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Q2: Answer: B
Objective: Diagnose dyssynergic defecation and treat with biofeedback therapy.
Rationale: This patient has a functional defecation disorder, or dyssynergic defecation. According to Rome III guidelines, to fulfill this diagnosis, the patient must satisfy criteria for functional constipation.
In addition, they must also have at least 2 of the following: 1) Evidence of impaired evacuation on balloon expulsion test or imaging; 2) inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging or EEG; and 3) inadequate propulsive forces assessed by manometry or imaging.
The treatment mainstay for functional defecation disorders is pelvic floor retraining and biofeedback. Although lubiprostone and fiber supplementation are used to treat constipation, this is not the treatment of choice for dyssynergic defecation. Amitriptyline is often used for functional gastrointestinal disorders, but is not the primary therapy for dyssynergic defection, and often can worsen constipation and therefore is not appropriate for this patient.
Finally, rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease or congenital aganglionic megacolon. This is thought to be due to the failure of neural crest cells to migrate during gestation. The manometric findings with Hirschsprung’s consist of lack of relaxation of internal anal sphincter with distention of the rectum. This is a diagnosis usually made during childhood. Adults with Hirschsprung’s disease usually describe severe constipation since birth. It is therefore not the most likely diagnosis in this patient.
Reference
1. Bharucha A.E., Wald A., Enck P., Rao S. Functional anorectal disorders. Gastroenterology 2006;130:1510-8.
Q2: Answer: B
Objective: Diagnose dyssynergic defecation and treat with biofeedback therapy.
Rationale: This patient has a functional defecation disorder, or dyssynergic defecation. According to Rome III guidelines, to fulfill this diagnosis, the patient must satisfy criteria for functional constipation.
In addition, they must also have at least 2 of the following: 1) Evidence of impaired evacuation on balloon expulsion test or imaging; 2) inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging or EEG; and 3) inadequate propulsive forces assessed by manometry or imaging.
The treatment mainstay for functional defecation disorders is pelvic floor retraining and biofeedback. Although lubiprostone and fiber supplementation are used to treat constipation, this is not the treatment of choice for dyssynergic defecation. Amitriptyline is often used for functional gastrointestinal disorders, but is not the primary therapy for dyssynergic defection, and often can worsen constipation and therefore is not appropriate for this patient.
Finally, rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease or congenital aganglionic megacolon. This is thought to be due to the failure of neural crest cells to migrate during gestation. The manometric findings with Hirschsprung’s consist of lack of relaxation of internal anal sphincter with distention of the rectum. This is a diagnosis usually made during childhood. Adults with Hirschsprung’s disease usually describe severe constipation since birth. It is therefore not the most likely diagnosis in this patient.
Reference
1. Bharucha A.E., Wald A., Enck P., Rao S. Functional anorectal disorders. Gastroenterology 2006;130:1510-8.
Q2: Answer: B
Objective: Diagnose dyssynergic defecation and treat with biofeedback therapy.
Rationale: This patient has a functional defecation disorder, or dyssynergic defecation. According to Rome III guidelines, to fulfill this diagnosis, the patient must satisfy criteria for functional constipation.
In addition, they must also have at least 2 of the following: 1) Evidence of impaired evacuation on balloon expulsion test or imaging; 2) inappropriate contraction of the pelvic floor muscles or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging or EEG; and 3) inadequate propulsive forces assessed by manometry or imaging.
The treatment mainstay for functional defecation disorders is pelvic floor retraining and biofeedback. Although lubiprostone and fiber supplementation are used to treat constipation, this is not the treatment of choice for dyssynergic defecation. Amitriptyline is often used for functional gastrointestinal disorders, but is not the primary therapy for dyssynergic defection, and often can worsen constipation and therefore is not appropriate for this patient.
Finally, rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease or congenital aganglionic megacolon. This is thought to be due to the failure of neural crest cells to migrate during gestation. The manometric findings with Hirschsprung’s consist of lack of relaxation of internal anal sphincter with distention of the rectum. This is a diagnosis usually made during childhood. Adults with Hirschsprung’s disease usually describe severe constipation since birth. It is therefore not the most likely diagnosis in this patient.
Reference
1. Bharucha A.E., Wald A., Enck P., Rao S. Functional anorectal disorders. Gastroenterology 2006;130:1510-8.
A 36-year-old woman presented to clinic with complaints of constipation. She reported daily bowel movements, but with a sensation of rectal fullness and incomplete evacuation. She strained with bowel movements at least 50% of the time. Her symptoms have been present for most of her adult life. She denied diarrhea or blood in her stools, and has had no recent unintentional weight loss. She was sent for anorectal manometry, which revealed adequate propulsive forces, but less than 20% relaxation of the basal resting sphincter pressure. Balloon expulsion is abnormal.