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Park SY. Diagnosis of Chronic Constipation. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:179-183. [PMID: 38783618 DOI: 10.4166/kjg.2024.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/10/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
Patients with chronic constipation (CC) usually complain of mild to severe symptoms, including hard or lumpy stools, straining, a sense of incomplete evacuation after a bowel movement, a feeling of anorectal blockage, the need for digital maneuver to assist defecation, or reduced stool frequency. In clinical practice, healthcare providers need to check for 'alarm features' indicative of a colonic malignancy, such as bloody stools, anemia, unexplained weight loss, or new-onset symptoms after 50 years of age. In the Seoul Consensus on the diagnosis and treatment of chronic constipation, the Bristol stool form scale, colonoscopy, and digital rectal examination are useful for objectively evaluating the symptoms and making a differential diagnosis of the secondary cause of constipation. If patients with CC improve to lifestyle modification or first-line therapies, the effort to determine the subtypes of CC is usually not considered. On the other hand, if conventional therapeutic strategies fail, diagnostic testing needs to be considered to distinguish between the different subtypes of functional constipation (normal-transit constipation, slow transit constipation, or defecatory disorder) because these subtypes of constipation have different therapeutic implications and a correct diagnosis is critical. In the Seoul consensus, physiological testing is recommended for patients with functional constipation who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and recommended a therapeutic regimen) or who are strongly suspected of having a defecatory disorder. The Seoul consensus contains statements of physiological testing, including balloon expulsion test, anorectal manometry, defecography, and colon transit time.
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Affiliation(s)
- Seon-Young Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital and Medical School, Gwangju, Korea
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Menand JA, Sandhu R, Israel Y, Reford E, Zafar A, Singh P, Cavaliere K, Saleh J, Smith MS, Jodorkovsky D, Luo Y. Digital Rectal Exams Are Infrequently Performed Prior to Anorectal Manometry. Dig Dis Sci 2024; 69:728-731. [PMID: 38170338 DOI: 10.1007/s10620-023-08243-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/10/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Digital rectal examination should be performed prior to anorectal manometry; however, real-world data is lacking. AIMS Characterize real world rates of digital rectal and their sensitivity for detecting dyssynergia compared to anorectal manometry and balloon expulsion test. METHODS A retrospective single-center study was conducted to examine all patients who underwent anorectal manometry for chronic constipation between 2021 and 2022 at one tertiary center with motility expertise. Primary outcomes consisted of the rate of digital rectal exam prior to anorectal manometry; and secondary outcomes included the sensitivity of digital rectal exam for dyssynergic defecation. RESULTS Only 42.3% of 142 patients had digital rectal examinations prior to anorectal manometry. Overall sensitivity for detecting dyssynergic defecation was 46.4%, but significantly higher for gastroenterology providers (p = .004), and highest for gastroenterology attendings (82.6%). CONCLUSIONS Digital rectal examination is infrequently performed when indicated for chronic constipation. Sensitivity for detecting dyssynergic defecation may be impacted by discipline and level of training.
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Affiliation(s)
- Joseph A Menand
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA.
| | - Robinderpal Sandhu
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA
| | - Yonatan Israel
- Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Emma Reford
- Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ahmun Zafar
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA
| | - Priyanka Singh
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Kimberly Cavaliere
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Jean Saleh
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Michael S Smith
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Daniela Jodorkovsky
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Yuying Luo
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
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Jensen ASH, Ytting H, Winther-Sørensen M, Burisch J, Bergquist A, Gluud LL, Wewer Albrechtsen NJ. Autoimmune liver diseases and diabetes. Eur J Gastroenterol Hepatol 2023; 35:938-947. [PMID: 37505973 DOI: 10.1097/meg.0000000000002594] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Autoimmune liver diseases include autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. They are chronic, heterogenous diseases affecting the liver which is a key metabolic organ that ensures glucose homeostasis. It is well known that patients with other chronic liver diseases such as cirrhosis and nonalcoholic fatty liver disease (NAFLD) display glucose disturbances like insulin resistance and have an increased risk of diabetes. Previous evidence on glucose disturbances in patients with autoimmune liver disease is scarce but does point towards a potentially increased risk of type 1 diabetes and type 2 diabetes. The underlying mechanisms are unknown but may reflect genetic predisposition, concurrent NAFLD and or cirrhosis development, and treatment (steroid) related impairment of glucose homeostasis. Therefore, increased awareness and surveillance of diabetes development in patients with autoimmune liver disease may be important. Overall, detection and treatment of diabetes generally follow the usual diabetes guidelines; however, in patients with advanced liver cirrhosis, HbA1c may not be a reliable marker of average glucose levels, and treatment with insulin is generally recommended. In addition, it has recently been suggested that sodium-glucose cotransporter 2 inhibitors may be beneficial in treating refractory ascites. Further research on diabetes risk in autoimmune liver disease is warranted.
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Affiliation(s)
- Anne-Sofie H Jensen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
| | - Henriette Ytting
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Rigshospitalet
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen
| | - Marie Winther-Sørensen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Johan Burisch
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
| | - Annika Bergquist
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- Department of Upper GI Diseases, Karolinska University Hospital, Department of Medicine, Karolinska Institutet, Stockholm
| | - Lise Lotte Gluud
- Gastro Unit, Copenhagen University Hospital - Amager and Hvidovre Hospital, Hvidovre
- Institute for Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen
| | - Nicolai J Wewer Albrechtsen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Tan AH, Chuah KH, Beh YY, Schee JP, Mahadeva S, Lim SY. Gastrointestinal Dysfunction in Parkinson's Disease: Neuro-Gastroenterology Perspectives on a Multifaceted Problem. J Mov Disord 2023; 16:138-151. [PMID: 37258277 DOI: 10.14802/jmd.22220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/21/2023] [Indexed: 06/02/2023] Open
Abstract
Patients with Parkinson's disease (PD) face a multitude of gastrointestinal (GI) symptoms, including nausea, bloating, reduced bowel movements, and difficulties with defecation. These symptoms are common and may accumulate during the course of PD but are often under-recognized and challenging to manage. Objective testing can be burdensome to patients and does not correlate well with symptoms. Effective treatment options are limited. Evidence is often based on studies in the general population, and specific evidence in PD is scarce. Upper GI dysfunction may also interfere with the pharmacological treatment of PD motor symptoms, which poses significant management challenges. Several new less invasive assessment tools and novel treatment options have emerged in recent years. The current review provides an overview and a practical approach to recognizing and diagnosing common upper and lower GI problems in PD, e.g., dyspepsia, gastroparesis, small bowel dysfunction, chronic constipation, and defecatory dysfunction. Management aspects are discussed based on the latest evidence from the PD and general populations, with insights for future research pertaining to GI dysfunction in PD.
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Affiliation(s)
- Ai Huey Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kee Huat Chuah
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yuan Ye Beh
- Department of Medicine, Hospital Pulau Pinang, Penang, Malaysia
| | - Jie Ping Schee
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sanjiv Mahadeva
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Dekker L, van Reijn-Baggen DA, Han-Geurts IJM, Felt-Bersma RJF. To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound. Int J Colorectal Dis 2023; 38:12. [PMID: 36645523 PMCID: PMC9842578 DOI: 10.1007/s00384-022-04304-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests. METHODS Between January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG). RESULTS A total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively. CONCLUSION DRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.
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Affiliation(s)
- L Dekker
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands.
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
| | - D A van Reijn-Baggen
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Urology, Leiden University Center, Leiden, The Netherlands
| | - I J M Han-Geurts
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - R J F Felt-Bersma
- Department of Surgery, Proctos Clinic, Bilthoven, The Netherlands
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Location VU, Amsterdam, The Netherlands
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Liu J, Lv C, Wang W, Huang Y, Wang B, Tian J, Sun C, Yu Y. Slow, deep breathing intervention improved symptoms and altered rectal sensitivity in patients with constipation-predominant irritable bowel syndrome. Front Neurosci 2022; 16:1034547. [PMID: 36408402 PMCID: PMC9673479 DOI: 10.3389/fnins.2022.1034547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/24/2022] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND AIM Limited treatment options have been shown to alter the natural course of irritable bowel syndrome (IBS). Slow, deep breathing (SDB) is a common pain self-management intervention. This pilot study aimed to explore the impact of SDB on measures of autonomic and anorectal functions as well as patient-reported symptoms in constipation-predominant IBS (IBS-C). METHODS Eighty-five IBS-C patients were enrolled in this study and randomly assigned to the experimental group (Group A, n = 42) and the control group (Group B, n = 43). SDB was conducted at six breathing cycles per minute with an inhalation for 4 s and exhalation for 6 s at a ratio of 2:3 and repeated for 30 min during the intervention. All subjects underwent high-resolution anorectal manometry (HRAM) and completed the standardized IBS symptom severity system (IBS-SSS) questionnaire. Meanwhile, changes in stool consistency, weekly frequency of complete spontaneous bowel movements (CSBMs), and weekly frequency of spontaneous bowel movements (SBMs) were recorded. All IBS-C patients received electrocardiogram (ECG) recordings for heart rate variability (HRV) analysis at baseline, weeks 3, 6. RESULTS At baseline, no differences were found between Groups A and B. The IBS-SSS score and its five sub-scores of Group B patients were significantly higher at week 6 than those of Group A patients (all p < 0.001). Furthermore, compared with Group B patients, Group A patients had a significantly higher threshold volume for the first sensation (p < 0.001), desire to defecate (p = 0.017), and maximum tolerable volume (p = 0.018) at week 6 of the SDB treatment. We also noted significant improvements in stool consistency (p = 0.002), weekly SBM frequencies (p < 0.001), and weekly CSBM frequencies (p = 0.018) of Group A patients at week 6 when compared with Group B patients. Finally, the corrected high frequency (HF) of Group A patients was significantly higher than the HF of Group B patients at week 3 (p < 0.001) and at week 6 (p < 0.001). Likewise, patients in Group A had a significantly higher root mean square of the successive differences (RMSSD) than that of patients in Group B at week 3 (p < 0.001) and at week 6 (p < 0.001). CONCLUSION We found that a 6-week SDB intervention improved symptoms and altered rectal sensation in IBS-C patients. Moreover, SDB enhanced vagal activity. These findings suggest that the effect of SDB on IBS-C may be due to mechanisms involving autonomic responses.
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Affiliation(s)
- Jie Liu
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chaolan Lv
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Wang
- Department of Gastroenterology, Affiliated Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Yizhou Huang
- Graduate School of Bengbu Medical College, Bengbu, China
| | - Bo Wang
- Graduate School of Bengbu Medical College, Bengbu, China
| | - Jiashuang Tian
- Department of Gastroenterology, Affiliated Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Chenyu Sun
- AMITA Health Saint Joseph Hospital Chicago, Chicago, IL, United States
| | - Yue Yu
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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