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D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Lin H, Zhang Z, Hu G, Wang X, Lin C, Chen Y. Acupuncture for fecal incontinence: Protocol for a systematic review and data mining. Medicine (Baltimore) 2019; 98:e14482. [PMID: 30762773 PMCID: PMC6408071 DOI: 10.1097/md.0000000000014482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fecal incontinence is a socially and emotionally destructive condition that has a negative impact on personal image, self-confidence, and quality of life. Acupuncture is commonly used to treat chronic conditions, including fecal incontinence. However, no relevant systematic review or meta-analysis has been designed to evaluate the effects of acupuncture on fecal incontinence. METHODS We will identify relevant randomized controlled trials (RCTs) from the Cochrane Library, Medline, Embase, PubMed, Springer, Web of Science, China National Knowledge Infrastructure, VIP Chinese Science and Technology Journals Database, Wanfang database, and clinical trial registration center from their inception to February 28, 2019. The primary outcome measures will be clinical effective rate, functional outcomes, and quality of life. Data that meets the inclusion criteria will be extracted and analyzed using RevMan V.5.3 software. Two reviewers will evaluate the studies using the Cochrane Collaboration risk of bias tool. Publication bias will be assessed by funnel plots, Egger test, and Begg test using the Stata software. Acupoints characteristics will be analyzed by Traditional Chinese Medicine inheritance support system. RESULTS This study will analyze the clinical effective rate, functional outcomes, quality of life, daily average number of fecal incontinence, and effective prescriptions of acupuncture for patients with fecal incontinence. CONCLUSION Our findings will provide evidence for the effectiveness and potential treatment prescriptions of acupuncture for patients with fecal incontinence. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019119680.
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Affiliation(s)
| | - Zhiqing Zhang
- South China Research Center for Acupuncture and Moxibustion
- Medical School of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou
| | - Guijuan Hu
- Medical School of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou
| | - Xiaotong Wang
- South China Research Center for Acupuncture and Moxibustion
- Medical School of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou
| | - Chunni Lin
- School of Foreign Languages, Xinhua College of Sun Yat-sen University, Dongguan, People's Republic of China
| | - Yongjun Chen
- South China Research Center for Acupuncture and Moxibustion
- Medical School of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou
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Sharma M, Feuerhak K, Zinsmeister AR, Bharucha AE. A pharmacological challenge predicts reversible rectal sensorimotor dysfunctions in women with fecal incontinence. Neurogastroenterol Motil 2018; 30:e13383. [PMID: 29856103 PMCID: PMC6160337 DOI: 10.1111/nmo.13383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/23/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND In order to understand the pathophysiology of rectal sensorimotor dysfunctions in women with fecal incontinence (FI) and rectal urgency, we evaluated the effects of a muscarinic antagonist and an adrenergic α2 agonist on these parameters. METHODS Firstly, rectal distensibility and sensation were evaluated with a barostat and sinusoidal oscillation at baseline and after randomization to intravenous saline or atropine in 16 healthy controls and 44 FI patients. Thereafter, FI patients were randomized to placebo or clonidine for 4 wk; rectal compliance and sensation were revaluated thereafter. The effect of atropine and clonidine on rectal functions and the relationship between them were evaluated. RESULTS At baseline, compared to controls, rectal capacity was lower (P = .03) while the mean pressure (P = .02) and elastance (P = .01) during sinusoidal oscillation were greater, signifying reduced distensibility, in FI. Compared to placebo, atropine increased (P ≤ .02) the heart rate in controls and FI and reduced (P = .03) the variability in rectal pressures during sinusoidal oscillation in controls. Clonidine increased rectal compliance (P = .04) and reduced rectal capacity (P = .03) in FI. The effects of atropine and clonidine on compliance (r = .44, P = .003), capacity (r = .34, P = .02), pressures during sinusoidal oscillation (r = .3, P = .057), pressure (r = .6, P < .0001), and volume sensory thresholds (r = .48, P = .003) were correlated. CONCLUSIONS The effects of atropine and clonidine on rectal distensibility and sensation were significantly correlated. A preserved response to atropine suggests that reduced rectal distensibility is partly reversible, mediated by cholinergic mechanisms, and may predict the response to clonidine, providing a pharmacological challenge.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Alan R. Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Department of Medicine
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Balemba OB, Stark TD, Lösch S, Patterson S, McMillan JS, Mawe GM, Hofmann T. (2R,3S,2'' R,3''R)-manniflavanone, a new gastrointestinal smooth muscle L-type calcium channel inhibitor, which underlies the spasmolytic properties of Garcinia buchananii stem bark extract. J Smooth Muscle Res 2016; 50:48-65. [PMID: 26081368 PMCID: PMC4826780 DOI: 10.1540/jsmr.50.48] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Garcinia buchananii Baker stem bark extract (GBB) is a traditional
medication of diarrhea and dysentery in sub-Saharan Africa. It is believed that GBB causes
gastrointestinal smooth muscle relaxation. The aim of this study was to determine whether
GBB has spasmolytic actions and identify compounds underlying these actions. Calcium
(Ca2+) imaging was used to analyze the effect of GBB on Ca2+
flashes and Ca2+ waves in guinea pig gallbladder and distal colon smooth
muscle. Intracellular microelectrode recording was used to determine the effect of GBB,
six fractions of GBB, M1–5 and M7, and
(2R,3S,2”R,3”R)-manniflavanone,
a compound isolated from M3 on action potentials in gallbladder smooth muscle. The
technique was also used to analyze the effect of GBB, M3, and
(2R,3S,2”R,3”R)-manniflavanone
on action potentials in the circular muscle of mouse and guinea pig distal colons, and the
effect of GBB and
(2R,3S,2”R,3”R)-manniflavanone
on slow waves in porcine ileum. GBB inhibited Ca2+ flashes and Ca2+
waves. GBB, M3 and
(2R,3S,2”R,3”R)-manniflavanone
inhibited action potentials. L-type Ca2+ channel activator Bay K 8644 increased
the discharge of action potentials in mouse colon but did not trigger or increase action
potentials in the presence of GBB and
(2R,3S,2”R,3”R)-manniflavanone.
GBB and
(2R,3S,2”R,3”R)-manniflavanone
inhibited action potentials in the presence of Bay K 8644. GBB and
(2R,3S,2”R,3”R)-manniflavanone
reduced the amplitude but did not alter the frequency of slow waves in the porcine ileum.
In conclusion, GBB and
(2R,3S,2”R,3”R)-manniflavanone
relax smooth muscle by inhibiting L-type Ca2+ channels, thus have potential for
use as therapies of gastrointestinal smooth muscle spasms, and arrhythmias.
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Affiliation(s)
- Onesmo B Balemba
- Department of Biological Sciences, University of Idaho, Moscow, Idaho, United States
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Bharucha AE, Stroetz R, Feuerhak K, Szarka LA, Zinsmeister AR. A novel technique for bedside anorectal manometry in humans. Neurogastroenterol Motil 2015; 27:1504-8. [PMID: 26227262 PMCID: PMC4584182 DOI: 10.1111/nmo.12636] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/20/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Currently, anorectal manometry (ARM), which is used to diagnose defecatory disorders and identify anal weakness in fecal incontinence (FI) is generally conducted in specialized laboratories. Our aims were to compare anorectal functions measured with high-resolution manometry (HRM) and a novel portable manometry device. METHODS Anal pressures at rest, during squeeze, and simulated evacuation, and rectal sensation were evaluated with portable and HRM in 20 healthy women, 19 women with constipation, and 11 with FI. The relationship between anal pressures measured with portable and HRM was assessed by the concordance correlation coefficient (CCC), Bland Altman test, and paired t-tests. KEY RESULTS Anal pressures at rest (CCC 0.45; 95% CI: 0.29, 0.58) and during squeeze (CCC 0.60; 95% CI: 0.46, 0.72) measured with portable and HRM were correlated and inversely associated with the risk of FI. During simulated evacuation, the CCC for rectal pressure (0.62; 95% CI: 0.43, 0.76) was greater than that for anal pressure (CCC 0.22; 95% CI: 0.04, 0.39) and the rectoanal gradient (CCC 0.22; 95% CI: 0.02, 0.41). Rectal sensory thresholds for first sensation, the desire to defecate, and urgency measured by portable and HRM were also significantly correlated between techniques. For several parameters, differences between portable and HRM were statistically significant and the Bland Altman test was positive. CONCLUSIONS & INFERENCES Anorectal pressures and rectal sensation can be conveniently measured by portable manometry and are significantly correlated with high-resolution manometry.
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Affiliation(s)
- Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Randolph Stroetz
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kelly Feuerhak
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Lawrence A. Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Alan R. Zinsmeister
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. Gastroenterology 2014; 146:37-45.e2. [PMID: 24211860 PMCID: PMC3913170 DOI: 10.1053/j.gastro.2013.10.062] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 01/13/2023]
Abstract
Gastroenterologists frequently encounter pelvic floor disorders, which affect 10% to 15% of the population. The anorectum is a complex organ that collaborates with the pelvic floor muscles to preserve fecal continence and enable defecation. A careful clinical assessment is critical for the diagnosis and management of defecatory disorders and fecal incontinence. Newer diagnostic tools (eg, high-resolution manometry and magnetic resonance defecography) provide a refined understanding of anorectal dysfunctions and identify phenotypes in defecatory disorders and fecal incontinence. Conservative approaches, including biofeedback therapy, are the mainstay for managing these disorders; new minimally invasive approaches may benefit a subset of patients with fecal incontinence, but more controlled studies are needed. This mini-review highlights advances, current concepts, and controversies in the area.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Satish S C Rao
- Section of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Georgia Regents University, Augusta, Georgia.
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Burgell RE, Scott SM. Rectal hyposensitivity. J Neurogastroenterol Motil 2012; 18:373-84. [PMID: 23105997 PMCID: PMC3479250 DOI: 10.5056/jnm.2012.18.4.373] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/05/2012] [Accepted: 09/13/2012] [Indexed: 01/20/2023] Open
Abstract
Impaired or blunted rectal sensation, termed rectal hyposensitivity (RH), which is defined clinically as elevated sensory thresholds to rectal balloon distension, is associated with disorders of hindgut function, characterised primarily by symptoms of constipation and fecal incontinence. However, its role in symptom generation and the pathogenetic mechanisms underlying the sensory dysfunction remain incompletely understood, although there is evidence that RH may be due to 'primary' disruption of the afferent pathway, 'secondary' to abnormal rectal biomechanics, or to both. Nevertheless, correction of RH by various interventions (behavioural, neuromodulation, surgical) is associated with, and may be responsible for, symptomatic improvement. This review provides a contemporary overview of RH, focusing on diagnosis, clinical associations, pathophysiology, and treatment paradigms.
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Affiliation(s)
- Rebecca E Burgell
- Academic Surgical Unit (GI Physiology Unit), Wingate Institute and Neurogastroenterology Group, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Rectal hyposensitivity for non-noxious stimuli, postprandial hypersensitivity and its correlation with symptoms in complete spinal cord injury with neurogenic bowel dysfunction. Spinal Cord 2012; 51:94-8. [PMID: 22929208 DOI: 10.1038/sc.2012.98] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN Prospective clinical study. OBJECTIVES To assess fasting and postprandial (PP) perception of rectal distension and its correlation with symptoms in patients with spinal cord injury (SCI) and neurogenic bowel dysfunction compared to ten healthy subjects (HS). SETTING Experimental Medicine and Motility Unit, Mexico General Hospital and National Institute of Rehabilitation. METHODS Twenty patients with complete SCI at cervical, thoracic and lumbar levels [American Spinal Injury Association (ASIA) A] were studied. Rectal sensitivity was evaluated with a barostat. RESULTS In SCI patients, while lower the rectal tone more time was used for defecate (R=0.50, P=0.048) and more PP episodes of fecal incontinence occur (R=0.54, P=0.030). The thresholds for non-noxious stimuli of first (23.6 mmHg, CI 19.5-27.7) vs 14.0 (CI 10.9-17.1), P=0.004; gas (27.9 mmHg, CI 19.9-35.8) vs 17.9 mmHg (CI 14.25-21.69), P=0.02 and urge-to-defecate sensation (33.2 mmHg, CI 27.5-38.8) vs 22.4 mmHg (CI 17.9-26.9), P=0.01 were reported by SCI patients at higher pressure than HS, respectively. SCI patients reported PP pain sensation at a lower pressure than controls (27.8 mmHg, CI 21.5-34.2 vs 36.5 mmHg, CI 31.8-41.2), P=0.04. CONCLUSION SCI patients preserve rectal sensation, present rectal hyposensitivity for non-noxious stimuli and PP hypersensitivity. Lower rectal tone was related to the time used for defecate and with fecal incontinence. The results suggest that an intact neural transmission between the spinal cord and higher centres is indispensable for noxious stimulus, but not for non-noxious stimuli. Also, barostat sensitivity studies can complement ASIA criteria to verify a complete injury.
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Abstract
PURPOSE OF REVIEW Fecal incontinence is a common condition, which leads to impaired quality of life and huge financial cost at an individual and societal level. Recent studies have identified novel and potentially modifiable risk factors. Newer diagnostic modalities are giving more detailed information about underlying disorders, helping to implement targeted treatment. Many therapeutic options exist, and newer treatments are changing outcomes. This article will review recent developments in mechanisms, diagnosis, and treatment of fecal incontinence. RECENT FINDINGS Potentially modifiable risk factors have recently been identified, and should translate to changes in clinical practice and hopefully patient outcomes. These include diarrhea, smoking, and dietary fiber. Advances have been made in anatomical and physiological testing of the anorectum and this may assist in clarifying the diagnosis and guiding management. The long-term benefit of biofeedback has been questioned but patient selection may be key. Novel pharmacological therapies (e.g., clonidine) and minimally invasive surgical procedures are changing outcomes in well selected patients. The development of a magnetic anal sphincter may add a new management alternative in patients who are refractory to conservative management. SUMMARY Fecal incontinence remains a clinical challenge. Only a minority of persons with fecal incontinence seek treatment, but for those who do, improved understanding of risk factors coupled with diagnostic techniques and treatments are improving outcomes.
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