Digital rectal examination and balloon expulsion test in the study of defecatory disorders: are they suitable as screening or excluding tests?

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and timeconsuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests ofDD. Methods. Weperformeda systematic search inPUBMEDandMEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (.. 2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to performbetter when a cut-off time of 2minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.info:eu-repo/semantics/publishedVersio

Diagnostic Approaches of Dysfunctional Anorectum and Pelvic Floor Disorders

Various causes of neuromuscular disorders of the pelvic floor muscles may affect the functional integrity of the pelvic floor and anorectum leading to the different pathological conditions such as anorectal incontinence, urinary incontinence and constipation of obstructed defecation, sexual dysfunction, and perineal pain syndromes. Diagnosis of the dysfunctional anorectum and pelvic floor disorders is an integrated approach that includes a thorough history, a careful physical examination, and selected specialized tests as well as the exclusion of organic disease (anorectal or endopelvic) which complement the patient’s evaluation contributing to objective and accurate diagnosis of their pathological cause leading to the optimal treatment

Optimizing the utility of anorectal manometry for diagnosis and therapy: A roundtable review and recommendations

BACKGROUND & AIMS: Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS: Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS: ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS: Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders

The Management of Constipation: Current Status and Future Prospects

Chronic constipation, a common condition, can have remarkably negative effects on a patient’s quality of life. Recent research has identified factors that may influence the prognosis of chronic constipation and suggests the need for adequate therapy. However, the major obstacles in this field were: (1) a small number of therapeutic options, (2) no clear diagnostic criteria, and (3) no effective method to collect information form the patients. These were due to the fact that bowel movement patterns vary widely among individuals, and also the functional constipation, including irritable bowel syndrome, is difficult to be distinguished from the chronic constipation. Recently, it has been demonstrated that the Rome IV diagnostic criteria of functional constipation and the Bristol stool form scale are useful for the objective evaluation and recording of stool. Based on these developments, and the increase of newly developed medicines the therapy for the constipation is significantly changing and therefore, if conventional therapy for chronic constipation is ineffective, switching of medicines is possible. Therefore, clinicians should update the information of these newly developed drugs available in clinics and diagnostic criteria. For this purpose, in this chapter, we have summarized the perspective on the current paradigm of treatment for chronic constipation focusing on recently introduced therapeutic drugs

AN ASSESSMENT OF INVESTIGATIONS FOR EVACUATORY DYSFUNCTION

MD (Res)Normal defecation is a complex physiological act that requires proper co-ordination between several organs and is heavily influenced by various extrinsic factors like diet. Difficulty in evacuation can lead to constipation. Chronic constipation affects a significant proportion of the population and poses a significant medical and economic burden to any country. Common investigations for chronic constipation were evaluated with a systematic review and clinical studies. Systematic review of anorectal manometry (ARM), the balloon expulsion test (BE) and fluoroscopic evacuation proctography (EP) for constipation showed wide variation in the diagnostic yield of these tests along with significant variation in test methodology and data interpretation. A proctographic study involving healthy volunteers confirmed that a range of so-called structural abnormalities can exist in health. Constipation is often a symptomatic diagnosis. Symptoms incorporated within the Rome III criteria, one of the most widely used diagnostic criterion for constipation, were unable to reliably predict the final proctographic diagnosis in a cohort of constipated patients. Agreement between ARM, BE and EP for the diagnosis of subtypes of constipation was assessed prospectively in consecutive patients satisfying the Rome III criteria for functional constipation. Despite strict adherence to the Rome III criteria, agreement between recommended investigations was poor. The final diagnosis was influenced by the choice of investigation. Chronic constipation is an enigmatic disorder. The confusion is further compounded by a lack of consensus on investigation protocols and the absence of a recognized 'gold standard' test. In order to identify the elusive 'gold standard', and hence reach a consensus, large and well-designed studies that can assess the clinical utility of these investigations are urgently required