Tackling two rarer problems of motility
Date: May 1, 2012
I just can’t go to the bathroom.
Hearing that from a new patient cues gastroenterologist Ellen Stein to a possible anorectal disorder, especially when there’s longstanding constipation that seems not to come solely from slowed GI transport.
“We work with a fair number of patients with these problems,” says Stein. And, thanks to Hopkins’ tertiary care status, she and colleagues aren’t strangers to such relatively rare cases.
In part because they aren’t common, the disorders tend to bring a lot of misery.
Take, for example, anal sphincter dyssynergy. “Nobody normally needs to learn to make a bowel movement,” Stein says, “but some patients—more often women—develop a maladaptive pattern of using rectal muscles. Often seemingly out of nowhere, they experience a paradoxical increase in sphincter tone when muscle relaxation is what’s wanted.”
With time, patients spend so much effort to get a result, Stein explains, that sphincter strength actually increases. “Then one day, tactics that previously worked for them don’t anymore,” she says.
“And that’s devastating.”
Stein’s first order is taking a good history and rectal exam. Because inability to defecate normally and ways to compensate can be hugely embarrassing, patients aren’t always forthcoming with symptoms. “We can talk an hour before I hear the sometimes I have trouble that clears a path for help.”
Physiologic tests are essential to diagnose the dyssynergy, with anal manometry a key technique. Recently, Hopkins has begun using 3D vector volume manometry, an improvement that reports pressure throughout the anal canal.
But how to treat muscle activity out-of-sync? Biofeedback has won Stein’s approval. “I tell patients it’s PT for the posterior,” she says, “and that it can bring a turnaround.”
In biofeedback, computer displays reveal pelvic floor muscle strength and provide immediate feedback on the accuracy of muscles contracted. “Injury and scarring—often from obstetric reasons—can change pelvic floor muscle function even years later. So if you can strengthen or relax the correct muscles,” says Stein, “you gain ability.”
Also uncommon is rumination, in which patients regurgitate food, then chew and reswallow it—sometimes over an hour. “It typically happens without thinking,” says Stein, and would seem merely unusual except for its effect of chronic acid reflux.
“Unlike cows,” she adds, “our mucosa isn’t meant for this intense acid exposure which overwhelms even PPI reflux therapy.”
Fortunately, manometry/impedance can distinguish patients who ruminate from other PPI non-responders.
Also fortunately, Stein says, patients can be helped by cognitive behavioral therapy, as well as baclofen, a drug that discourages revisiting one’s lunch.