High-resolution Anorectal Manometry Research Articles

The use of colonic and anorectal high-resolution manometry and its place in clinical work and in research.

In the esophagus, high-resolution manometry (HRM) has become a standard diagnostic tool in the investigation of suspected motility disorders. However, at the opposite end of the digestive tract (i.e., the colon and anorectum), the use of HRM still remains in its infancy, with relatively few published studies in the scientific literature. Further, the clinical utility of those studies that have been performed is largely undetermined. This review assesses all of the HRM studies published to date from both the colon and anorectum, explores the catheter types used, and attempts to determine the worth of HRM over traditional 'low-resolution' recordings from the same regions. Ultimately, this review addresses whether HRM currently provides information that will benefit patient diagnosis and treatment.

The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence.

Digital rectal examination (DRE) is a simple clinical method to diagnose anorectal disorders. High-resolution antorectal manometry (HRAM) based on a spatiotemporal plot is expected to promote improved diagnostic accuracy. However, there are no reports comparing the effectiveness of DRE and HRAM. The aim of our study was therefore to evaluate the diagnostic value of DRE compared with HRAM. A total of 309 consecutive patients with chronic constipation (n=268) or fecal incontinence (n=41) who underwent a standardized DRE, HRAM, and balloon expulsion test were enrolled in this study. The diagnostic yield of DRE compared with HRAM was determined, and agreement between DRE and HRAM data was evaluated. Of the constipated patients, 207 (77.2%) were diagnosed with dyssynergia using HRAM. The sensitivity, specificity, and positive predictive value of DRE in the diagnosis of dyssynergia were 93.2%, 58.7%, and 91.0%, respectively, and moderate agreement was seen between the two modalities (κ-coefficient =0.542, P<0.001). In patients with fecal incontinence, there was moderate agreement in terms of anal squeeze pressure between the two modalities (κ-coefficient =0.418, P=0.006); however, there was poor agreement for anal resting tone (κ-coefficient =0.079, P=0.368). DRE shows high sensitivity and positive predictive value in detecting dyssynergia compared with HRAM, and could therefore be used as a bedside screening test for the diagnosis of this disorder. Further studies are warranted to evaluate the correlation between DRE and HRAM in assessing anal sphincter pressure.

Sa1365 Successful Implantation of a Tissue Engineered Gut (TEG) Using Human Smooth Muscle and Human Enteric Neural Progenitor Cell

Introduction Conventional anal manometry (CAM) is widely used to measure sphincter function in patients with fecal incontinence (FI). However, results correlate poorly with symptom severity and may have limited impact on patient management. This study evaluated the discriminant utility of novel measures of anal resting and squeeze function using highresolution anorectal manometry (HRAM) compared to conventional measures. Methods Ninety-five healthy female volunteers (HV) (age 42 ± 13 years) and 95 females with FI (age 55 ± 16 years) underwent HRAM (solid state, 10 channels, 8 mm spacing). CAM data were subsampled from HRAM data. In each participant the CAM squeeze increment (CAM-SI) and CAM resting pressure (CAM-R) were compared with new derived HRAM ‘profile' measures (squeeze [HRAM-SP] and rest [HRAM-RP]). Results were compared between groups and metrics of diagnostic accuracy derived. Results Median St Marks Incontinence score was 11 (IQR=7) for FI vs. 1 (IQR=1) for HV, p <.001. In FI participants, abnormal squeeze function was demonstrated in 34/95 (36% sensitivity) using CAM-SI and 56/95 (59% sensitivity) using HRAM-SP (p <.001), resulting in superior receiver operator curve [ROC] characteristics for the novel measure (0.86 for HRAM-SP vs. 0.74 for CAM-SI). Regression demonstrated superiority of the HRAM-SP score (F = 17.91, adj R2 = 0.42) compared to CAM-SI scores (HRAM-SP: F = 12.52, adj R2 = 0.33; CAM-SI: F = 6.05, adj R2 = 0.18) in health status prediction. The difference between measures was less marked for analysis of anal resting pressure with abnormal function present in 24/95 (26% sensitivity) and 26/95 (27% sensitivity) when using CAM-R and HRAM-RP respectively. However slightly superior ROC characteristics were demonstrated for the novel measure (0.65 for HRAM-RP vs. 0.59 for CAM-R). Final cross tabulation of agreement between measures demonstrated that 25/ 61 patients who were classified as having normal function with the CAM measures displayed reduced function with wither the HRAM-R or HRAM-SP profile (26% of the cohort as a whole). Conclusions Novel HRAM measures appear superior in detecting impaired anal sphincter function in patients with FI over conventional measures and show enhanced correlation with symptom severity. In particular HRAM-SP has a 23% increase in sensitivity for detection of abnormal sphincter function in FI over conventional measures. The addition of this technique of analysis to manometric studies has a number of potential implications for clinical practice.

Sa1364 Prospective Comparison of Test Performance Between Traditional and High-Resolution Anal Manometry (HRAM) in Female Healthy Volunteers and Patients With Fecal Incontinence

Introduction Conventional anal manometry (CAM) is widely used to measure sphincter function in patients with fecal incontinence (FI). However, results correlate poorly with symptom severity and may have limited impact on patient management. This study evaluated the discriminant utility of novel measures of anal resting and squeeze function using highresolution anorectal manometry (HRAM) compared to conventional measures. Methods Ninety-five healthy female volunteers (HV) (age 42 ± 13 years) and 95 females with FI (age 55 ± 16 years) underwent HRAM (solid state, 10 channels, 8 mm spacing). CAM data were subsampled from HRAM data. In each participant the CAM squeeze increment (CAM-SI) and CAM resting pressure (CAM-R) were compared with new derived HRAM ‘profile' measures (squeeze [HRAM-SP] and rest [HRAM-RP]). Results were compared between groups and metrics of diagnostic accuracy derived. Results Median St Marks Incontinence score was 11 (IQR=7) for FI vs. 1 (IQR=1) for HV, p <.001. In FI participants, abnormal squeeze function was demonstrated in 34/95 (36% sensitivity) using CAM-SI and 56/95 (59% sensitivity) using HRAM-SP (p <.001), resulting in superior receiver operator curve [ROC] characteristics for the novel measure (0.86 for HRAM-SP vs. 0.74 for CAM-SI). Regression demonstrated superiority of the HRAM-SP score (F = 17.91, adj R2 = 0.42) compared to CAM-SI scores (HRAM-SP: F = 12.52, adj R2 = 0.33; CAM-SI: F = 6.05, adj R2 = 0.18) in health status prediction. The difference between measures was less marked for analysis of anal resting pressure with abnormal function present in 24/95 (26% sensitivity) and 26/95 (27% sensitivity) when using CAM-R and HRAM-RP respectively. However slightly superior ROC characteristics were demonstrated for the novel measure (0.65 for HRAM-RP vs. 0.59 for CAM-R). Final cross tabulation of agreement between measures demonstrated that 25/ 61 patients who were classified as having normal function with the CAM measures displayed reduced function with wither the HRAM-R or HRAM-SP profile (26% of the cohort as a whole). Conclusions Novel HRAM measures appear superior in detecting impaired anal sphincter function in patients with FI over conventional measures and show enhanced correlation with symptom severity. In particular HRAM-SP has a 23% increase in sensitivity for detection of abnormal sphincter function in FI over conventional measures. The addition of this technique of analysis to manometric studies has a number of potential implications for clinical practice.

Sa1339 Lessons Learned From 120 Consecutives 3-D High-Resolution Anorectal Manometry (HRAM)

Sa1339 Lessons Learned From 120 Consecutives 3-D High-Resolution Anorectal Manometry (HRAM)

Sa1371 Diabetic Constipation Patients Have the Same Characteristics of High Resolution Anorectal Manometry As Functional Defactory Disorder

Sa1371 Diabetic Constipation Patients Have the Same Characteristics of High Resolution Anorectal Manometry As Functional Defactory Disorder

Su1350 Characteristics of High Resolution Anorectal Manometry in Parkinson's Disease With Defecatory Disorder: A Comparison With Functional Defecatory Disorder

Su1350 Characteristics of High Resolution Anorectal Manometry in Parkinson's Disease With Defecatory Disorder: A Comparison With Functional Defecatory Disorder

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?

Sa1372 Can 3D High Resolution Anorectal Manometry Detect Anal Sphincter Defects in Patients With Fecal Incontinence?

Tu1229 Endoluminal Functional Lumen Imaging Probe (EndoFLIP) During Peroral Endoscopic Myotomy (POEM) for Achalasia Predicts Postoperative Clinical Success: A Multicenter Case-Control Study

Background: Anorectal manometry is useful in evaluating and planning treatment in patients with fecal incontinence (FI) and other disorders of defecation. Traditional water perfusion techniques are limited to 4 to 8 radial measurements obtained via a pullback technique. Three-dimensional high resolution anorectal manometry (3D HRAM) employs solid state micro transducers and can obtain 257 data points during resting, squeeze, and bear down (simulated defecation) sequences. Data are then reconstructed into a 3D format showing functional anatomy. While differences are known to exist between patients with FI and obstruction, patients with mixed disorders (of FI and obstruction) are less well described Objective: To determine physiologic differences between groups of female patients with FI, obstructed defecation, and mixed disorders. In addition to known parameters of mean resting pressure and maximal squeeze pressure, relationships between rectoanal pressure differential and percent anal relaxation were sought among the groups. Methods Retrospective chart review of 50 female patients undergoing 3D HRAM between 1/1/ 13 and 6/1/14. Physiologic values including mean resting, and maximal squeeze pressures, percent anal relaxation, and rectoanal pressure differential were recorded. Analysis of variance test, and linear regression analysis was performed as appropriate. Results:Women with mixed defecatory disorders had sphincter pressure profiles that were significantly different from patients with pure FI or obstruction (table). While rectoanal pressure differential was not different among the groups, patients with mixed disorders had a significant linear relationship between rectoanal pressure differential and percent anal relaxation that was not seen among the pure FI or obstructed groups (figure). Conclusion: Mixed defecatory disorders are associated with a unique physiologic profile that can be characterized using 3D HRAM. The mixed defecatory group demonstrates relationships between physiologic parameters that are not seen the incontinent or obstructed groups. This data will be helpful in the planning treatment regimens.

Sa1360 Canal Anal Pressure Profile At Rest and During Squeezing in Controls and Patients With Fecal Incontinence: A Study Using 3D Ano-Rectal High Resolution Manometry (3D ARHRM)

Sa1360 Canal Anal Pressure Profile At Rest and During Squeezing in Controls and Patients With Fecal Incontinence: A Study Using 3D Ano-Rectal High Resolution Manometry (3D ARHRM)

Assessment of Obstructive Defecation by High-Resolution Anorectal Manometry Compared With Magnetic Resonance Defecography

Patients with obstructive defecation have abnormalities of anorectal function and/or structure. Conventional anorectal manometry (ARM) can identify abnormal function and behavior (dyssynergia); however, agreement between manometry and defecography is only fair. High-resolution (HR)-ARM may improve diagnostic agreement by differentiating pressure effects caused by dyssynergia and obstruction. We compared HR-ARM findings with magnetic resonance (MR) defecography in the clinical assessment of patients with symptoms of obstructive defecation defined by Rome III criteria. HR-ARM (Manoscan AR 360; Given Imaging, Yoqeam, Israel) assessed anal sphincter function and pressure during simulated defecation. Abnormal manometric findings were classified according to the Rao system and compared with MR defecography as the reference standard. A total of 188 consecutive patients (155 women; age, 19-93 y) with obstructive defecation underwent a full investigation. Compared with patients with dyssynergia on MR imaging (n = 66), patients with structural pathology (n = 87) had lower resting (P < .003) and squeeze pressures (P < .011), but a higher rectoanal pressure gradient (P < .0001) on HR-ARM. High intrarectal pressure with a steep, positive pressure gradient consistent with outlet obstruction on HR-ARM was present in 24 patients with intra-anal intussusception on MR imaging. This pattern was not observed in other patients. Interobserver agreement was substantial for HR-ARM diagnoses (κ = 0.67; 95% confidence interval, 0.559-0.779). Diagnostic accuracy for dyssynergia was 82% compared with MR imaging (sensitivity, 77% [51 of 66]; specificity, 85% [104 of 122]). The diagnostic agreement between anorectal HR-ARM and MR defecography is high and pressure measurements accurately identify recto-anal dyssynergia and intra-anal outlet obstruction by structural pathology as causes of obstructive defecation.

Comparison of High-resolution Anorectal Manometry With Water-perfused Anorectal Manometry.

Background/AimsTo date, high-resolution manometry has been used mainly in the study of esophageal motility disorders and has been shown to provide more physiological information than conventional manometry, and is easier to interpret. This study aimed to evaluate the usefulness of high-resolution anorectal manometry (HRARM) compared to water-perfused anorectal manometry.MethodsPatients who complained of chronic constipation with/without fecal incontinence underwent both water-perfused anorectal manometry and HRARM in a random order on the same day. Resting and squeezing pressures of the anal sphincter, attempted defecation, rectoanal inhibitory reflex, rectoanal contractile reflex, Rao’s type of dyssynergia during attempted defecation, anal canal length, defecation dynamic parameters and measurement times for each method were analyzed.ResultsOf 14 patients, 7 were female, and the median age was 59 years (range 35–77). Indications for manometry were constipation (n = 8) and constipation with fecal incontinence (n = 6). Resting and squeezing pressures showed that the 2 methods were strongly correlated (resting pressure: r = 0.746, P = 0.002; squeezing pressure: r = 0.921, P < 0.001). In attempted defection, one equivocal case with water-perfused anorectal manometry was diagnosed type I pelvic floor dyssynergia with HRARM providing detailed pressure changes in internal and external anal spincters, and puborectalis muscle which improved assessment of anorectal disorders. The measurement time for HRARM was significantly shorter than that for water-perfused anorectal manometry (11.3 vs 23.0 minutes, P < 0.001).ConclusionsBoth water-perfused anorectal manometry and HRARM are well tolerated and reliable methods of evaluating defecation disorders of pelvic floor dysfunction. HRARM is likely to provide better physiological information and to require a shorter measurement time compared to water-perfused anorectal manometry.

High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies

Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI. This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test. Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM. We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.

Comparing Diagnostic Tests in Dyssynergic Defecation-Constipation

Introduction: Idiopathic chronic constipation is a common medical problem, with an average reported prevalence of 15% in North America. The prevalence of constipation is higher in women. Normal transit constipation, colonic inertia, and dyssynergic defecation (DD) are subtypes of idiopathic chronic constipation. There is limited agreement among tests to diagnose dyssynergic defecation. Dyssynergic defecatory symptoms, failure to expel a 60-mL balloon during a balloon expulsion test, and anal sphincter dyssynergic pattern on manometry testing are frequently used for diagnosing pelvic floor dyssynergia. The aim of this study is to compare the result of different studies in predicting DD. Methods: From January 2013 to May 2014, 143 consecutive constipated patients referred for pelvic floor testing were included in the study and the results of their work-ups were collected. Detailed questionnaires regarding patients’ defecatory symptoms, pertinent medical and surgical history, medication use, and digital rectal exam by gastroenterologists with motility expertise were collected prior to anorectal high-resolution manometry testing. Results: Our study includes 143 patients with constipation who were referred by their primary physician or gastroenterologist to our tertiary care center for pelvic floor testing. The mean age of the patients was 50 years with the majority of the patients being female (87%). Mean resting pressures were 62±6 mm Hg, mean squeeze pressures 143±13 mm Hg, and maximum tolerated volume was 201±63 mL; 111 patients (78%) had symptoms on questionnaire suggestive of DD. While 80 patients (56%) had an expert-performed digital rectal exam suggestive of DD, high-resolution manometry diagnosed dyssynergic pattern in 83 patients (58%). Expert-performed digital rectal exam is 87% sensitive and 85% specific for diagnosing DD versus dyssynergia documented by high-resolution manometry as the gold standard. Balloon expulsion test was abnormal (more than 2 minutes) in 57 subjects (40%). Among 32 patients with DD on manometry test who had normal balloon expulsion test (<2 min), 14 (43%) patients had resting anal pressure less than 45 mm Hg. Conclusion: Defecation is a complex process, influenced by stool consistency and pelvic floor neuromuscular sensation and function. While, there is no single criterion in diagnosing dyssynergic defecation (DD), the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia. Therefore, a careful interpretation of the test results is important in making the correct diagnosis.

High-resolution anorectal manometry in newborns: normative values and diagnostic utility in Hirschsprung disease.

Conventional methods of screening for Hirschsprung disease (HD) in newborns (barium enema, BE; anorectal manometry, ARM; rectal suction biopsy, RSB) have limitations and/or are invasive. High-resolution anorectal manometry (HR-ARM) is a minimally invasive technique that has potential to overcome most of these limitations, but normative data and performance characteristics have not been reported in newborns. The aims of our study were to assess anorectal sphincter metrics including resting pressure (RP), anal canal length (ACL), and rectoanal inhibitory reflex (RAIR) in healthy and asymptomatic newborns, and to explore the role of HR-ARM in the diagnosis of HD using these normal parameters. All procedures were performed using solid state HR-ARM equipment (Medical Measurement Systems, Enchede, The Netherland) by a single operator. In the first phase, 180 asymptomatic newborns (term newborns 95, preterm newborns 85) were studied, and anal RP, ACL, and RAIR were measured. In the second phase, 16 newborns with clinical manifestations of HD were studied (9 of whom had histopathologic confirmation), and parameters compared to asymptomatic newborns. Normative RP values were higher in term newborns compared with preterm newborns (p < 0.05), and correlated with age. Progressive maturation of the anal sphincter was evident with chronologic age, both in preterm and term newborns. RAIR was present in all normal subjects. Using absent RAIR as indicative of HD, HR-ARM had a sensitivity 89% and specificity of 83% compared to RSB; these performance characteristics were better than BE (sensitivity 78%, specificity 17%), with significantly higher diagnostic accuracy (80% vs 53%, respectively, p = 0.009). Anorectal sphincter pressure progressively matures with incremental increase in RP during the first months of life. HR-ARM is an effective and safe method that complements the diagnosis of HD in newborns.

Mo2026 Methane on Breath Test Predicts Altered Rectal Sensation During High Resolution Anorectal Manometry

Mo2026 Methane on Breath Test Predicts Altered Rectal Sensation During High Resolution Anorectal Manometry

Sa1085 Does High Resolution Ano-Rectal Manometry Under or Over Diagnose Pelvic Floor Dysfunction in Patients Who Present With Constipation and Difficulty Evacuating?

Sa1085 Does High Resolution Ano-Rectal Manometry Under or Over Diagnose Pelvic Floor Dysfunction in Patients Who Present With Constipation and Difficulty Evacuating?

Mo1236 Ileal Pouch Anal Anastomosis and Non-Relaxing Pelvic Floor Dysfunction

Patients with ileal pouch anal anastomosis (IPAA) have a 50% risk of developing pouchitis. Patients with IPAA may also experience abdominal and pelvic pain, bloating, and difficulty with pouch evacuation. These symptoms may be secondary to non-relaxing pelvic floor dysfunction (N-RFPD), an often unrecognized condition affecting the ileal pouch.We hypothesize that patients with chronic pouchitis are more likely to have non-relaxing pelvic floor dysfunction compared to patients without chronic pouchitis. Aims: To assess the prevalence of N-RPFD and clinical features in IPAA patients with and without chronic pouchitis who have presented with symptoms suggestive of a pouch evacuation disorder. Methods: We reviewed themedical records of patients with ulcerative colitis (UC) and IPAAwho underwent high resolution anorectal manometry (ARM), balloon expulsion and pouch sensation in response to inflation of a balloon from January 2007 to April 2012. History of pouchitis (based on clinical, endoscopic, and histologic findings) was recorded. N-RPFD was identified by abnormal ARM, abnormal defecography, or inability to expel a 50 mL balloon from the lower bowel despite addition of >200g weight. The balloon expulsion test was not performed in 3 patients. Results: Forty-two patients were identified for the study: 24 (57%) with chronic pouchitis and 18 (43%) with no history of pouchitis. All patients with a history of pouchitis had recurrent or antibiotic-dependent pouchitis. Data are shown in the table. Patients with history of pouchitis were more likely to have N-RPFD and abnormal balloon expulsion test, although this did not meet statistical significance. There were no differences in age, gender or average resting anal sphincter pressures. The volumes at first sensation, first urge to defecate, and first discomfort were not significantly different between the chronic pouchitis group and the group who never had pouchitis, suggesting no differences in pouch compliance in the two groups. Five of the 42 patients with evidence of N-RPFD completed a formal program in pelvic floor retraining with biofeedback. All 5 patients had improvement in symptoms of impaired pouch evacuation. Conclusions: The prevalence of N-RFPD is 55% in patients with IPAA performed for UC and appears to be more common in patients with (vs. without) a history of chronic pouchitis. These findings suggest that abnormal pouch emptying dynamics are common in patients with IPAA, and based on limited evidence N-RFPD is a treatable comorbidity. Further studies of pouch emptying dynamics should be explored to further characterize the impact of N-RPFD on pouch health.

679 Does Three Dimensional High Resolution Anorectal Manometry Increase Diagnostic Yield?

679 Does Three Dimensional High Resolution Anorectal Manometry Increase Diagnostic Yield?

Mo2021 A New High-Resolution Anorectal Manometry Parameter for Fecal Incontinence Based on Three-Dimensional Integrated Pressurized Volume of a Spatiotemporal Plot: Comparison Between Elderly Female Patients With Fecal Incontinence and Asymptomatic Normal Female Controls

Mo2021 A New High-Resolution Anorectal Manometry Parameter for Fecal Incontinence Based on Three-Dimensional Integrated Pressurized Volume of a Spatiotemporal Plot: Comparison Between Elderly Female Patients With Fecal Incontinence and Asymptomatic Normal Female Controls