- Email: [email protected]
Mo2011 Posterior Tibial Nerve Stimulation Improves Both Urge and Mixed Urge Plus Passive Faecal Incontinence
to calculate the strength of each variable in the model. Results: Of the 146 patients who underwent EAUS 119 (81%) returned all questionnaires. FI was present in 41/146 (35%), FI of flatus in 26/41 (63%), FI of stool in 13/41 (32%) and soiling in 13/41 (32%). Fistula ramifications increased the risk of FI (60%) compared to single fistula tract (31%). After adjusting for all other variables > 1 fistulotomy carried the highest risk (80%) compared to no fistulotomy (23%), and was the strongest independent predictor for FI (correlation coefficient = 0.81). A single fistulotomy, >1 I&D and high trans-sphincteric or suprasphincteric fistula type were also associated with FI. FI was more severe after surgery for complex fistula (WX 9.6 SD 6.6) compared to simple fistula (WX 4.8 SD 3.9), P = 0.006. Impact of FI on QOL was greater after surgery for complex fistula compared to simple fistula for lifestyle (P = 0.033), depression (P = 0.007), and embarrassment (P = 0.001). Conclusion: A surgical fistulotomy was the strongest factors associated with FI. Severity of FI increased with complexity of the perianal fistula, negatively influencing experienced QOL. A shift towards performing more sphincter sparing procedures for eradicating perianal fistula is warranted.
AGA Abstracts
lengthening may be due to recruitment and anterior pull of the puborectalis muscle contraction, acting on the proximal anal segment. Figure 1
Mo2010 The Efficacy of PTNS in Anal Sphincter Defects Kemal I. Kemal, Lalit Kumar, Ahsan Alam, Amanda J. Raeburn, Anton Emmanuel Introduction: Percutaneous Tibial nerve stimulation (PTNS) is an emerging ‘step-up' treatment for patients who have not responded to conservative treatment for faecal incontinence (FI). There is limited information about its efficacy in patients with sphincteric defects. The aim of this retrospective study was to assess the efficacy of PTNS in patients with FI, comparing between patients with different sphincter pathologies. Method: Consecutive patients were studied: all had improved following the initial 12 weeks of weekly PTNS treatment and were receiving maintenance. Based on baseline endoanal ultrasound patients were placed into four categories: 1) Both sphincters intact 2) External anal sphincter (EAS) defect 3) Internal anal sphincter (IAS) defect 4) Both sphincters damaged. The outcome parameters were Wexner FI incontinence score, stool consistency and FI episodes per week (based on diary). Outcomes were compared between the pre- and post-treatment, and between posttreatment and latest maintenance (mean 12.3 (SD 7.2 months) scores. Results: Data is presented on 46 patients (40 female, mean age of 57[25 to 78]) with a mixture of aetiologies. There was statistically significant improvement in all groups comparing pre- vs post-treatment Wexner Scores (mean and SD in table). In the post vs maintenance analysis there was significant symptom exacerbation only for the intact sphincter groups, whilst persistent improvement was seen in the other three groups. In all groups incontinence episodes were reduced after PTNS, and remained at low levels during maintenance (p<0.05 vs pre-PTNS for both). No such difference in stool consistency was seen (p>0.05 vs pre-PTNS for both).
Mo2011 Posterior Tibial Nerve Stimulation Improves Both Urge and Mixed Urge Plus Passive Faecal Incontinence Kemal I. Kemal, Lalit Kumar, Ahsan Alam, Amanda J. Raeburn, Anton Emmanuel Introduction: Percutaneous Tibial nerve stimulation (PTNS) is a minimally invasive, well tolerated emerging treatment for patients who have not responded to conservative treatment for faecal incontinence (FI). There is limited information about the difference in its efficacy in patients with different FI symptoms. The aim of this retrospective study was to assess the efficacy of PTNS in patients with FI, comparing between patients with different faecal incontinence symptoms. Method: Consecutive patients were studied: all had improved following the initial 12 weeks of weekly PTNS treatment and were receiving maintenance. Based on initial presenting FI symptoms the patients were placed into three categories: 1) Urge incontinence 2) Passive 3) Passive + Urge incontinence incontinence. The outcome parameters were Wexner FI incontinence score, stool consistency and FI episodes per week (based on diary). Outcomes were compared between the pre- and post-treatment, and between pre-treatment and latest maintenance (mean 12.4 (SD 7.2 months) scores. Results: Data is presented on 44 patients (6 male, mean age of 59[25 to 77]) with a mixture of aetiologies. (With only 3 patients in the passive incontinence group, no statistical analysis was undertaken.) There was statistically significant improvement in both other groups comparing pre-vs post-treatment Wexner Scores (mean and SD in table). In addition, in the pre vs maintenance analysis there was a significant improvement seen in symptoms. There was a statistically significant improvement observed in faecal continence episodes in the pre vs maintenance analysis, but no statistically significant change in stool consistency between any groups in pre vs post and pre vs maintenance analysis. Conclusion: We have shown that PTNS improves symptoms in patients with urge incontinence and those with mixed urge and passive symptoms. The symptom improvement was maintained in all patients. Larger numbers of patients with passive incontinence need to be studied.
Figure 1: bear-down on-commode Mo2009 Factors Associated With Fecal Incontinence and Quality of Life After Perianal Surgery for Cryptoglandular Fistulas Arjan P. Visscher, Daan Schuur, Jeroen Meijerink, Grietje Van der Mijnsbrugge, Charlotte Deen, Richelle J. Felt-Bersma Introduction: Surgical management of perianal fistulas remains a challenge as consequences of repetitive anal surgery can cause profound morbidity and impair experienced quality of life (QOL). In recent years new sphincter sparing procedures such as ligation of the intersphincteric fistula tract (LIFT) have been implemented potentially lowering the chance of developing fecal incontinence (FI). Aim: This study evaluated factors associated with FI and impact on QOL after surgical treatment for perianal sepsis. Methods: All patients with cryptoglandular perianal fistulas who underwent pre-operative endoanal ultrasound (EAUS) between 2002 and 2012 at our tertiary centre and in a local clinic specialised in proctologic surgery were sent questionnaires regarding FI (Wexner (WX)- and Vaizey (VS) score) and impact of FI on QOL (FIQL) in October 2013. Data was abstracted regarding patient's demographics and all surgical procedures ever received for perianal sepsis. Predictor variables analysed were sex, age of first complains, age at follow up, fistula type, fistula ramifications, no. of perianal abscesses surgically incised and drained (I&D) (0, 1, or > 1), no. of fistulotomys received (0, 1 or > 1) and no. of sphincter sparing procedures (mucosal advancement flap or fistulectomy) received (0, 1 or 2, or > 2). The likelihood of each of these outcomes was estimated by using a multivariate regression model. The correlation coefficient was calculated
AGA Abstracts
S-716
Mo2012 EndoFLIP: A New Diagnostic Modality for Measuring Anal Canal Function Lalit Kumar, Fahad Zaman, Anton Emmanuel Introduction Anorectal manometry is a commonly used technique to assess patients with fecal incontinence, but is known to have low reproducibility and poor validation in assessment of anal sphincter function. We report a pilot study on a novel technique using Functional Lumen Imaging Probe (FLIP) to improve assessment. Although FLIP has been used in upper GI studies its use in anorectal region is limited to three published studies, all of which used a 16 cm probe (as in upper GI studies). We used a purpose built shorter catheter to demonstrate bio-mechanical properties of the anus. Methods 19 healthy volunteers were recruited (9 females), mean age 34 (20-75). Catheters were purpose built, incorporating an anal and rectal balloon, each with its own separate inflation point. Anal canal balloon was made in three different sizes (2, 3 and 4cm long). Appropriate sized catheter corresponding to the length of subject's anal canal (based on manometry) was used. 3 cross sectional area (CSA) readings were obtained with 2cm balloon, 5 with 3cm and 10 with 4cm balloon. In order to obtain meaningful results, the anal canal balloon was required to be touching the lumen wall. This was achieved by varying inflation volumes according to the balloon size. Results Participants underwent standard water-perfused anal manometry followed by FLIP on the same day. To test repeatability the FLIP was repeated after 30 minutes on the same day. The parameters checked for repeatability included CSA during rest, squeeze, endurance squeeze and cough in addition to the intra balloon pressure during these phases. Anal canal was divided into three parts- distal, mid and proximal based on anatomy and preliminary data analysis. Study established the test-retest and intra-observer repeatability for CSA using Bland-Altman plot and Intra-class correlation coefficient (ICC). Pearson correlation coefficient (PCC) was used to establish correlation between CSA and pressure. Bland Altmans plots showed measurement points for all parameters to be within 2 SD of line of equality. ICC calculated individually for each part of anal canal showed high levels of repeatability for CSA measurements (Table 1). Pressure readings were also repeatable (Table 1). Pearson correlation coefficient showed a negative correlation, between CSA and pressure, at all the balloon volumes apart from the highest (Table 2). Conclusions By allowing determination of serial CSAs during distension EndoFLIP allows detailed and segmental description of geometric and mechanical properties of the anal canal. The CSA and pressure reading were repeatable and lower CSA was associated with higher pressure across all balloon volumes apart from the highest. Possible cause for this was excessive distension of anal canal at higher balloon volumes. Validity and repeatability of EndoFLIP has been proved by this study. Intra-class correlation coefficient values
Mo2014 Influence of Body Position on Anorectal Manometric Assessment in Functional Constipation Seksit Osatakul, Sopa Boonviriya, Sulee Saengnil, Bancha Ovartlarnporn Background: To date, there has been no study to evaluate the influence of posture on anorectal manometric measurements in patients with functional constipation. AIM: To examine the difference in anorectal manometric measurements in constipated patients when performing the test in lying compared with the sitting position. Methods: Thirty constipated patients (28 female; mean age, 42.3 ± 13.6 years) according to the Rome III criteria were included in this study. All patients underwent anorectal manometry (solid state technique) in both lying in the left-lateral with flexed knees and in the sitting position in random order. Commonly measured anorectal manometric variables at rest and attempted defecation with empty rectum of both positions were compared. Patients who showed an abnormal manometric pattern of defecation either in the sitting or left-lateral position proceeded to the anorectal manometric study during attempted defecation after rectal distension with a rectal balloon in the sitting position. The colonic transit study using Sitzmarks radiopaque markers and the 50 ml water-filled balloon expulsion test were also performed in all patients. In this study, the abnormal pattern of defecation was defined according to the criteria reported by Bharucha AE, et al (Gastroenterology 2006;130:1510-8). Results: The resting rectal pressure, maximum rectal straining pressure, and defecation index during attempted defecation in the sitting position were significantly higher than in the lying position. The rectal sensory threshold (data not shown) and defecation pattern between the two positions were comparable (Table). When attempting to defecate in the lying position with empty rectum, dyssynergic defecation and functional defecation disorder were observed in 16.7%(5/30) and 30%(9/ 30) of the patients, respectively. When sitting and attempted defecation with empty rectum, 33.3% (10/30) and 23.3% (7/30) of the patients showed dyssynergia and functional defecation disorder, respectively. Of 22 patients who showed an abnormal manometric pattern during attempted defecation with empty rectum either in the lying or sitting and in the both positions, only 6 (20%) patients exhibited an abnormal pattern of defecation when bearing down on a rectal balloon in the sitting position. Conclusion: Body position contributes to the results of anorectal manometry in patients with functional constipation. Anorectal manometric measurements with empty rectum in the lying and sitting position
Table 1 Pearson correlation coefficient values
Table 2 * McNemar chi-square test; 2-sides Mo2013 Mo2015
Predictability of Functional Defecation Disorder in Patients With Chronic Constipation Using a Standardized Constipation Symptom Questionnaire Colleen H. Parker, George A. Tomlinson, Adriano J. Correia, Louis W. Liu
Preliminary Significant Findings From a Randomised Control Trial of Posterior Tibial Nerve Stimulation in Systemic Sclerosis Associated Faecal Incontinence Shamaila Butt, Ahsan Alam, Amanda J. Raeburn, Jorge B. Liwanag, Voon Ong, Christopher Denton, Charles Murray, Natalia Zarate, Anton Emmanuel
Introduction: Functional defecation disorders (DD) are found in ~30% of patients with chronic constipation (CC). The Rome III diagnostic criteria for DD require objective tests (defecography, anorectal manometry (ARM) and balloon expulsion test (BET)) in addition to the presence of CC symptoms. It is important to identify those patients with CC who have DD, as effective treatment in patients with DD frequently requires biofeedback. A recent Canadian national survey indicates that the accessibility of defecography, ARM and BET are limited, namely, 41.7%, 68.3% and 30%, respectively. There is no study, to date, that demonstrates the value of constipation symptoms in predicting patients with DD. Objective: To determine the predictability of DD in patients with CC using a standardized constipation symptom questionnaire. Methods: 166 consecutive English speaking patients
Background The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly,
S-717
AGA Abstracts
AGA Abstracts
with CC referred to a tertiary academic hospital for ARM between January 1, 2012 and August 1, 2013 were asked to independently complete a 17-question questionnaire prior to the test. The questionnaire contains CC symptoms from the Rome III criteria for DD. Answers included dichotomized (yes or no) and symptom severity measures. The technician and physician were blinded to the questionnaire answers. DD was diagnosed if BET was >1 min and pelvic floor dyssynergy was demonstrated by ARM. Likelihood ratios (LR) were calculated for individual symptoms and prespecified combinations of symptoms. LRs larger than 5 or smaller than 0.2 are clinically useful. Results: 163 (79.8% female, age 50.1 (1890) yr) completed the questionnaire. Missing data were found in 3 questionnaires. DD was diagnosed in 87 (53.4%) patients. No single constipation symptom was statistically sufficient to predict a diagnosis of DD. Patients who reported sometimes feeling an urge to defecate and a prolonged straining duration (>5 min) were more likely to have DD (LR=7.74). In patients who reported needing to strain often or always but had a short straining duration (< 2 min) during defecation, diagnosis of DD was less likely (LR=0.041). Conclusion: This is the first prospective study to demonstrate the predictability of DD using patient reported constipation symptoms: presence of urge with excessive straining >5 min helps rule in, and presence of straining of short duration <2 min helps rule out DD. This result allows clinicians to efficiently screen CC patients for DD, hence more effectively utilizing the limited resources of ARM and BET.
AGA Abstracts
lengthening may be due to recruitment and anterior pull of the puborectalis muscle contraction, acting on the proximal anal segment. Figure 1
Mo2010 The Efficacy of PTNS in Anal Sphincter Defects Kemal I. Kemal, Lalit Kumar, Ahsan Alam, Amanda J. Raeburn, Anton Emmanuel Introduction: Percutaneous Tibial nerve stimulation (PTNS) is an emerging ‘step-up' treatment for patients who have not responded to conservative treatment for faecal incontinence (FI). There is limited information about its efficacy in patients with sphincteric defects. The aim of this retrospective study was to assess the efficacy of PTNS in patients with FI, comparing between patients with different sphincter pathologies. Method: Consecutive patients were studied: all had improved following the initial 12 weeks of weekly PTNS treatment and were receiving maintenance. Based on baseline endoanal ultrasound patients were placed into four categories: 1) Both sphincters intact 2) External anal sphincter (EAS) defect 3) Internal anal sphincter (IAS) defect 4) Both sphincters damaged. The outcome parameters were Wexner FI incontinence score, stool consistency and FI episodes per week (based on diary). Outcomes were compared between the pre- and post-treatment, and between posttreatment and latest maintenance (mean 12.3 (SD 7.2 months) scores. Results: Data is presented on 46 patients (40 female, mean age of 57[25 to 78]) with a mixture of aetiologies. There was statistically significant improvement in all groups comparing pre- vs post-treatment Wexner Scores (mean and SD in table). In the post vs maintenance analysis there was significant symptom exacerbation only for the intact sphincter groups, whilst persistent improvement was seen in the other three groups. In all groups incontinence episodes were reduced after PTNS, and remained at low levels during maintenance (p<0.05 vs pre-PTNS for both). No such difference in stool consistency was seen (p>0.05 vs pre-PTNS for both).
Mo2011 Posterior Tibial Nerve Stimulation Improves Both Urge and Mixed Urge Plus Passive Faecal Incontinence Kemal I. Kemal, Lalit Kumar, Ahsan Alam, Amanda J. Raeburn, Anton Emmanuel Introduction: Percutaneous Tibial nerve stimulation (PTNS) is a minimally invasive, well tolerated emerging treatment for patients who have not responded to conservative treatment for faecal incontinence (FI). There is limited information about the difference in its efficacy in patients with different FI symptoms. The aim of this retrospective study was to assess the efficacy of PTNS in patients with FI, comparing between patients with different faecal incontinence symptoms. Method: Consecutive patients were studied: all had improved following the initial 12 weeks of weekly PTNS treatment and were receiving maintenance. Based on initial presenting FI symptoms the patients were placed into three categories: 1) Urge incontinence 2) Passive 3) Passive + Urge incontinence incontinence. The outcome parameters were Wexner FI incontinence score, stool consistency and FI episodes per week (based on diary). Outcomes were compared between the pre- and post-treatment, and between pre-treatment and latest maintenance (mean 12.4 (SD 7.2 months) scores. Results: Data is presented on 44 patients (6 male, mean age of 59[25 to 77]) with a mixture of aetiologies. (With only 3 patients in the passive incontinence group, no statistical analysis was undertaken.) There was statistically significant improvement in both other groups comparing pre-vs post-treatment Wexner Scores (mean and SD in table). In addition, in the pre vs maintenance analysis there was a significant improvement seen in symptoms. There was a statistically significant improvement observed in faecal continence episodes in the pre vs maintenance analysis, but no statistically significant change in stool consistency between any groups in pre vs post and pre vs maintenance analysis. Conclusion: We have shown that PTNS improves symptoms in patients with urge incontinence and those with mixed urge and passive symptoms. The symptom improvement was maintained in all patients. Larger numbers of patients with passive incontinence need to be studied.
Figure 1: bear-down on-commode Mo2009 Factors Associated With Fecal Incontinence and Quality of Life After Perianal Surgery for Cryptoglandular Fistulas Arjan P. Visscher, Daan Schuur, Jeroen Meijerink, Grietje Van der Mijnsbrugge, Charlotte Deen, Richelle J. Felt-Bersma Introduction: Surgical management of perianal fistulas remains a challenge as consequences of repetitive anal surgery can cause profound morbidity and impair experienced quality of life (QOL). In recent years new sphincter sparing procedures such as ligation of the intersphincteric fistula tract (LIFT) have been implemented potentially lowering the chance of developing fecal incontinence (FI). Aim: This study evaluated factors associated with FI and impact on QOL after surgical treatment for perianal sepsis. Methods: All patients with cryptoglandular perianal fistulas who underwent pre-operative endoanal ultrasound (EAUS) between 2002 and 2012 at our tertiary centre and in a local clinic specialised in proctologic surgery were sent questionnaires regarding FI (Wexner (WX)- and Vaizey (VS) score) and impact of FI on QOL (FIQL) in October 2013. Data was abstracted regarding patient's demographics and all surgical procedures ever received for perianal sepsis. Predictor variables analysed were sex, age of first complains, age at follow up, fistula type, fistula ramifications, no. of perianal abscesses surgically incised and drained (I&D) (0, 1, or > 1), no. of fistulotomys received (0, 1 or > 1) and no. of sphincter sparing procedures (mucosal advancement flap or fistulectomy) received (0, 1 or 2, or > 2). The likelihood of each of these outcomes was estimated by using a multivariate regression model. The correlation coefficient was calculated
AGA Abstracts
S-716
Mo2012 EndoFLIP: A New Diagnostic Modality for Measuring Anal Canal Function Lalit Kumar, Fahad Zaman, Anton Emmanuel Introduction Anorectal manometry is a commonly used technique to assess patients with fecal incontinence, but is known to have low reproducibility and poor validation in assessment of anal sphincter function. We report a pilot study on a novel technique using Functional Lumen Imaging Probe (FLIP) to improve assessment. Although FLIP has been used in upper GI studies its use in anorectal region is limited to three published studies, all of which used a 16 cm probe (as in upper GI studies). We used a purpose built shorter catheter to demonstrate bio-mechanical properties of the anus. Methods 19 healthy volunteers were recruited (9 females), mean age 34 (20-75). Catheters were purpose built, incorporating an anal and rectal balloon, each with its own separate inflation point. Anal canal balloon was made in three different sizes (2, 3 and 4cm long). Appropriate sized catheter corresponding to the length of subject's anal canal (based on manometry) was used. 3 cross sectional area (CSA) readings were obtained with 2cm balloon, 5 with 3cm and 10 with 4cm balloon. In order to obtain meaningful results, the anal canal balloon was required to be touching the lumen wall. This was achieved by varying inflation volumes according to the balloon size. Results Participants underwent standard water-perfused anal manometry followed by FLIP on the same day. To test repeatability the FLIP was repeated after 30 minutes on the same day. The parameters checked for repeatability included CSA during rest, squeeze, endurance squeeze and cough in addition to the intra balloon pressure during these phases. Anal canal was divided into three parts- distal, mid and proximal based on anatomy and preliminary data analysis. Study established the test-retest and intra-observer repeatability for CSA using Bland-Altman plot and Intra-class correlation coefficient (ICC). Pearson correlation coefficient (PCC) was used to establish correlation between CSA and pressure. Bland Altmans plots showed measurement points for all parameters to be within 2 SD of line of equality. ICC calculated individually for each part of anal canal showed high levels of repeatability for CSA measurements (Table 1). Pressure readings were also repeatable (Table 1). Pearson correlation coefficient showed a negative correlation, between CSA and pressure, at all the balloon volumes apart from the highest (Table 2). Conclusions By allowing determination of serial CSAs during distension EndoFLIP allows detailed and segmental description of geometric and mechanical properties of the anal canal. The CSA and pressure reading were repeatable and lower CSA was associated with higher pressure across all balloon volumes apart from the highest. Possible cause for this was excessive distension of anal canal at higher balloon volumes. Validity and repeatability of EndoFLIP has been proved by this study. Intra-class correlation coefficient values
Mo2014 Influence of Body Position on Anorectal Manometric Assessment in Functional Constipation Seksit Osatakul, Sopa Boonviriya, Sulee Saengnil, Bancha Ovartlarnporn Background: To date, there has been no study to evaluate the influence of posture on anorectal manometric measurements in patients with functional constipation. AIM: To examine the difference in anorectal manometric measurements in constipated patients when performing the test in lying compared with the sitting position. Methods: Thirty constipated patients (28 female; mean age, 42.3 ± 13.6 years) according to the Rome III criteria were included in this study. All patients underwent anorectal manometry (solid state technique) in both lying in the left-lateral with flexed knees and in the sitting position in random order. Commonly measured anorectal manometric variables at rest and attempted defecation with empty rectum of both positions were compared. Patients who showed an abnormal manometric pattern of defecation either in the sitting or left-lateral position proceeded to the anorectal manometric study during attempted defecation after rectal distension with a rectal balloon in the sitting position. The colonic transit study using Sitzmarks radiopaque markers and the 50 ml water-filled balloon expulsion test were also performed in all patients. In this study, the abnormal pattern of defecation was defined according to the criteria reported by Bharucha AE, et al (Gastroenterology 2006;130:1510-8). Results: The resting rectal pressure, maximum rectal straining pressure, and defecation index during attempted defecation in the sitting position were significantly higher than in the lying position. The rectal sensory threshold (data not shown) and defecation pattern between the two positions were comparable (Table). When attempting to defecate in the lying position with empty rectum, dyssynergic defecation and functional defecation disorder were observed in 16.7%(5/30) and 30%(9/ 30) of the patients, respectively. When sitting and attempted defecation with empty rectum, 33.3% (10/30) and 23.3% (7/30) of the patients showed dyssynergia and functional defecation disorder, respectively. Of 22 patients who showed an abnormal manometric pattern during attempted defecation with empty rectum either in the lying or sitting and in the both positions, only 6 (20%) patients exhibited an abnormal pattern of defecation when bearing down on a rectal balloon in the sitting position. Conclusion: Body position contributes to the results of anorectal manometry in patients with functional constipation. Anorectal manometric measurements with empty rectum in the lying and sitting position
Table 1 Pearson correlation coefficient values
Table 2 * McNemar chi-square test; 2-sides Mo2013 Mo2015
Predictability of Functional Defecation Disorder in Patients With Chronic Constipation Using a Standardized Constipation Symptom Questionnaire Colleen H. Parker, George A. Tomlinson, Adriano J. Correia, Louis W. Liu
Preliminary Significant Findings From a Randomised Control Trial of Posterior Tibial Nerve Stimulation in Systemic Sclerosis Associated Faecal Incontinence Shamaila Butt, Ahsan Alam, Amanda J. Raeburn, Jorge B. Liwanag, Voon Ong, Christopher Denton, Charles Murray, Natalia Zarate, Anton Emmanuel
Introduction: Functional defecation disorders (DD) are found in ~30% of patients with chronic constipation (CC). The Rome III diagnostic criteria for DD require objective tests (defecography, anorectal manometry (ARM) and balloon expulsion test (BET)) in addition to the presence of CC symptoms. It is important to identify those patients with CC who have DD, as effective treatment in patients with DD frequently requires biofeedback. A recent Canadian national survey indicates that the accessibility of defecography, ARM and BET are limited, namely, 41.7%, 68.3% and 30%, respectively. There is no study, to date, that demonstrates the value of constipation symptoms in predicting patients with DD. Objective: To determine the predictability of DD in patients with CC using a standardized constipation symptom questionnaire. Methods: 166 consecutive English speaking patients
Background The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly,
S-717
AGA Abstracts
AGA Abstracts
with CC referred to a tertiary academic hospital for ARM between January 1, 2012 and August 1, 2013 were asked to independently complete a 17-question questionnaire prior to the test. The questionnaire contains CC symptoms from the Rome III criteria for DD. Answers included dichotomized (yes or no) and symptom severity measures. The technician and physician were blinded to the questionnaire answers. DD was diagnosed if BET was >1 min and pelvic floor dyssynergy was demonstrated by ARM. Likelihood ratios (LR) were calculated for individual symptoms and prespecified combinations of symptoms. LRs larger than 5 or smaller than 0.2 are clinically useful. Results: 163 (79.8% female, age 50.1 (1890) yr) completed the questionnaire. Missing data were found in 3 questionnaires. DD was diagnosed in 87 (53.4%) patients. No single constipation symptom was statistically sufficient to predict a diagnosis of DD. Patients who reported sometimes feeling an urge to defecate and a prolonged straining duration (>5 min) were more likely to have DD (LR=7.74). In patients who reported needing to strain often or always but had a short straining duration (< 2 min) during defecation, diagnosis of DD was less likely (LR=0.041). Conclusion: This is the first prospective study to demonstrate the predictability of DD using patient reported constipation symptoms: presence of urge with excessive straining >5 min helps rule in, and presence of straining of short duration <2 min helps rule out DD. This result allows clinicians to efficiently screen CC patients for DD, hence more effectively utilizing the limited resources of ARM and BET.