Anorectal Manometry
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Transcript Anorectal Manometry
Anorectal
Functional Testing
FUNCTIONAL
FUNCTIONALDIAGNOSTICS
DIAGNOSTICS
Copyright MFD 2001 - Any kind of reproduction is prohibited
GASTROINTESTINAL
Anorectal Functional Testing
The main function of the rectum is
to act as a reservoir of stool for
short periods of time.
This allows defecation to occur
voluntarily at the appropriate time.
The anal canal maintains fecal
continence and controls defecation.
Anorectal Manometry provides
information on the anorectal
muscle tone and the coordination
between the rectum and the anal
sphincters
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Anorectal anatomy
Sigmoid Colon
Rectum
Rectal Valves of Houston
Anal Canal
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Longitudinal Section of the Anal Canal
Levator ani muscle
Anal Canal
External Anal Sphincter
Internal Anal Sphincter
Anal Columns
Anus
FUNCTIONAL DIAGNOSTICS
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Innervation
Spinal cord
AUTONOMIC
VOLUNTAR
Y
Sympathetic
Pudendal
nerve
External anal sphincter
Parasympathetic
Internal anal sphincter
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Anorectal Mechanism
Information in the brain
“First Sensation”
“Urge!”
Rectum Filling expands Rectum Wall
as a continuous Stimulation
This Stimulation is transferred to the
brain via Sensory Pathways and
Efferent
Afferent
interpreted as a Sensation
Feces
Autonomic Reflex controls the
RectoAnal Inhibitory Reflex
Sensory
S2
S3
S4
Rectum
“Urge” - then Voluntary contraction
of External Sphincter
Motor
External Sphincter
Internal Sphincter
Defecation Process
- Relaxation of E.S.
- Abdominal Walls Contraction
Anorectal
- Anorectal Angle Reduced
Angle
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Defecation – continued
CONTRACTION
TO AVOID
DEFECATION
Contracted
muscle
Anorectal angle
Anal canal
lengthens
DEFECATION
Relaxed muscle
Anorectal angle
straightens
Anal canal
shortens
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Defecation – continued
DIAPHRAGM CONTRACTS
ABDOMINAL WALL
CONTRACTS
RECTUM
STRAIGHTENS,
ANORECTAL
ANGLE
REDUCED
LEVATORS RELAX &
ALLOW PELVIC FLOOR
FUNCTIONAL DIAGNOSTICS
DESCENT
GASTROINTESTINAL
When it doesn’t work …
Chronic constipation: Alteration in the frequency, size,
or
consistency of stools
Fecal incontinence: The inability to control the
emptying of
the rectum
Anismus: External anal sphincter & puborectal muscles
contract during straining
Hirsprungsdisease: no RAIR
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
When it doesn’t work …
Modify diet
Medications
Biofeedback Therapy
Surgery
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Tests to help choose best therapy
Colonic transit study
Sigmoidoscopy
Anorectal ultrasound
Barium defecography
PNMTLT
Anorectal manometry
Balloon expulsion test
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Anorectal Manometry
Measure resting pressure of:
Internal & external anal sphincters
Measure squeeze pressure of:
External anal sphincter
Determine the functional ability of:
Voluntary & involuntary muscles
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Indications for anorectal
manometry
Fecal incontinence
Chronic constipation
Preoperative
Rectal prolapse
Rule out Hirschsprung’s disease
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Anorectal Disorder
Concerns 10% of the population
Constipation
Incontinence
Mixed
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Constipation
Alteration in the frequency, size
or consistency of stools.
Symptoms:
Problems emptying bowels
Straining
Hard stool
Infrequent defecation
Incomplete evacuation
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Outlet Obstruction
Intussusception
Rectal prolapse
Rectocele
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Constipation
Etiology
Colorectal
Structural abnormalities
Volvulus, Strictures, Neurological (Hirschsprung’s disease), Tumors
Obstructions
Intussuception, Prolapse, Rectocele
Extracolorectal
Systemic
Hypothyroidism, Diabetes
Neurologic
Sclerosis, Cerebral & Spinal cord Injury, Denervation, Parkinson
Psysologic - Medication - Immobilization - Diet - Habits
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Megarectum
Reduced
sensation
Retained
hardening
fecal mass
Increased size
of rectum
Smooth muscle
hypertrophy
Reduced anal
inhibition
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Anismus
Other names:
Rectum
Spastic pelvic floor
Anal
Canal
Pelvic floor dyssynergia
Puborectal sling
Internal
sphincter
External
sphincter
External anal sphincter and puborectal
muscles contract during straining
Puborectal sling
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Polygraf ID
Complete
System
Polygraf ID
Puller
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Perfusion System & Transducers
Low cost perfusion system
Dent Pump
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Set-up Pressure & Catheter
1000 ml
STERILE
WATER
BAG
Pressure Gauge Set at
400 cmH2O / 300 mmHg
Balloon
P1 P2
Pressure Cuff
& Water Bag
P3 P4
Catheter
Perfusion Set 4
Balloon
Syringe 100 ml
Pressure
Transducers
P1 P2
P3 P4
Capillaries
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
RectoAnal Inhibitory Reflex (RAIR)
cmH2O
Balloon
30 ml
RP
Inflation Reflex
30 ml
40
50
IS
Inhibitory Reflex
Amplitude
Duration
Balloon
Syringe 100 ml
10-20”
3- 5”
Procedure:
50 ml
40 ml
10-20”
1- 2”
• Inflate rectal balloon with 10 ml of air
Within 3-5 sec. of inflation, air should be
completely withdrawn
• Repeat and increase volume by 10 ml
until the RAIR is obtained
• Testing sequence: 10, 20, 30, 40, 50 ml
ES
Time
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Rectal Volume Sensory Thresholds
The first volume of rectal distension, which
the patient can distinguish to the maximum
tolerable volume, is determined.
Balloon
Procedure:
• Inflate 10 ml of water at body temperature over 5 sec.
• Wait 20 sec. and ask the patient what he/she felt.
Balloon
- Did he/she feel anything and
Syringe 100 ml
- was the sensation temporary or constant?
• Fill the rectal balloon in increments, allowing a 20 sec.
accommodation period between inflations
Volume ml
30
40
60
90
120
150
180
Sensation
0
1
1
2
2
2
3
200
220
240
260
280
0 = no sensation, 1 = first sensation, 2 = constant sensation/urge, 3 = maximum tolerable sensation
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Sphincter Length (HPZ)
cm H2O
Pulling
P2 P3 P4
0.5 - 1 mm/sec.
P2
Puller
P3
Sphincter Length
P2 P3 P4
Procedure:
• Insert catheter in rectum - 3 lumens in rectum
• Let the patient rest quietly with no squeeze or straining
P4
Length cm
• Pull through catheter with puller at a constant speed
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Balloon Expulsion
RP Straining
Balloon - 50ml
EMG
Straining
cmH2O
Push
30” rest
ES
Balloon
cmH2O
Syringe 100 ml
Procedure:
• Ask the patient to push/strain as if
trying to defecate
Dyssynergia
Sphincter
Relaxation
EMG
µV
Time
• Repeat once or twice with more than
30 sec. between pushes
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Polygraf ID
Squeeze Test
Automatic Analysis
Menu
Markers
Tools
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Polygraf ID
RAIR
Automatic Analysis
Menu
Markers
Tools
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Polygraf ID
Continuous Pull Resting Pressure
Automatic Analysis
and Results
Menu
Markers
Tools
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
Pitfalls
Air bubbles in water lines
Leak in transducer connections
Catheter bent in rectum
Balloon bent in rectum
Low upstream pressure
Liquid on EMG electrodes / connectors
FUNCTIONAL DIAGNOSTICS
GASTROINTESTINAL
FUNCTIONAL
FUNCTIONALDIAGNOSTICS
DIAGNOSTICS
GASTROINTESTINAL