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Is Abnormality in the Conventional Anorectal Manometry Really Abnormal?

Authors:
Hyun Il Seo at University of Ulsan College of Medicine, Gangneung Asan Hospital
Hyun Il Seo
  • University of Ulsan College of Medicine, Gangneung Asan Hospital
Jungho Park at Seoul National University
Jungho Park
Chong Sohn at Kangbuk Samsung Hospital
Chong Sohn
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Is Abnormality in the Conventional Anorectal Manometry Really Abnorma
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Is Abnormality in the Conventional Anorectal Manometry Really Abnorma
l?.pdf
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JNM
Journal of Neurogastroenterology and Motility
Image and Learning
J Neurogastroenterol Motil, Vol. 16 No. 2 April, 2010
DOI: 10.5056/jnm.2010.16.2.213
ⓒ2010 The Korean Society of Neurogastroenterology and Motility
J Neurogastroenterol Motil, Vol. 16 No. 2 April, 2010
www.jnmjournal.org
213
Is Abnormality in the Conventional Anorectal
Manometry Really Abnormal?
Hyun Il Seo, MD, Jung Ho Park, MD, and Chong Il Sohn, MD*
Department of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
Received: March 9th, 2010 Accepted: April 6th, 2010
CC
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work
is properly cited.
*Correspondence: Chong Il Sohn, MD
Department of Gastroenterology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-dong,
Jongro-gu, Seoul 110-746, Korea
Tel: +82-2-2001-2057, Fax: +82-2-2001-2610, E-mail: chongil.sohn@samsung.com
Financial support: None.
Conflicts of interest: None.
Figure 1. Colored pressure topography plots of anorectal pressure during simulated defecation in left lateral decubitus position (A) and sitting
position (B). High resolution anorectal manometry (HR-ARM) finding in left lateral decubitus position revealed inappropriate increase of rectal
pressure (green color) and no decrease in anal sphincter pressure (yellow to red color). This finding was consistent with pelvic floor dyssynergia (A).
However, when HR-ARM was done with the patient in the sitting position, rectal pressure increased (yellow to red color) in coordination with
relaxation of the anal sphincter pressure (green color), which is a normal pattern of anorectal manometry (B).
A 54-year-old woman, with chronic abdominal discomfort
and difficulty in defecation, was admitted to the hospital. There
were no abnormal findings on abdominal X-ray and colonic
transit time remained within the normal values. The result by co-
lonoscopic examination was normal. Bulk-forming laxatives were
prescribed for a month, but symptomatic improvement was not
found at all. Then, a defecography and the high resolution ano-
rectal manometry (HR-ARM) of ManoScan TM system (Sierra
Journal of Neurogastroenterology and Motility
Hyun Il Seo, et al
214
Scientific Instruments, Los Angeles, CA, USA) were performed
to differentiate functional anorectal disorders. Defecogram did
not show significant findings. HR-ARM finding in left lateral
decubitus position revealed the inappropriate increase of rectal
pressure and no decrease in anal sphincter pressure (Fig. 1A).
These findings were consistent with pelvic floor dyssynergia.
However, when HR-ARM was performed with the patient in
the sitting position, the increase of rectal pressure could be found
in coordination with relaxation of the anal sphincter pressure
(Fig. 1B). These results were consistent with the previous report
obtained in the lying position; one-third showed dyssynergia and
one-half could not expel artificial stool. However, when sitting
with distended rectum, most patients showed a normal defecation
pattern and ability to expel stool.1
During the conventional water perfusion manometry, pa-
tients are expected to be in their lateral decubitus position, which
interferes with an optimal abdominal contraction and anal relaxa-
tion during simulated defecation. However, in case of
HR-ARM, patients can take sitting position in commode, which
is more physiological since patients can feel more comfortable
and they can generate enough movement of rectum for defecation
and adequate anal relaxation.2
In conclusion, defecation is best evaluated in the sitting posi-
tion of patient by using HR-ARM.
References
1. Rao SS, Kavlock R, Rao S. Influence of body position and stool char-
acteristics on defecation in humans. Am J Gastroenterol 2006;
101:2790-2996.
2. Jones MP, Post J, Crowell MD. High-resolution manometry in the
evaluation of anorectal disorders: a simultaneous comparison with
water-perfused manometry. Am J Gastroenterol 2007;102:850-855.
Anorectal Physiology
Chapter
  • Jan 2014
Disorders of the pelvic floor are common and cause considerable morbidity. It is important to identify which patients need which intervention and as importantly which patients will not benefit from intervention. This in turn depends on accurate clinical and physiological assessment as well as a multidisciplinary and multimodal approach to treatment. The latter is especially important since many of these patients have a global pelvic floor dysfunction which requires a holistic approach to the pelvic floor rather than dividing it into anterior, middle and posterior compartments. This chapter is divided into three sections: 1. Clinical assessment: history and examination 2. Standard physiological measurements 3. Advanced physiological measurements
View
High-Resolution Manometry in the Evaluation of Anorectal Disorders: A Simultaneous Comparison With Water-Perfused Manometry
Article
  • Apr 2007
High-resolution manometry (HRM) combined with novel interpretive software allows for the interpolation of manometric recordings into highly detailed topographical plots of intraluminal pressure events relative to time and location. To date, HRM has been used primarily in the study of esophageal disorders and has been shown to provide greater physiologic resolving power compared with standard manometric techniques. This preliminary feasibility study is the first report evaluating HRM and simultaneously performed water-perfused manometry (WPM) in patients referred for anorectal manometry (ARM). Consecutive patients referred for ARM underwent simultaneous WPM and HRM. WPM was performed using a 6-cm sleeve assembly with side-holes spaced at 3-cm intervals. HRM was performed using the ManoScan system (Sierra Scientific Instruments, Los Angeles, CA) consisting of a 36-channel catheter with sensors spaced at 1-cm intervals. Space-time pressure data were displayed in topographic form using ManoView analysis software that is part of the ManoScan system. Measurements of anal sphincter pressure at rest, during voluntary contraction, and during 40-mL rectal balloon distension were compared. A total of 29 patients were studied. Indications for manometry were constipation (19), incontinence (7), and fecal soilage (3). Simultaneously recorded resting, squeeze, and relaxation pressures showed the two methods to be significantly correlated although anal sphincter pressures recorded by HRM tended to be higher than those recorded with WPM. HRM provided greater resolution of the intraluminal pressure environment of the anorectum. These preliminary observations demonstrate that anorectal HRM highly correlated with WPM measurements and provided greater anatomic detail.
View
Influence of Body Position and Stool Characteristics on Defecation in Humans
Article
  • Dec 2006
Whether defecation is influenced by body position or stool characteristics is unclear. We investigated effects of body position, presence of stool-like sensation, and stool form on defecation patterns and manometric profiles. Rectal and anal pressures were assessed in 25 healthy volunteers during attempted defecation either in the lying or sitting positions and with balloon-filled or empty rectum. Subjects also expelled a water-filled (50 cc) balloon or silicone-stool (FECOM) either lying or sitting and rated their stooling sensation. When attempting to defecate in the lying position, a dyssynergic pattern was seen in 36% of subjects with empty rectum and 24% with distended rectum. When sitting, 20% showed dyssynergia with empty rectum and 8% with distended rectum. More subjects (p < 0.05) showed dyssynergia in lying position. When lying, 60% could not expel balloon and 44% FECOM. When sitting, fewer (p < 0.05) failed to expel balloon (16%) or FECOM (4%). FECOM expulsion time was quicker (p < 0.02). Stool-like sensation was more commonly (p < 0.005) evoked by FECOM than balloon. In the lying position, one-third showed dyssynergia and one-half could not expel artificial stool. Whereas when sitting with distended rectum, most showed normal defecation pattern and ability to expel stool. Thus, body position, sensation of stooling and stool characteristics may each influence defecation. Defecation is best evaluated in the sitting position with artificial stool.
View