Gillian Prott

Gastrointestinal Symptoms in Spinal Cord Injury: Relationships With Level of Injury and Psychologic Factors

INTRODUCTIONPrevious surveys of gastrointestinal symptoms after spinal cord injury have not used validated questionnaires and have not focused on the full spectrum of such symptoms and their relationship to factors, such as level of spinal cord injury and psychologic dysfunction. This study was designed to detail the spectrum and prevalence of gastrointestinal symptoms in spinal cord injury and to determine clinical and psychologic factors associated with such symptoms.METHODSEstablished spinal cord injury patients (>12 months) randomly selected from a spinal cord injury database completed the following three questionnaires: 1) Rome II Integrative Questionnaire, 2) Hospital Anxiety and Depression Scale, and 3) Burwood Bowel Dysfunction after spinal cord injury.RESULTSA total of 110 patients participated. The prevalence of abdominal bloating and constipation were 22 and 46 percent, respectively. Bloating was associated with cervical (odds ratio = 9.5) and lumbar (odds ratio = 12.1) level but not with thoracic level of injury. Constipation was associated with a higher level of injury (cervical odds ratio = 5.6 vs. lumbar) but not with psychologic factors. In contrast, abdominal pain (33 percent) and fecal incontinence (41 percent) were associated with higher levels of anxiety (odds ratio = 6.8, and odds ratio = 2.4) but not with the level of injury. CONCLUSIONSThere is a high prevalence and wide spectrum of gastrointestinal symptoms in spinal cord injury. Abdominal bloating and constipation are primarily related to specific spinal cord levels of injury, whereas abdominal pain and fecal incontinence are primarily associated with higher levels of anxiety. Based on our findings, further physiologic and psychologic research studies in spinal cord injury patients should lead to more rational management strategies for the common gastrointestinal symptoms in spinal cord injury.

Evidence for Pelvic Floor Dyssynergia in Patients With Irritable Bowel Syndrome

PURPOSE: Although functional constipation is known to often manifest concomitant features of pelvic floor dyssynergia, the nature of pelvic floor symptoms and anorectal dysfunction in non-diarrhea predominant irritable bowel syndrome is less clear. This study aims to compare anorectal sensorimotor function and symptoms of patients who have non-diarrhea predominant irritable bowel syndrome with those who have functional constipation. METHODS: We studied 50 consecutive female patients referred with constipation and 2 or more symptoms of pelvic floor dyssynergia, who also satisfied Rome II criteria for either non-diarrhea predominant irritable bowel syndrome (n = 25; mean age, 47 ± 3 y) or functional constipation (n = 25; 49 ± 3 y). Assessments included the Rome II Integrative Questionnaire, a validated constipation questionnaire, Hospital Anxiety and Depression scale, visual analog scores for satisfaction with bowel habit and for impact on quality of life, and a comprehensive anorectal physiology study. RESULTS: Both groups displayed physiological evidence of pelvic floor dyssynergia; but patients with non-diarrhea predominant irritable bowel syndrome exhibited a higher prevalence of abnormal balloon expulsion (P < .01) and less paradoxical anal contraction with strain (P = .045) than patients with functional constipation. These patients with irritable bowel syndrome also reported more straining to defecate (P = .04), a higher total constipation score (P = .02), lower stool frequency (P = .02), a trend toward harder stools (P = .06), and less satisfaction with bowel habit (P = .03) than patients with functional constipation. CONCLUSION: Patients with non-diarrhea predominant irritable bowel syndrome with symptoms of pelvic floor dyssynergia exhibit overall pelvic floor dyssynergia physiology similar to that of patients with functional constipation. Certain features, however, such as abnormal balloon expulsion, may be more prominent in the patients with irritable bowel syndrome. Therapeutic modalities, such as biofeedback, that are effective in patients with functional constipation with pelvic floor dyssynergia should therefore be considered in selected patients with irritable bowel syndrome with pelvic floor dyssynergia.

Predictors of outcome of anorectal biofeedback therapy in patients with constipation.

Aliment Pharmacol Ther 2011; 33: 1245–1251

Prolonged Balloon Expulsion Is Predictive of Abdominal Distension in Bloating

OBJECTIVES:Abdominal bloating and distension are common in patients with constipation. The precise mechanism of abdominal distension remains uncertain. We hypothesized that constipated patients with bloating plus distension exhibit a greater degree of anorectal dysfunction, potentially affecting gas evacuation, than those without distension. Therefore, our aim was to evaluate anorectal function and other clinical features in patients with constipation who exhibit bloating with and without distension.METHODS:In all, 88 female patients with abdominal bloating and either non-diarrhea irritable bowel syndrome (IBS) or functional constipation were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire, and all patients underwent comprehensive clinical assessment and anorectal function studies.RESULTS:Patients were divided into two groups: abdominal bloating with distension (D; n=53) and abdominal bloating without distension (ND; n=35). D featured a prolonged balloon expulsion time (P=0.005), a higher resting anal sphincter pressure (P=0.002), and a higher maximum anal sphincter squeeze pressure (P=0.015) than ND. They also experienced more bloating (P<0.001), more abdominal pain (P=0.004), harder stools (P=0.01), and more incomplete emptying (P=0.005). In logistic regression modeling, prolonged balloon expulsion time was a significant predictor of abdominal distension (P=0.018).CONCLUSIONS:This is the first study to show that prolonged balloon expulsion time predicts abdominal distension in patients with bloating and constipation. Hence, ineffective evacuation of gas and stool associated with prolonged balloon expulsion may be an important mechanism underlying abdominal distension.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

Background Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non‐diarrhea predominant IBS (non‐D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

What is the optimum methodology for the clinical measurement of resting anal sphincter pressure

Abstract  There are conflicting recommendations from consensus groups with regard to the assessment of resting anal sphincter pressure. Our aims were to evaluate and compare the performance of three recognized techniques for the clinical measurement of resting anal sphincter pressure.

The importance of a high rectal pressure on strain in constipated patients: implications for biofeedback therapy

A subset of patients with chronic constipation display a relatively high manometric rectal pressure on strain. We hypothesized that these patients represent a unique phenotype of functional defecatory disorder (FDD) and would benefit from undergoing anorectal biofeedback (BF).

Altered temporal characteristics of the rectoanal inhibitory reflex in patients with abdominal distension

The rectoanal inhibitory reflex (RAIR) is important in gas and stool evacuation. We examined RAIR features in patients with chronic constipation who exhibited bloating with and without abdominal distension, to determine whether alterations in RAIR may be a factor in the pathogenesis of abdominal distension. Seventy-five female patients with chronic constipation with or without abdominal distension were included in the study. The presence or absence of abdominal distension was assessed according to the Rome II questionnaire. All patients underwent both RAIR and rectal sensitivity testing, and specific RAIR parameters were analyzed. Patients were divided into two groups: abdominal bloating with distension (D, n = 55) and abdominal bloating without distension (ND, n = 20). D had a longer time to the onset of anal sphincter inhibition (latency of inhibition) (P = 0.03) compared with ND. In logistic regression analysis, a combination of age, latency of inhibition and the time measured from onset of inhibition to the point of maximum inhibition predicted abdominal distension (P = 0.002). There were no differences between groups for the time from point of maximum inhibition to recovery and for the percentage of internal anal sphincter relaxation. This is the first study to examine the role of RAIR in patients with abdominal distension. Female patients with constipation and abdominal distension exhibited differences in the temporal characteristics of, but not in the degree of, anal sphincter relaxation compared with patients without distension. Since this study was uncontrolled, further studies are necessary to determine the contribution of altered anorectal reflexes to abdominal distension.

Tu2019 Straining Rectal Pressure in Constipation: Could Excessively High Pressure Be Important Too?

mmHg; p=0.4) and nominal increases in compliance with HPD (0.6 ±0.7 ml/mmHg; p= 0.17). Between groups, these differences in barostat acclimation were significant for HPD (p=0.03) but not LPD (p =0.28). Rectal compliance did not correlate with subjective discomfort ratings of LPD or HPD in either group; however, lower mean rectal compliance with HPDs trended toward predicting more severe IBS symptoms (p=0.07) and higher symptomatic days (p=0.08). CONCLUSIONS: IBS patients have decreased dynamic rectal compliance with both low pressure and high pressure rectal distensions. While healthy individuals acclimate to a series of distensions by increasing rectal compliance, IBS patients experience minimal increases, or even losses in rectal compliance with subsequent distensions. These observations appear to relate to IBS symptom severity and frequency, and advance our understanding of the relevance of rectal compliance to IBS pathophysiology.

T1348 Predictors of Outcome of Biofeedback Therapy in Patients With Constipation

Background: Ano-rectal biofeedback therapy (BFT) is a safe and effective treatment in patients with constipation. Given the high prevalence of constipation, there is a need to prioritise patients. Therefore, the aim of this study was to further explore factors which predict success or failure of BFT. Several previous studies have examined this in part, with the only consistent finding being that the patients willingness to participate predicts success of therapy. Methods: 102 consecutive patients (mean age 48±2 yrs, 88 females) with constipation referred for anorectal BFT were evaluated. All patients completed the Rome questionnaire, a validated constipation questionnaire, and 10 cm visual analogue scales for willingness to participate in BFT, satisfaction with bowel habit and impact on quality of life. All patients underwent comprehensive anorectal manometry and balloon expulsion test. Patients were enrolled in a 6 weekly-visit BFT program. Independent predictors were identified using a bootstrapped backward elimination procedure based on linear regression with change in bowel satisfaction as the outcome. Only predictors selected in ≥50% of bootstrap samples were considered. Results: 96 patients completed the full course of BFT. Stool consistency (p=0.009), willingness to participate (p<0.001), balloon expulsion time (p=0.02) and resting anal sphincter pressure (p=0.04) were positively correlated with an improvement in bowel satisfaction scores. On the other hand, more laxative use (p=0.049) and a greater satisfaction with bowel habit at baseline (p<0.001) correlated with no improvement in bowel satisfaction scores. The outcome of BFTwas not influenced by age, duration of symptoms or compliance with therapy. Multiple linear regression indicated that stool consistency (p=0.02) and willingness to participate (p= 0.003) independently predicted an improvement in bowel satisfaction scores after BFT, and total constipation score (p=0.006) and baseline satisfaction with bowel habit (p<0.001) independently predicted worsening in bowel satisfaction scores after BFT. The model including these 4 variables explained 52% of the variance in treatment outcome. Conclusion: In agreement with previous studies, success of BFT is predicted by a greater willingness to participate. New findings are that (1) harder stools predict a successful outcome, while more prolonged balloon expulsion and anal sphincter hypertonia at baseline are associated with greater bowel satisfaction after BFT; and (2) the presence of more severe constipation predicts failure of BFT. This information should be taken into account when prioritising patients for BFT.