Giuseppe Chiarioni

Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation

Idiopathic chronic constipation is a frequent and disabling symptom, but its pathophysiological grounds are still poorly understood. In particular, there is little knowledge about the relationships between distal (anorectal area) and proximal (colonic area) motor abnormalities in this condition, especially concerning high-amplitude propagated colonic activity. For this purpose, we studied 25 patients complaining of severe idiopathic constipation and categorized them as normal- or slow-transit constipation according to colonic transit time. Twenty-five age-matched controls were also studied. Investigations included standard anorectal motility testing and prolonged (24-hr) colonic motility studies. Analysis of results showed that both groups of constipated patients displayed significantly different (P<0.05) minimum relaxation volumes of the internal anal sphincter, defecatory sensation thresholds, and maximum rectal tolerable volumes with respect to controls. Patients with normal-transit constipation also showed lower internal anal sphincter pressure with respect to slow-transit constipation and controls (P<0.001 andP<0.02, respectively). The daily number of high-amplitude propagated contractions (mass movements) as well as their amplitude and duration, was significantly reduced in both subgroups of constipated patients (P<0.02 vs controls). We conclude that (1) in normal-transit constipation, motor abnormalities are not limited to the anorectal area; (2) patients with slow-transit constipation probably have a severe neuropathic rectal defect; (3) prolonged colonic motility studies may highlight further the functional abnormalities in constipated subjects; and (4) an approach taking into account proximal and distal colon motor abnormalities might be useful to understand pathophysiological grounds of chronic constipation and lead to better therapeutic approaches.

Manometric investigation of anorectal function in early and late stage Parkinson's disease

Abnormal gastrointestinal function is relatively frequent in Parkinsons disease, and constipation is a disturbing symptom in many patients. However, it remains to be established whether anorectal abnormalities are characteristic of the late stages of the disease. Clinical and anorectal manometric function were investigated in groups of early and late stage parkinsonian patients. Thirty one patients (19 men, 12 women, age range 22 to 89 years) entered the study. The disease severity was assessed by Hoehn and Yahr staging: there were four (12.9%) stage I, seven (22.6%) stage II, 10 (32.2%) stage III, and 10 (32.2%) stage IV patients. Anorectal variables were measured by standard manometric equipment and techniques. Values obtained in early stage patients (Hoehn and Yahr stage I and II) were compared with those obtained in late stage patients (Hoehn and Yahr stage III and IV). Overall, more than 70% of patients complained of chronic constipation, with chronic laxative use reported in more than 30%. Late stage patients were slightly older than their early stage counterparts. Pelvic floor dyssynergia was documented in more than 60% of patients. Manometric variables were not different in the two groups. In conclusion, defecatory dysfunction is frequent in Parkinsons disease, it is not confined to late stage patients, and it is found early in the course of the disease. This has potential implications for a targeted therapeutic approach.

Upper gastrointestinal motor activity in patients with slow-transit constipation. Further evidence for an enteric neuropathy.

Recent evidence indicates that patients complaining of severe chronic idiopathic constipation may have motor abnormalities not limited to the colon. We studied by manometric means gastric and small bowel motility in a homogeneous group of patients with chronic idiopathic constipation ie, the slow transit type. Twenty-one patients were recruited for the study and compared to 33 healthy subjects. Manometric examination was carried out for about 5 hr fasting and 1 hr after a standard meal. Analysis of the manometric tracings revealed during fasting no abnormalities in number and configuration of migrating motor complex with respect to controls. However, in 70% of patients motor abnormalities were detected, represented by bursts of nonpropagated contractions and discrete clustered contractions. After feeding, the patient group displayed a significantly shorter antral motor response to the meal with respect to controls; moreover, intestinal bursts of nonpropagated contractions were found in 19% of patients, and 14% of them had an early return of the activity fronts. We conclude that patients with slow transit constipation frequently display motor abnormalities of the upper gut. These findings further strengthen the concept that this condition may represent a panenteric disorder.

Impaired colonic motor response to cholinergic stimulation in patients with severe chronic idiopathic (slow transit type) constipation

Chronic idiopathic constipation, especially the slow transit type, is a troubling problem often afficting young women. The pathophysiological basis for this entity is unknown, although a defective cholinergic innervation has been postulated. We tested the hypothesis that cholinergic colonic innervation is deranged in this condition by studying colonic motor activity after strong cholinergic stimulation with edrophonium chloride in 14 women complaining of slow transit constipation. Unlike healthy subjects, constipated patients showed minimal or no response to edrophonium injection. It is concluded that in slow transit constipation there is an important alteration of colonic cholinergic activity and that edrophonium chloride may represent a useful test drug for colonic pathophysiological investigations.

Biofeedback for pelvic floor dysfunction in constipation

Pelvic floor dyssynergia is one of the commonest subtypes of constipation, and the conventional treatment (dietary fibre and laxatives) is often unsatisfactory. Recently biofeedback training has been introduced as an alternative treatment. The authors review the evidence for this approach and conclude that, although controlled studies are few and open to criticism, about two thirds of patients with pelvic floor dyssynergia should benefit from biofeedback training Chronic constipation is a common self reported gastrointestinal problem that affects between 2% and 34% of adults in various populations studied. Among the subtypes of constipation, obstructed defecation seems particularly common, occurring in about 7% of the adult population.1 In most people with this conditionan inappropriate (paradoxical) contraction or a failed relaxation of the puborectal muscle and of the external anal sphincter often occurs during attempts to defecate (fig 1). This paradoxical contraction of the pelvic floor muscles during straining at defecation is considered a form of maladaptive learning and is generally defined (without specifying the underlying pathophysiological mechanism) as outlet dysfunction constipation or, more precisely, pelvic floor dyssynergia.2 Fig 1 Anorectal manometric tracings of a normal subject (upper tracing) and a patient with pelvic floor dyssynergia (lower tracing) during straining at defecation (arrows). Note that the normal subject relaxes the anal sphincter, whereas the patient displays a paradoxical contraction of the sphincter Cardinal symptoms of pelvic floor dyssynergia are straining at stools and feelings of incomplete evacuation, and the diagnostic criteria, recently updated in the Rome II report, include those for functional constipation (see box)3 plus at least two out of three investigations (radiology, manometry, and electromyography) showing inappropriate contraction or failure to relax the pelvic floor muscles during attempts to defecate.2 #### Summary points Obstructed defecation is a common subtype of constipation that may not be responsive to treatment with laxatives and dietary …

Endoluminal Instillation of Bisacodyl inPatients with Severe (Slow Transit Type)Constipation Is Useful to Test Residual ColonicPropulsive Activity

Background: Chronic constipation is a frequent symptom among the general population, and a minority of cases do not respond to any therapeutic measures, except surgery. The purpose of this study was to test the residual colonic motor propulsive activity with a pharmacologic stimulus in a series of patients referred for severe constipation. Patients: Twenty-five chronically constipated patients, slow transit type, age range 16–71 years, unresponsive to conventional medical treatment and referred for functional evaluation, entered the study. Methods: Colonic manometry by means of an endoscopically positioned probe was carried out in all patients. Following a basal recording period, a placebo solution followed by 10 mg bisacodyl solution was infused into the colon through the more proximal recording port. Results: After bisacodyl infusion, about 90% of patients showed a motor response characterized by the appearance (within on average 13 ± 3 min) of one or more high-amplitude propagated contractions, the manometric equivalent of mass movements, and about 75% of these were followed (mean 18.5 ± 4 min) by defecation. Conclusions: Physiological and pharmacological testing of colonic motor activity may be important in severely constipated patients, especially in those labeled as ‘intractable’, in whom more in depth investigation planning may encourage further therapeutic efforts.

Gluten-Free Diet Normalizes Mouth-to-Cecum Transit of a Caloric Meal in Adult Patients with Celiac Disease

The mechanisms responsible for boweldisturbances in celiac disease are still relativelyunknown. Recent reports suggested that small bowel motorabnormalities may be involved in this pathologicalcondition; however, there are no studies addressing smallbowel transit in celiac disease before and after agluten-free diet. We studied the mouth-to-cecum transittime of a caloric liquid meal in a homogeneous group of celiac patients presenting with clinical andbiochemical evidence of malabsorption and complaining ofdiarrhea. Sixteen patients were recruited andinvestigated by means of hydrogen breath test through ingestion of 20 g lactulose together with anenteral gluten-free diet formula. A urinary D-xylosetest was also done in each patient. Both breath testsand D-xylose tests were carried out basally and after a period of gluten-free diet. Twenty healthyvolunteers were recruited as a control group andunderwent the same breath testing. At the time of thediagnosis, mouth-to-cecum transit time was significantly prolonged in celiacs with respect to controls(243 ± 10 vs 117 ± 6 min, P = 0.0001). TheD-xylose test was also abnormal (average urinaryconcentration 2.8 ± 0.25 g, normal values>4.5). No correlation was found in patients between mouth-to-cecum transit timeand urinary D-xylose output (r = 0.22). After thegluten-free diet period, mouth-tocecum transit time inceliacs was significantly reduced compared to prediet transit (134 ± 8 vs 243 ± 10 min,P = 0.0001) and did not show statistical difference whencompared to that found in controls (P = 0.1). TheD-xylose test reverted to normal in all but twosubjects, who were found to be noncompliant with the diet.Mouth-to-cecum transit time is significantly prolongedin patients affected by untreated celiac disease whencompared to healthy controls. This alteration might notbe correlated to intestinal malabsorption, and theprolonged orocecal transit could be due to impairedsmall bowel function (deranged motility?). Sinceintestinal transit returned to normal values after an adequate gluten-free period, a link with severeactive mucosal lesions is suggestive.

Anorectal Dysfunction in Constipated Women With Anorexia Nervosa

OBJECTIVE To evaluate anorectal and colonic function in a group of patients with anorexia nervosa complaining of chronic constipation. PATIENTS AND METHODS Twelve women (age range, 19-29 years) meeting the criteria for anorexia nervosa and complaining of chronic constipation were recruited for the study. A group of 12 healthy women served as controls. Colonic transit time was measured by a radiopaque marker technique. Anorectal manometry and a test of rectal sensation were carried out with use of standard techniques to measure pelvic floor dysfunction. A subgroup of 8 patients was retested after an adequate refeeding program was completed. RESULTS Eight (66.7%) of 12 patients with anorexia nervosa had slow colonic transit times, while 5 (41.7%) had pelvic floor dysfunction. Colonic transit time normalized in the 8 patients who completed the 4-week refeeding program. However, pelvic floor dysfunction did not normalize in these patients. CONCLUSIONS Patients with anorexia nervosa who complain of constipation have anorectal motor abnormalities. Delayed colonic transit time is probably due to abnormal eating behavior.

Validation of the Balloon Evacuation Test: Reproducibility and Agreement With Findings From Anorectal Manometry and Electromyography

BACKGROUND & AIMS The balloon evacuation test (BET) measures the time required to evacuate a balloon filled with 50 mL water; it has been incorporated into many algorithms for diagnosis of pelvic floor dyssynergia. We aimed to assess the reproducibility of the BET, determine the upper limit of normal, and assess its concordance with evaluation of pelvic floor dyssynergia by anorectal manometry (ARM) and pelvic floor surface electromyography (EMG). METHODS The BET was tested in 286 consecutive patients with chronic constipation (mean age, 44 years; 91% female) before and after 30 days of conservative treatment at a tertiary gastroenterology clinic in Italy from March 2010 through May 2012. The BET was tested twice, 7 days apart, in 40 healthy individuals (controls: mean age, 38 years; 92% female). The 238 constipated patients who responded incompletely to conservative therapy were examined by ARM, EMG, and digital rectal examination. Forty-seven patients with conflicting ARM and BET results underwent defecography. RESULTS The balloon was evacuated within 1 minute by 37 controls (93%; 3 individuals required 1-2 minutes). Among patients with constipation, 148 (52%) passed the balloon within 5 minutes (110 passed the balloon in 1 minute, 35 passed it in 1-2 minutes, and 3 passed it in 2-5 minutes). The BET showed perfect reproducibility in 280 of the patients with constipation (98%) when a time less than 2 minutes was set as abnormal. The level of agreement between BET and ARM for dyssynergia was 78%, and between BET and EMG it was 83%. Thirty-two patients had abnormal results from the BET but normal results from ARM; 31 cases had inadequate straining (n = 11) or anatomic defects (n = 20), which could account for the abnormal findings from BET. CONCLUSIONS The BET is reliable for analysis of pelvic floor dyssynergia; the optimal upper limit of normal is 2 minutes. Findings from the BET have a high level of agreement with those from ARM and EMG.

ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders.

Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders.