Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)

Abstract

Although 30-50% of constipated patients exhibit dyssynergia, an optimal method of diagnosis is unclear. Recently, consensus criteria have been proposed but their utility is unknown. To examine the diagnostic yield of colorectal tests, reproducibility of manometry and utility of Rome II criteria. A total of 100 patients with difficult defecation were prospectively evaluated with anorectal manometry, balloon expulsion, colonic transit and defecography. Fifty-three patients had repeat manometry. During attempted defecation, 30 showed normal and 70 one of three abnormal manometric patterns. Forty-six patients fulfilled Rome criteria and showed paradoxical anal contraction (type I) or impaired anal relaxation (type III) with adequate propulsion. However, 24 (34%) showed impaired propulsion (type II). Forty-five (64%) had slow transit, 42 (60%) impaired balloon expulsion and 26 (37%) abnormal defecography. Defecography provided no additional discriminant utility. Evidence of dyssynergia was reproducible in 51 of 53 patients. Symptoms alone could not differentiate dyssynergic subtypes or patients. Dyssynergic patients exhibited three patterns that were reproducible: paradoxical contraction, impaired propulsion and impaired relaxation. Although useful, Rome II criteria may be insufficient to identify or subclassify dyssynergic defecation. Symptoms together with abnormal manometry, abnormal balloon expulsion or colonic marker retention are necessary to optimally identify patients with difficult defecation.

A Comparison of Standard Anorectal Manometry and High Resolution Manometry Patterns in Dyssynergic Patients

“…Moreover, whether patterns recorded using SARM and HRM are entirely comparable remains unknown. Currently, dyssynergic defecation classification using SARM relies on an expert-based pattern-recognition process proposed by Rao et al [2] . Recently, Ratuapli et al set out to determine whether HRM could identify DD phenotypes using principal components logistical modeling (PC) in patients with chronic constipation [12] .…”

“…Type I is characterized by a paradoxical increase in the residual anal pressure in the presence of adequate propulsive pressure, that is, increase in intrarectal pressure (45 mm Hg) type II is characterized by an inability to generate adequate expulsive forces, ie, no increase in intrarectal pressure, together with a paradoxical increase in residual intraanal pressure. Type III is characterized by generation of adequate expulsive forces, but absent or incomplete (<20%) reduction in intraanal pressure and type IV is characterized by an inability to generate adequate expulsive forces, that is, no increase in intrarectal pressue and absence of incomplete reduction in residual intraanal pressure [2] . The University of Iowa Institutional Review Board approved the study protocol.…”

“…The prevalence of Dyssynergic defecation (DD) in patients with chronic constipation approaches 50% [1][2][3] . Thus far, most referral centers had been using the Konigsberg standard solid-state anorectal manometry (SARM) catheter for anorectal motility testing.…”

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 Revised Edition

“…50 It was concluded that a negative test was useful for identifying patients who do not have dyssynergia. However, Rao et al 39,51 found that many patients with dyssynergia could expel the balloon, and they expressed the view that a normal test could not exclude the possibility of a defecatory disorder. BET can be helpful in predicting defecatory disorders, but other rectoanal function tests should be performed to confirm a diagnosis.…”

How to Perform and Interpret Balloon Expulsion Test

“…1 One study reported a sensitivity of 88%, a specificity of 89%, a positive predictive value of 67% and a negative predictive value of 97% for this test and suggested a normal BET might exclude a defecatory disorder. 5 However, Rao et al 10 found that many patients with dyssynergia could expel the balloon and they described a contradictory view that a normal test could not exclude the possibility of a defecatory disorder.…”