How to interpret a functional or motility test - defecography

The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders

AIM

Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process.

METHOD

Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up.

RESULTS

After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.

CONCLUSION

The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Defecating proctography: A pictorial essay

OBJECTIVES

To provide an illustrative description of the technique and spectrum of findings in defecating proctography.

KEY FINDINGS

Important findings on defecating proctography include rectocoele, enterocoele, sigmoidocoele, cystocoele, intussusception, rectal prolapse, descending perineum, incomplete emptying, anismus, and faecal incontinence. This review article illustrates these key findings with examples.

CONCLUSION

Defecating proctography is a well-established and cost-effective method of assessing disordered defecation. In conjunction with clinical information and other diagnostic tests, findings on defecating proctography can guide appropriate multidisciplinary management and may lead to improvement in embarrassing and debilitating symptoms in many patients.

IMPLICATIONS FOR PRACTICE

This review article provides a suggested technique and covers the spectrum of findings on defecating proctography.

Long-Term Risks of Parkinson's Disease, Surgery, and Colorectal Cancer in Patients With Slow-Transit Constipation

BACKGROUND & AIMS

Long-term outcomes of constipation have not been evaluated fully. We investigated the incidence of Parkinson's disease, constipation-related surgery, and colorectal cancer (CRC) in patients with constipation and slow-transit constipation (STC), followed up for up to 20 years.

METHODS

We collected data from 2165 patients (33.1% men; median patient age, 54 y; median symptom duration, 5.0 y) with a diagnosis of constipation (based on Rome II criteria) who underwent an anorectal function test and a colonic transit time study, from 2000 through 2010, at a tertiary university hospital in Seoul, South Korea. The presence of STC was determined from colonic transit time. We used the Kaplan-Meier method to analyze and compare cumulative probabilities of a new diagnosis of Parkinson's disease or CRC according to the presence of STC. The patients were followed up until the end of 2019.

RESULTS

During a median follow-up period of 4.7 years (interquartile range, 0.7-8.3 y), 10 patients underwent constipation-related surgery. The cumulative probabilities of constipation-related surgery were 0.7% at 5 years and 0.8% at 10 years after a diagnosis of constipation. Twenty-nine patients (1.3%) developed Parkinson's disease; the cumulative probabilities were 0.4% at 1 year, 1.0% at 5 years, and 2.6% at 10 years after a diagnosis of constipation. At 10 years, 1.3% of patients with STC required constipation-related surgery and 3.5% of patients with STC developed Parkinson's disease; in contrast, none of the patients without STC required constipation-related surgery (P = .003), and 1.5% developed Parkinson's disease (P = .019). In multivariate analysis, patient age of 65 years or older at the diagnosis of constipation (hazard ratio, 4.834; 95% CI, 2.088-11.190) and the presence of STC (hazard ratio, 2.477; 95% CI, 1.046-5.866) were associated independently with the development of Parkinson's disease. Only 5 patients had a new diagnosis of CRC during the follow-up period. The risk of CRC did not differ significantly between patients with vs without STC (P = .575).

CONCLUSIONS

In a long-term follow-up study of patients with constipation in Korea, most patients had no severe complications. However, patients older than age 65 years with a new diagnosis of STC might be considered for Parkinson's disease screening.

Understanding the physiology of human defaecation and disorders of continence and evacuation

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.

Can botulinum toxin help in managing children with functional constipation and obstructed defecation?

BACKGROUND

Functional constipation (FC) is a common pediatric healthcare problem worldwide. Obstructed defection syndrome (ODS) is frequently presented with an inability to coordinate the bowel movement with pelvic floor muscles. Botulinum toxin (BT) intraanal sphincteric injection can improve the obstructed defecation by relaxing the anal sphincter and reducing the required force to propel the stools.

PURPOSE

This study aimed to compare the changes in Rintala scores (as a mean of assessing defecatory function), in children with FC and ODS, managed by BT injection, bowel management program (BMP), and senna based laxatives (SBL), versus a control group managed by BMP and SBL only.

METHODS

Prospective randomized controlled study, started at December 2017 on 40 pediatric patients, divided into 2 equal groups (group A: managed by BMP and SBL, group B: like group A with once intraanal sphincteric BT injection) suffering from FC, ODS, with contrast enema showing persistence of ≤90 rectoanal angle (RAA) even with trials of defecation. Patients were excluded if they have neuromuscular abnormalities, hypothyroidism, previous colorectal or anal surgery. Rintala score was assessed before treatment, at 2 months, and 6 months after management.

RESULTS

The study included 18 females (45%) and 22 males (55%). Group A had equal gender distribution and mean age of 6.9 years, while group B had 12 males with mean age of 7.35 years. The mean follow up period was 11.35 months in group A and 11.6 months in group B. Mean Rintala scores of both groups at initial presentation, 2 months and 6 months follow up were: group A: 9.10, 9.40, 10.90; group B: 9.30, 10.70, 11.05 respectively, and showed no statistically significant difference (p value: 0.884, 0.294, 0.923 respectively). No complications were detected from BT injection like allergic reactions, neuromuscular urinary or lower limbs disturbances.

CONCLUSION

Intraanal sphincteric injection of botulinum toxin by the mentioned technique and dose, did not result in additional defecatory functional improvement (when assessed by Rintala score) over the routine protocol (using bowel management program and laxatives) of managing functional constipation with obstructed defecation. ANNOUNCEMENT: a preliminary report of this work was presented in the 34th Egyptian pediatric surgery association (EPSA) meeting in Cairo in November 2019.

TYPE OF STUDY

Treatment/prospective study.

LEVEL OF EVIDENCE

Level I.

Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

Anorectal Physiology Testing for Prolapse-What Tests are Necessary?

Rectal prolapse frequently occurs in conjunction with functional and anatomic abnormalities of the bowel and pelvic floor. Prolapse surgery should have as its goal not only to correct the prolapse, but also to improve function to the greatest extent possible. Careful history-taking and physical exam continue to be the surgeon's best tools to put rectal prolapse in its functional context. Physiologic testing augments this and informs surgical decision-making. Defecography can identify concomitant middle compartment prolapse and pelvic floor hernias, potentially targeting patients for urogynecologic consultation or combined repair. Other tests, including manometry, ultrasound, and electrophysiologic testing, may be of utility in select cases. Here, we provide an overview of available testing options and their individual utility in rectal prolapse.

MR defecography in ano-rectal dysfunction: a clinical-radiological correlation study

Background

The aim of this work is to assess the diagnostic accuracy of MR defecography in ano-rectal dysfunction [ARD] for proper treatment planning.

Results

MR defecography was done to 30 patients with ARD for detection of its functional and structural causes. Increased perineal descent was detected in 70% of cases, rectocele in 46.7%, rectal intussusception in 40%, cystocele in 26.7%, uterine prolapse in 27.7%, enterocele in 13.3%, and paradoxical puborectalis contraction in 30%.

Conclusion

MR defecography is an essential diagnostic tool for optimum management of ano-rectal dysfunction patients.

Clinical Features and Associations of Descending Perineum Syndrome in 300 Adults with Constipation in Gastroenterology Referral Practice

BACKGROUND

Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice.

AIMS

To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation.

METHODS

We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm descent of anorectal junction on imaging or estimated perineal descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients.

RESULTS

Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis.

CONCLUSIONS

DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.

Chronic constipation

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

Diagnosis and Management of Anorectal Disorders in the Primary Care Setting

Anorectal disorders are very common among a wide population of patients. Because patients may be embarrassed about the anatomic location of their symptoms, they may present to care late in the course of their illness. Care should be taken to validate patient concerns and normalize fears. This article discusses the diagnoses and management of common anorectal disorders among patients presenting to a primary care physician.

Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation

Background/Aims

Chronic constipation is a common gastrointestinal disorder diagnosed using Rome III criteria. Defecography is a radiographic method used to identify anatomic abnormalities of anorectum. The present study aimed to evaluate the defecographic findings in patients with severe idiopathic chronic constipation.

Methods

One hundred patients, who complained of severe idiopathic chronic constipation with abnormal balloon expulsion test, underwent defecography after injection of barium. An analysis of radiographs was performed by an expert radiologist for the diagnosis of descending perineum syndrome, rectocele, enterocele, rectal ulcer, rectal prolapse, fecal residue of post defecation, and etc. Then, they were compared between the two sexes.

Results

Normal defecography was only observed in two participants. Descending perineum syndrome was the most common abnormality (73.3%). The results showed that rectocele (80.8%) and descending perineum syndrome (69.2%) were most frequent in women. In males, descending perineum syndrome and rectal prolapse were more prevalent (87% and 43.5%, respectively). Compared with men, rectocele and rectal ulcer were more frequently observed in women (p<0.001, and p=0.04, respectively), while men were more affected by descending perineum syndrome (p=0.04). In total, women had a greater incidence of abnormal defecographic findings compared with men (p=0.02).

Conclusions

Defecography can be performed to detect anatomic abnormalities in patients with severe idiopathic chronic constipation and abnormal balloon expulsion test. This technique can assist physicians in making the most suitable decision for surgical procedure.

Use of Ultrasonography in Clarifying the Etiology of Anal Pain

Introduction

Anal pain is defined as pain originating from the anal canal or the perianal area that can be attributed to a variety of medical problems. The current study's aim was to evaluate the role of combined endoanal, transperineal, and in married women, transvaginal ultrasound in clarifying the etiology of anal pain among our patient study group.

Methodology

A total of 180 patients presented to our radiology department complaining of anal pain and were examined using transperineal, endoanal, and in women, transvaginal ultrasound aided with three-dimensional capability. The final diagnosis was reached, according to the surgical results and the histopathology reports in cases diagnosed with anorectal neoplasms and perianal masses.

Results

A total of 100 patients were diagnosed with perianal fistulas. Twenty-five cases presented with anal abscesses. In four cases, pilonidal sinus extended to the perianal spaces. Three cases had hiradenitis suppurativa, 13 cases showed occult anal sphincter defects, two cases had anorectal neoplasms, and one case was diagnosed with soft tissue ependymoma overlying the coccyx. Three cases were diagnosed with perianal soft tissue masses. One case was detected with recto vaginal fistulas, 10 cases showed thick internal anal sphincter, two cases had perianal cysts, and one case had perianal hematoma. Two cases showed hemorrhage in Douglas' pouch, and one case had pelvic collection sequelae of perforated pelvic appendicitis. Three cases had pelvic endometriosis; one case was detected with missed contraceptive device in the rectum. Three cases were diagnosed with prostatitis and two cases with prostatic abscesses. Two cases had prostatic carcinoma and one case had prostatic sarcoma.

Conclusion

The combined approaches of endoanal, transperineal, and in women, transvaginal ultrasound aided with three-dimensional capability proved highly valuable in clarifying the etiology of anal pain in our study group.

Chronic constipation in Rome IV era: The Indian perspective

Chronic constipation (CC) is a common problem in the community and in gastroenterology practice all over the world including India. After release of Rome IV guidelines in April 2016, there is increasing interest among gastroenterologists and physicians in India to look into special issues on CC in the Indian perspective. There are important differences in the bowel habit, definition, epidemiology, and pathophysiology including dietary factors and management of CC in India as compared to the West. As severity and frequency of abdominal pain, a symptom essential to diagnose constipation-predominant irritable bowel syndrome (IBS-C) rather than functional constipation (FC), is less common among Indian patients, FC is commoner than IBS-C in India. The pathophysiological mechanisms of CC may include slow colon transit, fecal evacuation disorder (FED), or a combination of these; though CC in a third to half of patients presenting to tertiary care facilities may result from these pathophysiological mechanisms, most patients presenting to primary care may have lifestyle and dietary issues. The current Rome IV algorithm dictates to explore the underlying physiological factors in the pathogenesis of functional gastrointestinal disorders including CC, which may translate to its personalized management. However, the availability of the methods to explore pathophysiological factors and manage CC caused by FED non-pharmacologically (using biofeedback) in India is limited. Though several pharmacological agents are available in India to manage CC, there are several unmet needs in its treatment. This review explores CC in India in relation to these issues, some of which are unique in the Indian perspective.

Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India

BACKGROUND

Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India.

METHODS

Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed.

RESULTS

Of 249 patients (43.7 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, and/or rectocele), respectively. Though 181/249 (72.6 %) had one test abnormality, 86/249 (34 %) had FED (greater than or equal to two abnormalities), 44/65 (67.6 %) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89 %) vs. 117/144 (81.2 %); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30 min; 21/39 (53.8 %) vs. 15/65 (23.1 %); p = 0.002], incomplete evacuation [75/77 (97.4 %) vs. 95/114 (83.3 %); p = 0.004], and >3 stools/week [60/75 (80 %) vs. 76/128 (60 %); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients.

CONCLUSION

FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.

The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children

BACKGROUND

Defecography is a study to assess anorectal function during evacuation.

OBJECTIVE

To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders.

MATERIALS AND METHODS

We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse.

RESULTS

We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful.

CONCLUSIONS

Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders.

Clinical and pelvic morphologic correlation after subtotal colectomy with colorectal anastomosis for combined slow-transit constipation and obstructive defecation

BACKGROUND

The treatment of slow-transit constipation combined with outlet obstruction is controversial. Subtotal colectomy with colorectal anastomosis is regarded as a safe and effective surgical option for refractory constipation.

PURPOSE

The clinical and morphologic outcomes of patients who underwent subtotal colectomy with colorectal anastomosis for refractory mixed constipation were prospectively evaluated.

DESIGN

This study is a nonrandomized, prospective review of gathered data.

SETTING

This investigation was conducted at a tertiary-care GI surgical center in China.

PATIENTS

The study prospectively included 42 consecutive patients with refractory constipation who were diagnosed with obstructed defecation syndrome combined with slow colon transit.

MAIN OUTCOME MEASURES

The primary outcomes measured were the Longo obstructive defecation syndrome score and the Wexner constipation scale. The pelvic morphologic changes were determined with defecography before surgery and at 6 and 24 months after surgery.

RESULTS

A significant reduction in the Wexner constipation score was observed between baseline (median 24) and 6 months (median 10), which was maintained until 24 months (median 8, compared with baseline, p < 0.01). Improvement in the constipation score was matched by an overall improvement in the Longo obstructive defecation syndrome score at the 6- and 24-month follow-up times (compared with baseline, p < 0.01). In 17 of 21 patients, preexisting intussusception was no longer visible during defecography. Rectoceles were significantly reduced in depth, from 36 mm to 8 mm (p < 0.01), whereas the number of detectable rectoceles was also significantly decreased, from 29 to 7 (p < 0.01). Incomplete evacuation disappeared in 28 of 38 patients. No stenosis was observed at the colorectal posterior side-to-side anastomosis. Most complications were managed conservatively without significant events.

LIMITATIONS

This study was performed in selected patients with constipation and did not include a comparison group.

CONCLUSIONS

Subtotal colectomy with colorectal anastomosis can correct pelvic anatomical disorders in patients with mixed refractory constipation. The clinical improvement of obstructed defecation syndrome after subtotal colectomy with colorectal anastomosis is highly correlated with the morphologic correction of the rectal redundancy.

Fecal Evacuation Disorder Among Patients With Solitary Rectal Ulcer Syndrome: A Case-control Study

Background/Aims

Data on frequency of fecal evacuation disorder (FED) among patients with solitary rectal ulcer syndrome (SRUS), hitherto an enigmatic condition, are scanty. Moreover, most such studies had limitations due to small sample size and lack of inclusion of healthy controls (HC).

Methods

Forty patients with SRUS underwent symptom assessments, sigmoidoscopy, anorectal manometry, defecography, balloon expulsion test (BET); endoscopic ultrasound (EUS) of anal sphincter complex was performed in a subgroup. Physiological tests (anorectal manometry and BET) were also performed in 19 HC.

Results

Patients with SRUS (26/40 male, age 37 [18–80] years) more often had FED than HC (10/19 male, age 43 [25–72] years) as shown by weight needed to expel the balloon (300 [0–700] g vs. 100 [0–400] g; P = 0.006), a trend towards abnormal BET (need of > 200 g weight for expulsion) (21/40 [53%] vs. 5/19 [26%], P = 0.058) and impaired anal relaxation (14/40 [35%] vs 2/19 [10.5%]; P = 0.048). Using Rome III criteria, most patients with SRUS reported having chronic constipation (36/40 [90%]) in spite of having normal (Bristol stool type IV, 21/40 [53%]) and diarrheal (types V, VI, VII, 6/40 [20%]) stool forms (Asian classification). SRUS patients more often (17/40 [43%]) had functional defecation disorder (Rome III criteria). Patients with SRUS with abnormal BET had thicker internal anal sphincter than those without (3.9 [3.4–7.0] mm vs 2.8 [2.0–4.0] mm; P = 0.01).

Conclusions

FED was commoner among patients with SRUS as evidenced by abnormal BET and sphincter relaxation. Those with abnormal BET had thicker internal sphincter on EUS than those without.

Understanding and treating refractory constipation

Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.