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Steven D. Wexner - One of the best experts on this subject based on the ideXlab platform.
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paradoxical puborectalis contraction and increased Perineal Descent
Clinics in Colon and Rectal Surgery, 2008Co-Authors: Ron G Landmann, Steven D. WexnerAbstract:Paradoxical puborectalis contraction and increased Perineal Descent are two forms of functional constipation presenting as challenging diagnostic and treatment dilemmas to the clinician. In the evaluation of these disorders, the clinician should take special care to exclude anatomic disorders leading to constipation. Physical examination is supplemented by additional diagnostic modalities such as cinedefecography, electromyography, manometry, and pudendal nerve tefninal motor latency. Generally, these investigations should be used in combination with the two playing the more relied upon techniques. Treatment is typically conservative with biofeedback playing a principal role with favorable results when patient compliance is emphasized. When considering paradoxical puborectalis contraction, failure of biofeedback is usually augmented with botulinum toxin injection. Increased Perineal Descent is generally treated with biofeedback and Perineal support maneuvers. Surgery has little or no role in these conditions. The patient who insists on surgical intervention for either of these two conditions should be offered a stoma.
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associations of defecography and physiologic findings in male patients with rectocele
Techniques in Coloproctology, 2001Co-Authors: Hong-hwa Chen, Juan J. Nogueras, Augustine J N Iroatulam, Omer Alabaz, Eric G. Weiss, Steven D. WexnerAbstract:This study evaluated the incidence and physiological findings in male patients with rectoceles. All defecographic studies were evaluated by a single colorectal surgeon. After diagnosis of rectocele in male patients, the patient's history, symptoms, and physiologic tests (anal manometry, pudendal nerve terminal motor latency [PNTML], assessment and electromyography [EMG]) were studied. A prominent rectocele was defined as one that did not empty during defecography and was associated with outlet obstructive syndrome. Forty (17%) rectoceles were diagnosed in 234 male patients with evacuatory disorders who underwent defecography. Rectoceles were anterior in 19 (48%) and posterior in 21 (52%) patients. The main complaint was constipation with difficult defecation in 33 (83%), followed by rectal pain in 5 (13%), rectal prolapse in 1 (3%), and incontinence in 1 (3%). Previous prostatic surgery had been performed in 16 (40%) patients. The mean age and duration of symptoms were 72.4 years (range, 30–88) and 10.3 years (range, 0.5–70), respectively. Excessive straining during evacuation was noted in 73%, unilateral or bilateral pudendal neuropathy in 24.5%, paradoxical puborectalis contraction in 49% and abnormal EMG in 11% of patients. Higher resting pressures with a mean 3.9 cm high pressure zone were noted in 29% of patients. The accompanying findings in defecography were, non-relaxing or partially relaxing puborectalis muscle (66%), Perineal Descent (65%), intussusception (23%), and sigmoidocele (15%). None of the patients underwent surgery for rectocele alone. In conclusion, rectocele is uncommon in males; it rarely appears as an isolated dysfunction as it is often associated with functional disorders of the pelvic floor. There is a frequent association between rectocele and prostatectomy. Clinical significance and therapeutic strategy remain unknown.
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intraobserver and interobserver measurements of the anorectal angle and Perineal Descent in defecography
Diseases of The Colon & Rectum, 2000Co-Authors: Jeong Seok Choi, Eric G. Weiss, Steven D. Wexner, Young Soon Nam, Constantinos Mavrantonis, Mara R Salum, Takuya Yamaguchi, Juan J. NoguerasAbstract:PURPOSE: Anorectal angle and Perineal Descent can be measured either by drawing a line defined by the impression of the puborectalis muscle and the tangential of the posterior rectal wall (Method A) or by drawing a straight line at the level of the posterior rectal wall parallel to the central longitudinal axis of the rectum (Method B). The aim of this study was to assess the reproducibility of measuring anorectal angle and Perineal Descent by two different methods according to intraobserver and interobserver measurement and to evaluate which method yields more consistent results. METHODS: Five physicians who have had an average of 1.3 years (range, 6 months to 1.5 years) experience in defecographic measurement drew both lines on 63 randomly selected defecographic films and measured anorectal angle and Perineal Descent by the two methods. The defecographic parameters were measured twice by each observer during a three-week interval. To avoid potential bias, one physician who did not participate in either measurement of Perineal Descent or anorectal angle performed all data collection. Intraobserver and interobserver agreement was quantified using Shrout and Fleiss intraclass correlation coefficients. RESULTS: The mean and range of intraclass correlation coefficients for intraobserver agreement of measuring anorectal angle and Perineal Descent by Method A were 0.71 (0.6–0.78) and 0.89 (0.74–0.97), respectively, whereas with Method B the coefficients were 0.81 (0.73–0.89) and 0.93 (0.89–0.99), respectively. Regarding the interobserver agreement of the five observers, the mean coefficients for measurement of both anorectal angle and Perineal Descent by both methods showed similar agreement levels (0.88 and 0.98 by Method A and 0.89 and 0.97 by Method B). The mean (± standard deviation) values of anorectal angle and Perineal Descent found by Method B were significantly larger than those found by Method A (103.3°±19.6 and 6.56±3.20 cm and 91.1°±25.6 and 5.64±3.42 cm, respectively;P<0.001). CONCLUSION: Intraobserver and interobserver intraclass correlation coefficients of anorectal angle and Perineal Descent, which were measured by both methods, were more than 0.60, indicating that both methods are reliable and consistent for measurement of anorectal angle and Perineal Descent. However, centers should consistently use the same line for measurement of anorectal angle and Perineal Descent because of the statistically significant differences between the two methods and the possibility of inconsistent results.
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prognostic significance of rectocele intussusception and abnormal Perineal Descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction
Diseases of The Colon & Rectum, 2000Co-Authors: Steve Heymen, Augustine J N Iroatulam, Omer Alabaz, Steven D. WexnerAbstract:PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal Perineal Descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal Perineal Descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal Perineal Descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108( 62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5( 8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal Perineal Descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal Perineal Descent (P=not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.
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patient position during cinedefecography influence on Perineal Descent and other measurements
Diseases of The Colon & Rectum, 1994Co-Authors: Marcio J N Jorge, Gow Ching Ger, Leopoldo Gonzalez, Steven D. WexnerAbstract:PURPOSE: This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions. METHODS: Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, Perineal Descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed Perineal Descent, nonrelaxing puborectalis, and premature evacuation. RESULTS: One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P 0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P=0.05). CONCLUSION: Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.
V Vitton - One of the best experts on this subject based on the ideXlab platform.
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Rectal intussusception: can high resolution three-dimensional ano-rectal manometry compete with conventional defecography?
Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society, 2016Co-Authors: A Benezech, M Bouvier, J C Grimaud, Karine Baumstarck, M. Cappiello, V VittonAbstract:BACKGROUND: Three-dimensional high-resolution anorectal manometry (3DHRAM), used for exploring anorectal disorders, was recently developed, providing interesting topographic data for the diagnosis of pelvic floor disorders such as excessive Perineal Descent. The aim of our study was to define a diagnostic strategy based on selected 3DHRAM parameters to identify rectal intussusceptions (RI), considering conventional defecography (CD) as the gold standard.ăMETHODS: All patients referred to our center in the previous 6 months for 3DHRAM to explore fecal incontinence or constipation, and who previously achieved CD, were eligible. 3DHRAM results were obtained for all classical parameters and the presence of a narrow band of high pressure in the anal canal during attempted defecation, which was recently found to be associated with RI in some studies. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criterion in order to propose a diagnostic strategy for RI.ăKEY RESULTS: Twenty-six patients (66%) presented with RI on CD. On 3DHRAM, according to our diagnostic strategy, the most relevant manometric criterion for the diagnosis of RI was the association of an anterior additional high-pressure area and an excessive Perineal Descent, with a positive predictive value of 100% [81.5-100], a specificity of 100% [75.3-100] and a sensibility of 69.2% [48.2-85.7].ăCONCLUSIONS & INFERENCES: In this study, 3DHRAM was used to diagnose RI, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.
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three dimensional high resolution anorectal manometry and diagnosis of excessive Perineal Descent a comparative pilot study with defaecography
Colorectal Disease, 2014Co-Authors: A Benezech, M Bouvier, J C Grimaud, Karine Baumstarck, V VittonAbstract:Aim Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can simultaneously provide physiological and topographical data on the terminal part of the digestive tract. Our object was to assess whether 3DHRAM is able to reliably diagnose excessive Perineal Descent already diagnosed with conventional defaecography, which is considered to be the gold standard. Method All patients referred to our centre for anorectal manometry and conventional defaecography were evaluated with a maximum of 6 months between the two examinations. Anorectal manometry was performed using the 3D High-Resolution Given Imaging® probe. Excessive Perineal Descent was defined as the downward movement of the anal high-pressure zone during straining. At the end of the straining effort, the high-pressure zone regained its initial position, thereby indicating that the probe had not moved. Results Nineteen female patients of median age 53 (21–70) years were included in the study. All cases with excessive Perineal Descent diagnosed using defaecography were visualized with 3DHRAM. The degree of Perineal Descent determined by 3D and conventional defaecography was compared (Spearman correlation 0.726, P = 0.01). In contrast, the averages measured were significantly different; the average was 11.68 ± 3.3 mm for 3DHRAM but 34.21 ± 13.3 mm for conventional defaecography (P = 0.002). Conclusion The results of the study demonstrate that 3DHRAM can diagnose excessive Perineal Descent with the same degree of reliability as defaecography. Quantitative measures were not correlated, however, possibly because of methodological differences. The study confirms the value of the morphological data provided by 3DHRAM.
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three dimension high resolution anorectal manometry can precisely measure Perineal Descent
Journal of Neurogastroenterology and Motility, 2013Co-Authors: V Vitton, J C Grimaud, M BouvierAbstract:A 65-year-old woman was referred to investigate a long history of intractable constipation. Clinical examination revealed a descending perineum and digital examination diagnosed a large rectocele without stool in the rectum. The patient underwent 3-dimension high-resolution anorectal manometry (3DHRAM), dynamic endo-anal ultrasonography (D-EUS) and conventional defecography. The 3DHRAM showed mean resting pressure of 84 mmHg, mean maximal squeezing pressure of 207 mmHg and length of the high-pressure zone of 2.7 mm. The recto-anal inhibitory reflex was present and the rectal sensitivity was normal (10 mL). However there was an incomplete anal relaxation during attempted defecation indicating a pelvic floor dyssynergia. In addition during attempted defecation a 9 mm Perineal Descent on the manometric probe was observed in the left lateral decubitus position (Figure). At the end of the bear down the perineum regained its initial position indicating that the probe has not moved. Conventional defecography showed a 9.2 mm Perineal Descent from the pubo-coccygeal line, a retentive rectocele of 69 mm and rectal intussusception. D-EUS showed no anal sphincter defect and, at dynamic time, showed a rectocele measured at 35 mm and descending perineum measured at 15 mm according to the method described by Vitton et al.1
Adil E Bharucha - One of the best experts on this subject based on the ideXlab platform.
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semi automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence
Neurogastroenterology and Motility, 2012Co-Authors: Jessica Noelting, Joel G Fletcher, Adil E Bharucha, Stephen J Riederer, David S Lake, Armando Manduca, Joseph L Melton, Alan R ZinsmeisterAbstract:The anal sphincters and pelvic floor muscles preserve fecal continence and participate in defecation (1). By visualizing structural (e.g., rectocele) and functional (e.g., impaired anal relaxation) disturbances, barium defecography and magnetic resonance imaging (MRI) facilitate the diagnosis of defecatory disorders, particularly when anal manometry and a rectal balloon expulsion test are inconclusive (2-6). MRI also reveals puborectalis atrophy and impaired pelvic floor contraction in some women with fecal incontinence (FI) (7-9). However, the clinical utility of barium defecography and MRI is limited by variable reproducibility of these assessments. For example, in one study, inter-observer agreement was good for identifying enteroceles and rectoceles but suboptimal for identifying intussusception, anismus, or the puborectalis impression by barium defecography (10). Moreover, for some measurements, agreement was much better for experienced observers (10). The American Gastroenterological Association technical review concluded that “there is poor agreement between independent observers in the measurement of the anorectal angle, a parameter thought to be critical to the interpretation of defecography results” (11). This is partly attributable to lack of a standardized definition for the rectal axis, which forms one aspect of the anorectal angle and can be drawn through the anterior, middle or posterior rectal wall. Moreover, the rectum is curvilinear, and the puborectalis indentation on the posterior rectal wall is variable. Hence, even minor differences in the orientation of the rectal axis can profoundly affect the anorectal angle. Lastly, the bony landmarks (e.g., pubic symphysis, coccyx) which are used to measure Perineal Descent may not be visible during barium defecography but are distinctly visualized on MR images (12). Nonetheless, and despite centralized training, a NIH-sponsored multi-institutional study concluded that “measurement variability adversely affects the utility of many MRI measurements for multicenter pelvic floor disorder research,” although agreement was better for bony than pelvic soft-tissue measurements during dynamic pelvic MRI (13). By contrast, we documented substantial inter-observer agreement for anorectal angles and the anorectal location at rest, during squeeze and evacuation measured by MRI in asymptomatic women and women with defecatory disorders; however, differences between observers were statistically significant (12). While most attention has focused on anorectal motion and the puborectalis, the coccyx also moves during pelvic floor contraction and rectal evacuation (14). The coccygei, which have a variable proportion of muscle and fibrous tissue, may pull forward and support the coccyx, after it has been pressed backwards, during defecation or parturition (14-16). With the levatores ani and piriforms, they close the posterior part of the pelvic outlet. Previous studies have evaluated the relationship of coccygeal mobility to age, sex, parity, and minor trauma but not to fecal incontinence. It is conceivable that coccygeal weakness may contribute to pelvic weakness in FI. Hence, the aims of this study were to (i) to develop a user-friendly semi-automated program to measure anorectal motion by defecography; (ii) evaluate the within-subject reproducibility of anorectal motion measured by this semi-automated program; (iii) to compare measurements of anorectal motion by a radiologist and a semi-automated program; and (iv) compare anorectal motion disturbances in women with and without FI. A more robust and refined approach to measure pelvic floor motion by MR defecography may enhance the utility of this technique in clinical practice and research studies.
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update of tests of colon and rectal structure and function
Journal of Clinical Gastroenterology, 2006Co-Authors: Adil E BharuchaAbstract:This review deals with the indications, methods, strengths, and limitations of anorectal testing in clinical practice. In chronic constipation, anal manometry and a rectal balloon expulsion test, occasionally supplemented by defecography, are useful to identify a functional defecatory disorder, because symptoms may respond to pelvic floor retraining. In patients with fecal incontinence, diagnostic testing complements the clinical assessment for evaluating the pathophysiology and guiding management. Manometry measures anal resting and squeeze pressures, which predominantly reflect internal and external anal sphincter function, respectively. Defecation may be indirectly assessed by measuring the recto-anal pressure gradient during straining and by the rectal balloon expulsion test. Endoanal ultrasound and magnetic resonance imaging (MRI) can identify anal sphincter structural pathology, which may be clinically occult, and/or amenable to surgical repair. Only MRI can identify external sphincter atrophy, whereas ultrasound is more sensitive for internal sphincter imaging. By characterizing rectal evacuation and puborectalis contraction, barium defecography may demonstrate an evacuation disorder, excessive Perineal Descent or a rectocele. Dynamic MRI can provide similar information and also image the bladder and genital organs without radiation exposure. Because the measurement of pudendal nerve latencies suffers from several limitations, anal sphincter electromyography is recommended when neurogenic sphincter weakness is suspected.
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phenotypic variation in functional disorders of defecation
Gastroenterology, 2005Co-Authors: Adil E Bharucha, Joel G Fletcher, Stephen J Riederer, Barb Seide, Alan R ZinsmeisterAbstract:Background & Aims: Although obstructed defecation is generally attributed to pelvic floor dyssynergia, clinical observations suggest a wider spectrum of anorectal disturbances. Our aim was to characterize phenotypic variability in constipated patients by anorectal assessments. Methods: Anal pressures, rectal balloon expulsion, rectal sensation, and pelvic floor structure (by endoanal magnetic resonance imaging) and motion (by dynamic magnetic resonance imaging) were assessed in 52 constipated women and 41 age-matched asymptomatic women. Phenotypes were characterized in patients by principal components analysis of these measurements. Results: Among patients, 16 had a hypertensive anal sphincter, 41 had an abnormal rectal balloon expulsion test, and 20 had abnormal rectal sensation. Forty-nine patients (94%) had abnormal pelvic floor motion during evacuation and/or squeeze. After correcting for age and body mass index, 3 principal components explained 71% of variance between patients. These factors were weighted most strongly by Perineal Descent during evacuation (factor 1), anorectal location at rest (factor 2), and anal resting pressure (factor 3). Factors 1 and 3 discriminated between controls and patients. Compared with patients with normal (n = 23) or reduced (n = 18) Perineal Descent, patients with increased (n = 11) Descent were more likely (P ≤ .01) to be obese, have an anal resting pressure >90 mm Hg, and have a normal rectal balloon expulsion test result. Conclusions: These observations demonstrate that functional defecation disorders comprise a heterogeneous entity that can be subcharacterized by Perineal Descent during defecation, Perineal location at rest, and anal resting pressure. Further studies are needed to ascertain if the phenotypes reflect differences in the natural history of these disorders.
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magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders
The American Journal of Gastroenterology, 2003Co-Authors: Joel G Fletcher, C M Harper, David M Hough, Stephen J Riederer, Reed F Busse, Thomas M Gluecker, Adil E BharuchaAbstract:Abstract Objective Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. Methods We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4–2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. Results Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and Perineal Descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive Perineal Descent in two patients. Conclusions Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.
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insights into the pathophysiology and mechanisms of constipation irritable bowel syndrome and diverticulosis in older people
Journal of the American Geriatrics Society, 2000Co-Authors: Michael Camilleri, Adil E Bharucha, J S Lee, Blanca E Viramontes, Eric G TangalosAbstract:OBJECTIVES: To review the epidemiology, pathophysiology and mechanisms of irritable bowel syndrome (IBS), constipation, and diverticulosis, for the purpose of addressing these three common conditions in older adults (>65 years of age). DESIGN: Using a MEDLINE search, we identified original English language journal articles and reviews from 1965 to December 1998. We also selected articles published before 1965 or after 1998 that were cross-referenced or pertinent to the topics researched. RESULTS: The prevalence of constipation and diverticulosis is higher in older than in younger adults. Significant risk factors for constipation in older women are failure of the anorectal angle to open or excessive Perineal Descent, which represent disturbances of pelvic floor function and rectal evacuation. In contrast, the prevalence of IBS is no greater than in younger adults. Nevertheless, these syndromes impact on the patient's functional status and quality of life. The mechanisms resulting in these gastrointestinal syndromes are unclear. Uncoordinated colonic activity and colonic segmentation may lead to IBS and diverticulosis, respectively, and these pathophysiological findings suggest disorders of inhibitory control of neuromuscular function. The total number of neurons in the myenteric plexus is decreased, and collagen deposited in the distal colon is increased with aging in humans. Animal studies suggest that senescent colonic muscle responds less to excitatory factors in vitro, and neural injury in older animals may result from apoptosis, defects of mitochondrial metabolism, and inadequate levels or response to neurotrophins. Future investigations will reveal whether similar mechanisms underlie human disease. Currently, treatment is aimed at relief of symptoms of IBS or constipation or dealing with the complications of diverticulosis. CONCLUSIONS: Constipation, IBS, and diverticulosis are common problems of aging. There is a need for further systematic research of the basic mechanisms in neuromuscular dysfunction with aging, including the studies of physical characteristics of the colonic wall, pelvic floor function (particularly in women with excessive Perineal Descent), and neurohormonal control of motility and sensation. Insights on the pathophysiology and mechanisms of neural injury may lead to more specific treatments in the future, e.g., serotonergic agents and neurotrophins. Meanwhile, collaborations between primary care physicians, geriatricians, and gastroenterologists can optimize management of these three common conditions that significantly impact the quality of life of older adults.
Michael Camilleri - One of the best experts on this subject based on the ideXlab platform.
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clinical features and associations of descending perineum syndrome in 300 adults with constipation in gastroenterology referral practice
Digestive Diseases and Sciences, 2020Co-Authors: Xiao Jing Wang, Priya Vijayvargiya, Victor Chedid, Michael CamilleriAbstract:BACKGROUND Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice. AIMS To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation. METHODS We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm Descent of anorectal junction on imaging or estimated Perineal Descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients. RESULTS Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis. CONCLUSIONS DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.
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audit of the diagnosis of rectal evacuation disorders in chronic constipation
Neurogastroenterology and Motility, 2019Co-Authors: Victor Chedid, Priya Vijayvargiya, Houssam Halawi, Seon Young Park, Michael CamilleriAbstract:Background Balloon expulsion test (BET) and high-resolution anorectal manometry (HRM) are used in diagnosis of rectal evacuation disorders (REDs); their performance characteristics are suboptimal. Methods We audited records of 449 consecutive patients with chronic constipation (CC). We documented anal sphincter tone and contraction, puborectalis tenderness, and Perineal Descent on digital rectal exam (DRE); maximum resting and squeeze pressures, and rectoanal pressure gradient on HRM; weight or time to balloon expulsion; colonic transit, and area of rectal area on radiograph (RASF). We based the diagnosis of RED on ≥2 abnormalities on both DRE and HRM, excluding results of BET, as the performance of BET is being investigated. Results of RED vs non-RED and results obtained using tbBET vs wbBET groups were compared. We used multivariate logistic regressions to identify predictors of RED using different diagnostic modalities. Key results Among 449 individuals, 276 were included (74 RED and 202 non-RED). Predominant exclusions were for no HRM (n = 79) or use of low resolution anorectal manometry (n = 77). Logistic regression models for abnormal tbBET showed time >60 seconds, RASF and age-predicted RED. For tbBET, the current cutoff of 60 seconds had sensitivity of 39.0% and specificity 93.0% to diagnose RED; on the other hand, applying the cutoff at 22 seconds, the sensitivity was 77.8% and specificity 69.8%. Conclusions & inferences The clinical diagnosis of RED in patients with CC is achieved with combination of DRE, HRM and an optimized, time-based BET. Prospective studies are necessary to confirm the proposed 22 second cutoff for tbBET.
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proximal megacolon in an adult
Clinical Gastroenterology and Hepatology, 2014Co-Authors: Priya Vijayvargiya, Michael CamilleriAbstract:A44-year-old woman, born and residing in the United States, presented with medically nonresponsive chronic constipation, requiring 1 gallon of polyethylene glycol electrolyte solution weekly to induce bowel movements. She consistently experienced incomplete evacuation. She was hospitalized once for suspected sigmoid volvulus that spontaneously resolved. Physical examination showed a distended tympanitic abdomen with palpable stool in the left lower quadrant. Rectal examination revealed a high resting anal sphincter tone and no coordinated Perineal Descent during simulation of defecation; these features were confirmed on anorectal manometry (high squeeze anal sphincter pressure and requirement of 200 g to facilitate 50-mL balloon evacuation from the rectum). Gastric emptying was normal, and colonic transit was delayed. She was diagnosed with pelvic floor dyssynergia and symptoms improved somewhat after biofeedback therapy. A plain abdominal radiograph (Figure A) showed a dilated colon, confirmed on computerized tomography scan. Sagittal views of the abdominal computerized tomography (Figure B) showed an elongated, dilated proximal colon with a decompressed rectum. Direct endoscopic visualization of the intersection of the dilated and nondilated colon showed no mass or constrictions. Because of persistent symptoms and megacolon, she underwent colectomy at another hospital. Figure C shows the resected specimen with a dilated ascending and transverse colon, normal-caliber descending colon and rectum, and no constricted transition zone between dilated and normal-caliber segments. No pathologic examination of the colon was available. The enteric nervous system is derived from vagal and sacral neural crest cells. Vagal neural crest cells migrate caudally through the entire length of the gastrointestinal tract and provide the majority of neurons and glia. The sacral neural crest cells migrate rostrally and contribute to the innervation of the distal colon and rectum. Colonic dysganglionosis presents as a continuous spectrum, ranging anatomically from hypoganglionosis in colonic sections of different lengths and distributions to a localized constriction with proximal dilatation in Hirschsprung disease (HD). Hypoganglionosis is a decrease vs a complete lack of ganglia, and it can present as localized or generalized megacolon, or it may occur concomitantly with HD. These disorders present with long-term constipation refractory to medical therapy. Although approximately 95% of HD cases are diagnosed before the age of 5, less severe cases may present after 10 years of age and are considered adult HD.
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insights into the pathophysiology and mechanisms of constipation irritable bowel syndrome and diverticulosis in older people
Journal of the American Geriatrics Society, 2000Co-Authors: Michael Camilleri, Adil E Bharucha, J S Lee, Blanca E Viramontes, Eric G TangalosAbstract:OBJECTIVES: To review the epidemiology, pathophysiology and mechanisms of irritable bowel syndrome (IBS), constipation, and diverticulosis, for the purpose of addressing these three common conditions in older adults (>65 years of age). DESIGN: Using a MEDLINE search, we identified original English language journal articles and reviews from 1965 to December 1998. We also selected articles published before 1965 or after 1998 that were cross-referenced or pertinent to the topics researched. RESULTS: The prevalence of constipation and diverticulosis is higher in older than in younger adults. Significant risk factors for constipation in older women are failure of the anorectal angle to open or excessive Perineal Descent, which represent disturbances of pelvic floor function and rectal evacuation. In contrast, the prevalence of IBS is no greater than in younger adults. Nevertheless, these syndromes impact on the patient's functional status and quality of life. The mechanisms resulting in these gastrointestinal syndromes are unclear. Uncoordinated colonic activity and colonic segmentation may lead to IBS and diverticulosis, respectively, and these pathophysiological findings suggest disorders of inhibitory control of neuromuscular function. The total number of neurons in the myenteric plexus is decreased, and collagen deposited in the distal colon is increased with aging in humans. Animal studies suggest that senescent colonic muscle responds less to excitatory factors in vitro, and neural injury in older animals may result from apoptosis, defects of mitochondrial metabolism, and inadequate levels or response to neurotrophins. Future investigations will reveal whether similar mechanisms underlie human disease. Currently, treatment is aimed at relief of symptoms of IBS or constipation or dealing with the complications of diverticulosis. CONCLUSIONS: Constipation, IBS, and diverticulosis are common problems of aging. There is a need for further systematic research of the basic mechanisms in neuromuscular dysfunction with aging, including the studies of physical characteristics of the colonic wall, pelvic floor function (particularly in women with excessive Perineal Descent), and neurohormonal control of motility and sensation. Insights on the pathophysiology and mechanisms of neural injury may lead to more specific treatments in the future, e.g., serotonergic agents and neurotrophins. Meanwhile, collaborations between primary care physicians, geriatricians, and gastroenterologists can optimize management of these three common conditions that significantly impact the quality of life of older adults.
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descending perineum syndrome audit of clinical and laboratory features and outcome of pelvic floor retraining
The American Journal of Gastroenterology, 1999Co-Authors: Gavin C Harewood, Bernard Coulie, Michael Camilleri, Doris Rathharvey, John H PembertonAbstract:OBJECTIVE: Our aim was to retrospectively analyze the Mayo Clinic experience of descending perineum syndrome from 1987-1997. METHODS: Clinical records were abstracted for demographic features, risk factors, results of anorectal and defecation tests, and a mailed questionnaire evaluated outcome and current symptoms. RESULTS: All results are mean +/- SD. Clinically, 39 patients (38 women, one man), mean age 53+/-14 yr, presented with constipation (97%), incomplete rectal evacuation (92%), excessive straining (97%), digital rectal evacuation (38%), and fecal incontinence (15%). Laboratory tests showed anal sphincter resting pressure was 54+/-26 mm Hg, and squeeze pressure was 96+/-35 mm Hg; expulsion from the rectum of a 50-ml balloon required > 200 g added weight in 27%; Perineal Descent was 4.4+/-1 cm (normal 4 cm; rectal balloon expulsion is an insensitive screening test for descending perineum syndrome. Pelvic floor retraining is a suboptimal treatment for this chronic disorder of rectal evacuation; the extent of Perineal Descent appears to be a useful predictor of response to retraining.
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Rectal intussusception: can high resolution three-dimensional ano-rectal manometry compete with conventional defecography?
Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society, 2016Co-Authors: A Benezech, M Bouvier, J C Grimaud, Karine Baumstarck, M. Cappiello, V VittonAbstract:BACKGROUND: Three-dimensional high-resolution anorectal manometry (3DHRAM), used for exploring anorectal disorders, was recently developed, providing interesting topographic data for the diagnosis of pelvic floor disorders such as excessive Perineal Descent. The aim of our study was to define a diagnostic strategy based on selected 3DHRAM parameters to identify rectal intussusceptions (RI), considering conventional defecography (CD) as the gold standard.ăMETHODS: All patients referred to our center in the previous 6 months for 3DHRAM to explore fecal incontinence or constipation, and who previously achieved CD, were eligible. 3DHRAM results were obtained for all classical parameters and the presence of a narrow band of high pressure in the anal canal during attempted defecation, which was recently found to be associated with RI in some studies. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criterion in order to propose a diagnostic strategy for RI.ăKEY RESULTS: Twenty-six patients (66%) presented with RI on CD. On 3DHRAM, according to our diagnostic strategy, the most relevant manometric criterion for the diagnosis of RI was the association of an anterior additional high-pressure area and an excessive Perineal Descent, with a positive predictive value of 100% [81.5-100], a specificity of 100% [75.3-100] and a sensibility of 69.2% [48.2-85.7].ăCONCLUSIONS & INFERENCES: In this study, 3DHRAM was used to diagnose RI, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.
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three dimensional high resolution anorectal manometry and diagnosis of excessive Perineal Descent a comparative pilot study with defaecography
Colorectal Disease, 2014Co-Authors: A Benezech, M Bouvier, J C Grimaud, Karine Baumstarck, V VittonAbstract:Aim Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can simultaneously provide physiological and topographical data on the terminal part of the digestive tract. Our object was to assess whether 3DHRAM is able to reliably diagnose excessive Perineal Descent already diagnosed with conventional defaecography, which is considered to be the gold standard. Method All patients referred to our centre for anorectal manometry and conventional defaecography were evaluated with a maximum of 6 months between the two examinations. Anorectal manometry was performed using the 3D High-Resolution Given Imaging® probe. Excessive Perineal Descent was defined as the downward movement of the anal high-pressure zone during straining. At the end of the straining effort, the high-pressure zone regained its initial position, thereby indicating that the probe had not moved. Results Nineteen female patients of median age 53 (21–70) years were included in the study. All cases with excessive Perineal Descent diagnosed using defaecography were visualized with 3DHRAM. The degree of Perineal Descent determined by 3D and conventional defaecography was compared (Spearman correlation 0.726, P = 0.01). In contrast, the averages measured were significantly different; the average was 11.68 ± 3.3 mm for 3DHRAM but 34.21 ± 13.3 mm for conventional defaecography (P = 0.002). Conclusion The results of the study demonstrate that 3DHRAM can diagnose excessive Perineal Descent with the same degree of reliability as defaecography. Quantitative measures were not correlated, however, possibly because of methodological differences. The study confirms the value of the morphological data provided by 3DHRAM.
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three dimension high resolution anorectal manometry can precisely measure Perineal Descent
Journal of Neurogastroenterology and Motility, 2013Co-Authors: V Vitton, J C Grimaud, M BouvierAbstract:A 65-year-old woman was referred to investigate a long history of intractable constipation. Clinical examination revealed a descending perineum and digital examination diagnosed a large rectocele without stool in the rectum. The patient underwent 3-dimension high-resolution anorectal manometry (3DHRAM), dynamic endo-anal ultrasonography (D-EUS) and conventional defecography. The 3DHRAM showed mean resting pressure of 84 mmHg, mean maximal squeezing pressure of 207 mmHg and length of the high-pressure zone of 2.7 mm. The recto-anal inhibitory reflex was present and the rectal sensitivity was normal (10 mL). However there was an incomplete anal relaxation during attempted defecation indicating a pelvic floor dyssynergia. In addition during attempted defecation a 9 mm Perineal Descent on the manometric probe was observed in the left lateral decubitus position (Figure). At the end of the bear down the perineum regained its initial position indicating that the probe has not moved. Conventional defecography showed a 9.2 mm Perineal Descent from the pubo-coccygeal line, a retentive rectocele of 69 mm and rectal intussusception. D-EUS showed no anal sphincter defect and, at dynamic time, showed a rectocele measured at 35 mm and descending perineum measured at 15 mm according to the method described by Vitton et al.1