Abstract
Introduction: Dyssynergic defecation (DD) is a treatable yet underdiagnosed cause of chronic constipation that significantly impacts quality of life. Because symptoms alone are not reliable for predicting DD, the digital rectal exam (DRE) and anorectal manometry (ARM) are vital components of the evaluation of constipation in patients who fail to respond to laxatives. We aim to evaluate the proportion of chronic constipation patients with persistent symptoms despite laxatives who have been evaluated with DRE and/or ARM. ARM is not available at our VA and requires a referral to the community. We also aim to identify the prevalence of DD in those referred for ARM. We hypothesized that DRE and ARM are underutilized at our center. Methods: We conducted a retrospective analysis of patients evaluated at the Dallas VA Gastroenterology clinic. We included adult patients ≥18 years with constipation for > 6 months with persistent symptoms despite laxatives. Patients were identified using ICD-9 and -10 codes and chart review. We performed a descriptive analysis to determine the proportion of patients who were evaluated with DRE and/or ARM. We also evaluated the prevalence of DD in patients who were referred for ARM. Results: In this preliminary analysis, we included 50 Veteran patients. Demographics are summarized in Table 1. Majority of patients reported < 3 bowel movements/week (62%, n=31). The most common symptoms were abdominal pain (21%, n=42), hard or lumpy stools (36%, n=18), and straining (32%, n=16). No patients were evaluated with a DRE, and 18% (n=9) were referred for ARM. Of these patients, 7 completed ARM, and 100% were diagnosed with DD. 3 of these 7 patients underwent pelvic physical therapy and/or biofeedback, and two of these patients had symptomatic improvement with therapy. Finally, 76% (n=38) of patients had a colonoscopy within the past 5 years, and 22% (n=11) of these colonoscopies were performed for evaluation of constipation. No colonoscopy identified a structural etiology of constipation. Conclusion: DD is a treatable and under-recognized cause of chronic constipation. In our study, we identified an underutilization of DRE and ARM to evaluate for DD. These findings suggest that DD is potentially underdiagnosed in our Veteran population. Additionally, colonoscopy was low yield in the evaluation of constipation. Since biofeedback is highly effective for DD, further investigation is needed to identify barriers to DRE and ARM referrals at our center.Table 1.: Title: Table. Reliability Statistics for Categorical Questions Evaluating Bloating and Distension Symptoms Footnotes: ***, near perfect agreement (k ≥ 0.81); **, substantial agreement (0.61 ≤ k < 0.81); *, moderate agreement (0.41 ≤ k < 0.61); k, Cohen's kappa coefficient; CI, confidence interval; Sx, symptom; d, days; hrs, hours
Published Version
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