Improving the utility of high‐resolution manometry for the diagnosis of defecatory disorders in women with chronic constipation

Abstract

Background We compared the utility of existing and modified versions of high‐resolution manometry for diagnosing defecatory disorders (DD). Methods In 64 healthy and 136 constipated women, we compared left lateral (LL) and seated manometry, and analyzed with existing (ManoView™) and new methods, for discriminating between constipated patients with normal and prolonged rectal balloon expulsion time (BET). In both positions, the rectoanal gradient (RAG) and, for the new analysis, the pressure topography pattern during evacuation were used to discriminate between constipated patients without and with DD. Key Results The BET was prolonged, suggestive of a DD, in 52 patients (38%). During evacuation, rectoanal pressures and the RAG were greater in the seated than the LL position (P≤.001). The new analysis identified 4 rectoanal pressure patterns. In the seated position, the BET was associated with the pattern (P=.0001), being prolonged in, respectively, 45%, 15%, 53%, and 0% of patients with minimal change, anal relaxation, paradoxical contraction, and transmission. Within each pattern, the RAG was greater (ie, less negative, P<.0001) in patients with a normal than a prolonged BET. Compared to the ManoView™ RAG in the LL position, the integrated analysis (ie, pattern and new RAG) in the LL position (P<.01) and the seated ManoView™ gradient (P=.02) were more effective for discriminating between constipated patients without and with DD. Conclusions & Inferences Anorectal HRM ideally should be performed in the more physiological seated position and analyzed by a two‐tier approach, which incorporates the overall pattern followed by the rectoanal gradient. These findings reinforce the utility of manometry for diagnosing DD.

Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation

“…219 HR-ARM is recommended to be performed in the left lateral position with an empty rectum, 129 but has poor content validity under such circumstance; studies in the upright, seated position are feasible and evidence is accumulating to suggest that this may improve test performance. [220][221][222] However, interpretation can be difficult as there is a wide overlap of findings between symptomatic and control subjects. In particular, blinded diagnostic accuracy studies suggest that specificity of previously well-accepted manometric patterns of dyssynergia may be as low as 13%.…”

Seated anorectal manometry during simulated evacuation: A physiologic exercise or a new clinically useful diagnostic test?

“…of healthy subjects and in 91% of the constipated patients, undermining the concept that these motor patterns might identify a pathological instead of a physiological condition, and demonstrating once again that well‐designed studies are crucial to understanding the real role of tests in clinical practice. This lack of specificity might perhaps improve by performing manometry in a seated position, as the results of the study by Sharma et al 22 show that motor patterns, such as paradoxical contraction during attempted evacuation, were recorded in 9% vs 18% of healthy controls in seated vs left lateral position, respectively. In line with this possibility, the increase in the likelihood ratio of the recto anal gradient in seated position for discriminating between constipated patients with normal or abnormal BET might hopefully reflect better diagnostic performances of this parameter in distinguishing between healthy subjects and constipated patients.…”

“…In this issue of Neurogastroenterology and Motility , Sharma et al 22 tested the hypothesis that conducting the ARM in a seated position, and applying a new way of analyzing the results, would increase the diagnostic accuracy of the test in discriminating between patients with normal and prolonged BET. The participants were given up to 3 min to expel a 4‐cm‐long balloon, filled with 50 ml of water, from the rectum, in privacy, while seated on a commode.…”

“…The definition of new phenotypes, including symptoms, abnormal aspects of colonic function, psychological characteristics, and carefully defined alterations of anorectal function, might hopefully help to better investigate the effects of treatments in more homogeneous subgroups of patients with defecation disorder. In this context, the study of Sharma et al 22 represents a clear example of how the investigated variables should be precisely defined. With a very sophisticated technique, Sharma et al showed that the change of body position influences anorectal pressures at rest and during attempted defecation, as well as the diagnostic performances of ARM.…”

A new method for assessing anal distensibility with a barostat and magnetic resonance imaging in healthy and constipated women

“…Anal manometry is widely used to diagnose defecatory disorders (DD) 1,2 . During evacuation, a reduced rectal propulsive force, high anal pressure, inadequate anal relaxation, and a less positive or more negative rectoanal gradient are the most widely used manometry criteria for DD 1‐3 . Some studies and a consensus document consider high anal resting pressure, also known as anal hypertension, as a feature of pelvic floor dysfunction, not only in DD, but also in patients with chronic anal fissure, levator ani syndrome or proctalgia fugax 4‐6 .…”