Manometria Ano-Rettale ad Alta Risoluzione: HARM

Giuseppe Chiarioni MD, RFF Divisione di Gastroenterologia B, AOUI

Verona, Verona Italy & Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Email: chiarioni@hotmail.com

Dr Giuseppe Chiarioni COI

Consulting/Speaker Board: Aboca, Alfa-Sigma, Allergan, Kiowa-Kirin, Malesci,

Pharmextracta, Takeda Rome Foundation: Anorectal Committee

International Anorectal Physiology Working Group

International Consultation on Incontinence

Why ARM is important ? • Physiological (?) evaluation of the two main functions of the

anorectum: – CONTINENCE AND DEFECATION.

1. Fecal incontinence 2. Constipation/ evacuatory dysfunction.

3. Facilitate biofeedback training.

4. Assess patients before surgery (controversial)

5. Objectively assess Tx outcome

6. Standardization???

Dinning P, Carrington E, Scott MS. Neurogastro and Motil 2015

Perfused Catheter Manometry: A Time Honored Procedure

Rectal function displayed on lower trace

LONG, AND LONG, LONG TIME AGO……

125 surveys, 30 different countries

ARM Controversial Issues • Physiological (?) evaluation of the two main functions of the

anorectum: – CONTINENCE AND DEFECATION.

1. DRE should/should not precede investigation 2. Enema two hours earlier/unprepared bowel

3. Left lateral/sitting position

4. Routine Signed Informed Consent

5. Controindications

6. Standardization (Sensation? Pushing effort?)

ARM MORE CONTROVERSIAL ISSUES

Lack of uniformity regarding equipment

Lack of standarization in protocol

Lack of normal values What is normal ? What is dissynergia? Metrics developed in conventional

are not for HR and 3-D HD Costs , fragility Clinical utility?

Given 2D Sandhill Scientifics

MMS Given 3D

HRM 3D -256 Channels -4 mm spacing -length: 6.4 cm.; 10.75 mm

3D visualization to accurately measure pressure over 360°.

Distally Long Sensor for Rectal Pressure Measure

More Stiff than 2D

Proposed definitions - Rest

Manoeuvre Metric Definition

Rest 60 seconds

Functional anal canal length length of anal canal (cm) in which pressure exceeded rectal pressure by >5 mmHg

Average anal resting pressure average maximum pressure (mmHg) over the FACL during the 1 minute period of rest

Proposed definitions - Squeeze

Manoeuvre Metric Definition

Short Squeeze 5 seconds three

attempts Long squeeze

30 seconds single attempts

Maximum absolute anal squeeze pressure

highest recorded pressure (mmHg) at any point during the squeeze manoeuvre

Maximum incremental anal squeeze pressure

maximum recorded pressure (mmHg) at any point during voluntary squeeze, minus the mean maximum resting pressure prior to the manoeuvre (over 5 seconds)

Average absolute anal squeeze pressure mean maximum recorded pressure (mmHg) over the duration of the 5 second voluntary squeeze manoeuvre

Average incremental anal squeeze pressure

mean maximum pressure (mmHg)sustained over the duration of the 5 second squeeze manoeuvre minus the mean maximum resting pressure prior to the manoeuvre (over 5 seconds)

Proposed definitions - Push

Manoeuvre Metric Definition

Push

Residual anal push pressure

lowest maximum pressure (mmHg) recorded within the anal canal over the duration of the 15 second push manoeuvre

Push relaxation percentage maximum relaxation percentage achieved over the duration of the 15-second push manoeuvre

Push rectal peak pressure

Maximum pressure (mmHg) recorded from within the rectum over the duration of the 15-second push manoeuvre

Rectoanal gradient Difference between the push rectal peak pressure and the residual anal push pressure (mmHg)

Proposed definitions - Cough

Manoeuvre Metric Definition

Cough two attempts

Maximum absolute anal cough pressure highest recorded pressure within the anal canal (mmHg) at any point during the cough manoeuvre

Maximum incremental anal cough pressure

highest recorded pressure within the anal canal (mmHg) at any point during the cough manoeuvre, minus the maximum resting pressure prior to the manoeuvre (over 5 seconds)

B20

Balloon Distension in the Rectum Normally Evokes Relaxation of the Internal Anal

Sphincter

Internal anal sphincter

External anal sphincter

Balloon to record pressure

Distending rectal balloon

Distension

B123

Fecal Incontinence Whitehead WE, Chiarioni G, Heymen S. Handbokk of Gastrointestinal Motility

and Functional Disorders (pp265-78). Rao SSC, Parkman HP, McCallum Eds; Slack Incorporated

5.4

4.2

2.4

1.2

0.0

4.8

3.6

1.8

0.6

3.0 Anus

S -Squeeze BD -Bear Down

0 mmHg

9.4

8.8

What is Synergia?

S BD Rest

20.0 sec

Rectal balloon

Increased rectal pressure

Anal relaxation

+

Positive rectoanal gradient

Dyssynergic Defecation: Perfused Catheter Manometry Tracing

Rectal function displayed on lower trace

5.4

4.2

2.4

1.2

0.0

4.8

3.6

1.8

0.6

3.0 Anus

S -Squeeze BD -Bear Down

0 mmHg 150

9.4

8.8

Low Rectal

BD S Rest

High Anal

S BD Rest

Hybrid

BD S

20.0 sec

Rest

Rectal balloon

What is Wrong in Defecatory Disorders?

Ratuapli S, …Bharucha AE, Gastroenterology 2013

Figure 1 Four main subtypes of dyssynergic defecation can be observed by anorectal manometry

Rao, S. S. C. et al. (2016) Diagnosis and management of chronic constipation in adults Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2016.53

28

• 170 subjects • 85 healthy volunteers (HV) / 85 patients with constipation

(FC) • analysis of ‘push’ manoeuvre blinded to subject status

Gut. 2016;65:447-55

29

Defining health status: ARM

C-ARM

HR-ARM

Grossi et al., Gut. 2016;65:447-55

Adil Bharucha MBBS, MD (US) Chair Satish Rao MD, PhD (US) Co-Chair

Members:

Richelle Felt-Bersma MD, PhD (The Netherlands)

Giuseppe Chiarioni MD (Italy) Charles Knowles PhD (UK)

Allison Malcolm MD (Australia) Arnold Wald MD (US)

Bill Whitehead PhD (US) Liaison

Members of the Anorectal Disorders Committee Rome IV

© UEG. 2017

The requirements for diagnosis of functional defecation disorders has altered slightly

ROME IV F3: The patient must satisfy the diagnostic criteria for functional constipation and/or constipation predominant IBS and during repeated attempts to defecate, there must be evidence for impaired evacuation, as demonstrated by 2 of the following 3 tests: a. Abnormal balloon expulsion test b. Abnormal anorectal evacuation pattern with manometry or anal surface EMG c. Impaired rectal evacuation with imaging F3a: Inadequate Defecatory Propulsion Inadequate propulsive forces, as measured with manometry, during attempted defecation with or without

inappropriate contraction of the anal sphincter and/or pelvic floor muscles F3b: Dyssynergic Defecation Inappropriate contraction of the pelvic floor as measured with anal surface EMG or manometry with

adequate propulsive forces during attempted defecation

Rome IV: Has it changed clinical practice? Anorectal disorders – Carrington / Chiarioni 32

BET: 16 F FOLEY CATHETER INFLATED WITH 50 ML TEPID WATER, TO BE WELL LUBRICATED BEFORE INSERTION COMMERCIALLY AVAILABLE

Rectocele and Excessive Descent of the Pelvic Floor