Background
Anorectal manometry (ARM) and balloon expulsion test (BET) are pivotal in investigation of anorectal disorders. There is controversy, however, about normal values and optimum methodology ...for performing these tests. Our aims were to compare BET using three different balloons and to establish normal values for ARM and BET in health.
Methods
Forty‐four female healthy subjects (mean age 56 ± 12 years) underwent ARM, followed by BET which was performed in a private toilet using three different catheters (party balloon, Foley catheter and a commercially available catheter) in a single‐blinded randomized order. Outcome measures were time to balloon expulsion and comprehensive measures of anal sphincter function, the push maneuver and rectal sensation.
Key Results
The Foley catheter took longer to expel compared to both party and commercial balloons (both pairwise P < 0.001) with a wider distribution of results (P < 0.001). Ten of 40 healthy subjects could not expel the Foley catheter within 120 seconds. On ARM, older age was associated with lower resting anal sphincter pressure (ρ = −0.3, P = 0.05) and lower anal squeeze pressure (ρ = −0.3, P = 0.05). Having at least one vaginal delivery (compared to none) was associated with lower anal squeeze pressures (P = 0.03) and a smaller difference between cough and squeeze pressures (P = 0.03).
Conclusions & Inferences
A commercial balloon exhibited superior results in vivo compared to the Foley catheter without the concerns of latex allergy and quality control present with the use of a party balloon. Normal values for high‐resolution water‐perfused manometry have been established and an effect seen for age and parity.
Balloon expulsion testing and anorectal manometry are commonly performed in the investigation of anorectal disorders, but the ideal methodology and normal ranges are not well established. In this randomized study of healthy subjects, we compare three commonly used catheters for balloon expulsion testing, and demonstrate that a commercially available balloon is preferred. Normal ranges for comprehensive high resolution, water‐perfused anorectal manometry are provided.
Background
Patients with obstructed defecatory symptoms (ODS) are commonly referred to either gastroenterologists (GE) or colorectal surgeons (CS). Further management of these patients may be ...impacted by this choice of referral.
Methods
An online survey of specialist practice was disseminated to GE and CS in Australia and New Zealand. A case vignette of a patient presenting with ODS was described, with multiple subsequent scenarios designed to delineate the responder's preferred approach to management of this patient.
Key Results
A total of 107 responders participated in the study, 62 CS and 45 GE. For a female patient with ODS not responding to pharmacological treatment, GE were more likely than CS to refer patients for anorectal manometry, while CS were more likely to refer for dynamic imaging. A quarter of CS and GE referred patients directly to pelvic floor physiotherapy, without any pre‐treatment testing. Knowing the result of dynamic imaging, especially if a rectocele was demonstrated, substantially influenced management for both of the specialties: GE became more likely to refer the patients for CS consultation and less likely to refer directly for biofeedback or physiotherapy and CS were more likely to opt for an operative pathway over conservative management than they were prior to knowledge of the imaging findings. The majority (>75%) of GE and CS did not find it necessary to obtain a gynecological consultation, even in the presence of a rectocele.
Conclusions & Inferences
Practice variation across medical specialties affects diagnostic and management recommendations for patients with ODS, impacting treatment pathways. Our findings provide an incentive toward establishing interdisciplinary, uniform, management guidelines.
In this online survey of specialist practice a case vignette of a patient presenting with obstructed defecatory symptoms was presented to colorectal surgeons and gastroenterologists. Practice variation across medical specialties affected diagnostic and management recommendations, impacting treatment pathways.
Response to Bellini et al Wald, Arnold; Bharucha, Adil E; Malcolm, Allison ...
The American journal of gastroenterology,
2022-May-01, Letnik:
117, Številka:
5
Journal Article
Introduction
The use of a footstool has been advocated to optimize posture when sitting on the toilet and thus facilitate bowel evacuation. We aimed to assess the alterations in defecatory posture, ...and the changes in simulated defecation with use of a footstool in patients with constipation.
Methods
Forty‐one patients (female 93%, mean 52 year, SD 14 year) with constipation referred to a tertiary neurogastroenterology unit were enrolled. A bowel questionnaire, Hospital Anxiety and Depression Scale, and Rome questionnaire were administered prior to anorectal manometry. Each patient underwent three rectal balloon expulsion tests in randomized order with no footstool, a 7‐inch, and a 9‐inch footstool. Additional assessments included angle between spine and femur, and visual analogue scales assessing ease of evacuation, urge to defecate, and discomfort with expulsion.
Key Results
Defecatory posture was significantly altered by footstool use, with progressive narrowing of the angle between the spine and femur as footstool height increased (p < 0.001 for all comparisons). Compared with no footstool, the use of a footstool was not associated with a change in balloon expulsion time and there was no difference between the two footstool heights. Subjectively, no significant change was identified in any of the three perceptions of balloon expulsion between no footstool and footstool use.
Conclusions and Inferences
Although the use of a footstool led to changes in defecatory posture, it did not improve subjective or objective measures of simulated defecation in patients with undifferentiated constipation. Therefore, the recommendation for its use during evacuation cannot be applied to all patients with constipation.
Although the use of a footstool during defecation changes the degree of hip flexion in the toileting position, we found that it does not improve the subjective or objective measures of simulated defecation in patients with undifferentiated constipation. Therefore, the recommendation for its use may not be applicable to all patients presenting with constipation.
Background
Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions.
Purpose
This review examines the indications, techniques, interpretation, strengths, and weaknesses of ...high‐resolution ARM (HR‐ARM), 3‐dimensional high‐resolution anorectal manometry (3D‐HR‐ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR‐ARM and 3D‐HR‐ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low‐cost, radiation‐free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age‐ and sex‐matched normal values, clinical features, and results of other tests. A larger database of technique‐specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR‐ARM for identifying abnormal mechanisms of defecation and continence.
Background
This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function ...testing including anorectal manometry (focused on high‐resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed.
Methods
Twenty‐nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face‐to‐face and three remote meetings to derive consensus between 2014 and 2018.
Key recommendations
The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.
Conclusions and Inferences
This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much‐needed standardization to these techniques.
This document summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance of anorectal function testing and introduces a consensus classification for disorders of anorectal function based on objective, physiological measurement.
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