Park, Seon‐Young

AbstractBackgroundBalloon expulsion test (BET) and high‐resolution anorectal manometry (HRM) are used in diagnosis of rectal evacuation disorders (REDs); their performance characteristics are suboptimal.MethodsWe audited records of 449 consecutive patients with chronic constipation (CC). We documented anal sphincter tone and contraction, puborectalis tenderness, and perineal descent on digital rectal exam (DRE); maximum resting and squeeze pressures, and rectoanal pressure gradient on HRM; weight or time to balloon expulsion; colonic transit, and area of rectal area on radiograph (RASF). We based the diagnosis of RED on ≥2 abnormalities on both DRE and HRM, excluding results of BET, as the performance of BET is being investigated. Results of RED vs non‐RED and results obtained using tbBET vs wbBET groups were compared. We used multivariate logistic regressions to identify predictors of RED using different diagnostic modalities.Key ResultsAmong 449 individuals, 276 were included (74 RED and 202 non‐RED). Predominant exclusions were for no HRM (n = 79) or use of low resolution anorectal manometry (n = 77). Logistic regression models for abnormal tbBET showed time >60 seconds, RASF and age‐predicted RED. For tbBET, the current cutoff of 60 seconds had sensitivity of 39.0% and specificity 93.0% to diagnose RED; on the other hand, applying the cutoff at 22 seconds, the sensitivity was 77.8% and specificity 69.8%.Conclusions & InferencesThe clinical diagnosis of RED in patients with CC is achieved with combination of DRE, HRM and an optimized, time‐based BET. Prospective studies are necessary to confirm the proposed 22 second cutoff for tbBET.

OBJECTIVES: Our aim was to characterize upper gastrointestinal (UGI) symptoms and associations in individuals with diabetes mellitus (DM) who had undergone evaluation of gastric emptying (GE) and accommodation (GA) at a referral center. METHODS: From the Mayo Clinic Rochester electronic medical records of adults with diabetes types 1 and 2 (DM1 and DM2) evaluated between January 1997 and December 2015, we extracted demographics, UGI symptoms, current medications, treatments for diabetes, GE solids by scintigraphy, GA by single photon emission computed tomography (SPECT), and diabetes complications. We compared subgroups with delayed (GE at 2 h <25% or GE at 4 h <75%), rapid (GE at 1 h > 35%), and normal GE, as well as reduced (<428 mL) and normal GA. RESULTS: We reviewed 108 patients (60.2% females, median age 49.0 years). Overall, 71.3% had DM2; one-third of these were insulin dependent and had fairly well-controlled diabetes (median HbA1c 6.7% (IQR 6.2; 7.9)). Manifestations of diabetic triopathy (peripheral neuropathy, nephropathy, and retinopathy) were uncommon at presentation with UGI symptoms. Nausea was the most common symptom (80.6%). There were single or combined GE (total 56%: rapid in 37%, slow in 19%) and GA (total 39%) abnormalities; there was normal GA and GE in 28%; 40.3% of the DM2 patients had accelerated GE at 1 h. GE at 1 h is associated with nausea/vomiting, and fasting gastric volume is associated with bloating. CONCLUSIONS: Among referred diabetic patients with UGI symptoms, GE and GA testing identifies potential targets for individualizing treatment and avoidance of empirical trials for the 28% with no disturbance of GE and GA.

Abstract Background Diagnosis of rectal evacuation disorders ( RED ) is currently based on anorectal manometry ( ARM ) and evacuation tests in specialized laboratories; we recently showed higher rectal gas volume ( RGV ) and maximum rectal gas transaxial area ( MRGTA ) measured on abdominal and pelvic computed tomography ( CT ) in patients with documented RED .The aim of this study was to obtain cut‐off values of RGV , MRGTA , and rectal area on scout film ( RASF ) to differentiate constipated patients with RED from those without RED , based on ARM , balloon expulsion test ( BET ), and colon transit test. Methods We identified 118 constipated patients (65 with RED ) with prior record of CT . Using standard CT software, we used a variable region of interest ( ROI ) program to measure RGV , MRTGA , and RASF , as previously described. We constructed receiver operating characteristics curves based on different values, and we estimated AUC , specificity, and positive predictive value ( PPV ) to detect RED in patients with constipation. Key Results Receiver operating characteristics of the models to predict RED showed AUC 0.751 for RGV and 0.737 for MRGTA (both P <.001), and 0.623 for RASF ( P =.029). At specificity of 90%, RGV of 30 mL had a PPV 77.3%, MRGTA of 10 cm 2 had a PPV 75.0%, and RFAS of 9 cm 2 had a PPV of 68.8% for identifying constipated patients with RED . Conclusions & Inferences Rectal gas measurements on abdominal imaging may indicate RED in patients with constipation. At ~90% specificity for RED , RGV of 20 or 30 mL or MRGTA of 10 cm 2 on CT has PPV ~75%, and RASF of >9 cm 2 has PPV of ~69%.

AbstractBackgroundThe prevalence of chronic opioid use among non‐cancer patients presenting with acute abdominal pain (AAP) is unknown. The aim was to characterize opioid use, constipation, diagnoses, and risk factors for surgical diagnoses among non‐cancer patients presenting with AAP to an emergency department (ED).MethodsWe performed a retrospective, observational cohort study of all (n=16,121) adult patients (88% from MN, IA and WI) presenting during 2014 with AAP. We used electronic medical records, and focused on 2352 adults with AAP who underwent abdominal CT scan within 24 hours of presentation. We determined odds ratios of association with constipation and features predicting conditions that may require surgery (surgical diagnosis).Key ResultsThere were 2352 eligible patients; 18.8% were opioid users. Constipation was more frequent in opioid (35.1%) compared to non‐opioid users [OR 2.88 (95% CI 2.28, 3.62)]. Prevalence of surgical diagnosis in the opioid and non‐opioid users was 35.3% and 41.7% respectively (P=.019). By univariate analysis, age and neutrophil count independently predicted increased risk, and chronic opioid use decreased risk of surgical diagnosis. Internal validation of logistic models using a randomly selected validation subset (25% of entire cohort, 587/2352) showed receiver operating characteristic (ROC) curves for the validation and full cohorts were similar.Conclusions and InferencesApproximately 19% of adults presenting with AAP were opioid users; constipation is almost three times as likely in opioid users compared to non‐opioid users presenting with AAP. Factors significantly associated with altered risk of surgical diagnoses were age, opioid use, and neutrophil count.