Study of defecation disorders in elderly patients / Estudo dos distúrbios da defecação em pacientes idosos

Abstract Introduction: Defecation disorders, whether anal incontinence or chronic intestinal constipation, are frequent pelvic floor alterations in the general population and are more common in those with risk factors,i.e., in the elderly, women with an obstetric background, and those with comorbidities, history of pelvic radiotherapy, diabetics, the bedridden, or those with history of orifice surgery, among others. Objective: To analyze the incidence of defecation disorders in geriatric patients treated at the Medical Specialties Outpatient Service (MSOS) of Hospital Santa Marcelina. Methods: Prospective, randomized study that interviewed the same patients in two moments: 1) subjective anamnesis through spontaneous history and 2) objective anamnesis with specific questionnaires to assess anal incontinence and chronic constipation. Results: Between March 2016 and June 2017, 149 patients were analyzed, of whom 114 (76.5%) were female, with a similar mean age between genders; 51.67% had symptoms of anal incontinence and/or chronic constipation. Only 35.5% of patients with complaints of fecal leakage or flatus spontaneously reported them, while 87.1% of constipated patients did so. In the present study, no significant correlation was observed between the mode of delivery (p = 0.106), pregnancy (p = 0.099), and the number of deliveries (p = 0.126) with anal incontinence. In turn, there was no higher incidence of chronic intestinal constipation in females (p = 0.099) and most patients with this complaint had Bristol type 1 or 2 stools. Conclusion: The incidence of defecation disorders in the geriatric population is high and, most notably, anal incontinence is not spontaneously reported by most patients.

Resumo Introdução: Os distúrbios da evacuação, seja a incontinência anal ou a constipação intestinal crônica, representam alterações do assoalho pélvico bastante frequente na população em geral e mais comumente naqueles com fatores de risco, ou seja, em idosos, mulheres com passado obstétrico, comorbidades, antecedente de radioterapia pélvica, diabéticos, acamados, história de cirurgias orificiais, dentre outros. Objetivo: Analisar a incidência de distúrbios defecatórios em pacientes geriátricos atendidos no Ambulatório de Especialidades Médicas (AME) do Hospital Santa Marcelina. Metodologia: Estudo prospectivo e aleatório com a entrevista do mesmo paciente em dois momentos: 1) Anamnese subjetiva através da história espontânea e 2) Anamnese objetiva com questionários específicos para avaliação de incontinência anal e constipação intestinal crônica. Resultados: Foram analisados 149 pacientes entre Março de 2016 e Junho de 2017, sendo 114 (76,5%) do sexo feminino com média de idade semelhante entre os sexos; 51,67% apresentavam sintomas de incontinência anal e/ou constipação intestinal crônica. Apenas 35,5% dos pacientes com queixas de escape de fezes ou flatos relataram de forma espontânea e 87,1% dos pacientes constipados o fizeram. No presente estudo não se verificou correlação significativa entre via de parto p = 0,106, gestação p = 0,099 e número de partos p = 0,126 com incontinência anal. Por outro lado, não se verificou maior incidência de constipação intestinal crônica no sexo feminino p = 0,099 e a maioria dos pacientes com essa queixa apresentavam fezes ressecadas tipo Bristol 1 ou 2. Conclusão: Incidência de distúrbios da defecação na população geriátrica é elevada e, notadamente a IA não é referida de forma espontânea pela maioria dos pacientes.

Importance of Rectal Sensitivity Abnormalities in Functional Defecation Disorders / 胃肠病学

Many studies have shown that visceral sensitivity abnormalities are associated with the occurrence of intestinal dysfunction. Functional defecation disorders (FDD) is a type of constipation characterized by difficulty in stool passage, sensation of incomplete evacuation, or need for manual maneuvers to pass stool, which seriously affects patient's quality of life. It is reported that 64% of obstructive defecation patients having impaired rectal sensation, and the most common symptom of patients with rectal hyposensitivity (RH) is constipation. It can be hypothesized that rectal sensitivity abnormalities (especially RH) are closely related to FDD. This article reviewed the advances in study on the correlation between rectal sensitivity abnormalities and FDD, the etiological factor, examination and treatment of FDD.

Effect of Baduanjin Combined with Biofeedback on Functional Defecation Disorders and Brain-gut Peptide / 中国康复理论与实践

@#Objective To investigate the clinical efficacy of Baduanjin combined with biofeedback on functional defecation disorders and the effect on serum brain-gut peptide.Methods From June, 2017 to February, 2018, 68 patients were randomly divided into control group (n=34) and observation group (n=34). Both groups received biofeedback therapy, and the observation group took the training of Baduanjin in addition, for twelve weeks. Then, their overall clinical efficacy, main syndrome score of constipation, the score of Patient Assessment of Constipation Quality of Life (PAC-QOL) and Brain-gut peptide level were compared before and after intervention.Results The total clinical efficacy was higher in the observation group than in the control group (Z=-2.065, P=0.039) without shedding cases. After treatment, the main symptoms of constipation significantly improved (t>2.162, P<0.05) in both groups, while the defecation inactivity, defecation time and abdominal distension score were significantly lower in the observation group than in the control group (t>2.837, P<0.01), as well as the defecation strain (t=-2.070, P<0.05); the score of PAC-QOL decreased (t>2.085, P<0.05) in both groups, and was lower (t=-2.243, P<0.05) in the observation group than in the control group; the level of serum 5-hydroxytryptamine (5-HT), nitric oxide (NO) and vasoactive intestinal peptide (VIP) decreased (t>2.420, P<0.05), while the level of serum substance P (SP) increased (t>6.780, P<0.001), the level of serum 5-HT, serum NO and serum VIP was lower (t>2.039, P<0.05), and the level of serum SP was higher (t=3.500, P<0.001) in the observation group than in the control group.Conclusion Baduanjin combined with biofeedback can improve the clinical efficacy of patients with functional defecation disorders, and its mechanism is closely related to the regulation of abnormal secretion and the expression of brain-gut peptide.

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.

Effects of biofeedback training on clinical symptoms,psychological status and quality of life in different subtypes of patients with functional defecation disorders / 中华消化杂志

Objective To compare the effects of biofeedback (BF) training on clinical symptoms , psychological status and quality of life in different subtypes of patients with functional defecation disorders (FDD) .Methods According to Rome Ⅲ criteria ,50 FDD patients were divided into non coordinated defecation (F3a) and the lack of promoting defecation (F3b) two subtypes .The patients of these two subtypes received BF training three times every week ,five to ten times each course ,two to three times training at home were required during and after treatment .The changes ,of clinical symptoms scores ,self‐rating anxiety scale (SAS) ,self‐rating depressive scale (SDS) and the patient assessment of constipation quality of life question naire (PAC‐QOL ) were compared between before and after BF training in the patients of two subtypes .The difference between two subtypes were also analyzed as well .Paired t‐test or Wilcoxon signed‐rank test was performed for comparison between before and after treatment ,and group t‐test or Wilcoxon rank sum test was for comparison between groups .Results Among 50 FDD patients , there were 13 cases of F3a type and 37 cases of F3b type .After BF training ,the clinical symptoms scores of two subtypes patients were both lower than those before BF training (5 .62 ± 3 .91 vs 8 .77 ± 3 .59 , 5 .89 ± 3 .67 vs 9 .35 ± 3 .22 ,t = 3 .264 and 6 .272 ,both P 0 .05) .After BF training ,the SAS scores of two subtypes patients were both lower than those before BF training (30 .85 ± 6 .67 vs 42 .46 ± 8 .37 ,30 .65 ± 7 .51 vs 38 .59 ± 8 .38 , t= 4 .536 and 6 .402 ,both P 0 .05) .After BF training ,the PAC‐QOL scores of two subtypes [0 .54 (0 .15 ,0 .88) 、0 .98 (0 .51 ,1 .34)] were both lower than those before BF training [2 .08(1 .18 ,2 .34) 、1 .86(1 .34 ,2 .29)] ,Z= - 2 .903 、- 4 .825 ,both P 0 .05) .Conclusions BF training is both effective on two subtypes of FDD ,which can improve clinical symptoms ,psychological status and quality of life ,and with There is no difference in efficacy between the two subtypes .

Biofeedback treatment in chronically constipated patients with dyssynergic defecation / Biofeedback aplicado al tratamiento de pacientes con estreñimiento crónico debido a defecación disinérgica

The aim of this study was to evaluate the effects of electromyographic biofeedback training in chronically constipated patients with dyssynergic defecation. With this purpose, ten patients (4 males, 6 females) with dyssynergic defecation unresponsive to dietary corrections and fibre supplements were selected and enclosed in the study on the basis of fulfilled the Rome III criteria for this functional gastrointestinal disorder. The study was carried out following a series of defined phases: clinical and psychophysiological assessment prior to the treatment (4 weeks), EMG-biofeedback treatment (8 sessions, two per week) and follow-up (4 weeks) one month later. In all phases, four clinical variables were assessed through selfmonitoring (frequency of defecations per week, sensation of incomplete evacuation, difficulty evacuation level, and perianal pain at defecation); moreover, psychophysiological measures were obtained through electromyography (EMG) of the external anal sphincter. Results show significant improvements in psychophysiological measures (EMGactivity during straining to defecate and anismus index), as well as in clinical variables. Biofeedback's benefits were maintained at the follow-up period.

El objetivo de este estudio fue evaluar los efectos del entrenamiento en biofeedback-EMG en pacientes con estreñimiento crónico debido a defecación disinérgica. Con este propósito, 10 pacientes (4 varones, 6 mujeres) con defecación disinérgica que no respondían a correcciones dietéticas y suplementos de fibra, fueron seleccionados e incluidos en el estudio sobre la base de cumplir los criterios Roma III para el diagnóstico de este trastorno funcional gastrointestinal. El estudio se llevó a cabo a lo largo de una serie de fases definidas: evaluación psicofisiológica y clínica previa al tratamiento (4 semanas), tratamiento por medio de biofeedback-EMG (8 sesiones, a razón de dos sesiones semanales) y seguimiento (4 semanas) un mes más tarde. En todas las fases, cuatro variables clínicas fueron evaluadas a través de autorregistro (frecuencia de defecaciones semanales, sensación de evacuación incompleta, nivel de dificultad de la evacuación y dolor perianal en la defecación); además, se obtuvieron medidas psicofisiológicas a través de electromiografía (EMG) del esfínter anal externo. Los resultados muestran mejoras significativas en las medidas psicofisiológicas (actividad-EMG durante el esfuerzo para defecar e índice de anismus), así como en las variables clínicas. Los beneficios del biofeedback se mantuvieron en el período de seguimiento.

Evaluation and Treatment of Pelvic Floor Disorders

Pelvic floor disorders are of interest to many surgeons who specialize in organ systems within this region. Colorectal surgeons are especially interested in disorders of the posterior compartment, which may broadly be divided into defecation disorders and fecal incontinence. These disorders distress patients socially and psychologically and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, are often incompletely understood, and cannot always be determined. However, over the past decades, advances in the understanding of these disorders, together with rational methods of evaluation in anorectal physiology laboratories, radiology studies, and new surgical techniques, have led to promising results. This review summarizes the evaluation and treatment strategies, as well as the recent updates on the clinical and the therapeutic aspects of pelvic floor disorders.