Assessment of functional defecation disorders using anorectal manometry

PURPOSE: The aim was to evaluate the discriminating accuracy of anorectal manometry (ARM) between nonconstipated (NC) subjects and functionally constipated (FC) subjects, and between FC subjects with and without functional defecation disorder (FDD). METHODS: Among female patients who visited anorectal physiology unit, those who could be grouped to following categories were included; FC group with FDD (+FDD subgroup), or without FDD (−FDD subgroup) and NC group. ARM was performed and interpreted not only with absolute pressure values, but also pattern classification and quantification of pressure changes in the rectum and anus during attempted defecation. RESULTS: There were 76 subjects in NC group and 75 in FC group. Among FC group, 63 subjects were in −FDD subgroup and 12 in +FDD subgroup. In pattern classification of pressure changes, type 0, as ‘normal’ response, was only slightly more prevalent in NC group than in FC group. When all ‘abnormal’ types (types 1–5) were considered together as positive findings, the sensitivity and specificity of pattern classification in diagnosing FC among all subjects were 89.3% and 22.7%. Those values in diagnosing FDD among FC group were 91.7% and 11.1%. Manometric defecation index (MDI) as a quantification parameter was significantly different between −FDD and +FDD subgroups. Other conventional absolute pressures were mostly comparable between the groups. CONCLUSION: Among all parameters of ARM, MDI was useful to diagnose FDD in FC patients. Other parameters including the pattern classification were questionable in their ability to diagnose FDD.

Clinical utility of balloon expulsion test for functional defecation disorders

PURPOSE: I investigated the diagnostic accuracy of balloon expulsion test (BET) with various techniques to find out the most appropriate method, and tried to confirm its clinical utility in diagnosing functional defecation disorders (FDD) in constipated patients. METHODS: Eighty-seven patients constituted the study population. FDD was defined when patients had at least two positive findings in defecography, manometry, and electromyography. BET was done 4 times in each patient with 2 different positions and 2 different volumes. The positions were seated position (SP) and left lateral decubitus position (LDP). The volumes were fixed volume (FV) of 60 mL and individualized volume with which patient felt a constant desire to defecate (CDV). The results of BETs with 4 different settings (LDP-FV, LDP-CDV, SP-FV, and SP-CDV) were statistically compared and analyzed. RESULTS: Of 87 patients, 23 patients (26.4%) had at least two positive findings in 3 tests and thus were diagnosed to have FDD. On receiver operating characteristic curve analysis, area under curve was highest in BET with SP-FV. With a cutoff value of 30 seconds, the specificity of BET with SP-FV was 86.0%, sensitivity was 73.9%, negative predictive value was 89.8%, positive predictive value was 65.4%, and accuracy rate was 82.8% for diagnosing FDD. CONCLUSION: SP-FV is the most appropriate method for BET. In this setting, BET has a diagnostic accuracy sufficient to identify constipated patients who do not have FDD. Patients with negative results in BET with SP-FV may not need other onerous tests to exclude FDD.

Prognostic Inflammation Score in Surgical Patients with Colorectal Cancer

Several inflammatory markers have been investigated as prognostic parameters in a variety of cancer population with mostly favorable results. This study aimed to verify the significance of common inflammatory markers as prognostic variables and assess whether a selective combination of them as prognostic inflammation score (PIS) could further improve their prognostic values in surgical patients with colorectal cancer (CRC). A total of 265 patients who had undergone curative resection of CRC were reviewed retrospectively. Preoperative levels of inflammatory markers such as serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and neutrophil/lymphocyte ratio (NLR) were assessed by uni- and multivariate survival analysis with disease-free (DFS) and disease-specific survival (DSS). PIS was constructed with a selective combination of inflammatory markers which were independently significant. On univariate analysis, CRP, ESR, and NLR were significantly associated with DFS and DSS. On multivariate analysis, CRP and NLR were independently significant prognostic variables for DSS and DFS respectively (P=0.013, P=0.021). When PIS was constructed with combination of CRP and NLR, it was independently and significantly associated with both DFS and DSS (P=0.006, P=0.010). Furthermore, PIS was superior to CRP for DSS (HR=15.679 vs. HR=5.183), and NLR for DFS in terms of prognosticating power (HR=4.894 vs. HR=2.687). When PIS is constructed with combination of CRP and NLR, it is a potentially significant prognostic variable associated with poor survival regardless pathologic prognostic variables in patients with CRC after curative resection.

Erratum: Significance of defecographic parameters in diagnosing pelvic floor dyssynergia / 대한외과학회지

There were term errors at the end portion of third paragraph in METHODS section of main text.

Significance of defecographic parameters in diagnosing pelvic floor dyssynergia / 대한외과학회지

PURPOSE: Defecography is known to be a sensitive and specific measurement of pelvic floor dyssynergia (PFD). However, its standardized parameter for diagnostic analysis is still incomplete. We attempted to determine which defecographic findings are most significant for PFD, and how closely they match other physiologic tests and clinical symptoms of functional pelvic outlet obstruction. METHODS: Ninety-six patients with constipation who completed work-up of their symptoms with defecography, anorectal manometry and electromyography (EMG) were included in the study. Internal consistency of defecographic findings, and agreements between defecographic findings and results of other tests were statistically analyzed (Crohnbach's alpha, Cohen's kappa, respectively). RESULTS: Of the 96 patients evaluated, obstructive symptoms of constipation were obvious in 35 (36.5%) by obstructive symptom score. As known defecographic findings for PFD, poor opening of the anal canal was found in 33 (34.4%), persistent posterior angulation of the rectum in 33 (34.4%), and poor emptying of the rectum in 61 (63.5%). Manometric defecation index, manometric evacuation index, and EMG findings compatible with PFD were in 81 (84.4%), 72 (75%), and 73 (76%), respectively. Internal consistency of three defecographic findings was good (alpha = 0.78). Agreements between each defecographic findings and each result of other tests were all poor. CONCLUSION: Among known defecographic findings for PFD, one specific finding cannot be considered more important than the others for its diagnosis. It is hard to expect consistent results of various diagnostic tests and to predict the presence of defecographic PFD by use of anorectal manometry, EMG, or even by clinical symptoms.

Determinant of Anal Resting Pressure Gradient in Association With Continence Function

BACKGROUND/AIMS: Gradient of resting pressure across the anal canal, which is known to have a role in continence mechanism, has 2 components of determination; pressure and length factor of the anal canal. This study evaluates which factor between them plays more significant role for the determination of the gradient in association with continence function. METHODS: Anal manometric measurements of 69 patients with fecal incontinence and 60 controls were retrospectively reviewed. In addition to resting pressure gradient, typical manometric parameters such as maximum resting pressure, basal resting pressure, length of the anal canal, length of high pressure zone and relative position of highest pressure, which were measured with rapid pull-through technique were all contrasted. RESULTS: Demographics of the 2 groups were similar. Maximum resting pressures of patients with incontinence and controls were 59.1 +/- 28.3, 74.6 +/- 24.0 mmHg (P = 0.001), respectively. Basal resting pressures were 5.7 +/- 6.4 and 7.3 +/- 3.9 mmHg (P = 0.097), lengths of the anal canal were 35.8 +/- 9.1 and 38.1 +/- 8.3 mm (P = 0.133), lengths of high pressure zone were 21.2 +/- 6.7 and 23.3 +/- 6.5 mm (P = 0.091), relative positions of highest pressure were 69.2 +/- 10.6 and 70.1% +/- 14.9% (P = 0.717) and resting pressure gradients were 2.28 +/- 1.08 and 2.74 +/- 1.14 mmHg/mm (P = 0.019), respectively. Difference was significant in maximum resting pressure and resting pressure gradient, but not in length factors such as full length of the anal canal, length of high pressure zone and relative position of highest pressure. CONCLUSIONS: Proximal location of high pressure zone in incontinent patients is not definite and resting pressure gradient of the anal canal depends more on pressure factor than length factor in association with continence function.

Comparative analysis of summary scoring systems in measuring fecal incontinence / 대한외과학회지

PURPOSE: For measuring symptoms of fecal incontinence, summary scoring systems are widely used, but rigorous psychometric validation or assessment of such systems in terms of patients' subjective perception has rarely been done to date. This study was designed to assess the correlation between each severity measure and patients' subjective perception or clinicians' clinical assessment. We attempted to compare summary scoring systems of severity measures and searched for which of them showed higher validity among them. METHODS: Consecutive patients who visited our clinic with fecal incontinence were prospectively evaluated. A total of 43 patients were included. Four summary scoring systems were chosen for comparison: the Rothenberger, Wexner, Vaizey and Fecal Incontinence Severity Index systems. They are correlated with subjective perception scores by patients, and also with clinical assessment scores by investigators. RESULTS: There was no significant difference between clinical scores of two investigators (paired t-test, P = 0.988). Inter-observer reliability was 0.95 (Intra-class correlation coefficient, 95% confidence interval 0.91 to 0.98). Significant correlations were proved between patients' subjective perception scores and all the summary scoring systems, and also between the mean clinical scores and all the summary scoring systems. The highest was with the Wexner scale (r = 0.66, P < 0.001) (r = 0.70, P < 0.001), and the lowest was with the Rothenberger scale (r = 0.58, P < 0.001) (r = 0.61, P < 0.001) in both correlations. CONCLUSION: The Wexner scale correlates the most closely with subjective perception of severity of symptoms by patients, and also with clinical assessment by investigators. We recommend the Wexner scale among summary scoring systems as a tool for measuring fecal incontinence.

Comparative analysis of summary scoring systems in measuring fecal incontinence / 대한외과학회지

PURPOSE: For measuring symptoms of fecal incontinence, summary scoring systems are widely used, but rigorous psychometric validation or assessment of such systems in terms of patients' subjective perception has rarely been done to date. This study was designed to assess the correlation between each severity measure and patients' subjective perception or clinicians' clinical assessment. We attempted to compare summary scoring systems of severity measures and searched for which of them showed higher validity among them. METHODS: Consecutive patients who visited our clinic with fecal incontinence were prospectively evaluated. A total of 43 patients were included. Four summary scoring systems were chosen for comparison: the Rothenberger, Wexner, Vaizey and Fecal Incontinence Severity Index systems. They are correlated with subjective perception scores by patients, and also with clinical assessment scores by investigators. RESULTS: There was no significant difference between clinical scores of two investigators (paired t-test, P = 0.988). Inter-observer reliability was 0.95 (Intra-class correlation coefficient, 95% confidence interval 0.91 to 0.98). Significant correlations were proved between patients' subjective perception scores and all the summary scoring systems, and also between the mean clinical scores and all the summary scoring systems. The highest was with the Wexner scale (r = 0.66, P < 0.001) (r = 0.70, P < 0.001), and the lowest was with the Rothenberger scale (r = 0.58, P < 0.001) (r = 0.61, P < 0.001) in both correlations. CONCLUSION: The Wexner scale correlates the most closely with subjective perception of severity of symptoms by patients, and also with clinical assessment by investigators. We recommend the Wexner scale among summary scoring systems as a tool for measuring fecal incontinence.

The Efficacy of the Coaxial Technique Using a 6-Fr Introducer Sheath in Stent Placement for Treating the Obstructions Proximal to the Descending Colon

OBJECTIVE: We wanted to evaluate the efficacy of stent placement using the coaxial technique with a stiff, long introducer sheath in patients with technical failure using an angiographic catheter for the obstructions proximal to the descending colon. MATERIALS AND METHODS: Self-expandable metallic stent placement was attempted under fluoroscopy-guidance in 77 consecutive patients who had malignant colorectal obstruction. Stent placement was performed using an angiographic catheter and a guide wire. If the angiographic catheter could not be advanced over the guide wire into the obstructive lesions proximal to the descending colon, then a 6-Fr introducer sheath was used. The technical success rate, the clinical success rate and the complications were analyzed. RESULTS: Successful stent placement was achieved in 75 of 77 patients (97%). The angiographic catheter failed to advance into the obstructive lesions of 11 patients (M:F = 7:4; mean age, 65.5 years) whose lesions were at the level of the splenic flexure or transverse colon. Therefore, the coaxial technique was implemented in all these 11 patients using a 6-Fr stiff introducer sheath and then the stent placement was successful. There were no complications related to the use of a stiff introducer sheath. Clinical success, which was defined as relief of clinical obstructive bowel symptoms, was obtained within 24 hours in all of patients. CONCLUSION: The coaxial technique using a stiff introducer sheath can increase the technical success of fluoroscopy-guided, self-expandable metallic stent placement in patients with colonic obstruction proximal to the descending colon.

Torus Hyperplasia of the Pyloric Antrum

Primary or idiopathic hypertrophy of the pyloric muscle in adult, so called torus hyperplasia, is an infrequent but an established entity. It is caused by a circular muscle hypertrophy affecting the lesser curvature near the pylorus. Since most of the lesions are difficult to differentiate from tumor, distal gastrectomy is usually preformed to rule out most causes of pyloric lesions including neoplastic ones through a pathological study. A 56-yr-old man with a family history of gastric cancer presented with abdominal discomfort of 1 month duration. Upper gastrointestinal endoscopy showed a 1.0 cm sized irregular submucosal lesion proximal to the pylorus to the distal antrum on the lesser curvature. On colonoscopy examination, a 1.5 cm sized protruding mass was noticed on the appendiceal orifice. Gastrectomy and cecectomy were done, and histological section revealed marked hypertrophy of the distal circular pyloric musculature and an appendiceal mucocele. To the best of our knowledge, this is the first case of torus hyperplasia with appendiceal mucocele which is found incidentally.

A Comparative Study about Complications of Laparoscopic Appendectomy in Children and Adults

PURPOSE: In recent studies, laparoscopic appendectomy has been widely performed for not only uncomplicated appendicitis but also perforated appendicitis. But, in children, the value of laparoscopic appendectomy for acute appendicitis is not yet established. Our retrospective study is to evaluate the safety of laparoscopic surgery for acute appendicitis in children. METHODS: We reviewed electronic medical records of a total of 595 patients (95 children and 500 adults), who had been operated upon for acute appendicitis, from August 2005 to February 2007. Those patients were divided into two groups; children and adults. Demographic data, duration of pain, diagnostic methods, length of stay, operative time, time under anesthetic, time to diet, perforation rate, and complication rates were analyzed. RESULTS: In eight adult patients, laparoscopic surgery was converted to open laparatomy. There was no significant difference in perforation rates (children 20.0% vs. adults 18.1%, P=0.714). However, postoperative complication rates were significantly higher in the children group (7.4%) compared to the adult group (2.2%). CONCLUSION: We noted that laparoscopic appendectomy should be applied cautiously, especially in pediatric groups due to the relatively high complication rate. However, we need to see more high-quality randomized trials.

Evaluation of Anal Continence Function by Advanced Anal Manometric Parameters

PURPOSE: Anal manometry is one of the most commonly used tests to evaluate fecal continence function. Advanced pressure parameters of the tests, such as fatigue rate index (FRI), resting rectoanal pressure gradient (RPG), cough index (CI), and radial asymmetry (RA) are recently devised to make up the inaccuracy of conventional parameters, but without solid verification. The object of this study is to investigate such parameters including conventional ones in incontinent patients compared with those in controls and to determine the significance of each parameter. METHODS: Forty-four patients with anal incontinence and 42 controls were studied. We examined conventional pressure parameters (mean resting pressure [MRP], maximum squeeze pressure [MXSP]) and advanced parameters (RPG, FRI, CI, RA), and compare those parameters with normal controls. Multiple logistic regression analysis and receiver operating characteristic curve analyses were also performed. RESULTS: No difference was detected in demographic factors between the two groups. Basic manometric parameters were significantly different between the two groups (MRP, 31.1+/-20.7 mmHg vs. 41.4+/-18.6 mmHg, P=0.0170; MXSP, 203.1+/-84.3 mmHg vs. 258.5+/-105.9 mmHg, P=0.0086). Among advanced parameters, RPG and FRI were significantly different (2.83+/-1.54 vs. 4.08+/-1.53, P=0.0003; 9+/-21.6 sec vs. 75.6+/-12.1 sec, P=0.0333), but CI and RA were not so different (0.74+/-0.45 vs. 0.61+/-0.33, P=0.1326; 22.7+/-7.0% vs. 21.1+/-7.6%, P=0.3244). Only RPG was significant in multiple logistic regression analysis (P=0.019). Areas under ROC curves were 0.65 for MRP, 0.65 for MXSP, 0.82 for RPG, and 0.73 for FRI. CONCLUSION: Among anal manometric pressure parameters, RPG and FRI as advanced parameters are more accurate than any other parameters in detecting fecal incontinence.

Hyperplastic Polyposis Associated with Two Synchronous Colon Cancers

Hyperplastic polyps are common large-bowel tumors, are frequently detected in middle- to old- aged people, and usually are minuscule lesions in the distal colon and rectum. Most hyperplastic polyps have no malignant potential, but recent studies suggest that some hyperplastic polyps can progress to colorectal cancers, possibly by the so-called serrated pathway. Hyperplastic polyposis is a rare syndrome characterized by multiple hyperplastic polyps, primarily in the proximal colon. Different from sporadic hyperplastic polyps, hyperplastic polyposis is alleged to have high potential for malignancy because patients with this syndrome may frequently have conventional adenomas, serrated adenomas, and adenocarcinomas. We report the case of a patient with hyperplastic polyposis, who had two synchronous colon cancers, as well as sessile serrated adenomas and tubular adenomas.

Re-evaluation of the Clinical Significance of the Fatigue Rate Index in the External Anal Sphincter

PURPOSE: The fatigue rate index (FRI) has been developed to access sustained voluntary contraction of the external anal sphincter. This study is designed to refine the technical aspects of measuring the FRI and to re-evaluate its clinical significance. METHODS: Thirty-eight patients with fecal incontinence (19 males, 19 females) and 37 (21 males, 16 females) controls were studied. Anal manometry was performed by using standard protocols. Fatigue was measured over a 20-sec squeeze at a high-pressure zone. The FRI was calculated from the maximum squeeze pressure (MXSP) and the fatigue rate. For the accuracy of the calculation, the mean resting pressure (MRP) was calibrated to zero before the metric procedure, representative segments of the calculation were selectively designated as those denoting sustained squeeze, and representative channels were designated from among 8 channels by using 3 or more of those showing typical sustaining-pressure curves. RESULTS: No difference in demographic factors was detected between the two groups. Basic manometric parameters were significantly different between the two groups (MRP, 29.4+/-21.3 vs. 44.4+/-17.8 mmHg, P=0.0015; MXSP, 205.9+/-98.0 vs. 274.2+/-106.5 mmHg, P=0.0051). The FRI was also significantly different (29.8+/-14.3 vs. 86.3+/-127.1 sec, P=0.0108). The areas under the receptor operating-characteristic curves for the MRP, the MXSP, and the FRI were 0.72, 0.69, and 0.84, respectively. The sensitivity and the specificity of the FRI for detecting fecal incontinence were 80% and 65% at 40 sec as a cut-off point. CONCLUSION: The FRI was proven to be more accurate than the MRP and the MXSP in detecting incontinence. With adequate modifications of the measuring method, measurement of the FRI could be done more easily and conveniently, but its cut-off point for detecting fecal incontinence was lower than previously reported.

Presence of Iron in Colorectal Adenomas and Adenocarcinomas

BACKGROUND/AIMS: Iron overload reportedly increases the risk of colorectal neoplasms, but the distribution of tissue iron in a colorectal neoplasm remains controversial. In this study, we attempted to determine the significance of tissue iron in colorectal adenomas and adenocarcinomas. METHODS: This study investigated 138 colorectal neoplasms (54 adenocarcinomas, 25 adenomas with high-grade dysplasia, and 59 adenomas with low-grade dysplasia) that were removed by surgical or endoscopic resection in Konkuk University Hospital between August 2005 and August 2006. Adjacent normal colon tissues and colorectal neoplasms were stained with Perls' Prussian blue to reveal ferric compounds. RESULTS: Positive Perls' staining was evident in 35.2% (19/54) of the adenocarcinomas and 22.6% (19/84) of the adenomas, and in only 2.2% (3/138) of the samples of adjacent normal colon tissue (p<0.001). Iron appears to reside exclusively in the stroma and outside the gland, rather than in the epithelial cells. Iron expression was strong in larger (p=0.004) and pedunculated (p<0.001) adenomas, and in all types of adenocarcinomas regardless of their size, shape, and location. CONCLUSIONS: The frequent presence of iron in the stroma of large adenomas, pedunculated adenomas, and adenocarcinomas indicates that iron deposition is a secondary phenomenon to intralesional hemorrhage rather than a consequence of epithelial-cell carcinogenesis.

Sonic Hedgehog Expression in Colorectal Neoplasms

BACKGROUND/AIMS: Dysregulation of the hedgehog pathway has been implicated in regeneration and carcinogenesis, leading to the expression of the sonic hedgehog (Shh) protein in gastrointestinal neoplasms. The expression of Shh in colon neoplasms and paired normal colonic mucosa was therefore investigated. METHODS: Forty-four colon cancers and 73 colon adenomas that were removed by surgical colectomy or colon polypectomy between August 2005 and August 2006 were included. Colorectal neoplasms and the adjacent normal colon tissue were examined by immunohistochemistry using rabbit polyclonal Shh antibody. RESULTS: Expression of Shh was up-regulated in adenomas and adenocarcinomas of the colon compared to normal colon tissues (p<0.001). The degree of Shh expression was not associated with the size, shape, or, location of the tumor, or as the age and gender of the patient. In normal colonic epithelium, Shh was expressed at the apex of the crypts and in a few basally-located cells. CONCLUSIONS: Higher levels of Shh expression in colonic adenoma and adenocarcinoma suggest that Shh is required during epithelial proliferation in the colon. Hedgehog signaling is likely to be associated with early tumorigenesis in colonic neoplasms.

Clinical Application of Anorectal Physiologic Tests

No abstract available.

Diagnosis and Management of Fecal Incontinence

Fecal incontinence is a common problem that is underreported, underdiagnosed and poorly managed. It profoundly affects the quality of life and psychological function. It is widely known that the diversity of causes of fecal incontinence and different modes of action of various treatment modalities mandates a tailored approach in each case. Currently, several diagnostic tests are available that can provide useful insights regarding the pathophysiology of fecal incontinence, and also several advanced treatment modalities which make it possible to rehabilitate most of these patients become recently available. Strictly speaking, however, no specific test can tell the exact etiology of fecal incontinence and the modes of action in various treatment modalities are still not well-defined. In this sense, policy of approach to patients with fecal incontinence can rather be straightforward. Patients with endosonographically proven sphincteric defect should be treated with sphincteroplasty. But for patients without such defect, less invasive procedures among recently available modalities should be the first consideration and then more invasive ones next in case of failure.

The Role of Rectoanal Inhibitory Reflex in the Anal Continence Function

PURPOSE: The rectoanal inhibitory reflex (RAIR) aids the anal continence function by a sampling process. On the other hand, it might impair the anal continence function because the internal anal sphincter is relaxed during the reflex. We assessed the parameters of RAIR in incontinent patients with or without a sphincter defect and compared them with healthy control subjects to clarify the exact role of that reflex in the anal continence function. METHODS: The recovery time, slope, amplitude, and area under the reflex curve of the RAIR were measured for 31 normal controls without any history of anorectal surgery (group A), 32 incontinent patients with a sphincter defect (group B), and 49 incontinent patients without a sphincter defect (group C). Incontinence was defined as bowel accidents of more than 3 by the Cleveland Clinic Florida score. A sphincteric defect was defined endoanal sonographically. The mean ages of group A, B, and C were 57.9+/-14.3, 54.5+/-13.6, and 61.8+/-15.4 years, respectively. RESULTS: When group A and group B+C were compared, the recovery times (seconds) were 17.5+/-3.5 and 14.8+/-5.5 (P=.003), the slopes (mmHg/second) were 0.67+/-3.04 and 3.27+/-2.44 (P<.001), the amplitudes (%) were 7.0+/-16.5 and 53.3+/-19.4 (P=.352), and the area under the reflex curve (mmHg*seconds) were 230.2+/-102.15 and 173.0+/-140.8 (P=.020). When group B and group C were compared, the recovery times were 15.0+/-5.8 and 14.7+/-5.3 (P=.828), the slopes were 3.6+/-2.8 and 3.1+/-2.2 (P= .388), the amplitudes were 54.2+/-22.4 and 52.7+/-17.4 (P=.737), and the area under the reflex curve were 188.0+/-151.1 and 163.2+/-134.3 (P=.443). All parameters of the RAIR, except the amplitude were significantly diminished in incontinent patients whether they had a sphincter defect or not. CONSLUSIONS: Although the RAIR functions against continence in normal conditions by inhibiting sphincteric tone, it behaves suitably for keeping continence in the presence of incontinence, whatever the cause is, by attenuating the degree of inhibition.

Diagnosis of Non-relaxing Puborectalis Syndrome by using the Manometric Defecation Index

PURPOSE: Currently, various tools are used for the diagnosis of nonrelaxing puborectalis syndrome (NRPRS), one of major causes of chronic constipation. Defecography, electromyography (EMG), balloon expulsion test, and a colon transit time study one examples of such tools, but none can be said to be the most accurate and effective one. A diagnosis is only made when two or more examinations show positive findings simultaneously. The aim of this study is to assess the correlation between EMG and the manometric defecation index (DI), which is a relatively new parameter, for the diagnosis of NRPRS. METHODS: Forty-two chronically cornstipated patients without any history of anal or abdominal surgery underwent both anorectal manometric and EMG tests. The manometric defecation index (DI) was defined as the ratio between the peak rectal pressure and the peak anal pressure when the pressures were measured simultaneously during push by the catheter with longitudinally arranged side holes. The ratio of EMG activity was defined as the ratio between the peak amplitude during push and the peak amplitude during rest when EMG activities were measured by using an anal plug electrode. The two variables were compared prospectively, and their correlation was analyzed. RESULTS: The manometric DI and the ratio of EMG activit in 42 patients were 0.80+/-0.75 and 1.50+/-0.65, respectively. The correlation coefficient between the two variables was -0.50 (P= 0.001). CONCLUSIONS: The manometric DI and the ratio of EMG activit were correlated significantly. Therefore, it can be said that the anorectal manometric test can replace the EMG test for diagnosis of NRPRS, which has less convenient access for most colorectal surgeons.