Rectal Evacuatory Dysfunction Research Articles

3117 “A Gut Feeling”: Autonomic Instability and Dysbiosis in Connective Tissue Disease

INTRODUCTION: Ehlers-Danlos Syndrome (EDS) is a connective tissue disease in which mutations in certain genes result in a disruption of normal collagen. There are several subtypes of the disease. Among the various subtypes which exist, hypermobility is the most common. Many of these patients can have co-existing gastrointestinal symptoms, which are often times overlooked by practitioners. CASE DESCRIPTION/METHODS: A 23 year old female presented with chest tightness, daily palpitations, and diarrhea which had been persistent for three days. Her past medical history was notable for spinal stenosis and lactose intolerance. She denied any associated abdominal pain, fever, or chills. Her family history was non contributory. One month later, she continued to have diarrhea and heartburn. She endorsed symptoms of mucorrhea with associated bright red blood per rectum, lower abdominal pain, and fecal urgency. A thorough physical examination revealed hyper flexible joints and greater than normal mobility of her fingers. After genetic testing, she was later diagnosed with Ehlers-Danlos Type 3. DISCUSSION: Up to 57% of patients with EDS have coexisting functional bowel disorders.1 Chronic gastrointestinal discomfort was reported in 86% of patients with Ehlers-Danlos – hyper mobile subtype.2 Gastrointestinal complications can include gastro esophageal reflux disease, hiatal hernia, gastritis, gastric emptying, irritable bowel syndrome (found in 62% of patients), rectal evacuatory dysfunction, and delayed colonic transit.1,2,4 Symptoms are thought to occur as a result of bidirectional signaling between gut bacteria and the brain. Enterochromaffin cells are not only accessible by enteric microbiota but also have contact with afferent and efferent nerve terminals acting as “transducers” between the gut and brain,8 able to secrete various compounds, including serotonin. One study showed that pretreatment of animals with probiotic formulation consisting of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 attenuated hypothalamic pituitary axis and autonomic nervous system activities, which were assessed through the measurement of plasma cortisol and catecholamines.10 In our patient, she was treated with a course of Rifaximin for IBS-D and was placed on a bowel regimen including a probiotic. At a four-week follow up, her symptoms had improved.

Rectal evacuatory dysfunction in patients with genital prolapse

Rectal evacuatory dysfunction in patients with genital prolapse

Severe Gastrointestinal Dysmotility in Patients With Ehlers-Danlos Syndrome: Case Series - 1 Center Experience

Gastrointestinal complications are relatively frequent in Ehlers-Danlos syndrome (EDS). Intestinal dysmotility is significantly more frequent in EDS patients than in general population and it has a very difficult investigational approach, requiring a high clinical suspicion for diagnosis. Therapeutic approach may be challenging in the context of limited options and disabling nature of the disease. EDS is considered a multisystem disease, as connective tissue is present throughout the body, the digestive tract can be affected as well. Previous studies have associated EDS with a spectrum of gastrointestinal complications such as chronic constipation, hiatus hernia, Crohn's disease, fecal incontinence, rectal evacuatory dysfunction, functional gastrointestinal disorder, gastroesophageal reflux, recurrent gastritis, delayed gastric emptying and recurrent abdominal pain. In this case series, the authors report six cases of global gut dysmotility in Ehlers-Danlos syndrome. We try to highlight that EDS can lead to significant gut failure that is not only difficult to diagnose but is challenging to treat. All the patient's required at least one form of nutritional support either by tube feeding or intravenous nutrition. Some of the patient's required surgical intervention to treat the significant dysmotility. The table below shows our patients characteristics, diagnostic and feeding methods and the surgical intervention if needed. All the reported patients were females diagnosed clinically with EDS hypermobility type (type 3), mean age was 24 years, mean BMI was 23 kg /m2. Five of them diagnosed with POTS (cases 1, 2, 3, 4, 5), only one patient had Mast cell activation syndrome (case 1).Three patients were diagnosed with SIBO (cases 3, 4, 6), five patients required parenteral nutrition (cases 1, 2, 4, 5, 6). Five patients needed tube feeds at some point (cases 1, 2, 4, 5, 6). (See table1). Sever gut dysmotility among patients with Ehlers-Danlos syndrome is not uncommon and possibly underdiagnosed. It must always be taken into account when treating EDS patients with persistent gastro-intestinal symptoms, especially in the presence of autonomic dysfunction features (including POTS) and failure to maintain weight.Table: Table. POTS, postural orthostatic tachycardia syndrome; SIBO, small intestinal bacterial overgrowth; MCAS, mast cell activation syndrome; SBFT, small bowel follow through

PTU-051 Post-Partum Defecatory Dysfunction: A Complex Problem Involving Co-Existing Faecal Incontinence and Rectal Evacuatory Disorder

IntroductionFaecal incontinence and urgency are well-recognised sequelae of obstetric injury, however there is a paucity of literature describing the co-existence of symptoms of rectal evacuatory dysfunction (RED) and faecal incontinence...

PWE-010 Biofeedback-A simple and Effective way of Managing Rectal Evacuatory Dysfunction Secondary to Pelvic Floor Dyssynergia and Rectal Hyposensitivity

IntroductionBiofeedback is safe and effective in the management of rectal evacuatory dysfunction (RED), but there is limited data on medium to long-term follow-up. This study evaluated the effectiveness of biofeedback...

Prospective Randomized Double-Blind Study of Temporary Sacral Nerve Stimulation in Patients With Rectal Evacuatory Dysfunction and Rectal Hyposensitivity

Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30-69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234-320] vs ON: 163 mL [133-193] vs OFF: 220 mL [183-257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323-377] vs ON: 262 mL [219-305] vs OFF: 298 mL [256-340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0-100] vs ON: 89% [11-100] vs OFF: 83% [11-100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9-26] vs ON: 10 [6-27] vs OFF: 13 [5-29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.

Fecal Incontinence in Men

The pathophysiology of fecal incontinence in men is poorly established. The aim of this study was to assess the coexistence of constipation and determine the impact of rectal sensorimotor dysfunction in males with fecal incontinence. This study was conducted at a tertiary referral center. Included were adult male patients referred for the investigation of fecal incontinence over a 5-year period who underwent full anorectal physiology testing and completed a standardized symptom questionnaire. Standardized symptom questionnaires were fully completed, and anorectal physiologic test results (including evacuation proctography) were evaluated. : The primary outcomes measured were the frequency of symptoms of associated constipation, the association of blunted rectal sensation (rectal hyposensitivity) with symptoms, and other physiologic measures. One hundred sixty patients met the inclusion criteria, and 47% of these patients described concurrent constipation. Fifty-four patients (34%) had sphincter dysfunction on manometry, only 19 of whom had structural abnormalities on ultrasound. Overall, 28 patients (18%) had rectal sensory dysfunction, 26 (93%) of whom had rectal hyposensitivity. Patients with rectal hyposensitivity were more likely to subjectively report constipation (77%) in comparison with patients with normal rectal sensation (44%; p = 0.001), allied with decreased bowel frequency (19% vs 2%; p = 0.003) and a sense of difficulty evacuating stool (27% vs 8%; p = 0.008). Cleveland Clinic constipation scores were higher in patients with rectal hyposensitivity (median score, 13 (interquartile range: 8-17) vs normosensate, 9 (5-13); p = 0.004). On proctography, a higher proportion of patients with rectal hyposensitivity had protracted defecation (>180 s; 35% vs 10%; p = 0.024) and incomplete rectal evacuation (<55% of barium neostool expelled, 50% vs 20%; p = 0.02). : This study was limited by the retrospective analysis of prospectively collected data. Only one-third of incontinent men had sphincteric dysfunction. Other pathophysiologies must therefore be considered. Nearly half of patients reported concurrent constipation, and one-sixth had rectal hyposensitivity, which was associated with higher frequencies of both symptomatic and objective measures of rectal evacuatory dysfunction. In the majority of adult males, fecal incontinence may represent a secondary phenomenon.

The Number of Retained Rectosigmoid Markers During Colonic Transit Testing Does Not Reliably Predict the Presence of Dyssynergic Defecation

tion). During a 4 week period of temporary stimulation, patients were randomized ONOFF/OFF-ON for two 2-week periods. Prior to insertion (PRE), and during each crossover period, outcome variables (bowel diaries, constipation and GIQoL scores) were assessed, and rectal sensory thresholds determined. Results: All thirteen patients completed the trial without complication. Following stimulation, there was a significant increase in percentage of successful bowel movements (PRE: median 34% [0-100] vs ON: 74% [20-100] vs OFF: 72% [0-100]; P=0.007), and Wexner constipation scores improved in 11/13 patients, (PRE: median 18 [9-26] vs ON: 12 [6-27] vs OFF: 13 [5-29]; P=0.01). Defaecatory desire volume (DDV) to rectal balloon distension were normalized in 11/13 patients (PRE: median 277 ml [120-380] vs ON: 163 ml [90-260] vs OFF: 220 ml [80-340 ml]; P=0.006) and maximum tolerable volume (MTV) in 11/13 (PRE: median 350 ml [270-420] vs ON: 262 ml [100400] vs OFF: 298 ml [120-410 ml]; P=0.01). There were no significant changes in health related quality of life measures (GIQoL, Sf36). Conclusion: Patients with constipation secondary to rectal evacuatory dysfunction with rectal hyposensitivity appear to benefit from SNS, at least in the short-term. The physiological results presented support a mechanistic role for rectal afferent modulation.

Prospective Randomized Double-Blind Placebo-Controlled Crossover Study of Sacral Nerve Stimulation in Patients With Severe Rectal Evacuatory Dysfunction Allied to Rectal Hyposensitivity

Prospective Randomized Double-Blind Placebo-Controlled Crossover Study of Sacral Nerve Stimulation in Patients With Severe Rectal Evacuatory Dysfunction Allied to Rectal Hyposensitivity

Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue?

Previous studies report an association between joint hypermobility (JHM), as a clinical feature of underlying connective tissue (CT) disorder, and pelvic organ prolapse. However, its association with rectal evacuatory dysfunction (RED) has not been evaluated. To investigate the prevalence of JHM in the general population and in patients with symptoms of RED referred for anorectal physiological investigation. Bowel symptom and Rome III questionnaires to detect irritable bowel syndrome were sent to 273 patients with RED. Patients then underwent full investigation, including evacuation proctography. A validated 5-point self-reported questionnaire was used to assess JHM in both the patient group and 100 age- and sex-matched controls [87 female, median age 55 (range 28-87)]. Seventy-three patients were excluded from analysis (incomplete questionnaire or investigation). Of 200, 65 patients [32%: 63 female, median age 52 (range 15-80)] and 14% of controls (P = 0.0005 vs patients) had features satisfying criteria for JHM. Overall constipation score (P < 0.0001), abdominal pain (P = 0.003), need for manual assistance (P = 0.009), and use of laxatives (P = 0.03) were greater in the JHM group than the non-JHM group. On proctography, 56 of JHM patients (86%) were found to have significant morphological abnormalities (e.g. functional rectocoele), compared with 64% of the non-JHM group (P = 0.001). The greater prevalence of JHM in patients with symptoms of RED, and the demonstration of significantly higher frequencies of morphological abnormalities than those without JHM, raises the possibility of an important pathoaetiology residing in either an enteric or supporting pelvic floor abnormality of CT.

Combined vertical reduction rectoplasty and sacral nerve stimulation for rectal evacuatory dysfunction and faecal incontinence associated with previous anorectal malformation

Functional outcomes following surgery for anorectal malformation are variable, with many children experiencing persisting anorectal dysfunction. We describe a 34-year-old female with previous vestibular fistula who experienced lifelong rectal evacuatory dysfunction and faecal incontinence; she was treated in a two stage process producing efficient defecation and almost total continence.

External Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration

Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol), designed to correct internal rectal prolapse, with or without rectocele. severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol patch in the rectovaginal plane. Short-term results for the "Express" are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography. This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair

The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients. Seventeen patients (13 women; median age 47 (range 20-67) years) with rectal evacuatory dysfunction and rectal intussusception, 13 of whom had a rectocele, were selected. The intussusception was corrected by external pelvic suspension of the rectum, using collagen strips attached to the rectal wall and pubis. The rectocele was repaired with a collagen patch. Patients were assessed before and 6 months after surgery by symptom and quality of life questionnaires, anorectal physiological investigation and proctography, and were followed up for a median of 12 months. Sepsis requiring exploration occurred in two patients but there was no extrusion or need to remove the collagen. Of the 15 patients assessed after surgery, total symptom scores were significantly decreased (P < 0.001) and quality of life scores improved (P < 0.001). Proctographically, the degree of intussusception was improved in ten patients; six patients had normal postoperative proctograms. The rectocele was reduced in size in all patients, and was not demonstrable in eight. An effective procedure for rectal intussusception and rectocele has been developed in a selected group of patients with marked evacuatory symptoms.

Comparative study of two sites of colonic conduit placement in the treatment of constipation due to rectal evacuatory disorders.

Chronic constipation may be treated by antegrade colonic irrigation via a colonic conduit. Two alternative sites of colonic conduit construction were evaluated for their effect on the symptoms of 21 consecutive women with intractable constipation primarily due to rectal evacuatory disorders. The conduit was constructed in the sigmoid colon in the first 11 patients and in the transverse colon in the subsequent ten. Symptomatic outcome was evaluated clinically and by questionnaires, with a prospective quality of life assessment in the transverse group. During a median follow-up of 12 (range 6-60) months, reflux or stenosis necessitated revision or dilatation in six patients. Irrigation with a median of 1.3 (0.8-2.0) litres of water achieved evacuation in all patients. Improvements in abdominal pain and bloating were reported by seven of the ten patients in the transverse conduit group, but benefit was found in only three of 11 in the sigmoid group. There was no significant improvement in quality of life scores. In the medium term, seven patients retained a transverse conduit compared with three with a sigmoid conduit. The transverse colonic conduit offers better relief from the symptoms of constipation due to rectal evacuatory dysfunction than the sigmoid conduit.