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Pictograms are Useful for the Identification of Dyssynergic Patterns Associated with Defecation
Sa1637 PICTOGRAMS ARE USEFUL FOR THE IDENTIFICATION OF DYSSYNERGIC PATTERNS ASSOCIATED WITH DEFECATION Mercedes Amieva-Balmori, Paulo Cesar Gomez-Castaños, Gabriela Rojas-Loureiro, Fausto Daniel Garcia-Garcia, Ana D. Cano Contreras, Shareni Galvez-Ríos, Jose M. Remes Troche Background: The use of pictograms has been used in functional gastrointestinal disorders to establish more clearly the perception of symptoms by patients. In a previous study (RemesTroche et al. DDW 2013) in 347 subjects with symptoms of chronic constipation and controls we showed that 98% of the healthy population adopts normal postures compared to 71% of patients suffering from pelvic floor dyssynergia (PFD). However, in this study, the utility of these postures were not compared with anorectal manometry and/or balloon expulsion test (BET). Aim: To evaluate the clinical utility of pictograms in patients with chronic constipation and to compare it with the diagnoses established by high-definition anorectal manometry (HDAM) and BET. Materials and methods: We consecutively evaluated subjects who were referred to our institution for chronic constipation over a period of 18 months. All subjects answered a symptom questionnaire that included 5 pictograms (previously validated) representing postures for defecation (Fig 1). Positions 1 and 2 are considered normal, posture 3 represents excessive push, 4 and 5 represent postures to open the anorectal angle. Subsequently all subjects underwent a HDAM- (256-sensor probe, Given, Yoqneam, Israel) and 2-minute BET. PFD was considered if they had 2 of 3 abnormal tests (anorectal examination, HDAM, and balloon expulsion). Manometrically patients with PFD were classified as having inadequate propulsion or inadequate anal sphincter relaxation/ contraction. Kappa,Sn,Sp,PPV and NPV were calculated. Results: We evaluated 96 subjects [82 women (85%)], mean age was 55.08 ± 16 years. 42 patients (43.8%) adopted one of the 3 positions suggestive of PD: 25 posture 3 and 17 postures 4 or 5. According to the definition of dyssynergy, 44 patients were classified with PFD. 76% of the patients with a dyssynergic posture had a manometric diagnosis of PFD (p = 0.0001). The agreement between a posture suggesting dyssynergia and the manometric diagnosis had a kappa of 0.537 (p = 0.0001). The sensitivity, specificity, positive and negative predictive value of the pictograms were 78%, 76%, 80.8% and 72.7% respectively. According to the subtypes of PFD 28 had inadequate propulsion and 16 inadequate relaxation or contraction. Figure 2 shows the association between pictograms and PFD subtypes according to HDAM. 89% of the patients with use of suppository had a diagnosis of PFD (p = 0.001) and 72% of these patients had a posture suggestive of dyssynergy (p = 0.06) Conclusions: This study demonstrates for the first time the diagnostic utility of pictograms associated with defecation for the diagnosis of PFD. The presence of an abnormal pictogram can guide and decide the need for diagnostic tests such as HDAM. Pictograms represent a very low cost tool available in the different scenarios where patients with chronic constipation are evaluated.
Sa1639 HISTORY OF DISORDERED EATING WITH RESTRICTIVE BEHAVIOR IS ASSOCIATED WITH SUSTAINED ALTERATIONS IN ANORECTAL AND COLONIC PHYSIOLOGY AMONG PATIENTS PRESENTING FOR CHRONIC CONSTIPATION Danielle Bellavance, Braden Kuo, Kyle Staller Background: Chronic constipation is a common complaint among patients with eating disorders (EDs), yet physiological parameters are not well characterized in this population. We sought to determine whether patients presenting for evaluation of chronic constipation with comorbid eating disorders exhibited altered colonic and anorectal physiology. Methods: We assembled a retrospective cohort of 37 ED patients presenting to a tertiary care center for evaluation of chronic constipation undergoing high-resolution anorectal manometry (HRARM) with balloon expulsion testing (BET) and transit testing via radiopaque marker (ROM) testing. ED patients in HR-ARM and transit groups were matched 1:1 by age and sex to controls with chronic constipation and no history of disordered eating. ED cases were classified by the presence of restrictive or binge eating behaviors and whether their disease was active or not. Our primary outcomes included differences in HR-ARM parameters and the presence of slow-transit via ROM testing. Results: Our study included 28 patients with restrictive eating behavior and 9 patients with binge eating behavior who were matched to 41 controls. Patients with restrictive eating were more likely to have a Dx of depression than controls, while binge eating patients were more likely to have a Dx of anxiety and depression. Of those with restricted eating, 6 patients underwent HR-ARM only, 5 patients underwent colonic transit testing only, and 17 patients underwent both tests. Compared to controls with chronic constipation, patients with restrictive eating were more likely to have delayed colonic transit (59.1% vs, 30.0%, P=0.05), lower mean rectoanal pressure differential(RAPD)(Figure 1), decreased mean and maximum resting anal pressures, and a higher proportion of an abnormal rectoanal inhibitory reflex (RAIR)(Table 1). There was no difference in proportion of patients with an abnormal BET (P all >0.05). In the binge eating group, there was no difference in colonic transit, mean resting anal pressures, RAPD, or BET compared to controls. (P>0.05) Binge eating behavior was associated with lower maximum squeeze pressure compared controls (157.8 vs. 208.3 mmHg, P=0.01). Multivariate analysis demonstrated that restrictive eating was independently-associated with slow transit (OR= 3.78, 95% CI: (1.04-15.8), P=0.05), more negative RAPD (β=-46.5, 95% CI: (-84.5-8.57), P=0.02), and abnormal RAIR (OR= 1.22, 95% CI: (1.03-1.46), P=0.02). Transit and HR-ARM parameters did not differ between patients based on current vs. past restrictive or binge eating behavior. Conclusion: Among patients presenting for the evaluation of chronic constipation, the presence of a comorbid restrictive eating disorder, regardless of whether it is active or not, is associated with alterations in colonic transit and pelvic floor function compared to constipated controls.
Sa1638 A SYSTEMATIC REVIEW AND META-ANALYSIS TO DETERMINE WHETHER BALLOON EXPULSION TESTING MIGHT BE AN APPROPRIATE INITIAL OFFICE-BASED TEST FOR DYSSYNERGIC DEFECATION Eric D. Shah, Jeremy Farida, William D. Chey BACKGROUND: Balloon expulsion testing (BET) is a recommended means of identifying dyssynergic defecation (DD) in patients with chronic constipation (CC) but remains poorly standardized and underutilized outside of specialized centers. We aimed to assess the clinical utility of BET as an initial test for DD and to determine appropriate testing parameters. METHODS: We performed a literature search (PubMED, EMBASE, conference abstracts from 1950-2016) to identify (1) case-control studies of DD or unselected CC subjects and healthy controls and (2) cohort studies of unselected subjects with CC. Eligible studies reported BET test parameters and results as well as presence of DD defined by constipation symptoms and a positive reference test (anorectal manometry[ARM], defecography, or electromyography[EMG]). Study quality was assessed using QUADAS criteria. We extracted age, sex, enrollment criteria, BET test parameters (subject position, stool surrogate, volume instilled, allowed expulsion time), and DD diagnostic criteria. Data were independently extracted by two authors. Meta-analysis was performed using a bivariate mixed-effects regression model. Meta-regression was performed to evaluate effects of individual test parameters. RESULTS: 12 studies (1,289 subjects) of BET in the seated position and 4 studies (497 subjects) in the left lateral position were included assessing unselected CC subjects.
S-315
AGA Abstracts
AGA Abstracts
Five additional case-control studies including 829 subjects were also assessed. The area under the curve (AUC) was greater than 0.79 in all analyses of BET as a diagnostic test for DD. Test performance characteristics are reported in Table 1. We performed meta-regression to clarify important test parameters and did not find differences in test results based on allowed expulsion time (p>0.9) and subject position (p>0.9). Pooled sensitivity (p>0.5) and specificity (p=0.06) were similar between seated and left lateral BET in analysis of unselected CC cohort studies, though specificity (p=0.03) was higher with left lateral BET in pooled analysis of all studies. While there were not enough studies to warrant meta-analysis of balloon distension characteristics, 13 of 17 studies instilled 50-60mL of water. There was significant between-study heterogeneity (I2>0.5) but no significant differences in metaregression of study region (p=0.4) or of ARM (p=0.4), defecography (p=0.5), or EMG (p= 0.11) as DD reference tests. There was no evidence of publication bias (p=0.5). CONCLUSIONS: The performance characteristics of BET support its use as a first-line, in-office test to identify patients with dyssynergia. Subject positioning does not significantly alter test performance. Wider utilization of BET could accelerate the time to accurate diagnosis and triage of DD patients to highly effective biofeedback training while avoiding additional testing and ineffective laxatives. Table 1: Performance characteristics of balloon expulsion testing in diagnosing dyssynergic defecation (stratified by subject positioning)
Sa1639 HISTORY OF DISORDERED EATING WITH RESTRICTIVE BEHAVIOR IS ASSOCIATED WITH SUSTAINED ALTERATIONS IN ANORECTAL AND COLONIC PHYSIOLOGY AMONG PATIENTS PRESENTING FOR CHRONIC CONSTIPATION Danielle Bellavance, Braden Kuo, Kyle Staller Background: Chronic constipation is a common complaint among patients with eating disorders (EDs), yet physiological parameters are not well characterized in this population. We sought to determine whether patients presenting for evaluation of chronic constipation with comorbid eating disorders exhibited altered colonic and anorectal physiology. Methods: We assembled a retrospective cohort of 37 ED patients presenting to a tertiary care center for evaluation of chronic constipation undergoing high-resolution anorectal manometry (HRARM) with balloon expulsion testing (BET) and transit testing via radiopaque marker (ROM) testing. ED patients in HR-ARM and transit groups were matched 1:1 by age and sex to controls with chronic constipation and no history of disordered eating. ED cases were classified by the presence of restrictive or binge eating behaviors and whether their disease was active or not. Our primary outcomes included differences in HR-ARM parameters and the presence of slow-transit via ROM testing. Results: Our study included 28 patients with restrictive eating behavior and 9 patients with binge eating behavior who were matched to 41 controls. Patients with restrictive eating were more likely to have a Dx of depression than controls, while binge eating patients were more likely to have a Dx of anxiety and depression. Of those with restricted eating, 6 patients underwent HR-ARM only, 5 patients underwent colonic transit testing only, and 17 patients underwent both tests. Compared to controls with chronic constipation, patients with restrictive eating were more likely to have delayed colonic transit (59.1% vs, 30.0%, P=0.05), lower mean rectoanal pressure differential(RAPD)(Figure 1), decreased mean and maximum resting anal pressures, and a higher proportion of an abnormal rectoanal inhibitory reflex (RAIR)(Table 1). There was no difference in proportion of patients with an abnormal BET (P all >0.05). In the binge eating group, there was no difference in colonic transit, mean resting anal pressures, RAPD, or BET compared to controls. (P>0.05) Binge eating behavior was associated with lower maximum squeeze pressure compared controls (157.8 vs. 208.3 mmHg, P=0.01). Multivariate analysis demonstrated that restrictive eating was independently-associated with slow transit (OR= 3.78, 95% CI: (1.04-15.8), P=0.05), more negative RAPD (β=-46.5, 95% CI: (-84.5-8.57), P=0.02), and abnormal RAIR (OR= 1.22, 95% CI: (1.03-1.46), P=0.02). Transit and HR-ARM parameters did not differ between patients based on current vs. past restrictive or binge eating behavior. Conclusion: Among patients presenting for the evaluation of chronic constipation, the presence of a comorbid restrictive eating disorder, regardless of whether it is active or not, is associated with alterations in colonic transit and pelvic floor function compared to constipated controls.
Sa1638 A SYSTEMATIC REVIEW AND META-ANALYSIS TO DETERMINE WHETHER BALLOON EXPULSION TESTING MIGHT BE AN APPROPRIATE INITIAL OFFICE-BASED TEST FOR DYSSYNERGIC DEFECATION Eric D. Shah, Jeremy Farida, William D. Chey BACKGROUND: Balloon expulsion testing (BET) is a recommended means of identifying dyssynergic defecation (DD) in patients with chronic constipation (CC) but remains poorly standardized and underutilized outside of specialized centers. We aimed to assess the clinical utility of BET as an initial test for DD and to determine appropriate testing parameters. METHODS: We performed a literature search (PubMED, EMBASE, conference abstracts from 1950-2016) to identify (1) case-control studies of DD or unselected CC subjects and healthy controls and (2) cohort studies of unselected subjects with CC. Eligible studies reported BET test parameters and results as well as presence of DD defined by constipation symptoms and a positive reference test (anorectal manometry[ARM], defecography, or electromyography[EMG]). Study quality was assessed using QUADAS criteria. We extracted age, sex, enrollment criteria, BET test parameters (subject position, stool surrogate, volume instilled, allowed expulsion time), and DD diagnostic criteria. Data were independently extracted by two authors. Meta-analysis was performed using a bivariate mixed-effects regression model. Meta-regression was performed to evaluate effects of individual test parameters. RESULTS: 12 studies (1,289 subjects) of BET in the seated position and 4 studies (497 subjects) in the left lateral position were included assessing unselected CC subjects.
S-315
AGA Abstracts
AGA Abstracts
Five additional case-control studies including 829 subjects were also assessed. The area under the curve (AUC) was greater than 0.79 in all analyses of BET as a diagnostic test for DD. Test performance characteristics are reported in Table 1. We performed meta-regression to clarify important test parameters and did not find differences in test results based on allowed expulsion time (p>0.9) and subject position (p>0.9). Pooled sensitivity (p>0.5) and specificity (p=0.06) were similar between seated and left lateral BET in analysis of unselected CC cohort studies, though specificity (p=0.03) was higher with left lateral BET in pooled analysis of all studies. While there were not enough studies to warrant meta-analysis of balloon distension characteristics, 13 of 17 studies instilled 50-60mL of water. There was significant between-study heterogeneity (I2>0.5) but no significant differences in metaregression of study region (p=0.4) or of ARM (p=0.4), defecography (p=0.5), or EMG (p= 0.11) as DD reference tests. There was no evidence of publication bias (p=0.5). CONCLUSIONS: The performance characteristics of BET support its use as a first-line, in-office test to identify patients with dyssynergia. Subject positioning does not significantly alter test performance. Wider utilization of BET could accelerate the time to accurate diagnosis and triage of DD patients to highly effective biofeedback training while avoiding additional testing and ineffective laxatives. Table 1: Performance characteristics of balloon expulsion testing in diagnosing dyssynergic defecation (stratified by subject positioning)