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Anorectal manometry and Biofeedback therapy

Anorectal manometry and Biofeedback therapy. Ashok Attaluri , MD. Overview. Indications Test performance Test interpretation Treatment options. Assessment-Defecation Disorders. Anorectal Manometry (ARM) Balloon or Fecom expulsion Test Anal Endosonography

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Anorectal manometry and Biofeedback therapy

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  1. Anorectalmanometry and Biofeedback therapy Ashok Attaluri, MD

  2. Overview • Indications • Test performance • Test interpretation • Treatment options

  3. Assessment-Defecation Disorders • AnorectalManometry (ARM) • Balloon or Fecom expulsion Test • Anal Endosonography • Rectal Sensation/Tone/Compliance • Pudendal Nerve Terminal Motor Latency • EMG • Defecography & MR Defecography • Colonic Manometry/Tone/Sensation • Anal Vectormanometry • Anal Mucosal electrosensitivity • Cortical Evoked Potentials • Commonly performed and regarded as useful • Probably Useful • Used in Research Labs Rao et al Neurogastro Motil 2002; 14:553-9

  4. ANORECTAL MANOMETRY • Assessment of: • Pressure, Sensory and Reflex activity of the anus and rectum • Dynamics of defecation and continence.

  5. Indications • Fecal Incontinence • Chronic Constipation • Pre/Post Surgery (pouch) • Facilitate Biofeedback Bowel Retraining • Functional anorectal pain • Rectal Prolapse • Solitary Rectal Ulcer Syndrome • Rao et al Neurogastro Motil 2002; 14:553-9

  6. Patient Preparartion • No need to fast • Enema the night before • Avoid drugs-opioids, anticholinergics, tegaserod, • Explain procedure/maneuvers • Check for latex allergy • Rectal Exam • No need for escort/sedation

  7. Equipment - ARM Recorder/Amplifier Water perfused Probe Solid State Microtransducer Probe

  8. ARM Probe Rao et al Neurogastro Motil 2002; 14:553-9

  9. High resolution ARM catheter Anal Canal Sensors Rectal Sensors Balloon

  10. Protocol • Introduce Lubricated Catheter, run in time • Squeeze x 2 • Attempted Defecation x 2 • Cough/Party Balloon reflex test x 2 • Intermittent Rectal Balloon Distension- From 10-250 CC • Rectoanal inhibitory reflex • Rectal Sensation • Rectal Compliance • Simulated Defecation – Balloon or FECOM • Optional: • Rectal Compliance • Saline Continence Test • Pudendal Nerve Terminal Motor Latency • Rao et al NeurogastroMotil 2002; 14:553-9

  11. Which Test & When ? Rao et al Neurogastro Motil 2002; 14:553-9

  12. Normal Defecation Rectum Strain 60cc 60cc + Strain Anal Canal Dyssynergic Defecation Strain 60cc 60cc + Strain

  13. Manometric Patterns-Attempted Defecation Rectal Normal Anal Dyssynergic Defecation Type I Type II Type III Rectal Rectal Rectal 50 0 mm Hg Anal Anal Anal Rao et al Neurogastro Motil 2002; 14:553-9

  14. 2 RESTING ARM 100 Rectal Sensor 12 100 10 100 8 100 Sensor Position Pressure (mmHg) 6 100 4 100 2 100 Sleeve 10 sec 0

  15. 3 RESTING ARM mmHg Rectal Sensors 12 140 11 120 100 10 Rectum Sensor Position 80 8 60 Sphincter 6 40 4 20 External 2 10 sec 0

  16. 4 Squeeze Maneuver 100 Squeeze Squeeze 12 Rectal Sensor 100 8 100 Pressure (mmHg) Sensor Position 6 100 4 100 2 10 sec 0

  17. mmHg 180 160 140 120 100 80 60 40 20 0 5 Squeeze Maneuver Rectal Sensors 12 11 Squeeze Squeeze 10 Sensor Position 8 6 4 2 10 sec

  18. 6 Simulated Defecation 100 Simulated Defecation Rectal Sensor 12 100 10 150 8 150 Sensor Position Pressure (mmHg) 6 150 4 150 2 150 Sleeve 10sec 0

  19. 7 Simulated Defecation mmHg Rectal Sensors 12 140 11 120 100 10 80 Sensor Position 8 60 6 40 4 20 2 0 10sec

  20. 8 Simulated Defecation movement artifact 100 SimuIated Defecation Rectal Sensor 12 100 10 100 8 100 Anal Sensor Position Pressure (mmHg) 6 100 4 100 2 150 Sleeve 6 sec 0

  21. 9 Simulated Defecation movement artifact mmHg Rectal Sensors 12 140 11 Simulated Defecation 120 100 10 80 8 Anal Sensor Position 60 6 40 4 20 2 6 sec 0

  22. 10 Simulated Defecation Type 1 Dyssynergic Defecation 100 Rectal Sensor 12 100 10 100 8 100 Sensor Position Pressure (mmHg) 6 100 4 100 2 100 SimuIated Defecation SimuIated Defecation Sleeve 6 sec 0

  23. 11 Simulated Defecation Type 1 Dyssynergic Defecation mmHg Rectal Sensors 12 140 11 Simulated Defecation Simulated Defecation 120 100 10 80 Sensor Position 8 * * 60 6 40 4 20 2 6 sec 0

  24. 12 Simulated Defecation Type 2 Dyssynergic Defecation mmHg Rectal Sensors 12 140 11 Simulated Defecation 120 100 10 80 Sensor Position 8 60 6 40 4 20 2 10 sec 0

  25. 13 Simulated Defecation Type 3 Dyssynergic Defecation mmHg Rectal Sensors 12 140 11 Simulated Defecation 120 100 10 80 Sensor Position 8 60 6 40 4 20 2 10 sec 0

  26. mmHg 180 160 140 120 100 80 60 40 20 0 14 Reflex striated muscle contraction Rectal Sensors 12 11 Cough Cough 10 Sensor Position 8 6 4 2 6 sec

  27. 15 Rectoanal inhibitory reflex 150 12 20 cc 40 cc 60 cc 100 10 100 8 100 Sensor Position Pressure (mmHg) 6 100 4 100 2 100 Sleeve 30 sec 0

  28. 16 Rectoanal inhibitory reflex mmHg 12 20 cc 40 cc 60 cc 140 11 120 100 10 80 Sensor Position 8 60 6 40 4 20 2 0 30 sec

  29. 17 Failure of rectoanal inhibitory reflex 150 Rectal Balloon 12 40 cc 60 cc 100 10 100 8 100 Pressure (mmHg) Sensor Position 6 100 4 100 2 100 Sleeve 10 sec 0

  30. 18 Failure of rectoanal inhibitory reflex mmHg 12 40 cc 60 cc 140 11 120 100 10 * * 80 Sensor Position 8 60 6 40 4 20 2 10 sec 0

  31. 19 Artifact mmHg 12 20 cc 40 cc 60 cc 80 cc 140 11 120 100 10 80 Sensor Position 8 60 6 40 4 20 2 0 30 sec

  32. Standard Report • General Information • Patient identifier, Meds, Indication • Type/Configuration of probe, Calibration,Balloon • Anal Sphincter & Rectal Pressures mm Hg • Resting, Squeeze,Attempteddefecation,Cough • Rectoanal Inhibitory reflex (present/absent) • Rectal Sensation (cc) • Thresholds for first, Desire to defecate, MTV • Balloon Expulsion Test -Time taken • Other Tests: Example; Saline continence, PNTML • Comments/interpretation Rao et al NeurogastroMotil 2002; 14:553-9

  33. ARM-Clinical Usefulness Constipation (n=69) Incontinence (n=56) Pre-op (n=10) Other (n=8) Total (n=143) Confirmed 75% 95% — 74% — New Information 81% 98% 80% 87% 88% Influenced Rx 67% 84% 100% 74% 76% Normal Study 19% 2% 20% 13% 12% Not Helpful 14% 14% 0% 13% 12% Rao et al, Am J Gastro1997; 92:469-75

  34. Diagnostic Utility ofAnorectal Manometry in Constipation Rao SS et al. Am J Gastroenterol. 2005;100:1605-1615.

  35. Biofeedback Therapy

  36. Biofeedback Bowel Retraining • A technique of conditioning and/or retraining the mind and the body to regulate defecation and/or continence

  37. Biofeedback Bowel Retraining Indications • Constipation - Dyssynergic Defecation • Fecal Incontinence Others (Research-Future) • Solitary Rectal Ulcer • Anorectal Pain • Hypersensitive Rectum + I.B.S. • Hyposensitive Rectum

  38. Biofeedback- Constipation/Dyssynergia Who are Eligible ? • Symptoms of Functional Constipation (Rome III) • At least 2 criteria must be fulfilled: • Dyssynergic Defecation-Types I, II, or III • Failure/Difficulty Expelling Balloon (> 1minute) • Prolonged colonic transit (> 20% marker retention) • Inability to Expel Barium Paste (>50% retention)

  39. Biofeedback-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

  40. Patient Preparation • Similar to Anorectal manometry • Usually no prep required • No diet or drug restrictions • No sedation • Dress patient in hospital attire • Place patient on Left lateral for probe insertion and rectal exam • If patient has stool may require an enema • Cognition/Vision/motivation important • Incontinence Training: On bed, supine/left lateral • Dyssynergia Training: On commode, sitting Courtesy of Rao SS

  41. Techniques of Biofeedback Therapy • Audio/Visual/Verbal Feedback (Manometry or EMG) • Diaphragmatic Breathing • Anal Relaxation • Condition Sensory Threshold • Recto - anal Coordination • Simulated Defecation Test • Feedback Withdrawal • Home Devices Courtesy of Rao SS

  42. Office Biofeedback Therapy - Equipment • Flexible Catheter: • 2 Pressure Sensors in Anal Canal • Rectal Balloon • Pressure Sensor in Rectum • Balloon or EMG Device • Amplifier/Recorder • Home Devices Courtesy of Rao SS

  43. Home Biofeedback - Equipment Courtesy of Rao SS

  44. Dyssynergia-Effects of Biofeedback BEFORE AFTER Rectum Rectum Anal Canal Anal Canal Courtesy of Rao SS

  45. Biofeedback Therapy-RCT • 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

  46. Univ of Iowa RCT • 77 subjects (69 women, mean age 43 years, mean duration 17 years) • Randomization breakdown: • Standard: 24 subjects • Biofeedback: 28 subjects • Sham Biofeedback: 25 subjects • 65 subjects completed the study, • 12 (16%) dropped out (10 due to non-compliance, 2 due to health issues) Rao et al CGH 2007

  47. No of CSBMs / Week Rao et al CGH 2007

  48. § p = 0.04 vs Sham Feedback ¤ p < 0.0001 vs Baseline § ¤ 80% ¤ 60% ¤ % Reporting Improved Bowel Satisfaction 40% 20% 0% Biofeedback Sham Feedback Standard Global Bowel Satisfaction= > 20 mm VAS Rao et al CGH 2007

  49. Defecation Index * † * =p<0.0001 vs. Baseline # 2.0 =p<0.0001 vs. Standard # † =p<0.0001 vs. Sham Feedback Baseline 1.5 End Active Defecation Index (mean ± S.E.M.) 1.0 0.5 0 Biofeedback Sham Feedback Standard Rao et al CGH 2007

  50. CONCLUSIONS • Biofeedback Therapy • improves anorectal function in most dyssynergic patients • normalizes stool frequency and straining in 75% of patients • Real change in pathophysiology and not due to coping strategies alone • Biofeedback therapy provides sustained improvement in bowel function Rao et al CGH 2007

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