Amanda Raeburn

Bowel biofeedback treatment in patients with multiple sclerosis and bowel symptoms.

BACKGROUND: Bowel symptoms are common in patients with multiple sclerosis, but current treatment is empirical. OBJECTIVE: This study aimed to identify effect of biofeedback on bowel symptoms, mood, and anorectal physiology in patients with multiple sclerosis. DESIGN: This was a prospective observational study: the amount of change between pre- and posttreatment values of outcome measures was compared and analyzed. Responders were considered to be patients who demonstrated an improvement greater than or equal to the 25th percentile of the change in bowel score. Comparison between responders and nonresponders was performed. SETTINGS: This investigation was conducted at a neurogastroenterology clinic, tertiary referrals center. PATIENTS: Thirty-nine patients with multiple sclerosis and constipation and/or fecal incontinence were included in the study. INTERVENTION: Patients were given bowel biofeedback therapy. MAIN OUTCOME MEASURES: The primary outcome measures were the Wexner Constipation and Wexner Incontinence scores. The secondary outcome measures were hospital anxiety and depression scores and anorectal physiology parameters. RESULTS: Data are reported as median and interquartile ranges. After biofeedback there was significant improvement in Wexner Constipation (12 (5–19) pretreatment vs 8 (4–14) posttreatment, P = .001), Wexner Incontinence (12 (3–15) pretreatment vs 4 (2–10) posttreatment, P < .001) and hospital depression scores (7 (3–11) pretreatment vs 5 (3–10) posttreatment, P = .015). The 5-second endurance squeeze pressure was also improved (21 (11–54) mmHg pretreatment vs 43 (26–59) mmHg posttreatment, P = .001). Posttreatment change of Wexner Constipation was −2(−5/0), and of Wexner Incontinence was −3(−9/0) (“−” indicates improvement). Therefore, those patients who had a reduction of at least 5 points in the Wexner Constipation score and/or of at least 9 points in the Wexner Incontinence score were considered responders (18 patients, 46%). They showed a greater improvement of only 5-second endurance squeeze pressure (23.5 (7.5/32.75) mmHg responders vs 4 (−6/20) mmHg nonresponders, P = .008); no difference was observed in the comparison of baseline variables with nonresponders. Significant negative relationship existed between the change in the Wexner Constipation score (−2 (−5/0)) and the pretreatment Wexner Constipation score (12 (5/19), &bgr; = −0.463, P < .001), and the change in the Wexner Incontinence score (−3 (−9/0)) with the pretreatment Wexner Incontinence score (12 (3/15), &bgr; = −0.590, P < .001). So, the higher the initial bowel symptom score, the greater the improvement. LIMITATIONS: This study was limited by the lack of a control group. CONCLUSIONS: Biofeedback improves bowel symptoms, depression, and 5-second endurance squeeze pressure in patients with multiple sclerosis.

Gut dysfunction in patients with multiple sclerosis and the role of spinal cord involvement in the disease

Objectives Bowel and bladder symptoms are highly prevalent in patients with multiple sclerosis (MS). Bladder dysfunction (affecting 75% of these patients) is caused by disease in the spinal cord, whilst the pathophysiology of bowel dysfunction is unknown. Pathways regulating both the organs lie in close proximity to the spinal cord, and coexistence of their dysfunction might be the result of a common pathophysiology. If so, the prevalence of bladder symptoms should be greater in patients with MS and bowel symptoms. This hypothesis is tested in the study. We also evaluated how patient-reported symptoms quantify bowel dysfunction. Patients and methods The Neurogenic Bowel Dysfunction questionnaire and the presence of bladder symptoms were recorded in 71 patients with MS and bowel symptoms. Disability, a surrogate clinical measure of spinal cord disease, was assessed using the Expanded Disability Status Scale. Bowel and bladder symptoms were quantified by patient-reported frequency, expressed in time percentage (0, 25, 50, 75 or 100% of the time the symptom was perceived), and patient-reported severity on a visual analogue scale between 0 and 100. Results The prevalence of bladder symptoms was 85%, which is higher than that expected in an unselected population of patients with MS. Neurogenic Bowel Dysfunction score was significantly correlated with both patient-reported frequency (r=0.860, P<0.0001) and severity of bowel symptoms (r=0.659, P=<0.0001), as well as with the Expanded Disability Status Scale (r=0.526, P<0.0001). Conclusion Our findings suggest that gut dysfunction in patients with MS is secondary to spinal cord disease. Patient-reported bowel symptoms quantify bowel dysfunction well.

Transanal irrigation for bowel symptoms in patients with multiple sclerosis.

BACKGROUND: Constipation and fecal incontinence affect 68% of patients with multiple sclerosis, but management is empirical. Transanal irrigation has been used successfully in patients with neurogenic bowel dysfunction. OBJECTIVE: The aim of this study was to evaluate the effect of transanal irrigation on the bowel symptoms and general health status in these patients and the characteristics of those that had successful treatment and to obtain data for power calculations necessary for future randomized controlled studies. DESIGN: This was a prospective observational study in which pre- and posttreatment questionnaires (bowel symptoms and health status) were compared. Patients for whom treatment resulted in at least 50% improvement in bowel symptoms were considered responders. Baseline variables including anorectal physiology tests and rectal compliance were compared between responders and nonresponders. SETTINGS: This study was conducted at a specialist neurogastroenterology clinic, tertiary referral center. PATIENTS: Included were 30 patients who had multiple sclerosis and constipation, fecal incontinence, or both. INTERVENTION: Transanal irrigation was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were the Wexner Constipation and Wexner Incontinence scores. The secondary outcomes was the SF-36 health survey. All scores were recorded before and after 6 weeks of treatment. RESULTS: At 6 weeks posttreatment, the Wexner Constipation score significantly improved (12 (8.75/16) pretreatment vs 8 (4/12.5) posttreatment, p = 0.001), as well as the Wexner Incontinence score (12 (4.75/16) pretreatment vs 4 (2/8) posttreatment, p < 0.001). The SF-36 score did not improve significantly(51.3 ± 7.8 pretreatment vs 50.4 ± 7.8 posttreatment, p = 0.051). Sixteen patients were responders and had higher baseline Wexner Incontinence scores (14 (11/20) responders vs 9 (4/15) nonresponders, p = 0.038) and SF-36 (53.9 ± 6.3 responders vs 47.9 ± 7.8 nonresponders, p = 0.027), as well as greater maximum tolerated volume to rectal balloon distension (310 (220/320) mL responders vs 168 (108/305) mL nonresponders, p = 0.017) and rectal compliance (15.2 (14.5/17.2) mL/mmHg responders vs 9.2 (7.2/15.3) mL/mmHg nonresponders, p = 0.019). LIMITATIONS: This study was limited by its small sample size and the lack of control group with alternative treatment. CONCLUSIONS: Transanal irrigation is effective to treat bowel symptoms in patients with multiple sclerosis. Responders (53%) had higher baseline incontinence symptoms and better perception of their health, as well as a more capacious and compliant rectum.

Effectiveness of percutaneous tibial nerve stimulation in managing refractory constipation

Chronic constipation can be aetiopathogenically classified into slow transit constipation (STC), rectal evacuation difficulty (RED) or a combination (BOTH). Although the efficacy of percutaneous tibial nerve stimulation (PTNS) in faecal incontinence has been well proved, a current literature search identifies only one study which assessed its effect on constipation. We aimed to evaluate the effectiveness of PTNS in patients with different causes of constipation.

Autonomic rectal dysfunction in patients with multiple sclerosis and bowel symptoms is secondary to spinal cord disease.

BACKGROUND: Most patients with multiple sclerosis report bowel symptoms, but the underlying pathophysiology is unclear. OBJECTIVE: We hypothesize that rectal dysfunction in multiple sclerosis is secondary to involvement of the spinal cord by the disease and that this can be measured by assessing rectal compliance. DESIGN: This was a case-control study. SETTINGS: The study took place in a neurogastroenterology clinic and tertiary referral center. PATIENTS: Forty-five patients with multiple sclerosis, 19 with a spinal cord injury above T5, and 25 normal control subjects were included in this study. Patients with multiple sclerosis were subdivided into 2 groups according to the Expanded Disability Status Scale, below 5 (multiple sclerosis minor disability, n = 25) or above 5 (multiple sclerosis major disability, n = 20), as a reflection of spinal cord involvement. MAIN OUTCOME MEASURES: Rectal compliance, Wexner constipation, and Wexner incontinence scores were measured. RESULTS: Data are presented as mean and SD. Expanded Disability Status Scale correlated with rectal compliance but not with Wexner constipation or Wexner incontinence scores. Post hoc analysis showed no significant difference in Wexner constipation and Wexner incontinence between the 2 multiple sclerosis groups. LIMITATIONS: Limitations to this study include the lack of an asymptomatic group with multiple sclerosis and the small sample size to evaluate bowel symptoms. CONCLUSIONS: Rectal compliance correlates with disability, and observed alterations in the rectal properties are secondary to spinal cord involvement. Our findings suggest that, in patients with neurologic impairment, rectal compliance is a surrogate of reflex activity of the spinal cord regulating rectal function and both a potential predictor of outcome and target for treatment. Multiple sclerosis patient subgroups had similar symptom burden, arguing that bowel dysfunction is multifactorial.

Mo2015 Preliminary Significant Findings From a Randomised Control Trial of Posterior Tibial Nerve Stimulation in Systemic Sclerosis Associated Faecal Incontinence

Introduction The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly, with none of these disadvantages. This is the preliminary data on a randomised placebo controlled trial of PTNS versus sham PTNS to determine if nerve modulation is an effective treatment in SSc associated FI. Methods We commenced a prospective randomised single-blind study of SSc patients with FI in February 2013 from a specialist Scleroderma unit. Baseline symptom scoring (bowel diary, Wexner), manometry and endoanal ultrasound were completed prior to randomization to PTNS or sham. PTNS was administered conventionally, by insertion of an acupuncture needle according to anatomical landmarks, connected to an electrical stimulator. Sham PTNS was administered in identical fashion but the PTNS surface electrode was not connected and instead separate TENS surface electrodes were connected to a TENS unit. Each patient underwent blinded intervention for 30 min periods, once a week for 12 weeks. The primary endpoints were the percentage reduction in faecal incontinence episodes and change in Wexner incontinence scores. Results A total of 13 SSc patients (11 f), mean age 61 (36–72) completed the trial by October 2013. Of these 6 (5 f) underwent PTNS and 7 (6 f) patients underwent sham stimulation. All PTNS patients showed a reduction (5–100%) in the number of FI episodes in comparison to 0 sham patients at 12 weeks (p Conclusion This pilot data is demonstrating significant effects of PTNS in Scleroderma-associated FI. We present this significant initial data but anticipate having at least 25 completed patients by May 2014. Disclosure of Interest None Declared.

S1238 Medium-Term Outcome with Trans-Anal Irrigation for Neurogenic Bowel Dysfunction Is Related to Rectal Compliance

Introduction: Bowel dysfunction is highly prevalent in patients with multiple sclerosis (MS) with a major impact on quality of life, regardless of disability status or disease duration. It is often associated with the failing of the other pelvic functions and its origin is unclear, whilst it is established that spinal cord involvement by MS is central to bladder dysreflexia. A similar mechanism could underlie constipation and incontinence and this study analysed their correlation with uro-genital dysfunction. Further clarification of the causes of bowel dysfunction in MS may contribute to improved treatment. Materials and methods: Data from 71 patients with MS (53 female, mean age 44, mean disease duration 78 months) attending a neuro-gastroenterology clinic were studied. 25 patients had relapsing remitting MS, 7 had primary progressive and 39 had secondary progressive disease. Severity of bowel, bladder and sexual dysfunction was quantified by a visual analogue scale and frequency by self-report of the proportion of time symptoms of dysfunction are present. Patients also completed the validated Neurogenic Bowel Dysfunction (NBD) questionnaire and Expanded Disability Status Scale (EDSS). Results: Whereas bladder dysfunction was related to disease duration (p=0.012), no such association existed for bowel dysfunction. Disease duration, gender and type of MS did not correlate with self-report of bowel dysfunction or NBD score. EDSS score was ≥ 5 (most severe) in 9 patients, ≤ 1 (mild) in 18 and 44 between 1.5 and 4.5. EDSS is significantly inversely correlated to NBD score (p=0.03) and self-reported bowel dysfunction (p<0.003). There was no relationship between EDSS and bladder dysfunction (p=0.25). NBD score correlated better with self-reported frequency of bowel dysfunction (p<0.03) than self-reported severity (p=0.07). Conclusions: Bowel dysfunction is not related to MS type or disease duration, in contrast to bladder dysfunction. In clinical assessment, the NBD questionnaire is complementary to, and not a replacement of, patient self-report. There is a relationship between disability status and bowel dysfunction but not bladder dysfunction; this suggests that bowel dysfunction may be related to disability factors as much as a direct neural mechanism.

OC-065 Motility and Oesophageal Clearance in Barrett’s Oesophagus

Introduction It is not clear if Barrett’s is a consequence of excessive reflux only or reduced clearance of refluxed materials. This study compares oesophageal reflux over 24 hours and High Resolution Manometry (HRM) response to solids in Barrett’s with non-Barrett’s reflux (NBR). Methods Reports for 19 consecutive patients (M58:F14) with ≥2 cm Barrett’s during 2015 were compared with 25 patients with NBR (M10:F16) and 13 patient controls with normal physiology/endoscopy (M3:F10). All had at least one typical symptom of heartburn, regurgitation or chest pain. All had HRM with the intention of completing 10x5cc water and 5x1cc bread. Contractile vigour was measured with the Distal Contractile Integral (amplitude x length x contraction time); DCI > 450 mmHg.cm.s and breaks in peristalsis of <5 cm were considered the lower limit of normal contraction as per Chicago Classification 3.0. Standard reflux and impedance parameters were assessed. 11/19 Barrett’s were on while all NBR were off treatment. Results Lower oesophageal sphincter pressure was lower in Barrett’s (8 vs. 14 mmHg; p = 0.009). Compared to NBR, patients with Barrett’s (2–10 cm) had significantly reduced DCI for both5 ml water (318 vs. 650 mmHg.cm.s; p = 0.007) and solid (1096 vs. 2002 mmHg.cm.s; p = 0.009). On the other hand, the likelihood of measuring a DCI of >450 was significantly reduced in Barrett’s only with solids (69% vs. 100%; p < 0.001) not water (32% vs. 54%; p = 0.224). Peristaltic effectiveness based on HRM was also reduced only for solids (44% vs. 65%; p = 0.029). All reflux parameters were similar between the two groups: total (p = 0.116), upright (p = 0.233) and supine reflux (p = 0.110), symptom index (p = 0.16), symptom association probability (p = 0.106) and total number of reflux events (p = 0.063). On the other hand, bolus clearance time (BCT) was significantly prolonged for Barrett’s (13 vs. 10 s; p = 0.009) solely due to prolonged supine BCT (14 vs. 10 s; p < 0.003). Bolus exposure time (BET) was significantly prolonged for Barrett’s (p = 0.011) due to both daytime (4.49% vs. 1.73%; p = 0.015) and nocturnal BET (0.75% vs. 0.24%; p = 0.002). Comparing those with prior endoscopic Barrett’s therapy (n = 6) with treatment naïve (n = 13), there was no difference in any motility or pH monitoring parameter apart from BET which was greater in those who received therapy (5.87% vs. 1.99%; p = 0.046). Conclusion Solids were superior to water swallows in demonstrating ineffective contractility in Barrett’s. This was associated with reduced nocturnal oesophageal clearance and increased exposure to refluxate during the day/night. These findings contribute to the theory of impaired contractility and reduced clearance despite acid-reducing medication in Barrett’s. Disclosure of Interest R. Sweis Conflict with: Organised Symposium funded by Given img/Diagmed, A. Raeburn: None Declared, E. Athanasakos: None Declared, N. Zarate-Lopez: None Declared, L. Lovat: None Declared, R. Haidry: None Declared, M. Banks: None Declared, A. Emmanuel: None Declared

The effects of antimuscarinic agents on rectal compliance in patients with supraconal spinal cord injury

Introduction Constipation affects up to 80% of spinal cord injury (SCI) patients and is cause of significant reduction of quality of life. Rectal compliance is determined by the rectal wall properties and by the supra-spinal modulation of the thoracic sympathetic and para-sympathetic lumbosacral efferents; it is increased in SCI patients with injury level above T5. Often this patient group has associated bladder dysfunction, and requires antimuscarinic agents (Tolterodine or Solifenacin), which are known to cause constipation. The authors aimed to assess the physiological effect of antimuscarinic agents on the anorectal function of patients with SCI above T5. Methods The authors prospectively collected data from 17 SCI patients (11 males, mean age 41, mean disease duration 13 months) attending a neuro-gastroenterology clinic at a tertiary centre. All had an established SCI above T5, and 11 had a complete injury. Anal manometry, assessment of rectoanal inhibitory reflex (RAIR) and rectal compliance were measured at baseline, and after antimuscarinic treatment was started (mean follow-up 12 weeks). Results Anal sphincter function parameters of squeeze and cough pressure were unchanged after antimuscarinic treatment (pre vs post 123±40 vs 122±36 p=0.827; 88±24 vs 87±26 p=0.859 respectively). However, resting anal pressure and rectal compliance were significantly raised after antimuscarinic treatment (82±18 vs 88±16 p=0.058; 19.2±5.0 vs 24.2±4.1 p<0.001). When analysing the three components of the RAIR, the percent amplitude of maximal sphincter relaxation was decreased (pre vs post 48%±8% vs 37%±6%, p=0.026) and excitation latency was increased (1.2±0.6 vs 1.5±0.7 s, p<0.001). Conclusion In SCI patients the use of antimuscarinic agents causes increased rectal compliance, reduced reflex relaxation of the anal sphincter and delayed latency of this reflex. These physiological changes all predispose towards constipation. In the absence of cortical modulation, in patients with a SCI level above T-5, sympathetic activity is effectively enhanced. The effect of these drugs underlines the importance of tonic parasympathetic input to rectal compliance and anorectal reflex function.

Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study: PTNS FOR FECAL INCONTINENCE IN MULTIPLE SCLEROSIS

Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non‐neurological settings.