Evaluating patients with anorectal incontinence

Fecal incontinence is a devastating disability, and although this condition is widely accepted as a problem in the elderly, it is now becoming apparent that much younger age groups are also frequently affected. Thorough assessment of anorectal incontinence is very important to choosing the most appropriate treatment. Careful history-taking and physical examination can identify the cause of most cases of incontinence and are essential in every patient. Several incontinence scoring systems have been proposed to provide an objective measure of a subject’s degree of fecal incontinence, but only one acknowledges the important contribution of the severity of symptoms to quality of life. The investigations used to evaluate anorectal physiology include anorectal manometry, anal endosonography, nerve stimulation techniques, electromyography, defecography, endoluminal magnetic resonance imaging, the saline continence test, and the balloon-retaining test. Although all of these tests are important, the most useful for patients with incontinence are anal manometry, anal endosonography, and the pudendal nerve terminal motor latency test, because they can identify anatomic or physiologic abnormalities for which there may be effective treatments

Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management

Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung’s disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery. (C) 2005 Blackwell Publishing Asia Pty Ltd

Synchronous primary duodenal bulb and cecal adenocarcinoma: case report and short review of the literature

BACKGROUND: Primary duodenal adenocarcinoma is a rare entity with an uncertain biologic behaviour whose diagnosis is usually achieved by endoscopy and biopsy. However, it lacks specific symptoms and its diagnosis may be delayed with poor prognosis. Villous adenomas are considered as premalignant lesions with high risk malignant transformation. METHODS: We report a rare case of a patient with two synchronous adenocarcinomas, one of the first portion of the duodenum as a villous tumor and the other in cecum colon. The patient submitted successfully to pacreatoduodenectomy and right hemicolectomy, while postoperatively received also adjuvant chemotherapy. RESULTS: Seventeen months after the operations the patient is alive with no evidence of recurrent or metastatic disease. CONCLUSIONS: The radical resection of primary duodenal adenocarcinoma is considered the treatment of choice, which should be accompanied by adjuvant chemotherapy preventing a recurrence at distant sites