Devinder Kumar· David J. Waldron· Norman S. Williams (Eds.)

Clinical Measurement in Coloproctology

With 83 Figures

Springer-Verlag London Berlin Heidelberg New York Paris Tokyo Hong Kong

D. Kumar, PhD, FRCS Senior Lecturer in Surgery, Department of Surgery, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK

D. J. Waldron, MCh, FRCS, FRCSI Senior Registrar in Surgery, Cork Regional Hospital, Cork, Republic of Ireland

N. S. Williams, MS, FRCS Director, The Surgical Unit, The Royal London Hospital, Whitechapel, London, E11BB, UK

Cover illustration: Fig. 12.3. A barium meal examination showing megaduodenum in a patient with familial visceral myopathy

ISBN-13 :978-1-4471-1824-4 e-ISBN-13 :978-1-4471-1822-0 DOl: 10.1007/978-1-4471-1822-0

British Library Cataloguing in Publication Data Kumar, Devinder Clinical measurement in coloproctology. 1. Man. Colon. Diseases 2. Man. Anus & rectum. Diseases I. Title II. Waldron, David J. III. Williams, Norman S. 616.34 ISBN-13:978-1-4471-1824-4

Library of Congress Cataloging-in-Publication Data Clinical measurement in coloproctology/[editors] Devinder Kumar, David J. Waldron & Norman S. Williams. p.em. Includes index. ISBN-13:978-1-4471-1824-4 1. Colon (Anatomy) - Diseases - Diagnosis. 2. Anorectal function tests. 3. Defecation disorders -Diagnosis. I. Kumar, Devinder, 1952- .11. Waldron, David J., 1956- III. Williams, Norman S., 1947-[DNLM: 1. Colonic Diseases - diagnosis. 2. Rectal Diseases - diagnosis. WI 520 C641] RCS03.C581991 616.3'4075 - dc20 DNLMlDLC for Library of Congress 90-10263

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Preface

Our current understanding of the pathophysiology of colorectal disorders is dependent upon our ability to carry out an accurate assessment of colorectal function. The techniques employed in making such an assessment, such as manometry, electromyo­graphy, defaecography and scintigraphy, are generally regarded as research tools and are therefore looked upon with a degree of scepticism by the practising clinician. In recent years, with the advancement in technology, development of new methods has enabled us to carry out a much more accurate and meaningful assessment of colorectal function. So much so that important and crucial decisions like surgical intervention are based on the results of such an assessment. Nevertheless, many of these techniques still continue to be regarded as part of a research worker's armamentarium.

The principal aim of this book is to document fully the scope of useful investigations and to present them in a clear and simplified manner, so that not only specialists but also non­specialists are able to understand and set up tests for specific colorectal disorders. It reviews the basic anatomy, physiology and histology of the colon and anorectum. All available methods for the assessment of colorectal function except for conventional radiology and colonoscopy have been discussed and their role in clinical practice established so that the reader understands what is "ideal", what is optimal and what constitutes research. Areas which have made major advances in recent years, such as the neorectum, have been discussed in a separate chapter, particularly focussing on problems in function of ileal and colonic pouches and coloanal anastomosis. Colonic function and its integration with anorectal function has also been included where appropriate.

We hope that the text, explaining the value of established and new techniques in the management of colorectal disorders, will be helpful not only to the devoted coloprocto­logist but to all general surgeons, physicians, people in training and of course the research scientists who wish to increase their understanding of colorectal pathophysiology.

Birmingham, Cork, London 1991

Devinder Kumar David J. Waldron

Norman S. Williams

Contents

List of Contributors ................................................................................. xiii

SECTION I. MORPHOLOGY AND TECHNIQUES

1. Morphology of the Colon and Anorectum ................................................. 3 J. Christensen

Introduction .......................................................................................... 3 Colonic and Anorectal Structure in Animals Other Than Man ......................... 3

The Relative Extent of the Sacculated Colon ......................................... 3 The Relative Size of the Caecum ......................................................... 4 Why Does Colonic Morphology Not Always Reflect Diet? ........................ 4

Gross Colonic and Anorectal Structure in Humans ........................................ 5 The Parts of the Organ ...................................................................... 5 The Appendix, Caecum and Ileocaecal Junction in Humans ...................... 5 The Ascending, Transverse, Descending and Sigmoid Parts of the Colon ..... 6 The Rectum and Anal Canal ............................................................... 6 The Shape of the Colon and Anorectum in Cross-section .......................... 7

The Construction of the Wall of the Colon and Anorectum ............................. 8 The Major Layers of the Wall ............................................................. 8 The Mucosa ............................................................................. :...... 9 The Muscularis Propria ...................................................................... 10 The Serosa ...................................................................................... 10

The Structure of Smooth Muscle in the Colon and Anorectum ......................... 11 Smooth Muscle Cells ......................................................................... 11

The Innervation of the Colon and Anorectum .............................................. 13 The Extrinsic Nerves ......................................................................... 13 The Intrinsic or Intramural Nerves ....................................................... 14

2. Measurement of Colonic Motor Function ............................................... ;.. 19 C. J. Steadman and S. F. Phillips

Introduction .......................................................................................... 19 Overview of Colonic Function ............................................................. 19 Early Observations of Colonic Motility: Interspecies Differences................ 19 General Observations of Colonic Function in Man .................................. 20

viii Contents

Colonic Electromyography ....................................................................... 20 Neuromuscular Organization of the Human Colon .................................. 20 Relationship Between Neuromuscular Organization and Myoelectric Activity 21 In Vivo Recording of Human Colonic Myoelectric Activity ....................... 21

Measurement of Colonic Contractile Activity ............................................... 23 Techniques for Recording Colonic Motility ............................................ 23 Basal Colonic Motility ....................................................................... 23 Colonic Peristalsis ............................................................................. 25 Future Directions ............................................................................. 25

Measurement of the Transit of Colonic Contents .......................................... 26 Historical Perspectives ....................................................................... 26 Rationale of Measures of Colonic Transit .............................................. 26 Which Transit Marker Is Best? ............................................................ 26

Combined Measurement of Motility and Transit ........................................... 30 Clinical Measurement of Colonic Function ................................................... 30

Basic Assessment ............................................................................. 30 Colonic Electromyography ................................................................. 32 Colonic Manometry .......................................................................... 32 Colonic Transit ................................................................................ 32

3. Measurement of Anorectal Function ........................................................ 37 D. Kumar, R. l. Hallan, N. R. Womack, P. R. O'Connell and R. Miller

Manometry D. Kumar ............................................................................. 37 Introduction .......................................................................................... 37 Methods of Recording Anorectal Manometry ............................................... 37

Short Non-ambulant Anorectal Recordings ............................................ 37 Balloon Systems ............................................................................... 37 Perfused Catheters ............................................................................ 38

Effect of Bowel Preparation ..................................................................... 38 Ambulant Recordings .............................................................................. 39

Rectal Manometry ............................................................................ 39 Anal Canal Manometry ..................................................................... 41

Interpretation of Records ......................................................................... 41 Normal Values of Anorectal Manometry ............................................... 42

Electromyography R. l. Hallan .................................................................. 42 Introduction .......................................................................................... 42 Physiology ............................................................................................ 43 Patient Position and Electrode Sterilization for Anal Sphincter Electromyography 44 Technique of EMG Recording .................................................................. 44 Surface Electrodes .................................................................................. 44 Needle Electrode Recordings, Concentric and Single Fibre ............................. 44 Analysis of Concentric Needle Motor Unit Potentials .................................... 45 Analysis of Single Fibre Motor Unit Potentials ............................................. 46 Fibre Density ......................................................................................... 46

Fine Wire Electrodes ......................................................................... 46 Stimulation Techniques ............................................................................ 46 Pudendal and Perineal Nerve Terminal Motor Latencies ................................ 47 Spinal Motor Latencies ............................................................................ 48 Spinal Latency Ratio ............................................................................... 48 Contribution of Electromyography to Knowledge of Pelvic Floor Physiology and

Pathophysiology .................................................................................. 48 Relevance of Electromyography to the Practice of Coloproctology ................... 49

Contents ix

Dynamic Assessment of Anorectal Function N. R. Womack and P. R. O'Connell.. 50 Introduction .......................................................................................... 50 Proctography ......................................................................................... 51

Balloon Proctography ........................................................................ 53 Dynamic Synchronous Proctography ..................................................... 54 Scintigraphy .................................................................................... 55 Proctometrogram ............................................................................. 56 Balloon Expulsion Tests ..................................................................... 58

Combined Urinary and Anorectal Assessment .............................................. 58 Conclusion ............................................................................................ 58

The Measurement of Anorectal Sensation R. Miller ........................................ 60 Sensory Endings in the Anorectum ............................................................ 60 Methods of Measurement ......................................................................... 60

Rectal Sensation ............................................................................... 60 Anal Sensation ................................................................................. 62

4. Measurement of Absorptive and Secretory Function .................................... 67 D. S. Rampton

Introduction .......................................................................................... 67 In Vivo Techniques ................................................................................. 68

General Remarks ............................................................................. 68 Balance Studies ................................................................................ 68 Bolus Infusions ................................................................................ 70 Mucosal Dialysis .............................................................................. 70 Transmucosal Potential Difference (PD) ............................................... 71 Perfusion Techniques ........................................................................ 72

In Vitro Techniques ................................................................................ 74 General Remarks ............................................................................. 74 Short-circuit Current Techniques ......................................................... 74 Other In Vitro Techniques ................................................................. 76

Conclusions ........................................................................................... 76

5. Histological Measurement in Coloproctology .............................................. 81 M. Swash

Histometric Studies of Human Muscle Biopsies ............................................ 82 Smooth Muscle ...................................................................................... 84

Other Tissues .................................................................................. 85 Striated Sphincter and Pelvic Floor Musculature ........................................... 85 Conclusions ........................................................................................... 86

SECTION ll. COLOPROCTOLOGICAL DISORDERS

6. Physiological Mechanisms ...................................................................... 89 D. Kumar

Introduction .......................................................................................... 89 Colonic Propulsive Activity ...................................................................... 89 Control of Colonic Contractions ................................................................ 90

Myogenic Control ............................................................................. 90 Neurogenic Control .......................................................................... 90

Colonic and Anorectal Reflexes ................................................. :............... 91 Peristaltic Reflex .............................................................................. 91

Gastro-colic Reflex ................................................................................. 91 Sampling Reflex ..................................................................................... 91

x Contents

Vesicoanal Reflex ................................................................................... 92 Passage of Flatus .................................................................................... 92 Mechanism of Defaecation ....................................................................... 93 Mechanism of Faecal Continence ............................................................... 93

7. Constipation ....................................................................................... 97 D. 1. Waldron

Introduction .......................................................................................... 97 General Investigations ............................................................................. 97

History and Physical Examination ........................................................ 97 Dietary Assessment .......................................................................... 98 Haematological and Biochemical Evaluation .......................................... 98 Radiological Assessment .................................................................... 98 Colonoscopy .................................................................................... 98 EUA and Full Thickness Rectal Biopsy ................................................. 98

Functional Assessment ............................................................................ 98 Anorectal Manometry ....................................................................... 98 Position of the Pelvic Floor ................................................................. 99 Dynamic Evacuation Studies ............................................................... 100 Neurological Assessment of the Pelvic Floor .......................................... 101 Large Bowel Transit Studies ............................................................... 102 Intraluminal Manometric Studies ......................................................... 102 Colonic Electromyographic Studies ...................................................... 103 Upper Gastrointestinal Assessment ...................................................... 104 Histological Studies ........................................................................... 104

Conclusion ............................................................................................ 105

8. Faecal Incontinence .............................................................................. 109 N. S. Williams

Pathophysiology ..................................................................................... 109 Neurological Causes .......................................................................... 109 Local Sphincter Pathology .................................................................. 111 Enteric Causes ................................................................................. 111 Multifactorial Causes .......................................................................... 111 Investigation of Faecal Incontinence ..................................................... 111 Physiological Investigations ................................................................ 112 Electrophysiological Tests .................................................................. 115

9. Neurological Disorders .......................................................................... 123 A. N. Smith and N. R. Binnie

Neurological Lesions ............................................................................... 123 Central Lesions ................................................................................ 123 Spinal Lesions .................................................................................. 125 Cauda Equina .................................................................................. 128 Developmental Anomalies of the Spine ................................................. 130 Spinal Cord Disease .......................................................................... 131 The Effect of Spinal Anaesthesia and Other Anaesthetic Agents ................ 132 Nerve Lesions .................................................................................. 132 Ganglion Cell Lesions ....................................................................... 135 Miscellaneous .................................................................................. 136

10. Rectal Prolapse, Solitary Rectal Ulcer Syndrome and Haemorrhoids ............. 141 M. M. Henry

Rectal Prolapse ...................................................................................... 141

Contents xi

Introduction .................................................................................... 141 Clinical Assessment .......................................................................... 141 Investigations .................................................................................. 142 Anal Sphincter Function .................................................................... 143

Solitary Rectal Ulcer Syndrome (SRUS) ..................................................... 143 Clinical Assessment .......................................................................... 144 Investigations .................................................................................. 144

Haemorrhoids ........................................................................................ 145 Investigations .................................................................................. 145

11. The Irritable Colon ............................................................................ 147 D. L. Wingate

Hypersensitivity of the Colorectum ............................................................ 147 Electromyographic Abnormalities in the Colon and Rectum ............................ 148 Contractile Abnormalities in the Colon and Rectum ...................................... 148

Other Directions .............................................................................. 148

12. Pseudo-obstruction ............................................................................. 151 P. R. O'Connell

Introduction .......................................................................................... 151 Clinical Presentation ............................................................................... 151

Acute Pseudo-obstruction .................................................................. 151 Chronic Pseudo-obstruction ................................................................ 152

Diagnosis .............................................................................................. 154 Acute Pseudo-obstruction .................................................................. 154 Chronic Pseudo-obstruction ................................................................ 155 Radiological Investigations ................................................................. 155 Manometry ..................................................................................... 156 Transit Studies ................................................................................. 157 Histopathology ................................................................................ 158

Treatment ............................................................................................. 158 Acute Pseudo-obstruction .................................................................. 158 Chronic Pseudo-obstruction ................................................................ 159

Conclusion ............................................................................................ 160

SECTION ID. ANORECTAL FUNCTION FOLLOWING SURGERY

13. Neorectum and Assessment of Anorectal Function Following Surgery 1. H. Pemberton

165

The Operation ....................................................................................... 165 Rationale ........................................................................................ 165 Indications ...................................................................................... 166 Patients .......................................................................................... 166 Technique ....................................................................................... 166 Other Approaches ............................................................................ 166

Physiology of Ileal Pouch-Anal Anastomosis ............................................... 168 Methodology ............................................................................... .,.. 168

Results ................................................................................................. 172 Anal Canal ...................................................................................... 172 Anorectal Angle and Movements of the Pelvic Floor ................................ 174 Anorectal and Anoneorectal Sensation and Reflex Mechanisms ................. 175

Rectal Anal Sphincter Inhibitory Response .................................................. 177 Neorectal Compliance and Capacity ........................................................... 178

xii Contents

Neorectal Motility .................................................................................. 178 Proximal Small Bowel Motility .................................................................. 181 Neorectal Motor Function ........................................................................ 182

Clinical Usefulness of Physiological Measurements After Ileal Pouch-Anal Anastomosis ...................................................................................... 183

Usefulness of Physiological Measurements in Patients with Specific Problems 184 Conclusion ............................................................................................ 185

14. Colo-anal Anastomosis ........................................................................ 189 D. J. Waldron

Introduction .......................................................................................... 189 Considerations in Sphincter-Saving Surgery (for Rectal Cancer) ....................... 189 Factors Involved in the Recto-anal Continence Mechanism ............................. 190 Surgical Procedures Associated with Low Pelvic Anastomoses ......................... 190

Ileo-anal Anastomosis ....................................................................... 191 Low Anterior Resection ..................................................................... 192 Pull-Through Colo-anal Anastomosis .................................................... 193 Transanal Colo-anal Anastomosis ........................................................ 194 Colonic Pouch-Anal Anastomosis ........................................................ 195

Investigation of Poor Function Following Colo-anal Anastomosis ..................... 197 Anorectal Manometry ....................................................................... 197 Proctometrogram ............................................................................. 197 Electromyography of the Pelvic Floor ................................................... 197 Proctography ................................................................................... 197

Conclusion ............................................................................................ 197

15. Assessment of the Paediatric Patient ....................................................... 201 V. Loening-Baucke

Introduction .......................................................................................... 201 Anatomy and Physiology .......................................................................... 201 Equipment, Conduct and Results of Anorectal Physiological Tests ................... 201

Equipment ...................................................................................... 201 Preparation of the Child for Testing ..................................................... 202 Measurements ................................................................................. 202

Indications for Anorectal Physiology Tests ................................................... 206 Chronic Constipation With or Without Faecal Soiling .............................. 206 Segmental Dilatation of the Colon ....................................................... 207 Hirschsprung's Disease (Aganglionosis Coli) .......................................... 208 Chronic Intestinal Pseudo-obstruction ................................................... 209 Myelomeningocoele .......................................................................... 209 Anorectal Anomalies .. ,..................................................................... 210 Anorectal Trauma ............................................................................ 210 Rectal Prolapse ................................................................................ 210 Neuromuscular Diseases .................................................................... 210

Conclusion ............................................................................................ 211

SUbject Index ......................................................................................... 213

Contributors

N. R. Binnie, FRCSEd Surgical Registrar, Department of General Surgery, Western General Hospital, Edinburgh EH4 2XU, UK

J. Christensen, MD Professor of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA 52242, USA

R. I. Hallan, MA, MB BS, PRCS, PRCSEd Registrar in Surgery and MRC Research Fellow in Anorectal Physiology, The Surgical Unit, The Royal London Hospital, Whitechapel, London EllBB, UK

M. M. Henry, MB, FRCS Consultant Surgeon, Central Middlesex Hospital, Acton Lane, London NWl0 7NS, UK

D. Kumar, PhD, FRCS Senior Lecturer in Surgery, Department of Surgery, Honorary Consultant Surgeon, Queen Elizabeth Hospital, Birmingham B15 2TH, UK

V. Loening-Baucke, MD Associate Professor of Paediatrics, University of Iowa College of Medicine, Iowa City, IA 52242, USA

R. Miller, MB BS, FRCS Senior Registrar in Surgery, Royal United Hospital, Bath BAl 3NG, UK

P. R. O'Connell, MD, FRCSI Senior Lecturer and Honorary Consultant Surgeon, The Surgical Unit, The Royal London Hospital, Whitechapel, London EllBB, UK

J. H. Pemberton, MD Associate Professor of Surgery, Mayo Medical School, and Consultant in General, Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

xiv Contributors

S. F. Phillips, MD Professor of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

D. S. Rampton, MA, BM, DPhil, FRCP Consultant Gastroenterologist and Senior Lecturer, Royal London Hospital and Medical College, London Ell B13, UK

A. N. Smith, MD, FRCSEd, FRCPEd, PRSE Wade Professor of Surgical Studies, Royal College of Surgeons of Edinburgh, Reader in Surgery, University Department of Surgery, Western General Hospital, Edinburgh EH42XU, UK

C. J. Steadman, MB BS, FRACP Gastrointestinal Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

M. Swash, MD, FRCP, MRCPath Consultant Neurologist, St. Mark's Hospital, City Road, London EC1V 2PS, and The Royal London Hospital, Whitechapel, London E11BB, UK

D. J. Waldron, MCh, PRCS, FRCSI Senior Registrar in Surgery, Cork Regional Hospital, Cork, Republic of Ireland

N. S. Williams, MS, PRCS Director, The Surgical Unit, The Royal London Hospital, Whitechapel, London E1 1BB, UK

D. L. Wingate, FRCP Director, GI Science Research Unit, The London Hospital Medical College, White­chapel, London E11BB, UK

N. R. Womack, FRCS Senior Registrar in Surgery, Bradford Royal Infirmary, Yorkshire, UK