The Colorectal Quiz Episode 9: Motility Disorders Part 2
With Dr. Mark Levitt & Dr. Anil Darbari & Dr. Kalib Graham & Dr. Jason Fisher · hosted by Dr. Amanda Jensen · Colorectal Channel
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Colonic transit and colonic function must be assessed in this patient; it is not purely a sphincter issue.
The massively dilated colon is a result of colonic dysfunction, with dilatation predominantly in the rectosigmoid.
A Sitz marker study is recommended to assess colonic transit.
Anorectal manometry should assess resting pressure; high resting pressure may indicate a patient amenable to anal Botox.
Conscious rectal sensitivity threshold is tested by gradually inflating a balloon to determine when the patient has a sensation to defecate.
Normal defecation physiology involves pushing from the belly (increasing intraabdominal pressure) and relaxing the anal sphincter, creating a positive pressure gradient.
Motility disorder patients may have a negative pressure gradient during defecation, termed dyssynergia, and may benefit from pelvic floor physical therapy or biofeedback.
Sitz marker study is performed by having the patient ingest markers and obtaining an X-ray at day 5.
Sitz marker study is used as a screening test; if markers are scattered throughout the colon or predominantly on the right side, colonic manometry may be indicated.
If all Sitz markers have disappeared on day-5 X-ray, the patient has stooled, even if they report not having done so; the markers do not dissolve.
Sitz marker study should be available in most settings worldwide.
Colonic manometry is not available everywhere in the world.
Sitz markers can be used as a colonic transit study by obtaining X-rays at days 0, 1, 2, and 4 to visualize marker transit through the colon.
Nuclear scintigraphy is an alternative to colonic manometry in centers without manometry capability but with nuclear medicine capacity.
From a surgeon's perspective, three colonic motility scenarios must be distinguished: (1) diffusely slow but functional, (2) normal motility with a segmental problem, and (3) severely slow throughout.
Colonic manometry provides information on peristaltic activity, specifically the motion of the colon.
Normal colonic physiology includes two strong contractions per day, called high-amplitude propagating contractions (HAPCs).
HAPCs start in the cecum and progress distally in a coordinated manner.
Presence of two HAPCs during an 18- or 24-hour colonic manometry study rules out colonic dysmotility.
Many patients undergoing colonic manometry have normal results, meaning they have slow transit but normal HAPCs.
If HAPCs are present throughout the colon, antegrade flush therapy is likely to work well.
Some patients have a true outlet issue with a normal colon on manometry.
Colonic manometry can characterize whether contractions are well coordinated (neuropathic problem) or low amplitude (myopathic problem).
Contractions should propagate from the right colon to the rectum; the rectum does not have the same contractions as the colon.
In Hirschsprung patients status post pull-through, the rectosigmoid brake is removed, and contractions may be seen extending from the right colon all the way to the sphincters.
Even if HAPCs are present and colonic motility appears normal, absence of response to stimulants on manometry indicates abnormal colonic motility.
In this case, the team concluded the patient did not have Hirschsprung disease; the absent RAIR was a sampling error, and calretinin staining was positive.
Over time, the colon may rehabilitate, and the patient may eventually need only laxatives, but mechanical emptying of the colon is a perfectly acceptable endpoint.
Enemas from below or from above (via Malone or cecostomy) are acceptable management; failure of this conservative therapy may then require resection.
The vast majority of patients with segmental disease respond to antegrade enemas only and do not need resection.
The case patient is a 10-year-old male with chronic constipation, soiling, poor appetite, and a water-soluble contrast enema showing a tortuous, redundant, dilated colon full of stool.
Anorectal manometry in this patient showed an absent rectoanal inhibitory reflex (RAIR).
If all Sitz markers are at the bottom of the colon, it suggests an outlet issue rather than a transit problem.
Sitz marker study is not a replacement for colonic manometry.
Anorectal manometry is the gold standard for diagnosing motility disorders, but it is expensive and not available everywhere.
Anorectal manometry showed the colon was diffusely slow, and the problem was primarily the sphincter.
The patient was offered a Malone antegrade continence enema (MACE) for antegrade flushes, in combination with Botox and biofeedback physiotherapy.
Patients who fail conservative management are those with slow transit throughout or segmental disease.
Historically, colons were resected in patients who, in retrospect, likely had only motility disorders and did not need surgery.