Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.     

New Metrics in High-Resolution and High-Definition Anorectal Manometry

Purpose of Review

To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques.

Recent Findings

The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence.

Summary

HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.

     

Anal Resting Pressures at Manometry Correlate with the Fecal Incontinence Severity Index and with Presence of Sphincter Defects on Ultrasound

Introduction  We describe the relationship between anorectal manometry, fecal incontinence severity, and findings at endoanal ultrasound. Methods  A total of 351 women completed the Fecal Incontinence Severity Index, underwent anorectal manometry, and endoanal ultrasound. Severity index and manometry pressures in 203 women with intact sphincters on ultrasound were compared with pressures in 148 women with sphincter defects. Relationships between resting and squeeze pressures, severity index, and size of sphincter defects were evaluated. Results  Mean severity index in patients with and without sphincter defect was 35.7 vs. 36.7 (not significant). Worsening index correlated with worsening mean and maximum resting pressure (P < 0.0001). Differences were observed in mean and maximum resting pressure between the patients with and without sphincter defects (26.6 vs. 37.2, P < 0.0001; 39.4 vs. 51.7, P < 0.001). Resting pressures correlated with the sizes of defect (P < 0.0001). Conclusions  Patients with and without sphincter defects had similar severity scores, but patients with defects had a significant decrease in resting pressures. Patients with larger sphincter defects had lower severity scores and resting pressures. Until a manometry cutoff can be set to discriminate between absence and presence of defects, both manometry and ultrasound should be offered to patients with history of anal trauma. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not available.     

Redundancy in the International Anorectal Physiology Working Group Manometry Protocol: A Diagnostic Accuracy Study in Fecal Incontinence

Digestive Diseases and Sciences - Anorectal manometry (ARM) is essential for identifying sphincteric dysfunction. The International Anorectal Physiology Working Group (IAPWG) protocol and London...     

The Favre System for Anorectal Manometry: Comparison with Other Manometry Systems in Vitro and in Healthy Volunteers

Background: The Favre system operates with airflow in a semi-closed circuit to transmit pressure. We aimed to evaluate the Favre system in comparison with other commonly used manometry systems. Methods: The Favre, Amdorfer, Arhan, and Synectics systems were evaluated in vitro and in 14 volunteers. Results: In vitro testing showed no relevant differences for latency, precision, or retest stability. In vivo, maximum resting pressure differed among all probes (P < 0.01) except for Arhan versus Arndorfer (NS). Maximum squeeze pressures differed among all probes (P < 0.01). Decrease of resting pressure during rectoanal inhibitory reflex was similar for Favre versus Arndorfer and Arhan versus Synectics (NS). Retest stability was higher with Favre than with Arndorfer (P < 0.05) and Synectics (P < 0.05) with regard to maximum resting pressure; it was higher with Favre than with Arhan (P < 0.01) and Arndorfer (P < 0.05) with regard to maximum squeeze pressure. Favre caused less discomfort than Synectics (P < 0.05) or Arndorfer (P < 0.05). Conclusion: The Favre probe is an excellent and cost-efficient system for routine anorectal manometry.     

Oddi括约肌测压及内镜下十二指肠乳头切开术对Oddi括约肌运动功能障碍诊治的意义

本文对60例胆囊切除术后复发腹痛患者进行0ddi括约肌测压研究,并探讨内镜下十二指肠乳头切开术(EPT)对Oddi括约肌基础压升高患者疗效。用低顺应性水灌注系统,三通道测压导管,观察Oddi括约肌基翻压、Oddi括约肌基础收缩幅度、频率和传播方式。对Oddi括约肌基础压>35mmHg者,随机分为两组,一组予以EPT治疗,另一组做为对照,并随访其疗效。结果发现:Oddi括约肌测压异常发生率为46.7％。Oddi括约肌基础压升高者,EPT治疗后,随访3～18月,有效率为91.7％,明显高于对照组(P<0.05)。结论:Oddi括约肌测压对Oddi括约肌运动功能障碍(SOD)的诊断具有较高价值。测压发现Oddi括约肌基础压升高患者EPT可获得满意的长期疗效。     

直肠前膨出与功能性排便障碍：肛门直肠压力与感觉功能检测

背景：直肠前膨出（RC）是一种多见于女性的肛肠疾病,与功能性排便障碍（FDD）的关系目前尚不明。目的：研究伴RC的FDD患者肛门直肠压力和感觉功能的变化,探讨RC与FDD的关系。方法：选取28例伴RC的FDD患者并分为伴轻度RC的FDD组和伴中-重度RC的FDD组,设不伴RC的FDD患者作为对照。所有患者行球囊排出试验、肛门直肠压力和感觉功能检测,并按照罗马Ⅲ标准将FDD患者进一步分为排便协同失调（F3a）和排便推进不足（F3b）两种亚型。结果：除伴中-重度RC的FDD组直肠排便收缩压显著低于不伴RC的FDD组外（P〈0.05）,其余各组间直肠静息压、肛管静息压、肛管最大缩榨压、直肠排便收缩压、肛门括约肌松弛率以及初始感觉容量、产生便意容量和最大耐受容量均无明显差异。与不伴RC的FDD组相比,伴RC的FDD组中F3b亚型比例显著升高（P〈0.05）。结论：伴中-重度RC的FDD患者直肠排便收缩压明显降低,伴RC的FDD患者多表现为F3b亚型,提示RC与FDD的发病可能具有相关性。     

Simultaneous Endoluminal Sonography and Manometry to Assess Anal Sphincter Complex in Normal Subjects

The purpose of this study was to usesimultaneous anal manometry and high-frequencyendoluminal ultrasonography (EUS) to determine therelationship between resting anal pressure andcross-sectional area of the internal and external anal sphincters.Eleven normal subjects underwent simultaneous anal EUSand manometry using catheters containing both pressureports and ultrasound transducers. Resting pressure and cross-sectional area of the sphincters weremade throughout the anal sphincter complex. The lengthof the internal anal sphincter (IAS) by sonography (27± 5 mm) was significantly less than the length of the high pressure zone (HPZ) by manometry(44 ± 8 mm; P < 0.001). Maximum IAScross-sectional area (CSA) occurred 10 ± 6 mmproximal to the peak resting pressure. The resting analpressure correlated with external anal sphincter (EAS) CSA (r =0.77), but not with IAS CSA (r = –0.17). The sumof EAS CSA and IAS CSA correlated strongly with restingpressure (r = 0.85). In conclusion, the IAS is shorter than the HPZ, with a significant distanceseparating maximum IAS CSA from peak resting pressure.The sum of the IAS and EAS CSAs, but not that of the IASalone, correlated with resting pressure. Thus, this study suggests that the EAS, in addition to theIAS, contributes to resting anal pressure.     

Atrophy and Defects Detection of the External Anal Sphincter: Comparison Between Three-Dimensional Anal Endosonography and Endoanal Magnetic Resonance Imaging

Purpose Using endoanal magnetic resonance imaging, atrophy of the external anal sphincter can be established. This aspect has not been thoroughly investigated using three-dimensional anal endosonography. The purpose of this study was to compare prospectively three-dimensional anal endosonography to magnetic resonance imaging in the detection of atrophy and defects of the external anal sphincter in patients with fecal incontinence. In addition, we compared both techniques for anal sphincter thickness and length measurements. Materials and Methods Patients with fecal incontinence underwent three-dimensional anal endosonography and magnetic resonance imaging. Images of both endoluminal techniques were evaluated for atrophy and defects of the external anal sphincter. External anal sphincter atrophy scoring with three-dimensional anal endosonography depended on the distinction of the external anal sphincter and its reflectivity. External anal sphincter atrophy scoring with magnetic resonance imaging depended on the amount of muscle and the presence of fat replacement. Atrophy score was defined as none, moderate, and severe. A defect was defined at anal endosonography by a hypoechogenic zone and at magnetic resonance imaging as a discontinuity of the sphincteric ring and/or scar tissue. Differences between three-dimensional anal endosonography and magnetic resonance imaging for the detection of external anal sphincter atrophy and defects were calculated. In addition, we compared external anal sphincter thickness and length measurements in three-dimensional anal endosonography and magnetic resonance imaging. Results Eighteen patients were included (median age, 58 years; range, 27–80; 15 women). Three-dimensional anal endosonography and magnetic resonance imaging did not significantly differ for the detection of external anal sphincter atrophy (P = 0.25) and defects (P = 0.38). Three-dimensional anal endosonography demonstrated atrophy in 16 patients, magnetic resonance imaging detected atrophy in 13 patients. Three-dimensional anal endosonography agreed with magnetic resonance imaging in 15 of 18 patients for the detection of external anal sphincter atrophy. Using the grading system, 8 of the 18 patients scored the same grade. Three-dimensional anal endosonography detected seven external anal sphincter defects and magnetic resonance imaging detected ten. Three-dimensional anal endosonography and magnetic resonance imaging agreed on the detection of external anal sphincter defects in 13 of 18 patients. Comparison between three-dimensional anal endosonography and magnetic resonance imaging for sphincter thickness and length measurements showed no statistically significant concordance and had no correlation with external anal sphincter atrophy. Conclusion This is the first study that shows that three-dimensional anal endosonography can be used for detecting external anal sphincter atrophy. Both endoanal techniques are comparable in detecting atrophy and defects of the external anal sphincter, although there is a substantial difference in grading of external anal sphincter atrophy. Correlation between three-dimensional anal endosonography and magnetic resonance imaging for thickness and length measurements is poor. Inconsistency between the two methods needs to be evaluated further. Supported in part by grant No. 945-01-013 from the Netherlands Organization for Health Research and Development. Presented in part at the United European Gastroenterology Week, Prague, Czech Republic, September 25 to 29, 2004. Reprints are not available.     

Comparison of Quality of Life and Anorectal Function After Artificial Sphincter Implantation

PURPOSE: Quality of life, a major outcome parameter in the treatment of anal incontinence, has not been assessed after artificial sphincter implantation. The purpose of this single-center, prospective, nonrandomized study was to assess quality-of-life differences in patients before and after artificial sphincter implantation and compare them with clinical incontinence scores and anal manometry. METHODS: Quality of life was assessed in 16 patients (14 females; mean age, 43 years) consecutively implanted with an Acticon NeosphincterTM. The Fecal Incontinence Quality of Life Scale, a quality-of-life instrument specifically designed for analysis of anal incontinence, included 27 items grouped in four domains: lifestyle, coping/behavior, depression/self-perception, and embarrassment. Fecal Incontinence Quality of Life Scale score (0 to 1, with 1 indicating better quality of life) was calculated preoperatively and postoperatively and compared with the Fecal Incontinence Score (on a scale of 0 to 120, with 120 being complete incontinence), an evacuation score, and maximal resting pressure. RESULTS: At a mean (standard deviation) of 25 (15) months,12 patients had an activated device, and 11 had satisfactory anorectal function. Significant improvement was observed postoperatively in the four separate quality-of-life domains. Mean (standard deviation) Fecal Incontinence Quality of Life Scale scores increased from 0.44 (0.14) preoperatively to 0.86 (0.18), 0.94 (0.06), and 0.83 (0.16) at 6, 12, and 24 months after implantation, respectively. For the same time periods, the mean (standard deviation) Fecal Incontinence Scores were 105 (14), 24 (26), 32 (35), and 32 (28), respectively (P< 0.05). A linear correlation was found between the improvement over time in quality of life measured by the Fecal Incontinence Quality of Life Scale and clinical evaluation of incontinence measured by the Fecal Incontinence Score (r2 = 0.97; P = 0.03). Mean (standard deviation) maximal resting pressure increased similarly from 42 (24) cm H2O preoperatively to 97 (23) cm H2O at the end of follow-up (P < 0.0001). CONCLUSION: After artificial sphincter implantation, quality of life as assessed by a new Fecal Incontinence Quality of Life Scale instrument was significantly improved. These results correlated with clinical assessment of anal incontinence and were associated with a significant increase in maximal anal resting pressure on manometry.     

Indomethacin and Canine Lower Esophageal Sphincter Pressure

A total of 20 experiments were carried out on 10 dogs to investigate the effect of indomethacin, administered rectally, on the canine lower esophageal sphincter pressure (LESP). Indomethacin increases LESP. Its effect begins 60 minutes after rectal administration and lasts for about 120 minutes. It readies its highest level 90 minutes after administration. Indomethacin has no effect on the canine fundal or esophageal pressure.     

Comparison of Ultrasound-Secretin Test and Sphincter of Oddi Manometry in Patients with Recurrent Acute Pancreatitis

Manometry is considered the gold standard forevaluating sphincter of Oddi dysfunction. It hasrecently been demonstrated that the ultrasound (US)secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddidysfunction yields a substantial percentage ofpathological findings in patients with acute recurrentpancreatitis. The aim of this study was to compare theresults of the US secretin test with sphincter of Oddimanometry findings in a consecutive series of patientswith recurrent acute pancreatitis. Forty-seven patientsadmitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwentultrasonographic measurement of the main pancreatic ductat baseline and for 60 min after maximal stimulationwith secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects,the test results were considered to indicate pathologywhen the duct was still dilated after 20 min. Withinthree to seven days the same patients underwent perendoscopic manometry. Thirty-six patients(17 men, 19 women; mean age 41 ± 15 years) had asuccessful US secretin test and sphincter of Oddimanometry. Eleven patients (30.6%) presented normalmanometric findings. Two of these had an abnormal USsecretin test. Twenty-five patients had abnormalmanometry findings, revealing stenosis in 19 (52.7%) (17with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test).Compared to manometry findings, the US secretin testsensitivity and specificity for sphincter of Oddidysfunction were 88% and 82%, respectively. Inconclusion, most patients with recurrent acute pancreatitishave sphincter of Oddi dysfunction documented by both atthe US secretin test and sphincter of Oddi manometry;results of the US secretin test are reliable compared to sphincter of Oddi manometry, andtherefore the US secretin test may offer a validalternative to the more expensive and invasivemanometric procedure for assessing sphincter of Oddidysfunction in patients with recurrent acutepancreatitis.     

Anorectal Manometry in the Diagnosis of Hirschsprung's Disease–Comparison with Clinical and Radiological Criteria

In 34 consecutive patients in whom the diagnosis of Hirschsprung's disease (HD) was suspected, the reliability of clinical symptoms, radiological parameters, and anorectal manometry was retrospectively and blindly evaluated by three independent investigators. In 19 patients the diagnosis of HD was histologically proved, while in the remaining 15 cases the diagnosis of idiopathic constipation was justified by persistent success of medical treatment at regular follow-up. Anorectal manometry was correctly diagnostic in all the patients who were examined. The recto anal inhibitory reflex, recorded in all the patients with idiopathic constipation was absent in patients suffering from HD. Moreover, other manometric parameters, peculiar to HD were found: a significant lower anal resting pressure and pain threshold, as well as a decreased frequency of spontaneous rhythmic oscillations. The reliability of radiological and clinical data for these diagnoses appeared to he inadequate. Therefore, the diagnosis of HD can be confidently stated only on the basis of manometric investigations.     

肠易激综合征便秘型和功能性便秘结、直肠肛门动力学研究

目的 研究肠易激综合征(IBS)便秘型和功能性便秘患者结肠、直肠动力,直肠感觉功能.方法 对IBS便秘型患者52例和功能性便秘患者48例进行肛门直肠测压检查,并做结肠传输试验.同时选择正常健康人作对照组.结果 IBS便秘型组和功能性便秘组与对照组间直肠静息压、肛管静息压和肛门括约肌最大缩榨压比较均未见明显差异.IBS便秘型组初感阈值及排便阈值(75.00±34.04 ml,117.31±37.60 ml)较正常对照(97.14±20.54 ml,138.57±19.94 ml)明显降低.功能性便秘组排便阈值及最大耐受阈值(187.92 ±68.62 ml,252.5±93.40ml)较正常对照组(138.57±19.94 ml,181.43±18.34 ml)明显升高.IBS便秘型组各项感觉阈值较功能性便秘组均明显降低.功能性便秘组较IBS便秘型组患者结肠传输试验符合出口梗阻的比例高,但无统计学差异.结论 IBS便秘型直肠感觉过敏,功能性便秘直肠感觉迟钝.