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Fecal Incontinence: A Primer for Individuals with Scleroderma

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Darren M. Brenner, MD, Assistant Professor of Medicine and Surgery at Northwestern University's Feinberg School of Medicine discusses fecal incontinence in scleroderma patients including its prevalence, diagnostics, types and therapeutics.

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Fecal Incontinence: A Primer for Individuals with Scleroderma

  1. 1. Northwestern University Feinberg School of Medicine Fecal Incontinence: A Primer for Individuals with Scleroderma Darren M. Brenner, MD Assistant Professor of Medicine and Surgery Northwestern University—Feinberg School of Medicine
  2. 2. 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 J Gastroenterol 1999;34;409-13.
  3. 3. Anatomy of the Anorectum Internal Anal Sphincter (IAS) External Anal Sphincter (EAS) Rectum (Compliance)
  4. 4. Fecal Incontinence Subtypes Passive FI Overflow Urge Stress • Unconscious loss of stool • Primarily related to IAS dysfunction Passive FI • Secondary to constipation/fecal impaction • ImpactionInhibition of IAS tone Overflow FI • Conscious knowledge of stool loss with inability to control • Primarily related to EAS dysfunction Urge FI • Uncommon and a/w (+) recto-anal Stress FI gradient
  5. 5. 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) Structural and/or functional Stool Characteristics
  6. 6. Diagnostic Evaluation • History • Physical exam, including digital rectal exam • Diagnostic tests Rao SSC et al. Am J Gastroenterol. 2004;99:1585-1604.
  7. 7. History Fecal Incontinence--Initial Clinic Visit Onset: Frequency: Stool Texture: Bristol Stool Scale Severity: (Qol) Subtypes: Passive: Urge: Stress: Overflow: Seepage Precipitants:
  8. 8. Diagnostic Testing Physiologic Test Measurements Evidence Anorectal manometry1 Quantifies sphincter pressures, sensation, rectal compliance and recto-anal reflexes Good Endoanal ultrasound Assesses IAS and EAS thickness, integrity Good Surface EMG1 Provides information on normal or weak tone Fair Adapted from: Rao SSC. Clin Gastroenterol Hepatol. 2010;8:910-919.
  9. 9. Anorectal Manometry High-Res Manometry Catheter: • 10 distal sensors • 2 Proximal sensors High-Def Manometry Catheter:
  10. 10. Resting Pressure Normal Weak
  11. 11. Internal Anal Sphincter Thinning Normal IAS Thinned IAS
  12. 12. Non-pharmacologic Management of Fecal Incontinence Intervention Mechanism of Action Side Effects Comments Incontinence pads Provides skin protection; prevents soiling; conduct moisture away from skin Skin irritation Whitehead WE, Bharucha AE. Gastroenterology. 2010;138:1231-1235. 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
  13. 13. 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 Scleroderma patients with fecal incontinence
  14. 14. Injectable Gel Treatment for FI • Biocompatible gel of dextranomer microspheres in hyaluronic acid • FDA-approved for the treatment of fecal incontinence in patients aged ≥18 years who have failed conservative therapy • Administration • Done in physician office or hospital outpatient department • Four injections through an anoscope • Injected into submucosal layer of the anal canal • No anesthesia required Solesta [package insert]. Oceana Therapeutics, Edison NJ, 2012. Accessed April 1, 2013 at: http:www.solestainfo.com/pdf/solesta-pi.pdf
  15. 15. Solesta ® Injection Pivotal Trial: Primary Endpoint Data Significantly higher responder rates in injection group at 6 months (Responder)* 52% n=136 80 60 40 20 *Responder = ≥50% reduction in incontinence episodes as compared with baseline. Graf W et al on behalf of the NASHA Dx Study Group. Lancet. 2011; 377: 997–1003. 31% n=70 0 Injection Sham Median number of incontinence episodes during 2 weeks in the active treatment group decreased from 15.0 (IQR 9.6–27.5) at baseline to 6.2 (2.0–15.5) at 12 months (P<.0001) P=.0089
  16. 16. Sacral Nerve Stimulation System 1. Tined lead is placed parallel to the sacral (S2, S3, or S4) nerve 2. Implantable neurostimulator generates mild electrical pulses that are delivered through the lead electrodes 3. Clinician and patient programmers are used to set the parameters of the electrical pulses 1 2 3 InterStim II Neuromodulator [manual]. Medtronic, Inc. Minneapolis, MN. 2012.
  17. 17. SNS Placement
  18. 18. Sacral Nerve Stimulation In SSc 25 20 15 10 5 0 Pre-SNS Post-SNS • 5 women • All failed conventional therapy • Liquid and solid stool • Median # weekly FI episodes=15 • Duration SSc=13 yrs • Duration FI=5 years Kenefick et al. Gut 2002;51:81-83 Weekly Incontinent Episodes Patient 5: lead displdged in 1st 24 hours Max response time 60 months Improvements in urgency, QoL Elevations in resting pressures identified
  19. 19. Summary FI is a common and debilitating disorder Due to anatomical/functional pelvic floor abnormalities and changes in stool characteristics Types: Passive, Urge, Overflow, Stress Diagnostics: ARM and US primary studies Therapeutics: None a panacea but rapidly improving outcomes

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