In Ja Yoon

The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence.

Objectives:Digital rectal examination (DRE) is a simple clinical method to diagnose anorectal disorders. High-resolution antorectal manometry (HRAM) based on a spatiotemporal plot is expected to promote improved diagnostic accuracy. However, there are no reports comparing the effectiveness of DRE and HRAM. The aim of our study was therefore to evaluate the diagnostic value of DRE compared with HRAM.Methods:A total of 309 consecutive patients with chronic constipation (n=268) or fecal incontinence (n=41) who underwent a standardized DRE, HRAM, and balloon expulsion test were enrolled in this study. The diagnostic yield of DRE compared with HRAM was determined, and agreement between DRE and HRAM data was evaluated.Results:Of the constipated patients, 207 (77.2%) were diagnosed with dyssynergia using HRAM. The sensitivity, specificity, and positive predictive value of DRE in the diagnosis of dyssynergia were 93.2%, 58.7%, and 91.0%, respectively, and moderate agreement was seen between the two modalities (κ-coefficient =0.542, P<0.001). In patients with fecal incontinence, there was moderate agreement in terms of anal squeeze pressure between the two modalities (κ-coefficient =0.418, P=0.006); however, there was poor agreement for anal resting tone (κ-coefficient =0.079, P=0.368).Conclusions:DRE shows high sensitivity and positive predictive value in detecting dyssynergia compared with HRAM, and could therefore be used as a bedside screening test for the diagnosis of this disorder. Further studies are warranted to evaluate the correlation between DRE and HRAM in assessing anal sphincter pressure.

Normal values for high-resolution anorectal manometry/topography in a healthy Korean population and the effects of gender and body mass index

High‐resolution manometry (HRM) based on spatiotemporal plots is increasingly being used. The aim this study was to evaluate, for the first time, the influence of gender, with adjustment for age, body mass index (BMI), and vaginal delivery, on anorectal functions in asymptomatic adults.

Genetic Evaluation of ALADIN Gene in Early-Onset Achalasia and Alacrima Patients

Background/Aims ALADIN gene has been known to cause achalasia, alacrima, adrenal abnormalities and a progressive neurological syndrome. A considerable proportion of achalasia patients has been known to show alacrima (decreased secretion of tear). However, the genetic mechanism between achalasia and alacrima has not been defined yet. We postulated that ALADIN gene may be involved in the occurrence of early-onset achalasia; thus, we investigated the correlation of ALADIN gene in early-onset achalasia patients. Methods From 1989 to 2007, patients who were diagnosed as primary achalasia before age 35 were enrolled. All of the enrolled patients were asked for (1) blood sampling for DNA, (2) Shirmer test and (3) dysphagia questionnaires. Results The ALADIN gene in exon 1, 2, 10, 11 and 12 from 19 patients was investigated (M:F = 12:7). The mean age of patients at diagnosis was 27 ± 5 (15-35) years old. Eight out of 19 (42%) showed alacrima by the positive Shirmer test. In spite of thorough exam in the genetic study, there was no definite abnormal genetic finding in this study. Conclusions A considerable number of achalasia patients showed alacrima. Due to the limitation of this study, it is difficult to conclude that early-onset achalasia may have significant correlations with the ALADIN gene.

A novel high-resolution anorectal manometry parameter based on a three-dimensional integrated pressurized volume of a spatiotemporal plot, for predicting balloon expulsion in asymptomatic normal individuals

Anorectal manometry with simulated evacuation (SE) has limited applicability in predicting balloon expulsion (BE) test results. The newly developed high‐resolution anorectal manometry (HRAM) technique can yield spatiotemporal plots with three‐dimensional pressurization. We aimed to define new parameters based on three‐dimensional integrated pressurized volume (IPV) for predicting the BE test results in asymptomatic normal individuals.

Anorectal function and the effect of biofeedback therapy in ambulatory spinal cord disease patients having constipation

Abstract Objective. Constipation in patients with mild spinal cord disease is not well investigated yet. We aimed to investigate anorectal function and the effect of biofeedback therapy in constipated patients with mild spinal cord diseases. Material and methods. A total of 14 constipated patients with myelopathy and 32 with radiculopathy were enrolled retrospectively. All patients were able to walk independently. The control group comprised of 100 constipated patients without any neurologic problem. Colonic transit time and the presence of dyssynergia were assessed before biofeedback therapy. All patients answered structured questionnaires on constipation, before and after biofeedback therapy. Results. The mean rectosigmoid colonic transit time of the myelopathy group was significantly delayed (myelopathy, 18.6 ± 14.6 h; radiculopathy, 12.8 ± 11.9 h; control, 9.6 ± 11.2 h; p = 0.032). Delay in total colonic transit time was more frequent in the myelopathy group (myelopathy, 57.1%; radiculopathy, 23.3%; control, 18.5%; p = 0.004). On anorectal manometry, the squeezing pressure of the anal sphincter was decreased in the myelopathy group (myelopathy, 132.3 ± 73.3 mmHg; radiculopathy, 179.9 ± 86.1 mmHg; control 200.4 ± 82.4 mmHg; p < 0.05). The success rate of biofeedback therapy was lower in the myelopathy group (28.6% for myelopathy vs. 62.0% for control group; p = 0.034). The response rate to biofeedback therapy was similar between radiculopathy and control group (62.5% for radiculopathy vs. 62.0% for control group; p = 1.000). Conclusions. In constipation associated with mild myelopathy, delayed colonic transit and dyssynergic defecation were major pathophysiologic abnormalities and biofeedback was less effective compared with control group. However, in the radiculopathy group, biofeedback was as effective as in the control group.

Biofeedback therapy in constipated, female patients and caused by radical hysterectomy or vaginal delivery

Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.

Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery.

Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.

New diagnostic criteria for nutcracker esophagus using conventional water-perfused manometry: A comparison between nutcracker esophagus with and without gastroesophageal reflux disease

Background and Aim:  Controversy continues as to whether nutcracker esophagus (NE) is a ‘real’ manometric disease due to its poor correlation with clinical symptoms such as chest pain or dysphagia. While new NE criteria were proposed in a recent study, that study included NE patients both with and without gastroesophageal reflux disease (GERD). We aimed to analyze both general NE (with or without GERD) and pure NE (without GERD) patients in terms of distal esophageal amplitude (DEA) and its correlation with symptoms.

Effect of biofeedback therapy in constipation according to rectal sensation.

Background/Aims The pathophysiologic mechanism of rectal hyposensitivity (RH) is not well documented, and the significance of RH in biofeedback therapy (BFT) has not been evaluated. Thus, we aimed to assess the effect of BFT in constipated patients according to the presence of RH. Methods Five hundred and ninety constipated patients (238 males and 352 females) underwent anorectal physiologic assessments. Of these, anorectal manometry was performed before and after BFT in 244 patients (63 RH and 181 non-RH patients). Results The success rate of BFT was 56% in the RH and 61% in the non-RH group (p=0.604). The measurements of resting pressure, squeezing pressure, desire to defecate volume, urge to defecate volume, and maximum volume were decreased after BFT in the RH group (p<0.05), whereas only resting and squeezing pressures were decreased in the non-RH group (p<0.05). Among the RH group, individuals who responded to BFT showed decreased resting pressure, squeezing pressure, desire to defecate, urge to defecate, and maximum volume and increased balloon expulsion rate; among those who did not respond to BFT, only desire to defecate volume was improved. Conclusions In constipated patients with RH, changes of anorectal manometric findings differed in comparison to patients without RH. The responses to BFT showed both anorectal muscle relaxation and restoration of rectal sensation.

Basal and residual lower esophageal pressures increase in old age in classic achalasia, but not vigorous achalasia

Background and Aim:  The relationship between age and esophageal motility parameters (i.e. basal and residual pressure of the lower esophageal sphincter [LES]) remains to be established in achalasia patients, possibly because most previous studies did not distinguish between classic and vigorous achalasia patients. We investigated the relationship between age and esophageal motility parameters in both classic and vigorous achalasia patients.