Abnormal Balloon Expulsion Test Research Articles

Differential Findings on Anorectal Manometry in Patients with Parkinson's Disease and Defecatory Dysfunction.

Gastrointestinal dysfunction, particularly constipation, is among the most common non-motor manifestations in Parkinson's Disease (PD). We aimed to identify high-resolution anorectal manometry (HR-ARM) abnormalities in patients with PD using the London Classification. We conducted a retrospective review of all PD patients at our institution who underwent HR-ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex-specific normal values, HR-ARM recordings were re-analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69-74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto-anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.

Anorectal manometry for the diagnosis of pelvic floor disorders in patients with hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome

IntroductionFunctional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls.MethodsWe conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher’s exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation.ResultsA total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients.ConclusionsThese results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Recto-anal Pressures in Constipated Men and Women Undergoing High-Resolution Anorectal Manometry.

In constipated individuals, high-resolution anorectal manometry (HRM) may suggest the presence of a defecatory disorder. Despite known physiological differences between men and women, our understanding of functional anorectal pathophysiology is based upon predominantly female cohorts. Results are generalized to men. To evaluate whether recto-anal pressure patterns in constipated men are similar to those in constipated women. The electronic health records at Mayo Clinic, Rochester were used to identify constipated adult patients, without organic anorectal disease, who had undergone HRM and balloon expulsion testing (BET) in 2018, 2019, and 2020. Comparative analyses were performed. Among 3,298 constipated adult patients (2,633 women, 665 men), anal and rectal pressures were higher in men. Women more likely to have HRM findings suggestive of a defecatory disorder (39% versus 20%, P < 0.001). Women were more likely to exhibit a type 4 pattern (27% versus 14%, P < 0.001), and less likely to exhibit a type 1 pattern (14% versus 38%, P < 0.001), of dyssynergia. Men were more likely to have an abnormal balloon expulsion test (BET, 34% versus 29%, P = 0.006). Nominal logistic regression demonstrates that male sex, age over 50years, reduced recto-anal gradient during simulated evacuation, and types 2 and 4 dyssynergia are associated with an abnormal BET. In this large retrospective study, constipated men and women exhibited different patterns of dyssynergia both in the presence and absence of an abnormal BET. These findings were independent of sex-specific baseline physiological differences.

Can a Defecation Posture Modifying Device Correct an Abnormal Balloon Expulsion Test in Chronically Constipated Patients?

Evacuation disorders are common among chronically constipated (CC) patients who fail to respond to laxatives and are typically diagnosed by anorectal manometry (ARM) and/or balloon expulsion testing (BET).1,2 Recently, there has been emerging interest in the use of defecation posture-modifying devices (DPMDs) to improve constipation symptoms, presumably by replicating the physiologic benefits of squatting on stool evacuation, such as straightening of the anorectal angle and relaxing the pelvic floor. However, the ability of DPMDs to normalize anorectal function in adult patients with CC has not been studied.

Rectal Evacuation Disorders in Patients Presenting With Chronic Functional Diarrhea

Defecatory disorders include a spectrum of conditions that manifest as spastic rectal evacuation disorders or flaccid disorders causing obstructed defecation.1 Functional defecation disorders are usually evidenced by 2 of the following 3 tests documenting impaired evacuation: abnormal balloon expulsion test, abnormal anorectal evacuation pattern with manometry, or impaired rectal evacuation by imaging. Descending perineal syndrome is defined by at least 4-cm caudal movement of the anorectum upon defecation with a failure of rectoanal angle opening, outlet obstruction, and incomplete defecation.

S0456 Revisiting the Cut-Off for an Abnormal Balloon Expulsion Test: Can We Make Testing More User Friendly?

INTRODUCTION: Chronic constipation (CC) is a common gastrointestinal complaint in clinical practice. Anorectal Manometry (ARM), Balloon Expulsion Testing (BET), and Defecography (DEF) are used to evaluate for dyssynergic defecation (DD) in CC patients. Literature provides poor to moderate agreement between ARM, BET, and DEF. The current threshold for a normal BET is <60 seconds. This threshold, though widely adopted, has not been rigorously validated. Our aim was to determine if a shorter or longer expulsion time offers improved performance characteristics to the current cut off for an abnormal BET of <60-seconds. METHODS: A retrospective cross-sectional study was conducted on 4746 CC patients ≥18 years of age who were referred for AFT at a single tertiary-care center from July 2003 to February 2020. All CC patients underwent an ARM and BET with a sub-set completing an ARM, BET, and DEF (n = 726). Abnormal AFT were defined as the following: ARM = simulated defecation responses with ≤20% anal relaxation; BET = the inability to expel a 50 ml water-filled balloon in ≤60-seconds; DEF = paradoxical contraction, increase anorectal angle, and/or the inability to expel barium contrast. DD was defined as an abnormal ARM and DEF. Linear BET time marks were coded for an abnormal test every 30-seconds: 30–120 seconds. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated for each 30-second BET time point using an abnormal ARM, DEF, and DD as individual state variables. RESULTS: Demographics (N = 4746) were as follows: mean age 48.8 ± 16.4 years (18–93), mean BMI 27.5 ± 7.2, 81.8% female, and 85.3% Caucasian. The BET sensitivity and specificity were similar at 30, 60, 90, and 120 seconds for an abnormal ARM, DEF, and DD (Table 1). The PPV for identifying an abnormal ARM for BET using a threshold of 120 seconds (sec) = 79%, for BET 90 sec = 68.0%, BET 60 sec = 62.1%, and BET 30 sec = 47.7% (Table 1). The NPV for BET 120 sec = 27.9%, BET 90 sec = 44.6%, BET 60 sec = 50.9%, and BET 30 sec = 62.7% (Table 1). Similar profiles for PPV and NPV for abnormal DEF and DD relative to various BET time thresholds (Table 1). CONCLUSION: A BET threshold of <60 seconds offers the best combination of performance characteristics for dyssynergic defecation relative to a few different gold standards and should remain the standard for defining an abnormal BET.Table 1

Abnormal Balloon Expulsion Test in Patients with Fecal Incontinence.

Functional defecatory dysfunction is attributed to the pathophysiology of fecal incontinence (FI) in some patients. We hypothesized that patients with FI and abnormal balloon expulsion test (BET) have distinct manometric characteristics as compared to the patients with FI and normal BET. We aimed to compare the anorectal pressure profile in patients with FI, with or without abnormal BET and to identify risk factors associated with abnormal BET in FI. We performed a retrospective review of 77 consecutive patients with ROME IV FI. Wilcoxon rank sum test, t-test, and Fisher exact tests were performed for comparison. Multivariable logistic regression was performed to identify factors associated with abnormal BET. Thirty-two percent of patients had abnormal BET. Demographics and surgical history and clinical symptoms, except for sensation of incomplete evacuation (p=0.02) and abdominal pain (p=0.03), were comparable in both groups. Anorectal pressure profile except for the median rectal propulsive pressures were similar between groups. Rectal propulsive pressures at simulated defecation were significantly lower in patients with abnormal BET (p=0.02). Mean sensory threshold for first sensation was also significantly higher in patients who had abnormal BET (p=0.03). Rectal propulsive pressures (OR: 1.03, 95% CI: 1.00-1.06, p=0.032) and rectal sensory threshold for first sensation (OR:0.94, 95% CI: 0.90-0.99, p=0.02) were able to predict abnormal BET independently. In patients with FI and similar clinical and anal pressure profile, rectal sensory threshold and rectal propulsive pressures at simulated defecation can determine normal BET.

Magnetic imaging defecography results are comparable to high-resolution manometry and conventional X-ray defecography in the assessment of functional pelvic floor disorders.

X-ray defecography or magnetic resonance defecography (MRD) and high-resolution anorectal manometry (HR-ARM) are essential for the diagnosis of pelvic floor disorders (PFD). However, there is only scarce information available about the accuracy of MRD in the functional assessment of the pelvic floor. The aim of this study was to examine the accuracy of MRD in the diagnosis of pelvic floor disorders by examining the intra-test agreement with x-ray defecography and HR-ARM in patients with PFD. The study population included adults referred to our institution in January 2018-February 2020 for MRD as part of their evaluation of PFD. The MRD results were compared with X-ray defecography and HR-ARM. Forty-two patients were included in the study (36 female, 86%, mean age 56.9years ± 15.8, range 19-86years). When compared to X-ray defecography, the sensitivity of MRD for the evaluation of normal rest and squeeze pressures was high (0.83 and 1, respectively). High sensitivity rates were observed for the detection of pelvic organ prolapse and pelvic floor dyssynergia (0.84-1). When compared to HR-ARM, the sensitivity of MRD for the evaluation of squeeze and dyssynergia was very good (0.92and 1, respectively), and good for the evaluation of rest pressure (0.6). Inter-test agreement was high (0.5, 0.6, 0.6 for rest, squeeze and dyssynergia). Excellent rates of sensitivity as well as almost perfect intra-test agreement was found between abnormal balloon expulsion test and the diagnosis of dyssynergia and pelvic organ prolapse on MRD (1, 0.81). This study demonstrated substantial diagnostic agreement between HR-ARM and MRD in the diagnosis of pathological etiologies for functional pelvic floor disorders, mainly obstructed defecation syndrome.

Diagnostic value of the balloon expulsion test compared with anorectal manometry in Indian patients with dyssynergic defecation.

IntroductionDigital rectal examination (DRE) and balloon expulsion test (BET) are simple tests to diagnose dyssynergic defecation (DD).AimTo determine differences in symptoms and manometry findings in patients with abnormal BET and normal BET. The secondary objective was to ascertain the sensitivity and specificity of BET and DRE + BET for the diagnosis of DD in an Indian setting using ARM findings as the gold standard.Material and methodsRetrospective analysis of patients with chronic constipation referred for anorectal manometry (ARM) between December 2012 and March 2019. DD was diagnosed using ARM. Findings on BET and, in a subset of cases, on DRE + BET were compared with ARM findings. The data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Agreement of BET and DRE + BET with ARM was calculated using Cohen’s κ coefficient. A p-value of < 0.05 was considered significant.ResultsA total of 1006 cases (734 males, 73%) formed the study cohort. Patients with abnormal BET more frequently reported digitation, bleeding per rectum, and straining (p < 0.00001). Moreover, they had a significantly higher median basal pressure compared to those with normal BET (80 vs. 67, p = 0.03). DD was significantly more common in those with abnormal BET. The sensitivity, specificity, PPV, and NPV of BET in detecting DD were 28.29%, 97.15%, 81.13%, and 75.78%, respectively. The percentage of agreement was 76.34%, and there was fair degree of correlation between the two tests. In a smaller subset of cases (166), DRE and BET findings were both available for analysis. We noted that the sensitivity, specificity, PPV, and NPV of combined DRE + BET were 57.63%, 88.79%, 73.91%, and 79.17%, respectively. The Cohen’s κ correlation coefficient was 0.49, suggesting moderate agreement.ConclusionsPatients with abnormal BET more frequently report digitation, straining, and bleeding per rectum, and have higher resting anal pressure. BET is a good screening test for DD in an Indian setting.

Is Dyssynergic Defecation an Unrecognized Cause of Chronic Constipation in Patients Using Opioids?

The impact of opioids on anorectal function is poorly understood but potentially relevant to the pathogenesis of opioid-induced constipation (OIC). To evaluate anorectal function testing (AFT) characteristics, symptom burden, and quality of life in chronically constipated patients prescribed an opioid (OIC) in comparison with constipated patients who are not on an opioid (NOIC). Retrospective analysis of prospectively collected data on 3,452 (OIC = 588 and NOIC = 2,864) chronically constipated patients (Rome 3) who completed AFT. AFT variables included anal sphincter pressure and response during simulated defecation, balloon expulsion test (BET), and rectal sensation. Dyssynergic defecation (DD) was defined as an inability to relax the anal sphincter during simulated defecation and an abnormal BET. Patients completed Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. The mean age of the study cohort was 49 years. Most patients were women (82%) and whites (83%). Patients with OIC were older than NOIC patients (50.7 vs 48.3, P = 0.001). OIC patients were significantly more likely to have DD (28.6% vs 21.4%, P < 0.001), an abnormal simulated defecation response on anorectal manometry (59% vs 43.8%, P < 0.001), and an abnormal BET (48% vs 42.5%, P = 0.02) than NOIC patients. OIC patients reported more severe constipation symptoms (P < 0.02) and worse quality of life (P < 0.05) than NOIC patients. Chronically constipated patients who use opioids are more likely to have DD and more severe constipation symptoms than NOIC.

504 Golden-Finger: Digital Rectal Exam Predicts Dyssynergic Defecation but Not Type of Dyssynergy Pattern on ARM

INTRODUCTION: Functional defecation disorders are a common cause of chronic constipation and the diagnosis include an abnormality in two or more of the following tests: balloon expulsion test (BET), anorectal manometry (ARM) or uncoordinated defecation on electromyography. Additionally, there have been four types of anorectal manometry dyssynergy patterns identified. Rao et al have shown that digital rectal examination (DRE) performed by a single expert gastroenterologist can accurately detect patients with dyssynergia. We conducted a study evaluating whether DRE performed by gastroenterology specialists could predict the presence and type of dyssynergia in patients with chronic constipation. METHODS: Patients with chronic constipation as defined by Rome IV criteria were evaluated by GI specialty providers at a single tertiary care hospital. After performing a DRE, each provider documented a prediction regarding the type of dyssynergy pattern that would be identified on ARM as well as whether the patient would pass the balloon during BET. An abnormal BET was defined as failure to pass the balloon in less than 60 seconds. Patients subsequently underwent ARM and BET and results of predicted and measured values on ARM and BET were compared. RESULTS: 21 patients were referred to undergo ARM and BET. 19 patients met the inclusion criteria. 16 displayed a dyssynergy pattern on ARM. Of the 16 patients, 11 were also identified to have features of dyssynergia on DRE with a detection rate of 69% (Table 1). One patient was noted to have features of dyssynergia on DRE but had normal ARM. Two patients had normal DRE with normal ARM. 11 of the 16 patients with dyssynergia on ARM had abnormal BET. Of the 11 patients with abnormal BET, 7 were predicted to have abnormal BET based on DRE (64% detection rate). DRE predicted the correct type of dyssynergia (type 1-4) in 31% of patients (Table 2). CONCLUSION: Studies have shown that DRE can predict dyssynergia when performed by a single expert gastroenterologist with a detection rate of 73%. Our analysis suggests that DRE can be used to predict dyssynergia on ARM and outcomes of BET even when multiple providers perform the exam. However, DRE is not a good predictor of the type of dyssynergia. Further studies are needed to evaluate the differences in detection rates between types of dyssynergia classified by ARM, and to assess whether there is a difference in detection rates between trainees and attendings.

476 Pelvic Floor Dysfunction Is Associated With Reduced Urinary Flow Rate in Younger Men

INTRODUCTION: In younger men, in whom organic prostate disease is uncommon, the etiology of lower urinary tract symptoms (LUTS) is frequently unclear. Studies suggest that in this young cohort voiding phase dysfunction is more common than storage phase dysfunction or normal urodynamics. Abnormal pelvic floor muscle relaxation, which can result in constipation, could potentially result in voiding dysfunction also. To date, no studies have investigated the relationship between posterior pelvic floor dysfunction and LUTS in young men. METHODS: Men who had undergone both anorectal manometry and uroflowmetry (i.e. had lower gastrointestinal and urinary symptoms) between October 2012 and September 2018 were identified. Patients &gt;40 years old were excluded to reduce the likelihood of prostate disease. Clinical data was extracted from the electronic health records. Descriptive and comparative analyses were performed. RESULTS: Of 47 identified patients, 13 were excluded due to a history of neurogenic bowel/bladder, urethral/anal surgery or significant neurological disease. The mean age and standard deviation (SD) of the 34 men analyzed was 30 ± 6 years. Twenty patients demonstrated an abnormal balloon expulsion test (BET). The median (and interquartile range [IQR]) number of LUTS was 1.5 (1-2). An abnormal BET was not associated with symptoms of nocturia, hesitancy, incomplete emptying or the total number of LUTS (2 vs 1, P = 0.6). An abnormal balloon expulsion test was associated with a lower maximum urinary flow rate (Qmax, 14 vs 29 mls/sec, P &lt; 0.001) but not flow duration (34 vs. 27 seconds, P = 0.2), residual urine volume (55 vs. 43 mls, P = 0.7) or urine volume (300 vs. 301 mls, P = 0.5). No correlation was seen between anal pressures at rest or during simulated evacuation and maximum urinary flow rate. No correlation was found between functional constipation and Qmax, LUTS or abnormal uroflow. No relationship between rectal sensory thresholds and urinary symptoms was identified. CONCLUSION: In this study of young men undergoing both anorectal manometry and uroflow, pelvic floor dysfunction was not associated with specific LUTS but was associated with a clinically significant reduction in maximum urinary flow rate. However an objective diagnosis of functional constipation was not associated with urologic abnormalities. Further studies will be needed to prospectively characterize this cohort and to identify whether PFD-associated LUTS and reduced flow respond to biofeedback therapy.

Clinical and anorectal manometry profile of patients with functional constipation and constipation-predominant irritable bowel syndrome.

Functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C) have significant healthcare impact. Clinical and investigative data of patients with these disorders in Indian population is scarce. We aimed to compare the clinical and anorectal manometric profile of patients with FC and IBS-C. Consecutive patients with chronic constipation undergoinganorectal manometry (ARM) and balloon expulsion test (BET) were enrolled. Thirty healthy volunteers served as controls (HC). Functional defecatory disorder (FDD) was diagnosed according to ROME IV criteria if both ARM and BET were abnormal. Of the 231 patients enrolled (median age 47years, 87.8% males), FC and IBS-C were diagnosed in 132 (57.1%) and 99 (42.9%) patients, respectively. Significant clinical differences between FC and IBS-C patients included older age, lower stool frequency/week, higher frequency of straining, and greater frequency of incomplete evacuation (p < 0.001). ARM revealed abnormal defecatory pattern in 55.3% (n = 73) FC patients and 47.5% (n = 47) IBS-C patients. Of them, 54.7% (40/73) of FC patients had inadequate defecatory propulsion while 89.4% (42/47) of the IBS-C patients had dyssynergic defecation (p < 0.001). Abnormal BET was seen in 67.4% of FC patients and 43.4% of IBS-C patients. Thus, FDD was diagnosed in 55.3% and 46.5% of FC and IBS-C patients, respectively. Rectal hyposensitivity was present in 60.6% of FC patients compared with 2% of IBS-C patients (p < 0.001). There were significant differences in clinical and manometric profile of FC and IBS-C patients. Compared with IBS-C patients, FC patients were older, had higher prevalence of FDD, less often had dyssynergic defecation, and had higher prevalence of rectal hyposensitivity.

Pelvic Floor Symptom Related Distress in Chronic Constipation Correlates With a Diagnosis of Irritable Bowel Syndrome With Constipation and Constipation Severity but Not Pelvic Floor Dyssynergia.

Background/AimsAlthough symptoms related to the pelvic floor, such as pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS), are common in patients with chronic constipation (CC), its impact is not clear. Our aims were to investigate the following (1) compare pelvic floor symptom related dysfunction in irritable bowel syndrome with constipation (IBS-C) and functional constipation (FC), and (2) symptom correlation with findings on anorectal manometry (ARM) and balloon expulsion test.MethodsThis was a retrospective analysis of patients with CC undergoing ARM. IBS-C and FC were diagnosed by Rome III criteria. Pelvic Floor Distress Inventory (PFDI-20) was used to measure pelvic floor symptom distress. Constipation Severity Scale was used to assess constipation severity.ResultsA total of 107 patients underwent ARM (64 FC, 43 IBS-C). The overall PFDI-20 score in IBS-C was higher compared with FC patients (118.0 vs 79.2, P = 0.001). In those with IBS-C, POP, LUTS, and colorectal symptoms subscales were all higher compared with FC patients (P < 0.05 for each). On multivariable regression, IBS-C (P = 0.001) and higher constipation severity (P = 0.001) were both independently associated with higher PFDI scores. ARM parameters and abnormal balloon expulsion test did not correlate with PFDI scores.ConclusionsCompared with FC patients, those with IBS-C have significantly higher distress from pelvic floor specific symptoms including POP and LUTS. Higher abdominal pain among IBS-C patients did not entirely explain these findings. A diagnosis of IBS-C and higher constipation severity correlated with PFDI-20 scores, but dyssynergia did not.

New Metrics in High-Resolution and High-Definition Anorectal Manometry.

To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques. The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence. HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.

How Do We Evacuate Stool? Insights From Combined High-Resolution Anorectal Manometry With Defecography

Introduction: The sense of incomplete evacuation is a feature of a defecatory disorder- however the mechanism of evacuation is not well understood. The aim of this study was to use simultaneous barium defecography and high resolution anorectal manometry (HRAM) to elucidate the mechanism of defecation in patients and controls Methods: Simultaneous seated HRAM and defecography (using180ml barium paste) were performed in 26 constipated women and 22 asymptomatic controls. Anal diameter and rectal pressures during evacuation and percentage of barium emptied, and the rectoanal pressure gradient during evacuation were calculated. Values less than 25th percentile for controls was considered abnormal. Results: Healthy women evacuated 80% of barium paste (median, IQ range-18-90%) while patients evacuated 21% (0-70%). Five controls and 12 patients evacuated < 18% of barium (25th percentile for controls). They were classified as “poor-evacuators” or PE); of these 9 had an abnormal balloon expulsion test (>60 seconds). The rest were classified as “adequate evacuators” (AE). Rectal and anal pressures increased initially during evacuation in all women. Thereafter, anal pressures declined, but the rectoanal pressure gradient exceeded 0 mm Hg only in AEs, enabling evacuation in this group. Rectal pressure at the onset of evacuation (median 87 vs 47mmHg, p=0.1) and anal diameter during evacuation (13 vs 0mm, p=0.002) was greater in AEs than PEs. Among AEs, a moving average of recto-anal pressure gradients (median = 4.2 mmHg) was positive (>0 mm Hg) for a median duration of 5s, which is 60% of the median duration of evacuation (8.5s). Among constipated PEs, disturbances were inadequate rectal pressure (4 patients) or impaired anal relaxation (8 patients). In a multivariate linear regression model, the rectoanal gradient, average anal canal diameter, and duration of anal relaxation during evacuation explained 40% of the variation in percent of barium emptied (p=0.0001). Conclusion: Adequate evacuation of barium (≥18%) is characterized by an initial simultaneous increase in rectal and anal pressure followed by anal relaxation. Conversely, either an inadequate increase in rectal pressure or in anal diameter during evacuation leads to incomplete evacuation. Not all women who have poor evacuation are symptomatic. The simultaneous increase in rectal and anal pressures during evacuation may be mediated by a reflex induced by increased abdominal pressure. Simultaneous defecography with HRAM may be useful in the clinical evaluation of chronic constipation.

Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation.

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. 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. 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). 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.

Anorectal Disorders

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

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

Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India. Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed. Of 249 patients (43.7 ± 16.2years, 174 males), 135/242 (55.8%), 57/249 (22.9%), and 83/136 (61.0%) had abnormal balloon expulsion test (>200g), anorectal manometry [>100mmHg resting pressure (n = 4), >167mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4cm, 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 [≥30min; 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. 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.

Thickened internal anal sphincter has been reported to be a typical finding in solitary rectal ulcer syndrome.

tion disorder among patients with solitary rectal ulcer syndrome (SRUS). The study showed that SRUS patients with abnormal balloon expulsion test had thicker internal anal sphincter (IAS), compared to those with normal tests. In fact, thickened IAS has been reported to be a typical endoanal sonographic finding in SRUS. 2,3 This finding could be associated with hypertrophy, possibly resulting from chronically increased work demand. A thickened IAS in patients with SRUS also is reported to be highly predictive of high-grade rectal intussusception. 4 Therefore, the result of Sharma et al’s study is not a novel finding but adds to the body of evidence demonstrating thickened anal sphincter as a typical endoanal feature in SRUS. As far as we know, several measuring points are required for the assessment of IAS thickness, since the thickness of IAS is not uniform. However, we could not find detailed methods for the measurement of IAS thickness in their article. We present typical endoscopic and sonographic findings of SRUS in a 59-year-old woman. She was referred to our constipation clinic for refractory constipation. Colonoscopy showed large ulcer with fold convergence (Figure A). The thickness of the IAS was measured at 4 different circumferential points. Endoanal sonography demonstrated thickened IAS irrespective of the level of anal canal (Figures B and C). Pathology showed fibrous obliteration and extension of smooth muscle fibers into the lamina propria. The confirmatory diagnosis of SRUS was made based on clinical presentation, endoscopic appearance and characteristic histologic features.