Jessica Valestin

Long-Term Efficacy of Biofeedback Therapy for Dyssynergic Defecation: Randomized Controlled Trial

OBJECTIVES:Although biofeedback therapy is effective in the short-term management of dyssynergic defecation, its long-term efficacy is unknown. Our aim was to compare the 1-year outcome of biofeedback (manometric-assisted pelvic relaxation and simulated defecation training) with standard therapy (diet, exercise, laxatives) in patients who completed 3 months of either therapy.METHODS:Stool diaries, visual analog scales (VASs), colonic transit, anorectal manometry, and balloon expulsion time were assessed at baseline, and at 1 year after each treatment. All subjects were seen at 3-month intervals and received reinforcement. Primary outcome measure (intention-to-treat analysis) was a change in the number of complete spontaneous bowel movements (CSBMs) per week. Secondary outcome measures included bowel symptoms, changes in dyssynergia, and anorectal function.RESULTS:Of 44 eligible patients with dyssynergic defecation, 26 agreed to participate in the long-term study. All 13 subjects who received biofeedback, and 7 of 13 who received standard therapy, completed 1 year; 6 failed standard therapy. The number of CSBMs per week increased significantly (P<0.001) in the biofeedback group but not in the standard group. Dyssynergia pattern normalized (P<0.001), balloon expulsion time improved (P=0.0009), defecation index increased (P<0.001), and colonic transit time normalized (P=0.01) only in the biofeedback group.CONCLUSIONS:Biofeedback therapy provided sustained improvement of bowel symptoms and anorectal function in constipated subjects with dyssynergic defecation, whereas standard therapy was largely ineffective.

Methanogenic flora is associated with altered colonic transit but not stool characteristics in constipation without IBS

OBJECTIVES:About 35% of humans have methane-producing gut flora. Methane-producing irritable bowel syndrome (IBS) subjects are generally constipated. In animal models, methane infusion slows intestinal transit. Whether methanogenic flora alters colonic transit or stool characteristics and its relationship to constipation is unclear. The aim of this study was to examine the prevalence and association of methanogenic flora in patients with slow transit (ST) constipation and normal transit (NT) constipation and non-constipated controls.METHODS:Ninety-six consecutive subjects with chronic constipation (CC) (Rome III) were evaluated with radio-opaque marker (ROM) transit studies and were classified as ST (>20% ROM retention) or NT. All constipated subjects and 106 non-constipated controls underwent breath tests to assess methane production. Baseline CH4 of ≥3 p.p.m. was used to define presence of methanogenic flora. Stool frequency and consistency were assessed using a prospective stool diary. Correlation analyses were performed.RESULTS:Forty-eight subjects had ST and 48 had NT. Prevalence of methanogenic flora was higher (P<0.05) in ST (75%) compared to NT (44%) or controls (28%). ST patients had higher methane production compared to NT and controls (P<0.05). NT patients also produced more methane compared to controls (P<0.05). There was moderate(P<0.05) correlation among baseline, peak, and area under the curve (AUC) of methane response with colonic transit but not with stool characteristics.CONCLUSIONS:Presence of methanogenic flora is associated with CC. Methane production after carbohydrate challenge and its prevalence were higher in ST than NT, although stool characteristics were similar in both groups. Methane production correlated with colonic transit, suggesting an association with stool transport but not with stool characteristics.

Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation.

Aliment Pharmacol Ther 2011; 33: 822–828

Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth

Whether intestinal dysmotility and the use of a proton pump inhibitor (PPI) either independently or together contributes to small intestinal bacterial overgrowth (SIBO), and/or small intestinal fungal overgrowth (SIFO) is not known.

Topographic and manometric characterization of the recto‐anal inhibitory reflex

Background  Recto‐anal inhibitory reflex (RAIR) is an integral part of normal defecation. The physiologic characteristics of RAIR along anal length and anterior‐posterior axis are unknown. The aim of this study was to perform topographic and vector‐graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components.

Diagnostic utility of wireless motility capsule in gastrointestinal dysmotility.

Goals To examine the diagnostic utility of wireless motility capsule (WMC) in patients with suspected gastrointestinal (GI) dysmotility. Background Subjects with suspected GI motility disorders undergo invasive and expensive diagnostic tests. In these patients, whether WMC provides clinically useful information is unknown. Study Patients with symptoms of dysmotility and normal endoscopic/radiologic evaluations were assessed with WMC test and conventional motility tests (CMT). Diagnostic utility of WMC was assessed retrospectively by examining device agreement and new information compared with CMT. Results On the basis of predominant symptom(s), 86 patients were classified into 2 subgroups: lower GI (LGI=50) and upper GI (UGI=36). Clinical suspicion was confirmed in 52% and 66% of patients, respectively, and there was good device agreement between WMC and CMT in 76% and 81% in the LGI and UGI groups, respectively. There was new diagnostic information with the WMC test in 53% of the LGI (P=0.006) and 47% of the UGI group (P=0.001). WMC detected generalized motility disorder in 44 (51%) patients and influenced management in 30% of LGI and 50% of UGI subjects. Conclusions WMC confirmed clinical suspicion, provided new diagnostic information, influenced clinical management, and detected many patients with generalized motility disorder. It had good device agreement with conventional tests.

Translumbar and transsacral motor-evoked potentials: a novel test for spino-anorectal neuropathy in spinal cord injury.

OBJECTIVES:Spinal cord injury (SCI) causes anorectal problems, whose pathophysiology remains poorly characterized. A comprehensive method of evaluating spino-anorectal function is lacking. The aim of this study was to investigate the neuropathophysiology of bowel dysfunction in SCI by evaluating motor-evoked potentials (MEP) of anus and rectum following transspinal magnetic stimulation and anorectal physiology.METHODS:Translumbar and transsacral magnetic stimulations, anorectal manometry, and pudendal nerve terminal motor latency (PNTML) were performed in 39 subjects with SCI and anorectal problems and in 14 healthy controls, and data were compared. MEPs were recorded with an anorectal probe containing bipolar ring electrodes.RESULTS:The MEPs were significantly prolonged (P<0.05) bilaterally, and at lumbar and sacral levels, as well as at rectal and anal sites in SCI subjects compared with controls. A total of 95% of SCI subjects had abnormal MEPs and 53% had abnormal PNTML. All subjects with abnormal PNTML also demonstrated abnormal MEP, but 16/17 subjects with normal PNTML had abnormal MEP. Overall, SCI patients had weaker anal sphincters (P<0.05), higher prevalence of dyssynergia (85%), and altered rectal sensation (82%).CONCLUSIONS:Translumbar and transsacral MEPs revealed significant and hitherto undetected lumbosacral neuropathy in 90% of SCI subjects. Test was safe and provided neuropathophysiological information that could explain bowel dysfunction in SCI subjects.

Rectoanal reflexes and sensorimotor response in rectal hyposensitivity.

PURPOSE: Rectal hyposensitivity commonly causes anorectal disorders, but its underlying mechanism is unknown. We hypothesized that subjects with rectal hyposensitivity have altered rectoanal reflexes and/or sensorimotor response. METHODS: We performed stepwise graded balloon distensions of the rectum in 30 subjects with constipation and rectal hyposensitivity and in 23 healthy controls. Thresholds for first sensation, desire, and urgency to defecate were assessed. The lowest balloon volume that evoked rectoanal inhibitory reflex, rectoanal contractile reflex, and sensorimotor response and manometric characteristics and rectal compliance were examined. RESULTS: Reflex responses were present in all subjects. The balloon volumes were higher in subjects with rectal hyposensitivity for inducing rectoanal inhibitory reflex (P = .008) and contractile reflex (P = .001) compared with controls. All controls showed a sensorimotor response, but in 13 hyposensitive subjects (43%) the onset of sensorimotor response was associated with absent sensation and in 17 (57%), with a transient rectal sensation. Thresholds for eliciting sensorimotor response were similar between patients and controls, but the amplitude, duration, and magnitude of response were higher (P < .05) in patients. Rectal compliance was similar between controls and hyposensitive subjects with transient sensation but higher (P = .001) in subjects with absent sensation. CONCLUSIONS: Constipated subjects with rectal hyposensitivity demonstrate higher thresholds for inducing rectoanal reflexes and abnormal characteristics of sensorimotor response. These findings suggest either disruption of afferent gut-brain pathways or rectal wall dysfunction. These altered features may play a role in the pathogenesis of bowel dysfunction in rectal hyposensitivity.

A BI-DIRECTIONAL ASSESSMENT OF THE HUMAN BRAIN-ANORECTAL AXIS

Background  Brain‐gut dysfunction has been implicated in gastrointestinal disorders but a comprehensive test of brain‐gut axis is lacking. We developed and tested a novel method for assessing both afferent anorectal‐brain function using cortical evoked potentials (CEP), and efferent brain‐anorectal function using motor evoked potentials (MEP).

Lack of seasonal variation in the incidence of eosinophilic oesophagitis in adolescent and adult non-PPI-responsive oesophageal eosinophilia midwestern US populations

Background Eosinophilic oesophagitis (EoO) has been associated with allergic disorders as well as aeroallergens. The current literature has shown a possible association between seasonal variation, mainly in the spring, and the incidence of EoO. However, this data was based on small population studies that did not exclude proton-pump inhibitor (PPI)-responsive oesophageal eosinophilia (PPI-ROE) in their cohort. Aim The aim of this study was to determine if there is a seasonal variation associated with the diagnosis of EoO in patients that had been treated with high-dose PPI prior to diagnosis. Methods Oesophageal biopsies were obtained from a cohort of patients who presented with symptoms of dysphagia, odynophagia, and heartburn during a 10-year period. Symptomatic patients who had biopsies from the mid and distal oesophagus with ≥20 eosinophils per high-power field (hpf) while on high-dose PPI treatment for at least 5 weeks were diagnosed as having EoO. The monthly and seasonal incidences were determined (winter, January–March; spring, April–June; summer, July–September; Autumn, October–December). Results A total of 20,718 patients were identified and their records evaluated. From this cohort, 193 (0.93%) symptomatic patients had biopsy-proven oesophageal eosinophilia (≥20 eosinophils/hpf) and no seasonal variation was seen in this group. However, only 57 (0.28%) had been adequately treated with PPI prior to diagnosis (i.e. non-PPI-ROE biopsy-proven EoO; ≥20 eosinophils/hpf: 39 males, 18 females; age 29.5 years). The most common medical history components included asthma (12.3%) and food allergies (3.5%), and the most common presenting symptoms included dysphagia (50.9%) and heartburn (26.3%). The monthly and seasonal incidences in our cohort were with no apparent trend (p = 0.713 and 0.703, respectively). Conclusions The incidence of EoO was consistent across all 12 months as well as during the four seasons. Our data does not support a seasonal variation in relation to the incidence of EoO in the US midwestern non-PPI-ROE population.