Anorectal Manometry May Reduce the Number of Rectal Suction Biopsy Procedures Needed to Diagnose Hirschsprung Disease

Objectives: The aim of the study was to evaluate whether anorectal manometry (ARM), which is used to test the rectoanal inhibitory reflex (RAIR), is a safe alternative for reducing the number of invasive rectal suction biopsy (RSB) procedures needed to diagnose Hirschsprung disease (HD). Methods: Between 2010 and 2017, we prospectively collected the ARM results of 105 patients suspected of having HD. Following the outcome, the patients either underwent additional tests to confirm HD or they were treated conservatively. Primary ARM-based diagnoses were compared with the definitive diagnoses based on the pathology reports and/or clinical followups. Additionally, we analyzed whether modifications to our ARM protocol improved diagnostic accuracy. Results: The sensitivity of ARM and RSB was comparable (97% vs 97%). The specificity of ARM, performed according to our initial protocol, was significantly lower than that of RSB. After we modified the protocol the difference between the specificity of ARM and RSB was no longer statistically significant (74% vs 84%, respectively, P = 0.260). The negative predictive value of ARM was 100%, while their positive predictive value was significantly lower than that of RSB (56% vs 97%, P <0.001). Conclusions: ARM is a viable screening tool for HD and, provided it is performed properly, it can be used to exclude HD with absolute certainty. By contrast, an absent rectoanal inhibitory reflex on ARM should always be followed by an RSB to confirm the diagnosis of HD. Using ARM as the diagnostic of first choice could reduce the number of invasive biopsies

The anorectal defaecation reflex:a prospective intervention study

Aim Our hypothesis is that there may be a neural pathway with sensory afferent neurons in the anal canal that leads to rectal contraction to assist defaecation. We aimed to compare rectal motility between healthy participants with or without anal anaesthesia. Method This prospective intervention study consisted of two test sessions: a baseline session followed by an identical second session. During each session we performed the anal electrosensitivity test, the rectoanal inhibitory reflex test and rapid phasic barostat distensions. Prior to the second session, participants were randomly assigned to receive either a local anal anaesthetic or a placebo. Results We included 23 healthy participants aged 21.1 +/- 0.5 years, 13 of whom received an anal anaesthetic and 10 a placebo. All participants showed a transient rectal contraction during the first test session, which decreased significantly after anal anaesthesia (18.6 ml vs. 4.9 ml, p = 0.019). The maximum rectal contraction was comparable to the baseline results in the placebo group. Furthermore, the electrosensitivity at the highest centimetre of the anal canal correlated with the maximum rectal contraction (r = -0.452, p = 0.045). Conclusion All healthy study participants display an involuntary, reproducible rectal reflex contraction that appears to be innervated by afferent nerves in the proximal anal canal. The rectal reflex contraction appears to play a role in defaecation and we therefore refer to this phenomenon as the anorectal defaecation reflex. Knowledge of the anorectal defaecation reflex may have consequences for the diagnostics and treatment of constipation

Fissurectomy combined with botulinum toxin A:a review of short- and long-term efficacy of this treatment strategy for chronic anal fissure; a consecutive proposal of a treatment algorithm for chronic anal fissure

Background Several studies have investigated the short- and long-term efficacy of fissurectomy combined with botulinum toxin A injection for patients with chronic anal fissure. Objective To evaluate the short- and long-term efficacy of the combined treatment strategy of fissurectomy with botulinum toxin A for chronic anal fissure and to discuss recurrence rates in the light of current theory on the aetiology of anal fissure. Materials and methods This is a narrative review. We conducted an article search using PubMed and calculated the means of the reported efficacy ranges. Results Fissurectomy combined with botulinum toxin A injections freed at least 78% of the patients from symptoms and yielded a fissure healing rate of up to 86%. Within 12 months after treatment a 3% recurrence rate was reported. On average, the long-term recurrence rate was 22%. One study reported a 50% recurrence rate 22 months after treatment. Conclusion The efficacy of fissurectomy combined with botulinum toxin A injection for chronic anal fissure is high. The short-term recurrence rate is low, while long-term recurrence is relatively high. Extended follow-up indicates that recurrence of chronic anal fissure is possibly caused by anal basal pressure building up steadily once again. If so, the cause of renewed increase of pressure should be addressed. Based on the literature and on our clinical experience, we assume that the underlying cause of increasing anal basal pressure is that patients use their pelvic floor muscles inadequately and this in turn leads to chronic anal fissure

The puborectal continence reflex functions independently of the pudendal nerve

Aim The ability of patients with poor pudendal nerve function to voluntarily contract their external anal sphincter is limited. However, it is not known whether the condition of the pudendal nerve influences voluntary puborectal muscle contraction. Recently, we described the puborectal continence reflex that maintains faecal continence by involuntary contractions of the puborectal muscle. We aim to investigate whether both voluntary and involuntary contractions of the puborectal muscle are influenced by the condition of the pudendal nerve. Method We retrospectively analysed 129 adult patients who underwent anorectal function tests at the Anorectal Physiology Laboratory. Anal electrosensitivity was used as a measurement of the pudendal nerve function. Voluntary and involuntary contractions of the puborectal muscle were defined as maximum puborectal muscle contractility and maximum pressure at the level of the puborectal muscle during the balloon retention test. Results Voluntary contraction of the puborectal muscle was significantly decreased in patients with pudendal nerve damage (P = 0.002). Involuntary contractions, however, were not associated with the condition of the pudendal nerve (P = 0.63). Multiple linear regression analysis showed that the condition of the pudendal nerve and patients' sex significantly predicted voluntary contraction but not involuntary contraction. Conclusion Voluntary contractions of the puborectal muscle are significantly decreased in patients with pudendal nerve damage, while involuntary contractions of the puborectal muscle are comparable to those of patients without nerve damage. We conclude that the puborectal continence reflex, which controls involuntary contractions of the puborectal muscle, is not regulated by the pudendal nerve

Prevalence of Defecation Disorders and their Symptoms is Comparable in Children and Young Adults:Cross-Sectional Study

Purpose: We aimed to compare the prevalence rates and associated symptoms of constipation and fecal incontinence in children and young adults and evaluate how these patient groups cope with these disorders. Methods: A cross-sectional study was performed in which 212 children (8-17 years) and 149 young adults (18-29 years) from the general Dutch population completed a questionnaire about defecation disorders. Results: Constipation occurred in 15.6% of children and 22.8% of young adults (p=0.55), while the prevalence of fecal incontinence was comparable between groups (7%, p=0.91). The symptoms associated with constipation occurred as often in children as in young adults, while most fecal incontinence symptoms occurred more often in young adults. Approximately 43% of children had constipation for more than 5 years, while 26% of young adults experienced constipation since childhood. Only 27% of constipated children and 21% of constipated young adults received treatment (mostly laxatives). For fecal incontinence, 13% of children and 36% of young adults received treatment (mostly antidiarrheal medications or incontinence pads). Conclusion: In contrast to the general belief, the prevalence of defecation disorders and associated symptoms seem to be comparable in children and young adults. Only a few people with defecation disorders receive adequate treatment

Fecal continence outcomes are associated with the type, height, and stage procedure of ileal pouch-anal anastomosis

Purpose This study aims to analyze the quality of life in patients with an ileal pouch-anal anastomosis (IPAA) and to investigate the association between height and type of the anastomosis, the number of stage procedures and age, and the fecal continence outcomes. Methods This is a cross-sectional retrospective study in patients who had undergone IPAA between 1992 and 2016 (N = 133). We sent questionnaires to 102 eligible patients (64% response rate). We used the Wexner score to assess fecal incontinence: 0 = no incontinence to 20 = complete incontinence. We used RAND-36 to measure quality of life. Results Patients who underwent mucosectomy with hand-sewn anastomoses (n = 11, 17%) had significantly higher median Wexner scores than patients with stapled anastomoses (10 versus 3, P = 0.003). Lower anastomoses correlated significantly with increasing Wexner scores (r = - 0.468, P <0.001). Quality of life of incontinent patients was diminished. Patients who were older at the time of IPAA surgery had higher Wexner scores (P = 0.004), while the time between surgery and questionnaire did not influence their Wexner scores (P = 0.810). Considering the stage procedures, multiple linear regression showed that the two-stage procedure without diverting ileostomy was significantly associated with higher Wexner scores (B = 0.815, P = 0.02), adjusted for sex (P = 0.008) and anastomosis type (P = 0.002). The three-stage procedure showed equally low complications and anastomotic leakage rates. Conclusion Mucosectomy with more distal, hand-sewn anastomosis and increasing age at IPAA surgery was associated with poorer fecal continence outcomes. The three-stage procedure appears to give the best fecal continence results without increasing complications. Furthermore, incontinence reduced patient's quality of life

A possible physiological mechanism of rectocele formation in women

BACKGROUND: We aimed to determine the anorectal physiological factors associated with rectocele formation.METHODS: Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected.RESULTS: Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011).CONCLUSION: Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.</p

The influence of demographic characteristics on constipation symptoms:a detailed overview

Background Diagnosing constipation remains difficult and its treatment continues to be ineffective. The reason may be that the symptom patterns of constipation differ in different demographic groups. We aimed to determine the pattern of constipation symptoms in different demographic groups and to define the symptoms that best indicate constipation. Methods In this cross-sectional study the Groningen Defecation and Fecal Continence questionnaire was completed by a representative sample of the adult Dutch population (N = 892). We diagnosed constipation according to the Rome IV criteria for constipation. Results The Rome criteria were fulfilled by 15.6% of the study group and we found the highest prevalence of constipation in women and young adults (19.7 and 23.5%, respectively). Symptom patterns differed significantly between constipated respondents of various ages, while we did not observe sex-based differences. Finally, we found a range of constipation symptoms, not included in the Rome IV criteria, that showed marked differences in prevalence between constipated and non-constipated individuals, especially failure to defecate ( increment = 41.2%). Conclusions Primarily, we found that certain symptoms of constipation are age-dependent. Moreover, we emphasize that symptoms of constipation not included in the Rome IV criteria, such as daily failure to defecate and an average duration of straining of more than five minutes, are also reliable indicators of constipation. Therefore, we encourage clinicians to adopt a more comprehensive approach to diagnosing constipation

How Should the Low Anterior Resection Syndrome Score Be Interpreted?

BACKGROUND: Bowel dysfunction after low anterior resection is often assessed by determining the low anterior resection syndrome score. What is unknown, however, is whether this syndrome is already present in the general population and which nonsurgical factors are associated. OBJECTIVE: The purpose of this study was to determine the prevalence of minor and major low anterior resection syndrome in the general Dutch population and which other factors are associated with this syndrome. DESIGN: This was a cross-sectional study. SETTINGS: The study was conducted within the general Dutch population. PATIENTS: The Groningen Defecation and Fecal Continence Questionnaire was distributed among a general Dutch population-based sample (N = 1259). MAIN OUTCOME MEASURES: Minor and major low anterior resection syndrome were classified according to the scores obtained. RESULTS: The median, overall score was 16 (range, 0-42). Minor low anterior resection syndrome was more prevalent than the major form (24.3% vs 12.2%; p <0.001). Bowel disorders, including fecal incontinence, constipation, and irritable bowel syndrome were associated with the syndrome, whereas sex, age, BMI, and vaginal delivery were not. Remarkably, patients with diabetes mellitus were significantly more prone to experience minor or major low anterior resection syndrome. The ORs were 2.8 (95% CI, 1.8-4.4) and 3.7 (95% CI, 2.2-6.2). LIMITATIONS: We selected frequent comorbidities and other patient-related factors that possibly influence the syndrome. Additional important factors do exist and require future research. CONCLUSIONS: Minor and major low anterior resection syndrome occur in a large portion of the general Dutch population and even in a healthy subgroup. This implies that the low anterior resection syndrome score can only be used to interpret the functional result of the low anterior resection provided that a baseline measurement of each individual is available. Furthermore, because people with low anterior resection syndrome often experience constipation and/or fecal incontinence, direct examination and diagnosis of these conditions might be a more efficient approach to treating patient bowel dysfunctions

Validation of the Chinese DeFeC questionnaire:a comprehensive screening tool for symptoms and causes of constipation and incontinence

BACKGROUND: Currently, the diagnosis of defecation disorders in China is usually based on varied and ambiguous criteria. We aimed to translate the Groningen Defecation and Fecal Continence (DeFeC) questionnaire to Chinese and test its reproducibility and feasibility in the general Chinese population.METHODS: The Groningen Defecation Questionnaire was translated into Chinese according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN). The feasibility and reproducibility were evaluated by performing a test-retest online survey and calculating the Cohen's kappa (κ) coefficient [or intraclass correlation coefficient (ICC)], with 0.01-0.20 considered slight agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, substantial agreement; and 0.81-1.00, almost perfect agreement.RESULTS: In total, 130 respondents completed the questionnaire twice, with a mean age of 47.08±12.46 years. No remarks were made that indicted that the questions were difficult to understand. The median time to complete the questionnaire was 20.78 min [interquartile range (IQR), 14.83-29.20 min] for the first time. The κ coefficient of all defecation function-related domains ranged between 0.25 and 0.71, with an average value of 0.53. The constipation and fecal incontinence-related domains showed a substantial and moderate agreement level, as indicated by κ of 0.65 and 0.52, respectively. The Agachan constipation score and Wexner incontinence score showed perfect and substantial agreement, as indicated by an ICC of 0.88 and 0.74, respectively.CONCLUSIONS: The Chinese version of the Groningen DeFeC questionnaire is highly feasible and reproducible and can be applied in clinical and research activities for the Chinese population.</p