Diagnosis Of Dyssynergic Defecation Research Articles

A simple four symptom-based BEDS score to predict dyssynergic defecation in patients with chronic constipation.

Dyssynergic defecation (DD) is a disorder of anorectal function characterized by impaired relaxation or inappropriate contraction of pelvic floor muscles on attempted defecation. Based on previous Indian studies, we devised a symptom score (bleeding per rectum, excessive straining for stools, digitation, sense of incomplete evacuation/blockage-BEDS) and tried to determine if it can identify which patients with chronic constipation are more likely to have DD. This is a prospective observational cohort study in which consecutive adult patients (> 18years) with chronic constipation who were referred to our centre for anorectal manometry (ARM) between 2019 and 2023 were included. Prior to tests, patients were asked in detail regarding their symptoms and scoring was done. ARM was done by a single observer. Diagnosis of DD was based on standard criteria. Statistical tests used were median, range and percentages, Chi-square test and Mann-Whitney U-test. The data was analyzed for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Agreement of symptom-based scoring and DD diagnosis as per criteria was calculated using Cohen's κ coefficient. A p value of < 0.05 was considered statistically significant. As many as 244 patients (males 140, median age 42years) formed the study cohort. Of these, 104 (42.6%) have DD. Sense of incomplete evacuation/sense of blockage (72.1% vs. 40%, p < 0.0001), excessive straining (73.1% vs.22.1%, p < 0.0001) and digitation (28.8% vs. 13.5%, p 0.003) were more commonly reported in patients with DD. Taking a cut-off score of > / = 2, sensitivity of 69.2%, specificity 81.4% and positive likelihood ratio of 3.73 were noted. Similarly, if the score of > / = 3 was considered, the likelihood ratio increased to 4.71 with an increase in specificity (94.29%) and fall in sensitivity (26.92%). Symptom-based BEDS score of > / = 2 is useful in identifying patients with DD.

Diagnostic performance of dynamic MR defecography in assessment of dyssynergic defecation.

To assess diagnostic performance of MR defecographic findings in diagnosis of dyssynergic defecation (DD). This retrospective study included 46 patients with chronic constipation who met the Rome IV criteria for diagnosis of present or absent DD and underwent MRI between Jan 2015 and June 2020. Patients were divided into DD group (n = 24) and non-DD group (n = 22). Nine parameters were analyzed by two radiologists: anorectal angle (ARA) and M line at rest, defecation, and change between 2 phases; anal canal width; prominent puborectalis muscle; abnormal evacuation. Receiver operating characteristic (ROC) curves were plotted to extract the optimal cut-offs and area under the curve (AUC). Multivariate analysis was performed. Seven findings showed statistically significant difference between DD and non-DD groups. M line at defecation had highest odds ratio, followed by ARA change, ARA at defecation, M line change, prominent puborectalis muscle, abnormal evacuation and anal canal width, respectively. ARA change and prominent puborectalis muscle had highest specificity (95.5% and 100%, respectively). The optimal cut-offs of ARA at defecation, ARA change, M line at defecation, M line change and anal canal width were 122°, 1.5°, 3.25cm, 1.9cm and 8.5mm, respectively. Multivariate logistic regression revealed two significant findings in differentiating between DD and non-DD, including M line at defecation (OR 23.31, 95% CI 3.10-175.32) and ARA at defecation (OR 13.63, 95% CI 1.94-95.53) with sensitivity, specificity, PPV, NPV and AUC of 79.2%, 95.5%, 95%, 80.8% and 0.87(95% CI 0.78-0.97), respectively. MR defecography has high diagnostic performance in diagnosis of DD. Although M line and ARA at defecation are two significant findings on multivariate analysis, ARA change less than 1.5 degrees and prominent puborectalis muscle have good specificity in DD diagnosis.

Magnetic resonance defecography findings of dyssynergic defecation.

Dyssynergic defecation (DD) is defined as paradoxical contraction or inadequate relaxation of the pelvic floor muscles during defecation, which causes functional constipation. Along with the anal manometry and balloon expulsion tests, magnetic resonance (MR) defecography is widely used to diagnose or rule out pelvic dyssynergia. Besides the functional abnormality, structural pathologies like rectocele, rectal intussusception, or rectal prolapse accompanying DD can also be well demonstrated by MR defecography. This examination can be an uncomfortable experience for the patient, so the imaging method and the importance of patient cooperation must be explained in detail. The defecatory phase of the examination is indispensable for evaluation, and inadequate effort should be ruled out before diagnosing DD. MR defecography provides important data for the diagnosis of DD, but optimal imaging criteria should be applied. Further tests can be suggested if patient co-operation is not sufficient or MR defecography findings are irrelevant.

Comparison of Anorectal Function as Measured with High-Resolution and High-Definition Anorectal Manometry

Introduction: Anorectal manometry (ARM) provides comprehensive assessment of pressure activity in the rectum and anal canal. Absolute pressure values might depend on the catheter used. Objective: Our aim was to compare the results obtained by different anorectal catheters in children with functional anorectal disorders. Methods: Children diagnosed with functional defecation disorders based on the Rome IV criteria were prospectively enrolled. ARM was performed in the supine position successively using 2 different probes in each patient in random order. Resting, squeeze pressures, and bear-down maneuver variables obtained by high-resolution (2-dimensional [2D]) and high-definition (3-dimensional [3D]) catheters were compared. Results: We prospectively included 100 children {mean age 7.5 [standard deviation (SD) ± 4.3] years; 62 boys}. Mean resting pressures were significantly higher when measured with the 3D than with the 2D catheter (71 [SD ± 19.4] vs. 65 [SD ± 20.1] mm Hg, respectively; p = 0.000). Intrarectal pressure measured by 3D and 2D catheters was similar (35 vs. 39 mm Hg, respectively; p = 0.761), but the percent of anal relaxation appeared to be higher for the 3D than for the 2D probe (12 vs. 5%, respectively; p = 0.002). Dyssynergic defecation (DD) was diagnosed in 41/71 patients (57.7%) using the 3D probe and in 51/71 children (71.8%) using the 2D probe (p = 0.044). Cohen’s kappa showed only fair agreement between the catheters (κ = 0.40) in diagnosis of DD. Conclusions: Our study demonstrated significantly different values of pressures obtained with different types of catheters. Normal ranges for conventional manometry cannot be applied to high-resolution systems, and results obtained by different types of manometry cannot be compared without adjustments (NCT02812823).

Three-dimensional high-resolution anorectal manometry: cut-off values for diagnosis of dyssynergic defecation in children.

Dyssynergic defecation (DD) may be one of the most important causes of constipation, but its diagnostic criteria have not been formally validated in children. This study aims to evaluate constipated children with 3DHRAM (three-dimensional high-resolution anorectal manometry) and determine a new pediatric cut-off for DD variables. 205 patients diagnosed with functional constipation (FC) based on Rome III criteria were prospectively enrolled. Data were compared to a historical control group (C). Initially, the diagnosis of DD was based on adult criteria and divided into 4 types. A new cut-off value for percent anal relaxation was determined based on ROC curve analysis. The FC group presented significantly lower values of percent anal relaxation during straining compared to the C group (9.5% vs. 20%, respectively, p=0.03). Based on adult criteria, DD was found in 53% of the FC group and 46% of the C group (p=0.3), with type II occurring most frequently (35.8%). New cut-off value of 31% for percent anal relaxation in children was derived based on the ROC curve analysis. Based on this new cut-off value, DD was diagnosed in 69.3% of constipated children, with type IV occurring most frequently (28.9%). The analysis of segmental pressure showed significant influence of segments at the locations of the puborectalis muscle and external anal sphincter. We found that during bear down maneuver the percent anal relaxation variable significantly differed between patients and controls. The higher cut-off value should be used when 3DHRAM and the standard four-type classification are used to diagnose DD in children.

Manometric parameters, when measured with the 3-dimensional high-definition anorectal manometry probe, poorly predict prolonged balloon expulsion time.

There are little data evaluating the performance of the 3-dimensional high-definition anorectal manometry (3D-HDAM) system in the diagnosis of dyssynergic defecation. Physical properties of the thicker, rigid, 3D-HDAM probe may have implications on the measurements of anorectal pressures. Our aim was to compare 3D-HDAM to balloon expulsion test and magnetic resonance (MR) defecography. Consecutive constipated patients referred for anorectal function testing at the Calgary Gut Motility Centre (Calgary, Canada) between 2014 and 2019 were assessed. All patients underwent anorectal manometry with the 3D-HDAM probe, and a subset underwent BET or MR defecography. Anorectal manometric variables were compared between patients who had normal and abnormal BET. Over the study period, 81 patients underwent both 3D-HDAM and BET for symptoms of constipation. 52 patients expelled the balloon within 3 minutes. Patients with abnormal BET had significantly lower rectoanal pressure differential (RAPD) (-61 vs. -31mmHg for normal BET, p=0.03) and defecation index (0.29 vs. 0.56, p=0.03). On logistic regression analysis, RAPD (OR: 0.99, 95% CI: 0.97-0.99, p=0.03) remained a negative predictor of abnormal BET. On ROC analysis, RAPD had an AUC of 0.65. There was good agreement between dyssynergic patterns on 3D-HDAM and defecographic evidence of dyssynergia (sensitivity 80%, specificity 90%, PLR 9, NLR 0.22, accuracy 85%). Manometric parameters, when measured with the 3D-HDAM probe, poorly predict prolonged balloon expulsion time. RAPD remains the best predictor of prolonged balloon expulsion time. The 3D-HDAM probe may not be the ideal tool to diagnose functional defecatory disorders.

Facilitating Diagnosis of Dyssynergic Defecation in Children With Acquired Outlet Dysfunction Constipation

Facilitating Diagnosis of Dyssynergic Defecation in Children With Acquired Outlet Dysfunction Constipation

Dyssynergic Defecation in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Inflammatory bowel disease (IBD) patients often continue to experience nonspecific gastrointestinal symptoms despite quiescent disease. Unlike non-IBD patients, IBD patients with dyssynergic defecation (DD) may present with various symptoms such as diarrhea, fecal incontinence, constipation, and rectal discomfort. Despite its importance and treatability, DD in IBD patients is not well recognized in practice. We conducted a systematic review and meta-analysis on the prevalence, diagnosis, and management of DD in IBD patients with ongoing defecatory symptoms. We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews (from 1966 through February 2017) to identify relevant studies on the prevalence, diagnostic methods, or management of DD in IBD patients with and without ileal pouch-anal anastomoses (IPAAs). A random effects model was used to calculate the pooled estimates with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics, Cochran Q statistic, and sensitivity analyses. Seven studies (n = 442) were included. In patients with ongoing defecatory symptoms, the prevalence of DD without IPAA ranged from 45% to 97%, and in patients with IPAA, it ranged from 25% to 75%. The prevalence of DD in IPAA patients with and without pouchitis ranged from 17% to 67% and 29% to 50%, respectively. The pooled response rate to biofeedback therapy in patients without IPAA was 70% (95% CI, 55%-84%; I2 = 95%; P < 0.01), and it was 86% (95% CI, 67%-98%; I2 = 61%; P = 0.05) in those with IPAA. Despite limited data, the current literature suggests that DD is highly prevalent in active or quiescent IBD patients with ongoing defecatory symptoms and is responsive to biofeedback therapy. Although more studies are needed, DD should be considered in IBD patients with persistent defecatory symptoms.

Characterization of Anorectal Functions and Overall Colonic Transit in Female and Male Patients with Dyssynergic Defecation

Purpose: In non-elderly healthy people, there are no significant differences between genders in anal sphincter resting pressure1 or colonic transit2. There is a paucity of information regarding males with dyssynergic defecation (DD). Gender differences have not previously been evaluated in patients with DD. Our purpose was to compare anal sphincter pressures, balloon expulsion weights, and overall colonic transit by gender in DD. Methods: Medical records of 407 patients with constipation in whom a diagnosis of DD was made, based on evaluation by a single gastroenterologist (MC) at a tertiary medical center, were reviewed. Data from a previously published cohort of 390 patients (1994 to 2011) was updated to include patients up to June 2012. DD was characterized by anorectal manometry (ARM), balloon expulsion test, and overall colonic transit using validated scintigraphy. Primary endpoints were maximum anal resting pressure (ARP), maximum anal squeeze pressure (ASP), added weight (BW) to allow balloon expulsion (data censored if patient unable to expel balloon despite addition of >470 g) and overall colonic transit (geometric center, GC) at 24h (GC24). Effects of gender on study endpoints were assessed by Mann-Whitney rank sum test. Our lab previously reported normal GC24 values in 209 controls3: median=2.3 (IQR 1.8, 2.9): males (n=72): 2.6 (2.1, 3.1); females (n=136): 2.1 (1.7, 2.6). Results: The DD patient cohort consisted of 66 males (M) and 341 females (F). Median (IQR) values of age and BMI were: 45.5y (30.0, 58.0) and 23.6 kg/m2 (21.5, 26.3) for M; 37.0y (26.0, 49.0) and 21.4 kg/m2 (19.1, 24.5) for F. Significant differences by gender were observed in ARP, ASP and GC24. GC24 was significantly slower in both genders compared to same gender controls. Data in table are median (IQR) values with corresponding n=size/group in DD patients. Conclusion: Patients with DD have slower overall colonic transit compared to gender matched controls. In DD patients, males have significantly higher resting and squeeze anal sphincter pressures, and females have slower overall colonic transit at 24 hours. These data suggest that interpretation of tests in patients with suspected DD should be based on data from same gender controls.Table: [1748]

Tu2029 Does Dyssynergy on High Resolution Anorectal Manometry Correlate With Specific Symptoms?

BACKGROUND: Although the pathophysiology and management of dyssynergic defecation (DD) differs from that of other types of constipation, it shares many of the same symptoms. The diagnosis of DD relies largely on anorectal manometry, defecography, or balloon expulsion tests, which are not available in all practices. Ideally, a specific symptom from the history could suggest DD, leading the physician to efficiently utilize these resources. METHODS: For 5months, data was prospectively collected frompatients undergoing high resolution anorectal manometry (HRARM) for an indication of constipation. Patients completed the validated questionnaire “patient assessment of constipation” (PAC-SYM) and a 7 item bowel habits questionnaire (BHQ) prior to HRARM. The BHQ was designed to further characterize the evacuation process such as need and frequency for digital extraction of stool (TABLE 1). HRARM was performed using a solid state catheter with 10 circumferential sensors spaced at 0.6cm intervals. Sensation was assessed by inflating the rectal balloon with saline at 10cc increments. HRARMs were analyzed and mean anorectal pressures were collected. Presence of a dyssynergy pattern (either paradoxical contraction or inadequate relaxation of the anal sphincter) was noted. Statistical analysis was performed using Spearman's correlation coefficient and the point biserial correlation coefficient. RESULTS: Thirty patients presenting for HRARM fully completed the questionnaires. The median age was 39, 83.4% patients were female, 16.6% male, 70% were white, 23.3% black, and 6.7% other races. The mean total PAC-SYM score was 21 (range 7-41) of which 0 is the minimum and 48 the maximum score possible. The mean total BHQ score was 6.7 (range 2-12) of which 0 is the minimum and 28 the maximum score possible. On HRARM, a dyssynergy pattern was seen in 70% of the patients, of which 58.8%were characterized by paradoxical contraction of the sphincter and 41.2% by inadequate relaxation. Impaired rectal sensation was seen in 79% of patients. There was no statistically significant correlation between the total PAC-SYM score, total BHQ score, or score from any individual question and the presence of dyssynergy. There was no significant correlation between the total PAC-SYM score, total BHQ score, or score from any individual question and the percent anal relaxation during bear down maneuvers (TABLE 2). CONCLUSION: Even with the inclusion of a customized bowel habit questionnaire that aimed totarget anorectal symptoms, a significant correlation between symptoms and dyssynergy could not be found. This highlights the importance of a focused rectal exam and physiologic testing such as anorectal manometry in the diagnosis of DD. Bowel Habits Questionnaire (BHQ)

Tu2030 A Ghrelin Enhancer, Rikkunshito, Ameliorates Anorexia in Cachexia Model of Pulmonary Fibrosis

BACKGROUND: Although the pathophysiology and management of dyssynergic defecation (DD) differs from that of other types of constipation, it shares many of the same symptoms. The diagnosis of DD relies largely on anorectal manometry, defecography, or balloon expulsion tests, which are not available in all practices. Ideally, a specific symptom from the history could suggest DD, leading the physician to efficiently utilize these resources. METHODS: For 5months, data was prospectively collected frompatients undergoing high resolution anorectal manometry (HRARM) for an indication of constipation. Patients completed the validated questionnaire “patient assessment of constipation” (PAC-SYM) and a 7 item bowel habits questionnaire (BHQ) prior to HRARM. The BHQ was designed to further characterize the evacuation process such as need and frequency for digital extraction of stool (TABLE 1). HRARM was performed using a solid state catheter with 10 circumferential sensors spaced at 0.6cm intervals. Sensation was assessed by inflating the rectal balloon with saline at 10cc increments. HRARMs were analyzed and mean anorectal pressures were collected. Presence of a dyssynergy pattern (either paradoxical contraction or inadequate relaxation of the anal sphincter) was noted. Statistical analysis was performed using Spearman's correlation coefficient and the point biserial correlation coefficient. RESULTS: Thirty patients presenting for HRARM fully completed the questionnaires. The median age was 39, 83.4% patients were female, 16.6% male, 70% were white, 23.3% black, and 6.7% other races. The mean total PAC-SYM score was 21 (range 7-41) of which 0 is the minimum and 48 the maximum score possible. The mean total BHQ score was 6.7 (range 2-12) of which 0 is the minimum and 28 the maximum score possible. On HRARM, a dyssynergy pattern was seen in 70% of the patients, of which 58.8%were characterized by paradoxical contraction of the sphincter and 41.2% by inadequate relaxation. Impaired rectal sensation was seen in 79% of patients. There was no statistically significant correlation between the total PAC-SYM score, total BHQ score, or score from any individual question and the presence of dyssynergy. There was no significant correlation between the total PAC-SYM score, total BHQ score, or score from any individual question and the percent anal relaxation during bear down maneuvers (TABLE 2). CONCLUSION: Even with the inclusion of a customized bowel habit questionnaire that aimed totarget anorectal symptoms, a significant correlation between symptoms and dyssynergy could not be found. This highlights the importance of a focused rectal exam and physiologic testing such as anorectal manometry in the diagnosis of DD. Bowel Habits Questionnaire (BHQ)

Determination of the frequency of dyssynergic defecation and patient characteristics in patients with functional constipation

Dyssynergic defecation, a subgroup of functional constipation, is a relatively new definition, diagnostic criteria of which have recently been described. Distribution of subgroups of functional constipation in our population is scarcely known. We aimed to evaluate the demographic characteristics and defecation features of patients as we determined the frequency of dyssynergic defecation in patients with functional constipation in our community. Eighty-two patients, 52 women and 30 men, with functional constipation were included in the study by using a questionnaire after secondary causes were excluded. Colonic transit time and balloon expulsion tests were performed to determine sub-groups of functional constipation. Colonoscopy and/or sigmoidoscopy in all patients and double contrast colonography in some patients were obtained at the beginning of the study to exclude anatomic and organic causes and patients with constipation predominant irritable bowel syndrome were also excluded from the study. The results of the study revealed that functional constipation in our community occurs more frequently in women and at relatively older (middle to old) age. Patients with normal transit constipation pattern are the largest portion (52.4%) of patients with functional constipation, whereas dyssynergic defecation is the second most frequent (25.6%) reason among this population. The frequency of dyssynergic constipation is lower in our population compared to western communities, but the symptoms are similar. We believe that the questionnaire we used is helpful in revealing defecation characteristics and when combined with balloon expulsion test and colonic transit time measurements it can be a valuable tool in the diagnosis of dyssynergic defecation.

What Are the Key Questions Which Aid in the Diagnosis of Dyssynergic Defecation

What Are the Key Questions Which Aid in the Diagnosis of Dyssynergic Defecation

The corner of the coloproctologist: What to ask to radiologist

Defecation disorders, fecal incontinence, often associated to urinary and genital dysfunction, represent symptoms of a large number of functional and structural alterations of pelvic floor. They can be evaluated by functional and morphologic tests. A perfect anatomic and functional knowledge of the anorectum and pelvic floor is indispensable for a correct diagnostic and therapeutic path. Incontinence due to sphincter lesions can be diagnosed only by imaging techniques. In defecation disorders the issue is complex because functional and anatomic alterations can coexist. The radiological diagnosis of dyssynergic defecation is a diagnosis of confidence that enhances its value when manometric and electromyographic evidence of pelvic dyssynergia are detected. When anatomical alterations are detected the aim is to understand their physiopathology, to make a more precise diagnosis and treatment, and to minimize the errors of an inappropriate therapy. Our attention is focused on the information provided by imaging techniques about anorectum and pelvic floor abnormalities for optimal therapeutic planning.