A prospective study evaluating emotional disturbance in subjects undergoing defecating proctography

Assessment of defecation disorders using high-resolution MRI-defecography

AIMS

The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders.

METHODS

44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T.

RESULTS

MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases.

CONCLUSION

As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.

Providing Trauma Informed Care During Anorectal Evaluation

PURPOSE OF REVIEW

Patients with a history of gastrointestinal (GI) conditions report high rates of psychological trauma. This review discusses the impact of previous trauma, as well as interactions with the medical system, on a patient's physical and mental health. Trauma-informed strategies for improving patient care during gastroenterology procedures are provided.

RECENT FINDINGS

History of trauma increases risk of developing GI conditions and re-traumatization during sensitive anorectal procedures (i.e., anorectal manometry, balloon expulsion testing). Trauma-informed strategies include consistent trauma screening for all patients, obtaining consent before and during procedures, creating a safe environment, allowing for privacy, and post-procedure debriefing. Due to high rates of psychological trauma in the gastroenterology setting and the risk of medical trauma from the GI procedures themselves, having an established trauma-informed plan of care for all patients can reduce risk of iatrogenic harm and improve quality of care for patients with GI conditions.

Early adverse life events and post-traumatic stress disorder in patients with constipation and suspected disordered defecation

BACKGROUND

Early adverse life events (EALs) and post-traumatic stress disorder (PTSD) are associated with irritable bowel syndrome (IBS). Disordered defecation (DD) presents with symptoms of IBS or functional constipation (FC) and is associated with psychological distress. However, the role of trauma and stress in chronic constipation is poorly defined. We aimed to examine EALS, PTSD, and psychological symptoms in patients with constipation and suspected DD.

METHODS

We conducted a survey study among adults with constipation who completed anorectal manometry (ARM) and balloon expulsion testing (BET). Data were collected on socio-demographics, EALs, PTSD, bowel symptoms, quality of life, and anxiety and depression. We performed comparisons between individuals with normal versus abnormal ARM or BET, subgroup analysis by detailed ARM and BET findings, and latent class analysis using individual EAL domains.

KEY RESULTS

Among 712 eligible patients, 69 completed the study. EALs and provisional PTSD were present in 75.4% and 27.5%, respectively; rates did not differ between those with normal versus abnormal ARM or BET. Normal testing was associated with higher rates of specific EAL domains (emotional abuse and mental illness), higher depression scores, and poorer mental component scores in both primary and subgroup comparisons (all p < 0.05). Normal testing was associated with a lower likelihood of high-EAL latent class (p = 0.01) membership. Presence of IBS or FC did not influence associations.

CONCLUSIONS & INFERENCES

Early adverse life events and PTSD are prevalent in patients with constipation and suspected DD. Those with normal ARM and BET have higher rates of prior emotional abuse and poorer mental health.

Prevalence and Impact of Post-traumatic Stress Disorder in Gastrointestinal Conditions: A Systematic Review

Psychological distress is often observed in patients with gastrointestinal illness. To date, there has been limited research conducted to assess the prevalence and impact of post-traumatic stress disorder (PTSD) in gastrointestinal cohorts. The aim of this systematic review is to review the evidence for the prevalence of PTSD in gastrointestinal cohorts versus comparator groups (healthy controls and chronic illness groups), predictive factors associated with the development and management of PTSD and the impact on patient outcomes. Adult studies were identified through systematic searches of eight databases (MEDLINE, Embase, Emcare, PsycINFO, Ovid Nursing, CINAHL, Informit Health Collection, and Cochrane Library) in February 2020. The overall pooled prevalence rate of PTSD in GI cohorts was 36%; however, the prevalence rate in non-veteran-specific gastrointestinal cohorts of 18% across all GI classification groups is likely to be the more representative rate. The non-gastrointestinal chronic illness cohort PTSD prevalence rate was 11%. Predictors identified in the development of post-traumatic stress in gastrointestinal cohorts include: female gender, poor social support, life adversity, subjective pain, and dietary choices. Post-traumatic stress was found to exacerbate gastrointestinal symptoms in a Crohn's Disease sample, whereby disease exacerbation was four times in those who met the criteria for probable PTSD. Post-traumatic stress symptoms affect around one in five individuals (non-veteran status) with a gastrointestinal condition. Further research is needed to understand the psychological and biological mechanisms by which PTSD increases the risk of developing and exacerbating gastrointestinal symptoms.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

INTRODUCTION

Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation.

DESIGN

After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation.

KEY RESULTS

Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation.

CONCLUSIONS AND INFERENCES

European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.

Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation

BACKGROUND

Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined.

AIM

To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers.

METHODS

Electronic searches of major databases were performed without date restrictions.

RESULTS

From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study).

CONCLUSIONS

Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.

[Domestic violence and constipation: an integrative review]

Objetivo.

Buscar evidências na literatura sobre a relação entre violência doméstica e constipação intestinal.

Metodologia.

Foi realizada uma revisão integrativa, baseada no método preconizado em seis etapas e construída conforme a metodologia PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Foram examinados artigos publicados entre 2005 e 2015 que relacionassem violência doméstica e constipação intestinal. As buscas ocorreram em setembro e outubro de 2015 nas bases de dados PubMed, MEDLINE, Scopus e Web of Science. A seleção compreendeu três etapas: busca, pré-seleção e inclusão de artigos.

Resultados.

Dos 177 artigos inicialmente identificados, foram selecionados 11. Dos 11 selecionados, sete eram quantitativos, três eram qualitativos e um era misto. Quatro enfocaram crianças e adolescentes, dois investigaram o conhecimento médico sobre a relação entre violência doméstica e constipação intestinal, um revisou distúrbios digestivos em idosos, um avaliou os resultados do biofeedback em constipados com e sem histórico de violência, um avaliou disfunção evacuatória e relacionou o resultado de defecografias com histórico de violência doméstica e dois estudos eram relatos de especialistas. Três estudos apresentaram nível de evidência 1B e grau de recomendação A. Todos os estudos detectaram relação entre violência doméstica e constipação intestinal.

Conclusão.

Os resultados desta revisão indicam que existe correlação entre violência doméstica e constipação intestinal. É recomendável a investigação dessa relação nas práticas em saúde.

Methods of Evaluation of Anorectal Causes of Obstructed Defecation

Obstructed defecation is a complex disorder that results in impaired propagation of stool from the rectum. It is one of the major subtypes of functional constipation and can be secondary to either functional or anatomic etiologies. Patients with obstructed defecation typically present with symptoms of abdominal discomfort, a sensation of incomplete evacuation and rectal obstruction, passage of hard stools, the need for rectal or vaginal digitation, excessive straining, and reduced stool frequency. Evaluation of obstructed defecation is multimodal, starting with a thorough history and physical examination with focus on the abdominal, perineal, and rectal examination. Additional modalities to elicit the diagnosis of obstructed defecation include proctoscopy, colonic transit time studies, anorectal manometry, a rectal balloon expulsion test, defecography, electromyography, and ultrasound. The results from these studies should be taken in the context of each patient's clinical situation, as there is no single criterion standard for the diagnosis of obstructed defecation. Surgery is typically a last resort for these patients and the majority of patients will have good symptomatic management with diet and lifestyle changes. Patients who are found to have functional mechanisms behind their obstructed defecation also benefit from pelvic floor exercises and biofeedback therapy.

Comparison of dynamic transperineal ultrasound and defecography for the evaluation of pelvic floor disorders

INTRODUCTION

X-ray defecography is considered the gold standard for imaging pelvic floor pathology. However, it is limited by the capability to demonstrate only the posterior pelvic compartment, significant radiation exposure, and inconvenience. Dynamic transperineal ultrasound (DTP-US) can visualize all of three pelvic floor compartments, is free of radiation, and does not cause significant discomfort. The aim of this study was to evaluate the level of consistency between defecography (DEF) and DTP-US in the diagnosis of pelvic floor deformations.

METHODS

One hundred and five women (age 56 ± 11 years) suffering from constipation and fecal incontinence were clinically evaluated and further examined by DEF and DTP-US. The rate of diagnosis of pelvic floor hernias using the DTP-US was compared to that found on DEF.

RESULTS

The specificity for the diagnosis of rectoceles was of 82% for mid-size rectocele and 98% for large rectoceles, and the sensitivity was of 59% for mid-size rectoceles and 50% for larger rectoceles. The sensitivity for the detection of intussusceptions, enteroceles, and rectal prolapse were 82, 74, and 75%, respectively. The specificity was 84% for the detection of intussusception, 92% for enteroceles, and 97% for the diagnosis of rectal prolapse. Higher rates of DTP-US diagnosis were obtained when the intussuscepted rectum moved closer toward the ultrasound probe.

CONCLUSIONS

The sensitivity of DTP-US was good to excellent and the specificity was high. The added value of this technique in exploring all the compartments of the pelvic floor as well as the perineal muscles makes DTP-US a preferred procedure.