Evaluation of constipation in children using high-resolution anorectal manometry

This prospective, cross-sectional study, conducted from July 2018 to March 2019, aimed to determine the causes of constipation using high-resolution anorectal manometry. Among 33 children enrolled in the study, 31 (94%) children presented with complaints of constipation with mean duration of 2.3 ± 2.5 years and 12 (36.4%) children also had associated complaints of faecal incontinence with mean duration of 3.5 ± 2.8 years. Seven children (21.2%) had normal high-resolution anorectal manometry parameters; anal sphincter hypotonia with decreased squeeze in one child, anal sphincter hypertonia with other abnormal parameters were noted in 25 and absent recto-anal inhibitory reflex in two. The causes of constipation determined were functional constipation in 30 (91%) children, suspected Hirschsprung’s disease in two and suspected dyssynergic defecatory disorder in one. Almost 90% had functional constipation of which anal hypotension and anal hypertension may be a part of chronic functional constipation.

O5 Dose mean opening pressure predominantly assess internal anal sphincter function

Introduction We have suggested that mean Opening Pressure (Op) recorded during Anal Acoustic Reflectometry (AAR) predominantly represents IAS function however, the extent remains unknown. The aim was to investigate this by excluding the external anal sphincter during general anaesthetic (GA) with confirmed neuromuscular blockade (NMB). Method Patients undergoing elective abdominal surgery requiring GA+NMB were approached. Patients had pre-operative (awake) and during GA + NMB (asleep) AAR measurements performed. The rectoanal inhibitory reflex (RAIR) was assessed permitting the Op value to also be recorded when the IAS was inhibited. Op was recorded at prerectal distension and then after 100 mls of air was inflated within a balloon in the rectum (post-rectal distension). Result 19 patients were included. The values of Op (cmH20) and the reductions observed during the RAIR when awake/asleep are as follows: Awake Op: prerectal distension (64.94) and post-rectal distension (35.35) therefore mean change 29.59 cmH2O i.e. 44.6% reduction Asleep Op: prerectal distension (37.64) and post-rectal distension (15.55) therefore mean change 22.1 i.e. 55.3% reduction The contribution of the IAS to Op is calculated as follows: (Mean change Op awake x 100)/% reduction in RAIR asleep = IAS contribution awake (29.59cmH20 x 100)/55.3 = 53.51cmH20 Total mean Op awake—IAS contribution awake = EAS contribution awake 64.94cmH20–53.51cmH20 (82.4%) = 11.43cmH20 (17.6%) Conclusion The IAS accounts for 82.4% of Op at rest and it remains our hypothesis that Op primarily represents IAS function. Take-home Message Opening pressure primarily represents internal anal sphincter function.

DISORDERS OF PERIPHERAL CIRCULATION AMID CHRONIC OSTEOCHONDROSIS OF THE LUMBAR SPINE

Проведен анализ состояния периферического кровообращения у 28 мужчин, больных остеохондрозом поясничного отдела позвоночника, сопровождающегося люмбалгией с клинической симптоматикой нарушения периферического кровообращения нижних конечностей. Все больные, принимавшие участие в нашем исследовании, подписали информированное согласие на участие в программе и соглашение о неразглашении личных данных и протокола исследований. Критериями для анализа являлись изменения клинической симптоматики остеохондроза поясничного отдела позвоночника, обусловленной им люмбалгии и показателей оксиметрического исследования, которые были зафиксированы при первичном обращении и через 7 суток на фоне проводимого лечения и регрессии болевого синдрома. Таким образом, полученные результаты свидетельствовали о рефлекторном нарушении периферического кровообращения за счет развития патологического спинально-вазального тормозного рефлекса, обусловленного люмбалгией, которые восстанавливаются на фоне регрессии патологической импульсации в поясничном отделе позвоночника. Целесообразно продолжить исследования в этом направлении. The state of peripheral circulation in 28 men were analyzed, patients with osteochondrosis of the lumbar spine, accompanied by lumbodynia with clinical symptoms of impaired peripheral circulation of the lower extremities was carried out. All patients who took part in our study signed an informed consent to participate in the program and a non-disclosure agreement of personal data and research protocol. The criteria for the analysis were clinical symptoms of osteochondrosis of the lumbar spine caused by lumbodynia and indicators of oximetry studies, which were recorded during the initial visit and after 7 days amid treatment and regression of pain syndrome. Thus, the results indicated a reflex disorder of the peripheral circulation due to the development of a pathological spinal-vasal inhibitory reflex caused by lumbodynia, which is restored amid regression of pathological impulses in the lumbar spine. It is advisable to continue research in this direction.

Absent or impaired rectoanal inhibitory reflex as a diagnostic factor for high-grade (grade III–V) rectal prolapse: a retrospective study

Background Clinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse. Methods In this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated. Results Frequencies of fecal incontinence (p = 0.002) and feeling of prolapse (p < 0.001) were significantly higher in the high-grade group. The maximum resting (77.5 vs. 96 mmHg, p = 0.011) and squeezing (128.7 vs. 165 mmHg, p = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%, p < 0.001). In a multivariate analysis, the feeling of prolapse (odds ratio [OR], 23.88; 95% confidence interval [CI], 4.43–128.78; p < 0.001) and absent or impaired RAIR (OR, 5.36; 95% CI, 1.91–15.04, p = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse (p < 0.001). The sensitivity of absent or impaired RAIR as a predictor of high-grade prolapse was 63.3% and specificity 74.0%. Conclusions Absent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Changes in the parameters of the rectoanal inhibitory reflex in children with functional constipation and large rectum

Background. Abdominal ultrasound and anorectal manometry are part of the investigations used to assess children with functional constipation. This study aimed at assessing the changes in the characteristics of the rectoanal inhibitory reflex (RAIR) in children with functional constipation and correlating them with the dimensions of the rectum, measured by abdominal ultrasound. A secondary objective was to compare the rectum size in children with and without constipation. Method. We retrospectively reviewed the clinical data and investigations results of 51 children (mean age±standard deviation (SD) =5.8±3.5 years) with functional constipation who came to our clinic between January 2013 and February 2020. The assessment of these patients included both the assessment of the transverse diameter of the rectal ampulla by abdominal ultrasound and anorectal manometry. The studied parameters of RAIR were: the minimal volume of air necessary to induce RAIR, in all the patients with functional constipation, and in 20 of them, relaxation time, latency and relaxation percentage. A control group was formed of 27 children (mean age±DS=5.1±4 years) without digestive diseases and with normal intestinal transit, who were assessed by abdominal ultrasound. Results. The mean value ±SD of the volume of air necessary to induce RAIR was 21.9±12.1 cm3 air. There was no correlation between the rectum transverse diameter and the minimal air volume that triggered RAIR (r=-0.01, p=0.94). The mean value ±SD of the transverse diameter of the rectum in patients with functional constipation was 39±14 mm, and in children without constipation 26±6 mm (p<0.05). The mean duration of the symptoms in children with functional constipation was 2.8 years. Conclusions. There were no correlations between the volume of air that induced the RAIR and the transverse diameter of the rectum in children with functional constipation. The transverse diameter of the rectum was increased in children with long-term functional constipation.

Anorectal malformation with long perineal fistula: one of a special type

The anorectal malformation with long perineal fistula is a rare anomaly in the spectrum of anorectal malformations. Aim of the study is to describe the series of patients with anorectal malformation with long perineal fistula and compare the outcome with patient with standard perineal fistula. From March 2012 to January 2019, 7 patients who suffered from anorectal malformation with long perineal fistula were retrospectively reviewed. Three were operated on primarily by our department, and 4 cases were re-operated after a perineal anoplasty repair performed elsewhere. Four were operated by laparoscopy assisted anorectoplasty, and 3 cases were repaired by posterior sagittal anorectoplasty. The follow-up outcomes were compared with 71 cases of normal perineal fistula (NPF) in the same period. 7 cases have been followed up for 0.5–4 years (M = 2.57 ± 1.26) after definitive surgery. Their bowel function score was lower than normal perineal fistula (SPF = 12, range: 5–18; NPF = 18.5, range: 18–20). Four cases underwent anorectomanometry. The incidence of rectoanal inhibitory reflex was lower in the special type group. (p = 0.14). Three cases of contrast enema using barium: 2 cases of colorectal dilatation and thickening changes, 1 case showed no obvious abnormalities. Anorectal perineal fistula should be examined by distal colostogram at preoperation. This should be altered in: When suspecting a case of anorectal malformation type long perineal fistula a preoperative contrast enema could give insight of the anatomy befor performing a anoplasty.

Perineal Fistula With High Dilated Colon: One of a Special Type of Anorectal Malformations

Background The perineal fistula with high dilated colon is a rare anomalous in the spectrum of anorectal malformations. The aim of this study is to explore the diagnosis and treatment of this special type of perineal fistula (SPF), and to avoid the severe consequence due to misdiagnosis.Methods From March 2012 to January 2019, 7 patients who suffered from perineal fistula with high dilated colon were retrospectively reviewed. Three were operated on primarily by our department, and 4 cases were re-operated after a perineal anoplasty repair performed elsewhere. Four were operated by laparoscopic anorectoplasty (LARP), and 3 cases were repaired by posterior sagittal anorectoplasty (PSARP). The follow-up outcomes were compared with 71 cases of normal perineal fistula (NPF) in the same period.Results 7 cases have been followed up for 0.5-4 years (M=2.57±1.26) after definitive surgery. Their bowel function score (BFS) was lower than normal perineal fistula (SPF=12, rang:5-18; NPF=18.5, rang:18-20). Four cases underwent anorectomanometry. The incidence of rectoanal inhibitory reflex (RAIR) was lower in the special type group. (p=0.14). Three cases of barium enema angiography: 2 cases of colorectal dilatation and thickening changes, 1 case showed no obvious abnormalities.Conclusions Anorectal perineal fistula should be examined by distal colostogram at preoperation. Select appropriate surgical approach is essential for children’s defecation function, and blind surgery can seriously affect long-term defecation function.

The reciprocal jaw-muscle reflexes elicited by anterior- and back-tooth-contacts—a perspective to explain the control of the masticatory muscles

Aims Tooth-contact sensations are considered essential to boost jaw adductor muscles during mastication. However, no previous studies have explained the importance of the inhibitory reflex of human anterior-tooth (ANT)-contacts in mastication. Here I present the “reciprocal reflex-control-hypothesis” of mammalian mastication. Subjects and setting of the study I demonstrate the hypothesis with the live kinematics of free jaw-closures as inferred from T-Scan recordings of dental patients. Results The jaw-closures started with negligible force, predominantly with ANT-contacts (the AF-bites). The first ANT-contact inhibited the first kinematic tilt of the mandible, whereas the bites starting from a back-tooth (BAT)-contact (the BF-bites) accelerated the first tilt. The second tilt established a low-force static tripod of the ANT- and bilateral BAT-contacts for a fixed mandible-maxilla relation. Thereafter, semi-static bite force increased rapidly, relatively more in the BAT-area. Discussion and Conclusions In the vertical-closure phase of chewing, the primate joint-fulcrum (class 3 lever) conflicts with the food-bolus-fulcrum in the BAT-area (class 1 lever). The resilient class 3 and 1 lever systems are superseded by an almost static mechanically more advantageous class 2 lever with a more rigid fulcrum at the most anterior ANT-contact. For humans, the class 2 levered delivery of force also enables forceful horizontal food grinding to be extended widely to the BAT-area.