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Christoffersen T, Kornholt J, Riis T, Sonne DP, Klarskov N. Effect of Single-Dose Imipramine on Anal Sphincter Tone in Healthy Women: A Randomized, Placebo-Controlled Study Using Anal Acoustic Reflectometry. Int Urogynecol J 2024; 35:1873-1879. [PMID: 39167201 PMCID: PMC11420375 DOI: 10.1007/s00192-024-05890-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/14/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Despite the high prevalence of fecal incontinence, existing treatment options may be inadequate. Drugs that enhance the tone of the anal sphincter complex could potentially be an effective pharmacological approach. This study investigated the effect of the tricyclic antidepressant imipramine on anal sphincter tone in healthy women, employing anal acoustic reflectometry as the evaluating method. METHODS In a double-blind, randomized, placebo-controlled crossover study, 16 healthy female volunteers were randomized to one of two treatment sequences. The participants attended two study visits separated by at least 7 days' washout. At each visit, they received a single dose of 50 mg imipramine or matching placebo, in alternating order. We assessed the anal opening pressure under the resting state and during voluntary squeezing of the pelvic floor. Measurements were performed pre-dose and 1 h after drug administration, corresponding to the estimated time of peak plasma concentration of imipramine. RESULTS All participants completed the study. In total, 44% of the participants reported at least one adverse effect, primarily anticholinergic. Compared with placebo, imipramine increased anal opening pressure by 15.2 cmH2O (95% confidence interval [CI] 2.0-28.2 cmH2O, p = 0.03) in the resting state and 15.1 (95% CI 4.2-26.0 cmH2O, p = 0.01) cmH2O during squeezing. CONCLUSIONS The findings indicate that imipramine increases anal sphincter tone in healthy women. However, further research is required to evaluate its clinical impact on individuals with fecal incontinence. This research also demonstrates the effectiveness of using anal acoustic reflectometry for assessing pharmacological effects on anal sphincter function.
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Affiliation(s)
- Thea Christoffersen
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jonatan Kornholt
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Novo Nordisk A/S, Bagsvaerd, Denmark
| | - Troels Riis
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
| | - David P Sonne
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Klarskov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gynecology and Obstetrics, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Hiramoto B, Flanagan R, Muftah M, Shah ED, Chan WW. Centrally Distributed Adiposity as a Modifiable Risk Factor for Fecal Incontinence: United States Population-based Analysis. Clin Gastroenterol Hepatol 2024; 22:1908-1916.e1. [PMID: 38657883 PMCID: PMC11344694 DOI: 10.1016/j.cgh.2024.04.002] [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: 10/27/2023] [Revised: 02/14/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND AIMS Fecal incontinence (FI) is highly prevalent with substantial impacts on quality of life and health care utilization. The impact of obesity on FI remains unclear, with differing conclusions using body mass index (BMI) as a risk factor. We aimed to determine the association between obesity and FI, and whether this relationship is dependent on the distribution of adiposity (waist circumference-to-height ratio [WHtR]). METHODS This was a population-based analysis of the National Health and Nutrition Examination Survey, including participants who responded to the bowel health survey in 2005 to 2010. FI was defined by the accidental bowel leakage of solid stool, liquid, or mucus at least once in the past month. Stepwise multivariable logistic regression models were constructed to assess risk factors for FI. RESULTS A total of 7606 participants were included, with an overall FI prevalence of 9.2%. When stratified by quartiles of body measurements, FI was increasingly prevalent from the 1st to the 4th quartile for both WHtR (range, 5.3%-12.5%) and BMI (range, 7.1%-10.5%). WHtR was associated with FI and was a stronger predictor than BMI in all quartiles of body measurement. On multivariable analysis, WHtR remained a significant predictor of FI comparing the 4th with the 1st quartile of body measurements (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.11-2.80; P = .017), whereas BMI was not. A WHtR cutoff of >0.592 optimized the Youden index in prediction of FI in the overall sample. CONCLUSION WHtR was independently associated with increased odds of FI in this nationally representative sample of United States adults, whereas BMI was not consistently correlated. This suggests bowel continence may depend more on how body mass is distributed.
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Affiliation(s)
- Brent Hiramoto
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Ryan Flanagan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Mayssan Muftah
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Eric D Shah
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Swartz JL, Zifan A, Tuttle LJ, Sheean G, Tam RM, Mittal RK. Fecal incontinence patients categorized based on anal pressure and electromyography: Anal sphincter damage and clinical symptoms. Neurogastroenterol Motil 2024; 36:e14810. [PMID: 38689439 DOI: 10.1111/nmo.14810] [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: 12/26/2023] [Revised: 03/01/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Disruption of external anal sphincter muscle (EAS) is an important factor in the multifactorial etiology of fecal incontinence (FI). OBJECTIVES We categorize FI patients into four groups based on the location of lesion in neuromuscular circuitry of EAS to determine if there are differences with regards to fecal incontinence symptoms severity (FISI) score, age, BMI, obstetrical history, and anal sphincter muscle damage. METHODS Female patients (151) without any neurological symptoms, who had undergone high-resolution manometry, anal sphincter EMG, and 3D ultrasound imaging of the anal sphincter were assessed. Patients were categorized into four groups: Group 1 (normal)-normal cough EMG (>10 μV), normal squeeze EMG (>10 μV), and normal anal squeeze pressure (>124 mmHg); Group 2 (cortical apraxia, i.e., poor cortical activation)-normal cough EMG, low squeeze EMG, and low anal squeeze pressure; Group 3 (muscle damage)-normal cough EMG, normal squeeze EMG, and low anal squeeze pressure; and Group 4 (pudendal nerve damage)-low cough EMG, low squeeze EMG, and low anal squeeze pressure. RESULTS The four patient groups were not different with regards to the patient's age, BMI, parity, and FISI scores. 3D ultrasound images of the anal sphincter complex revealed significant damage to the internal anal sphincter, external anal sphincter, and puborectalis muscles in all four groups. CONCLUSION The FI patients are a heterogeneous group; majority of these patients have significant damage to the muscles of the anal sphincter complex. Whether biofeedback therapy response is different among different patient groups requires study.
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Affiliation(s)
- Jessica L Swartz
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ali Zifan
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
| | - Lori J Tuttle
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | | | - Rowena M Tam
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ravinder K Mittal
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
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Geng HZ, Xu C, Yu Y, Cong J, Zhang Z, Li Y, Chen Q. Ileorectal intussusception compared to end-to-end ileorectal anastomosis after laparoscopic total colectomy in slow-transit constipation. Curr Probl Surg 2024; 61:101471. [PMID: 38823891 DOI: 10.1016/j.cpsurg.2024.101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/30/2024] [Accepted: 03/03/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Hong Zhi Geng
- Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China; Department of Anorectal Surgery, Hepu People's Hospital, Beihai City, Guangxi Zhuang Autonomous Region, Beihai City, China
| | - Chen Xu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Yongjun Yu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Jiying Cong
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Zhao Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Yuwei Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Qilong Chen
- Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
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Leroi AM, Queralto M, Zerbib F, Siproudhis L, Vitton V, Amarenco G, Etienney I, Mion F, Bridoux V, Philip J, Brochard C, Damon H, Lacroix E, Gillibert A, Gourcerol G. Intrarectal injections of botulinum toxin versus placebo for the treatment of urge faecal incontinence in adults (FI-Toxin): a double-blind, multicentre, randomised, controlled phase 3 study. Lancet Gastroenterol Hepatol 2024; 9:147-158. [PMID: 38128556 DOI: 10.1016/s2468-1253(23)00332-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Non-randomised studies assessing intrarectal botulinum toxin type A (BoNTA) injections for faecal incontinence are promising. We aimed to evaluate the efficacy of BoNTA for the treatment of faecal incontinence in a randomised study. METHODS In this randomised, double-blind, placebo-controlled study, we included adult patients who had at least one urgency or faecal incontinence episode per week for at least 3 months and who had experienced a failure of conservative or surgical treatment from eight French specialist hospital units with the skills to manage patients with faecal incontinence. Patients were randomly assigned (1:1) by a central web form to receive intrarectal submucosal injections of either 200 units of BoNTA (Botox; Allergan, Irvine, CA, USA; BoNTA group) or an equivalent volume of saline (placebo group), stratified by Cleveland Clinic Severity scores (CCS score; ≥12 or <12). Patients, investigators, study site staff, and sponsor personnel were masked to treatment allocation up to the 6-month visit. The primary endpoint was the number of episodes of faecal incontinence and urgency per day assessed using 21-day patient bowel diaries 3 months after the treatment. The primary analysis was performed using a modified intention-to-treat (mITT) approach (ie, in all the randomised patients who had received a treatment) with adjustment for baseline faecal incontinence and urgency episodes. After the final data collection at 6 months after injections, patients were unmasked and offered the BoNTA treatment if they were in the placebo group (rescue therapy) without masking, with an additional 6 months of safety follow-up. This trial is registered with ClinicalTrials.gov, number NCT02414425. FINDINGS Between Nov 25, 2015, and Nov 25, 2020, we randomly assigned 200 patients to receive either BoNTA (n=100) or placebo (n=100) injections. Due to withdrawals before the injections, 96 patients were included in the BoNTA group and 95 patients were included in the placebo group (mITT analysis). The mean number of faecal incontinence and urgency episodes per day in the BoNTA group decreased from 1·9 (SD 2·2) at baseline to 0·8 (1·8) at 3 months after the injections, and from 1·4 (1·1) to 1·0 (1·0) in the placebo group, with a baseline-adjusted mean group difference at 3 months estimated at -0·51 (95% CI -0·80 to -0·21, p=0·0008). No serious treatment-related adverse events were reported in the trial. The most frequently reported non-serious adverse event (treatment related or not) following the BoNTA or placebo injections was constipation (reported in 68 [40%] of 169 patients who received the BoNTA injections and 38 [40%] of 95 patients who received placebo injections). INTERPRETATION BoNTA injections are an efficacious treatment for urge faecal incontinence. Further research will define the optimum selection criteria, dose, site of injection, re-injection frequency, and long-term results. FUNDING General Direction of Healthcare (French Ministry of Health).
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Affiliation(s)
- Anne-Marie Leroi
- Université de Rouen Normandie, Institut National de la Santé et de la Recherche Médicale (INSERM), ADEN UMR1073, Centre Hospitalier Universitaire (CHU) Rouen, Centre d'Investigation Clinique-Centre de Ressources Biologiques (CIC-CRB) 1404, Department of Digestive Physiology, Rouen, France.
| | - Michel Queralto
- Colproctology Unit, Clinique des Cèdres, Cornebarrieu, France
| | - Frank Zerbib
- CHU de Bordeaux, Centre Médico-chirurgical Magellan, Hôpital Haut-Levêque, Department of Gastroenterology, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Laurent Siproudhis
- Department of Gastroenterology, Inphy CIC1414, CHU Rennes, Université de Rennes 1, Rennes, France
| | - Véronique Vitton
- Department of Gastroenterology, Hôpital Nord, Assistance-Publique Hôpitaux de Marseille, Aix-Marseille Université, France
| | - Gérard Amarenco
- Sorbonne Université, Groupe de Recherche Clinique (GRC) 001, GREEN GRC en Neuro-Urologie, Assistance Publique - Hôpitaux de Paris, Tenon Hospital, Paris, France
| | - Isabelle Etienney
- Department of Coloproctology, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Francois Mion
- Université de Lyon, Department of Digestive Physiology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Valerie Bridoux
- Université de Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, Department of Digestive Surgery, Rouen, France
| | - Julie Philip
- Colproctology Unit, Clinique des Cèdres, Cornebarrieu, France
| | - Charlène Brochard
- Diseases of the Digestive Tract Department, Functional Digestive Explorations Division, Centre Hospitalier Régional Universitaire Pontchaillou, CIC1414, Université de Rennes 1, Rennes, France; INSERM U1235, Université de Nantes, Nantes, France
| | - Henri Damon
- Université de Lyon, Department of Digestive Physiology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Elie Lacroix
- Department of Biostatistics, CHU Rouen, Rouen, France
| | | | - Guillaume Gourcerol
- Université de Rouen Normandie, Institut National de la Santé et de la Recherche Médicale (INSERM), ADEN UMR1073, Centre Hospitalier Universitaire (CHU) Rouen, Centre d'Investigation Clinique-Centre de Ressources Biologiques (CIC-CRB) 1404, Department of Digestive Physiology, Rouen, France
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Varma R, Feuerhak KJ, Mishra R, Chakraborty S, Oblizajek NR, Bailey KR, Bharucha AE. A randomized double-blind trial of clonidine and colesevelam for women with fecal incontinence. Neurogastroenterol Motil 2024; 36:e14697. [PMID: 37890049 PMCID: PMC10842236 DOI: 10.1111/nmo.14697] [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: 06/25/2023] [Revised: 09/11/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Diarrhea and rectal urgency are risk factors for fecal incontinence (FI). The effectiveness of bowel modifiers for improving FI is unclear. METHODS In this double-blind, parallel-group, randomized trial, women with urge FI were randomly assigned in a 1:1 ratio to a combination of oral clonidine (0.1 mg twice daily) with colesevelam (1875 mg twice daily) or two inert tablets for 4 weeks. The primary outcome was a ≥50% decrease in number of weekly FI episodes. KEY RESULTS Fifty-six participants were randomly assigned to clonidine-colesevelam (n = 24) or placebo (n = 32); 51 (91%) completed 4 weeks of treatment. At baseline, participants had a mean (SD) of 7.5 (8.2) FI episodes weekly. The primary outcome was met for 13 of 24 participants (54%) treated with clonidine-colesevelam versus 17 of 32 (53%) treated with placebo (p = 0.85). The Bristol stool form score decreased significantly, reflecting more formed stools with clonidine-colesevelam treatment (mean [SD], 4.5 [1.5] to 3.2 [1.5]; p = 0.02) but not with placebo (4.2 [1.9] to 4.1 [1.9]; p = 0.47). The proportion of FI episodes for semiformed stools decreased significantly from a mean (SD) of 76% (8%) to 61% (10%) in the clonidine-colesevelam group (p = 0.007) but not the placebo group (61% [8%] to 67% [8%]; p = 0.76). However, these treatment effects did not differ significantly between groups. Overall, clonidine-colesevelam was well tolerated. CONCLUSIONS AND INFERENCES Compared with placebo, clonidine-colesevelam did not significantly improve FI despite being associated with more formed stools and fewer FI episodes for semiformed stools.
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Affiliation(s)
- Revati Varma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly J Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahul Mishra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Sjödahl J, Ingemansson A, Bureychak T, Norlin AK, Jones MP, Faresjö Å, Walter S. Defecation symptoms in primary health care patients with irritable bowel syndrome. Scand J Gastroenterol 2024; 59:16-24. [PMID: 37612888 DOI: 10.1080/00365521.2023.2248538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The objectives of the present study were to (a) measure the prevalence of defecation symptoms in IBS, (b) investigate the relationship between stool consistency and defecation symptoms in IBS, and (c) investigate the association of defecation symptoms with health-related quality of life (HRQL) and self-reported stress in patients with IBS cared for in a primary health care setting. METHODS Ten primary health care centres joined the study. 282 patients with IBS as well as 372 non-IBS controls filled in gastrointestinal symptom diaries prospectively for two weeks as well as the Perceived Stress Scale-14 (PSS14) and the EuroQol barometer to measure perceived stress and HRQL, respectively. RESULTS Incomplete evacuation was present in 51% vs. 21% of the stools among the IBS patients and the non-IBS controls, respectively. The need to strain during defecation was existing in 41% vs. 33% of the stools for the IBS patients and the non-IBS controls, respectively. Urgency was experienced in 37% of the stools in the IBS patients compared with 18% of the stools in the non-IBS controls. Patients with IBS experienced in a significant higher degree of overlapping symptoms per stool (p < 0.001 to p = 0.007). The occurrence of all defecation symptoms in the same patient was related to decreased HRQL, and increased stress (p = 0.001 to p < 0.001). CONCLUSIONS An overlap between IBS and symptoms from the anorectal region related to defecation was found in a primary health care population. Defecation symptoms are very common in primary care IBS-patients, it co-occurs with increased self-perceived stress, and decreased HRQL.
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Affiliation(s)
- Jenny Sjödahl
- Department of Gastroenterology, University Hospital Linköping, County Council of Östergötland, Linköping, Sweden
| | - Anna Ingemansson
- Department of Gastroenterology, University Hospital Linköping, County Council of Östergötland, Linköping, Sweden
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Tetyana Bureychak
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Anna-Karin Norlin
- Pain and Rehabilitation Centre and Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linköping, Sweden
| | - Michael P Jones
- School of Psychological Sciences, Macquarie University, North Ryde, NSW, Australia
| | - Åshild Faresjö
- Department of Health, Medicine and Caring Sciences (HMV), Division of Society and Health/Public Health, Linköping University, Linköping, Sweden
| | - Susanna Walter
- Department of Gastroenterology, University Hospital Linköping, County Council of Östergötland, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences (HMV), Division of Diagnostics and Specialist Medicine, Linköping University, Linköping, Sweden
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Lan N, Smukalla STM, Chang S. Fecal Incontinence and Defecatory Disorders in Patients With Ileal Pouch-Anal Anastomosis. Gastroenterol Hepatol (N Y) 2023; 19:41-47. [PMID: 36865815 PMCID: PMC9972658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Functional anorectal disorders are common in patients with ileal pouch-anal anastomosis (IPAA) and often have a debilitating impact on quality of life. The diagnosis of functional anorectal disorders, including fecal incontinence (FI) and defecatory disorders, requires a combination of clinical symptoms and functional testing. Symptoms are generally underdiagnosed and underreported. Commonly utilized tests include anorectal manometry, balloon expulsion test, defecography, electromyography, and pouchoscopy. The treatment for FI begins with lifestyle modifications and medications. Sacral nerve stimulation and tibial nerve stimulation have been trialed on patients with IPAA and FI, resulting in improvement in symptoms. Biofeedback therapy has also been used in patients with FI but is more commonly utilized in defecatory disorders. Early diagnosis of functional anorectal disorders is important because a response to treatment may significantly improve a patient's quality of life. To date, there is limited literature describing the diagnosis and treatment of functional anorectal disorders in patients with IPAA. This article focuses on the clinical presentation, diagnosis, and treatment of FI and defecatory disorders in patients with IPAA.
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Affiliation(s)
- Nan Lan
- 1Department of Gastroenterology, Columbia University Irving Medical Center, New York, New York
| | - Scot t M. Smukalla
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
| | - Shannon Chang
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
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9
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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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10
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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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Desprez C, Gourcerol G, Savoye‐Collet C, Bridoux V, Duflot T, Leroi A. Relationship between anal functional lumen imaging probe (EndoFLIP®) results and the clinical presentation of faecal incontinence. Colorectal Dis 2022; 24:1379-1389. [PMID: 35717676 PMCID: PMC9795963 DOI: 10.1111/codi.16225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
AIM Faecal incontinence (FI) subtypes (urge, passive, mixed) are linked to the physiopathological mechanism of FI. Previous studies have failed to demonstrate a consistent relationship between FI subtype and anal sphincter dysfunction. Our aim was to evaluate the relationship between anal sphincter function, assessed using the new EndoFLIP® technology, and FI subtype. METHOD Patients referred for FI were prospectively enrolled between October 2015 and May 2021 in a registry, and data were retrospectively examined. Each patient underwent a clinical assessment as well as three-dimensional high-resolution or water-perfused anorectal manometry, anal EndoFLIP®, and anorectal electrophysiological and endoanal ultrasound tests. The results of the investigations were compared across FI subtypes. RESULTS The cohort included 133 patients, 54 (41%) of whom met the criteria for urge FI, 40 (30%) for passive FI and 39 (29%) for mixed FI. The resting anal distensibility index (DI) at 50 ml of distension was significantly lower in patients with urge FI than in patients with passive FI (p = 0.04). At rest, a DI at 50 ml of distension ≥7.3 mm2 mmHg-1 and a DI at 40 ml of distension <1.3 mm2 mmHg-1 were associated with the passive and urge FI subtypes, respectively, with poor discriminatory power (an accuracy of 0.49 compared with 0.33 for random assignment). There were no differences in anorectal manometry, endoanal ultrasound or electrophysiological test results among the urge, passive and mixed FI subgroups (all p > 0.05). CONCLUSION The anal sphincter DI using the EndoFLIP® system displayed poor predictive performance in distinguishing among FI subtypes.
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Affiliation(s)
- Charlotte Desprez
- Department of Digestive PhysiologyRouen University HospitalRouenFrance
| | - Guillaume Gourcerol
- Department of Digestive Physiology, CIC‐CRB 1404, Inserm U1073, CHU Rouen'Normandie Université, UNIROUENRouenFrance
| | | | - Valérie Bridoux
- Department of Digestive Surgery, Inserm U1073'Normandie Université, UNIROUEN, CHU RouenRouenFrance
| | - Thomas Duflot
- Department of Pharmacology'Normandie Université, UNIROUEN, Inserm U1096, CHU RouenRouenFrance
| | - Anne‐Marie Leroi
- Department of Digestive Physiology, CIC‐CRB 1404, Inserm U1073, CHU Rouen'Normandie Université, UNIROUENRouenFrance
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12
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Perrin S, Billecocq S. Impact des lésions obstétricales du levator ani sur la continence anale. Prog Urol 2022; 32:1519-1530. [DOI: 10.1016/j.purol.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/27/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
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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: 18] [Impact Index Per Article: 9.0] [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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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: 24] [Impact Index Per Article: 12.0] [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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15
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MRI measurements predict major low anterior resection syndrome in rectal cancer patients. Int J Colorectal Dis 2022; 37:1239-1249. [PMID: 35503128 DOI: 10.1007/s00384-022-04169-9] [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] [Accepted: 04/22/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Current low anterior resection syndrome (LARS) score is lagging behind and only based on clinical symptoms patient described. Preoperative imaging indicators which can be used to predict LARS is unknown. We proposed preoperative MRI parameters for identifying major LARS. METHODS Patients receiving curative restorative anterior resection from Sept. 2007 to Sept. 2015 were collected to complete LARS score (median 75.7 months since surgery). MRI measurements associated with LARS were tested, and a multivariate logistic model was conducted for predicting LARS. Receiver operating characteristic curve was used to evaluate the model. RESULTS Two hundred fifty-five patients undergoing neoadjuvant chemoradiotherapy and 72 patients undergoing direct surgery were enrolled. The incidence of major LARS in NCRT group was significantly higher (53.3% vs.34.7%, P = 0.005). In patients with neoadjuvant chemoradiotherapy, the thickness of ARJ (TARJ), the distance between the tumor's lower edge and anal rectal joint (DTA), and sex were independent factors for predicting major LARS; ORs were 0.382 (95% CI, 0.198-0.740), 0.653 (95% CI, 0.565-0.756), and 0.935 (95% CI, 0.915-0.955). The AUC of the multivariable model was 0.842 (95% CI, 0.794-0.890). In patients with direct surgery, only DTA was the independent factor for predicting major LARS; OR was 0.958 (95% CI, 0.930-0.988). The AUC was 0.777 (95% CI: 0.630-0.925). CONCLUSIONS Baseline MRI measurements have the potential to predict major LARS in rectal cancer, which will benefit the decision-making and improve patients' life quality.
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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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Rasijeff AMP, García‐Zermeño K, Di Tanna G, Remes‐Troche J, Knowles CH, Scott MS. Systematic review and meta-analysis of anal motor and rectal sensory dysfunction in male and female patients undergoing anorectal manometry for symptoms of faecal incontinence. Colorectal Dis 2022; 24:562-576. [PMID: 35023242 PMCID: PMC9303800 DOI: 10.1111/codi.16047] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 02/01/2023]
Abstract
AIM Manometry is the best established technique to assess anorectal function in faecal incontinence. By systematic review, pooled prevalences of anal hypotonia/hypocontractility and rectal hypersensitivity/hyposensitivity in male and female patients were determined in controlled studies using anorectal manometry. METHODS Searches of MEDLINE and Embase were completed. Screening, data extraction and bias assessment were performed by two reviewers. Meta-analysis was performed based on a random effects model with heterogeneity evaluated by I2 . RESULTS Of 2116 identified records, only 13 studies (2981 faecal incontinence patients; 1028 controls) met the inclusion criteria. Anal tone was evaluated in 10 studies and contractility in 11; rectal sensitivity in five. Only three studies had low risk of bias. Pooled prevalence of anal hypotonia was 44% (95% CI 32-56, I2 = 96.35%) in women and 27% (95% CI 14-40, I2 = 94.12%) in men. The pooled prevalence of anal hypocontractility was 69% (95% CI 57-81; I2 = 98.17%) in women and 36% (95% CI 18-53; I2 = 96.77%) in men. Pooled prevalence of rectal hypersensitivity was 10% (95% CI 4-15; I2 = 80.09%) in women and 4% (95% CI 1-7; I2 = 51.25%) in men, whereas hyposensitivity had a pooled prevalence of 7% (95% CI 5-9; I2 = 0.00%) in women compared to 19% (95% CI 15-23; I2 = 0.00%) in men. CONCLUSIONS The number of appropriately controlled studies of anorectal manometry is small with fewer still at low risk of bias. Results were subject to gender differences, wide confidence intervals and high heterogeneity indicating the need for international collective effort to harmonize practice and reporting to improve certainty of diagnosis.
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Affiliation(s)
- Annika M. P. Rasijeff
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Karla García‐Zermeño
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Gian‐Luca Di Tanna
- George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - José Remes‐Troche
- Instituto de Investigaciones Médico BiológicasUniversidad VeracruzanaVeracruzMéxico
| | - Charles H. Knowles
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
| | - Mark S. Scott
- National Bowel Research Centre and GI Physiology UnitBlizard InstituteCentre for Neuroscience, Surgery & TraumaQueen Mary University of LondonLondonUK
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Banasiuk M, Dziekiewicz M, Dobrowolska M, Skowrońska B, Dembiński Ł, Banaszkiewicz A. Three-dimensional High-resolution Anorectal Manometry in Children With Non-retentive Fecal Incontinence. J Neurogastroenterol Motil 2022; 28:303-311. [PMID: 35362455 PMCID: PMC8978114 DOI: 10.5056/jnm20216] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/14/2021] [Accepted: 05/07/2021] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Three-dimensional high-resolution anorectal manometry (3D-HRAM) is a precise tool to assess the function of the anorectum. Our aim is to evaluate children diagnosed with non-retentive fecal incontinence (NRFI) using 3D-HRAM. Methods In all children diagnosed with NRFI, manometric parameters and 3-dimensional reconstructions of the anal canal subdivided into 8 segments were recorded. All data were compared to raw data that were obtained from asymptomatic children, collected in our laboratory and published previously (C group). Results Forty children (31 male; median age, 8 years; range, 5-17) were prospectively included in the study. Comparison of the NRFI group and C group revealed lower values of mean resting pressure (74.4 mmHg vs 89.2 mmHg, P < 0.001) and maximum squeeze pressure (182 mmHg vs 208.5 mmHg, P = 0.018) in the NRFI group. In the NRFI group, the thresholds of sensation, urge and discomfort (40 cm3, 70 cm3, and 140 cm3, respectively) were significantly higher than those in the C group (20 cm3, 30 cm3, and 85 cm3, respectively; P < 0.001). In the NRFI group, 62.5% presented a mean resting pressure above the fifth percentile, and 82.5% of patients presented a maximum squeeze pressure above the fifth percentile. The comparisons between segments obtained from these patients and those obtained from the C group revealed several segments with significantly decreased pressure values in the NRFI group. Conclusions Our study demonstrated lower pressure parameters in children with NRFI. In patients with normal resting pressures, 3D-HRAM may reveal segments with decreased pressures, which may play a potential role in the pathomechanism of incontinence.
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Affiliation(s)
- Marcin Banasiuk
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Marcin Dziekiewicz
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Magdalena Dobrowolska
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Barbara Skowrońska
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
| | - Łukasz Dembiński
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Poland
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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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Mittal RK, Tuttle LJ. Anorectal Anatomy and Function. Gastroenterol Clin North Am 2022; 51:1-23. [PMID: 35135656 DOI: 10.1016/j.gtc.2021.10.001] [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: 02/21/2023]
Abstract
Anatomy of pelvic floor muscles has long been controversial. Novel imaging modalities, such as three-dimensional transperineal ultrasound imaging, MRI, and diffusion tensor imaging, have revealed unique myoarchitecture of the external anal sphincter and puborectalis muscle. High-resolution anal manometry, high-definition anal manometry, and functional luminal imaging probe are important new tools to assess anal sphincter and puborectalis muscle function. Increased understanding of the structure and function of anal sphincter complex/pelvic floor muscle has improved the ability to diagnose patients with pelvic floor disorders. New therapeutic modalities to treat anal/fecal incontinence and other pelvic floor disorders will emerge in the near future.
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Affiliation(s)
- Ravinder K Mittal
- Department of Medicine/Gastroenterology, University of California, San Diego, ACTRI, 9500 Gilman Drive, MC 0061, La Jolla, CA 92093-0990, USA.
| | - Lori J Tuttle
- Department of Medicine/Gastroenterology, University of California, San Diego, USA; San Diego State University, San Diego, CA, USA
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Sorkhi S, Seo Y, Bhargava V, Rajasekaran MR. Preclinical applications of high-definition manometry system to investigate pelvic floor muscle contribution to continence mechanisms in a rabbit model. Am J Physiol Gastrointest Liver Physiol 2022; 322:G134-G141. [PMID: 34877885 PMCID: PMC8742739 DOI: 10.1152/ajpgi.00295.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
External anal sphincter (EAS), external urethral sphincters, and puborectalis muscle (PRM) have important roles in the genesis of anal and urethral closure pressures. In the present study, we defined the contribution of these muscles alone and in combination with the sphincter closure function using a rabbit model and a high-definition manometry (HDM) system. A total of 12 female rabbits were anesthetized and prepared to measure anal, urethral, and vaginal canal pressures using a HDM system. Pressure was recorded at rest and during electrical stimulation of the EAS and PRM. A few rabbits (n = 6) were subjected to EAS injury and the impact of EAS injury on the closure pressure profile was also evaluated. Anal, urethral, and vaginal canal pressures recorded at rest and during electrical stimulation of EAS and PRM demonstrated distinct pressure profiles. EAS stimulation induced anal canal pressure increase, whereas PRM stimulation increased the pressures in all the three orifices. Electrical stimulation of EAS after injury resulted in about 19% decrease in anal canal pressure. Simultaneous electrical stimulation of EAS and PRM resulted in an insignificant increase of individual anal canal pressures when compared with pressures recorded after EAS or PRM stimulations alone. Our data confirm that HDM is a viable system to measure dynamic pressure changes within the three orifices and to define the role of each muscle in the development of closure pressures within these orifices in preclinical studies.NEW & NOTEWORTHY We anticipate that with this new HDM technology, physiological changes within these orifices may be redefined using the extensive data that are generated from 96 sensors. When compared with conventional methods, HDM offers the advantages of an increased response rate, as well as the utilization of 96 circumferential sensors to simultaneously measure pressure along the three orifices. Our findings suggest a potential use of this technology to better define urinary leak point pressure.
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Affiliation(s)
- Samuel Sorkhi
- 1Department of Urology, University of California San Diego Medical Center, San Diego, California
| | - Youngjin Seo
- 1Department of Urology, University of California San Diego Medical Center, San Diego, California
| | - Valmik Bhargava
- 2Department of Medicine, University of California San Diego Medical Center, San Diego, California
| | - Mahadevan Raj Rajasekaran
- 1Department of Urology, University of California San Diego Medical Center, San Diego, California,3San Diego Veterans Affairs Health Care System, San Diego, California
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Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat Rev Gastroenterol Hepatol 2021; 18:751-769. [PMID: 34373626 DOI: 10.1038/s41575-021-00487-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.
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ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol 2021; 116:1987-2008. [PMID: 34618700 DOI: 10.14309/ajg.0000000000001507] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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Comparison of Patient Impact and Clinical Characteristics Between Urgency and Passive Fecal Incontinence Phenotypes. Female Pelvic Med Reconstr Surg 2021; 26:570-574. [PMID: 29979355 DOI: 10.1097/spv.0000000000000603] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine if categorizing fecal incontinence (FI) as urgency or passive FI is clinically meaningful, we compared clinical severity, quality of life, physical examination findings, and functional and anatomic deficits between women with urgency and passive FI. METHODS This study is a prospective cross-sectional study of women with at least monthly FI. All women completed the St Mark's Vaizey and the Fecal Incontinence Quality of Life questionnaires and underwent anorectal manometry and endoanal ultrasound. We compared women with urgency FI to women with passive FI. RESULTS Forty-six women were enrolled, 21 (46%) with urgency FI and 25 (54%) with passive FI. Clinical severity by Vaizey score did not differ between groups (urgency 11.7 ± 1.6 vs passive 11.0 ± 1.0, P = 0.51). Women with urgency FI had worse median (range) lifestyle and coping scores than passive FI (Fecal Incontinence Quality of Life: lifestyle domain 2.5 [1, 4] vs 3.8 [1, 4], P = 0.04; coping domain 1.7 [1, 3] vs 2.4 [0.9, 4], P < 0.01). Women with urgency FI had higher anal resting and squeeze pressure than passive FI (60 ± 4 mm Hg vs 49 ± 3 mm Hg, P = 0.03; 78 [48, 150] mm Hg vs 60 [40, 103], P = 0.05). Internal anal sphincter defects were more common in women with passive FI (41.7% vs 30.0%, P = 0.53) and external anal sphincter defects more common in women with urgency FI (25% vs 16.7%, P = 0.71), but this did not reach statistical significance. CONCLUSIONS We identified functional and anatomic differences between women with urgency FI and passive FI. Pheonotyping women with FI into these subtypes is clinically meaningful.
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Litta F, Marra AA, Ortega Torrecilla N, Orefice R, Parello A, De Simone V, Campennì P, Goglia M, Ratto C. Implant of Self-Expandable Artificial Anal Sphincter in Patients With Fecal Incontinence Improves External Anal Sphincter Contractility. Dis Colon Rectum 2021; 64:706-713. [PMID: 33496487 DOI: 10.1097/dcr.0000000000001857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND External anal sphincter contractility significantly contributes to control the passage of stool. An artificial anal sphincter placed into the intersphincteric space is a safe and effective procedure to treat fecal incontinence, even if its mechanism of action has not been fully elucidated. OBJECTIVE The aim of this study was to evaluate external anal sphincter contractility changes after a self-expandable hyexpan prostheses was implanted into the intersphincteric space of the anal canal and clinical outcomes compared. DESIGN This was a prospective clinical study. SETTINGS The study was conducted at a university teaching hospital. PATIENTS Consecutive patients affected by fecal incontinence for at least 6 months after failure of conservative treatment were included. INTERVENTIONS All of the patients underwent 10-prostheses implantation and were examined preoperatively and postoperatively by endoanal ultrasound and anorectal manometry. MAIN OUTCOME MEASURES Fecal incontinence symptoms were assessed by severity scores. The external anal sphincter muscle tension was calculated using a specific equation. RESULTS Thirty-nine patients (34 women; median age = 68 y) were included in the study; no morbidity was registered. After a median follow-up period of 14 months, both the median maximum voluntary squeeze pressure and the median inner radius of the external anal sphincter significantly increased. A statistically significant increase of external anal sphincter muscle tension was detected. A decrease of any fecal incontinence symptom and an improvement in severity scores were observed at the last follow-up examination. The external anal sphincter contractility was significantly higher in patients reducing incontinence episodes to solid stool by >50% and improving their ability to defer defecation for >15 minutes. LIMITATIONS This was a single-center experience with a relatively small and heterogeneous sample size, patients with a potentially more severe disease because our institution is a referral center, and an absence of quality-of-life evaluation. CONCLUSIONS Artificial anal sphincter implantation improved the external anal sphincter muscle tension; there was a positive correlation between its increase and the clinical outcome. See Video Abstract at http://links.lww.com/DCR/B468. IMPLANTE DE ESFNTER ANAL ARTIFICIAL AUTOEXPANDIBLE EN PACIENTES CON INCONTINENCIA FECAL MEJORA LA CONTRACTILIDAD DEL ESFNTER ANAL EXTERNO ANTECEDENTES:La contractilidad del esfínter anal externo contribuye significativamente al control del paso de las heces. Un esfínter anal artificial colocado en el espacio interesfinteriano es un procedimiento seguro y eficaz para tratar la incontinencia fecal, incluso si su mecanismo de acción no se ha definido por completo.OBJETIVO:El objetivo de este estudio fue evaluar los cambios en la contractilidad del esfínter anal externo después de la implantación de una prótesis de hyexpan autoexpandible en el espacio interesfinteriano del canal anal y comparar los resultados clínicos.DISEÑO:Estudio clínico prospectivo.ENTORNO CLINICO:El estudio se realizó en un hospital universitario.PACIENTES:Pacientes consecutivos afectados por incontinencia fecal durante al menos 6 meses, tras fracaso de tratamiento conservador.INTERVENCIONES:Todos los pacientes fueron sometidos a la implantación de 10 prótesis, y fueron examinados pre y postoperatoriamente mediante ecografía endoanal y manometría anorrectal.PRINCIPALES MEDIDAS DE VALORACION:Los síntomas de incontinencia fecal se evaluaron mediante puntuaciones de gravedad. La tensión del músculo del esfínter anal externo se calculó mediante una formula específica.RESULTADOS:Treinta y nueve pacientes (34 mujeres; mediana de edad 68 años) fueron incluidos en el estudio; no se registró morbilidad. Después de un período de seguimiento medio de 14 meses, tanto la presión de compresión voluntaria máxima media como el radio interior medio del esfínter anal externo aumentaron significativamente. Se detectó un aumento estadísticamente significativo de la tensión del músculo del esfínter anal externo. En el último examen de seguimiento se observó una disminución de cualquier síntoma de incontinencia fecal y una mejora en las puntuaciones de gravedad. La contractilidad del esfínter anal externo fue significativamente mayor en los pacientes que redujeron los episodios de incontinencia a heces sólidas en más del 50% y mejoraron la capacidad para diferir la defecación durante más de 15 minutos.LIMITACIONES:Experiencia de un solo centro; tamaño de muestra relativamente pequeño y heterogéneo; pacientes con una enfermedad potencialmente más grave porque nuestra institución es un centro de referencia; ausencia de evaluación de la calidad de vida.CONCLUSIONES:La implantación del esfínter anal artificial mejoró la tensión muscular del esfínter anal externo; hubo una correlación positiva entre su aumento y el resultado clínico. Consulte Video Resumen en http://links.lww.com/DCR/B468.
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Affiliation(s)
- Francesco Litta
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Angelo A Marra
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | | | - Raffaele Orefice
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Angelo Parello
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Veronica De Simone
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Paola Campennì
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Marta Goglia
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
| | - Carlo Ratto
- Proctology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Sbeit W, Khoury T, Mari A. Diagnostic approach to faecal incontinence: What test and when to perform? World J Gastroenterol 2021; 27:1553-1562. [PMID: 33958842 PMCID: PMC8058654 DOI: 10.3748/wjg.v27.i15.1553] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/01/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Mari
- Gastroenterology and Endoscopy Unit, The Nazareth Hospital, EMMS, Nazareth 464000, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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Abstract
Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.
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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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Kim H, Shim J, Seo Y, Lee C, Chang Y. What Is Fecal Incontinence That Urologists Need to Know? Int Neurourol J 2021; 25:23-33. [PMID: 33504128 PMCID: PMC8022170 DOI: 10.5213/inj.2040240.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/26/2020] [Indexed: 12/13/2022] Open
Abstract
Fecal incontinence (FI) undoubtedly reduces quality of life and adversely affects the social life of the affected individual. FI has a higher prevalence with age and has an equivalent prevalence to urinary incontinence in patients with genitourinary disease, but is often not confirmed in these cases. A thorough investigation is needed to diagnose FI, with the common etiology of this condition in mind, and several questionnaires can be used to identify symptoms. The physical examination contains digital rectal examination carries out to identify the patient's condition. Ultrasound, colonoscopy, and rectum pressure test can be performed. Patients educated in diet-related issues, bowel movements, and defecation mechanism. Nonoperative options such as diet control and Kegel exercise should be performed at first. Surgical treatment of FI is considered when conservative management and oral medications produce no improvement. Surgical options include less invasive procedures like bulking agent injections, and more involved approaches from sacral nerve stimulation to invasive direct sphincter repair and artificial bowel sphincter insertion. Good outcomes in FI cases have also recently been reported for barrier devices.
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Affiliation(s)
- HongWook Kim
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea
- Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Jisung Shim
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Yumi Seo
- Department of Urology, Dankook University College of Medicine, Cheonan, Korea
| | - Changho Lee
- Department of Urology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Youngseop Chang
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea
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Sharma M, Feuerhak K, Corner SM, Manduca A, Bharucha AE. A new method for assessing anal distensibility with a barostat and magnetic resonance imaging in healthy and constipated women. Neurogastroenterol Motil 2021; 33:e13972. [PMID: 32815246 PMCID: PMC7864861 DOI: 10.1111/nmo.13972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/08/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Defecation requires relaxation of the internal and external anal sphincters. High anal resting pressure is associated with painful constipation, defecatory disorders, and increased healthcare utilization in constipated patients; the mechanisms are unclear. Perhaps patients with a high anal resting pressure have a less distensible canal, which impedes defecation. METHODS In 50 of 64 participants (33 healthy and 17 constipated women), anal pressures and distensibility were measured, respectively, with manometry and balloon distention combined with magnetic resonance imaging; rectal balloon expulsion time (BET) was also studied. RESULTS The BET (P = .006) was longer, and the mean (SD) rectoanal pressure gradient (-58[40] vs -34[26] mm Hg, P = .03) was more negative in constipated than healthy women; anal resting pressure was not different. During anal distention, the balloon expanded rapidly at an opening pressure of 49 (18) mm Hg, which was lower (P < .0001) than resting pressure (90 [25] mm Hg). The resting pressure was correlated with the opening pressure (r = 0.57, P < .0001) and inversely (r = -0.38, P = .007) with maximum volume but not with anal distensibility (volume-pressure slope). In healthy women, the difference (opening-resting pressure) was correlated with anal relaxation during evacuation (r = 0.35, P = .04). Anal distensibility and sensory thresholds were not different between constipated and healthy women. CONCLUSIONS Among healthy and constipated women, a greater anal resting pressure is correlated with greater opening pressure and lower maximum volume during distention, and, hence, provides a surrogate marker of anal distensibility. The difference (opening-resting pressure), which reflects anal relaxation during distention, is correlated with anal relaxation during evacuation. Anal resting pressure and distensibility were comparable in healthy and constipated women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Armando Manduca
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Personality of patients with fecal incontinence. Int J Colorectal Dis 2021; 36:331-337. [PMID: 33000298 DOI: 10.1007/s00384-020-03758-w] [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] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Although idiopathic fecal incontinence (FI) patients have some psychological characteristics, the personality of FI patients was not described. The present study aims to describe the clinical and personality characteristics of FI patients. PATIENTS AND METHODS This retrospective observational study included 996 outpatients, 72 with fecal incontinence. They filled out the Rome III diagnostic questionnaire, the personality inventory MMPI-2, the questionnaires for urological and sexual disorders, and Likert scales for bowel disorders perceived symptom severity. The main outcome measures were the presence in FI patients of functional gastrointestinal disorders, the self-reported symptom severity, and the personality profile. RESULTS Patients were mainly females (72%). FI patients were characterized by higher age (P = 0.015), and by a higher prevalence of functional diarrhea (P = 0.001), urological (P = 0.001), and sexual disorders (P = 0.005). These patients also report higher diarrhea severity (P < 0.001) and lower abdominal pain severity (P = 0.009). The personality of FI patients is distinguished by a higher score for psychopathic deviate (P = 0.006), social responsibility (P = 0.003), Mac Andrew revised scale (P = 0.005), and antisocial practice (P = 0.007), and a lower score for type A behavior (P = 0.005). CONCLUSION FI patients are characterized not only by older age, and a high prevalence of diarrhea but also by a specific personality profile characterized by an unfavorable comparison with others.
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Ambartsumyan L, Shaffer M, Carlin K, Nurko S. Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation. Neurogastroenterol Motil 2021; 33:e13971. [PMID: 32902923 DOI: 10.1111/nmo.13971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/07/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal. AIMS To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity). METHODS HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups. KEY RESULTS 3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence. CONCLUSIONS AND INFERENCES Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.
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Affiliation(s)
- Lusine Ambartsumyan
- Division of Gastroenterology & Hepatology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michele Shaffer
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kristen Carlin
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts, USA
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Maeda K, Yamana T, Takao Y, Mimura T, Katsuno H, Seki M, Tsunoda A, Yoshioka K. Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version. J Anus Rectum Colon 2021; 5:52-66. [PMID: 33537501 PMCID: PMC7843140 DOI: 10.23922/jarc.2020-057] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022] Open
Abstract
Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).
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Affiliation(s)
- Kotaro Maeda
- International Medical Center Fujita Health University Hospital, Toyoake, Japan
| | - Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshihiko Takao
- Division of Colorectal Surgery, Department of Surgery, Sanno Hospital, Tokyo, Japan
| | - Toshiki Mimura
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Mihoko Seki
- Nursing Division, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Kazuhiko Yoshioka
- Department of Surgery, Kansai Medical University Medical Center, Osaka, Japan
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Maeda K, Mimura T, Yoshioka K, Seki M, Katsuno H, Takao Y, Tsunoda A, Yamana T. Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version. J Anus Rectum Colon 2021; 5:67-83. [PMID: 33537502 PMCID: PMC7843146 DOI: 10.23922/jarc.2020-079] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.
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Affiliation(s)
- Kotaro Maeda
- International Medical Center Fujita Health University Hospital, Toyoake, Japan
| | - Toshiki Mimura
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Kazuhiko Yoshioka
- Department of Surgery, Kansai Medical University Medical Center, Osaka, Japan
| | - Mihoko Seki
- Nursing Division, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Yoshihiko Takao
- Division of Colorectal Surgery, Department of Surgery, Sanno Hospital, Tokyo, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center, Tokyo, Japan
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Rangan V, Nee J, Singh P, Ballou S, Iturrino J, Hirsch W, Lembo A. Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea. Dig Dis Sci 2020; 65:3679-3687. [PMID: 32468228 DOI: 10.1007/s10620-020-06349-5] [Citation(s) in RCA: 2] [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: 07/06/2019] [Accepted: 05/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear. METHODS We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3 months. RESULTS A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea. CONCLUSIONS In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - William Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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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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Remes-Troche J, Valdovinos-Diaz M, Viebig R, Defilippi C, Bustos-Fernández L, Sole L, Hani-Amador A. Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [PMCID: PMC7603990 DOI: 10.1016/j.rgmxen.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The COVID 19 pandemic has forced the establishment of measures to avoid contagion during diagnostic and therapeutic tests in gastroenterology. Gastrointestinal motility studies involve a high and intermediate risk of transmission of infection by this virus. Given its elective or non-urgent indication in most cases, we recommend deferring the performance of these tests until there is a significant control of the infection rate in each country, during the pandemic. When health authorities allow a return to normalcy and in the absence of effective treatment or a preventive vaccine for COVID 19 infection, we recommend a strict protocol to classify patients according to their infectious-contagious status through the appropriate use of tests to detect the virus and its immune response, as well as the use of protective measures to be followed by health personnel to avoid contagion during the performance of a gastrointestinal motility test.
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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: 11] [Impact Index Per Article: 2.8] [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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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Latest Advances in Intersphincteric Resection for Low Rectal Cancer. Gastroenterol Res Pract 2020; 2020:8928109. [PMID: 32765603 PMCID: PMC7387965 DOI: 10.1155/2020/8928109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.
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Anorectal Functional Outcomes Following Doppler-Guided Transanal Hemorrhoidal Dearterialization: Evidence from Vietnam. Adv Ther 2020; 37:1136-1144. [PMID: 31997241 DOI: 10.1007/s12325-020-01238-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Doppler-guided transanal hemorrhoidal dearterialization (THD) was considered a less invasive and innovative method to treat hemorrhoidal disease, but it may impact the anal area during dearterialization and mucopexy. Thus, this study aimed to assess any changes in anorectal manometry of grade III and IV hemorrhoidal patients following THD treatment. METHODS This prospective observational study was conducted with patients who had grades III and IV hemorrhoidal disease. The patients were treated using THD at the Department of Surgery in the National Hospital of Traditional Medicine (Hanoi, Vietnam) between June 2012 and December 2013. Anorectal manometry was performed prior to THD and again between 6 and 12 months following the procedure. RESULTS A total of 40 patients were enrolled in the study, including 32 with grade III hemorrhoids and 8 with grade IV hemorrhoids. The proportion of male patients (65%) was higher than that of female patients (35%), and the majority of patients (82.5%) were > 40 years old. The mean duration of symptoms prior to treatment was 12.3 years. The mean length of the anal sphincter was unchanged before and after THD (3.64 ± 0.40 cm prior to treatment vs. 3.66 ± 0.48 cm following treatment; p = 0.57). Significant differences in treatment-related changes were detected for all anorectal manometric measurements except maximum squeezing pressure (p < 0.05). No patient showed anal stenosis or fecal incontinence. CONCLUSION The THD technique did not change the length of the anal sphincter 6 months after hemorrhoid treatment. The values of anal pressure and rectal sensation decreased almost significantly between treatment and the follow-up visit. We suggest that further studies, which include larger sample sizes, should be conducted to confirm THD effectiveness in terms of anorectal functions.
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Remes-Troche JM, Valdovinos-Díaz MA, Viebig R, Defilippi C, Bustos-Fernández LM, Sole L, Hani-Amador AC. Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2020; 85:428-436. [PMID: 32773251 PMCID: PMC7833070 DOI: 10.1016/j.rgmx.2020.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/28/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022]
Abstract
The COVID-19 pandemic has forced the establishment of preventive measures against contagion during the performance of diagnostic and therapeutic tests in gastroenterology. Digestive tract motility tests involve an intermediate and elevated risk for the transmission of COVID-19 infection. Given their elective or non-urgent indication in the majority of cases, we recommend postponing those tests until significant control of the infection rate in each Latin American country has been achieved during the pandemic. When the health authorities allow the return to normality, and in the absence of an effective treatment for or preventive vaccine against COVID-19 infection, we recommend a strict protocol for classifying patients according to their infectious-contagious status through the appropriate use of tests for the detection of the virus and the immune response to it, and the following of protective measures by the healthcare personnel to prevent contagion during the performance of a gastrointestinal motility test.
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Affiliation(s)
- J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México.
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R Viebig
- Instituto Brasileiro de Estudos e Pesquisas de Gastroenterología e Especialidades, São Paulo, Brasil
| | - C Defilippi
- Sección de Gastroenterología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | | | - L Sole
- Consultorios de Motilidad Digestiva (CMD), Buenos Aires, Argentina
| | - A C Hani-Amador
- Unidad de Gastroenterología Hospital San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
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Zifan A, Mittal RK, Kunkel DC, Swartz J, Barr G, Tuttle LJ. Loop analysis of the anal sphincter complex in fecal incontinent patients using functional luminal imaging probe. Am J Physiol Gastrointest Liver Physiol 2020; 318:G66-G76. [PMID: 31736339 PMCID: PMC6985842 DOI: 10.1152/ajpgi.00164.2019] [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] [Indexed: 01/31/2023]
Abstract
Cardiac loops have been used extensively to study myocardial function. With changes in cardiac pump function, loops are shifted to the right or left. Functional luminal imaging probe (FLIP) recordings allow for loop analysis of the anal sphincter and puborectalis muscle (PRM) function. The goal was to characterize anal sphincter area-pressure/tension loop changes in fecal incontinence (FI) patients. Fourteen healthy subjects and 14 patients with FI were studied. A custom-designed FLIP was placed in the vagina and then in the anal canal, and deflated in 20-ml steps, from 90 to 30 ml. At each volume, subjects performed maximal voluntary squeezes. Area-pressure (AP) and area-tension (AT) loops were generated for each squeeze cycle. Three-dimensional ultrasound imaging of the anal sphincter and PRM were obtained to determine the relationship between anal sphincter muscle damage and loop movements. With the increase in bag volume, AP loops and AT loops shifted to the right and upward in normal subjects (both anal and vaginal). The shift to the right was greater, and the upward movement was less in FI patients. The difference in the location of AP loops and AT loops was statistically significant at volumes of 50 ml to 90 ml (P < 0.05). A similar pattern was found in the vaginal loops. There is a significant relationship between the damage to the anal sphincter and PRM, and loop location of FI patients. We propose AP and AT loops as novel ways to assess the anal sphincter and PRM function. Such loops can be generated by real-time measurement of pressure and area within the anal canal.NEW & NOTEWORTHY We describe the use of area-pressure (AP) and area-tension (AT)-loop analysis of the anal sphincters and puborectalis muscles in normal subjects and fecal incontinent patients using the functional luminal imaging probe (FLIP). There are differences in the magnitude of the displacement of the loops with increase in the FLIP bag volume between normal subjects and patients with fecal incontinence. The latter group shifts more to the right in AP and AT space.
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Affiliation(s)
- Ali Zifan
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Ravinder K. Mittal
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - David C. Kunkel
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Jessica Swartz
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Garrett Barr
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Lori J. Tuttle
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
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Preoperative incremental maximum squeeze pressure as a predictor of fecal incontinence after very low anterior resection for low rectal cancer. Surg Today 2019; 50:516-524. [PMID: 31797125 DOI: 10.1007/s00595-019-01926-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Very low anterior resection (VLAR) is performed widely, but some patients are left with fecal incontinence (FI), which compromises their quality of life (QOL) severely. This study sought to identify the predictive factors of postoperative FI after VLAR, which remain unclear. METHODS We evaluated the anorectal manometry data of patients who underwent VLAR to identify the risk factors for postoperative FI among the various clinicopathological factors and manometric characteristics. FI and QOL were analyzed using the Wexner score and EORTC QLQ-C30, respectively. RESULTS The subjects of this study were 40 patients who underwent VLAR for low rectal cancer between April, 2015 and May, 2018. There were 11 (27%) patients in the major-FI group and 29 (73%) in the minor-FI group. Multivariate analysis revealed that low preoperative incremental maximum squeeze pressure (iMSP) was an independent risk factor for postoperative major-FI. Postoperative QOL tended to be worse in the major-FI group. CONCLUSIONS Preoperative low iMSP increases the risk of major-FI and impaired QOL after VLAR. This highlights the importance of performing preoperative anorectal manometry to evaluate the patient's anal function as well as to select the most appropriate operative procedure and early multifaceted treatment such as medication, rehabilitation, and biofeedback for postoperative FI.
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Putz C, Alt CD, Wagner B, Gantz S, Gerner HJ, Weidner N, Grenacher L, Hensel C. MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury. Spinal Cord 2019; 58:203-210. [PMID: 31506586 DOI: 10.1038/s41393-019-0351-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A prospective single arm study. OBJECTIVES Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. SETTING A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. METHODS Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. RESULTS The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. CONCLUSIONS MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.
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Affiliation(s)
- Cornelia Putz
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,University Duesseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, 40225, Duesseldorf, Germany
| | - Bjoern Wagner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Simone Gantz
- Department of Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Hans J Gerner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Lars Grenacher
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Diagnostic Clinic Munich, Department of Radiology and Nuclear Medicine, Augustenstraße 115, 80798, Muenchen, Germany
| | - Cornelia Hensel
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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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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Methodologic Validation of a Faster Pelvic Floor Test: Two Randomized Studies in Anal Acoustic Reflectometry. Dis Colon Rectum 2019; 62:623-630. [PMID: 30540659 DOI: 10.1097/dcr.0000000000001290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anal acoustic reflectometry investigates the opening and closing function of the anal canal using reflected sound waves to measure a cross-sectional area at different pressures. Anal acoustic reflectometry is reliable and repeatable, distinguishes between continence and incontinence and between subgroups of incontinence, correlates with symptom severity, and does not distort the anal canal during investigation. OBJECTIVE The purpose of this study was to validate anal acoustic reflectometry methodology by asking 2 questions: can anal acoustic reflectometry be used alongside manometry (order study) and can anal acoustic reflectometry be performed faster (filling study). The secondary aim was to assess the response of the anal canal to stretch using anal acoustic reflectometry. DESIGN This research included 2 prospective randomized studies. SETTINGS The study was conducted at a tertiary referral center. PATIENTS Patients undergoing investigation for fecal incontinence were included. INTERVENTION For the order study, patients were prospectively randomized to anal acoustic reflectometry, manometry, 2-minute rest and then manometry, anal acoustic reflectometry, or vice versa. For the filling study, patients were prospectively randomized to fast rate anal acoustic reflectometry (5 cm H2O/1 s), manometry, 2-minute rest and then manometry, normal rate anal acoustic reflectometry (5 cm H2O/3 s), or vice versa. MAIN OUTCOME MEASURES The primary outcome was no difference in anal acoustic reflectometry or manometry variables. Demographic and clinical data were recorded. RESULTS The order study included 30 patients with a median age of 63 years (range, 30-84 y); 77% were women. No difference was found among all of the variables of anal acoustic reflectometry and manometry regardless of which test was performed first. The filling study included 50 patients with a median age of 62 years (range, 30-78 y); 80% were women. No difference was found between fast and normal rates of anal acoustic reflectometry and manometry in any order. LIMITATIONS This study was limited by its comparison with water-perfused manometry. CONCLUSIONS Anal acoustic reflectometry and manometry can be performed at the normal or fast rate of anal acoustic reflectometry in any order. A fast rate of anal acoustic reflectometry did not augment the response of the anal canal to stretch as measured by anal acoustic reflectometry and manometry. This study validates a faster anal acoustic reflectometry technique and vindicates previous data. See Video Abstract at http://links.lww.com/DCR/A821.
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Carter D, Bardan E, Maradey-Romero C. Clinical and physiological risk factors for fecal incontinence in chronically constipated women. Tech Coloproctol 2019; 23:429-434. [PMID: 31016549 DOI: 10.1007/s10151-019-01985-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 04/02/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fecal incontinence (FI) and chronic constipation (CC) are disabling symptoms that cause a significant public health problem. The pathophysiology of combined constipation and FI is not fully understood. Our aim was to delineate the clinical, physiological and anatomical factors that may contribute to the association of FI and CC. METHODS A retrospective study was performed in a pelvic floor unit in a tertiary medical center. Consecutive female patients diagnosed with CC were included, and further divided into two groups according to the co-occurrence of FI. Demographic characteristics, anorectal physiology (obtained by manometry) and pelvic anatomical pathology (as assessed by dynamic pelvic ultrasound) were recorded and subsequently compared. RESULTS A total of 267 women were included in the study. Of those, 62 patients (23%) had an associated FI (CCFI). The CCFI group had higher body mass index (BMI) levels and a trend toward younger average age as compared to the group without FI (CCNFI). The number of vaginal and instrumental deliveries was similar in both groups. Anal resting and squeeze pressures were significantly lower in the CCFI group (64 ± 21 vs 48 ± 18, p = 0.004 and 141 ± 136.2 vs. 97.5 ± 38.6, p = 0.02, respectively). Rectal sensation abnormalities were common, but did not differ between both groups. Dyssynergic defecation and rectocele were more common in the CCNFI group (68% vs. 51%, p = 0.04 and 39% vs. 24%, p = 0/045, respectively. CONCLUSIONS Lower anal pressures and higher BMI were found among women with coexisting FI and CC. Pelvic floor anatomical and functional abnormalities are common in women diagnosed with CC and FI, but dyssynergia and diagnosis of significant rectocele, which cause obstructed defecation, were more common in the CCNFI group.
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Affiliation(s)
- D Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat Gan, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - E Bardan
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Maradey-Romero
- Department of Gastroenterology, Chaim Sheba Medical Center, Ramat Gan, Israel
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Abstract
PURPOSE OF REVIEW Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS. RECENT FINDINGS Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.
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Affiliation(s)
- Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8124, Saint Louis, MO, 63110, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8124, Saint Louis, MO, 63110, USA.
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Ledgerwood‐Lee M, Zifan A, Kunkel DC, Sah R, Mittal RK. High-frequency ultrasound imaging of the anal sphincter muscles in normal subjects and patients with fecal incontinence. Neurogastroenterol Motil 2019; 31:e13537. [PMID: 30680849 PMCID: PMC6405312 DOI: 10.1111/nmo.13537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/15/2018] [Accepted: 12/05/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The current "gold standard" to diagnose anal sphincter morphology and disruptions utilizes low-frequency (3-9 MHz) ultrasound (US) imaging techniques that provide a general outline of the sphincter muscles, but not their microstructural details. High-frequency US transducers (7-15 MHz) have been used to study the muscle architecture (direction of muscle fascicles) in the limb muscle. AIMS The goal of our study was to visualize the microstructural anatomy of the anal sphincters, specifically the external anal sphincter (EAS), using high-frequency US imaging. METHODS Studies were conducted in asymptomatic female and male subjects and patients with fecal incontinence. US images were acquired using a low-frequency US (3-9 MHz) and high-frequency (7-15 MHz) US transducer. The latter was placed intra-anally to image the anal canal at 12, 9, 3, and 6 o'clock positions. RESULTS The low-frequency US images revealed the general outline of the anal sphincter muscles. On the other hand, high-frequency imaging visualized muscle fascicles and connective tissue inside the external anal sphincter (EAS). In FI patients, there was loss of muscle fascicles and alteration in the echo-intensity pattern in the region of damaged EAS suggestive of muscle fibrosis. CONCLUSION High-frequency ultrasound imaging is a powerful tool to visualize the microstructural details of the EAS. Our studies show that damage to the EAS muscle results in the alteration of its myoarchitecture, that is, loss of muscle fascicles and increase in the muscle connective tissue.
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Affiliation(s)
- Melissa Ledgerwood‐Lee
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - David C. Kunkel
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Robert Sah
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Ravinder K. Mittal
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
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