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PubMed1987

Esophageal chest pain. Value of high-dose provocative testing with edrophonium chloride in patients with normal esophageal manometries.

The unequivocal diagnosis of esophageal chest pain requires the demonstration of simultaneous manometric changes and chest pain. Numerous provocative agents have been used to enhance the diagnostic value of esophageal manometry. Our aims were to: evaluate consecutively a large group of patients with proven noncardiac chest pain and normal baseline manometric studies, using edrophonium chloride, 10 mg, and determine the value of provocative testing in clinical practice. One hundred twenty patients with normal standard baseline esophageal manometries were studied using blinded testing with edrophonium chloride and followed clinically by questionnaire. A positive response of both chest pain and manometric changes was observed in 34%, a negative response in 49%, and an indeterminate response in 17% of patients. Baseline manometric features, including high-amplitude contractions, did not predict the response to edrophonium chloride. Following edrophonium chloride administration, the change in amplitude, duration, and number of repetitive contractions from baseline was significantly greater in positive responders. Edrophonium decreased the velocity of propagated contractions in positive responders (P less than 0.05), but not in nonresponders. Response to edrophonium chloride could not be predicted by patient age, sex, or clinical symptomatology. Seventy percent of patients in both groups had symptoms indistinguishable from ischemic heart disease. After making a specific diagnosis of esophageal chest pain, patients showed a marked clinical improvement, with a significant decrease in physical limitation, emergency room visits, hospital and CCU admissions, and in further cardiac testing. We conclude that provocative testing with edrophonium chloride will make it possible to definitively implicate the esophagus in over 30% of patients with normal baseline manometric findings and noncardiac chest pain.

Adult↗
PubMed1991

Reproducibility of endoscopic sphincter of Oddi manometry.

Results from endoscopic sphincter of Oddi manometry are being used to support the diagnosis of sphincter dysfunction in patients with unexplained pain after cholecystectomy. However, there are few data on the reproducibility of manometric records or motility diagnosis during a second test. In this study, the reproducibility of manometric records was assessed in 12 patients with pain after cholecystectomy by performing a second study after three months. Manometric tracings were evaluated without access to patients details and scored for sphincter basal pressure, frequency and amplitude of phasic contractions, propagation of phasic contractions, and responses to intravenous injection of cholecystokinin octapeptide (20 ng/kg). At the initial manometric study, four patients were diagnosed as normal, four as stenotic, and four as dyskinetic. Those diagnosed as normal and stenotic at the first study had an identical diagnosis at the second study. However, the diagnosis of dyskinesia was reproduced only in two of the four patients. In the other two patients a diagnosis of "stenosis" and "normal" was made at the second study. Cholecystokinin octapeptide (20 ng/kg intravenous bolus) produced inhibition of phasic contractions in all studies, both initially and at three months. We conclude that endoscopic sphincter of Oddi manometry is reproducible when the initial diagnosis is either normal or stenosis. However, the diagnosis of dyskinesia is poorly reproducible, perhaps due to the episodic nature of this manometric disorder or to progression of sphincter of Oddi dysfunction.

Adult↗
PubMed1983

Contraction abnormalities of the esophageal body in patients referred to manometry. A new approach to manometric classification.

A method is proposed for classifying conventional esophageal manometry findings according to the features observed in the esophageal body rather than the disease name. Patients who demonstrate increases in mean distal wave amplitude, mean distal wave duration, or number of abnormal motor responses (repetitive or simultaneous contractions) or the presence of triple-peaked waves are classified as having distal contraction abnormalities. Severity is scored by the cumulative number of these abnormalities. Of the 210 patients referred for esophageal manometry over a 23-month period, 119 (57%) were found to have one or more of the contraction abnormalities, making this the most common esophageal body manometric classification. The presence of one or two abnormalities was most common. Patients with all four abnormalities represented less than 5% of the referred population and, as a group, would satisfy usual manometric criteria for diffuse esophageal spasm. The proposed system allows for recognition of patients with only one or several of the manometric features typically seen in diffuse esophageal spasm and provides a method for intra- and interstudy comparison of patients with these common findings.

Adult↗
PubMed1993

Modern solid state computerized manometry of the pharyngoesophageal segment.

There has been renewed interest in the use of manometry of the pharyngoesophageal segment in the investigation of pharyngeal dysphagia. Advances in technology have alleviated previous difficulties presented by factors such as the rapid response rate of the striated muscle and asymmetry of the upper esophageal sphincter. Close attention to technique can overcome difficulties with movement artifacts encountered during deglutition. Manometry is being used to study normal swallow function and the effects of physiologic changes. There are also increasing numbers of reports in the literature of manometric studies in patients with oropharyngeal dysphagia. This technique provides information on pressure changes and augments that information obtained from a barium swallow.

Deglutition↗
PubMed1990

Contributions of evacuation proctography and anorectal manometry to evaluation of adults with constipation and defecatory difficulty.

We prospectively evaluated 36 patients who complained of chronic constipation and/or defecatory difficulties to determine the role of anorectal manometry and evacuation proctography in delineating the pathogenesis of these complaints. Twenty patients with constipation also underwent a colonic transit study with radioopaque markers, which identified one group with normal transit (N = 10) and another with slow transit (N = 10). Nine of 36 patients (25%) had inappropriate puborectalis muscle contraction or exhibited weak expulsion efforts during evacuation proctography, and these correlated highly with poor rectal emptying of barium paste (20 +/- 6% vs 61 +/- 5% in patients with normal relaxation; P less than 0.01). However, poor rectal emptying did not correlate with the presence of high-grade intussusceptions, large rectoceles, anorectal angles at rest or with straining, rectal diameter, clinical features, or colonic transit. Moreover, abnormal expulsion patterns as seen with anorectal manometry correlated poorly with the presence of inappropriate puborectalis contraction and decreased rectal emptying by proctography. Although anatomic abnormalities occurred frequently in patients with constipation and/or defecatory difficulties, they were also prevalent in asymptomatic controls. In view of these findings, surgical intervention to correct anatomic abnormalities in patients with constipation and/or defecatory difficulties should be considered only with great caution.

Administration, Oral↗
PubMed1990

Prolonged anorectal manometry and external anal sphincter electromyography in ambulant human subjects.

We have developed a method for prolonged combined anorectal manometry and electromyography (EMG) of the external anal sphincter in ambulant subjects. Fourteen healthy volunteers were studied for a total of 284 hr (mean of 20.3 hr/subject). Anorectal manometry was performed using a probe with twin pressure sensors. EMG was recorded by one indifferent and two differential silver-silver chloride surface electrodes positioned 0.5-0.75 cm from the anus on either side. The sampling reflex occurred frequently and was significantly (P less than 0.001) more common during wakefulness than during sleep and also following meals than during fasting (P less than 0.01). The passage of flatus was associated with transient relaxation of the anal canal in 19% of episodes. In contrast, there was a contractile episode with no preceding relaxation in 75% of episodes. The anal sphincter had significantly (P less than 0.05) more action potentials (APs) during the day (12.8 +/- 3.2 APs/10 min) than at night (1.6 +/- 1.3 APs/10 min). During micturition, anal canal pressure rose (mean 15 mm Hg) in association with powerful external anal sphincter contractions. Our data show that, normally, contractile activity both in the anal canal and external anal sphincter maintains fecal continence during micturition and the passage of flatus. The technique should lead to a better understanding of the normal mechanisms of fecal continence during waking and sleep and of the pathophysiology of disorders of anorectal function.

Action Potentials↗
PubMed1994

Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: a study using continuous ambulatory manometry.

PURPOSE: The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques. METHOD: In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy. RESULTS: Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0-30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1-48/hours)) or in control individuals (median, 5.6/hours (0-31/hours)) (P < 0.001). CONCLUSIONS: These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.

Adult↗
PubMed1990

Evaluation of an air-filled microballoon and mini-transducer in the clinical practice of anorectal manometry. Preliminary communication.

Anorectal manometry is becoming a commonly applied investigation in the field of colon and rectal surgery. Until now, however, most of this testing was performed in specialized units, which involved considerable expense and expertise to run. The authors assessed a commercially available mini-transducer and an air-filled microballoon catheter for their applicability to clinical anorectal manometry. This system is very accurate and is proving very useful in the ambulatory setting, on hospital wards, and in the operating room. It provides a simple alternative for areas where more sophisticated manometric systems are not available.

Adult↗
PubMed1995

Endosonography of the anal sphincter after ileal pouch-anal anastomosis. Relation with anal manometry and fecal continence.

PURPOSE: The aim of the present study was to visualize supposed defects of the internal anal sphincter after ileal pouch-anal anastomosis (IPAA) by anal endosonography and to relate these findings with anal manometry and fecal continence. METHODS: We investigated 23 patients, visualized the sphincter complex by anal endosonography, and quantified the anatomic changes of the sphincter. Anal resting and squeezing pressures as well as length of the anal canal were determined by anal manometry. Continence was objectively scored by an observer not involved in treatment of patients and subjectively by patients themselves. RESULTS: At anal endosonography, the mean thickness of the internal anal sphincter was 1.16 mm (95 percent confidence interval, 0.98-1.33), which is significantly less than in normal volunteers. Tapering of the internal anal sphincter only occurred in six patients (of whom two had a gap in the internal sphincter). In 17 patients endosonography showed a thin internal anal sphincter without essential variation in thickness over the complete circumference. Approximately eight weeks after ileostomy closure following IPAA, maximum resting pressure (MRP) and length of the anal canal appeared to be significantly decreased compared with values before IPAA (P = 0.001 and 0.002, respectively). These differences were less striking (P = 0.05 and 0.04, respectively) when measured six or more months after ileostomy closure. The extent of reduction of the MRP and thickness of the internal anal sphincter were not correlated with grade of continence or with subjectively scored continence. CONCLUSIONS: IPAA leads to a reduction of thickness of the internal anal sphincter and reduction of the MRP. Tapering or gaps in the internal anal sphincter are probably caused by direct trauma to this sphincter because of mucosectomy, whereas in cases of circular reduction of thickness of the internal anal sphincter without tapering or gaps, direct trauma is an unlikely explanation; this reduction is probably caused by denervation. IPAA compromises continence to a variable degree in 18 of 23 patients. No correlations were found between the extent of reduction of the MRP and the extent of reduction in internal anal sphincter thickness or between these two parameters and objectively or subjectively scored continence. Difficulties in obtaining reliable information on continence may be a causal factor. A striking discrepancy was noticed among objective, scored disturbances in continence, and overall satisfaction concerning level of continence by patients themselves.

Adenomatous Polyposis Coli↗
PubMed1996

Analysis of fasting antroduodenal manometry in children.

Antroduodenal manometry has been used to determine the pathophysiology associated with signs and symptoms of gastrointestinal motility disorders. The diagnostic value of antroduodenal manomentry has been limited by the paucity of data from normal children. In this study, we compared antroduodenal manometry findings from 95 patients with symptoms suggesting a gastrointestinal motility disorder to 20 control children. Phase III of the migrating motor complex (MMC) was less frequent in patients (P < 0.05), especially in those who required total parenteral nutrition (P < 0.001), than in controls. Abnormal migration of phase III and short intervals between phase IIIs were more frequent in patients than in controls (P < 0.01 and P < 0.05, respectively). During phase II, persistent low-amplitude contractions and sustained tonic-phasic contraction were found only in parenteral-nutrition-dependent children. Short or prolonged duration of phase III, absence of phase I following phase III, tonic contractions during phase III, low amplitude of phase III contractions in a single recording site and clusters of contractions or prolonged propagating contractions during phase II were not more frequent in patients than in controls. We conclude that there are five manometric features having a clear association with pediatric gastrointestinal motility disorders: (1) absence of phase III of the MMC, (2) abnormal migration of phase III, (3) short intervals between phase III episodes, (4) persistent low-amplitude contractions, and (5) sustained tonic-phasic contractions.

Adolescent↗
PubMed2000

Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months.

PURPOSE: Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique. METHODS: A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs. RESULTS: Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Adult↗
PubMed2000

Ambulatory manometry in patients with colonic J-pouch and straight coloanal anastomoses: randomized, controlled trial.

PURPOSE: Bowel function after ultralow anterior resection may be improved by a colonic J-pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J-pouch. METHODS: Forty-seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J-pouch was constructed with 6-cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery. RESULTS: Values are expressed below as mean and (standard error of the mean). Patients with colonic J-pouch were found to have less frequent stools (4.6 (0.3) vs. 7.1 (0.9) stools/day; P < 0.05) and stool clustering (35 vs. 63.2 percent; P < 0.05) and were less unlikely to soil when passing flatus (85 vs. 35.3 percent; P < 0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J-pouch group (30.3 (3.7) vs. 18 (2.6) mmHg; P < 0.05). Stool frequency was predicted by the mean rectal pressures (t = 3.368; P = 0.003). However, higher mean rectal pressures were tolerated by the colonic J-pouch for each daily bowel movement (6.7 (0.6) vs. 4.4 (0.5) mmHg/stool; P = 0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3) vs. 26 (2.3) mmHg; P = 0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6-cm colonic J-pouches. CONCLUSIONS: A colonic J-pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow-up.

Adenocarcinoma↗
PubMed1993

The place of esophageal manometry in the diagnosis of dysphagia.

Esophageal manometry allows to quantify intraluminal pressure changes as the basis of normal or abnormal esophageal motility. It is a complementary diagnostic procedure which should only be performed after endoscopic and fluoroscopic examinations and may be helpful in the detection of various motility disorders like diffuse esophageal spasm, nutcracker esophagus and vigorous achalasia. Manometry is recommendable for therapy control after medical and surgical therapy, and mandatory prior to surgical reflux therapy.

Deglutition Disorders↗
PubMed1984

Assessment of bowel control with anorectal manometry after surgery for anorectal malformation.

Bowel function after surgery for anorectal malformation was assessed by Kelly's score in 101 children over 3 years of age. Seventy-two were examined using anorectal manometry. In the "good" group, resting pressure of the anal canal was as high as in the normal children, and the frequency of contraction waves in the anal canal was the same as in the normal children. Recto-anal reflex was recognized in about three fourths of the "good" group. On the other hand, in the "poor" group resting pressure was low, in only one were contraction waves evident and in none was there a recto-anal reflex. The findings of the anorectal manometry placed the "fair" group between the "good" and the "poor" groups. The clear contraction waves of the anal canal or the clear recto-anal reflex related to a resting pressure in the anal canal of over 20 cmH2O. This high pressure in the anal canal is important for good and continence, and depends on a precise pull-through of the rectum into the puborectalis muscle.

Anal Canal↗
PubMed1989

The external anal sphincter. Relationship between anal manometry and anal electromyography and its clinical relevance.

Anal manometry and anal electromyography (EMG) were performed in 45 patients to evaluate the external anal sphincter. Their symptoms were soiling (N = 6), incontinence (N = 10), and obstipation (N = 19). Clinical diagnoses were previous anal surgery (N = 16), rectal prolapse--partial, total, intussusception (N = 16), puborectalis syndrome (N = 4), neurologic disorders (N = 3), and others (N = 6). The relationship between the maximum squeeze pressure (MSP) measured with anal manometry and the maximum (voluntary) contraction pattern (MCP) and signs of denervation (DEN) measured with anal EMG were examined. The correlation coefficient between MSP and MCP was 0.55 (P less than .001) and between MSP and DEN 0.13 (NS). A normal MSP always showed a normal MCP, a normal MCP showed an abnormal MSP in 43 percent only. In conclusion, the clinical value of anal EMG seems limited. Assessment of an additional anal EMG seems indicated in incontinent patients with previous anal surgery with a low MSP to estimate muscle function, whenever anal surgery is considered. Anal EMG during straining can easily confirm the clinical diagnosis of puborectalis syndrome.

Adolescent↗
PubMedDate not supplied

Ano-rectal manometry as an evaluating test for impaired ano-rectal function in diabetes mellitus.

Diarrhea and/or rectal incontinence may represent a sign of autonomic neuropathy in diabetes. The present investigation was performed to study ano-rectal function and reactivity to appropriate stimuli in 20 diabetic patients with or without autonomic neuropathy (14 insulin-dependent diabetics; 6 non-insulin-dependent diabetics; mean age 39.2 years; mean duration of diabetes 12.6). Twenty-five healthy subjects (mean age 43.5 years) were studied as controls. All subjects underwent ano-rectal manometry by means of special open-ended-tip catheters connected with a 6-channel polygraph. A rectal latex balloon was inflated with 30 or 60 ml air to induce a stimulus which, under normal conditions, is apt to relax the internal sphincter and to contract the external one (ano-rectal inhibitory reflex). Eleven diabetics had symptoms and signs of autonomic neuropathy: 8 of these (73%) showed marked abnormalities of ano-rectal function (i.e. no response even to maximum stimulus or contraction of both sphincters). All non-neuropathic patients showed a normal pattern of ano-rectal manometry. A relationship between abnormal response to rectal stimulation and the presence of autonomic neuropathy involving the pelvic parasympathetic section or regional intramural plexuses may be suspected and demonstrated in diabetic neuropathic patients.

Adult↗
PubMed2007

Assessment of anal sphincter function by Sengstaken-Blakemore tube anal manometry.

BACKGROUND: Anal manometry is a useful tool for testing the effectiveness of surgical treatment. However, most techniques for anal pressure measurement are not easily available because of high cost. The aim of the present study was to introduce an easy and reproducible method for measuring anal pressures in testing the effectiveness of surgical procedures. MATERIALS AND METHODS: We used a Sengstaken-Blakemore tube connected to a mercury manometer. After calibration of the system by inflating the distal (gastric) balloon and filling connection lines to the mercury manometer with 0.9% NaCl solution, resting and squeezing anal pressures were measured. The system was used on 50 human subjects (35 with anal fissure and 15 normal volunteers). Left lateral internal sphincterotomy had been performed in the anal fissure cases. Anal pressures were measured preoperatively and on postoperative days (POD) 2 and 20. RESULTS: Preoperative resting anal pressures in the group with anal fissure (83.4 +/- 1 mmHg) were significantly higher than those in the group of normal individuals (52 +/- 1.2 mmHg; p = 0.001). Resting anal pressures after the sphincterotomy (29 +/- 1 mmHg) were found to be significantly lower on POD 2, and resting anal pressure measurements (47 +/- 1 mmHg) on POD 20 were lower than the corresponding preoperative values. These values are closer to those of normal volunteers (p = 0.016). CONCLUSIONS: Anal manometry can be performed with this easily constructible and inexpensive system. This reproducible method can be used in the assessment of the results of surgical treatment in patients with anal and perianal diseases.

Anal Canal↗
PubMed1997

Esophageal manometry in systemic sclerosis: screening procedure or confined to symptomatic patients?

The predictive value of esophagus-related symptoms for the diagnosis of esophageal dysmotility induced by systemic sclerosis (SSc) was prospectively evaluated in 50 consecutive patients with SSc. Patients were classified as symptomatic when either dysphagia or repeated episodes of heartburn were present. All patients underwent esophageal manometry; SSc-induced esophageal dysfunction was diagnosed when there was aperistalsis or marked hypocontractility of the distal two-thirds of the esophageal body. Twenty-nine patients (58%) had a history of esophagus-related symptoms, while 21 patients (42%) were asymptomatic. Compared to esophageal manometry, esophagus-related symptoms had a sensitivity of 64%, a specificity of 52%, a negative predictive value of 50% and a positive predictive value of 62% for the diagnosis of SSc-induced esophageal dysfunction. In conclusion, the association of esophagus-related symptoms and esophageal motility pattern is poor. As clinical management strategies depend on proof of esophageal dysfunction, screening examinations are mandatory in all patients with SSc.

Adult↗