Northwestern University Feinberg School of Medicine Fecal Incontinence in the Scleroderma Patient: What We Know and Where We Should Go Darren M. Brenner, MD Assistant Professor of Medicine and Surgery Northwestern University—Feinberg School of Medicine
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Northwestern University Feinberg School of Medicine
Fecal Incontinence in the Scleroderma Patient:
What We Know and Where We Should Go
Darren M. Brenner, MD
Assistant Professor of Medicine and Surgery
Northwestern University—Feinberg School of Medicine
Prevalence of Fecal Incontinence:
General Population Versus Scleroderma
Overall prevalence of
fecal incontinence: 9.0%1
Prevalence in patients with
scleroderma (SSc) 22-38%2,3
*Data from NHANES 2005/2006 and 2009/2010 surveys. N=52,195.
Ditah I et al. Am J Gastroenterol. 2012;107:S717. Abstract 1762.; Omair and Lee. J Rheumatol 2013;39:992-6.;
Trezza.Scand Jgastroenterol 1999;34;409-13.
Fecal Incontinence Has a Profound Impact
on Quality of Life
1
2
3
4
Lifestyle Coping Depression Embarrassment
FI patients GI patients not affected by FI
P<.01
*Quality of life measured using the Fecal Incontinence Quality of Life Scale, a validated 4 scale, 29-item survey.
Rockwood TH et al. Dis Colon Rectum. 2000;43:9-16.; Mohamed and Lett J Rheumatolo 2012;39:92-6.
Score
*
QoL significantly lower for SSc patients with FI compared to
SSc patients without FI and controls
Anorectal angle
Descent of pelvic floor
Straining to defecate
Symphysis pubis
Anorectal angle
Coccyx
External anal
sphincter
Puborectalis
Rectum
At rest
Modified from AGA slide: IV-9
Normal Defecation
Anatomy of the Anorectum
Welton ML et al. Anorectum. In: Doherty GM, ed. Current Diagnosis & Treatment Surgery. New York, NY:
The McGraw-Hill Companies, Inc.;2010:698-723.
Pathophysiology of Fecal Incontinence
Rao SSC. Gastroenterology. 2004;126:S14-S22.
Structural
Abnormalities
Functional
Abnormalities Stool
Characteristics
Structural Abnormalities
ANS=autonomic nervous system; CNS=central nervous system
Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.
Anatomic Structure Cause Mechanistic Effect
Anal sphincter muscle • Obstetric injury
• Hemorrhoidectomy, anal dilation,
secondary to neuropathy
Sphincter weakness
Loss of sampling reflex
Rectum • Inflammation
• IBD
• Radiation
• Rectal prolapse
• Aging
• IBS
Loss of accommodation
Loss of sensation
Hypersensitivity
Puborectalis muscle • Excessive perineal descent
• Aging
• Trauma
Obtuse anorectal angle
Sphincter weakness
Pudendal nerve • Obstetric or surgical injury
• Excessive straining/perineal descent
• Rectal prolapse
Sphincter weakness
Sensory loss, impaired
reflexes
CNS, spinal cord, ANS • Spinal cord, head injury
• Back surgery
• Multiple sclerosis, diabetes, stroke,
avulsion injury
Loss of sensation
Impaired reflexes
Secondary myopathy
Loss of accommodation
Functional Abnormalities
Anorectal sensation impairment1
• May be caused by aging, neurologic damage, mental impairment2
• Impairment in anorectal sensation may lead to:1
- Excessive accumulation of stool
- Fecal overflow
- Impairment of the sampling reflex
Fecal impaction caused by dyssynergic defecation1
• May result in fecal retention with overflow and leakage of liquid stool
1. Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604; 2. Engel AF et al. Gut. 1994;35:857-859.
Stool Characteristics
Stool consistency, volume, and presence of irritants in the stool may
contribute to fecal incontinence
• Large-volume liquid stools require intact sensation and unimpaired sphincter function to be retained
Stool characteristics may be influenced by:
• Infection (SIBO)Diarrhea
• Inflammatory bowel disease
• Irritable bowel syndrome
• Medications
• Food intolerances
Rao SSC et al. Gastroenterology. 2004;126:S14-S22.
Most Common Deficiencies Identified in SSc
Patients
• Loss of RAIR
• Decreased Anal Sensation
•Thinning of the IAS
• Fibrosis of the IAS
• Decreased Anal Pressure
• Diarrhea/ Constipation
Thoua et al. AJG 1012:107:597-603. Thoua et al. Rheumatology 2011;50(9):1596-602.
Fynne et al. Scand J Rheumatol 2011;40(6):462-66. Koh et al. Dis Colon Rectum 2009;52(2):315-18.
Indicative of
Neuropathy (Functional)
Indicative of
Myopathy (Structural)
Stool Characteristics
Structural and/or
functional
Diagnostic Evaluation
• History
• Physical exam, including digital rectal exam
• Diagnostic tests
Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.
Potential Risk Factors and Relevant Coexisting
Medical Conditions
Bharucha AE et al. Gastroenterology. 2010;139:1559-1566.
Variable Odds Ratios (95% CI)
BMI (per unit) 1.1 (1.004, 1.1)
Current smoker 4.7 (1.4, 15)
Diarrhea 53 (6.1, 471)
IBS 4.8 (1.6, 14)
Cholecystectomy 4.2 (1.2, 15)
Rectocele 4.9 (1.3, 19)
Stress urinary incontinence 3.1 (1.4, 6.5)
Obstetric risk factors (grade 1) 0.8 (0.4, 1.9)
Obstetric risk factors (grade 2) 1.1 (0.4, 3.6)
Obstetric risk factors (grade 3) 1.9 (0.7, 5.2)
Assess Diet, Medications, and Lifestyle
Adapted from National Institute for Health and Clinical Excellence (NICE). CG49 Faecal incontinence: tables. Available at:
http://www.nice.org.uk/CG49Tables#table2. Accessed March 30, 2013.
Fiber Fiber supplements, whole-grain cereals or bread, whole-wheat based cereals
Intervention Mechanism of Action Side Effects Comments
Incontinence pads
Provides skin protection; prevents soiling; conduct moisture away from skin
Skin irritation
Disposable provides better skin protection than nondisposable
Enemas Evacuates rectum, decreasing likelihood of FI
Inconvenient; side effects from specific preparations
Anorectal biofeedback
Improves rectal sensation; coordinates external anal sphincter contraction; may increase anal sphincter tone
None
Success is more likely if the patient is motivated, with intact cognition, absense of depression, and with some rectal sensation; availability and cost can be problematic
Long-term Results of Biofeedback for
Fecal Incontinence
Lacima G et al. Colorectal Dis. 2010;12(8):742-749.
38
48.1
11.4
2.5
12.5 12.5
22.5
52.5
0
10
20
30
40
50
60
Biofeedback
No treatment
Solid Stool FI Assessed 1,6,36,60 MONTHS
Perc
en
tag
e
Group A Group B Group C Group D
Group A: Continence fully recovered
Group B: >75% reduction in # of incontinence episodes
Group C: <75% reduction in # of incontinence episodes
Group D: No improvement or worse than before therapy
Pharmacologic Management of
Fecal Incontinence
• Antidiarrheals
•Tricyclic antidepressants
• Bile acid binding resins
No pharmacologic treatments have been adequately evaluated in large,
randomized, controlled studies in patients with fecal incontinence
No pharmacologic treatments have been evaluated in controlled studies in