The Experts below are selected from a list of 2220 Experts worldwide ranked by ideXlab platform
Samuel Nurko - One of the best experts on this subject based on the ideXlab platform.
-
can propofol be used to assess the presence of the rectoanal inhibitory reflex during Anorectal Manometry studies
Journal of Pediatric Gastroenterology and Nutrition, 2021Co-Authors: Ricardo A Arbizu, Leonel Rodriguez, Maureen Amicangelo, Samuel NurkoAbstract:Objectives To study changes in intra-anal pressure (IAP) and characteristics of the rectoanal inhibitory reflex (RAIR) during Anorectal Manometry (ARM) in patients undergoing anesthesia induction with propofol. Methods Prospective study in which ARM was performed at baseline while patients were awake and repeated after propofol induced anesthesia. We studied IAP and the presence and characteristics of the RAIR before and after propofol. Results A total of 27 patients were included (63% male; 9.2 years). Three patients had obstructive symptoms after Hirschsprung's Disease repair (HSCR), and 24 had intractable constipation. At baseline the RAIR was present on 21/27 patients and absent in 6/27. Of the 6 patients with an absent RAIR, it remained absent in 4/6 (3 known HSCR, and 1 new diagnosis of IAS achalasia), and 2/6 had a normal RAIR during propofol. Therefore RAIR was present in all patients with constipation. The mean resting IAP was significantly lower after propofol. The percentage of IAS relaxation after lower balloon volume inflations was significantly higher during propofol (P < 0.05). No difference was observed over the latency time or the total relaxation time after propofol. Conclusions Propofol can be used to assess the presence of the RAIR during ARM in children who are uncooperative and undergoing other procedures under anesthesia. On the other hand propofol significantly reduces the resting IAP and increases the percentage of internal anal sphincter relaxation after balloon distention. These findings may impact the interpretation to decide if an intervention is needed, or if there is a possible spinal neuropathy.
-
comparison of longitudinal and radial characteristics of intra anal pressures using 3d high definition Anorectal Manometry between children with anoretal malformations and functional constipation
Neurogastroenterology and Motility, 2021Co-Authors: Lusine Ambartsumyan, Michele L Shaffer, Kristen Carlin, Samuel NurkoAbstract:BACKGROUND Pathophysiology of fecal incontinence (FI) in children with Anorectal malformations (AM) is not well understood. Standard or high-resolution Anorectal Manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition Anorectal Manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal. AIMS To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity). METHODS HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups. KEY RESULTS 3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence. CONCLUSIONS AND INFERENCES Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.
-
longitudinal and radial characteristics of intra anal pressures in children using 3d high definition Anorectal Manometry new observations
The American Journal of Gastroenterology, 2013Co-Authors: Lusine Ambartsumyan, Leonel Rodriguez, Claudio Morera, Samuel NurkoAbstract:Longitudinal and Radial Characteristics of Intra-Anal Pressures in Children Using 3D High-Definition Anorectal Manometry: New Observations
-
Anorectal Manometry may identify children with spinal cord lesions
Journal of Pediatric Gastroenterology and Nutrition, 2011Co-Authors: Anees Siddiqui, Rachel Rosen, Samuel NurkoAbstract:BACKGROUND AND OBJECTIVE We previously showed that approximately 10% of patients with intractable constipation have spinal abnormalities without any other physical findings. Given that spinal magnetic resonance imaging is costly and often requires deep sedation in children, it would be useful to find a screening tool to determine who has a higher likelihood of having a spinal abnormality. The aim of the study was to determine whether Anorectal Manometry is a useful screening test in predicting which patients will have abnormal spinal MRIs. PATIENTS AND METHODS This is a case-control study comparing the Anorectal manometries of 10 children with constipation who had abnormal spinal MRIs (cases) to the manometries of 10 age-matched children with normal MRIs (controls). RESULTS The maximum relaxation of the sphincter after balloon distention was achieved with a significantly smaller balloon in the cases as compared with the controls (35 ± 20 vs 60 ± 23 mL; P = 0.02). The dose-response curve of sphincter relaxation at different balloon distention was shifted to the left in patients with spinal lesions. Anal spasms after balloon distention were noted in 60% of the patients with abnormal magnetic resonance images compared with 0% of the controls (P < 0.003). There were no other differences. CONCLUSIONS Patients with spinal cord abnormalities may show changes in Anorectal Manometry. Anal spasms on Anorectal Manometry are significant predictors of spinal abnormalities. Also, patients with spinal abnormalities have maximum sphincter relaxations with smaller balloon sizes. Further studies are needed to determine the utility of Anorectal Manometry as a screening test for spinal abnormalities in patients with constipation.
John O. Clarke - One of the best experts on this subject based on the ideXlab platform.
-
three dimensional Anorectal Manometry enhances diagnostic gain by detecting sphincter defects and puborectalis pressure
Digestive Diseases and Sciences, 2017Co-Authors: Shreya Raja, Francis Okeke, Ellen M Stein, Sameer Dhalla, Monica Nandwani, Kristle Lynch, Prakash C Gyawali, John O. ClarkeAbstract:Background Constipation and fecal incontinence (FI) are common and are often evaluated with Anorectal Manometry. Three-dimensional high-resolution Anorectal Manometry (HRAM) is a promising technology; however, implementation has been limited by lack of metrics and unclear clinical utility.
-
three dimensional Anorectal Manometry enhances diagnostic gain by detecting sphincter defects and puborectalis pressure
Digestive Diseases and Sciences, 2017Co-Authors: Shreya Raja, Francis Okeke, Ellen M Stein, Sameer Dhalla, Monica Nandwani, Kristle Lynch, Prakash C Gyawali, John O. ClarkeAbstract:Constipation and fecal incontinence (FI) are common and are often evaluated with Anorectal Manometry. Three-dimensional high-resolution Anorectal Manometry (HRAM) is a promising technology; however, implementation has been limited by lack of metrics and unclear clinical utility. To investigate the diagnostic utility of 3D HRAM compared to 2D HRAM. Three-dimensional HRAM studies performed from April 2012 to October 2013 were identified and re-interpreted by two blinded investigators examining 3D function. Disagreements were resolved by a third investigator. Puborectalis (PR) visualization, focal defects, and dyssynergy were reported. Differences between groups were analyzed with Fisher’s exact test. Discordance was analyzed with McNemar Chi-square test. Two hundred and twenty-one 3D HRAM studies were identified. Mean age and BMI were 52.2 ± 17.4 and 27.1 ± 7.5 years (81% female, 74% white). Most common indications for 3D HRAM were constipation (65%) and FI (28%). PR function was visualized in 81% (rest), 97% (squeeze), and 73% (strain). PR was visualized less often at rest in FI than constipation (68 vs. 85%, p = 0.007). Defects were identified twice as often in FI than constipation (19 vs. 10%, p = 0.113). Twenty-nine defects (86% anterior) were visualized on 3D HRAM. Inter-reader agreement was moderate for PR function (κ = 0.471), but fair for focal defects (κ = 0.304). PR function and focal defects can be visualized on 3D-HRAM with added diagnostic benefit compared to 2D. Fair inter-reader agreement for focal defects highlights the need for quantitative metrics.
-
high resolution Anorectal Manometry and dynamic pelvic magnetic resonance imaging are complementary technologies
Journal of Gastroenterology and Hepatology, 2015Co-Authors: Daniela Jodorkovsky, Ellen M Stein, Katarzyna J Macura, Susan L Gearhart, Kerry B Dunbar, John O. ClarkeAbstract:Background and Aim 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. Methods 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. Results 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. Conclusion 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.
Adil E Bharucha - One of the best experts on this subject based on the ideXlab platform.
-
high resolution Anorectal Manometry an expensive hobby or worth every penny
Neurogastroenterology and Motility, 2017Co-Authors: G Basilisco, Adil E BharuchaAbstract:Introduced approximately 10 years ago, high-resolution Manometry catheters have fostered interest in Anorectal Manometry. This review, which accompanies two articles in this issue of Neurogastroenterology and Motility, reviews the methods, clinical indications, utility, and pitfalls of Anorectal Manometry and revisits the American Gastroenterological Association (AGA) Medical Position Statement on Anorectal Testing Techniques, which was last published in 1999. High-resolution Manometry provides a refined assessment of the Anorectal pressure profile, obviates the need for station pull-through maneuvers, and minimizes movement artifacts. In selected cases, this refined assessment may be useful for identifying structural abnormalities or anal weakness. However, many Manometry patterns that were previously regarded as abnormal are also observed in a majority of healthy patients, which substantially limits the utility of Manometry for identifying defecatory disorders. It is our impression that most conclusions of the AGA medical position statement from 1999 remain valid today. High-resolution techniques have not substantially affected the number of publications on or management of Anorectal disorders. The ongoing efforts of an international working group to standardize techniques for Anorectal Manometry are welcome. Although high-resolution Manometry is more than an expensive hobby, improvements in catheter design and further research to rigorously define and evaluate these techniques are necessary to determine if they are worth every penny.
-
diagnostic accuracy study of Anorectal Manometry for diagnosis of dyssynergic defecation
Gut, 2016Co-Authors: Ugo Grossi, Emma V Carrington, Adil E Bharucha, Emma J Horrocks, Mark S Scott, Charles H KnowlesAbstract:Objective The diagnostic accuracy of Anorectal Manometry (AM), which is necessary to diagnose functional defecatory disorders (FDD), is unknown. Using blinded analysis and standardised reporting of diagnostic accuracy, we evaluated whether AM could discriminate between asymptomatic controls and patients with functional constipation (FC). Design Derived line plots of Anorectal pressure profiles during simulated defecation were independently analysed in random order by three expert observers blinded to health status in 85 women with FC and 85 age-matched asymptomatic healthy volunteers (HV). Using accepted criteria, these pressure profiles were characterised as normal (ie, increased rectal pressure coordinated with anal relaxation) or types I–IV dyssynergia. Interobserver agreement and diagnostic accuracy were determined. Results Blinded consensus-based assessment disclosed a normal pattern in 16/170 (9%) of all participants and only 11/85 (13%) HV. The combined frequency of dyssynergic patterns (I–IV) was very similar in FC (80/85 (94%)) and HV (74/85 (87%)). Type I dyssynergia (‘paradoxical’ contraction) was less prevalent in FC (17/85 (20%) than in HV (31/85 (36.5%), p=0.03). After statistical correction, only type IV dyssynergia was moderately useful for discriminating between FC (39/85 (46%)) and HV (17/85 (20%)) (p=0.001, positive predictive value=70.0%, positive likelihood ratio=2.3). Interobserver agreement was substantial or moderate for identifying a normal pattern, dyssynergia types I and IV, and FDD, and fair for types II and III. Conclusions While the interpretation of AM patterns is reproducible, nearly 90% of HV have a pattern that is currently regarded as ‘abnormal’ by AM. Hence, AM is of limited utility for distinguishing between FC and HV.
-
how to perform and interpret a high resolution Anorectal Manometry test
Journal of Neurogastroenterology and Motility, 2015Co-Authors: Tae Hee Lee, Adil E BharuchaAbstract:High-resolution Anorectal Manometry (HR-ARM) and high-definition Anorectal Manometry (HD-ARM) catheters have closely spaced water-perfused or solid state circumferentially-oriented pressure sensors that provide much better spatiotemporal pressurization than non-high resolution catheters. This is a comprehensive review of HR-ARM and HD-ARM Anorectal Manometry catheter systems, the methods for conducting, analyzing, and interpreting HR-ARM and HD-ARM, and a comparison of HR-ARM with non-high resolution Anorectal Manometry. Compared to non-high resolution techniques, HR-ARM and HD-ARM studies take less time and are easier to interpret. However, HR-ARM and HD-ARM catheters are more expensive and fragile and have a shorter lifespan. Further studies are needed to refine our understanding of normal values and to rigorously evaluate the incremental clinical utility of HR-ARM or HD-ARM compared to non-high resolution Manometry.
-
a novel technique for bedside Anorectal Manometry in humans
Neurogastroenterology and Motility, 2015Co-Authors: Adil E Bharucha, Randolph W Stroetz, Kelly Feuerhak, Lawrence A Szarka, Alan R ZinsmeisterAbstract:Background Currently, Anorectal Manometry (ARM), which is used to diagnose defecatory disorders and identify anal weakness in fecal incontinence (FI) is generally conducted in specialized laboratories. Our aims were to compare Anorectal functions measured with high-resolution Manometry (HRM) and a novel portable Manometry device. Methods Anal pressures at rest, during squeeze, and simulated evacuation, and rectal sensation were evaluated with portable and HRM in 20 healthy women, 19 women with constipation, and 11 with FI. The relationship between anal pressures measured with portable and HRM was assessed by the concordance correlation coefficient (CCC), Bland Altman test, and paired t-tests. Key Results Anal pressures at rest (CCC 0.45; 95% CI: 0.29, 0.58) and during squeeze (CCC 0.60; 95% CI: 0.46, 0.72) measured with portable and HRM were correlated and inversely associated with the risk of FI. During simulated evacuation, the CCC for rectal pressure (0.62; 95% CI: 0.43, 0.76) was greater than that for anal pressure (CCC 0.22; 95% CI: 0.04, 0.39) and the rectoanal gradient (CCC 0.22; 95% CI: 0.02, 0.41). Rectal sensory thresholds for first sensation, the desire to defecate, and urgency measured by portable and HRM were also significantly correlated between techniques. For several parameters, differences between portable and HRM were statistically significant and the Bland Altman test was positive. Conclusions & Inferences Anorectal pressures and rectal sensation can be conveniently measured by portable Manometry and are significantly correlated with high-resolution Manometry.
-
phenotypic identification and classification of functional defecatory disorders using high resolution Anorectal Manometry
Gastroenterology, 2013Co-Authors: Shiva K Ratuapli, Adil E Bharucha, Jessica Noelting, Doris M Harvey, Alan R ZinsmeisterAbstract:Background & Aims Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of Anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; Anorectal Manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution Anorectal Manometry. Methods We evaluated Anorectal pressures, measured with high-resolution Anorectal Manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution Anorectal Manometry. Results Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times. Conclusions Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.
Tae Hee Lee - One of the best experts on this subject based on the ideXlab platform.
-
how to perform and interpret a high resolution Anorectal Manometry test
Journal of Neurogastroenterology and Motility, 2015Co-Authors: Tae Hee Lee, Adil E BharuchaAbstract:High-resolution Anorectal Manometry (HR-ARM) and high-definition Anorectal Manometry (HD-ARM) catheters have closely spaced water-perfused or solid state circumferentially-oriented pressure sensors that provide much better spatiotemporal pressurization than non-high resolution catheters. This is a comprehensive review of HR-ARM and HD-ARM Anorectal Manometry catheter systems, the methods for conducting, analyzing, and interpreting HR-ARM and HD-ARM, and a comparison of HR-ARM with non-high resolution Anorectal Manometry. Compared to non-high resolution techniques, HR-ARM and HD-ARM studies take less time and are easier to interpret. However, HR-ARM and HD-ARM catheters are more expensive and fragile and have a shorter lifespan. Further studies are needed to refine our understanding of normal values and to rigorously evaluate the incremental clinical utility of HR-ARM or HD-ARM compared to non-high resolution Manometry.
-
Comparison of High-resolution Anorectal Manometry With Water-perfused Anorectal Manometry
Journal of neurogastroenterology and motility, 2015Co-Authors: Hye Ran Kang, Ji Eun Lee, Joon Seong Lee, Tae Hee Lee, Su Jin Hong, Jin Oh Kim, Seong Ran Jeon, Hyun Gun KimAbstract:Background/Aims To 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.
-
high resolution Anorectal Manometry and anal endosonographic findings in the evaluation of fecal incontinence
Journal of Neurogastroenterology and Motility, 2012Co-Authors: Tae Hee Lee, Joon Seong LeeAbstract:A 65-yeduring the past 2 years. She usually was not aware of it although sometimes she was not able to hold back stool until going to the bathroom in time. The stools were usually soft and formed. She denied neurologic symptoms, urinary incontinence and pelvic or perianal injury. She had 2 children by natural childbirth. She has taken nonsteroidal anti-inflammatory drug for osteoarthritis. Perianal examination showed unremarkable findings. Digital rectal examination revealed weak resting tone and normal increase with squeeze. However, digital rectal examination is not reliable and is subject to interobserver differences due to several factors including the size of the examiner's finger, the technique and the cooperation of patient.1 Thereforear-old woman presented with moderate volume of fecal incontinence high-resolution Anorectal Manometry (ManoScan, Sierra Scientific Instruments, Los Angeles, CA, USA) and anal endosonography were performed. The high-resolution Anorectal Manometry showed a very low mean resting anal pressure, relatively intact maximal squeezing pressure and short duration of the sustained squeezing pressure. However abrupt increase of anal sphincter pressure above rectal pressure that could prevent stress incontinence was observed during cough (Fig. 1). Because resting anal pressure predominantly represents the internal anal sphincter (IAS) pressure and the squeezing pressure predominantly measures the external anal sphincter pressure, these findings imply defect in IAS with normal external anal sphincter.2 The anal endosonography also revealed the presence of scarring of IAS from the 8 to 1-o'clock direction (Fig. 2). In this patient, fecal incontinence was turned out to be caused by the IAS defect. Figure 1 The low mean resting anal pressure (28 mmHg), maximum squeezing pressure (135 mmHg) and short duration of sustained squeezing pressure (5 second) are observed. During coughing, abrupt increase of anal sphincter pressure is noted. Figure 2 Anal endosonography shows the presence of scarring of internal anal sphincter from the 8 to 1-o'clock direction.
-
high resolution Anorectal Manometry for acquired megarectum in a patient with parkinson s disease
Journal of Neurogastroenterology and Motility, 2012Co-Authors: Tae Hee Lee, Joon Seong LeeAbstract:A 74-year-old woman previously diagnosed with Parkinson's disease visited the hospital complaining of progressively worsening difficulty with defecation. She had a long history of constipation. A digital rectal examination revealed a hard mass of stool in the rectum. Abdominopelvic CT revealed a large amount of fecal material in a megarectum (Fig. 1). High-resolution Anorectal Manometry (HR-ARM; ManoScan, Sierra Scientific Instruments, Los Angeles, CA, USA) with balloon expulsion was performed. Figure 1 Abdominopelvic CT revealed fecal impaction in a megarectum. The HR-ARM showed a low mean resting anal pressure, the maximum squeezing pressure, and incomplete anal relaxation with inadequate propulsive force during defecation suggesting type IV pelvic floor dyssynergia (Fig. 2).1 During the rectal balloon dilatation, the rectoanal inhibitory reflex (RAIR) was present, suggesting an intact myenteric reflex, which is absent in Hirschsprung's disease.2 The minimum volume for the RAIR was 60 mL. Figure 2 The average resting anal pressure (4.7 mmHg) and maximum squeezing pressure (17.8 mmHg) were low. During defecation, high-resolution Anorectal Manometry showed incomplete relaxation of the anal sphincter with inadequate propulsive force. During rectal ... Preston et al3 defined megarectum in adults as a bowel width ≥ 6.5 cm at the pelvic brim on a lateral X-ray of the abdomen. Although there is no uniform definition of megarectum for patients with constipation, it is essential to evaluate whether the megarectum is the result or cause of the constipation. Given the presence of RAIR and type IV pelvic floor dyssynergia, HR-ARM provided information that megarectum was not caused by Hirschsprung's disease, but must have resulted from chronic constipation with prolonged fecal impaction.
Joon Seong Lee - One of the best experts on this subject based on the ideXlab platform.
-
Comparison of High-resolution Anorectal Manometry With Water-perfused Anorectal Manometry
Journal of neurogastroenterology and motility, 2015Co-Authors: Hye Ran Kang, Ji Eun Lee, Joon Seong Lee, Tae Hee Lee, Su Jin Hong, Jin Oh Kim, Seong Ran Jeon, Hyun Gun KimAbstract:Background/Aims To 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.
-
high resolution Anorectal Manometry and anal endosonographic findings in the evaluation of fecal incontinence
Journal of Neurogastroenterology and Motility, 2012Co-Authors: Tae Hee Lee, Joon Seong LeeAbstract:A 65-yeduring the past 2 years. She usually was not aware of it although sometimes she was not able to hold back stool until going to the bathroom in time. The stools were usually soft and formed. She denied neurologic symptoms, urinary incontinence and pelvic or perianal injury. She had 2 children by natural childbirth. She has taken nonsteroidal anti-inflammatory drug for osteoarthritis. Perianal examination showed unremarkable findings. Digital rectal examination revealed weak resting tone and normal increase with squeeze. However, digital rectal examination is not reliable and is subject to interobserver differences due to several factors including the size of the examiner's finger, the technique and the cooperation of patient.1 Thereforear-old woman presented with moderate volume of fecal incontinence high-resolution Anorectal Manometry (ManoScan, Sierra Scientific Instruments, Los Angeles, CA, USA) and anal endosonography were performed. The high-resolution Anorectal Manometry showed a very low mean resting anal pressure, relatively intact maximal squeezing pressure and short duration of the sustained squeezing pressure. However abrupt increase of anal sphincter pressure above rectal pressure that could prevent stress incontinence was observed during cough (Fig. 1). Because resting anal pressure predominantly represents the internal anal sphincter (IAS) pressure and the squeezing pressure predominantly measures the external anal sphincter pressure, these findings imply defect in IAS with normal external anal sphincter.2 The anal endosonography also revealed the presence of scarring of IAS from the 8 to 1-o'clock direction (Fig. 2). In this patient, fecal incontinence was turned out to be caused by the IAS defect. Figure 1 The low mean resting anal pressure (28 mmHg), maximum squeezing pressure (135 mmHg) and short duration of sustained squeezing pressure (5 second) are observed. During coughing, abrupt increase of anal sphincter pressure is noted. Figure 2 Anal endosonography shows the presence of scarring of internal anal sphincter from the 8 to 1-o'clock direction.
-
high resolution Anorectal Manometry for acquired megarectum in a patient with parkinson s disease
Journal of Neurogastroenterology and Motility, 2012Co-Authors: Tae Hee Lee, Joon Seong LeeAbstract:A 74-year-old woman previously diagnosed with Parkinson's disease visited the hospital complaining of progressively worsening difficulty with defecation. She had a long history of constipation. A digital rectal examination revealed a hard mass of stool in the rectum. Abdominopelvic CT revealed a large amount of fecal material in a megarectum (Fig. 1). High-resolution Anorectal Manometry (HR-ARM; ManoScan, Sierra Scientific Instruments, Los Angeles, CA, USA) with balloon expulsion was performed. Figure 1 Abdominopelvic CT revealed fecal impaction in a megarectum. The HR-ARM showed a low mean resting anal pressure, the maximum squeezing pressure, and incomplete anal relaxation with inadequate propulsive force during defecation suggesting type IV pelvic floor dyssynergia (Fig. 2).1 During the rectal balloon dilatation, the rectoanal inhibitory reflex (RAIR) was present, suggesting an intact myenteric reflex, which is absent in Hirschsprung's disease.2 The minimum volume for the RAIR was 60 mL. Figure 2 The average resting anal pressure (4.7 mmHg) and maximum squeezing pressure (17.8 mmHg) were low. During defecation, high-resolution Anorectal Manometry showed incomplete relaxation of the anal sphincter with inadequate propulsive force. During rectal ... Preston et al3 defined megarectum in adults as a bowel width ≥ 6.5 cm at the pelvic brim on a lateral X-ray of the abdomen. Although there is no uniform definition of megarectum for patients with constipation, it is essential to evaluate whether the megarectum is the result or cause of the constipation. Given the presence of RAIR and type IV pelvic floor dyssynergia, HR-ARM provided information that megarectum was not caused by Hirschsprung's disease, but must have resulted from chronic constipation with prolonged fecal impaction.