Urban Karlbom

Evaluation of a Questionnaire in the Assessment of Patients with Faecal Incontinence and Constipation

BACKGROUND A self-reported questionnaire may be a useful instrument in assessing patients with faecal incontinence and constipation. METHODS Reliability, discrimination, validity, and sensitivity were evaluated in 16 control subjects 36 patients with faecal incontinence, and in 38 with constipation. The reliability was measured by a test-retest procedure (kappa (kappa) statistics or Spearman rank test), and validity by comparing the questionnaire and a diary. Discrimination was assessed by comparing the patient groups with the controls, and sensitivity by comparing selected answers before and after treatment. RESULTS Overall reliability (faecal incontinence group, mean kappa = 0.57; constipation group, mean kappa = 0.60; controls, mean kappa = 0.95) and validity were judged acceptable. In the incontinence group occurrence of faecal incontinence per se was reproducible (kappa = 0.66), as was the need to wear a pad (kappa = 0.85). Stool frequency, percentage toilet time spent straining and digitation was reproducible in patients with constipation (kappa = 0.80, r = 0.56; p < 0.001, kappa = 0.83 respectively). Several items distinguished both patient groups from healthy controls (p < 0.05 to p < 0.001). Sensitivity to surgical treatment was seen in several items in both patient groups. CONCLUSIONS The questionnaire appears to be a valid measure of symptoms in faecal incontinence and constipation with sufficient discriminatory capacity.

Does surgical repair of a rectocele improve rectal emptying

PURPOSE: This study was undertaken to assess results of surgical repair of rectocele and to identify possible determinants of outcome from patients history and preoperative defecography. Another aim was to evaluate how surgery affects rectal evacuation. METHOD: Thirty-four women with constipation and rectal emptying difficulties underwent surgery with a transanal technique. A preoperative defecography was performed in each patient. They were followed up after a median of 10 (range, 2–60) months with a questionnaire (n=34) and a defecography (n=31). Computer-based image analysis of defecographies was used to evaluate rectal evacuation. RESULTS: In 27 patients (79 percent), the result of surgery was good with subjectively improved emptying. The need for vaginal or perineal digitation preoperatively was related to a good result (P<0.05), whereas a previous hysterectomy (P<0.01) and a large rectal area on defecography (P<0.01) related to a poor result. Preoperative use of enemas, motor stimulants, or several types of laxatives also related to a poor outcome (P<0.05). Surgical treatment resulted in reduction of the rectocele (P<0.001), an elevated position of the anorectal junction (P<0.05), and improved rectal evacuation on defecographies (P<0.001). CONCLUSIONS: Surgical repair reduces the size of the rectocele and improves rectal emptying. These changes are accompanied by a symptomatic improvement in the majority of patients. Preoperative patient data and defecography may help in selecting patients for surgery.

Submucosal injection of stabilized nonanimal hyaluronic acid with dextranomer: a new treatment option for fecal incontinence.

PURPOSE: NASHA™ Dx gel has been used extensively for treatments in the field of urology. This study was performed to evaluate NASHA™ Dx gel as an injectable anal canal implant for the treatment of fecal incontinence. METHODS: Thirty-four patients (5 males, 29 females; median age, 61 years; range, 34 to 80) were injected with 4 × 1 ml of NASHA™ Dx gel, just above the dentate line in the submucosal layer. The primary end point was change in the number of incontinence episodes and a treatment response was defined as a 50 percent reduction compared with pretreatment. All patients were followed up at 3, 6, and 12 months. RESULTS: The median number of incontinence episodes during four weeks was 22 (range, 2 to 77) before treatment, at 6 months it was 9 (range, 0 to 46), and at 12 months it was 10 (range, 0 to 70, P = 0.004). Fifteen patients (44 percent) were responders at 6 months, compared with 19 (56 percent) at 12 months. No long-term side effects or serious adverse events were reported. CONCLUSIONS: Submucosal injection of NASHA™ Dx gel is an effective treatment for fecal incontinence. The effect is sustained for at least 12 months. The treatment is associated with low morbidity

Anorectal physiology in relation to clinical subgroups of patients with severe constipation.

Objective  The aim of this study was to evaluate anorectal physiology in relation to clinically defined subgroups of patients with idiopathic constipation and to analyse relationships between anorectal physiology and rectal evacuation.

Segmental colonic transit studies : Comparison of a radiological and a scintigraphic method

Objective  Colonic transit studies are used to diagnose slow transit constipation (STC) and to evaluate segmental colonic transit before segmental or subtotal colectomy. The aim of the study was to compare a single X‐ray radio‐opaque marker method with a scintigraphic technique to assess total and segmental colonic transit in patients with STC.

Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay.

Objective  Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side‐effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right‐ or left‐sided delay.

Results of biofeedback in constipated patients

PURPOSE: The aims of this study were to assess the results of biofeedback treatment in constipated patients and to identify variables that might be used to predict the outcome. METHOD: Twenty-eight patients (5 men; median age, 46 (range, 22–72) years) with any degree of paradoxical activation measured with thin hook needle electromyography in the external sphincter or puborectalis muscle were included. The symptom duration varied between 1 and 30 (median, 9) years. The patients had eight outpatient training sessions with electromyography-based audiovisual feedback. All patients were followed up prospectively with a validated bowel function questionnaire from which a symptom index was created. RESULTS: At three months, nine patients had no improvement and underwent other treatments. The remaining 19 patients were followed up for a median of 14 (range, 12–34) months. Twelve patients (43 percent) stated they had improved rectal emptying. A good result was associated with increased stool frequency (P< 0.05), improved symptom index (P<0.01), and reduction of laxative use (P<0.05). A long symptom duration, a high pretreatment symptom index, and laxative use were related to a poor result (P<0.01–0.05). The improved group had less perineal descent (P<0.05), and a prominent puborectalis impression on defecography tended to be more common (P=0.06). CONCLUSION: With the use of wide inclusion criteria, biofeedback was successful in 43 percent of patients, with a treatment effect lasting at least one year. The results suggest that biofeedback should be used as the initial treatment of constipated patients with a paradoxical puborectalis contraction.

Results after sacral nerve stimulation for chronic constipation.

Sacral nerve stimulation is an established treatment for fecal incontinence and initial reports describe successful results also in subjects with chronic constipation.

The Accuracy of Clinical Examination in the Diagnosis of Rectal Intussusception

PURPOSE:This study was designed to compare routine clinical examination and defecography in the diagnosis of rectal intussusception in constipated patients and study relationships between rectal intussusception and symptoms.METHODS:A total of 127 consecutive patients with functional constipation were examined in the left-lateral position with rectal palpation and rectoscopy according to a protocol. An overall clinical judgment was made if the patient had intussusception, unclear finding, or no intussusception. Defecography was performed without knowledge of the results of the clinical evaluation. Symptom duration varied between 0.5 to 60 (median, 10) years. All patients fulfilled a bowel questionnaire and all had a full physiologic workup.RESULTS:A diagnosis by digital examination (P = 0.002) and by rectoscopy (P = 0.002) as well as the overall judgment (P = 0.0002) was clearly related to a longer intussusception as measured by defecography. Five of six intra-anal intussusceptions were correctly assessed by clinical examination, whereas the correlation to defecography was poor in the group with short intussusceptions. Neither clinical nor defecographic diagnosis of rectal intussusception were related to the main symptoms of constipation but both were associated with a tendency toward lower anal resting pressures (P = 0.04 and P = 0.06) and an obtuse anorectal angle (during evacuation, P = 0.01 and P = 0.01).CONCLUSIONS:There is no clear relationship between rectal intussusception and constipation. However, intussusception is related to sphincter function and may be of clinical relevance. A normal clinical examination will exclude most long intussusceptions, whereas a positive finding needs further evaluation with defecography.

Long-term functional outcome after restorative proctocolectomy in patients with ulcerative colitis

Aim  The aim of this study was to evaluate the long‐term functional outcome of ileal pouch–anal anastomosis for ulcerative colitis and to compare symptoms over time.