: PMC10701329 DOI: 10.3748/wjg.v29.i41.5657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/14/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C) represent a spectrum of constipation disorders. However, the majority of previous clinical investigations have focused on Western populations, with limited data originating from China. AIM To determine and compare the colorectal motility and psychiatric features of FC and IBS-C in an Eastern Chinese population. METHODS Consecutive chronic constipation patients referred to our motility clinic from December 2019 to February 2023 were enrolled. FC and IBS-C diagnoses were established using ROME IV criteria, and patients underwent high-resolution anorectal manometry (ARM) and a colonic transmit test using the Sitz marker study. Constipation-related symptoms were obtained through questionnaires. Anxiety and depression were assessed by the Hamilton anxiety rating scale and the Hamilton Depression Rating Scale-21. The clinical characteristics and colorectal motility patterns of FC and IBS-C patients were compared. RESULTS No significant differences in sex, age or abdominal discomfort symptoms were observed between IBS-C and FC patients (all P > 0.05). The proportion of IBS-C patients with delayed colonic transit was higher than that of patients with FC (36.63% vs 15.91%, P < 0.05), while rectosigmoid accumulation of radiopaque markers was more common in the FC group than in the IBS-C group (50% vs 26.73%, P < 0.05). Diverse proportions of these dyssynergic patterns were noted within both the FC and IBS-C groups by ARM. IBS-C patients were found to have a higher prevalence of depression than FC patients (66.30% vs 42.42%, P < 0.05). The scores for feelings of guilt, suicide, psychomotor agitation, diurnal variation, obsessive/compulsive disorder, hopelessness, self-abasedment and gastrointestinal symptoms were significantly higher in IBS-C patients than that in FC patients (P < 0.05). For IBS-C (χ2 = 5.438, P < 0.05) but not FC, patients with normal colon transit time were significantly more likely to have anxiety than those with slow colon transit time. For IBS-C patients but not FC patients, the threshold of first constant sensation, desire to defecate and sustained urgency were all weakly correlated with the degree of anxiety (r = 0.414, r = 0.404, and r = 0.418, respectively, P < 0.05). The proportion of patients with a low threshold of desire to defecate among IBS-C patients with depression was lower than that in those without depression (69.6% vs 41.9%, χ2 = 4.054, P < 0.05). CONCLUSION Our findings highlight both overlapping and distinctive patterns of colon transit, dyssynergic patterns, anorectal sensation, psychological distress, and associations of psychiatric and colorectal motility characteristics in FC and IBS-C patients in an Eastern Chinese population, providing valuable insights into the pathophysiological underpinnings of these disorders.
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Affiliation(s)
- Chao-Lan Lv
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, Anhui Province, China
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Geng-Qing Song
- Department of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, United States
| | - Jie Liu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, Anhui Province, China
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
| | - Wei Wang
- Department of Gastroenterology, Affiliated Anhui Provincial Hospital, Anhui Medical University, Hefei 230001, Anhui Province, China
| | - Yi-Zhou Huang
- Department of Gastroenterology, Graduate School of Bengbu Medical College, Bengbu 233000, Anhui Province, China
| | - Bo Wang
- Department of Gastroenterology, Graduate School of Bengbu Medical College, Bengbu 233000, Anhui Province, China
| | - Jia-Shuang Tian
- Department of Gastroenterology, Affiliated Anhui Provincial Hospital, Anhui Medical University, Hefei 230001, Anhui Province, China
| | - Meng-Qing Yin
- Department of Gastroenterology, Affiliated Anhui Provincial Hospital, Anhui Medical University, Hefei 230001, Anhui Province, China
| | - Yue Yu
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, Anhui Province, China
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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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Zhou W, Triadafilopoulos G, Gurland B, Halawi H, Becker L, Garcia P, Nguyen L, Miglis M, Muppidi S, Sinn D, Jaradeh S, Neshatian L. Differential Findings on Anorectal Manometry in Patients with Parkinson's Disease and Defecatory Dysfunction. Mov Disord Clin Pract 2023; 10:1074-1081. [PMID: 37476327 PMCID: PMC10354598 DOI: 10.1002/mdc3.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/22/2023] [Accepted: 04/15/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Gastrointestinal dysfunction, particularly constipation, is among the most common non-motor manifestations in Parkinson's Disease (PD). We aimed to identify high-resolution anorectal manometry (HR-ARM) abnormalities in patients with PD using the London Classification. Methods We conducted a retrospective review of all PD patients at our institution who underwent HR-ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex-specific normal values, HR-ARM recordings were re-analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. Results 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69-74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto-anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Conclusion Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.
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Affiliation(s)
- Wendy Zhou
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - George Triadafilopoulos
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Brooke Gurland
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Houssam Halawi
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Laren Becker
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Patricia Garcia
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Linda Nguyen
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
| | - Mitchell Miglis
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Srikanth Muppidi
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Dong‐In Sinn
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Safwan Jaradeh
- Stanford University, Department of Neurology and Autonomic DisordersStanford Neuroscience Health CenterStanfordCAUSA
| | - Leila Neshatian
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCAUSA
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Sharma A, Rao S. Editorial: faecal incontinence is prevalent in IBS, as are effective treatment options! Aliment Pharmacol Ther 2023; 57:1174-1175. [PMID: 37094309 DOI: 10.1111/apt.17486] [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: 04/26/2023]
Affiliation(s)
- Amol Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Bharucha AE. When to Order Anorectal Function Testing. Gastroenterol Hepatol (N Y) 2023; 19:59-61. [PMID: 36865821 PMCID: PMC9972655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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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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Mishra R, Gautam M, Oblizajek NR, Bharucha AE. Reproducibility of high-resolution manometry among healthy and constipated persons. Neurogastroenterol Motil 2022; 34:e14438. [PMID: 36017816 PMCID: PMC9722563 DOI: 10.1111/nmo.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/30/2022] [Accepted: 07/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although high-resolution manometry (HR_ARM) is commonly used to diagnose defecatory disorders, its intraindividual day-to-day reproducibility is unknown. Since these measurements entail voluntary effort, this study aimed to evaluate the intraindividual day-to-day reproducibility of HR_ARM. METHODS In 22 healthy women (35 years [14] mean [SD]) and 53 constipated patients (42 years [13], 46 women), the rectal balloon expulsion time (BET), and anorectal pressures were measured with HR_ARM on 2 days separated by a median (interquartile range) of 15 days (11-53) in healthy and 40 days (8-75) in constipated patients. Anorectal pressures were evaluated at rest (20 s), during squeeze, and during evacuation. Rectal sensation was also evaluated in constipated patients. The agreement between both measurements was evaluated with Lin's concordance correlation coefficient (CCC) and other tests. RESULTS Among constipated patients, the anal resting (mean CCC [95%CI] 0.62 [0.43-0.76]) and squeeze pressures (CCC 0.65 [0.47-0.79]), rectoanal gradient during evacuation (CCC 0.42 [0.17-0.62]), and rectal sensory thresholds (CCC for urgency 0.72 [0.52-0.84]) were concordant. Between days 1 and 2, one or more outcomes, characterized as normal or abnormal, differed in 79% of constipated patients, i.e., anal resting and squeeze pressures, the gradient, and the rectal BET differed in, respectively, 25%, 19%, 36%, and 10% of constipated patients. The rectal BET was prolonged in three healthy persons (both days) and either on 1 day (six patients) or 2 days (33 patients) in constipated patients. CONCLUSIONS While HR_ARM variables and the BET are reproducible within healthy and constipated persons, the outcome on repeat testing differed in 79% of constipated patients.
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Affiliation(s)
- Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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ElWazir M, Gautam M, Mishra R, Oblizajek NR, Blackett JW(W, Bharucha AE. Automated extraction of anorectal pressures from high-resolution manometry reports. Neurogastroenterol Motil 2022; 34:e14411. [PMID: 35593217 PMCID: PMC9588692 DOI: 10.1111/nmo.14411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND During high-resolution anorectal manometry (HR_ARM), the raw data are converted into software-derived summary variables (e.g., rectoanal gradient during evacuation) that capture only a snapshot of the data collected during HR_ARM and are less useful than newer indices, which are also derived from the raw data, for diagnosing defecatory disorders (DD). However, it is cumbersome and time-consuming to extract raw data from the program and calculate such indices. This study aimed to devise a user-friendly approach to extract anorectal pressures measured with HR_ARM. METHODS Anorectal pressures at rest, during anal squeeze, and evacuation were measured with HR_ARM in 180 women, among whom 60 each were healthy, had DD, or fecal incontinence. A reverse engineering approach extracted pressure values from color images in HR_ARM reports. The summary variables generated by the software and a reverse engineering approach were compared with Lin's concordance correlation coefficient (CCC), paired t-tests, and Bland-Altman's tests. RESULTS Anorectal pressures summarized by the software and a reverse engineering method were highly concordant for anal resting (CCC [95% CI], 0.98 [0.97, 0.99]) and squeeze pressures (0.99 [0.99, 0.99) and the rectoanal gradient during evacuation with an empty (0.98 [0.97, 0.98]) and a filled balloon (0.99 [0.99, 0.99]). For most variables, the paired t and Bland-Altman comparisons were not significant. CONCLUSIONS Anorectal pressures can be accurately determined from pressure topography images in HR_ARM reports. In future, this reverse engineering approach can be harnessed to compile large HR_ARM datasets across centers and to uncover newer, potentially more useful summary rectoanal pressure variables.
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Affiliation(s)
- Mohamed ElWazir
- Department of Cardiovascular Medicine, Suez Canal University, Ismailia, Egypt
| | - Misha Gautam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Nehra AK, Sheedy SP, Johnson CD, Flicek KT, Venkatesh SK, Heiken JP, Wells ML, Ehman EC, Barlow JM, Fletcher JG, Olson MC, Bharucha AE, Katzka DA, Fidler JL. Imaging Review of Gastrointestinal Motility Disorders. Radiographics 2022; 42:2014-2036. [PMID: 36206184 DOI: 10.1148/rg.220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The motor function of the gastrointestinal tract relies on the enteric nervous system, which includes neurons spanning from the esophagus to the internal anal sphincter. Disorders of gastrointestinal motility arise as a result of disease within the affected portion of the enteric nervous system and may be caused by a wide array of underlying diseases. The etiology of motility disorders may be primary or due to secondary causes related to infection or inflammation, congenital abnormalities, metabolic disturbances, systemic illness, or medication-related side effects. The symptoms of gastrointestinal dysmotility tend to be nonspecific and may cause diagnostic difficulty. Therefore, evaluation of motility disorders requires a combination of clinical, radiologic, and endoscopic or manometric testing. Radiologic studies including fluoroscopy, CT, MRI, and nuclear scintigraphy allow exclusion of alternative pathologic conditions and serve as adjuncts to endoscopy and manometry to determine the appropriate diagnosis. Additionally, radiologist understanding of clinical evaluation of motility disorders is necessary for guiding referring clinicians and appropriately imaging patients. New developments and advances in imaging techniques have allowed improved assessment and diagnosis of motility disorders, which will continue to improve patient treatment options. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Avinash K Nehra
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Shannon P Sheedy
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - C Daniel Johnson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Kristina T Flicek
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Sudhakar K Venkatesh
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jay P Heiken
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael L Wells
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Eric C Ehman
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - John M Barlow
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Joel G Fletcher
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Michael C Olson
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Adil E Bharucha
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - David A Katzka
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
| | - Jeff L Fidler
- From the Department of Radiology (A.K.N., S.P.S., K.T.F., S.K.V., J.P.H., M.L.W., E.C.E., J.M.B., J.G.F., M.C.O., J.L.F.) and Division of Gastroenterology and Hepatology (A.E.B., D.A.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.)
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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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