Functional Defecation Disorders Research Articles

A novel wireless, smartphone-based biofeedback training device for functional defecatory disorders: a pilot study.

Functional defecatory disorders (FDDs) are highly prevalent around the world. Biofeedback is an effective treatment for FDDs. Traditionally, this treatment is performed by clinicians in a limited number of hospitals because of procedure-related expenses and a need for a dedicated procedure room. To make the biofeedback therapy more widely available, we have designed a novel wireless, smartphone-based biofeedback device, with the ultimate goal of performing the therapy at home. The aim of this pilot study was to investigate whether the developed device can be employed to treat patients with FDDs in a clinical setting, prior to employing it in a home setting. From March 2018 to July 2018, we performed the biofeedback therapy using the newly developed wireless, smartphone-based device in patients with FDDs 30min daily during weekdays for 2weeks. A Visual Analogue Scale (VAS) for bowel satisfaction, Patient Assessment of Constipation-Symptoms (PAC-SYM), Patient Assessment of Constipation Quality of Life (PAC-QOL), and a balloon expulsion test were assessed at baseline and after the therapy. Thirteen patients were recruited and ten of them (mean age 70.3 ± 8.9years, female:male ratio: 3:7) completed the study. Spontaneous bowel movements, complete spontaneous bowel movements, and VAS were all significantly increased after the therapy compared with baseline, respectively (6.5 ± 4.3 vs. 1.5 ± 2.2, p = 0.006; 3.1 ± 2.2 vs. 0.2 ± 0.6, p = 0.002; 49.5 ± 31.0 vs. 12.0 ± 9.2, p = 0.003). There was a significant decrease in the PAC-SYM and PAC-QoL after the biofeedback therapy (0.7 ± 0.6 vs. 1.4 ± 0.3, p = 0.001; 0.7 ± 0. 6 vs. 1.5 ± 0.4, p = 0.001). The therapy reduced the balloon expulsion time significantly (83.9 ± 68.8s vs. 160.0 ± 36.7s, p = 0.002). No obvious adverse events related to the procedure itself occurred. Biofeedback training using the newly developed wireless, smartphone-based device is feasible in the clinic setting, and it seems to be a promising method for improving constipation and related symptoms in patients with FDDs. These findings could be used to develop a much-needed, home-based, suitably powered, randomized, controlled clinical trial.

Can We Rely on the Rome IV Questionnaire to Diagnose Children With Functional Gastrointestinal Disorders?

Background/AimsTo investigate the intra-rater (test-retest) reliability of the diagnosis of functional gastrointestinal disorders (FGIDs) as measured by the Questionnaire on Pediatric Functional Gastrointestinal Disorders, Rome IV version (QPGS-IV) in children.MethodsA prospective cohort study was conducted in a public school in Cali, Colombia. Children and adolescents between 11 and 18 years of age were given the self-report Spanish version of the QPGS-IV at day 0 (baseline) and at day 2 (48 hours later).ResultsThe study protocol was completed by 215 children, of which 97 (45%) were excluded from analysis due to the inability to follow the questionnaire’s instructions. The final analysis included data of 118 children (mean age 15.0 ± SD 1.8 years old, 58.5% boys). The most common diagnoses were functional dyspepsia, functional constipation, and irritable bowel syndrome. We found a moderate intra-rater reliability (κ = 0.61-0.65) for diagnosing an FGID in general, a functional abdominal pain disorder, and the diagnosis of functional dyspepsia. We found a weak intra-rater reliability (κ = 0.46-0.54) for diagnosing a functional defecation disorder, functional constipation, irritable bowel syndrome, and the postprandial distress syndrome subtype of functional dyspepsia.ConclusionsOur study shows that a large proportion of children cannot adequately complete the QPGS-IV and that the intra-rater reliability among those who did adequately follow the instructions is moderate. We advise to test the children’s understanding of the instructions prior to completion of questionnaires and recommend to not rely exclusively on a self-reported questionnaire to select, recruit, or evaluate pediatric patients for FGIDs for research purposes.

Diagnostics of functional disorders of the gastrointestinal tract in patients with constipation

The purpose of the review is to acquaint general practitioners, therapists, gastroenterologists with the possibilities of diagnosing functional disorders of the gastrointestinal tract associated with constipation, as well as to draw attention to the need for additional examination methods for a comprehensive assessment of functional disorders of the gastrointestinal tract in patients with constipation on pathogenesis.Functional constipation is an urgent problem today due to its prevalence among different age groups, a negative impact on the quality of life, as well as the variability of the clinical forms of diseases associated with this symptom. The modern diagnostic algorithm for chronic constipation consists of several stages, including the identification of signs of the disease, according to the Rome criteria of the IV revision (2016), the identification of symptoms of “red flags” and laboratory and instrumental research. It should be borne in mind that functional constipation is often based on the pathology of the anorectal zone, which is an important factor in the diagnosis and development of further therapeutic strategies. The article provides an overview of modern and promising methods for diagnosing functional disorders of defecation, taking into account functional disorders of the anorectal zone associated with constipation.Functional methods such as anorectal manometry, rectal sensory test and balloon expulsion test are the most studied and obligatory tests for an objective assessment of the sensorimotor function of the anorectal zone. In Russia, these methods are used very little, which requires extensive familiarization of practitioners with the advantages of these techniques. Knowledge and application of the presented examination algorithms will help the clinician to increase the overall diagnostic efficiency and apply the most justified tactics of managing patients with functional pathology of the digestive system associated with constipation.

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).

Functional Constipation in Older Adults: Prevalence, Clinical Symptoms and Subtypes, Association with Frailty, and Impact on Quality of Life

Introduction: Functional constipation (FC) is very prevalent in older adults, especially in women, but its relationship with frailty is not fully understood. The aims were to assess FC prevalence, clinical symptoms and subtypes, association with frailty, and impact on quality of life (QoL) in older people. Methods: This epidemiological study included 384 individuals aged over 70 years recruited from the community, a hospital, and a nursing home and stratified into robust, pre-frail, and frail groups (Fried criteria). The following criteria were evaluated: frailty, FC (Rome III criteria), stool consistency (Bristol Stool Chart), comorbidities (Charlson), dependency (Barthel), QoL (EQ5D), and clinical and sociodemographic data. Defined by symptom aggregation were 2 main clinical subtypes as follows: slow colonic transit time (CTT) and functional defecation disorder (FDD). Results: Mean age was 79.11 ± 6.43 years. Overall FC prevalence was 26.8%, higher in women (32.4% women vs. 21.8% men; p = 0.019) and highest in frail patients (41.7% frail vs. 33.9% pre-frail vs. 24.2% robust; p < 0.001). Straining and hard stools (Bristol 1–2) were the most prevalent symptoms (89.3 and 75.7%, respectively). Frailty and benzodiazepine intake were independently associated with FC. Patients with FC obtained poorer QoL scores in the EQ5D (perceived health 66.09 ± 17.8 FC patients vs. 56.4 ± 19.03 non-FC patients; p < 0.05). The FDD subtype became significantly more prevalent as frailty increased (6.5, 25.8, and 67.7% for robust, pre-frail, and frail patients, respectively); the slow CTT subtype was significantly more frequent in robust patients (38.5% robust vs. 30.5% pre-frail vs. 23.1% frail), p = 0.002. Discussion/Conclusion: FC prevalence in older adults was high, especially in women, and was associated with frailty and poor QoL. Clinical subtypes as related to frailty phenotypes reflect specific pathophysiological aspects and should lead to more specific diagnoses and improved treatment.

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.

Effectiveness of Biofeedback Therapy on Quality of Life in Patients with Dyssynergic Defecation Disorder.

The first option to be considered in the treatment of functional defecation disorder is to correct the dyssynergia. However, limited studies exist to show the effectiveness of biofeedback. We evaluated the effect of biofeedback on the severity of constipation, quality of life, and anorectal manometry in patients with dyssynergic defecation in which the biofeedback method was applied. Effectiveness of biofeedback method on the quality of life of 24 dyssynergic defecation patients according to Rome III criteria after clinical and balloon expulsion tests (BETs) and colonic transit time was measured. Data were collected with patient identification form, Bristol Stool Chart, Constipation Quality of Life Scale forms, Visual Analogue Scale, diaphragmatic breathing exercises form, constipation diary, and constipation biofeedback monitoring form. Dyssnergic defecation cases received 6-week biofeedback training. For the same timeframe, the control group had a catheter into the rectum without any intervention. Constipation severity was reduced in both groups before biofeedback to post-biofeedback (P < .05). Anal canal pressure, BET, colonic transit time, and quality of life significantly improved in biofeedback patients compared with controls. Biofeedback has a favorable effect on therapy and quality of life in dyssynergic defecation cases.

The Puborectal Muscle and External Anal Sphincter Can Act Independently of each other in Functional Defecation Disorders

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Sampling reflex: pathogenic role in functional defecation disorder.

The sampling reflex is necessary to begin defecation or flatulence. It consists of a simultaneous rectoanal inhibitory reflex (RAIR) mediated by relaxation of the internal anal sphincter and rectoanal excitatory reflex (RAER) mediated by contraction of the external anal sphincter. The aim of this study was to evaluate the sampling reflex in patients with functional defecation disorder (FDD). A prospective cohort study was conducted on 58 obstructed defecation syndrome (ODS) patients with FDD. All 58 patients and 20 controls were evaluated with anorectal manometry to study the sampling reflex. Quantitative RAIR (total duration of reflex; maximal amplitude of relaxation; residual pressure at the lowest point of the RAIR) and RAER data (maximal amplitude of contraction; duration) were obtained. The straining test on manometry was considered positive for FDD if there was a muscle contraction/lack of relaxation or an insufficient pressure gradient for the passage of feces. Defecography was performed on all the patients with assessment of the anorectal angle and persistence or increase of puborectalis indentation. Fifty (86.2%) FDD patients had an altered sampling reflex, showing incomplete/short duration of RAIR and excessive contraction/duration of RAER. More specifically, there was a correlation between a positive straining test and a short total duration of RAIR (ρ 0.92) as well as with excessive duration of RAER (ρ 0.89). There was also a correlation between lack of muscle relaxation on defecography and short total duration of RAIR ((ρ 0.79) and between lack of muscle relaxation on defecography and excessive duration of RAER (ρ 0.83). Altered maximal amplitude relaxation had the highest sensitivity in detecting impairment of RAIR (87.9) while maximal amplitude contraction had the highest sensitivity in detecting impairment of RAER (89.6). High residual pressure at the lowest point of RAIR had the highest specificity in detecting impairment of RAIR (80.0) while RAER duration had the highest specificity in detecting impairment of RAER (77.7). The sampling reflex is impaired in patients with FDD. This finding provides an important insight into the pathogenesis of obstructed functional defecation.

Seated anorectal manometry during simulated evacuation: A physiologic exercise or a new clinically useful diagnostic test?

Symptoms such as a feeling of incomplete evacuation, straining, absence of the call to stool, anal blockage, or digitation suggest the presence a functional defecation disorder. As symptoms do not distinguish between patients with and without functional defecation disorder, Rome IV criteria recommend that this disorder is diagnosed when two of three tests are positive: balloon expulsion test (BET), anorectal manometry (ARM), and defecography. However, previous studies have demonstrated that the agreement among these tests is limited. In this issue of Neurogastroenterology and Motility, Sharma et al tested the hypothesis that conducting the ARM in a seated position would increase the diagnostic accuracy of the test in discriminating between patients with normal and prolonged BET. This minireview discusses the current knowledge on the role of the techniques to diagnose defecation disorder and the potential role of the ARM in a seated position.

Medications for constipation in 2020.

Chronic constipation is a common problem that substantially impacts the quality of life of patients and families, healthcare professionals, and resources. The purpose of this review is to discuss the medications that are available for management of chronic constipation, including medications that have been approved by the FDA for adults, other been studied in pediatrics now, and might become available within the upcoming years. Recent developments in the evaluation of childhood constipation are providing a better understanding into defecation disorders in children and not only new therapies are becoming available, including medications, but also other therapies, such as biofeedback for treatment of functional defecation disorders, electrical stimulation, and surgeries. The aim of this article is to provide an update on the medications that are available for management of chronic constipation, especially with the development and study of newer medications, such as Linaclotide and Lubiprostone with promising results in both adult and pediatric patients. This review will help us identify and have a better understanding regarding what medications are available for use and the indications, so that we can better manage patients with chronic constipation. VIDEO ABSTRACT.

Rectal Distension Increased the Rectoanal Gradient in Patients with Normal Rectal Sensory Function.

Frequent observation of abnormal manometric patterns consistent with dyssynergia in healthy volunteers has warranted the need for reassessment of the current methods to enhance the diagnostic value of anorectal manometry in functional defecatory disorders. Whether rectal distention at simulated evacuation will affect anorectal pressure profile and increase rectoanal gradient is not known. One hundred and eight consecutive patients with chronic constipation, 93 females, median age 53years (interquartile range: 40-65), were studied. Simulated evacuation was performed firstly with empty balloon and subsequently after balloon distention to 50 and 100ml. Anorectal pressures were compared. We also performed subgroup analysis in relation to outcome of balloon expulsion test (BET). In addition, we studied the effect of rectal distension on the rectoanal pressure gradient with respect to rectal sensory function. Rectal balloon distension at simulated evacuation improved rectoanal gradient and decreased the rate of dyssynergia during high-resolution anorectal manometry. In subgroup analysis, the increase in rectoanal gradient and correction of dyssynergia with rectal distension was limited to the patients who had normal BET and normal rectal sensory function. Rate of anal relaxation, residual anal pressures, and rectoanal gradient were significantly different between patients with and without normal BET at 50ml of rectal distension. Rectoanal gradient recorded only after rectal distension, along with BMI and maximum tolerable volumes, could predict BET results independently in patients with chronic constipation. Rectal distension during simulated evacuation will affect the anorectal pressure profile. Increase in rectoanal gradient and correction of dyssynergia was only significant in patients with normal rectal sensory function and normal BET.

Examining Hyper-Reactivity to Defecation-Related Sensations in Children With Functional Defecation Disorders (FDD)

Abstract Date Presented 03/27/20 This study investigated the relationship between sensory reactivity and FDD. Parents of three- to six-year-old children with and without FDD completed two questionnaires: the Toileting Habit Profile Questionnaire-Revised and the Short Sensory Profile. Children with FDD had higher levels of sensory hyper-reactivity. Screening for sensory hyper-reactivity may be important when working with children with FDD who have difficulty participating in toileting routines. Primary Author and Speaker: Isabelle Beaudry-Bellefeuille Additional Authors and Speakers: Shelly Lane Contributing Authors: Alison Lane, Eduardo Ramos-Polo

Epidemiology of Functional Abdominal Pain Disorders and Functional Defecation Disorders in Adolescents in Curacao.

Functional abdominal pain disorders (FAPDs) and functional defecation disorders (FDDs) are common in children and adolescents, but prevalence rates from the Caribbean are lacking. Therefore, our aim was to determine the prevalence of FAPDs and FDDs in adolescents in Curacao and to assess the influence of psychosocial factors on the prevalence of FAPDs and FDDs. The prevalence of FAPDs and FDDs in children and adolescents living in Curacao, ages 11 to 18 years, was assessed using the Rome IV Questionnaire on Pediatric Gastrointestinal Disorders (RIV-QPGD). FAPDs and FDDs were diagnosed according to the Rome IV criteria. Sociodemographic characteristics, somatic symptoms, early adverse life events, stressful life events, and physical and emotional abuse were evaluated as associated factors. Out of 946 questionnaires distributed, 783 were included for further analysis. The mean age of adolescents was 14.7 years (±1.6) with 61.7% being girls. A total of 266 adolescents (34%, 95% confidence interval [CI] 30.7-37.5) met Rome IV criteria for at least 1 FAPD or FDD. Twenty-nine adolescents (3.7%) qualified for 2 functional gastrointestinal disorders. Functional constipation (18.6%) and irritable bowel syndrome (12.3%) were the most prevalent disorders. After multivariate logistic regression analyses, dizziness (odds ratio [OR] 1.84, 95% CI 1.28-2.64) was significantly associated with having a FAPD or FDD. FAPDs and FDDs are common in adolescents in Curacao. Dizziness is associated with the presence of a FAPD or FDD.

重视功能性排便障碍的规范化治疗

重视功能性排便障碍的规范化治疗

Examining hyper-reactivity to defecation related sensations in children with functional defecation disorders

Background: Adequate sensory perception and reactivity to sensory stimuli associated with defecation is key to successful stool toileting. Preliminary reports suggests that some of the difficulties that many children with FDD experience with toileting could be related to sensory hyper-reactivity. Objective: This study investigated the relationship between sensory hyper-reactivity and functional defecation disorders (FDD). Methods: Parents of three to six-year-old children with and without FDD completed two questionnaires; the Toileting Habit Profile Questionnaire-Revised (THPQ-R; tool that measures sensory hyper-reactivity to defecation related sensations) and the Short Sensory Profile (SSP). On both questionnaires, low scores indicate more concerns. Between group comparisons and the relationship between scores on the THPQ-R and on the sensory hyper-reactivity items of the SSP were examined. Results: The sensory hyper-reactivity mean score of the SSP was lower for children with FDD. The difference was statistically significant (p < .0005). There was a positive correlation between THPQ-R and SSP hyper-reactivity scores (r274 = .485, p < .0005). Further, higher levels of sensory hyperreactivity (low SSP score) were associated with a higher frequency of the challenging defecation behaviors described in the THPQ-R (low THPQ-R score). Conclusion: Health practitioners do not usually consider sensory hyper-reactivity as a possible factor contributing to the difficulties of the child with FDD. Our results indicate that routine screening for sensory hyper-reactivity may be an important practice element when working with children with FDD. In addition, the present study adds support to the validity of the THPQ-R in identifying behaviors potentially linked to sensory hyper-reactivity.

Clinical Characteristics of Different Primary Constipation Subtypes in a Chinese Population.

Goal:To investigate the clinical characteristics of different primary constipation subtypes, including symptom clusters, psychological problems, quality of life (QOL), and to explore the role of constipation symptoms and the mental state in the QOL of constipation subtypes.Background:Patients with chronic constipation (CC) may be unsatisfied with their therapy and suffer recurrent symptoms. Different constipation subtypes require different treatments; therefore, it is important to identify the features of different constipation subtypes.Study:CC patients (n=206) visiting our gastroenterology clinic were studied. CC subtypes were diagnosed using the Rome-IV criteria. We used validated questionnaires to investigate the symptom severity, mental state, and QOL of patients. QOL was assessed with the Patient Assessment of Constipation Quality of Life (PAC-QOL) and SF-36 questionnaire. Results of symptom, mental and QOL scores are expressed as means with 95% confidence interval.Results:Three groups of CC patients differed in their constipation scoring system and the Patient Assessment of Constipation Symptoms (PAC-SYM) total scores, and both were significantly higher in the functional defecation disorder (FDD) group compared with that in the normal transit constipation (NTC) group. FDD patients tended to have more severe “abdominal symptoms,” “rectal symptoms” than NTC group. No significant difference in General Anxiety Disorder 7-item or Patient Health Questionnaire-9 results was found among the 3 groups. Significantly more patients with FDD suffered more “physical discomfort” and had poorer QOL in the “physical function” dimension of SF-36. FDD and NTC patients mainly showed associations between CC-related QOL and constipation severity, while slow transit constipation patients’ QOL was significantly associated with anxiety and depression.Conclusion:Patients with FDD suffer more severe constipation symptoms and have a lower QOL than patients in other CC subgroups. FDD and NTC patients’ QOL is mainly linked to constipation symptoms, while that of slow transit constipation is mainly related to mental states such as anxiety and depression.

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.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography.

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

Probiotics for Childhood Functional Gastrointestinal Disorders: Do We Know What We Advise?

Limited information is available on clinicians’ advising practices and perceived familiarity of probiotics in the management of childhood functional abdominal pain disorders (FAPDs) and functional defecation disorders (FDD). This study aimed to investigate pediatricians’ and general practitioners’ (GPs) advising practices and perceived familiarity of probiotics in the management of FAPDs and FDD. A cross-sectional survey was administered to Dutch pediatricians and GPs, including 27 questions about perceived familiarity of probiotics, followed by questions related to advising practices and reasons for advising or not advising probiotics. The responses of 319 pediatricians and 67 GPs were included. Significantly more pediatricians indicated to be familiar with probiotics compared to GPs (71% vs. 48% respectively, p < 0.001). Significantly more pediatricians advised probiotics compared to GPs for FAPDs (54% vs. 25%, respectively, p < 0.001) and for FDD (17% vs. 7%, respectively, p < 0.05). Primary reason to advise probiotics was patient request; main reason not to advise probiotics was personal lack of knowledge regarding probiotic use. Conclusions: Increased familiarity and appropriate advising of probiotics in treatment of childhood FAPDs and FDD among pediatricians and GPs is required. Improved familiarity of probiotics is important to provide appropriate information about probiotic use to children and caregivers and may facilitate shared decision-making.