Three-dimensional high-resolution anorectal manometry can predict response to biofeedback therapy in defecation disorders.

PURPOSE: Biofeedback therapy (BT) is a simple and effective technique for managing outlet constipation and fecal incontinence. Several clinical factors are known to predict BT response, but a 50% failure rate persists. Better selection of BT responsive patients is required. We aimed to determine whether the defecation disorder type per high-resolution manometry (HRM) was predictive of BT response. METHODS: We analyzed clinical, manometric, and ultrasound endoscopic data from patients who underwent BT in our department between January 2015 and January 2016. Patients were classified into four groups per the following defecation disorder classification criteria: rectal pressure > 40 mmHg and anal paradoxical contraction (type I); rectal pressure < 40 mmHg and anal paradoxical contraction (type II); rectal pressure > 40 mmHg and incomplete anal relaxation (type III); and rectal pressure < 40 mmHg and incomplete anal relaxation (type IV). An experienced single operator conducted ten weekly 20-min sessions. Efficacy was evaluated with the visual analog scale. RESULTS: Of 92 patients, 47 (50.5%) responded to BT. Type IV and type II defecation disorders were predictive of success (p = 0.03) (OR = 5.03 [1.02; 24.92]) and failure (p = 0.05) (OR = 0.41 [0.17; 0.99]), respectively. The KESS score severity before BT (p = 0.03) (OR = 0.9 [0.81; 0.99]) was also predictive of failure. CONCLUSION: The manometry types identified according to the defecation disorder classification criteria were predictive of BT response. Our data confirm the role of three-dimensional HRM in the therapeutic management of anorectal functional disorders.

Three-dimensional high-resolution anorectal manometry in functional anorectal disorders: results from a large observational cohort study.

BACKGROUND: The aim of the study was to describe the results of 3D high-resolution anorectal manometry (3DHRAM) in a large cohort of patients with functional anorectal disorders. METHODS: In this single-center retrospective study, all consecutive patients referred for investigation of fecal incontinence (FI) or dyssynergic defecation (DD) underwent 3DHRAM. The parameters analyzed were usual manometric data, repartition of dyssynergic patterns, and the prevalence of a new "muscular subtype classification" underlying dyssynergia, anal sphincter defects, and pelvic floor disorders. RESULTS: Final analyses were performed in 1477 patients with a mean age 54 ± 16 years; 825 patients suffered from DD, and 652 patients suffered from FI. Among these patients, 86% met the diagnostic criteria for dyssynergia. Type II dyssynergia was the most frequently observed (56%) in women and men suffering from FI and in women with DD. Type I was the most frequently observed in men with DD (49%). Regarding the muscle type subgroups, combined puborectalis muscle involvement with an external anal sphincter profile was the most frequently observed. The global prevalence of rectal intussusception and excessive perineal descent were 12% and 21%, respectively. Type III dyssynergia was more frequently associated with pelvic floor disorders than were other types of dyssynergia (p < 0.001). CONCLUSION: This large cohort study provides reference values for 3DHRAM in patients with functional anorectal disorders. Further studies are necessary to assess the prevalence of pelvic floor disorders in healthy volunteers and to develop new scores and classifications including all of these new parameters.

Treatment Persistence of Infliximab Versus Adalimumab in Ulcerative Colitis: A 16-Year Single-Center Experience.

BACKGROUND: Infliximab and adalimumab are widely used in the treatment of patients with ulcerative colitis (UC). There are few published data on the treatment persistence of infliximab and adalimumab in patients with UC. METHODS: We aimed to compare the treatment persistence rates of infliximab versus adalimumab as first- and second-line tumor necrosis factor antagonists (anti-TNF), to identify factors potentially associated with persistence, and to evaluate reasons for withdrawal in UC patients. We performed a retrospective, single-center cohort study of UC patients treated with infliximab or adalimumab for at least 6 months between June 2002 and May 2018. RESULTS: The median (interquartile range [IQR]) duration of follow-up was 5.4 (3.2-8.3) years. For first-line anti-TNF agent, data on 160 patients with UC were analyzed. The mean (SD) duration of persistence was 3.4 (3.5) years and 2.1 (2.0) years in the infliximab and adalimumab subgroups, respectively (P = 0.24). Concomitant use of 5-aminosalicylate was associated with higher persistence of first-line anti-TNF treatment in the overall population (hazard ratio [HR] 0.5; 95% CI, 0.3-0.8; P = 0.002). For second-line anti-TNF agent, data on 43 patients were analyzed. The mean (SD) duration of persistence was 2.0 (1.7) years and 3.2 (3.1) years in the infliximab and adalimumab subgroups, respectively (P = 0.95). No factors were associated with persistence of second-line anti-TNF treatment. CONCLUSIONS: Infliximab and adalimumab showed similar levels of persistence as first- and second-line anti-TNF treatments. Concomitant use of 5-aminosalicylates was associated with higher persistence of first-line anti-TNF treatment.

Keratoconus in Inflammatory Bowel Disease Patients: A Cross-sectional Study.

BACKGROUND AND AIMS: Increasing evidence suggests that keratoconus may have an inflammatory component. The possible association of keratoconus with inflammatory bowel disease (IBD) has yet to be determined. The aim of this study was to determine the prevalence of keratoconus and suspect keratoconus in patients with IBD. METHODS: All consecutive adult IBD patients seen in the Department of Gastroenterology, Nancy, University Hospital, France, between March 2014 and June 2014 were included. Pregnant women, rigid lens wearers, patients with a family history of keratoconus and patients with a history of refractive surgery were excluded. A control group of healthy subjects was included. All included patients underwent a corneal topography (OPD-Scan III, Nidek) to detect keratoconus or suspect keratoconus. Rabinowitz videokeratographic indices were the basis of corneal topography interpretation. RESULTS: Two hundred and one IBD patients were included, 150 with Crohn's disease and 51 with ulcerative colitis. Mean age was 38.7 years and 121 were women. Mean disease duration was 10.8 years. Two IBD patients were diagnosed with keratoconus (1%) and 38 with suspect keratoconus (18.9%). Overall prevalence of keratoconus and suspect keratoconus was 19.9% (95% confidence interval [CI] 17.5-22.0). None of the 100 healthy subjects had keratoconus, while three were diagnosed with suspect keratoconus (p = 0.0002 versus IBD patients). Only smoking was identified as a risk factor (p = 0.029), especially in Crohn's disease. CONCLUSION: Inflammatory bowel disease patients may carry an increased risk of keratoconus and suspect keratoconus, smoking further increasing this risk. This supports the hypothesis of an inflammatory origin of keratoconus.