Chapters Transcript Video Evaluation of Chronic Constipation Beyond Laxatives Presented by R. Matthew Reveille, Rocky Mountain Regional VA Medical Center, Aurora, CO. some things that come into play that affect on the epidemiology of constipation per se. So now let's define constipation. Using the Rome criteria. Rome three Criteria patient must have experienced at least two of the symptoms you see below over the preceding three months. Rome four is coming up, and it'll be interesting to see whether they will redefine or tweet the definition that we see here. There's a very fine line between chronic idiopathic constipation and probably what we see Justus often ivy s constipation predominant, irritable bowel syndrome. But suffice it to, say, going down the list of symptoms. Few of the three bowel movements per week and the normal range for western populations is between three bowel movements per day and three bowel movements per week, and that defines normal range, straining at stool. We all strained on occasion, but not to the point of die a free sis or other symptoms associated with that the stools lump in your heart. Is there a sensation that they really are having difficulty getting the stool through the anal outlet? Or, once they do, if they're successful, do they feel like they still have stool waiting to be eliminated by a further attempt. And the issue about manual maneuverings requiring to defecate and Manu maneuvers could be all over the map. If you've taken care of patients with this problem for years, you've learned that they have come up with very unique ways by which to evacuate the rectum of retained stool. Now many patients with chronic idiopathic constipation are relatively asymptomatic on. Therefore, they're probably not going to come to the physician until things were way down the line. But we're going to define chronic idiopathic constipation in terms of folks who have no abdominal symptoms. That is C I, C, Dash N A and patients who have see I see but also have an abdominal complaint, and that is abdominal bloating. Pain with defecation, spotting of blood with defecation. This various diarrhea that occurs in some of these patients without the utility of a laxative and low back pain just simply the attraction of the music colon from the colon that is laden with excessive waste. So deaf initially, C I c dash n A is no abdominal symptoms. See, I see and C I c dash A at C I. C with abdominal symptoms is that important. But let's look at how this impacts the studies that have been done using clinical trials and how we define these patients when we enrolled them interventional studies you can see from the pie grand here that see I see without abdominal symptoms is about 1/5 of patients in this survey patients with abdominal symptoms, 41%. So the predominant group had some symptoms and then I, b s Nashiri ideas, constipation, almost 40%. The great difficulty with the definitions lies here. We've drawn a fine line and probably the the, uh this line probably blurs because many investigators now believe that this is simply a spectrum of neuromuscular dysfunction in patients with chronic constipation complaints. One of the big differentiating factors between I. B s and 19 I B. S is abdominal pain relief with defecation. And we know that I b s patients, that visceral hypersensitivity and by and large see, I see patients have not been well studied, but don't tend to have some other measurements of visceral hypersensitivity. Some patients may have chronic constipation and have suggestions by history alone that they have outlet type dysfunction, that sense of incomplete evacuation needing to return to the comm owed more than one occasion just to get subsequent evacuation attempts. And we have patients who will spend the entire morning going to and from the CA mode until they finally get relief or come in for some council and evaluation digital extraction. Think outlet. Obstruction 10 is miss that feeling that I always have to have a bowel movement, Yet they're incapable. Now You and I are familiar with this term when we talk about inflammatory bowel disease. But the mechanism of that awareness that heightened awareness and the inability to evacuate anything is a little different in chronic idiopathic constipation than it is in inflammatory bowel disease. And last but not least, patients will try to take enemies and then tell you that they can't expel the anima, think outlet type constipation, some of the alarm symptoms that I think we're all aware of, and we should be very attentive to. It's simply the one of rectal bleeding abdominal pain that suggests I B s or obstruction and not simply chronic idiopathic constipation. The inability to pass gas that suggests either a very abnormal evacuation mechanism and or obstruction to the indirect injunction and last but not least, the patient vomiting. You should be thinking about something beyond constipation, but it's obstruction whether they have a more global suit obstruction syndrome. Uh, needs to be determined, and vomiting should prompt you to think just outside outside the box a little bit and look at the rest of the G I tract. So alarm symptoms need warrant. Need some evaluation? Um, now what I want to do is refer back to guidelines based on the current guidelines. Let's talk about all the medication options. I think it's important. Understand a few nuances about what we do. The first of all is that many of these agents are effective and could be effective even in patients with transit disorders if used in the proper dose and or combination. One of the principal decisions is number one costs to the patient. We spend billions of dollars and over the counter ballads every year in this country, and so cost comes into play and also insurance coverage. Let's not forget that we have to play that game. Um, let's look at the evidence and the recommendations for the use of each class of laxatives in constipation in general and and chronic idiopathic constipation. The role of a bulking agent, a soluble fiber Such a silly um, versus inside herbal fireworks such as calcium carbon Phil Uh, it's recommended that perhaps across a week of our food intake that two thirds of our fiber and take the Sybil and one third be inside herbal fiber. We find that soluble fiber tends to improve lax ation in patients better than insoluble fiber under most circumstances. Now the recommendation for using this as a tri ALS is very strong. Although the global body of evidence is fairly low, it's a simple, easy thing to do. And if the patients are counseled early on about installation of fiber and the onset of gas and bloating, and that it does adapt over time, they will be able to follow through. I've had too many patients try fiber for two weeks, complain of gas and bloating and lack of success, and then can the whole idea not having given it an adequate time for Bala adaptation to occur after bulking agents the next thing or non absorbable osmotic agents, there is strong, uh, high quality evidence for polyethylene glycol in small amounts used on a daily basis. Everybody's familiar with that regiment. It seems to be very helpful to strong recommendation to try this now. Once a day does, it may not be sufficient in patients who have more severe variants of transit. Constipation problems on it is relatively affordable, and insurance covered so it comes in is a strong player that at least gastroenterologists in my community tend to lean on quite a bit. There's also evidence for lack Oculus. I think that would be a little cruel and someone who's lactose intolerant or somebody who have problems with gas, pain and bloating. However, Lentulus also comes with a strong recommendation. Although the body of controlled studies in chronic constipation, the evidence quality is a little bit lower. Interestingly, we have had a resurrection of interest in simply using magnesium magnesium oxide, uh, magnesium hydroxide. In the absence of chronic renal failure, magnesium is an osmotic agent is very effective. I have folks who with energetic Val, who are taking six magnesium tablet today, maybe with a little bit of fiber or pro kinetic, and they seem to get along quite well and never had problems with retention of hard stools. Unfortunately in the guidelines, that wasn't a recommendation or enough evidence to support that. As a regular part of practice, Kalanick stimulants deserves some attention. In my years of training, we were taught that if you used a stimulant irritant laxative over the long haul that you would somehow burn out the nerve endings of the G. I track well after 25 years, about five years ago, several investigators to some beautiful meta analysis of studies with some physiologic studies and concluded that that was actually myth And that fact that in fact, Mr Cottle Isa very effective agent over the long haul, it could be used safe, that downside art that it has. It does cause quite a bit of cramping, But it's a very strong, uh, laxative. It could be used in small amounts, even on a daily basis. One interesting thing is that all the other agents here on this chart, uh, are not all that great with counteracting the effects of narcotics on an opioid bound. Now this talk is not about opioid constipation. Today we know their data for liberal Protestant and one o'clock tied for opioid induced constipation. But the Onley agent that works on smooth muscle in the G I tract that goes behind the narcotic receptor is actually busy. Kotal so busy Cottle has been part of my armamentarium for as long as I practice. The evidence for its use on both short term and long term is moderate, and the recommendation to use that is strong. Unfortunately, we can't say the same for all the scent asides and center based teas, The Kalanick secretary agents came onto the market here in the past 10 years. You're all familiar with uber Preston and, more recently, a nucleotide. I participated in phase three clinical trials with these drugs. I found them to be very effective. One side effect was nausea with uber pro Stone and occasionally are three allergies. But there's strong recommendation based on well done studies with the high quality of evidence. So taking into some total all the agents there. Under the current list of guidelines, you have a pretty good set of options for medical therapy, for constipation as an occasion and maybe constipation at the proper dose. In an idiopathic more chronic setting. The pro Connectix included blue collar pride or not part of the recommendations. Yet because they're not part of our available in this country. But we hope that they will be at some point in their future. So those are the guideline based first line therapies for constipation. Okay, sad night. You've tried all these. You're assuming your patients compliant. What do you dio? Well, let's talk about the case that we wanted to present today. This is 74 year old male who was referred for evaluation of chronic constipation. Uh, he gave a history of years of having intermittent problem, but it seemed to be slowly progressive and was worse thing to a significant degree over the previous year. Previous colonoscopy showed only sigmoid diverticular Asus. He reports about moment, maybe 2 to 3 days. It starts out his hard with training and then it becomes soft toward the terminus of the elimination. He feels still still in the rectum, Uh, and occasionally he is needed to digitally remove stool and spends much of his time seldom feeling that he had a quality full evacuation. He seldom feels empty now. More recently, his history was just prior to the presentation for evaluation. He had a history of SIA Tika after a recent fall, but those symptoms that tended to subside by the time he came in for further evaluation. Uh, fact, the elimination problem had continued to get worse, despite the fact that the back pain had gone away. Talk about more of that potential significance here in a minute. Now he's tried Metamucil. Compliance is always in question, but he tried Metamucil with adequate water intake. He's tried all the stool softeners, and more recently, his primary care doctor had put him on Luber Preston. But the results have been inconsistent. Um, and he was on 24 micrograms B i. D. His other medications were metformin and Actos protected diabetes and thyroid, and his thyroid was on target. So we way check that, of course. But everything else seemed to be status quo, and yet the malfunction was worsening. So he presented for evaluation. Um, the duration and the type of symptoms made us try to put him into this category of primary idiopathic constipation. But even in this general basket category, I think we've been able to subset the type of motor dysfunction that's responsible for the patient's symptoms. So let me take you through the accepted definitions of the subtypes of idiopathic constipation, slow normal transit constipation, that is, the transit from seeking direct um, is normal and that the patient complaints of altered defecation are less than frequent urges. Now the problem with urges as follows. If the rectum has normal sensation and the patient does not describe a daily urged, and it still simply doesn't get to the rectum, it's a volume sensing organ. It gives us the cue to have a bowel movement. If, on the other hand, the rectum has been Nora genic Lee, disconnected from the nervous system, then still could get to the rectum and they wouldn't know it. So when the patient tells me they've lost the urge to have that movement every day or every second day, the first thing in my mind is, Is it getting there in the first place or when it gets to the rectum? Is it is the rectum did neurologically challenged, and so that helps me to think path of physiologically about these subtypes. Normal transfer constipation. Things ought to get down to the down to the rectum, at least to the rector signaled Junction. Compare that with slow transit constipation, where the real problem is the upstream colon from seeking to signal the muscular contractions or abnormal there's abnormal motor unit density. There could be, uh, infrequent, propulsive mass movements from right to left There, lots of things have been described that occur in slow transit constipation. And last but not least, this is probably the most important part about today's case. Those patients who seem to have pelvic floor dysfunction that is pelvic floor dis energy. This is the term that will use throughout the remainder of the talk. And obviously, since we're talking about motor dysfunction and this is an area that we could measure and assess, we wanna be specific to think about this particular case presentation and whether or not this patient has just pelvic floor dysfunction. Or maybe there's something else. So normal Transit Constipation is the most common type of primary ethic. Constipation still passes through the colon and a normal rates. They find it difficult, difficult to evacuate the bowels. Patients in this category sometimes also meet the criteria for and then see. The difference is again the issue about pain and discomfort that is relieved with a bowel movement. In the idea. See patients the slow transit variant is characterized by infrequent bowel movements, reduced frequency of urgency and the additional need to strain to defecate. It occurs more commonly in females. Patients with slow transit constipation have impaired phase of Kalanick motor activity. UH, they demonstrate at times and physical examination, mild abdominal distension and palpable stool and the second one called Apparent Authentically. If you have been looking at the literature, there's been several reports now about doing abdominal massage, abdominal self massage, and there's always an example of a female patient with left lower quadrant bloating and a stool filled colon. I'm curious as to whether application of these massage techniques may represent an alternative alternative to a medication for patients, but it remains to be seen. But in your female patients who, uh, demonstrate that type of behavior, it might be worth mentioning. Abdominal massage. The last group is the group that we want to focus on today. Those patients who helped pelvic floor dis energia. It's characterized by pelvic Florida anal sphincter dysfunction. Normally, when we bear down toe, have a bowel movement way, inhibit our anal sphincter muscle, and then the the Ebola is propelled by upstream Kalanick contraction opens the sphincter and we eliminate if the elevator and I muscles failed to relax with the proper sequence, you can have obstruction of defecation, the anal sphincter contracts when it's supposed to relax. Uh, that's also gonna be the same problem with failure to eliminate easily. And the harder they strain, the less they eliminate. That's the great paradox of evacuation. Their symptoms include a sense of incomplete evacuation and sometimes again, that use a digital assists. So keeping those three sub categories in mind and trying to keep it in perspective, this particular patient, if we take constipation in general, what are the things that we could do diagnostically to further pursue? The current recommendation suggests that we ought not do everything you see on this slide until after we've done an adequate therapeutic trial of a Siris of laxatives of different classes. Perhaps stair stepped on one another till we get a result, and so we don't get the result that we need to move along. They don't recommend a lot of testing, however, there's something that makes sense. Certainly, if they're over 50 or they've had rectal bleeding, then some type of Kalanick and Scott pick evaluation or imaging evaluation should be done. Uh, fundamentals. CBC is not a standard recommendation, but in the right age group, if you're looking for additional reasons to perform colonoscopy than a patient is anemic on CBC is someone who's gonna fall off your idiopathic algorithm and onto another algorithm. Fundamentally, I think everybody looks to check TSH and chemistry panel and in my chemistry panel, I actually include magnesium, and I want to be sure that I've got normal renal function. If I am anticipating the use of some of these agents, if you think the patient has a transit problem, then you might want to measure Kalanick Transit. We'll show you how to do that. Um, if you think that based on symptoms they have more of an outlet problem with retention and digital assists and things like that, then you want to start with an outlet evaluation. And those were seen here on the third grouping of suspected pelvic floor disorder, a de photography, and tell Vic Emery. Studies are also on option and we'll show an example of those utility. And lastly, if you think you've got I b sc, follow the room three criteria first because that may be able to truncate how much else? Additional testing that you're gonna dio keep in mind. And this is always the great clinical difficulty that there tends to be some overlap in some of these groups. In fact, in the slow transit constipation group, uh, up to 25% of these patients may have more global motor dysfunction has picked up by radio telemetry capsule monitoring on. Also, if you assess for gastric emptying, you'll see that they have element of gastric process as well. So sometimes we have to think outside the box to understand the total picture. Now, in chronic idiopathic constipation, these air the test on one emphasize and summarize a little bit for you. The first one is actually the simple one. If you think the patient has obstructed defecation, a digital examination the office for the patient is then instructed to bear down. To try to expel. Your finger is often predictive of abnormal pelvic floor mechanics in the right hand. In a proper hand, The Examiner connection. Determine whether the pupil, right Alice Sling, actually encroaches on the examiners finger when it should fall back toward the concepts and not be palpable during maximum effort to expel the examiners fingers. So it turns out, at least from our colleagues in Korea, that this had ah, high predictive value for detecting further and erectile outlet problems, and lead lead to some of these other tests. Will talk about balloon expulsion, indirect Manama Tree and pelvic GMG Uh, this is a great starting point. It would be nice to know that we could do this and council our colleagues in bed bedside evaluations in the office prior to being referred for extensive and sometimes expensive testing. So imagine that we're back to the Golden Finger for assessment of outlet type constipation problems. The next test is balloon expulsion test. I'll show you that in a minute, but it has a high predictive value for determining patients who have outlet type dysfunction, and it correlates and corroborates with an erect in Manama tree. In about two thirds up to 70% of patients, there's concordance. Occasionally, Manama trees normal, the expulsion testes abnormal or vice versa, and you have to go further with additional testing. Pelvic floor AMG is something that I used as a regular part of my Manama tree practice on anyone for whom the complaint is constipation, and my concern is that they have some outlet or pelvic floor dis energia below the line. Kalanick Transit Studies. If the outlet seems to be functioning normally, you need to move upstream to decide where the motor pattern, where the motor problem lies and Kalanick transit studies. Now, over the years, there've been several methods, and they're different vendors selling different types of marker capsules all around the globe. Thes air radio. Take little rings and gelatin capsules that air ingested on 12 and or three days. And subsequently X rays were done. Uh, in pediatrics. They've been compared to using radio new clients, integrity and, more recently, the development of a radio telemetry capsule that measured pressure pH and body temperature. And you could assess regional transit of each section of the G I tract eso. You could get a nice idea whether the it's a global motor problem, whether it's defined in the colon. Um, and the downside of that technology is that Onley allows you to determine total colonic transit time and not segmental colonic transit time. So in that regard, I'll show you the type of transit study that I've used successfully over the years and how to do the calculation and then last but not least, de photography using a variety of different contrast imaging modalities. So, based on the current guidelines, patients with intractable idiopathic or chronic constipation should be considered toe. Undergo balloon expulsion test and interrupted Manama tree with the MG if it's available without a Kalanick Transit study, what's the evidence for this? Up to 50% of patients who demonstrate abnormal defecation mechanics and demonstrate slow transit constipation normalize that constipation completely, and they're slow. Transit dissipates once they've had successful results from pelvic floor retraining. So we would be wasting a lot of resource is for at least 50% of patients to Once we did an outlet type evaluation and worked on that aspect of constipation, their entire valve function would return to normal. If the initial testing our is normal, that is Anoma Tree normal balloon expulsion appears normal or you've corrected an abnormal mechanic. Then, if that's all that achieved and yet symptoms persist, then the guideline says. Now it's time to move upstream, upstream with some assessment of colonic motor disease. So now let's let's take this case that we're talking about. This elderly gentleman who's had chronic years of constipation had a recent sion, Icka, which resolved. But despite that is about getting worse. Let me first comment about Sadiq A before we open up this study, Um, keep in mind that the sacral plexus is s one As to the potential nervous as 234 and pelvic parasympathetic that run down through the lower spine and branch out into the pelvis control rectal and descending colon function. So spinal cord patients, the low spinal cord patient is not just gonna have anal sphincter mechanic problems. Potentially over time, they're going to have evidence of loss of propulsion in the rector signaled region. Um so when I hear someone had psychotic, I'm always concerned that they may be developing some Noura genic distal bowel dysfunction as a function of their bulging disk and nerve root compression. The fact that this one away yet his sentence got worse and you'll see here, man geometrically way. Think that neurologically that was not going to be the problem. So I'm going to minimize this screen and we're gonna go to the life study here. I apologize for that hot looking car there in the background. For those of you can see it, I don't own one of those. Um, so this is a study done, uh, by one of my nurses. I'm gonna walk through this rather quickly. The resting tone here is fairly normal. Were in the orange brown area. The patient demonstrates a good squeeze. I'll open this up for you briefly so you can see what squeeze looks like in this patient versus pushed. This is the high resolution study. So we're saying we're looking at color at 12 and three centimeters up to the anal canal. When we see a squeeze or a positive deflection, we're getting a color that's into this range. So we know that we're gonna be fairly normal. Let's move down. We usually do a couple efforts here just for consistency on. Then we will then see not just how strong can they squeeze. But how long can they squeeze? And the patient develops a ah wobbly effort over the course of 30 seconds that we do this in this individual, they're rare and sensation. Their ability to sense things occurs very early on which I was encouraged by my first worried when I heard his story was that we were gonna see findings related to dirt District, a protrusion and nerve root compression. But his first awareness is at 15, which is completely normal, and it as we move up in volume, inflation's he's feeling things very reliably. Um, notice that as we increase the volume, we're seeing Mawr and Mawr intrusion of the abnormal pressure rectal pressure down into the Anal Canal. This is what we call the rare response the rectal, an inhibitory reflex, which is volume incremental at 60 MLS. After that, the next thing we actually put this patient through because of his complaint, I wouldn't recommend that you do this on everyone. But if you have constipation complaint, you should do this on all your patients. I'll explain the difference here. So in this in this particular study, after we've done our rare testing with sensation, we asked the patient to try to expel the catheter and balloon from the rectum on a series of trials. Now there's several problems with that Number one is in most laboratories, the patients left side down. Number two is the patients in front of at least one set of eyes looking at their peri anal region. Why you're asking them to expel the balloon? And there may be more than that in terms of an audience. So there to abnormal situations right off the bat. Number three with a few labs that do people upright. This is thes Catheters are very fragile, and doing them upright does place the catheter at risk of fracture. It's not a quick, cheap prepare. That, being said, we're getting high resolution evaluation of the entire anal canal, which is much more predictive than what we used to see with solid state at a single channel. So in this case, without any additional volume in the balloon, we've asked the patient to push. This upper line represents interruptible or inter balloon pressure. The next line here represents interested pressure, so there's an increase in interested pressure, and concurrently, as we're looking at the Anal Canal, were saying that with the onset of that effort, we're also seeing a rise in Anil Canal pressure, which is not what you'd expect. We should have liked to see that this was a nice relaxation event that almost looks like a little bit of a rare event, and in this case there's paradoxical rise. Now this is only suspicious for a suggestive of Innes HMAS. So we do a second trial, and the results are relatively the same we're seeing. We're seeing a deeper orange color, which means a rising pressure. We would expect to see a fall in anal canal pressures in that setting and so to try to get rid of some of the artifact of lying left side down and having somebody push against the tiny tiny catheter. What we've done in our lab over the years is that we then ask patients way, place the catheter in, and then we asked patiently inflate the balloon to 60 ccs. We give him 60 ml. Bolas. That's 60. MLS is something that 95% of individuals could feel, uh, and no pun intended. They could get the rectum around, and then they can try toe demonstrate, a more normal rectal notification mechanic. But even in this case, there's paradoxical rise in anal canal pressure, even with the assistance and the queue here of using 60 ccs with the push, so by an erectile geometric criteria, this is suspicious for an business or pelvic floor. This energy. Okay, I'm certainly at this point willing to stop and ask to see if there's any question for the audience about the actual patient themselves. And if not, we will move on. There are no direct questions yet. Great. Okay. Also want to point out something else from a neurologic standpoint, when you'd innovate the distal bowel from lower lower spinal disease? The other thing that you lose his rectal sensation in this cation. In this case, as we look at slow sensation along this third portion of our study, first sensation is 35. Urgent 85 maximum tolerable. 1 75. And those were not consistent with somebody with a Nora genic bow. Uh, typically would see that these numbers will have shifted widely to the right first sensation could be undetectable. Could be 85. Could be 100. Urge would be elevated at 150 maximum tolerable may not even be achievable. So energetic distal bowel. Uh, sensory loss results in a skew of these sensory parameters. Way off to the right. Okay, so this is just the highlight of what we just showed here with the man a metric expulsion attempts what we call simulated defecation. I think that's how we'll define that when we're finished with our international working group. So we went ahead and proceeded within the M. G. And in this case, I think the mg is very helpful. I still use the M g to confirm my suspicion by Manana tree to make the diagnosis of announcements. In this case we have in the upper lead, we have E m G sensor attached to the abdominal wall, and in the lower sensor, we use the Perry plug internal. You can use a variety of different sensors in and around the ankle area. By the bottom line is, you're picking a PMG signal of the anal sphincter and adjacent neighborhoods. So in this case, we asked him to squeeze. You don't see much with the abdomen, usually very office used just for holding the breath. At the same time, you see a dramatic rise. In fact, this is an excellent response. This is about 42 micro volts in response, which is an excellent E M g s. We signal. So we've got good signal and a good response on the part of the patient. As we move down, we asked the patient to push. And in this case, the push here shows a paradoxical increase in MG activity associated with some modest abdominal wall contraction. And on three subsequent trials 12 three We see paradoxical rise in anal sphincter canal. Uh, the contractions associated with abdominal wall contractions. Now, uh, we have defined on a previous webinar, the four main types of minusma. So let's look at that. The center of this slide shows a normal pattern to defecation trials and simulated defecation is the increased rectal pressure and reduction in anal canal pressure and hopefully, forward Bullis feces movement. The type one is paradoxical. Rise in both abdominal wall in anal sphincter type two. There's not much going on with the rectal wall, and yet the stricter contracts, paradoxically, in Type three, the abdominal wall contracts. In the annals, sphincter is simply non relaxing, and in type four, things tend to be generally feeble, both abdominal wall in the end of canal and I would profit that probably in this patient we would feel most comfortable that this is a type one and isthmus over time. So just to show you another AMG showing the difference between a squeeze and push showing the paradox pelvic, this energy of my AMG. So now we've done mg and we've done in erectile studies. Um, the next thing I would do or something I would do concurrently with balloon expulsion. The problem defining what's normal for balloon expulsion is that globally everybody does this differently. Hopefully you have a method in your practice that has been consistent and reliable. That is predictive of someone without lead type dysfunction. However, the school in a working group was struggling with the finding normal for this and this particular paper, I think, is maybe one of the most predictive ways to use this. And this is what we do in our practice. Philip, balloon the 50 mls of water, uh, and then have them sit on the toilet. Interestingly, if you use this volume, um, 93% of normals can expel the balloon on a remote within 60 seconds. In 100% of normals can do this within two minutes so that two minutes actually now to find the upper limit of normal, Um, if you do something vastly different than this, you might want to try this. Try to validate it in your own practice. But I think this is something that we now know from several office based studies can be done to the office of a primary care physician with a folding balloon and an expulsion for two minutes on the comm oat. So, um, this has high predictive value for definition defining outlet type problems. But if you do to interrupt the Manama tree and you do balloon expulsion test, there's still a third of patients. They're gonna be discordant on that. What do you dio? Um, I'm gonna save that photography for the last part of the talk. But let's say that this was normal and that we wanna move upstream. Now we have the ability to study colonic transit either by radio telemetry capsule, um, sent a graffiti or Kalanick transit studies, and these air these classic radio opaque markers. Many doctors will do the single capsule technique words ingested on one day and abdominal examinations taken on day five. Um, the late transit is defined here is greater than 20% retention of 24 or 30 markers. Uh, Evans measured the time it took to pass those large bound 25 men and 18 women and demonstrate that 95% of normals will pass more than 80% of the markers within this time window. So you do one X ray on day five, and you can determine whether that patient meet screening criteria to move on further work up. My preference is a multiple capsule technique. Unique markers seen here on day one day, two day three are ingested, day 123 and sequencing on Day four and day seven K. U B X rays obtained Kalanick. Times can then be assessed with each segment. Uh, and I'll show you the formula, which has been quite helpful for me for a long time that the normative date of Kalanick Transit adults they're available for these large, larger numbers of radio pig studies. The mean Kalanick transit time was 30 to 40 hours, with upper limit enormous being 70 hours in mixed populations. There were differences, differences in colonic transit, times based on age, gender, race and the methodology. The first definitions of how to do the measurements were described by our hand, and we'll show you the picture for that. As expected, a little bit. Women had a longer, maximal Kalanick transit time compared with men. And interestingly, if women were tested during their menstrual cycle, they had a different Kalanick transit time then when they were between between cycles on the left is the a diagram of K. You be with three sets of markers that have been dispersed throughout the colon Theme markers for measurement that I've shown. You hear those that were defined by our hand back in the 1990 of that or thereabouts for regional Kalanick transit time. So over here, any markers in this zone effects right colonic transit, timing mechanisms, measurements descending colon here and a line drawn. I actually did withdraw this smell five here to the interior iliac spine. Anything above this is left Colon. Anything down here is wrecked a signal. So if you've not used this formula, it's worth having and accessing. So what we do? We count the markers in each segment on day four, right left breakfast signal and then the total that we count. And then on day seven, right left rector sigmoid and the total remaining and you add up. The vertical columns multiplied times 1.2 and that gives you the average Kalani transit to that segment of the colon. Very helpful, especially if you think that there may be a regional or global transit problem summarized on left at Day five. Our Day four and day seven. If a day seven, you're clear, that's normal transit. If you still have markers completely dispersed throughout the colon during those x rays, we diagnosis. That is Kalanick inertia or slow transit constipation. And last but not least, we used to talk about something called hind gut dysfunction early. The sigmoid had a motor motor abnormality. The fact that the radio opaque markers all cluster in the rectum suggests, but we now know, is not diagnostic of an outlet type problems. So we need to do more work if we get this type of pattern on our transit studies de photography. I remember the days of mixing bearing and paste with artificial potatoes and using that as our simulated stool. Uh, the various manufacturers nowadays have been able to take over that job for us, but death Akagera fee can be considered in patients who have discordant balloon expulsion tests, and they director Manama Tree. It identifies an atomic problems with the evacuation apparatus that may be causing discomfort. Sense of incomplete evacuation, the need for manual assistance. It's not uncommon. Thio here, a multi Paris female, say that she has to place her fingers vaginally post eerily to support the rectal wall. What she's doing is supporting erectus eel to allow the rectum to empty is effectively as possible. For those of you have done this for a long time, you understand that the greatest difficulty has been trying to describe an atomic abnormalities seen on death photography with that being the cause of the patients. Obstructed definition defecation. Um, RG i colleagues or colorectal surgeons are Euro guides and Joanne to have to do the surgery. Consider surgery. We always struggling with the fact that if I repair the rector seal as the patient's evacuation mechanic going to get better on, there's no really preoperative, predictive way to tell them that, Um, so you have to be careful if you look at a series of normals. Up to 25 to 35% of patients or normal volunteers would looked at carefully with them. Are death photography will have minor wrecked wall abnormalities that are no worse? No, no more or less substantial anatomically than patients who are complaining of the symptoms of obstructive defecation. So caution is advised if you move to death photography and you make a treatment plan on the basis of an an atomic finding on death, photography keep in mind and normal mechanics of the public floor all controlled largely by the pew Brick Tallis. We've seen these in other courses, but the pupil, Rick Tallis Sling Muscle defines an an erectile angle at rest. In this case, a sad to review of the Marie showing they had erectile angle in the rectum with the contrast when we asked the patient to squeeze, there's a shortening of the pupil, Rick Tallis muscle on a tightening acuity and the angle effectively excluding the rectum from the anus and keeping contents in the rectum. And when we asked the patient to eliminate the pupil, right, tell us, relaxes it falls back toward the Kochs, it's, and we open up the center rectal angle, effectively permitting a shoot c h u t e by which still could be evacuated. Interestingly, uh, in populations that have to sit in squat to eliminate their bows. The more that we squat, The greater the opening of the puberty Tallis sling during defecation. In this example, the Marie de Photography was performed on on this lateral view. What you see is that there's much more rectal contrast still above the anal sphincter. In this case, this is a example of a great to wreck. To seal a great three right to seal would enter down to the intro Otis of the pelvis and great Four would be frank prolapse through the vaginal opening. So this is not a serious rectus eel, But you can see that this anterior wall is where still could be misdirected during an attempt to defecate. When the patient stands up, the record snaps back, and now they feel as if they still have wasted to eliminate. And they probably do. So let me summarize the guidelines. There's a monogram out there from the H A and A C G. And just to just to summarize and highlight how we would work up a patient with chronic idiopathic constipation in the history and physical, which to me is still very important. I can predict off of what I'm gonna find with testing, uh, from the history of physical. The guidelines are as follows. We follow this down, but I wanted I added two things. One is be careful and thorough and evaluating medications and supplements there many medication classes out there that make constipation worse or cause constipation to begin with. So don't undergo an expensive, extensive work up. If you've got a calcium channel blocker that's a notorious culprit for causing constipation. Try to think of an alternative on the other side of the graph here is Do a good quality digital rectal examination asked after you test a test tone and feel for defects. Yes and the squeeze and then ask them to expel the finger with your finger over. The pupil would tell a sling just in front of concepts. You may find obstructive defecation mechanics very early on in the valuation. Consider focused metabolic structural evaluations. The labs. We talked about a therapeutic trial. The patient is inadequate. Adequate response, then in a Manama tree and balloon expulsion tests. If it's normal, assess colonic transit and move up. If it's inconclusive, considered testing, too, uh, rectify the disparity between the two tests and that these air abnormal you have a defecation disorder, and at this point, it doesn't talk about therapy. But there would be directed toward pelvic floor rehabilitation, which is an arduous task and, unfortunately, not available in every center, uh, and then even met major metropolitan areas. So for patients lived three or four hours from any major medical center, this could be quite a task for them in sub setting or constipation. If you have a transit constipation problem, laxatives have provided improvement. You go with it. If they provide no improvement. You modify the regimen, consider adding things, and you may even add some of the new pro kinetics or intestinal secreted gods out there as well. What you should do is follow down the right side of this path, if you will. With me, improvement is easy. Go with what you know. Go with what works. No improvement. You need to move down the right side of the algorithm. Measure that we know we've got a transit problem. Measure the transit problem on medications. If it's normal, you make adjustments. If it's delayed, this is when you really need to think outside the box. Think that they may have a more global motor problem and think about gastric emptying studies, Aziz. Well, um, And as we move down the algorithm over here to a more generalized disorder, uh, maybe Prue kala pride type drugs is where we need to go. And if gastric emptying is normal, you may refer to a specialty center to consider barest at studies Kalanick man a metric studies, uh, and the more advanced surgical things that are done to some of our highest respected surgical referral centers for this disorder in the country. And last, but not least for the outlet type constipation. They have a difficult Torrey disorder retraining Dietitian Bow program and also, at times, a psychologic intervention. If they're making progress, follow them. If there's no improvement after you've done all this and by the way, this takes quite sometimes 6 to 12 weeks weekly therapy, very intensive to try to get patients who have learned an abnormal, difficult torrey pattern to do it right. And then you move down with repeat testing to collect transit, make sure you didn't miss anything upstream or if the B e t is normal, get back there and be sure that they don't have some dynamic and atomic problem that as contributing to their obstructive definition. And last but not least, way always put This is the back end here. But consider surgery and my career have had five patients who opted for total proactive collected me from intractable idiopathic constipation. None of them were pseudo obstruction patients When we looked at their palace sista. Logically, all of them were satisfied that after years of being bothered by intractable chronic constipation that their lives had, uh, improved. So at that point, I will close and thank everybody for their attention on this very seemingly on the surface, mundane but really a very difficult problem for many of our patients. And I'll entertain any questions at this point. Thank you, Dr evilly, for that comprehensive presentation. Wendy, are there questions for Dr Readily? Yes. There are a few here. Um, so are you recommending, uh, the balloon expulsion on all of the constipation patients and follow up to that? If the balloon expulsion is completed within two minutes, Uh, do you stop there? Even if their push wasn't satisfactory during the Inter actual. But if the balloon wasn't expelled in the two minutes, do you go on and do additional testing. Okay, Well, I guess I should ask. I'll ask the less into the last part first at the balloon. Expulsion test is normal within two minutes. And Manama Tree suggested abnormality. My confirmation for that is actually A and G. But keep in mind that this balloon expulsion text test has got a very high predictive value, although it's not 100%. So my b e t is normal, and then Manama tree is a little bit off. I'm gonna make sure that the mg confirms that I still have a dynamic the anal sphincter that I need to rehabilitate with with retraining both their normal then and then I'm really Then I really need to move upstream immediately with the Kalanick transit study. Um, and a two problem always comes when things were inconclusive and sometimes it's worth repeating the B e t. The first part of the question again. Wendy, did you have that written down? Do you recommend the balloon expulsion with each and every study for constipation? Um, honestly, my screen has been a history based if I have symptoms of infrequent urge and I and I get no story from the patient of any of these issues that suggests outlet obstruction, that the answer is now, I don't normally do a b t. I've used my history, Thio. Be very specific as to the testing on any of these patients who fall into this group category of constipation. Okay. And to be clear, not using the high resolution probe for the balloon expulsion, Uh, I am not. I'm using and you can use air or sailing. I think, Ah, water filled balloon at 50 or 60 MLS. And like I said, we're trying to define this so that everybody can have the same test with the same value, and everybody around the globe could use the same test. And the B E t is such a cheap thing to do. I don't know why primary care wouldn't wanna have that, especially if they're dealing with a group of, uh, patients for constipation is a frequent complaint that they might wanna have that available in the office setting. Okay. And then e m g. If you have it available, you're using it for patients who have discordance between the bt and the push of the erectile or what other group would you use? Thank you. I use it. You know, I don't know that MGs available to everybody. I think the plug AMG sensors air good add ons to the currently available systems and a moderate investment. But if I see paradoxical rise in anal sphincter canal pressure during, uh, the A simulated defecation by Manama tree I felt to this point that the m G is where you make the diagnosis is suggested by Manama Tree. It is diagnosed with certainty with the AMG now, in terms of correction of pelvic dis energia, if you look at using man a metric retraining versus using AMG retraining AMG performed superior early to man a metric retraining when you're talking about this patient, these patients with pelvic dis energy. So I use M G as a therapeutic intervention after it's confirmed my diagnostic impression from the Manama tree. Thank you, Wendy. I think we have time for one or two more questions. That's all the questions we have at this time. Very good. Yeah, Thank you. That was very well done. Okay. Thank you. Dr Evilly, we've consumed our time and I would like to thank everyone on the line for participating again. Anyone who would like to listen to a recording of this webinar. You'll receive a follow up email within the next 24 hours with a connection link to the recording. And we encourage you to share that email with your colleague's so they too can benefit from this event. Thank you, Dr Readily. And thank you, participants. We appreciate your time thanks to all. Created by Related Presenters R. Matthew Reveille, MD GastroenterologyAdvanced Endoscopic Interventional View full profile
