DOCSLIB.ORG

Functional Disorders of the Biliary Tract and Pancreas

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Functional Disorders of the Biliary Tract and Pancreas II48 Gut 1999;45(Suppl II):II48–II54 Functional disorders of the biliary tract and pancreas E Corazziari, E A ShaVer, W J Hogan, S Sherman, J Toouli Abstract Normal gall bladder and sphincter of The term “dysfunction” defines the motor Oddi function disorders of the gall bladder and the The gall bladder and the sphincter of Oddi sphincter of Oddi (SO) without note of the (SO) act as an integrated unit to regulate bile potential etiologic factors for the diYculty flow from the liver through the biliary tract into to diVerentiate purely functional altera- the duodenum.1 The SO similarly controls pancreatic exocrine output. During fasting, Chair, Committee on tions from subtle structural changes. Dys- Functional Biliary and function of the gall bladder and/or SO hepatic bile enters the gall bladder for storage. Pancreatic Disorders, produces similar patterns of biliopancre- The gall bladder accommodates this increase Multinational Working atic pain and SO dysfunction may occur in in volume through receptive relaxation without Teams to Develop the presence of the gall bladder. The any significant rise in pressure and by concen- Diagnostic Criteria for symptom-based diagnostic criteria of gall trating bile to keep its volume small. The gall Functional bladder evacuates bile by smooth muscle Gastrointestinal bladder and SO dysfunction are episodes Disorders (Rome II), of severe steady pain located in the epigas- contraction, coordinated with reduced tone in Cattedra di trium and right upper abdominal quad- the SO. During fasting, about 25% of the emp- Gastroenterologia I, rant which last at least 30 minutes. Gall tying of gall bladder contents occurs periodi- Clinica Medica II, cally every 100–120 minutes, mediated by Università “La bladder and SO dysfunctions can cause significant clinical symptoms but do not motilin, which acts via vagal cholinergic nerves Sapienza,” and is synchronized with the migratory motor Rome, Italy explain many instances of biliopancreatic 2 E Corazziari type of pain. The syndrome of functional complex of the intestine. Eating initiates over abdominal pain should be diVerentiated 75% of gall bladder emptying through neural Co-Chair, Committee from gall bladder and SO dysfunction. In (cephalic and local gastroduodenal reflexes) on Functional Biliary and hormonal (predominantly cholecystokinin and Pancreatic the diagnostic workup, invasive investiga- tions should be performed only in the (CCK) acting via cholinergic nerves) Disorders, influences.3 Non-adrenergic, non-cholinergic Multinational Working presence of compelling clinical evidence inhibitory nerves produce SO relaxation Teams to Develop and after non-invasive testing has yielded through the release of vasoactive intestinal Diagnostic Criteria for negative findings. Gall bladder dysfunction Functional peptide (VIP) and nitric oxide, acting as post- is suspected when laboratory, ultrasono- Gastrointestinal ganglionic neurotransmitters.4 The neural sup- graphic, and microscopic bile examination Disorders (Rome II), ply to the biliary tract includes vagal eVerent have excluded the presence of gallstones Department of nerves releasing acetylcholine, sympathetic fib- Medicine, and other structural abnormalities. The ers releasing norepinepherine, and sensory University of Calgary, finding of decreased gall bladder emptying nerves containing substance P. Sensory fibers Calgary, Alberta, at cholecystokinin-cholescintigraphy is the Canada influence the neural response, acting via the only objective characteristic of gall blad- E A ShaVer vagus through central reflexes.5 Derangements der dysfunction. Symptomatic manifesta- of any of these components may lead to inter- Division of tion of SO dysfunction may be mittent upper abdominal pain, transient eleva- Gastroenterology and accompanied by features of biliary ob- tions of liver or pancreatic enzymes, common Hepatology, struction (biliary-type SO dysfunction) or Milwaukee, WI, USA bile duct dilatation, or episodes of pancreatitis. W J Hogan significant elevation of pancreatic en- zymes and pancreatitis (pancreatic-type Definition of gall bladder and sphincter SO dysfunction). Biliary-type SO dysfunc- Division of of Oddi dysfunction Gastroenterology and tion occurs more frequently in post- Motor dysfunction of the gall bladder and SO Hepatology, cholecystectomy patients who are Indiana University has long been suspected as a major feature of categorized into three types. Types I and II, several clinical entities that manifest with a School of Medicine, but not type III, have biochemical and Indianapolis, IN, USA similar pattern of upper abdominal pain (table S Sherman cholangiographic features of biliary ob- 1). Unlike other functional gastrointestinal dis- struction. Pancreatic-type SO dysfunction orders, however, abnormalities are beginning Gastrointestinal is less well classified into types. When non- Surgical Unit, to be identified by new technologies, although invasive investigations and endoscopic ret- in many instances a cause-and-eVect relation- Flinders Medical rograde cholangiopanreatography show Centre, ship has not been substantiated. Clinical SA, Australia no structural abnormality, manometry of symptoms may not coincide temporally with J Toouli both biliary and pancreatic sphincter may the demonstrated abnormality. Further, im- be considered. paired gall bladder emptying occurs in many Correspondence to: Eldon (Gut 1999;45(Suppl II):II48–II54) 6 ShaVer, MD, Professor and patients with cholesterol gallstones, yet most Head, Department of Keywords: biliary tract disease; sphincter of Oddi Medicine, Foothills Medical Centre, 1403 29th Street dysfunction; gallstone disease; pancreatitis; endoscopic Abbreviations used in this paper: SO, sphincter of NW, Calgary, Alberta T2N retrograde cholangiopancreatography; cholescintigraphy; Oddi; CCK, cholecystokinin; VIP, vasoactive intestinal 2T9, Canada. Email: endoscopic ultrasonography; cholecystokinin; magnetic peptide; ERCP, endoscopic retrograde [email protected] resonance cholangiopancreatography; Rome II cholangiopancreatography. Functional disorders of the biliary tract and pancreas II49 Table 1 Functional gastrointestinal disorders the gall bladder and SO” without attempting to attribute its cause(s) or to identify often subtle A. Esophageal disorders morphological changes. This classification A1. Globus A2. Rumination syndrome consists of: A3. Functional chest pain of presumed esophageal origin (1) gall bladder dysfunction, and A4. Functional heartburn A5. Functional dysphagia (2) SO dysfunction, which may be subdivided A6. Unspecified functional esophageal disorder into: (a) biliary-type and (b) pancreatic- B. Gastroduodenal disorders type. B1. Functional dyspepsia B1a. Ulcer-like dyspepsia The following clinical observations should B1b. Dysmotility-like dyspepsia be considered with regard to gall bladder and B1c. Unspecified (non-specific) dyspepsia SO dysfunction: B2. Aerophagia B3. Functional vomiting + gall bladder and SO dysfunction manifest C. Bowel disorders symptomatically with the same type of pain; C1. Irritable bowel syndrome although the diagnosis of SO dysfunction is C2. Functional abdominal bloating + C3. Functional constipation usually made following cholecystectomy, SO C4. Functional diarrhea dysfunction can manifest clinically in pa- C5. Unspecified functional bowel disorder tients with an intact biliary tract; D. Functional abdominal pain D1. Functional abdominal pain syndrome + psychosocial aspects appear to be variably D2. Unspecified functional abdominal pain interrelated with gall bladder and SO E. Biliary disorders E1. Gall bladder dysfunction dysfunction; E2. Sphincter of Oddi dysfunction + the syndrome of chronic functional abdomi- F. Anorectal disorders nal pain may manifest with clinical charac- F1. Functional fecal incontinence F2. Functional anorectal pain teristics similar to biliopancreatic type of F2a. Levator ani syndrome pain. F2b. Proctalgia fugax F3. Pelvic floor dyssynergia G. Functional pediatric disorders E1. Gall bladder dysfunction G1. Vomiting G1a. Infant regurgitation The central symptom of gall bladder dysfunc- G1b. Infant rumination syndrome tion is biliary-type pain. Currently, the only G1c. Cyclic vomiting syndrome objective characteristic is decreased gall blad- G2. Abdominal pain G2a. Functional dyspepsia der emptying. Available techniques have not G2b. Irritable bowel syndrome clarified its basis (perhaps there is more than G2c. Functional abdominal pain one cause) and cannot exclude other entities G2d. Abdominal migraine G2e. Aerophagia such as impaired filling or an overly sensitive G3. Functional diarrhea gall bladder. G4. Disorders of defecation G4a. Infant dyschezia G4b. Functional constipation EPIDEMIOLOGY G4c. Functional fecal retention Gallstones are the most common aZiction of G4d. Non-retentive fecal soiling the gall bladder, but only 10–20% of patients ever develop symptoms.10 Further, there is no association with dyspepsia.11 The frequency of (over 80%) never develop symptoms. Struc- biliary pain in those without gallstones may be tural changes, particularly those indicative of as high as 7.6% of men12 and 20.7% of chronic inflammation, may not necessarily cor- women,13 or as low as 2.4% overall, as reported relate with impaired emptying in patients with in an ultrasonographic survey.14 biliary dyskinesia.7 The presumed mechanism for biliary pain is obstruction leading to disten- sion and inflammation. This might result from DIAGNOSTIC CRITERIA incoordination between the gall bladder and Episodes
Load more

Recommended publications
  • Anorectal Disorders Satish S
    Gastroenterology 2016;150:1430–1442 Anorectal Disorders Satish S. C. Rao,1 Adil E. Bharucha,2 Giuseppe Chiarioni,3,4 Richelle Felt-Bersma,5 Charles Knowles,6 Allison Malcolm,7 and Arnold Wald8 1Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia; 2Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, Minnesota; 3Division of Gastroenterology of the University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; 4Division of Gastroenterology and Hepatology and UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; 5Department of Gastroenterology/Hepatology, VU Medical Center, Amsterdam, The Netherlands; 6National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, United Kingdom; 7Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia; 8Division of Gastroenterology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin This report defines criteria and reviews the epidemiology, questionnaires and bowel diaries are correlated,5 some pathophysiology, and management of the following com- patients may not accurately recall bowel symptoms6; hence, mon anorectal disorders: fecal incontinence (FI), func- symptom diaries may be more reliable. tional anorectal pain, and functional defecation disorders. In this report, we examine the prevalence and patho- FI is defined as the recurrent uncontrolled passage of fecal physiology of anorectal disorders, listed in Table 1,and material for at least 3 months. The clinical features of FI provide recommendations for diagnostic evaluation and are useful for guiding diagnostic testing and therapy. management. These supplement practice guidelines rec- ANORECTAL Anorectal manometry and imaging are useful for evalu- ommended by the American Gastroenterological Associa- fl ating anal and pelvic oor structure and function.
    [Show full text]
  • Overlap in Patient with Functional Dyspepsia and Unspecified Functional Anorectal Pain
    Acta Interna The Journal of Internal Medicine Vol. 6 No. 2 December 2016 Website Journal : http://jurnal.ugm.ac.id/jain Overlap in Patient with Functional Dyspepsia and Unspecified Functional Anorectal Pain Suharjo Broto Cahyono,1 Putut Bayupurnama,2 Neneng Ratnasari,2 Siti Nurdjanah2 1Department of Internal Medicine, Charitas Hospital, Palembang 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University-Sardjito General Hospital, Yogyakarta ABSTRAK Gangguan gastrointestinal fungsional (GGIF) mewakili gangguan yang sering dijumpai dan perlu mendapatkan perhatian dalam bidang gastroenterologi. Gangguan ini menyebabkan kecemasan, distress dan morbiditas. Pasien dengan gangguan ini sering memperlihatkan manifestasi klinis secara tumpang tindih. Pasien dispepsia fungsional seringkali tumang tindih dengan gangguan gastrointestinal lain, termasuk nyeri anorektal fungsional. Keadaan tumpang tindih ini dapat menimbulkan keluhan yang makin berat, kualitas hidup yang lebih buruk dan skor somatisasi yang lebih tinggi, dan pasien mengalami kecemasan, depresi atau insomnia lebih sering dibandingkan pasien yang tanpa problem tumpah tindih. GGIF ditegakkan berdasarkan kriteria Rome III dan eksklusi penyakit organik. Pendekatan multimodalitas dibutuhkan dalam mengatasi pasien yang menderita gangguan gastrointestinal fungsional. Pada tinjaun kasus ini, dilaporkan seorang pasien laki laki menderita gangguan dispepsia fungsional dan nyeri anorektal fungsional tidak spesifik. Kata kunci : gangguan
    [Show full text]
  • Prevalence of Functional Disorders of the Bowel, Rectum, and Anus in a Tertiary Urogynecology Population
    200 Jelovsek J E1, Barber M D1, Walters M D1, Paraiso M F1 1. The Cleveland Clinic Foundation PREVALENCE OF FUNCTIONAL DISORDERS OF THE BOWEL, RECTUM, AND ANUS IN A TERTIARY UROGYNECOLOGY POPULATION Hypothesis / aims of study Straining is frequently mentioned as a possible etiologic factor in pelvic floor disorders and pelvic denervation. Constipation is a disease that results in frequent straining often seen in patients with pelvic floor disorders. The overall prevalence of constipation in the U.S. population is 14.7%, with 4.6% being functional constipation, 4.6% outlet subtype, 2.1% IBS- constipation subtype, and 3.4% IBS-outlet[1]. The prevalence and clinical subtypes of constipation and other functional bowel, rectal and anal disorders have not been well characterized in women with urinary incontinence (UI) and pelvic organ prolapse (POP). The specific aims of this study were: (1) to determine the prevalence of functional bowel disorders as defined by the Rome II criteria in a tertiary urogynecology clinic, (2) to determine the prevalence of subtypes of constipation, and (3) to determine whether demographic, clinical, or physical exam factors are associated with different types functional bowel, anal, and rectal disorders in patients with prolapse and incontinence. Study design, materials and methods This was a cross-sectional study design. One hundred and fifty consecutive female subjects presenting to a tertiary referral, urogynecology clinic were identified. Demographic, general medical, and physical exam information were collected. The prevalence of functional bowel disorders and functional disorders of the anus and rectum as defined by the Rome II criteria[2] were collected.
    [Show full text]
  • Anorectal Disorders
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE HHS Public Access provided by Carolina Digital Repository Author manuscript Author ManuscriptAuthor Manuscript Author Gastroenterology Manuscript Author . Author Manuscript Author manuscript; available in PMC 2017 September 25. Anorectal Disorders Satish S. C. Rao1, Adil E. Bharucha2, Giuseppe Chiarioni3,4, Richelle Felt-Bersma5, Charles Knowles6, Allison Malcolm7, and Arnold Wald8 1Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia 2Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, Minnesota 3Division of Gastroenterology of the University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy 4Division of Gastroenterology and Hepatology and UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 5Department of Gastroenterology/Hepatology, VU Medical Center, Amsterdam, The Netherlands 6National Centre for Bowel Research and Surgical Innovation, Blizard Institute, Queen Mary University of London, London, United Kingdom 7Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia 8Division of Gastroenterology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Abstract This report defines criteria and reviews the epidemiology, pathophysiology, and management of the following common anorectal disorders: fecal incontinence (FI), functional anorectal pain, and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals, and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases.
    [Show full text]
  • Female Chronic Pelvic Pain Syndromes 1 Standard of Care
    BRIGHAM AND WOMEN’S HOSPITAL Department of Rehabilitation Services Physical Therapy Standard of Care: Female Chronic Pelvic Pain Syndromes ICD 9 Codes: 719.45 Pain in the pelvic region 625.9 Vulvar/pelvic pain/vulvodynia/vestibulodynia (localized provoked vestibulodynia or unprovoked) 625.0 Dyspareunia 595.1 Interstitial cystitis/painful bladder syndrome 739.5 Pelvic floor dysfunction 569.42 Anal/rectal pain 564.6 Proctalgia fugax/spasm anal sphincter 724.79 Coccygodynia 781.3 Muscular incoordination (other possible pain diagnoses: prolapse 618.0) Case Type/Diagnosis: Chronic pelvic pain (CPP) can be defined as: “non-malignant pain perceived in structures related to the pelvis, in the anterior abdominal wall below the level of the umbilicus, the spine from T10 (ovarian nerve supply) or T12 (nerve supply to pelvic musculoskeletal structures) to S5, the perineum, and all external and internal tissues within these reference zones”. 1 Specifically, pelvic pain syndrome has been further defined as: “the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction with no proven infection or other obvious pathology”.1 Generally, female pelvic pain has been defined as pain and dysfunction in and around the pelvic outlet, specifically the suprapubic, vulvar, and anal regions. A plethora of various terms/diagnoses encompass pelvic pain as a symptom, including but not limited to: chronic pelvic pain (CPP), vulvar pain, vulvodynia, vestibulitis/vestibulodynia (localized provoked vestibulodynia or unprovoked vestibulodynia), vaginismus, dyspareunia, interstitial cystitis (IC)/painful bladder syndrome (PBS), proctalgia fugax, levator ani syndrome, pelvic floor dysfunction, vulvodynia, vestibulitis/vestibulodynia dyspareunia, vaginismus, coccygodynia, levator ani syndrome, tension myaglia of the pelvic floor, shortened pelvic floor, and muscular incoordination of the pelvic floor muscles.
    [Show full text]
  • Hereditary Proctalgia Fugax and Constipation: Report Ofa Second Family
    Gut 1995; 36: 581-584 581 Hereditary proctalgia fugax and constipation: report of a second family Gut: first published as 10.1136/gut.36.4.581 on 1 April 1995. Downloaded from A F Celik, P Katsinelos, N W Read, M I Khan, T C Donnelly Abstract Kamm et al9 recently described several A second family with hereditary proctalgia members of a family with proctalgia fugax fugax and internal anal sphincter hyper- and constipation associated with hypertrophy trophy associated with constipation is and hypertonia of the internal anal sphincter. described. Anorectal ultrasonography, We recently discovered a second family manometry, and sensory tests were con- living in the Sheffield area with similar sympto- ducted in two symptomatic and one matology and laboratory (physiological) asymptomatic subjects within the same findings. This report confirms the description family and further clinical information of the first family and presents some new was obtained from other family members. clinical, physiological, and therapeutic data The inheritance would correspond to that help to explain the pathophysiology an autosomal dominant condition with of this syndrome and may indicate its incomplete penetration, presenting after management. the second decade of life. Physiological studies showed deep, ultraslow waves and an absence of internal anal sphincter Methods relaxation on rectal distension in the two most severely affected family members, PATIENTS suggesting the possibility ofa neuropathic origin. Both of these patients had an Case 1 (PB) abnormally high blood pressure. After This 60 year old man was referred with moder- treatment with a sustained release formu- ate constipation and anal pain. His constipa- lation of the calcium antagonist, nife- tion had been present since childhood but has dipine, their blood pressure returned to become more troublesome in the past 15 years.
    [Show full text]
  • CRS Case Log Coding
    CODE DESCRIPTION Procedure Category Defined Case Category 46288 Fistula, advancement flap repair, skin or mucosal Anorectal Procedures Endorectal Advancement Flap Fistulotomy, fistula repair 46020 Fistula, seton placement only Anorectal Procedures Fistulotomy, fistula repair 46030 Fistula, seton/drain removal Anorectal Procedures Fistulotomy, fistula repair 46045 Fistulotomy, LIFT Anorectal Procedures Fistulotomy, fistula repair 46280 Fistulotomy, primary, secondary, + seton, NOS Anorectal Procedures Fistulotomy, fistula repair 46706 Fistula, repair, fibrin glue Anorectal Procedures Fistulotomy, fistula repair 46707 Fistula, repair, plug Anorectal Procedures Fistulotomy, fistula repair 46710 Fistula, repair, ileoanal anastomosis, perineal any Anorectal Procedures Fistulotomy, fistula repair 46712 Fistula, repair, ileoanal anastomosis, abdomino-perineal Anorectal Procedures Fistulotomy, fistula repair 57300 Fistula, rectovaginal repair, transanal or transvaginal Anorectal Procedures Fistulotomy, fistula repair 57305 Fistula, rectovaginal repair, abdominal Anorectal Procedures Fistulotomy, fistula repair 57307 Fistula, rectovaginal repair, abdominal, ostomy Anorectal Procedures Fistulotomy, fistula repair 46221 Hemorrhoids, internal, rubberband ligation RBL Anorectal Procedures Hemorrhoidectomy-excisional any kind, PPH 46250 Hemorrhoidectomy, external, simple Anorectal Procedures Hemorrhoidectomy-excisional any kind, PPH 46260 Hemorrhoidectomy, internal Anorectal Procedures Hemorrhoidectomy-excisional any kind, PPH 46320 Hemorrhoidectomy,
    [Show full text]
  • Common Anorectal Disorders Amy E
    Common Anorectal Disorders Amy E. Foxx-Orenstein, DO, Sarah B. Umar, MD, and Michael D. Crowell, PhD Dr Foxx-Orenstein is an associate profes- Abstract: Anorectal disorders result in many visits to healthcare sor, Dr Umar is an assistant professor, and specialists. These disorders include benign conditions such as Dr Crowell is a professor in the Division hemorrhoids to more serious conditions such as malignancy; of Gastroenterology at the Mayo Clinic in thus, it is important for the clinician to be familiar with these Scottsdale, Arizona. disorders as well as know how to conduct an appropriate history Address correspondence to: and physical examination. This article reviews the most common Dr Amy E. Foxx-Orenstein anorectal disorders, including hemorrhoids, anal fissures, fecal Division of Gastroenterology incontinence, proctalgia fugax, excessive perineal descent, and Mayo Clinic pruritus ani, and provides guidelines on comprehensive evalua- 13400 East Shea Blvd. tion and management. Scottsdale, AZ 85259 Tel: 480-301-6990 E-mail: [email protected] norectal disorders are a common reason for visits to both primary care physicians and gastroenterologists. These disorders are varied and include benign conditions such as Ahemorrhoids to more serious conditions such as malignancy; thus, it is important for the clinician to be familiar with these disorders as well as know how to conduct an appropriate history and physical examination. This article reviews the most common anorectal disor- ders, including hemorrhoids, anal fissures, fecal incontinence (FI), proctalgia fugax, excessive perineal descent, and pruritus ani, and provides guidelines on comprehensive evaluation and management. Hemorrhoids Hemorrhoids are an extremely common condition, affecting approximately 10 million persons per year.
    [Show full text]
  • Miopatía Vacuolar Del Esfínter Anal Interno Como Causa Infrecuente De Proctalgia Fugaz Y Estreñimiento
    1130-0108/2015/107/1/52-53 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS REV ESP ENFERM DIG (Madrid COPYRIGHT © 2015 ARÁN EDICIONES, S. L. Vol. 107, N.º 1, pp. 52-53, 2015 Letters to the Editor Vacuolar internal anal sphincter myophaty Discussion as a rare cause of proctalgia fugax and Anorectal and perianal pain has been described related to dif- constipation ferent diseases, most of which are easily recognized (hemorrhoids, perianal sepsis or tumors); however, in many cases no organic cause can be attributed even after performing a meticulous phys- ical examination and the mandatory complementary studies (1). Key words: Proctalgia fugax. Constipation. Myopathy. Internal anal sphincter. Dear Editor, A 62-year-old female patient with a history of arterial hyper- tension treated with the combination of trandolapril and ver- apamil, an anxiety-depressive disorder and a left mastectomy for breast cancer years ago, currently in remission, presented com- plaining of intense proctalgia mainly at night, with an obstruc- tive defecation syndrome and expulsive constipation of 5 years of evolution. Physical examination revealed a hypertonic anal sphincter and intense pain during rectal palpation. Three-dimen- sional endoanal ultrasonography showed an enlarged internal anal sphincter (IAS) with more than 4.5 mm of thickness (Fig. 1A). Anorectal manometry showed a hypotonic external anal sphincter (EAS), elevated resting pressure and deficient relaxation of the IAS (with ultraslow waves), and rectal hyposensitivity (Fig. 1B). Initial medical treatment was provided with calcium antagonists of retarded action and β2 adrenergic agonists, with no significant clinical improvement. Surgery consisting of a 1 cm transanal internal sphincter myomectomy and a mucosal plasty was car- ried out, with satisfactory postoperative recovering.
    [Show full text]
  • Standard of Care: Anorectal Disorders ICD 10 Codes
    Department of Rehabilitation Services Physical Therapy Standard of Care: Anorectal Disorders ICD 10 Codes: Constipation (outlet dysfunction): K5902 Anal Spasm: K594 Constipation (NEC): K5900 Other Specified Diseases of Anus or Rectum: K6289 Fecal Incontinence (full): R159 Fecal Incontinence (incomplete emptying): R150 Fecal Incontinence (smearing): R151 Fecal Incontinence (fecal urgency): R152 Additional ICD-10 codes that may be used to address common coexisting impairments: Pelvic muscle wasting: N8184 Rectocele: N816 Muscle spasm: M62838 Case Type / Diagnosis: dyssynergic defecation (outlet dysfunction); slow transit constipation, fecal incontinence, anorectal pain/Levator Ani Syndrome, proctalgia fugax Anorectal disorders encompass multiple diagnoses including: dyssynergic defecation, fecal incontinence and levator ani syndrome, all of which are evaluated and treated in pelvic health physical therapy. The current Rome IV diagnostic criterion (released in May 2016), which is the standard for clinical practice and research for functional gastrointestinal disorders, recognizes several anorectal disorders, including: fecal incontinence, functional anorectal pain, and functional defecation disorders and functional constipation.1 Please refer to the tables below for complete review of the Rome IV diagnostic criteria for each condition. 1,2 . Anorectal disorders are common and affect up to 25% of the adult and pediatric population, causing a significant negative impact on quality of life and a burden to health care. 3 The exact definition of fecal incontinence and anal incontinence is important in differential diagnosis for the pelvic floor physical therapist. Fecal incontinence, (FI) as defined by Bharucha, is uncontrolled passage of fecal material recurring for less than or equal to 3 months and is not considered a medical problem before age four.
    [Show full text]
  • Coccygodynia and Proctalgia Fugax Problem
    Clinical notes eliminated pilonidal disease as an inpatient hospital Coccygodynia and proctalgia fugax problem. However, if hospitalization is desired, the length of stay will be shorter and the patient will be LESTER I. TAVEL, D.O., DR.P.H., FAOCPR, HAP able to return to work earlier. This procedure has Houston, Texas been used on poorly healing or delayed healing wounds after complete surgical excision in the Coccygodynia is a syndrome associated with pain in operating room, with good results. the coccygeal region. The pain may occur at the I believe that this is a simple, logical approach to coccyx and its articulation with the sacrum, or, occa- correspond with most writers on this subject.8 sionally, as reflex pain in the sacroiliac articulation, down the back of the thigh, or in the levator ani or supragluteal muscles. 1. Aird, I.: Pilonidal sinus of the axilla. Brit Med J 1:902-3, 26 Apr 52 Coccygodynia is encountered most often in per- 2. Hardaway, R.M.: Pilonidal sinus of the umbilicus. US Air Force Med J sons 20 to 40 years old. Because of pelvic structure, 10:88-9, Jan 59 3. Patcy, D.H., and Scarff, R.W.: Pilonidal sinus in a barbers hand with childbearing, constipation, and the disturbances observations on postanal pilonidal sinus. Lancet 2:13-4, 3 Jul 48 often associated with the menopause, women are its 4. Patey, D.H., and Scarff, R.W.: Pathology of postanal pilonidal sinus: Its most frequent victims. Thin persons are more likely bearing on treatment. Lancet 2:484-6, 5 Oct 46 to suffer it because they lack a protective cushion of 5.
    [Show full text]
  • Painful Iceberg Animals Either by Pressing Their Vets to Try Them Or, More Probably, Securing Supplies by Their
    1414 BRITISH MEDICAL JOURNAL VOLUME 282 2 lAy 1981 in 1970. There was worldwide interest in the Swann Report, ary Record2 as, "A small group of people with expertise in some agreeing, some disagreeing, but all wanting to know the agriculture, public health, veterinary medicine, bacterial Br Med J (Clin Res Ed): first published as 10.1136/bmj.282.6274.1414 on 2 May 1981. Downloaded from outcome of what looked like a serious attempt to understand genetics, and clinical medicine." Walton considered that such a and possibly limit the spread of antibiotic resistances among group would need access to laboratory facilities; would need to bacteria. be provided with data on antibiotic use and prevalence of Alas for good intentions and hopes, however: what legisla- antibiotic resistance; and should be able to develop a close tion brought into existence in 1973 was not the powerful working relationship with the pharmaceutical industry. committee recommended by Swann but a joint subcommittee Walton is pessimistic in concluding that such a proposal of the Committee on Safety of Medicines and the Veterinary will "never get past first base." Certainly the drastic response Products Committee. The two parent committees were of ministers to the subcomminee's own proposals justifies concerned mainly with applications from pharmaceutical pessimism, especially with the present shortage of Government firms for product licences and test certificates. In practice, the spending on real investment and especially on medical Veterinary Products Committee consulted the Joint Sub- education and preventive medicine. But there are perhaps Committee on Anti-microbial Substances a great deal while some possibilities.
    [Show full text]