Blackett, John W.

Fecal incontinence (FI) is the involuntary and recurrent loss of stool. FI significantly affects both physical and social well-being, while imposing a substantial economic burden. The global prevalence of FI is approximately 8%. Risk factors include advanced age, diarrhea, anal sphincter damage from obstetric trauma or anorectal surgery, pelvic floor abnormalities (such as rectal prolapse), inflammatory bowel disease, and neurological conditions. Despite greater understanding of the impact of FI and advances in diagnostic techniques and treatment options, management remains inconsistent, likely because of limited awareness of available therapies. Patients often benefit from conservative treatments, including dietary modifications, fiber supplementation, antidiarrheal agents, and physical therapy, especially when these are tailored to specific symptoms and rigorously applied. Next level options include anorectal biofeedback therapy, the perianal injectable bulking agent dextranomer, or anal/vaginal barrier devices, which can be effective for patients if tolerated. Transanal irrigation may be considered for patients with neurogenic bowel and fecal retention to aid in rectal cleansing and prevent FI. Sacral neuromodulation is the preferred surgical treatment of FI. Noninvasive anal electrical and percutaneous tibial nerve stimulation are not superior to placebo in controlled trials. Translumbosacral magnetic stimulation was beneficial in an uncontrolled trial; sham-controlled trials are necessary. Owing to limited long-term efficacy, anal sphincteroplasty is typically reserved for younger patients with obstetric anal sphincter defects. Colostomy is considered a last resort. Injection of autologous muscle cells into the external anal sphincter has shown promise in small uncontrolled trials, although it has not yielded significant results in most controlled trials.

INTRODUCTION: An estimated 15%–29% of patients report new gastrointestinal (GI) symptoms after coronavirus-19 disease (COVID-19) while 4%–31% report new depressive symptoms. These symptoms may be secondary to gut microbiome tryptophan metabolism and 5-hydroxytryptamine (5-HT)-based signaling. METHODS: This study used specimens from 2 patient cohorts: (i) fecal samples from patients with acute COVID-19 who participated in a randomized controlled trial testing prebiotic fiber and (ii) blood samples from patients with acute COVID-19. Six months after recovering from COVID-19, both cohorts answered questions related to GI symptoms and anxiety or depression. Microbiome composition and function, focusing on tryptophan metabolism-associated pathways, and plasma 5-HT were assessed. RESULTS: In the first cohort (n = 13), gut microbiome L-tryptophan biosynthesis during acute COVID-19 was decreased among those who developed more severe GI symptoms (2.0-fold lower log activity comparing those with the most severe GI symptoms vs those with no symptoms, P = 0.06). All tryptophan pathways showed decreased activity among those with more GI symptoms. The same pathways were also decreased in those with the most severe mental health symptoms after COVID-19. In an untargeted analysis, 5 additional metabolic pathways significantly differed based on subsequent development of GI symptoms. In the second cohort (n = 39), plasma 5-HT concentration at the time of COVID-19 was increased 5.1-fold in those with GI symptoms alone compared with those with mental health symptoms alone ( P = 0.02). DISCUSSION: Acute gut microbiome-mediated reduction in 5-HT signaling may contribute to long-term GI and mental health symptoms after COVID-19. Future studies should explore modification of 5-HT signaling to reduce post-COVID symptoms.

AbstractBackgroundDuring high‐resolution anorectal manometry (HR_ARM), the raw data are converted into software‐derived summary variables (e.g., rectoanal gradient during evacuation) that capture only a snapshot of the data collected during HR_ARM and are less useful than newer indices, which are also derived from the raw data, for diagnosing defecatory disorders (DD). However, it is cumbersome and time‐consuming to extract raw data from the program and calculate such indices. This study aimed to devise a user‐friendly approach to extract anorectal pressures measured with HR_ARM.MethodsAnorectal pressures at rest, during anal squeeze, and evacuation were measured with HR_ARM in 180 women, among whom 60 each were healthy, had DD, or fecal incontinence. A reverse engineering approach extracted pressure values from color images in HR_ARM reports. The summary variables generated by the software and a reverse engineering approach were compared with Lin's concordance correlation coefficient (CCC), pairedt‐tests, and Bland–Altman's tests.ResultsAnorectal pressures summarized by the software and a reverse engineering method were highly concordant for anal resting (CCC [95% CI], 0.98 [0.97, 0.99]) and squeeze pressures (0.99 [0.99, 0.99) and the rectoanal gradient during evacuation with an empty (0.98 [0.97, 0.98]) and a filled balloon (0.99 [0.99, 0.99]). For most variables, the paired t and Bland–Altman comparisons were not significant.ConclusionsAnorectal pressures can be accurately determined from pressure topography images in HR_ARM reports. In future, this reverse engineering approach can be harnessed to compile large HR_ARM datasets across centers and to uncover newer, potentially more useful summary rectoanal pressure variables.