INDIVIDUAL ASSIGNMENT

GASTROINTESTINAL
2 year / 3 Semester / 2021 / FMUI 2020
st st

Mohamad Arbian Karim

2006489400 – Group A

PBL Trigger 1

How is The Diagnosis of Fecal Incontinence and Constipation using Radiology and
Labaratory Examination

Introduction
Fecal incontinence is a condition in which solid or liquid feces is lost unintentionally. There
are a variety of definitions for fecal incontinence, some of which include flatus (passing gas)
and others that are limited to stool. Faecal incontinence (FI) is a debilitating complication of a
variety of illnesses that impairs quality of life and contributes to patient disability, morbidity,
and societal burden.1,2

Constipation is characterized by the passing of feces infrequently or difficulty with

evacuation of feces. There are two types of constipation: primary and secondary. There are
three pathophysiologic kinds of primary constipation. Slow Transit Constipation is a
condition in which stool transit through the colon is delayed for an extended period of time.
Dyssynergic Defecation is defined as the incapacity or difficulty in removing feces from the
rectum. Constipation-predominant irritable bowel syndrome is characterized by symptoms of
constipation with discomfort or pain as a prominent feature. Diet, medications, behavioral,
lifestyle, endocrine, metabolic, neurological, mental, and other diseases can all contribute to
secondary constipation.3,4

Given the different causes of fecal incontinence, determining and identifying the underlying
pathomechanisms is critical. High-resolution anorectal manometry, transrectal
ultrasonography, magnetic resonance imaging, and electromyography are among the
investigational methods available.2

Several novel manometric, neurophysiologic, and radiologic approaches for detecting

constipation have been found, improving the accuracy of identifying the neuromuscular
causes of chronic constipation. Digital rectal examination, Bristol stool scale, colonic
scintigraphy, wireless motility capsule for colonic and whole gut transit evaluation, high
resolution anorectal manometry, and colonic manometry are some of the tools used.4

In this LTM, we will be discussing the diagnosis of fecal incontinence and constipation using
radiologic and labaratory exams.
Topics Discussion
A. Fecal Incontinence
Defecography is a radiographic image of the act of defecation that allows the pelvic
floor to be seen in movement. It is possible to evaluate the anorectal angle during
defecation, the existence of rectocele or intussusception, the length of perineal
descent, and the completeness of rectal emptying. This test detects anatomic and
mechanical contributors to blocked defecation, however there is a lot of interobserver
variance, which makes it difficult to compare results. These images require expertise
to interpret, and can be misleading at times. For these reasons, magnetic resonance
(MR) defecography, which uses real-time cine-MR methods to examine the rectum
and pelvic organs during defecation, is gaining popularity. The advantage of MR
imaging (MRI) is that it can reveal additional pelvic anatomy, such as the vagina,
bladder, uterus, and small intestine, which helps with picture interpretation.
Additional advantages of MRI are that it can reveal anatomic information about the
anal sphincter muscles.5,6

Fig. 1 MRI defecography. (A) Anatomy before act of defecation; the bladder appears
intense on these T2 images, as does the rectum, which is filled with water-soluble
contrast. (B) Internal intussusception as seen as a chevron sign (arrow) observed
during the act of defecation. MRI, magnetic resonance imaging.6
 Fig. 2 Stepwise approach of faecal incontinence investigation. EMG:
Electromyography; MRI: Magnetic resonance imaging; TRUS: Trans-rectal
ultrasound.2

The usage of labaratory examination is not required for fecal incontinence.

B. Constipation

a. Radiologic Imaging

i. Plain abdominal radiograph

In patients with a suspicion of constipation, a plain radiograph of the

abdomen is a low-cost, regularly used diagnostic to supplement the
clinical history and physical examination. Recent research, however,
suggests that simple abdominal radiography has limited use in the
diagnosis of constipation. Furthermore, there was a weak connection
with intestinal transit, in addition to significant inter-observer
heterogeneity in radiological evaluation of fecal burden. This suggests
that simple abdominal radiography may not be a good way to check for
fecal loading in those who are constipated.4

ii. Barium enema

An intraluminal mass, redundant sigmoid colon, megacolon,

megarectum, extrinsic compression, and intraluminal masses can all be
detected with a barium enema. However, there are just a few research
that have looked into its therapeutic value. An organic lesion was not
 discovered with barium enema in a retrospective analysis of 62
patients. Constipation was found in 22% of 791 individuals in another
retrospective analysis, and it was equally common in those with an
abnormal examination. Both trials came to the same conclusion:
barium enema could not be used to diagnose organic illness. Barium
enema can identify Hirschsprung disease, although manometry and
histology are required.4

iii. Defecography

Defecography entails employing fluoroscopic methods to image the

rectum with contrast material and observe the process, rate, and
completeness of rectal evacuation. It provides information on the
anorectum's structural and functional alterations. The procedure
involves injecting 150 mL of contrast into the patient's rectum, then
having the patient compress, cough, and expel the barium. Poor levator
ani muscle activation, prolonged retention or failure to evacuate the
barium, absence of a stripping wave in the rectum, mucosal
intussusceptions, and/or rectocele are the most prevalent observations.4

Radiation exposure, embarrassment, interobserver bias, and uneven

technique are a few of the disadvantages. As a result, defecography is
indicated as a supplement to clinical and manometric evaluation.4

iv. Magnetic resonance imaging

Anorectal diseases can be assessed using MRI and dynamic pelvic

MRI (MR defecography). This is the only imaging technique that can
assess both global pelvic floor anatomy and dynamic motion at the
same time. Endoanal MRI can detect changes in the external anal
sphincter that aren't visible with endoanal ultrasound, but MRI
fluoroscopy can see the pelvic floor and viscera directly during rectal
evacuation and squeezing exercises. Free selection of imaging planes,
no radiation exposure, a good temporal resolution, and great soft tissue
contrast are only a few of the advantages. In comparison to the supine
position, dynamic pelvic MRI in the sitting position gives a more
physiological approach.4

b. Labaratory Examination
To rule out an underlying metabolic or pathological condition, a complete
blood count, biochemical profile, serum calcium, glucose levels, and thyroid
function tests are generally adequate. Serum protein electrophoresis, urine
porphyrins, serum parathyroid hormone, and serum cortisol levels may be
asked if there is a high index of suspicion. However, no studies have been
conducted to evaluate the clinical usefulness of regular blood tests alone,
therefore there is no evidence to support or refute their utility.4
Summary

The usage of radiologic imaging is important to assess the location and severity of
constipation and fecal incontinence. Mostly MR Defecography is used as it can see the bowel
movement of the patient and does not expose the patient or the radiologist of radiation. The
utility of labaratory examination such as blood tests is unknown if it could help diagnose
fecal incontinance or constipation.

References

1. Landefeld CS. National Institutes of Health State-of-the-Science Conference

Statement: Prevention of Fecal and Urinary Incontinence in Adults. Ann Intern Med
[Internet]. 2008 Mar 18;148(6):449. Available from: http://annals.org/article.aspx?
doi=10.7326/0003-4819-148-6-200803180-00210
2. Sbeit W, Khoury T, Mari A. Diagnostic approach to faecal incontinence: What test and
when to perform? World J Gastroenterol [Internet]. 2021 Apr 21;27(15):1553–62.
Available from: https://www.wjgnet.com/1007-9327/full/v27/i15/1553.htm
3. Jani B, Marsicano E. Consti pati on: Evaluati on and Management. 2018;(June).
4. Rao SSC, Meduri K. What is necessary to diagnose constipation? Best Pract Res Clin
Gastroenterol [Internet]. 2011 Feb;25(1):127–40. Available from:
https://linkinghub.elsevier.com/retrieve/pii/S1521691810001563
5. Hayden D, Weiss E. Fecal Incontinence: Etiology, Evaluation, and Treatment. Clin
Colon Rectal Surg [Internet]. 2011 Mar 23;24(01):064–70. Available from:
http://www.thieme-connect.de/DOI/DOI?10.1055/s-0031-1272825
6. Olson C. Diagnostic Testing for Fecal Incontinence. Clin Colon Rectal Surg [Internet].
2014 Sep 24;27(03):85–90. Available from: http://www.thieme-connect.de/DOI/DOI?
10.1055/s-0034-1383901