PROF. MASSIMO BELLINI - 1° Giornata Master ECM in Gastroenterologia 2016 (11/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma Sito: www.asmad.net Canale Youtube: https://youtu.be/9M_V3xFBgcI

1. Resp. Ambulatorio Disturbi Funzionali eResp. Ambulatorio Disturbi Funzionali e
Motori dell’Apparato DigerenteMotori dell’Apparato Digerente
U. O. Gastroenterologia UniversitariaU. O. Gastroenterologia Universitaria
(Dir. Prof. S. Marchi)(Dir. Prof. S. Marchi)
Massimo Bellini
LA MANOMETRIA DEL TRATTO
INFERIORE

2. “La manometria anorettale e
la manometria colica servono
a qualcosa?”
procedure
standardization
useful in clinical practice?
normal
values
different
reports
sharing and
interpretation
of data

3. No technique studies defecation in its natural
condition
• Patient’s position
• Fecal consistency
• Needles, probes, catheters can
alter the defecation dynamics
• Patient’s embarassment
Simulated acts, asking the patient not in response to
a real need, in artificial and unnatural conditions
Careful medical history, rectal digital
examination (with proctoscopy) and diagnostic
tests are different but complementary tools
(AGA,2013)
“..test results need to be interpreted in the overall clinical context”

4. Digital Rectal Examination
DRE in 495/878 (56.4%)
F/M: ns
-First evaluation: 54.7%
-Follow up visit: 56.6%
ns
(BMC Gastroenterology, in press)

5. IASIAS
EASEAS
P-R muscleP-R muscle
Rectal press.Rectal press.
Rect. percept.Rect. percept.
ComplianceCompliance
ReservoirReservoir
Perineal desc.Perineal desc.
ARAARA
Pudendal nervePudendal nerve
RestingResting
press.press.
SqueezeSqueeze
press.press.
RectalRectal
Percep.Percep.
Compl.Compl.
MANOMETRYMANOMETRY DEFECOGRAPHYDEFECOGRAPHY EUSEUS EMGEMG
++
++
++
++
++
++
++
++
++
++
++
++
++
++
++
++
(modif. da Wienbeck, 1989(modif. da Wienbeck, 1989))
++
++
Strain.Strain.
press.press.
++
++
++ ++

6. Catetere aCatetere a
perfusioneperfusione
stazionariastazionaria Catetere aCatetere a
stato solidostato solido
ambulatorialeambulatoriale
Manometria colica

7. Attività colica
segmentaria
HAPC
(Bassotti G, WJG 2005)
LAPC

8. -attività propagata (HAPC e
LAPC): può essere alterata in
frequenza, in ampiezza, in
durata;
-attività segmentaria: mantenuta
o perduta, ma soprattutto
sovvertimento della periodicità
dell’attività motoria.
normal
STC
Rao S, 2009
Slow Transit Constipation

9. Manometria colica: applicazioni cliniche
Rao S, 20 0 9
La manometria del colon nella STC può avere
significato diagnostico in ordine alla successiva
opzione terapeutica, conservativa o chirurgica. (IV C)

10. Right colonRight colon
TransverseTransverse
coloncolon
Left colonLeft colon
(gc. dott. M. Corsetti)
Pan-colonic pressurizations associated with relaxations of the anal
sphincter: new colonic motor pattern that seems to be defective in patients
with treatment-refractory chronic constipation and may have a role in
the transport of colonic gas and in the facilitation of the propagating
sequence-induced colonic transport.
Anal sphincter
Cervelli in fuga….

11. ANORECTAL MANOMETRY
CONSTIPATION
FECAL INCONTINENCE
PELVIC FLOOR REHABILITATION
ANORECTAL PAIN ?
COLO-RECTAL SURGERY

12. Anorectal Manometry
Resting pressure
Maximal voluntary contraction (EAS)
Anal and rectal pressure at straining
RAIR (IAS)
“Cough reflex”
Rectal sensation
Rectal compliance
(Balloon Expulsion Test)

13. Catetere rettale 8 canali
n.8 a 1 cm dal palloncino
n 7, 6, 5, 4 a 5 cm;
n 3 a 6 cm;
n 2 a 6.5 cm;
n1 a 7 cm .
Gruppo “Ischia”

16. 20-24-36 canali
HRM “a perfusione”

17. Catetere HRAM stato solido (2D)
• Dieci “canali” statici di rilevazione pressoria (12 punti di rilevazione
per ciascun sensore), 6mm di distanza l’uno dall’altro; 5.6 cm di
rilevazione pressoria per canale anale.
• Due sensori rettali a 3 cm dai sensori anali.
• Attraverso l’interpolazione dei dati tra sensori adiacenti la pressione
diventa un “continuum” spaziale e i valori sono espressi come
intensità di colore.
Diametro 4.2 mm
12 sensori circonferenziali

18. Catetere HRM 3D
• 256 canali disposti in 16 anelli assiali
• spaziatura tra anelli adiacenti: 4 mm.
• lungh. totale: 6.4 cm.; 10.75 mm
Visualizzazione tridimensionale canale
anale > valutazione accurata risposta
pressoria di ogni tratto del canale a 360°.
Copertura con palloncino 33 mm (400 cc).
All’estremità distale: sensore “lungo” per la
valutazione della pressione rettale

19. ANORECTAL MANOMETRY: parameters (I)
Resting pressure
anal fissure, anal pain
fecal incontinence
Squeezing
fecal incontinencestrength
strength pelvic pain?
fecal incontinence
lack of coordination of pelvic muscles
duration
(Azpiroz F, 2002)
(Tuteja AK, 2004)
dyssynergic defecationor
Anal pressure
during straining

20. ANORECTAL MANOMETRY: parameters (II)
Rectal pressure
during straining
<45 mmHg Inadequate defecatory propulsion
RectoAnal inhibitory
reflex (RAIR)
absent Hirschprung; megarectum
incomplete
scleroderma? rectal ischemia?
neurological disorders?
dyssynergic defecation?
strength
and/or
duration
“urge incontinence”
(cauda equina lesions)
(pudendal neuropathy)
(peripheral neuropathy)
“Cough reflex”
abdominal pressure
EAS contraction
(Azpiroz F, 2002)
(Tuteja AK, 2004
(Barucha AE, 2006)

21. Rectal Sensibility
(after balloon inflation)
first sensation
constant sensation
max. tolerable
volume
proctitis
IBS
surgical resection
fecal incontinence
megarectum
perineal descent
autonomic neuropathy
spina bifida
myelomeningocele
dyschezia
(Azpiroz F, 2002)(Azpiroz F, 2002)
(Tuteja AK, 2004)(Tuteja AK, 2004)
ANORECTAL MANOMETRY: parameters (III)
Inflation of a rectal balloon during ARM is a cheap and reproducible
surrogate for barostat testing of rectal sensation but is limited by the
intrinsic elastic properties of the balloon, which reduce the ability to
determine rectal compliance (Staller K, 2015; Rao S, Rome IV 2016)
Rectal complianceRectal compliance
Muscle toneMuscle tone
Visceral distensibilityVisceral distensibility
PP
VV
megarectum
fibrosis
chronic ischemia
radiotherapy
diabetes
dyschezia
fecal incontinence

22. Pressione basale canale anale

23. Contrazione Volontaria Massimale

24. Riflesso retto-anale inibitorio

25. 40 cc.40 cc. 40 cc.40 cc.

26. Compliance rettale
Pressione
Volume
-tono muscolare-tono muscolare
-elasticità viscerale-elasticità viscerale

27. Roma IV
FUNCTIONAL
DEFECATION
DISORDERS
Inadequate
Defecatory
Propulsion
Dyssynergic
Defecation

28. Pressione anale e rettale durante lo “straining”
1 cm
1,5
cm
2 cm
5 cm
pressionepressione
rettalerettale
canale
anale
Normale

29. Tipo I
1 cm
1,5 cm
2 cm
5 cm
straining
Contrazione paradossa

30. Tipo II
1 cm
1,5
cm
2 cm
5 cm
straining
Insufficienti forze propulsive

31. Tipo III
1 cm
1,5 cm
2 cm
5 cm
straining
Rilasciamento assente o insufficiente

32. Defecatory Patterns
Rectal pressure Anal pressure
Normal (≥ 45 mmHg) Decreased
Tipe I (≥ 45 mmHg)
Increased (paradoxical
contraction)
Tipe II (< 45 mmHg)
Increased (paradoxical
contraction)
Tipe III (≥ 45 mmHg)
Absent/insufficient
relaxation (<20%)
Tipe IV (< 45 mmHg)
Absent/insufficient
relaxation (<20%)
DD
DD
(Rao S, Rome IV, 2016)

33. Balloon expulsion test
87.5% sensitivity and 89% specificity with PPV and NPV of 64% and
97% for diagnosing defecatory disorders: it helps to identify patients
without a defecatory disorder (Minguez, 2004)
Little standardization about the patient’s position, size,
shape, filling volume and type of balloon.
Recommended normal values (depending on the
technique) range from <1 minute to up to 5 minutes
(AGA, 2013)
BET is reliable for analysis of pelvic floor dyssynergia (Chiarioni, 2014)
The optimal upper limit of normal is 2 minutes (Chiarioni, 2014)
BET: useful screening test for FDD, but it does not define the
mechanism of disordered defecation.
Because the balloon may not mimic the patients’ stool, a normal
BET does not always exclude a defecation disorder.
(Rao S, Rome IV, 2016)

35. (Staller K, 2015)

36. PELVIC FLOOR REHABILITATION
FUNCTIONAL DEFECATION DISORDERS
Resting pressure: P-R Stretching
Anal dilator
Pressure
Rectal compliance : Volumetric
rehabilitation
Threshold volumes:
Recognition
volumes
Ineffective balloon
expulsion:
Kinesitherapy Muscle Coordination
Voluntary contraction:
strength/duration
Kinesiterapy
BF ES
EAS and P-R function
Muscle Coordination
or insufficient pressure
Voluntary relaxation:

38. (Staller K, 2015)

39. ARP = anal resting pressure;
MVC = maximal voluntary contraction;
CRST = conscious rectal sensitivity threshold;
MTV = maximal tolerated volume.
(Pucciani F, 2007)(Pucciani F, 2007)
Algorithm of multimodal rehabilitation program for
FECAL INCONTINENCE

40. ANORECTAL PAIN
The role of DD in proctalgia fugax is
unclear, and ARM is not recommended
without other factors suggestive of DD.
Impaired pelvic floor muscle relaxation and abnormal BET have
been shown to correlate with anorectal pain and favorable
response to biofeedback therapy.
In a patient with chronic proctalgia: evidence that DD may be
playing a role in anorectal pain beyond constipation (Hart SL, 2012)
ARM with BET should be employed after normal
structural assessment to diagnose DD.

41. Both WPAM and HRAM are well tolerated and reliable.
HRAM
(1) simplified set up with improved sphincter localization,
(2) better physiological information (elimination of movement artifacts),
(3) collecting more data (more sensors at close intervals)
(4) simultaneously measuring pressure over the entire length of the anal
canal and circumferentially
(5) simplified data interpretation and more sophisticated analysis,
(6) ease of reporting and storing the patient reports,
(7) possible in sitting position (2D)
more fragile, shorter life-span, greater maintenance needed
BUT
(Kang HR, 2015)
(Lee YY, 2013)

42. «Esophageal HRM has become a standard diagnostic tool… in the colon and
anorectum the use of HRM still remains in its infancy, with relatively few
published studies in the scientific literature”.
Esophageal HRM: 716 quotations(PubMed)
55
quotations
37 «original paper»
12 editorials
6 letters/»case report»“High resolution/definition
anorectal manometry”
2007 – 2016
“…the majority of studies are of low quality, comprising exploratory case series,
….many describe data collected retrospectively, which therefore have likely
suffered from selection and performance bias”.

43. BEAR DOWN: “trumpet” SQUEEZE: “sandy clock”
RESTING PRESSURE
“dumbbell”
»…ed elli avea del cul fatto trombetta»
(Inf. XXI, v. 139)
2D3D
2D
3D3D
2D

44. COUGH
New insights? New markers?

45. VALSALVA

46. Squeeze: not only by the contraction of the external anal sphincter
(EAS), but also by the contraction of the puborectalis muscle (PR).
The EAS is responsible for contraction in the distal part and the PR
for contraction in the proximal part of the anal canal.
The neglect of surgical repair of the puborectalis muscle during
sphincteroplasty (targeted at a damaged external sphincter) could be the
reason for the low success rate (short-term success rate: 43−89%)
(Herold A, 2008) (Liu J, 2006)
SQUEEZE

47. Excessive perineal descent was defined as the downward
movement of the anal high-pressure zone during straining.
At the end of the straining effort, the high-pressure zone
regained its initial position, thereby indicating that the position of
the probe within the rectum had not moved

48. It is suggested that the increased rectal pressure with
a narrow band of high pressure within the anal canal
during simulated evacuation suggests rectal
intussusception.
(Heinrich H, 2015)

49. Three-dimensional high-resolution anorectal manometry and Recto-Anal
Delta Contractile Integral for the assessment of functional defecatory
disorders: toy or tool?
Gambaccini D, Bellini M, de Bortoli N, Zari M, Russo S, Martinucci I, Ricchiuti A, Surace L, Costa
F, Mumolo MG, Marchi S.
U.O. Gastroenterologia Universitaria- AOUP, Pisa, Italy
21 FDD pts
Endoanal and endorectal pressure values during the push straining to
calculate the contractile integral (CI) which is a measure of duration and
strength
Endoanal CI evaluated on a space including the anal canal for the whole
duration of the push straining. By using the function “isobaric contour”
pressures lower than mean resting pressure of the anal canal excluded.
Endorectal CI calculated on a 10 mm space for the whole duration of push
straining.
Recto-Anal Delta Contractile Integral (RAD-CI): the difference between
endoanal CI (proportionally correlated to 10 mm) and endorectal CI.
RAD-CI showed a correlation with BET better
than traditional Recto Anal Pressure Gradient

50. No study conclusively demonstrates a clinical,
diagnostic or interventional advantage of HRAM/3-D
HDAM over conventional manometry.
HRARM and HDARM offer a new dimension in understanding
anorectal function. They can reveal the pathophysiologic
mechanisms of many defecation disorders (not only functional),
and provide the basis for correctly selected therapeutic
management
More prospective research establishing the clinical benefits
of HRAM/ 3-D HDAM is required prior to recommendation
of these techniques over and above conventional anorectal
manometry (Dinning PG 2015)
There is a considerable way to go to mirror
the success of esophageal HRM.

53. The discrepancy could reflect anxiety in the laboratory setting and/or the
challenge of a defecation in the left lateral position with an empty rectum
(Grossi U , 2015)
-36% of asymptomatic subjects: dyssynergia during traditional manometry
in the recumbent position compared with 20% in the seated position
(p<0.05) (Rao SS, 2006)

54. MR defecography shows rectocele with anal intussusception
HR-ARM accurately identifies recto-anal dyssynergia and the subgroup of
patients with outlet obstruction due to rectal intussusception directing those
with dyssynergia to behavioural treatment and others to further investigation
by defecography. (Heinrich H, 2015)

55. normale
megaretto

56. normale
RCU

57. -High accuracy for the diagnosis of dyssynergia using HRAM
(77% sensitivity, 85% specificity) in 66 patients with
dyssynergia on MR defecography. A specific manometric pattern
(high intra-rectal pressure with a steep, positive pressure
gradient consistent with outlet obstruction) only in patients with
MR intra-anal intussusception > HRAM can accurately diagnose
some patients with either ‘functional’ or ‘structural’ causes of
their evacuatory difficulty. (Heinrich H, 2015)
No correlation between 3D-HRAM findings and structural
pelvic defects on MR defecography (only a weak correlation
between intrarectal pressure at rest and rectocele size and
organ prolapse) (Jodorkovsky D, 2015)

58. Functional Defecation Disorders
Paradoxical
contraction
Inadequate defecatory
propulsion
Paradox. contraction
Absent/insufficient
relaxation
Inadequate defecatory
propulsion
Absent/insufficient
relaxation

59. -3D HRAM provides simultaneous
physiological and anatomical data
that may be used to identify an anal
sphincter defect, although its
sensitivity is lower than EUS.
-Pressures correlated with the
presence of an anal sphincter
defect diagnosed by EUS.

60. Agreement between ARM (indirect assessment of evacuation) and
direct tests (evacuation proctography or ballon expulsion) only slight.
Body position (ARM: left lateral; proctography and BET: sitting) and
the degree of rectal filling may affect the incidence of dyssynergia,
and may explain the poor agreement between various test used to
diagnose ED.
The substantive lack of agreement between all investigations
suggests that currently available tests or current classification
systems (or both) have deficiencies.

61. ARM is not a test of evacuation but rather a test for
functional abnormalities that may impair evacuation.
DD: recto-anal incoordination is common in health >
questioning the validity of ARM in isolation.
Agreement between ARM (indirect assessment of
evacuation) and direct tests (evacuation proctography
or ballon expulsion) only slight.
Body position (ARM: left lateral; proctography and
BET: sitting) and the degree of rectal filling may affect
the incidence of dyssynergia, and may partly explain
the poor agreement between various test used to
diagnose ED.

62. ARM in isolation is of limited utility for distinguishing between patients
with symptoms of ED and healthy volunteers.
ARM may identify the precise functional deficit, i.e., impaired rectal
expulsive force, high anal pressure, or both.
The substantive lack of agreement between all investigations suggests
that currently available tests or current classification systems (or both)
have deficiencies.
Potential limitations of a single test for diagnosing ED.
(Palit S, 2016)

63. Our results….. support the use of ARM with
BET as an initial investigation for CC.
Should anorectal manometry always be performed in patients
with chronic constipation?
It should be performed in patients who do not improve with
first-line treatments for chronic constipation (II B)

64. -Chronic constipation: DRE high sensitivity and positive predictive value
(PPV) compared with HRAM in the diagnosis of dyssynergia (moderate
agreement between the two procedures).
-Fecal incontinence: DRE high PPV compared with HRAM in assessing anal
squeeze pressure (moderate agreement between the two procedures)
Need for appropriate DRE performance, even in the HRAM era.
(in

65. Limitations of the HDAM-3D
Software does not provide data regarding certain
parameters such as the sustained squeeze pressure,
defecation index, dyssynergic pattern and rectal compliance
-is approximately twice the diameter and rigid and does not
conform to the anorectal angle
-has to be hand-held (possible artifacts if it is not held in the neutral position
during maneuvers such as squeeze and bearing down)
-has larger diameter and is rigid > sphincter is stretched>
the force of its contraction is likely to be higher, and this
may partly explain the higher squeeze pressures found with
HDAM-3D.
-is rigid and it is not possible to perform a bearing down
maneuver on the commode
Probe

66. -Balloon Expulsion test ?
-2D: media dei 12 punti di
ogni
sensore (mostrata in 2D)
-3D: visualizzazione di
ognuno dei 16 punti di
registrazione di ognuno dei
16 sensori di pressione
eSleeve function reduces the
data from a number of
sensors into a single
maximum value at each time
point.
simultaneously measuring pressure
recordings over the entire length of
the anal canal and circumferentially
> continuous display of pressure
without loss of signals, unlike
conventional manometry
non artefatti di movimento

67. Does HR technology improve clinical
utility of AR manometry?
-HRM provides a dynamic and continuous representation of
anorectal pressure, which is both more visually arresting and
intuitive compared to traditional line plots.
-Qualitative assessment of HRAM color contour plots can display
findings unrecognized with conventional manometry (Carrington EV, 2014)
-Color topographic display allows for better appreciation of catheter
movement relative to the anorectum
-Procedure time: HRAM study is ~12 min quicker than a
traditional ARM, although duration is dependent on the
complexity of the protocol undertaken (Sauter M,2014)
(Kang HR, 2015)
(Dining PG, 2015)
-HRAM (2D) in sitting position (Rao S, 2015)
(Dining PG, 2015)
-Conventional ARM >: measurements as a result of the sum of all
muscles; it does not allow the individual contribution of each muscle
component to intraanal pressures
(Ambartsumyan L, 2013)

68. HRAM better defines functional anatomy of the anal canal.
Due to its relatively short length, its proximity to the distal
rectum, and movement that occurs during squeeze and
push, traditional manometry utilizing single-point pressure
sensors is less adequate to define functional anatomy
(Dinan PG, 2015).
Pelvic floor rehabilitation (PFR)
-203 patients: HRAM as a basis for recommending PFR >
outcome success reported in 66%. (Jodorkovsky D, 2015)
-25 patients awaiting PFR for dyssynergia (diagnosed by a
conventional manometry). HRAM confirmed the diagnosis in
24/25 patients, although correlation between observed
defecatory patterns, as defined by the 2 techniques, was low. 19
patients (76%) were subsequently reclassified by HRAM when
the ‘bearing down’ maneuver was performed in the sitting
position
increased detail provided by HRAM, leading to a more
accurate representation of the defecation process
(Soubra M, 2014)

69. HRM-3D vs HRM
-3D-HRM better evaluation of paradoxical contraction of P-R
muscle (Xu Chen, 2014)
-3D-HRM can intuitionally reflect any pressure defection
caused by fecal incontinence > more accurate diagnosis
Guida più efficace alla riabilitazione del pavimento pelvico
-correlation of anatomy with pressure profiles distinguishing
each component of the HPZ. Novel information about
sensorimotor response, RAIR, rectoanal contractile
response, anal /vaginal morphology (Coss-Adame E, 2015)
(Jodorkovsky D,
2014)
-HRM-3D > ricostruzione del viscere come una figura solida,
tridimensionale, quasi come una metodica di imaging
(EUS, RM).
-Information regarding axial and radial asymmetry of the anal sphincter > a
better understanding of the mechanisms of fecal continence.
(Cheeney G, 2012)
(Ambartsumyan L, 2013)

70. Similar proportions of participants with a negative pressure gradient
(patients with FC: 85% vs HV: 62%) > limited utility to distinguish health
from disease in practice.
Simulated defecation may drive the recording catheter against the wall of
the anal canal producing a ‘contact pressure’ > negative rectoanal
pressure gradient (Sauter M, 2014)
HR-ARM accurately identifies recto-anal dyssynergia and the
subgroup of patients with outlet obstruction due to rectal
intussusception directing those with dyssynergia to behavioural
treatment and others to further investigation by defecography.
(Heinrich H, 2015)

71. Latex
balloon distension was used in the current
study for
pragmatic reasons (busy clinical practice),
though it is
accepted that barostat assessment, using an ‘,
would have better controlled for possible
rectal morphological differences between men
and women.
The apparent differences in pathophysiology
between sexes may have implications for
treatment.
With fewer males presenting with sphincter
dysfunction,
non-surgical treatment options, such as bowel
retraining incorporating biofeedback, should be
considered
Barostat: Infinitely compliant bag

72. SFINTERI ANALI e
CONTRAZIONE
VOLONTARIA

73. RIFLESSO RETTO-ANALE INIBITORIO