To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound.

BACKGROUND: Anorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests. METHODS: Between January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG). RESULTS: A total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively. CONCLUSION: DRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.

Perianal fistulas and the lift procedure: results, predictive factors for success, and long-term results with subsequent treatment.

BACKGROUND: Treatment of a perianal fistula is difficult due to the risk of fecal incontinence and recurrence. The ligation of intersphincteric tract (LIFT) procedure is a sphincter-saving procedure associated with success rates ranging from 57 to 94%. The aim of our study was to find predictors for a favorable outcome of the LIFT procedure, evaluation of postoperative fecal incontinence, quality of life, and subsequent treatment with long-term follow-up. METHODS: This study was performed in patients who underwent LIFT between 2013 and 2015 at our institution. Their medical data were retrieved from the electronic patient files. The fistula characteristics were described by physical examination, three-dimensional endoanal ultrasound, and perioperative evaluation. Recurrence rate, postoperative fecal incontinence, and quality of life were assessed with the Patient-Reported Outcome Measurement (PROM). Thirty-two months later, long-term follow-up including subsequent procedures was evaluated. RESULTS: Forty-five patients [17 men, mean age 40 years (range 24-67 years)] were included. In 41 (84%) patients, the fistula was classified as complex; 32 (71%) were referrals with a history of previous fistula surgery. The initial success rate was 18 (40%). Only the height of the internal fistula opening (≥ 15 mm p < 0.03) was associated with recurrence. The LIFT procedure did not affect the occurrence of fecal incontinence or soiling. Recurrence showed a trend with a lower PROM (p = 0.07). Twenty-four months later, further surgery leads to cure in 34 (75%), asymptomatic fistulas in 7 (16%), and persisting active fistulas in 4 (9%) patients. CONCLUSIONS: Initial LIFT had a success rate of 40% and with subsequent surgical treatment 75%. Recurrence after LIFT is related to the height of the internal fistula opening and is associated with diminished quality of life. Continence was not affected by initial LIFT.

Botox treatment in patients with chronic functional anorectal pain: experiences of a tertiary referral proctology clinic.

BACKGROUND: Anorectal pain is a symptom which may have both structural and functional causes, and can, sometimes, develop into a chronic pain syndrome. Functional causes in particular are challenging to treat when conservative treatment measures fail. Botulinum toxin A (BTX-A) can be applied to relax the anal sphincter and/or levator ani muscle to break the vicious circle of pain and contraction. In our tertiary referral proctology clinic, we evaluated the outcome of patients treated with BTX-A for chronic functional anorectal pain. METHODS: Our electronic database was searched for patients who had BTX-A treatment for chronic functional anorectal pain from 2011 to 2016. All medical data concerning history, treatments, and clinical outcome were retrieved. The clinical outcome (resolution of pain) was scored as good, temporary, or poor. RESULTS: A total of 113 patients [47 (42%) males; age 51years, SD 13 years, range 18-88 years] with chronic functional anorectal pain were included. The outcome of BTX-A treatment was good in 53 (47%), temporary in 23 (20%), and poor in 37 (33%). To achieve this outcome, 29 (45%) patients needed a single treatment, 11 (44%) a second treatment, and 13 (54%) ≥ 3 treatments. CONCLUSIONS: Chronic functional anorectal pain can be treated successfully with BTX-A in 47% of patients who fail conservative management. Repeated injections may be needed to ensure complete cure in a subgroup of patients.

Impacts of perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease.

BACKGROUND: Patient reported outcomes regarding perianal disease and faecal incontinence in the community-based inflammatory bowel disease population are poorly described. AIMS: To determine the impacts of perianal disease and faecal incontinence on quality of life and employment in inflammatory bowel disease patients. METHODS: For this cross-sectional study, a comprehensive survey was sent out to members of the Dutch National Crohn's and Colitis patient organisation. Validated questionnaires regarding faecal incontinence and active perianal disease were used to estimate its prevalence's. The effect on the quality of life (36-Item Short Form Survey) and on employment status (multivariate binary regression analysis) was assessed in this inflammatory bowel disease population. RESULTS: A total number of 1092 returned questionnaires (58% responders) were used for analysis; 750 respondents (69%) were female; mean age was 47 years (IQR 35-59). In 621 patients (57%) Crohn's disease, in 422 (39%) ulcerative colitis and in 49 (4%) patients unclassifiable inflammatory bowel disease was self-reported. The 114 patients (10%) with a stoma were excluded for continence related analyses. Faecal incontinence was reported in 555 patients (57%), was comparable between the different inflammatory bowel disease diagnoses and affected all 36-Item Short Form Survey subscales adversely (incontinence vs continence: Physical functioning 75 vs 84, P < 0.0001; Limitations due to physical health 49 vs 63, P < 0.0001; Limitations due to emotional problems 49 vs 64, P < 0.0001; Energy/fatigue 47 vs 53, P < 0.0001; Emotional well-being 71 vs 74, P = 0.005; Social functioning 63 vs 73, P < 0.0001; Pain 66 vs 75, P < 0.0001; General health 41 vs 48, P < 0.0001). Active perianal disease was reported in 39% Crohn's disease, 16% ulcerative colitis (84% fissures) and 20% unclassifiable inflammatory bowel disease patients. Faecal incontinence was more common in patients with perianal disease (67% vs 53%, P = 0.003). When correcting for age, disease duration, inflammatory bowel disease-related surgery and faecal incontinence, active perianal disease was independently affecting employment (OR 0.67; 95% CI 0.50-0.91; P = 0.01). CONCLUSIONS: Faecal incontinence and perianal disease are quality of life determining factors. Faecal incontinence needs more attention among clinicians, and development of new (drug) therapies needs to be focussed on perianal disease.

Results of long-term retrograde rectal cleansing in patients with constipation or fecal incontinence.

BACKGROUND: The aim of the present study was to determine the success rate, quality of life and predictive factors of success associated with long-term rectal cleansing (RC) for defecatory disorders. METHODS: All patients who started RC between January 2010 and August 2014 in our referral hospital were sent questionnaires concerning actual RC, Short Form 36 Health Survey (SF-36), Fecal Incontinence Quality of Life (FI-QoL) and the Beck Depression Inventory (BDI). In addition, they were contacted in May and December 2015 for further follow-up information. RESULTS: Eighty-six patients were offered RC, and 60 patients (45 women, 15 men) started RC. Thirty-three (55 %) patients stopped RC after a median time of 6 months. Twenty-seven (45 %) continued for a median time of 12 months. Forty-three (72 %) patients responded to the questionnaires. SF-36 showed that patients still using RC had more energy and were less fatigued than patients who discontinued therapy. No significant difference was found between patients who stopped and continued RC concerning age, gender, defecation disturbance, underlying disorders, anorectal function, colon-transit time, FI-QoL or BDI-score. Twenty-three patients (38 %) were still performing RC after 21 months, 22 patients (37 %) after 28 months and 1 patient was lost to follow-up. CONCLUSIONS: RC is a moderately effective long-term alternative in patients who do not respond to medical therapy and biofeedback exercises. There is a high dropout rate in the first months, but a moderate rate of continuation in the period hereafter. No predictive factors for continuation were found in medical history or function tests. Those who continued RC performed better on the SF-36 subscale energy/fatigue.

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound.

AIM: Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS). METHOD: Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula. RESULTS: There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%. CONCLUSION: The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life.

BACKGROUND: Surgical management of cryptoglandular fistulas is a challenge because the consequences of anal surgery potentially include fecal incontinence and impaired quality of life. OBJECTIVE: To assess factors associated with fecal incontinence after surgery for simple and complex cryptoglandular fistulas and to determine the impact of incontinence on quality of life. DESIGN: The design is retrospective and cross-sectional. SETTINGS: This study was conducted at an academic tertiary center and at a private center specializing in proctologic surgery. PATIENTS: All patients who underwent preoperative endoanal ultrasound for cryptoglandular fistula between 2002 and 2012. MAIN OUTCOME MEASURES: A questionnaire was sent out in October 2013 to evaluate incontinence (Wexner-score) and its impact on quality of life (FIQL). Variables tested for association were patient demographics, fistula type, number of incised abscesses (0, 1, >1), number of fistulotomies (0, 1, >1) and number of sphincter-sparing procedures (0, 1, >1). RESULTS: Of the 141 patients participating, 116 (82%; 76 men, 40 women) returned all the questionnaires. Median follow-up from the first perianal fistula surgery was 7.8 years (range, 2.1-18.1 years). Thirty-nine patients (34%) experienced incontinence. Surgical fistulotomy, multiple abscess drainages and a high transsphincteric or suprasphincteric fistula tract were associated with incontinence. As compared to simple fistula (Wexner score, 1.2 [SD, 2.1]), incontinence was worse after surgery for complex fistula (Wexner score, 4.7 [SD, 6.2], p = 0.001), as were quality of life elements, including lifestyle (p = 0.030), depression (p = 0.077) and embarrassment (p < 0.001). LIMITATIONS: Mainly retrospective design without a standardized treatment protocol. CONCLUSION: Surgical fistulotomy is the strongest risk factor for fecal incontinence. The severity of incontinence increases with the complexity of the fistula, negatively influencing quality of life. Special attention should be paid to these patients so as to mitigate symptoms later in life. A shift to sphincter-sparing procedures appears warranted.

Clinical response and sustainability of treatment with temperature-controlled radiofrequency energy (Secca) in patients with faecal incontinence: 3 years follow-up.

BACKGROUND: Controlled delivery of radio frequent energy (Secca) has been suggested as treatment for faecal incontinence (FI). OBJECTIVE: The objective of the study is to evaluate clinical response and sustainability of Secca for FI. DESIGN: This is a prospective cohort study. PATIENTS: This study involved patients who had failed full conservative management for FI. INTERVENTIONS: This study was performed between 2005 and 2010. MAIN OUTCOME MEASURES: FI was scored using the Vaizey score (VS). A clinically significant response to Secca was defined as ≥50 % reduction in incontinence score. Impact of FI on quality of life (QOL) was measured using the FIQL. Data was obtained at baseline, at 6 months and at 1 and 3 years. Anal endosonography and anal manometry were performed at 3 months and compared to baseline. RESULTS: Thirty-one patients received Secca. During follow-up, 5/31 (16 %), 3/31 (10 %) and 2/31 (6 %) of patients maintained a clinically significant response after the Secca procedure. Mean VS of all patients was 18 (SD 3), 14 (SD 4), 14 (SD 4) and 15 (SD 4), at baseline, 6 months and 1 and 3 years. No increases in anorectal pressures or improvements in rectal compliance were found. Coping improved between baseline and t = 6 months. No predictive factors for success were found. LIMITATIONS: This is a non-randomised study design. CONCLUSION: This prospective non-randomised trial showed disappointing outcomes of the Secca procedure for the treatment of FI. The far minority of patients reported a clinically significant response of seemingly temporary nature. Secca might be valuable in combination with other interventions for FI, but this should be tested in strictly controlled randomised trials.

Fecal incontinence, sexual complaints, and anorectal function after third-degree obstetric anal sphincter injury (OASI): 5-year follow-up.

INTRODUCTION AND HYPOTHESIS: Our aim was to evaluate alterations in anorectal function after anal sphincteroplasty for third-degree obstetric anal sphincter injury (OASI) in relation to clinical outcome. METHODS: In this retrospective, descriptive, cross-sectional study conducted between 1998 and 2008, women with persisting fecal incontinence (FI) after 3a OASI and all women with grade 3b or 3c OASI were sent for anorectal function evaluation (AFE) consisting of anal manometry and endosonography 3 months after sphincteroplasty. In 2011, questionnaires regarding FI (Vaizey/Wexner), urinary incontinence (UI) [International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF)], sexual function [Female Sexual Function Index (FSFI)], and quality of life (QOL) (Rand-36) were sent and women were asked to undergo additional AFE. RESULTS: Sixty-six women underwent AFE. Mean follow-up was 5.0 years. Forty (61%) patients returned questionnaires regarding FI and UI. Prevalence of FI was 63% flatus, 50% liquid stool, and 20% solid stool. Thirty-two of 40 also reported on QOL and SF. Sexual dysfunction was present in the majority of women (cutoff value 26.55) and more pronounced in larger OASI. Sixteen of 40 women underwent additional AFE. Women with combined internal (IAS) and external (EAS) anal sphincter injury (n = 6) had worse FI (P < 0.050) and lower anal pressures (P = 0.040) than women with isolated EAS injury (n = 10). CONCLUSION: Follow-up after third-degree OASI suggests poor anorectal and sexual function. Women with combined external and internal OASI show more deterioration in anorectal function and experience worse FI. Therefore, special attention should be paid to these women in order to mitigate these symptoms later in life.

Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation.

INTRODUCTION AND HYPOTHESIS: Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions. METHODS: Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography. RESULTS: One hundred and thirteen women were referred and classified as having idiopathic constipation (n = 100), neurological disorder (n = 8), or others (n = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P = 0.002) and had no rectoceles identified (P = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia. CONCLUSION: Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.

A novel device reduces anal pain after rubber band ligation: a randomized controlled trial.

BACKGROUND: Anal pain is a well-known sequel of rubber band ligation (RBL). A plastic device, the anal cooler which can be frozen in a freezer, has been developed to reduce anal pain. It contains a mixture of glycols and has a minimum temperature of 4 °C. This study was designed to investigate the efficacy of the anal cooler in pain relief after RBL. METHODS: Between 2009 and 2010, 100 patients who underwent RBL were prospectively randomized into an anal cooler group (n = 50) or a control group (n = 50). The anal cooler group was instructed to use the cooler when they had pain. All patients were asked to keep a pain diary (0 = no pain; 10 = extreme pain), and follow-up was performed after 3-6 weeks. RESULTS: It was found that 24/50 patients (48 %) in the anal cooler group and 31/50 (62 %) in the control group needed oral analgesics (NS). In total, 36/50 patients (72 %) used the anal cooler. Of these, 9/36 patients (25 %) noticed improvement. Of the remaining 27/36 patients (75 %) who did not notice improvement, 5/36 patients (14 %) found the insertion of the cooler uncomfortable and 1/36 patients (3 %) experienced nausea. No complications occurred during or after the use of the cooler. The 14/50 patients (28 %), who did not use the cooler, had a lower post-banding pain score compared with patients who used the cooler (1.4 vs 6.4; P < 0.001). CONCLUSIONS: Although post-banding pain after RBL is usually mild, the anal cooler seems to relieve anal pain in 25 % of the patients who used the device.

Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment.

OBJECTIVE: Anorectal function tests are often performed in patients with faecal incontinence who have failed conservative treatment. This study was aimed to establish the additive value of performing anorectal function tests in these patients in selecting them for surgery. PATIENTS AND METHODS: Between 2003 and 2009, all referred patients with faecal incontinence were assessed by a questionnaire, anorectal manometry and anal endosonography. Patients with diarrhea, inflammatory bowel disease, pouches or rectal carcinoma were excluded. RESULTS: In total, 218 patients were evaluated. Of these, 107 (49%) patients had no sphincter defects, 71 (33%) had small defects and 40 (18%) had large defects. Anorectal manometry could not differentiate between patients with and without sphincter defects. Patients with sphincter defects were only found to have a significantly shorter sphincter length and reduced rectal capacity compared to patients without sphincter defects. Forty-three patients (20%) had a normal anal pressures ≥ 40 mmHg. Seventeen patients (8%) had also a dyssynergic pelvic floor both on clinical examination and anorectal manometry. Fifteen patients (7%) had a reduced rectal capacity between 65 and 100 ml. There was no difference in anal pressures or the presence of sphincter defects in these patients compared to patients with a rectal capacity >150 ml. There was no correlation between anorectal manometry, endosonography and faecal incontinence severity scores. CONCLUSION: In patients with faecal incontinence who have failed conservative treatment, only anal endosonography can reveal sphincter defects. Anorectal manometry should be reserved for patients eligible for surgery to exclude those with suspected dyssynergic floor or reduced rectal capacity.

Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients.

AIM: Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. METHOD: Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. RESULTS: Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC-curve was 0.84 (P < 0.001; 95% confidence interval, 0.80-0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. CONCLUSION: Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.

Irritable bowel syndrome and chronic constipation in patients with endometriosis.

AIM: The aim of this study was to evaluate how many patients with endometriosis have concomitant irritable bowel syndrome (IBS) and/or constipation according to the Rome III criteria. Furthermore, the value of an additional gastroenterological consultation with therapeutic advice was evaluated. METHOD: Patients with proven endometriosis were included in a prospective, single-centre study. A questionnaire was undertaken regarding IBS and chronic constipation. Patients with symptoms consistent with the Rome III criteria for IBS were referred to our gastroenterological outpatient clinic. RESULTS: In total 101 patients were included. Endometriosis was diagnosed surgically in 97% and visually in the vagina in 3%. Fifteen per cent of the patients with endometriosis also had IBS and 14% of the patients with endometriosis had functional constipation without IBS. Of the 22 patients finally presenting to the gastroenterologist, five had a significant stenotic rectosigmoid lesion and were treated surgically. The remaining 17 patients were treated conservatively. Defecation symptoms improved in 86% and pain was reduced in 64%. CONCLUSION: In patients with endometriosis, 29% also had IBS or constipation. Referral to a gastroenterologist resulted in improvement of defaecation in 86%, and 64% reported a reduction in the degree of pain.

Acromegaly is associated with an increased prevalence of colonic diverticula: a case-control study.

OBJECTIVE: In acromegaly, overproduction of GH and IGF-I causes abnormal extracellular matrix regulation. We hypothesized that this may predispose to the development of colonic diverticula. Because the relation between acromegaly and colonic diverticula is unknown, the study aim was to assess the prevalence of colonic diverticula in patients with cured acromegaly. DESIGN: This was a case-control study. METHODS: We screened reports of colonoscopies performed for the purpose of screening for polyps in 107 patients with cured or biochemically controlled acromegaly and in 214 age- and sex-matched controls for the presence of diverticula, dolichocolon, and polyps. In patients, the findings were related to GH/IGF-I concentrations at the time of diagnosis of acromegaly and to the duration of GH/IGF-I excess. RESULTS: In acromegaly, colonic diverticula were present in 37% of patients, dolichocolon in 34%, and adenomatous polyps in 34%, which was increased compared with controls (odds ratio 3.6, 95% confidence interval 1.4, 5.7; 12.4, 95% confidence interval 6.8, 18.0; 4.1, 95% confidence interval 1.9, 6.4, respectively). The presence of colonic diverticula was associated with both GH and IGF-I concentrations at the time of diagnosis of acromegaly, when adjusted for the duration of active disease. The presence of dolichocolon and adenomatous polyps was associated with higher IGF-I concentrations at diagnosis. CONCLUSIONS: Acromegaly is associated with an increased prevalence of colonic diverticula. In addition to the known irreversible effect of GH excess on collagen of joints and cardiac valves, this observation indicates an irreversible effect of GH and/or IGF-I on the collagen in the colon.

There is no increased risk for colorectal cancer and adenomas in patients with diverticulitis: a retrospective longitudinal study.

AIM: This study was designed to assess the relationship between diverticulitis and the development of colorectal cancer (CRC) and colonic adenomas. METHOD: A retrospective study was longitudinally conducted. Patients who had been admitted to the hospital between 1990 and 2000 with diverticulitis were retrieved and the incidence of CRC and prevalence of colonic adenomas in these patients was determined. Data were collected from the electronic clinical and pathology records. The incidence of CRC and prevalence of adenomas in this patient cohort was compared with the general population. The patients were followed until 2008. RESULTS: A total of 288 patients with diverticulitis were included (167 of whom were female patients [58%]). The mean age of patients at admittance for diverticulitis was 66 years (range: 27-92). CRC was detected in five patients (1.7%) (95% CI 0.8-3.5) with a mean age of 77 years; colonic adenomas were found in 18 patients (6.3%) (95% CI 4.3-9.0) with a mean age of 62 years. The lifetime risks of developing CRC and adenomas were presumed to be 4% and 20% respectively. Expected rates for CRC and adenomas in our patients were calculated as 17 (95% CI 4.0-8.6) and 69 patients (95% CI 20.1-28.3) respectively. CONCLUSION: This study showed a lower prevalence of CRC and colonic adenomas in patients with diverticulitis compared with the lifetime risk which means that diverticulitis is not a risk factor for development of CRC and adenomas. Long-term colonic screening after a negative colonoscopy for diverticulitis (generally performed several weeks after recovery) does not seem to be justified.

[Faecal incontinence: physiotherapy first before referral for further diagnostics and therapy]. / Fecale incontinentie: eerst fysiotherapie, dan verwijzing voor verdere diagnostiek en behandeling.

The predictive value of diagnostic tests for faecal incontinence with respect to the outcome of physiotherapy was investigated in a recent study. No obvious predictors were found. This is not surprising. Diagnostic tests are known to exhibit a large overlap with healthy controls. Further, the study was carried out in 15 hospitals, each of which had its own method for performing these tests. Physiotherapy according to a treatment protocol was given by 48 physiotherapists. The Vaizey score was used as the outcome measure and revealed an improvement of 50% or more in 13% of patients. However, some clinical changes important for the patient are missed by this score. The rate of effectiveness for physiotherapy reported in literature is around 70%. This study not only shows that diagnostic tests have little predictive value regarding the outcome of physiotherapy, but, more importantly, that all patients with faecal incontinence should have physiotherapy first. Patients who do not improve should be referred to a specialist for further diagnostics and therapy.

Diverticulosis and diverticulitis form no risk for polyps and colorectal neoplasia in 4,241 colonoscopies.

BACKGROUND AND AIMS: There are conflicting data concerning the association between diverticular disease and colorectal carcinoma (CRC). This study was performed to determine the prevalence and association of diverticulosis, diverticulitis, polyps, and CRC. MATERIALS AND METHODS: In a cross-sectional, retrospective study, we analyzed the colonoscopy reports of complete colonoscopies and patho-histological results of all patients referred for colonoscopy in a period of 3 months in 18 hospitals in The Netherlands. Diverticulosis was defined as three or more diverticula present and diverticulitis as diverticulosis with inflammation. Polyps were also coded according to localization and size. Advanced neoplastic lesions were defined as polyps >or=10 mm in diameter and/or villous architecture and/or adenomas with high grade dysplasia and/or invasive cancer. Actual and previous described CRC were registered. RESULTS: A total of 4,241 patients were included in the study [1,996 (47%) male], mean age of 59 and range 18-95. Diverticula, diverticulitis, and polyps were seen in 1,052 (25%), 75 (2%), and 1,282 (30%) patients, respectively. No association was found between patients with polyps and those with and without diverticulosis (p=0.478). Invasive adenocarcinoma and adenomas >or=10 mm were most frequently observed. CRC was present in 372 (9%) patients. Negative relation between diverticulosis and CRC and invasive adenocarcinoma was observed. No association was found between polyps and CRC and patients with diverticulitis and CRC. In conclusion, there is no relation between patients with diverticulosis and higher incidence of polyps or CRC when using age-stratified analysis. No increased risk for polyps or CRC was found in patients with diverticulitis.

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

PURPOSE: Pelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence. MATERIALS AND METHODS: Two hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score. RESULTS: After pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD+/-3) was reduced with 3.2 points (p<0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R2, 0.20; p=0.05). CONCLUSION: Additional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.