Biofeedback therapy for dyssynergic defecation

Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults; it is defined by incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate. This is believed to be a behavioral disorder because there are no associated morphological or neurological abnormalities, and consequently biofeedback training has been recommended for treatment. Biofeedback involves the use of pressure measurements or averaged electromyographic activity within the anal canal to teach patients how to relax pelvic floor muscles when straining to defecate. This is often combined with teaching the patient more appropriate techniques for straining (increasing intra-abdominal pressure) and having the patient practice defecating a water filled balloon. In adults, randomized controlled trials show that this form of biofeedback is more effective than laxatives, general muscle relaxation exercises (described as sham biofeedback), and drugs to relax skeletal muscles. Moreover, its effectiveness is specific to patients who have dyssynergic defecation and not slow transit constipation. However, in children, no clear superiority for biofeedback compared to laxatives has been demonstrated. Based on three randomized controlled studies in the last two years, biofeedback appears to be the preferred treatment for dyssynergic defecation in adults.

Chronic proctalgia and chronic pelvic pain syndromes:New etiologic insights and treatment options

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs:chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing:A recently published large randomized,controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle-a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders.

Bloating and functional gastro-intestinal disorders: Where are we and where are we going?

Bloating is one of the most common and bothersome symptoms complained by a large proportion of patients. This symptom has been described with various definitions, such as sensation of a distended abdomen or an abdominal tension or even excessive gas in the abdomen, although bloating should probably be defined as the feeling(e.g. a subjective sensation) of increased pressure within the abdomen. It is usually associated with functional gastrointestinal disorders, like irritable bowel syndrome, but when bloating is not part of another functional bowel or gastrointestinal disorder it is included as an independent entity in Rome Ⅲ criteria named functional bloating. In terms of diagnosis, major difficulties are due to the lack of measurable parameters to assess and grade this symptom. In addition, it is still unclear to what extent the individual patient complaint of subjective bloating correlates with the objective evidence of abdominal distension. In fact, despite its clinical, social and economic relevance, bloating lacks a clear pathophysiology explanation, and an effective management endorsement, turning this common symptom into a true challenge for both patients and clinicians. Different theories on bloating etiology call into questions an increased luminal contents(gas, stools, liquid or fat) and/or an impaired abdominal empting and/or an altered intra-abdominal volume displacement(abdomino-phrenic theory) and/or an increased perception of intestinal stimuli with a subsequent use of empirical treatments(diet modifications, antibiotics and/or probiotics, prokinetic drugs, antispasmodics, gas reducing agents and tricyclic antidepressants). In this review, our aim was to review the latest knowledge on bloating physiopathology and therapeutic options trying to shed lights on those processes where a clinician could intervene to modify disease course.

Bio-feedback treatment of fecal incontinence: Where are we, and where are we going?

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects,and scarce invasiveness. Well-designed randomized,controlled trial are eagerly awaited to solve this therapeutic dilemma.

Neuromodulation for fecal incontinence: An effective surgical intervention

Fecal incontinence is a disabling symptom with medical and social implications,including fear,embarrassment,isolation and even depression.Most patients live in seclusion and have to plan their life around the symptom,with secondary impairment of their quality of life.Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected.However,surgery must be considered in the nonresponder population.Recently,sacral nerve electrostimulation,lately named neuromodulation,has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management,by some unknown mechanism.Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile.This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.

Manometric assessment of idiopathic megarectum in constipated children

AIM: Chronic constipation is a frequent finding in children. In this age range, the concomitant occurrence of megarectum is not uncommon. However, the definition of megarectum is variable, and a few data exist for Italy.We studied anorectal manometric variables and sensation in a group of constipated children with megarectum defined by radiologic criteria. Data from this group were compared with those obtained in a similar group of children with recurrent abdominal pain.METHODS: Anorectal testing was carried out in both groups by standard manometric technique and rectal balloon expulsion test.RESULTS: Megarectum patients displayed discrete abnormalities of anorectal variables and sensation with respect to controls. In particular, the pelvic floor function appeared to be impaired in most patients.CONCLUSION: Constipated children with megarectum have abnormal anorectal function and sensation. These findings may be helpful for a better understanding of the pathophysiological basis of this condition.

Disorders of the brain-gut interaction and eating disorders

BACKGROUND Eating disorders(ED)involve both the nervous system and the gastrointestinal tract.A similar double involvement is also found in disorders of the brain-gut interaction(DGBI)and symptoms are sometimes similar.AIM To find out where there is an association and a cause-effect relationship,we looked for the comorbidity of DGBI and ED.METHODS A systematic review was undertaken.A literature search was performed.Inclusion criteria for the articles retained for analysis were:Observational cohort population-based or hospital-based and case-control studies,examining the relationship between DGBI and ED.Exclusion criteria were:Studies written in other languages than English,abstracts,conference presentations,letters to the Editor and editorials.Selected papers by two independent investigators were critically evaluated and included in this review.RESULTS We found 29 articles analyzing the relation between DGBI and ED comprising 13 articles on gastroparesis,5 articles on functional dyspepsia,7 articles about functional constipation and 4 articles on irritable bowel syndrome.CONCLUSION There is no evidence for a cause-effect relationship between DGBI and ED.Their common symptomatology requires correct identification and a tailored therapy of each disorder.

Hypnosis and upper digestive function and disease

Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential infl uence of hypnosis on uppe digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of uppe digestive motor and secretory function. The presen evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases o the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.