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    MEDICINA

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    5 views9 pages

    Manometria Anorectal 2014

    Uploaded by

    Boris Ariel Hernandez Briones
    MEDICINA

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
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    ET ECSU ALLO UN Neurogastrocnterol Motil [2014) 26, 529-837 do 10.1111 /mo12297 Normal values for high-resolution anorectal manometry/ topography in a healthy Korean population and the effects of gender and body mass index HJ, LEE,* K. W. JONG 8D. YE," |S. BYEON, * SHAN, JW. KIM, SK PARK," 11. YOON, * SOK YANG," [-HKIM* & 5.1. MYUNG H.§, KOO," §.¥, SEO," D-H YANG," K-1. KIM," *Department of Gastroenterology, Asan Digestive Disease Reseatch Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea ‘Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine Seoul, Korea Division of Gastrenterology, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea Key Messages © This study investigated, for the first time, the influences of gender and body mass index (BMI] on high- resolution anorectal manomewy |HRM) parameters in asymptomatic normal Asian men and women populations + We performed HRM in 54 asymptomatic healthy Koreans. A multivariate linear regression analysis has been conducted to identify the independent effects of various physical statuses (age; gender, BMI, and vaginal delivery] on HRM parameters + All pressure activities and the rectal perception of desire to defecate were found to be independently associated with gender, BMI showed a positive corrclation with anal resting pressure and a negative correlation with the minimal rectal volume for frst sensation, HRM parameters may be associated with gender and BML Abstract Background High-resolution manometry (HRM) based on spatiotemporal plots 1s increasingly being tively. We evaluated anorectal pressures, rectal sen: sation using a HRM probe, and balloon expulsion ume. Multivariate linear regression analysis was used, The aim this study was to evaluate, for the first time, the influence of gender, with adjustment for tage, body muss index (BMI), and vaginal delivery, on anorectal functions in asymptomatic adults Methods Fifty-four asymptomatic healthy subjects (ME age ~ 20-67 years) who matched by age and gender were enrolled prospec 2727, were Address jor Correspondence Seung-Jac Myung, MD, PRD, Department of Gastrventetology, Asan Medical Center, University of Ulsan College of Mesicine, 88, Olympic-ro 44g, Songpa-ge, Seoul 138-786, Ko Tels -82-2-4010-9917, fax e-mail: simyung@ame seoul kr Received: 24 May 2018 Accepted jor publication: § December 01 © 2014 John Wiley & Sons Led performed to identify the independent effects of each factor, Key Results Anal resting pressure (median {OR}, 32 [18] vs 46 [27} mmilg, p< 0.001), anal squeeze pressure (75 [28] vs 178 (72) mmHg p< 0.001) rectal pressure (33 [26] vs 63 [46] mmitlg P= 0.009) and anal pressure (16 [27] vs 30 /36] mmilg P= 0019) during simulated evacuation with rectal distention, and the threshold for the desize to defecate (60 [20] vs 80 [60] mL. p = 0.020) were significantly lower in women than in men, BAIL was positively correlated with anal resting pressure (95% CI: 0.598: 2.947) and negatively correlated with the threshold for first sensation (95% Cl: ~0.099 t0 ~0.015), Vast nal delivery did not affect any of the anorectal HRM parameters. Conclusions « Inferences HRM parameters may be associated with gender and BML Therefore, gender and BMI should be taken into consideration when interpreting HRM restrlts, Keywords Asians, body mass index, gender, high- resahution anorectal manometry, reference values. Abbreviations: BET, balloon expulsion time; BMI, body mass index; Hy, fecal incontinence, HRM, high-resolu- tion manometry; RAIR, rectoanal inhibitory reflex INTRODUCTION Defecation disorder is a common disease that oceurs in 2-80% af the adult population’ * and its prevalence in Asia is being recognized increasingly. Anorectal manometry with balloon expulsion test- ing is one of the first-line diagnastic tools for defeca- tion disorder and is widely used to determine anorectal pressures and sensory function.® Moreover, the man- agement of defecation disorders can be influenced by manometry results.’ High-resolution manometry (HRM] based on spatiotemporal plots is increasingly being used in preference to traditional linear wave- based manometry. HRM takes advantage of an increased number of recording sitcs to cxamine the spatial and temporal relationships between pressure data and provides greater physiologic resolution and minimization of movement artifacts." New attempts to characterize defecatory disorders using HRM have already been made.* Hence, novel HRM technalogies that provide an improved manometric topographic display and analysis are expected to assist in the accurate diagnosis and optimal treatment of patients with defecatory disorders * Itis noteworthy that normal HRM values remain to be determined with the exception af those provided by a previous study that involved a relatively small women population from a Western country” The contractility of the gastrointestinal smooth muscles has been known to vary by age and gender, moreover, the proportion of men with defecation disorders in Asia seems to be more common than in Western coun- tries"! Hence, the normal data ranges in men and an. investigation into the effects of age and gender on HRM values are required Other than age and gender, body mass index |BMI) is a factor that could affect anorectal parameters, A higher BMI is a well-known risk factor for fecal incontinence |FI).'?"¥ Recently, a study has reported the association between BMI and anal pressures mea- sured using conventional anorectal manometry.!* In addition, the vaginal-delivery history is thought to affect anorectal parameters, as there have been a number of reports regarding defecation disorder and FI following delivery! '? However, detailed analyses of the influence of BMI and vaginal delivery on anorectal physiology are scarce. Moreover, no study has performed multivariate analysis to confirm the independent effects of various physical parameters lage, gender, BMI, and vaginal delivery) on anorectal functions in a normal population ‘The aim af this study was to evaluate, for the first time, the influence of gender, with adjustment for age, BMI, and vaginal delivery, on anorectal functions in age- and sex-matched asymptomatic normal adults, METHODS Study population ‘The study population consisted nf 54 healthy Rorean participants From March 2012 ta September 2012, asymptomatic adults tanging from 20 to 70 years old were prospectively enrolled in this study through a public advertisement. To evaluate the influence uf gender and age on HRM profiles, equal numbers of these participants were enrolled for each decade of age and gender All subjects had normal physical abdominal and anurectal digital examinations. Exclusion criteria included constipation; Fl, any positive response to the Rome Ill questionnaire; abnormal eolo- fnoscopy or barium enema findings (such as cancer, ulcer, colitis, hemorthage, obstruction, and perforation), abdominal surgery [except appendectomy}, any anorectal surgery: significant cardio. vascular, respitatory, psychiatric, neurologic, endocrine, hepatic, renal disease; the use nf any medication that has an influen m gastrointestinal tract motility, and pregnancy, Demographic data were collected on cach patient, including age, gender, height, ‘weight, and parity. Our study protocol was approved by the Institutional Review Board of the Asan Medical Center (protocal no, 2012-0082) Informed consent was obtained in all eases. Study protocol Bowel preparations were not routinely used, Each of the partic! pants received sodium phosphate enemas (Fleet enemas CB Fleet Lynchburg, VA, USA} 2 h before their examination, Participants ‘were studied in the left lateral decubitus position with hips flexed 10 90°, HIRM was performed with a solid-state HRM probe |4-mm ater diameter, Sandhill Scientific, Denver, CO, USA! comprised nf 22 pressure sensors. The intzaballoon sensor was used to measure the pressure inside the balloon during the complian study. The rectal pressure sensor and the anal anal sensors were used to measure pressure within the rectal vault and the anorectal sphincter, respectively, during the manometry study, Four dire tional sensmes were pasitioned throughout che anal canal to measure the pressure at every centimeter of the posterior, left, anterior, and right quadrants of the sphincter. The anal pressures obtained from all the sensors within the anal sphincter were averaged to provide a mean sphincter pressure. The extemal reference channel was located 1 em outside the anal verge and enabled visibility of the distal border uf the sphincter ‘The lubricated probe was inserted until the baseline position- ing band was situated in the anal verge. Alter allowing, the © 2014 John Wiley & Sons Led Volume 26, Number 4, April 2014 pressure to stabilize the resting sphincter pressures were deter ‘mined. Squeeze pressure was measured as the highest squeeze pressure value obtained dusing 5 of voluntary contraction of the nal sphincter and was recorded asthe average of three mane ‘ers. The rectal and anal pressures during simulated evacuation ‘vere then determined here and aftr the distension ofa rectal Balloon with SO mL of water, The rectoanal inhibitory rellex IRATR) was determined while injecting up 4 50 aL of ai int the nubjec’s tectum, positive RAIR texponse vecired, if any Channel registered a 15% or greater drop im volume and returned to the renting pressure. Rectal sensition wat evaluated by {inflating the rectal balloon with a hand-held syringe in 10 mL fofements of ir (up to a total of 24D mil), and the threshold volumes for fest sensation, dese to defecate, and urgeney sere recorded. These parameters were analyzed using Biowiew analysis ‘soltware withthe aSIGHT G8 HRM system Sandhill Sent alloon expulsion time (BET) was determined wish balloon filed wich 30-mL of water. An elapse sine of more than 1 min was regarded as failure and the balloon eas removed, ifthe patticipants were unable to expel the balloon within 5 min”! Data analysis The medians and interquartile ranges for each of the anorectal HRM parameters were_genceated. according «gender mals female, BMI (225, 225) BMU25 ts the index of overweight based tim the World Healeh Organization [WHO] BMI classifications ind vaginal delivery jo vaginal delivery, vaginal delivery). The fnlucnce of each physical parameter (age, gender, BMI, and ‘vaginal delivery om anorectal HRM parameters was evaluated ft, the Independent effects of these. physical actor, wore adjusted forthe elfets of other factors on anorectal HRM parameters, wore evaluated Statistical analysis Statistical analyses were performed with SPSS statistical snfteare version 1800, SPSS, Chicago, IL, USA Differences in the ontinuous variable ofthe two groups wete evaluated with the ‘Mann-Whitney U-test. Differences in eategotcal variables were evaluated with the Chi-squared test or Fisher's exact test, The 'ssociations berween each physical parameter of the participants tnd the anorectal parameters were evaluated using linea regres ‘om analysis, and multvasiate analysis was performed t identify the independent effects nf various physical parameters cm the anorectal parameters. Lincar regression models on the orginal scale valuss or with lng transformed nuteome values, depending tim the Shapiro Wille normality test, were Attd, If the log ttansfommed outcome vatiale didnot satisfy: the normality sssumption, the generalized leat modl with Tog link gamana Aistnhution or an inverse-link gamma distribution assumption ‘was considered. The adopted statisti methods were subse ‘quently noted in the reales tables, All p= O05 were considered statistically significant. RESULTS Clinical characteristics of the study population A total of 54 healthy Korean participants (27 men |50.0%); median age = 37.5 years [range = 20-67)) were studied, The number of subjects in the 20-29, 30-39, © 2014 John Wiley & Sons Led Normal values for high-resolution manometry 40-49, 50-59, and 60 years or older age ranges were 16, 13, 13, 9, and 3, respectively. The mean BMI was 23.18 kg/m*, Among the study participants, 14 were overweight (BMI > 25 and <30 kg/m') and three were ‘obese (BMI > 30 kg/m") according to the WHO BMI classifications. OF the 27 women in our cohort, 18 had given birth (range = 0-2; median = 2) via 26 vaginal deliveries and six Cesarean sections, Anorectal HRM parameters ‘The anorectal HRM parameters among the study cohort are listed in Table S1. The mean anal resting and anal squeeze pressures were 40 and 129 mmHg, respec tively, The mean rectoanal gradient during simulated evacuation with rectal distention was 19 mmHg, and 10 participants (18.5%| had negative rectoanal gradi ents, The mean defecation index was 2.4, The mean anal relaxation was 37%, and 23 participants (42.6%) displayed paradoxical anal contraction. In the sensory test, the average values of the minimal rectal balloon volume for the first sensation, desire to defecate, and urgeney, were 16, 81, and 136 mL, respectively. The mean BET was 30s and eight of the participants (14.8%) were unable to expel the balloon in L-min, Influence of age on anorectal HRM parameters ‘The association of age with anorectal HRM parameters ‘was examined by linear regression analysis (Table 2) [Age did not correlate with any anorectal HRM param- eter in the multivariate model, which was adjusted for the effect of gender, BMI, and vaginal delivery Influence of gender on anorectal HRM parameters ‘The anorectal parameters for HRM according to gender are indicated in Table 1, In the multivariate model, which was adjusted for the effects of age, BMI, and vaginal delivery (Table 1 and Table $2), all pressure activities measured using HRM were found to be independently associated with gender and the pressure parameters were much lower in women than in men, The anal resting {median 32 vs 46 mmblg, p< 0.001, Fig. 1A) and squeeze (median 75 vs 178 mmHg, Pp <0.001; Fig, IB} pressures were significantly lower in the women participants. Rectal pressures (median 438 vs 58 mmHg, p = 0,009; Fig, 1C) and anal pressures (median 30 vs 16 mmHg, p = 0.019, Fig. 1D) during ‘simulated evacuation with rectal distention were also lower in women and as a consequence, they did not differ in terms of rectoanal gradient between sexes Hf Lee et a ‘Table 1 Influence of gender om anorectal HRM parameters Neurogastroenteralogy and Motility Mate n= 27) Female a =27) Univariate Malware Vanible Median OR} Median OR) pralue pralue Anal vesting prose 269-56) maa) =n001 ‘001 Anal squeeze pressure! vs ua0-a12) 7560-89)

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