Marije Deutekom

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

BackgroundAnal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography.MethodsA cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography.ResultsAbsent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (±SD) manometric findings: mean resting pressure 41.3 (±20), 43.8 (±20) and 61.6 (±23) Hg (p<0.001); incremental squeeze pressure 20.6 (±20), 38.4 (±31) and 62.4 (±34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography.ConclusionsAnal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.

Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial.

BackgroundColorectal cancer (CRC) is the second most prevalent type of cancer in Europe. Early detection and removal of CRC or its precursor lesions by population screening can reduce mortality. Colonoscopy and computed tomography colonography (CT colonography) are highly accurate exams and screening options that examine the entire colon. The success of screening depends on the participation rate. We designed a randomized trial to compare the uptake, yield and costs of direct colonoscopy population screening, using either a telephone consultation or a consultation at the outpatient clinic, versus CT colonography first, with colonoscopy in CT colonography positives.Methods and design7,500 persons between 50 and 75 years will be randomly selected from the electronic database of the municipal administration registration and will receive an invitation to participate in either CT colonography (2,500 persons) or colonoscopy (5,000 persons) screening. Those invited for colonoscopy screening will be randomized to a prior consultation either by telephone or a visit at the outpatient clinic. All CT colonography invitees will have a prior consultation by telephone. Invitees are instructed to consult their general practitioner and not to participate in screening if they have symptoms suggestive for CRC. After providing informed consent, participants will be scheduled for the screening procedure. The primary outcome measure of this study is the participation rate. Secondary outcomes are the diagnostic yield, the expected and perceived burden of the screening test, level of informed choice and cost-effectiveness of both screening methods.DiscussionThis study will provide further evidence to enable decision making in population screening for colorectal cancer.Trial registrationDutch trial register: NTR1829

Lower Risk of Advanced Neoplasia Among Patients With a Previous Negative Result From a Fecal Test for Colorectal Cancer

BACKGROUND & AIMS Consecutive rounds of fecal occult blood tests (FOBTs) are used to screen for colorectal cancer (CRC); they detect precursor lesions and early-stage disease. We assessed whether the positivity rate and the positive predictive values (PPVs) for advanced neoplasia and CRC decrease with repeated testing by using fecal immunochemical tests (FITs). METHODS Data were collected from 2 rounds of screening. In the first round, average-risk persons (50 to 74 years old) were randomly assigned to groups that received the guaiac FOBT or FIT. In the second round, the subjects received only FIT (1594 received FIT after guaiac FOBT and 2022 received FIT after FIT). The positivity rate and PPV for advanced neoplasia and CRC were compared between second-round participants with a previous negative test result (FIT after guaiac FOBT or FIT after FIT) and first-round participants (guaiac FOBT or FIT). RESULTS The rate of positive results from FIT was 7.4% in the FIT-after-FIT group, compared with 8.1% in the first-round FIT group (P = .34). A significant decrease was observed in the PPV for advanced neoplasia between the first and second round from 55% (132/239) to 44% (112/252; P = .017). The PPV for CRC was 8% (20/239) in the first round versus 4% (9/252) in the second round (P = .024). Ten interval cancers were diagnosed. There were no significant differences in stages of cancers detected in the first and second round or the interval cancers. CONCLUSIONS The rate of positive results from FIT does not decrease after repeated CRC screening, but the PPVs of FIT for advanced neoplasia and for CRC are significantly lower among second-round participants who tested negative in the first round.

Clinical Presentation of Fecal Incontinence and Anorectal Function: What Is the Relationship?

OBJECTIVES:Fecal incontinence is classified into various types passive, urge, and combined. Its clinical presentation is thought to be related to the underlying physiological or anatomical abnormality. The aim of the present study was to evaluate the associations between the frequency of clinical symptoms and anatomic and functional characteristics of the anorectum of patients with severe fecal incontinence.METHODS:Associations were explored in a consecutive series of 162 patients (91% women, mean age 59 [SD ± 12] yr) with a mean Vaizey incontinence score of 18 (SD ± 3).RESULTS:Urge incontinence was reported as “daily” by 55%, “often” by 27%, and “sometimes” by 7% of all patients. No significant associations were observed between the frequency of urge incontinence and either manometric data, anal mucosal sensitivity testing, or defects of internal anal sphincter (IAS) or external anal sphincter (EAS). A significant relation was observed between the frequency of urge incontinence and maximal tolerable volume (P = 0.03) and atrophy of the EAS (P = 0.05). Passive incontinence was reported as “daily” by 14%, “often” by 30%, and “sometimes” by 14% of all patients. Resting and maximal squeeze pressure were both associated (P < 0.001) with the frequency of passive incontinence. No relationship could be detected between clinical presentation and rectal sensation, anal mucosal sensitivity, defects, or atrophy of IAS or EAS.CONCLUSION:Most patients reported combined incontinence (59%) and underlying pathophysiologic abnormalities were identified. The hypothesized associations between urge and passive incontinence and functional and anatomical impairment of the anorectum are less clear-cut than previously assumed. Patients presenting with fecal incontinence should undergo physiologic investigation.

MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence.

OBJECTIVE External anal sphincter atrophy seen at endoanal MRI may predict poor outcome of surgical anal sphincter repair for an external anal sphincter defect. The purposes of this study were to compare external phased-array MRI to endoanal MRI for depicting external anal sphincter atrophy in patients with fecal incontinence and to evaluate observer reproducibility in detecting external anal sphincter atrophy with these techniques. SUBJECTS AND METHODS Thirty patients with fecal incontinence (23 women, seven men; mean age, 58.7 years; age range, 37-78 years) underwent both endoanal and external phased-array MRI. Images were evaluated for external anal sphincter atrophy by three radiologists. Measures of differences and agreement between both MRI techniques and of interobserver and intraobserver agreement of both techniques were calculated. RESULTS The MRI techniques did not significantly differ in their ability to depict external anal sphincter atrophy (p = 0.63) with good agreement (kappa = 0.72). Interobserver agreement was moderate (kappa = 0.53-0.56) for endoanal MRI and moderate to good (kappa = 0.55-0.8) for external phased-array MRI. Intraobserver agreement was moderate to very good (kappa = 0.57-0.86) for endoanal MRI and fair to very good (kappa = 0.31-0.86) for external phased-array MRI. CONCLUSION External phased-array MRI is comparable to endoanal MRI in depicting external anal sphincter atrophy and, thereby, in selecting patients for anal sphincter repair. Because results among interpreters varied considerably depending on the experience level, both techniques can be recommended in the diagnostic workup of fecal incontinence only if sufficient experience is available.

Selecting an outcome measure for evaluating treatment in fecal incontinence

PURPOSEVarious outcome measures exist to evaluate treatment in fecal incontinence, including descriptive, severity (fecal incontinence scoring systems), and impact (quality-of-life questionnaires) and diagnostic measures. We studied associations between changes after treatment for a number of outcome measures and compared them to patients’ subjective perception of relief.METHODSWe analyzed data of 66 patients (92 percent female; mean age, 62 years) (Vaizey score, Wexner score, two impact scales, utility, resting pressure, and maximal incremental squeeze pressure) at baseline and after physiotherapy. In a standardized interview by phone, we asked patients to compare their situation before and after treatment. Correlations between changes in outcome measures were calculated. These changes were compared with patients’ subjective perception.RESULTSThere was a high correlation between the changes in the Vaizey and the Wexner scores (r = 0.94, P < 0.01). Changes in Vaizey and Wexner scores correlated moderately with changes in maximum incremental squeeze pressure (r = −0.29, −0.30, both P < 0.05). Changes in utility and resting pressure were not correlated with changes in any of the other measurements (all r values between −0.086 and 0.18). Average severity scores (Vaizey and Wexner) were 1 point lower for patients who rated their situation as worse or equal (62 percent), 4 points lower for patients who reported their situation to be better (21 percent), and 9 points lower in patients who rated their situation much better (17 percent) (P < .05).CONCLUSIONSeverity measures are best related to patients’ subjective perception of relief.

Implementation of population screening for colorectal cancer by repeated fecal occult blood test in the Netherlands

BackgroundColorectal cancer (CRC) is the third most prevalent type of cancer in the world. Its prognosis is closely related to the disease stage at the time of diagnosis. Early detection of symptomless CRC or precursor lesions through population screening could reduce CRC mortality. However, screening programs are only effective if enough people are willing to participate. This study aims to asses the uptake of a second round of fecal occult blood test (FOBt) based screening and to explore factors that could potentially increase this uptake.Methods and designTwo years after the first screening round, 10.000 average risk persons, aged 50 to 75, will again receive an invitation to participate in immunohistochemical FOBt (iFOBt) based screening. Eligible persons will be recruited through a city population database. Invitees will be randomized to receive either an iFOBt with a faeces collection paper or an iFOBt without a collection paper. The iFOBts will be analyzed in a specialized laboratory at the Academic Medical Centre. Positive iFOBts will be followed by a consultation at our outpatient clinic and, in the absence of contra-indications and after informed consent, by a colonoscopy. The primary outcome measure is the participation rate. Secondary outcome measures are the effect of the addition of a collection paper on the participation rate, reasons for participation and non-participation, measures of informed choice and psychological consequences of screening and measures of psychological and physical burden associated with the iFOBt and the colonoscopy. Another secondary outcome measure is the diagnostic yield of the program.DiscussionIn order to implement population screening for colorectal cancer in the Netherlands, information is needed on the uptake of repeated rounds of FOBt-based screening and on factors that could potentially increase this uptake in the future since effectiveness of such a program depends on the willingness of persons to participate. This study will provide information on the actual uptake and perception of a second round of iFOBt-based screening. The results of this study will contribute to the future implementation of a national colorectal screening program in the Netherlands.Trial registrationDutch Trial register: NTR1327

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

PurposePelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence.Materials and methodsTwo hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score.ResultsAfter pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD ± 3) was reduced with 3.2 points (p < 0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R2, 0.20; p = 0.05).ConclusionAdditional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.

The Role of Endoluminal Imaging in Clinical Outcome of Overlapping Anterior Anal Sphincter Repair in Patients with Fecal Incontinence

OBJECTIVE Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair. SUBJECTS AND METHODS Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome. RESULTS After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003). CONCLUSION Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Inconclusive psychometric properties of the Vaizey score in fecally incontinent patients: a prospective cohort study.

To determine the psychometric properties of the total Vaizey score and its individual items.