Rao-Satish Dyssynergic-Defecation-MP9-13 - LS...
Transcript of Rao-Satish Dyssynergic-Defecation-MP9-13 - LS...
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Satish S.C. Rao, MD, PhD, FACG
Dyssynergic DefecationDyssynergic Defecation
Satish S.C. Rao, MD, PhD, FACGProfessor of Medicine
Chief, Division of Gastroenterology/HepatologyDirector, Digestive Health Center, MCG
Augusta University, Augusta, GA
ObjectivesObjectives
What is Dyssynergic Defecation?
Pathophysiology of DD?
Advances in diagnosis and treatment
RCTs for Biofeedback Therapy Dyssynergic Defecation
How does Biofeedback work?
Insights from studies of Brain-Gut Interactions
ACG 2016 Annual Postgraduate Course Copyright 2016 American College of Gastroenterology
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Satish S.C. Rao, MD, PhD, FACG
Constipation & Most Bothersome symptomConstipation & Most Bothersome symptom
Symptoms US Household
n= 10,018
Self-Reported
(27%),n=312
Rome II (15%)
n=171
Straining during B.M 32.4% 17.5%
Hard /Lumpy Stool 29% 20.4% 11.1%
< 3 B.M /week 9% 13.2% 12.3%
Sensation stool can’t be passed 24% 12.9% 5.8%
Feeling of Incomplete evacuation 30% 12.4% 6.4%
A need to press around anus 12% 5.6% 6.4%
Pare et al, Canada
Pare et al. Am J Gastroenterol 2001Stewart et al. Am J Gastroenterol 1999
Stewart et al
EvacuationDisorders
Primary Constipation
Rao SSC. Gastroenterol Clin North Am. 2003;32:659-683.
Pathophysiology of Constipation
Dyssynergic Defecation
RectoceleProlapse
Perineal descent
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Satish S.C. Rao, MD, PhD, FACG
What’s in a Name?What’s in a Name?
Anismus
Paradoxical puborectalis contraction
Pelvic outlet obstruction
Spastic pelvic floor syndrome
Pelvic floor dyssynergia- Rome II
Obstructive Defecation
Dyssynergic Defecation-Rome III/IV
Case Study 48-year-old secretary
Case Study 48-year-old secretary
Increasing constipation- 5 years Began during college days B.M once or twice a week Hard, pellet-like stool, excessive straining, incomplete
evacuation and occasional bleeding Spends 30 mins on toilet Occasional digital disimpaction Tried OTC laxatives, lubiprostone, PEG-no relief BM only after enema + suppository and laxatives
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Satish S.C. Rao, MD, PhD, FACG
History Contd..History Contd..
Past Hx: Migraines, seasonal allergy, No back or pelvic injury, Gravida 1, para 1
Drugs: HFD=30g/day, Senna=2/day, lubiprostone =24 mcg/bid
O/E: lower abdominal fullness
What would you do next?What would you do next?
0
50
100
150
200
GI Faculty
GI Fellows
Primary Care
Internal Med
Med Students
DREs performed in previous
year(n)
Rectal Examinations Performed in Previous Year by Clinical Status (5% - 95%)*
Figure 2 Boxplot – Rank, Revised
* GI faculty and fellows had 18 outlier values ranging from 205 -1600
Wong et al, AJG,2012
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Satish S.C. Rao, MD, PhD, FACG
3-step DRE-PROTOCOL3-step DRE-PROTOCOL
1) Inspection
2) Perianal sensation & anocutaneous reflex: normal, impaired, absent
3) Digital maneuvers: mass, tenderness, stool
Squeeze x 2: normal, weak, increased
Bearing down x 2 push effort, sphincter relaxation, perineal descent
Clinically dyssynergia if … any 2; • inability to
•contract abdominal muscles •relax anal sphincter
• paradoxical contraction of anal sphincter • absence of perineal descent
Tantiphlachiva K, Rao S et al, CGH 2010
Rao ©
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Satish S.C. Rao, MD, PhD, FACG
Yield of rectal exam in dyssynergia, n=209Yield of rectal exam in dyssynergia, n=209
All patients had DRE and anorectal manometry and BET
ParameterSensitivity
(%)Specificity
(%)
Dyssynergia from DRE 75% 87%
Balloon expulsion test 49 90%
Tantiphlachiva K, Rao P, Attaluri A, Rao S, CGH 2010
Pathophysiology of DyssynergiaPathophysiology of Dyssynergia
35 patients with chronic constipation,
m/f = 5/30, x age = 44 yrs (21-81 yrs),
25 healthy controls
ASSESSMENTS:• Anorectal manometry• Simulated defecation with 50 cc balloon• Defecography• Colonic transit study
Rao et al,Am J Gastroenterol 1998;93:1042-50
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Satish S.C. Rao, MD, PhD, FACG
Dyssynergic Defecation-Pathophysiology
• Impaired Rectoanal coordination– Paradoxical anal contraction
– Inadequate rectal contraction/pushing force
– Absent/Inadequate anal relaxation
• Impaired Rectoanal sensation ~ 50%
• Learnt = 67%
• Yet to Learn = 33%
Rao et al, Am J Gastroenterol 1997;92:469-75
Rao et al, J Clin Gastro 2004;38;680-5
Can symptoms predict dyssynergia?Can symptoms predict dyssynergia?
Symptom prevalenceNormal pattern
(n=30)Dyssynergia
(n=70)
Excessive straining 92% 89%
Abdominal fullness 80% 84%
Incomplete evacuation 72% 95%
Abdominal discomfort 88% 77%
Digital maneuvers to defecate 28% 51%
Rao et al, Neurogastroenterol Motil 2004; 16: 589
100 patients with difficult defecation
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Tools for EvaluationTools for Evaluation
• History
• Physical Examination
Digital Rectal Examination
• Stool Diary-Bristol Stool Scale
• Diagnostic Tests
Physiological
Morphological
StructuralRao SSC. Gastroenterol Clin N Am 36 (2007) 687-711
Date Time of Bowel
Movement
Straining
Yes/No
Feeling of incomplete
BM
Yes/No
Stool Consiste-ncy (1-7)
Urge
Yes/No
Digital
Yes/No
Drug Comments
Stool Diary-Constipation; Rao ©Record your stool habit for one week
1
3
4
5
6
1
1
2
7Liqui
Name:Hosp. No:
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Satish S.C. Rao, MD, PhD, FACG
Evaluation of Colonicand Anorectal FunctionEvaluation of Colonic
and Anorectal Function
Colonic Marker StudyAnorectal manometry
Day 1- Bisects
Day 2- Rings
Day 3-Trisects
Day 6 (120 hrs)
- Plain abdomen x-ray
-
Balloon Expulsion Test
Normal Bearing Down- Rao ©Normal Bearing Down- Rao ©
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Satish S.C. Rao, MD, PhD, FACG
Types of Dyssynergic DefecationTypes of Dyssynergic Defecation
Normal
Rectal
Anal
Rao et al, Neurogastroenterol Motil 2004; 16: 589
Dyssynergic patterns:PhenotypesDyssynergic patterns:Phenotypes
P-
Puborectalis
EAS-
External anal sphincter
D -
Difusse
P-
Puborectalis
EAS-
External anal sphincter
D -
Diffuse
I II III IV
S.Rao et al DDW 2016
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Satish S.C. Rao, MD, PhD, FACG
Dyssynergia Type 1- SubtypesDyssynergia Type 1- Subtypes
Type I-PuborectalisType I-Puborectalis
Type I- EASType I- EAS
Type 1-DiffuseType 1-Diffuse
S.Rao et al DDW 2016
48-yr old Secretary
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Satish S.C. Rao, MD, PhD, FACG
Effect of Body Position on Defecation Patterns
Rest Bearing down
Rectal pressure
Rest Bearing down
Bearing Down Lying Bearing Down on Commode
Courtesy of S.Rao
Diagnostic Criteria-Dyssynergic DefecationDiagnostic Criteria-Dyssynergic Defecation
1. The patient must satisfy diagnostic criteria for functional constipation-Rome III
2. During repeated attempts to defecate must demonstrate Dyssynergic pattern of defecationManometryEMG
3. Patient must demonstrate one other abnormal test:a. Abnormal balloon expulsion Test (> 1 minute)b. Prolonged Colonic Transit Time (radioopaque
markers or SmartPill or Scintigraphy)c. Abnormal Defecogarphy (>50% barium retention)
Bharucha et al, Gastroenterology 2006; 130: 1514Rao SSC. Gastroenterol Clin N Am 36 (2007) 687-711
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How to Treat Dyssynergic Defecation ?
How to Treat Dyssynergic Defecation ?
General Measures Diet, exercise, fluids & habit training Laxatives/Prokinetics
Specific Treatment Botox injection Biofeedback therapy Cognitive Behavioral Therapy Surgery
Myectomy- 30% improvement Colostomy
Rao SSC. Gastroenterol Clin N Am (2008)
Botox-DyssynergiaBotox-Dyssynergia
Ron et al 2001 Dis Col
Joo et al 1996
Dis Col Rec
Hallan et al Lancet 1988
n(f) 25(15) 4 7
Diagnosis ARM + B.Defecation
EMG +Defecography
EMG
Botulinum Toxin A 20 u 6-15u 3 ng
F.up 1,4,12,24 wks 10 mo 4 wks
Success 30% 50% 57%
Complications (pain, incont.) 12.5% 5.6% 29%
3 Uncontrolled trials
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Biofeedback TherapyBiofeedback Therapy
• A technique of conditioning and/or retraining the mind and body to normalize bowel movement.
How many of you perform Biofeedback ?
Biofeedback-DyssynergiaBiofeedback-Dyssynergia
» Goals of Therapy :• A) Teach Diaphragmatic
breathing exercise
• B) Teach anal sphincter &
pelvic floor relaxation
• C) Improve Rectal Sensation
• D) Eliminate Sensory Delay
• E) Improve Recto-anal Coordination
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Satish S.C. Rao, MD, PhD, FACG
Visual/Audio/Verbal Feedback
Doctor/Therapist
Visual, Audio & Verbal Feedback
RCT of Biofeedback Therapy Effects on CSBM & Dyssynergia- ITT Analysis
RCT of Biofeedback Therapy Effects on CSBM & Dyssynergia- ITT Analysis
0
1
2
3
4
Biofeedback Sham Feedback Standard
CS
BM
s p
er W
eek
(M
ean
+ S
.E.M
.)
Baseline
Post-Therapy
¤ § §§
§§ p = 0.0062 vs Standard
¤ p < 0.02 vs Baseline
§ p < 0.05 vs Sham¤ § §§
Rao et al Clin Gastro Hepatol 2007
0%
20%
40%
60%
80%
100%
Biofeedback Sham Feedback Standard
% o
f P
atie
nts
wit
h D
yssy
ner
gia
afte
r T
reat
men
t
¤:p < 0.0001 vs Sham,Standard,& Baseline
¤
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Biofeedback Standard
Mea
n C
SB
Ms
/ W
eek
±S
.E.
BaselineOne Year¤ §
§ p<0.0001 vs Standard
¤ p<0.0001 vs Baseline
Rao et al Am J Gastro 2010
Long Term Outcome of Biofeedback- CSBM/weekLong Term Outcome of Biofeedback- CSBM/week
Home vs Office Biofeedback-Responder Analysis
Home vs Office Biofeedback-Responder Analysis
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
HOME OFFICE
RESPONDER= > 1 CSBM/wk + > 20 mm Change in VAS
HOME
OFFICE
TOST= p =0.006
Rao et al DDW 2011
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Biofeedback Therapy-RCTsBiofeedback Therapy-RCTs Biofeedback Vs PEG 14.6 g for Dyssynergia
Chiarioni et al, Gastroenterology 2006; 130: 657-64
Biofeedback vs Diazepam for Dyssynergia Heymen et al, Dis Col Rectum 2007
Biofeedback vs Sham Therapy vs Standard Therapy Rao et al CGH 2007
Biofeedback vs Standard Therapy-One Year outcome Rao et al Am J Gastroenterol 2010
Home vs Office Biofeedback Therapy- Efficacy & Cost Effectiveness Rao et al, DDW 2011 & Go et al, DDW 2011
Evidence Level: Type 1; Recommendation Grade : ARao et al: American & European NGM Societies, Neurogastro Mot 2015
Biofeedback Bowel RetrainingBiofeedback Bowel Retraining
Advantages:
• Safe• Effective• Painless And Well Tolerated• Inexpensive
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Stimulation Parameters• Sample frequency 2000 Hz• Epoch duration 300 ms• Amplifier gain 100,000 Hz• Artifact rejection = On• Band pass filter 1-500 Hz• Stimulus frequency 0.2 Hz• Number of stimuli : 200 (50 x 4)
Electrical Stimulation
Aff
eren
t Pat
hway
CEPs recording
Recto-Cortical and Ano-Cortical Evoked Potentials (Afferent Brain-gut interaction)
1
2
3
4 Computer system analysis
Recto-Cortical Evoked Potentials (CEP)-Grand average of 200 electrical stimulations
Recto-Cortical Evoked Potentials (CEP)-Grand average of 200 electrical stimulations
50 (ms)
P1
N1
P2
N2
Normal
50 (ms)
P1
N1
P2
N2
Onset to P1: 48.1 milisecondsAmplitude: 4. 96 µV
Onset to P1: 66.62 milisecondsAmplitude: 1.04 µV
7
6
5
4
3
2
1
0
7
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5
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2
1
0
50 (ms)
P1
N1
P2
N2
Onset to P1: 44 milisecondsAmplitude: 2.79 µV
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6
5
4
3
2
1
0
Dyssynergic-After BF
µv
Dyssynergic-Before BF
Rao et al DDW 2011
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Efferent Brain-Gut axis Assessment
MEPs recording
Eff
eren
t p
ath
way
2
4 Computer system analysis
1
3
TMS stimulation
Stimulation Parameters• Stimulation intensity 85-100%• Good response = MEP amplitude >10 μV • 3-6 consecutive trials
Coss Adame E, Rao S et al NGM 2012
Results
Trans-cranial magnetic stimulation
Left Right
Anal(ms)
Rectal(ms)
Anal(ms)
Rectal (ms)
Before Treatment 26±1 24±0.7 24±0.7 24±0.6
After Treatment 22±0.5* 21±0.4* 21±0.4* 21±0.5*
Healthy Controls 22±1† 21±1† 22±1† 20±1†
* p<0.05, Before vs After Treatment ; Pair t test, values expressed mean ± SEM† p<0.05, Before Treatment vs Healthy Controls
Coss Adame E, Rao S et al NGM 2012
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CONCLUSIONSCONCLUSIONS
• Biofeedback therapy modulates the neurobiologic brain-gut axis and thereby improves bowel function in patients with DD
• Our study provides a mechanistic basis for biofeedback therapy in DD
Coss Adame E, Rao S et al NGM 2012
Take Home PointsTake Home Points
• Dyssynergic Defecation causes Constipation in ~40%• HRAM increases diagnostic sensitivity but body position is critical • Biofeedback is mainstay treatment & not Experimental• RCTs have established short term and long term efficacy of
biofeedback therapy in dyssynergic defecation• -Grade A Evidence- Rao et al Neurogastro Motil 2015
• Gut-Brain-gut axis is deranged in Dyssynergic patients & Biofeedback Therapy restores normal function
• Home Biofeedback is efficacious and cost-effective
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