Pathophysiology of Anorectal Disorders

项目总结/摘要 排便是一个内脏的过程，需要增加直肠压力与肛门括约肌协调 和骨盆底松弛排便障碍（DD）由以下症状和客观特征定义： 排便障碍我们对正常和紊乱排便的理解来自于 压力测量（高分辨率测压[HRM]）或排空（排粪造影，直肠球囊 驱逐测试），但从来没有两者。HRM通常在左侧卧位进行，直肠排空。这 可以部分解释为什么直肠肛门梯度（直肠肛门压力）在排空过程中是负的，即使在 大多数无症状的人，这破坏了我们对正常排便机制的概念。之间 对于患者，这些测试的结果往往是不一致的，阻碍了DD的诊断。过度紧张和 排便期间“适应不良”的骨盆底收缩与DD有关。然而，腹壁 排便时的运动及其与骨盆底运动的协调性尚未在健康人中进行研究 或DD患者。最后，即使在对照临床试验中，骨盆底生物反馈疗法， 治疗DD，仅使60%的DD患者受益。这种治疗并不普遍，也不能报销; 因此需要额外的治疗。每项研究都旨在改善人类患者的护理。 具体目标1：解决我们对正常和无序机制的认识中的根本差距 排粪与DD的诊断：1 a）用排粪造影重新定义正常排粪时相; 1b）确定男性与女性DD的主要原因。 直肠肛门压力和排空将通过HRM、钡剂和磁共振排粪造影测量， 男性和女性健康对照以及120名男性和女性DD患者。 具体目标2：腹壁运动在正常和排便障碍中的作用：2a）评价 健康和DD女性排便期间的腹盆协调; 2b）评估腹盆协调 生物反馈治疗前后排便协调性。 将在休息时和各种操作期间评价腹壁运动和直肠肛门压力， 包括模拟疏散，在30名健康妇女和60名DD妇女。 具体目标3：阐明这些概念以管理DD：3a）评估脚凳对直肠的影响， 3 b）评估DD的症状。 将在85名女性术前和术后评价直肠肛门压力和排空以及肠道症状 DD患者被随机分配到脚凳。一个多学科的合作团队将应用创新的 以高度精炼的方式解决这些假设的方法。

PROJECT SUMMARY/ABSTRACT Defecation is a viscerosomatic process that requires increased rectal pressure coordinated with anal sphincter and pelvic floor relaxation. Defecatory disorders (DD) are defined by symptoms and objective features of impaired defecation. Our understanding of normal and disordered defecation are derived either from measurements of pressures (high-resolution manometry [HRM]) or emptying (defecography, rectal balloon expulsion test), but never both. HRM is usually conducted in the left lateral position with an empty rectum. This may partly explain why the rectoanal gradient (rectal – anal pressure) during evacuation is negative, even in most asymptomatic people, which undermines our concept of the mechanisms of normal defecation. Among patients, results of these tests are often inconsistent, hindering the diagnosis of DD. Excessive straining and “maladaptive” pelvic floor contraction during defecation is implicated to cause DD. However, abdominal wall motion during defecation and its coordination with pelvic floor motion have not been studied in healthy people or those with DD. Finally, even in controlled clinical trials, pelvic floor biofeedback therapy, the cornerstone of managing DD, only benefits 60% of DD patients. This treatment is not widely available or reimbursable; therefore additional therapies are necessary. Each study is designed to improve patient care in humans. Specific Aim 1: Address fundamental gaps in our knowledge of the mechanisms of normal and disordered defecation and the diagnosis of DD: 1a) Redefine the phases of normal evacuation using manodefecography; 1b) Identify the primary causes of DD in men versus women. Recto anal pressures and evacuation will be measured with HRM, barium, and MR manodefecography in 120 male and female healthy controls and 120 male and female DD patients. Specific Aim 2: Role of abdominal wall motion in normal and disordered defecation: 2a) Evaluate abdominopelvic coordination during defecation in healthy and DD women; 2b) Evaluate abdominopelvic coordination during defecation before and after biofeedback therapy. Abdominal wall motion and rectoanal pressures will be evaluated at rest and during various maneuvers, including simulated evacuation, in 30 healthy women and 60 women with DD. Specific Aim 3: Incorporating these concepts to manage DD: 3a) To assess the effects of a footstool on recto- anal functions in DD; 3b) To assess the symptoms in DD. Recto anal pressures and emptying as well as bowel symptoms will be evaluated before and after 85 female DD patients are randomized to a footstool. A multi-disciplinary collaborative team will apply innovative approaches to address these hypotheses in a highly refined manner.