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.     

肛门直肠测压的临床研究

肛门直肠测压是通过压力感受器对肛管直肠腔内压力变化进行测定的方法,它可以帮助了解、量化和评估肛管、直肠自制排便的功能,为排便异常等肛管、直肠疾病的研究提供病理生理学依据,并指导临床治疗,是一种安全、简便、无创、客观的检测技术。本文就肛门直肠测压在肛直肠疾病诊断与疗效评估等方面作一综述。     

Endoanal Ultrasound Compared to Anorectal Manometry for the Evaluation of Fecal Incontinence: A Study of the Effect These Tests Have on Clinical Outcome

Tests for evaluating incontinence include endoanal ultrasound (EUS) and anorectal manometry. We hypothesized that EUS would be superior to anorectal manometry in identifying the subset of patients with surgically correctable sphincter defects leading to an improvement in clinical outcome in these patients. The purpose of this study was to compare these 2 techniques to determine which is more predictive of outcome for fecal incontinence. Thirty-five unselected patients with fecal incontinence were prospectively studied with EUS and anorectal manometry to evaluate the internal anal sphincter (IAS) and external anal sphincter (EAS). EUS was performed with Olympus GFUM20 echoendoscope and a hypoechoic defect in the EAS or IAS was considered a positive test. Anorectal manometry was performed with a standard water-perfused catheter system. A peak voluntary squeeze pressure of < 60 mm Hg in women and 120 mm Hg in men was considered a positive test. All patients were administered the Cleveland Clinic Continence Grading Scale at baseline and at follow-up. Improvement in fecal control was defined as a 25% or greater decrease in continence score. EUS versus manometry were compared with subsequent surgical treatment and outcome. P-values were calculated using Fisher's exact test. Patients (n = 32; 31 females) were followed for a mean 25 months (range 13–46). Sixteen patients had improved symptoms (50%). There was no correlation between EUS or anorectal manometry sphincter findings and outcome. Seven of 14 (50%) patients who subsequently underwent surgery versus 9 of 18 (50%) without surgery improved (P = .578). In long-term follow-up, approximately half of patients improve regardless of the results of EUS or anorectal manometry, or whether surgery is performed. Supported in part by a Glaxo-Wellcome Institute for Digestive Health Award.     

Lack of correlation of anorectal manometry with symptoms of chronic childhood constipation and encopresis

Chronic constipation is an extremely common problem in children. Many authors have advocated using anorectal manometric examination during evaluation of chronic childhood constipation and encopresis as a means of developing individualized modes of treatment. PURPOSE: This study was designed to prospectively examine frequency and severity of symptoms of childhood constipation and encopresis and associate these symptoms with anorectal manometric findings. METHODS: Forty-four children with chronic constipation participated in the study. Before performing anorectal manometry, bowel-related symptoms were collected for two consecutive weeks with a computerized voice mail system. Anorectal manometry was performed using a triple lumen catheter attached to a hydraulic manometry infusion system. RESULTS: Frequency of voluntary bowel movements did not correlate with any manometric parameters. Frequency of fecal soiling, age at onset of symptoms, and duration of symptoms were all highly correlated with degree of sphincter spasm during attempted defecation; however, none of these variables correlated with any other manometric parameter. Amount of pain associated with bowel movements correlated with frequency of soiling and was inversely correlated with maximum squeeze pressure but was not correlated with any other manometric parameter. CONCLUSIONS: In children with chronic constipation and encopresis, sphincter spasm demonstrated with anorectal manometry is highly correlated with frequency of fecal soiling, age at onset, and duration of symptoms; however, none of the other commonly measured manometric parameters appear to correlate with symptoms of chronic childhood constipation and encopresis.Supported by National Institutes of Health Grant RO1 HD 28160.     

Assessment of Rectocolonic Morphology and Function in Patients with Chagas Disease in Barcelona (Spain)

The aim of this study was to determine the relationship between colonic symptoms, radiological abnormalities, and anorectal dysfunction in patients with Chagas disease. We performed a cross-sectional study of untreated patients diagnosed with Chagas disease. All patients were evaluated clinically (by a questionnaire for colonic symptoms based on Rome III criteria) and underwent a barium enema and anorectal manometry. A control group of patients with functional constipation and without Chagas disease was included in the study. Overall, 69 patients were included in the study: 42 patients were asymptomatic and 27 patients had abdominal symptoms according to Rome III criteria. Anorectal manometry showed a higher proportion of abnormalities in symptomatic patients than in asymptomatic ones (73% versus 21%, respectively; P < 0.0001). Megarectum was detected in a similar proportion in the different subgroups regardless of the presence of symptoms or abnormalities in anorectal functions. Among non-Chagas disease patients with functional constipation, 90% had an abnormal anorectal manometry study. Patients with Chagas disease present a high proportion of constipation with dyssynergic defecation in anorectal manometry but a low prevalence of impaired rectoanal inhibitory reflex, although these abnormalities may be nonspecific for Chagas disease. The presence of megarectum is a nonspecific finding.     

高分辨肛门直肠测压在先天性巨结肠中的应用进展

高分辨肛门直肠测压技术是在传统肛门直肠测压技术上的进步,是一种非侵入性的、简单的、安全的测定直肠运动及肛管排便功能、较传统的测压技术分辨率更高、分析数据更方便的测压方法。本文旨在对高分辨肛门直肠测压技术的发展及其在先天性巨结肠诊断、鉴别诊断及手术评估方面的应用作一概述。     

A Novel Technique to Identify Patients with Megarectum

Purpose Traditional methods of identifying patients with persistent dilation of the rectum, or megarectum, are associated with inherent methodologic limitations. The purpose of this study was to use a barostat to establish criteria for the diagnosis of megarectum and to assess rectal diameter during isobaric (barostat) and volumetric (barium contrast) distention protocols in constipated patients with megarectum on anorectal manometry. Methods During fluoroscopic screening, rectal diameter was measured at minimum distending pressure of the rectum, achieved using a barostat. It was also measured during evacuation proctography (volumetric distention). Having established a normal range in 25 healthy volunteers, 30 constipated patients with evidence of megarectum on anorectal manometry (elevated maximum tolerable volume on latex balloon distention) were studied. A further 10 constipated patients without evidence of megarectum were studied (normal rectum). Results Megarectum was diagnosed when the rectal diameter was greater than 6.3 cm at minimum distending pressure. Rectal diameter at minimum distending pressure was increased in 20 patients (67 percent) with megarectum on anorectal manometry, but was normal in the remaining 10 patients (33 percent) and all patients with a normal rectum on anorectal manometry. Rectal diameter was increased at evacuation proctography in only 15 patients (50 percent) with evidence of megarectum on anorectal manometry. Conclusions The prevalence of megarectum is overestimated and underestimated when rectal diameter is assessed using anorectal manometry and contrast studies, respectively. Controlled (pressure-based) distention combined with fluoroscopic imaging allowed accurate identification of patients with megarectum on the basis of a rectal diameter greater than 6.3 cm at the minimum distention pressure. Measurement of rectal diameter at minimum distention pressure may be useful in those patients with an elevated maximum tolerable volume on anorectal manometry when surgery is being contemplated. Presented at the meeting of the Association of Coloproctologists of Great Britain and Ireland, Birmingham, United Kingdom, July 2004. Published in abstract form in Colorectal Dis 2004;6(Suppl 1):72. Marc A. Gladman is supported by the Frances and Augustus Newman Foundation Research Fellowship of the Royal College of Surgeons of England.     

Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment

Objective

Anorectal function tests are often performed in patients with faecal incontinence who have failed conservative treatment. This study was aimed to establish the additive value of performing anorectal function tests in these patients in selecting them for surgery.

Patients and methods

Between 2003 and 2009, all referred patients with faecal incontinence were assessed by a questionnaire, anorectal manometry and anal endosonography. Patients with diarrhea, inflammatory bowel disease, pouches or rectal carcinoma were excluded.

Results

In total, 218 patients were evaluated. Of these, 107 (49%) patients had no sphincter defects, 71 (33%) had small defects and 40 (18%) had large defects. Anorectal manometry could not differentiate between patients with and without sphincter defects. Patients with sphincter defects were only found to have a significantly shorter sphincter length and reduced rectal capacity compared to patients without sphincter defects. Forty-three patients (20%) had a normal anal pressures ≥40?mmHg. Seventeen patients (8%) had also a dyssynergic pelvic floor both on clinical examination and anorectal manometry. Fifteen patients (7%) had a reduced rectal capacity between 65 and 100?ml. There was no difference in anal pressures or the presence of sphincter defects in these patients compared to patients with a rectal capacity >150?ml. There was no correlation between anorectal manometry, endosonography and faecal incontinence severity scores.

Conclusion

In patients with faecal incontinence who have failed conservative treatment, only anal endosonography can reveal sphincter defects. Anorectal manometry should be reserved for patients eligible for surgery to exclude those with suspected dyssynergic floor or reduced rectal capacity.     

Ambulatory manometric recording of anorectal activity

PURPOSE: Ambulatory anorectal manometry is usually analyzed by computer analysis only. An in-depth analysis with visual assessment of the recordings combined with computer analysis is presented. METHODS: Recordings of 20 to 24 hours in length were performed on ten healthy subjects. Spontaneous anal canal relaxations were analyzed and related to changes in rectal pressure and any reported rectal sensation. Pressure variations in the anorectum, including the rectal motor complex, were studied. RESULTS: In the awake subject the frequency of anal canal relaxations was 14.5 to 18.7/hour, and the frequency was 4.3/hour while asleep. They can be divided into two different subtypes. The amplitude of the pressure fall was 26 to 29 mmHg, but diminished during sleep to 19 mmHg. The duration of each relaxation was 16 to 19 seconds. Passage of flatus and the sensation of flatus in the rectum occurs 1.5 and 1.2 times per hour, respectively, usually with simultaneous anal canal relaxation. The frequency of rectal motor complexes in the midrectum was 0.4/hour and in the lower rectum was 0.7/hour; the duration was 10.3 and 5.8 minutes, respectively, with no nocturnal variation. The complexes could not be related to anorectal events. CONCLUSIONS: The study provides supplementary knowledge of anorectal physiology, particularly of anal canal relaxation, and proposes a more detailed method for evaluation of data obtained by ambulatory anorectal manometry.     

High-resolution manometry in the evaluation of anorectal disorders: a simultaneous comparison with water-perfused manometry

INTRODUCTION: High-resolution manometry (HRM) combined with novel interpretive software allows for the interpolation of manometric recordings into highly detailed topographical plots of intraluminal pressure events relative to time and location. To date, HRM has been used primarily in the study of esophageal disorders and has been shown to provide greater physiologic resolving power compared with standard manometric techniques. This preliminary feasibility study is the first report evaluating HRM and simultaneously performed water-perfused manometry (WPM) in patients referred for anorectal manometry (ARM). METHODS: Consecutive patients referred for ARM underwent simultaneous WPM and HRM. WPM was performed using a 6-cm sleeve assembly with side-holes spaced at 3-cm intervals. HRM was performed using the ManoScan system (Sierra Scientific Instruments, Los Angeles, CA) consisting of a 36-channel catheter with sensors spaced at 1-cm intervals. Space-time pressure data were displayed in topographic form using ManoView analysis software that is part of the ManoScan system. Measurements of anal sphincter pressure at rest, during voluntary contraction, and during 40-mL rectal balloon distension were compared. RESULTS: A total of 29 patients were studied. Indications for manometry were constipation (19), incontinence (7), and fecal soilage (3). Simultaneously recorded resting, squeeze, and relaxation pressures showed the two methods to be significantly correlated although anal sphincter pressures recorded by HRM tended to be higher than those recorded with WPM. HRM provided greater resolution of the intraluminal pressure environment of the anorectum. CONCLUSIONS: These preliminary observations demonstrate that anorectal HRM highly correlated with WPM measurements and provided greater anatomic detail.     

生物反馈治疗大便失禁的疗效评价

目的　评价生物反馈方法治疗大便失禁患者的疗效。方法　对 2 6例大便失禁患者进行生物反馈治疗 ,治疗前后分别做肛肠测压和肌电图检查 ,评价患者的肛门功能。结果　 2 6例患者肛管最大收缩压、收缩肌电振幅、持续收缩时间、直肠感觉阈值和感觉收缩时间治疗前、后均有显著差异 (P <0 .0 1)。结论　生物反馈治疗大便失禁有效     

Anorectal manometry under anesthesia in the investigation of children with chronic constipation

Anorectal manometry under anesthesia was performed in 18 children, 15 of whom had long histories of constipation and had been on regular regimens of laxatives and enemas with no success. In these 15 patients, Hirschsprung's disease had not been demonstrated by barium enema. Anesthesia was induced and maintained with ketamine (intravenously or intramuscularly) in 16 patients, while halothane was used in the other two. It was found that anesthesia did not affect the events that are usually documented during anorectal manometry in the awake patient. In patients with a history of constipation, after mamometry, a rectal suction biopsy was taken, followed by a therapeutic anal stretch. Results of biopsies confirmed the manometric findings in all patients. Results of the present study demonstrate that ketamine may be used to anesthetize young patients suffering from chronic constipation for the purpose of performing anorectal manometry and taking a rectal suction biopsy (to exclude Hirschsprung's disease), followed by a therapeutic anal stretch. This work, the results of which are presented in this paper, was carried out at the Hospital for Sick Children, Great Ormond Street, London, England.     

Anorectal manometry and defecography in the diagnosis of fecal incontinence.

We carried out anorectal manometry and defecography prospectively in 43 consecutive patients with fecal incontinence. A subgroup of 17 patients with severe incontinence was identified radiologically by a short and incompletely closed anal canal. In these patients, the anal resting pressure was significantly lower than in the rest of the group (34.9 +/- 11.4 mm Hg versus 60.0 +/- 25.7 mm Hg, respectively; p less than 0.01). The anorectal angle did not change in 24 patients during squeezing, indicating a dysfunction of the puborectalis muscle. Manometric data did not differ between this subgroup and patients with a more acute anorectal angle during voluntary sphincter contraction. This indicates that the anal pressures recorded manometrically do not reflect the function of a muscular component that is important in the maintenance of fecal continence. We conclude that anorectal manometry and defecography are complementary diagnostic tools in the investigation of patients with fecal incontinence.     

Anal Sphincter Damage After Vaginal Delivery

PURPOSE: This study was designed to assess the relationship of anal endosonography and manometry to anorectal complaints in the evaluation of females a long time after vaginal delivery complicated by anal sphincter damage. METHODS: Thirty-four patients with anal sphincter damage after delivery, 22 with and 12 without anorectal complaints, and 12 controls without anorectal complaints underwent anal endosonography, manometry, and rectal sensitivity testing. Complaints were assessed by questionnaire, with a median follow-up of 19 years. RESULTS: Median maximum anal resting pressures were significantly lower in patients with anal sphincter damage with complaints (31 mmHg) than in controls (52 mmHg; P < 0.001). Median maximum anal squeeze pressures were significantly lower in patients with (55 mmHg) and without (69 mmHg) complaints than in controls (112 mmHg; P < 0.001 for both). Maximum anal resting pressures were significantly lower in patients with anorectal complaints after anal sphincter damage than in patients without complaints (P = 0.02). Results of anal manometry showed a large overlap between all groups. Rectal sensitivity showed no significant differences between the three groups. Persisting sphincter defects, shown by anal endosonography, were significantly more present in patients with anal sphincter damage after delivery with (86 percent) and without (67 percent) complaints than in controls (8 percent; P < 0.001 and P < 0.01, respectively). No differences in the number of echocardiographically proven sphincter defects were found between patients with or without anorectal complaints after anal sphincter damage CONCLUSIONS: Echographically proven sphincter defects are strongly associated with a history of anal sphincter damage during delivery. Sphincter defects are present in the majority of patients with anorectal complaints. Anal manometry provides little additional therapeutic information when performed after anal endosonography in patients with anorectal complaints after anal sphincter damage during delivery.     

Anismus: a marker of multi-site functional disorders?

PURPOSE: This study was undertaken to assess the clinical significance of anismus in patients who complain of constipation. PATIENTS AND METHODS: Thirty control subjects and 93 consecutive patients complaining of functional constipation took part in the study. Colonic transit time study and anorectal manometry were performed. Questions about depression and urinary and sexual diseases were added to a questionnaire based on the Rome II criteria, and visual analog scales about four items (constipation, diarrhoea, abdominal bloating and abdominal pain). RESULTS: Constipated patients have lower threshold sensation volume, lower constant sensation volume, and lower maximum tolerable volume than controls. Thirty-seven patients (40%) were found to have anismus, based on anorectal manometry. No significant difference was found between constipated patients with anismus and constipated patients without anismus, using anorectal manometry. Constipated patients had longer colorectal transit time than controls, but neither total nor segmental colonic transit time was correlated with the presence or absence of anismus. In patients with anismus, a higher frequency of oesophageal symptoms, dysmotility-like dyspepsia, aerophagia, functional bowel disorders, functional abdominal pain, soiling, and dyschezia was found. In addition, a higher frequency of urinary complaints, sexual complaints, and depression was found. Anismus was associated with increased awareness of constipation, abdominal bloating, and abdominal pain, but not with diarrhoea.     

How accurate is clinical examination in diagnosing and quantifying pelvirectal disorders? A prospective study in a group of 50 patients complaining of defecatory difficulties

We prospectively evaluated 50 patients (38 females and 12 males; mean age, 44.7±15 years) who complained of defecatory difficulties to determine the accuracy of the clinical examination in diagnosing and quantifying pelvirectal abnormalities. Each parameter was then compared with the features of anorectal manometry and evacuation proctography performed by two independent observers. Global agreement between clinical diagnosis and the reference method (radiology for rectoceles, rectal intussusceptions, and abnormal perineal descent; manometry for anismus) was observed in 80 percent of cases. In rectoceles, anismus, and rectal intussusceptions especially, excellent negative predictive values were obtained (96, 96, and 80 percent, respectively). Clinical examination always diagnosed high-grade intussusceptions. Nevertheless, abnormal perineal descent was poorly evaluated in 20 patients. When compared with anal manometry, digital assessment was able to quantify resting and squeeze pressures and length of the anal canal with excellent correlation and good global agreement as well as predicting a short or hypotonic anal canal. Clinical assessment is usually sufficient and accurate in most pelvirectal disorders encountered in patients complaining of defecatory difficulties. Both anorectal manometry and evacuation proctography retain a definite but limited place in investigating pelvirectal disorders.Presented at the Digestive Disease Week, American Gastroenterological Association, San Francisco, California, May 13, 1992.     

Evaluation of two-dimensional intraoperative neuromonitoring for predicting urinary and anorectal function after rectal cancer surgery

Purpose

The aim of this study was to compare the results of two-dimensional intraoperative neuromonitoring (IONM) with the postoperative urinary and anorectal function of rectal cancer patients.

Methods

A consecutive series of 35 patients undergoing low anterior resection were investigated prospectively. IONM was performed with electric stimulations of the pelvic splanchnic nerves under simultaneous manometry of the bladder and electromyography (EMG) of the internal anal sphincter (IAS). Urinary and anorectal function were evaluated preoperatively and at follow-up by standardized questionnaires, digital rectal examination scoring system, and long-term catheterization rate.

Results

The rate of postoperative newly developed bladder dysfunction was 17 %. IONM with bladder manometry had a sensitivity of 100 %, specificity of 96 %, positive predictive value of 83 %, negative predictive value of 100 %, and overall accuracy of 97 %, respectively. The proportion of patients with severely impaired anorectal function at follow-up was 8 %. The sensitivity, specificity, and positive and negative predictive values for IONM with EMG of the IAS were, respectively, 100, 96, 67, and 100 % with an accuracy of 96 %. The degree of agreement for IONM with EMG of the IAS was good for anorectal function (к?=?0.780) and poor for urinary function (к?=?0.119). IONM with bladder manometry yielded a very good degree of agreement for urinary function (к?=?0.891) and a fair agreement for anorectal function (к?=?0.336).

Conclusions

The two-dimensional IONM method is suitable for verification of bladder and IAS innervation. Accurate prediction of urinary and anorectal function necessitates both bladder manometry and EMG of the IAS.     

Anorectal manometry

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.     

Clinical value of anorectal manometry index in neurogenic fecal incontinence

PURPOSE: The present communication is an endeavor to assess the value of a simple motility index to separate patients with neurogenic or idiopathic fecal incontinence from those patients with the secondary form of the disease. METHODS: Study population consisted of 23 patients with idiopathic fecal incontinence and 13 patients with fecal incontinence secondary to surgical or obstetric trauma. They all had a standard anorectal manometric study after a 12-hour fast. A motility index was then prepared taking into consideration the peak sphincter pressure values, contractility endurance, and rectal sensory threshold. RESULTS: Despite differences in the mean peak squeeze pressure and sensory threshold between the two groups, there were significant overlaps for all parameters of standard anorectal manometry in both groups. However, patients with idiopathic incontinence had an index of smaller than 28, and the group with the secondary form of incontinence had indexes higher than 30. CONCLUSIONS: 1) None of the four parameters of a conventional anorectal manometry can accurately separate patients with neurogenic incontinence from those with secondary forms of the disorder. 2) The anorectal motility index presented here can accurately separate the two groups. 3) This index is superior to the standard anorectal manometry in evaluating patients with fecal incontinence.     

Iatrogenic colorectal perforation induced by anorectal manometry： Report of two cases after restorative proctectomy for distal rectal cancer

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed alter restorative proctectomy for distal rectal cancer.