Characteristics of Fecal Incontinence Using High Resolution Manometric assessment in Viet Duc hospital

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIV ERSITY ***.„ NGUYEN HUU TRI CHARACTERISTICS OF FECAL INCONTINENCE USING HIGH RESOLUTION MANOMETRIC ASSESSMENT IN VIETDƯC HOSPITAL Major: General Doctor Code : 52720201 GRADUATE THESIS 2015-2021 Supervisors: M.S Nguyen Ngoc Anil Hanoi - 2021 r-u -ÍM CỊỈ ugc V Hl ACKNOWLEDGEMENT First of all I gratefully acknowledge the Board of President, the University Training and Management Department of Hanoi Medical University and the Colorectal surgery center of Viet Due University Hospital for giving me the precious opportunity to this study Throughout the diesis I wish to express my deepest gratitude to my supervisors M.S Nguyen Ngoc Anil for her excellent guidance, inspiration, encouragement, extremely helpful comments and supporting me during the process of the study I also want to send my special thanks to all the participants My research would not have been possible without their cooperation Finally I would also like to thank my friends and family who always beside me support and encourage me Hanoi May lOtli 2020 Student Nguyen Huu Tri r-u -ÍM Qỉ ugc V Hl DECLARATION I hereby declare Thar the work entitled is my original work and have not been published in any other dissertation, thesis for qualifications or any medical literature I did not copy from any other's work or from any other sources except the attached references which were listed clearly in the text I also pledge the data collected in the thesis is completely honest If there is anything wrong I would bear all responsibilities Hanoi May 10th 2021 Student Nguyen Huu Tri r-u -ÍM CỊỈ ugc V Hl TABLE OF CONTENTS INTRODUCTION .1 CHAPTER 1: LITERATURE REVIEW 1.1 Anatomy and physiology of the anorectal area 1.1.1 General anorectal anatomy 1.12 Anorectal physiology and incontinence mechanism 1.2 General introduction of fecal incontinence 1.2.1 Definition and classification 1.22 Etiology 1.23 Pathophysiology 1.2.4 Risk factors 10 1.3 Diagnosis of fecal incontinence 10 1.3.1 Clinical manifestation 10 1.3.2 Fecal incontinence’s investigation tests .11 1.4 Treatment of FI 21 1.4.1 Nonoperative management 21 1.42 Surgery7 .24 1.5 Previous researches on FI 25 1.5.1 World 25 1.52 Vietnam 27 CHAPTER 2: SUBJECTS AND METHOD 28 2.1 Subjects 28 2.1.1 Sampling method .28 2.12 Inclusion criteria 28 2.13 Exclusion criteria .28 2.2 Study settings .28 2.3 Study method .29 2.4 Research variables and indicators .30 2.5 Data analysis 31 2.6 Ethical consideration 31 CHAPTER 3: RESULTS 32 3.1 General features of study population 32 3.2 Risk factors 33 3.3 Etiology of fecal incontinence 34 3.4 HR AM in study population .36 3.4.1 Comparing men and women 36 3.42 Comparing men and women 38 3.5 3.6 Severity of FI hi research population 39 Influence of severity of FI on HRAM 39 CHAPTER DISCUSSION .~ 41 4.1 General features of study population 41 4.1.1 Age .41 4.12 Gender 41 4.13 BMI 42 4.2 Risk factors 42 4.2.1 Vaginal deliver’ 42 4.2.2 Physical limitation 43 4.2.3 Urinary’ incontinence 43 4.3 Etiology’ of fecal incontinence 43 4.4 HR AM in FI patients 45 4.4.1 Pressure values 45 4.42 HPZ andRAIR 47 4.43 Rectal balloon volume 48 4.4.4 HR AM results comparing urge and passive incontinence .48 4.5 Severity of FI 49 4.4.1 Severity of FI comparing urge and passive incontinence 49 4.42 The correlation between FI severity and HRAM 49 CHAPTER 5: CONCLUSION -51 REFERENCES APPENDIX r-u -ÍM Qỉ ugc V Hl LIST OF ABBREVIATIONS FI: Fecal incontinence ARM: Anorectal manometry HRAM: High-resolution anorectal manometry IAS: Internal anal sphincter EAS: External anal sphincter EAƯS: Endoanal ultrasound MARP: Maximum anal resting pressure MASP: Maximum anal squeeze pr essure HPZ: High pressure zone AƯC: Area under the curve EAUS: Endoanal ultrasound r-u -ÍM Qỉ ugc V Hl LIST OF ABBREVIATIONS r-u -ÍM Qỉ ugc V Hl LIST OF ABBREVIATIONS r-u -ÍM Qỉ ugc V Hl LIST OF FIGURES Figure 1.1 Anatomical Structure of the anorectum .3 Figure 1.2: Anatomy of anorectal area Figure 1.3: Nerves of the anorectal area Figure 1.4: High-resolution anorectal manometry .12 Figure 1.5: Filling the balloon during rectal sensibilty test 15 Figure 1.6: Anterior defect in external anal sphincter visualized on endoanal ultrasonography 18 Figure 1.7: MRI defecography 19 Figure 1.8: Stimulating the pudendal nerve 20 Figure 1.9: The nerves stimulator is implanted beneath the buttocks skin 24 Figure 3.1: HRA.M results comparing men and women 37 Fig 3.2: Bivariate distribution between Wexner score and maximum anal resting pressure(a) maximum anal squeeze pressure (b) 39 Fig 3.3: Bivariate disttibution between Wexner score and first sensation volume (a), max tolerable volume(b) 40 r-u -ÍM CỊỈ ugc V Hl LIST OF TABLES Table 1.1: Normal Values of anorectal manometry .16 Table 3.1: General features of study population 32 Table 3.2: Risk factors comparing uige and passive Fecal Incontinence 33 Table 3.3: Causes of Fecal incontinence comparing urge and passive incontinence 34 Table 3.4: Causes of Fecal Incontinence comparing women and men 35 Table 3.5: HR AM results comparing men and women .36 Table 3.6 Values of HRAM comparing passive and urge incontinence 38 Table 3.7: Wexner score in different types of FI .39 Table 4.1 Values of HRAM in FI and asymptomatic people 45 Table 4.2 MARP and MASP comparing urge and pasive incontinence 48 r-u -ÍM Qỉ Hgc V Hl 47 shorter in Osterberg’s study (2.2cm vs 3.1cm; p0.05) [91] [20] Since the HPZ works as a pressure barrier which prevents stool leaking The reduction of HPZ indicates a more profound motor function pathology rather than sensory pathology FI in short-HPZ- patients would improve more significantly when receiving treatment aimed at anatomic reconstruction and improved motor function, i.e surgery rather than treatment improving sensation, i.e electrostimulation or biofeedback The frequency of RAIR decreased (94%) and the threshold \olume to elicit RAIR increased (133% normal value) in FI patients which implied a damaged to the nervous system innervating anorectal area 4.4.3 Rectal balloon volume First sensation volume, constant volume and max tolerable volume decreased in FI patients, ranging from 69% to 81% normal values Mion’s study and Rasmussen’s study also found rectal balloon volumes low in FI patients comparing with healthy people [20] [24] The decreased in theses compliances would imply impaired sensation in anorectal area 4.4.4 HRAM results comparing urge and passive bicontinence Table 4.2 MARP and HASP comparing urge and passive incontinence Values Our study Engel et al Maximum anal resting pressure (mmHg) Maximum anal squeeze pressure (mmHg) Hoke et al U: 40.1 P:50.1 U: 373 P: 46.9* Ư: 34.4 P:31.0 U: 88.1 P: 102.0 U: 53.2 P: 30.9* Ư: 67.4 P: 70.6 Abbreviations: u urge incontinence; p passive incontinence *: p-value