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OBJECTIVE: The symptoms of fecal incontinence and constipation can arise from a variety of alterations of anorectal function. The aim of this study was to investigate components of the anorecal reflex in patients with these symptoms, to determine the functional significance of the various physiological parameters. METHODS: 21 healthy volunteers (controls), 78 incontinent and 74 constipated patients were recruited and symptom burden determined using the Wexner incontinence and constipation questionnaires. All participants underwent standardised anorectal physiology including anorectal manometry, anorectal distension and electrosensitivity thresholds, rectal mucosal blood flow and rectoanal inhibitory reflex measurement. RESULTS: Patients with passive incontinence had lower resting sphincter pressures than controls (38 vs 87cmH2 O, p

Background Most patients with multiple sclerosis report bowel symptoms, but the underlying pathophysiology is unclear. Objective We hypothesize that rectal dysfunction in multiple sclerosis is secondary to involvement of the spinal cord by the disease and that this can be measured by assessing rectal compliance. Design This was a case-control study. Settings The study took place in a neurogastroenterology clinic and tertiary referral center. Patients Forty-five patients with multiple sclerosis, 19 with a spinal cord injury above T5, and 25 normal control subjects were included in this study. Patients with multiple sclerosis were subdivided into 2 groups according to the Expanded Disability Status Scale, below 5 (multiple sclerosis minor disability, n = 25) or above 5 (multiple sclerosis major disability, n = 20), as a reflection of spinal cord involvement. Main outcome measures Rectal compliance, Wexner constipation, and Wexner incontinence scores were measured. Results Data are presented as mean and SD. Expanded Disability Status Scale correlated with rectal compliance but not with Wexner constipation or Wexner incontinence scores. Post hoc analysis showed no significant difference in Wexner constipation and Wexner incontinence between the 2 multiple sclerosis groups. Limitations Limitations to this study include the lack of an asymptomatic group with multiple sclerosis and the small sample size to evaluate bowel symptoms. Conclusions Rectal compliance correlates with disability, and observed alterations in the rectal properties are secondary to spinal cord involvement. Our findings suggest that, in patients with neurologic impairment, rectal compliance is a surrogate of reflex activity of the spinal cord regulating rectal function and both a potential predictor of outcome and target for treatment. Multiple sclerosis patient subgroups had similar symptom burden, arguing that bowel dysfunction is multifactorial.

Introduction Timed barium esophagram (TBE) is an objective measurement of esophageal emptying in achalasia. Post-therapy reduction of residual barium column height correlates imperfectly with short term symptomatic outcomes. We hypothesise that surface area (SA) of the barium column may be more accurate than height; firstly, by incorporating improvement in esophageal width that often occurs post-therapy, but also by correcting for artificially higher height values due to esophageal contraction occurring. We aimed to compare the correlation of TBE outcome measures of height and SA with symptom improvement post-therapy. Method Achalasia patients who underwent therapy between 2015–6 and had TBE and Eckardt score (ES) performed at baseline as well as within 6 months post-therapy were included. TBE images were acquired 5 mins following ingestion of 200 mL barium. Barium height was measured between the gastro-esophageal junction and the superior extent of any residual barium column. After manually defining column boundaries, software was used to calculate SA. Adequate symptom relief was defined as ES reduction to ≤3. On TBE, metrics of adequate emptying evaluated were i) post-therapy column height 50% reduction in column height from pre to post-therapy and iii)>50% reduction in column SA from pre to post-therapy. Results Of 18 patients, 11 had dilatation and 7 POEM. Reductions with therapy of both 5 min barium column height (14.7±8.7 to 7.9±6.0 cm; p=0.01) and SA (52.7±43.5 to 24.5±26.0cm2; p=0.02) were noted. Symptoms also improved; median baseline ES 7 (IQR 5.25–8) improved to 0 (IQR 0–1) post-therapy. However there was poor concordance between post-therapy barium height and symptomatic relief (i.e. post-therapy column >5 cm despite ES ≤3 or vice versa), and the correlation (R) between these two variables was poor. Similar poor concordance was seen when adequate emptying was defined by >50% reduction in column height, but >50% reduction in SA paralleled symptom relief most closely. Conclusion In TBE performed on achalasia patients post-therapy, reduction in SA of the residual barium column compared with baseline values parallels symptomatic relief more closely than reduction of column height. Disclosure of Interest None Declared

BACKGROUND Bowel symptoms are common in patients with multiple sclerosis, but current treatment is empirical. OBJECTIVE This study aimed to identify effect of biofeedback on bowel symptoms, mood, and anorectal physiology in patients with multiple sclerosis. DESIGN This was a prospective observational study: the amount of change between pre- and posttreatment values of outcome measures was compared and analyzed. Responders were considered to be patients who demonstrated an improvement greater than or equal to the 25th percentile of the change in bowel score. Comparison between responders and nonresponders was performed. SETTINGS This investigation was conducted at a neurogastroenterology clinic, tertiary referrals center. PATIENTS Thirty-nine patients with multiple sclerosis and constipation and/or fecal incontinence were included in the study. INTERVENTION Patients were given bowel biofeedback therapy. MAIN OUTCOME MEASURES The primary outcome measures were the Wexner Constipation and Wexner Incontinence scores. The secondary outcome measures were hospital anxiety and depression scores and anorectal physiology parameters. RESULTS Data are reported as median and interquartile ranges. After biofeedback there was significant improvement in Wexner Constipation (12 (5-19) pretreatment vs 8 (4-14) posttreatment, P = .001), Wexner Incontinence (12 (3-15) pretreatment vs 4 (2-10) posttreatment, P < .001) and hospital depression scores (7 (3-11) pretreatment vs 5 (3-10) posttreatment, P = .015). The 5-second endurance squeeze pressure was also improved (21 (11-54) mmHg pretreatment vs 43 (26-59) mmHg posttreatment, P = .001). Posttreatment change of Wexner Constipation was -2(-5/0), and of Wexner Incontinence was -3(-9/0) ("-" indicates improvement). Therefore, those patients who had a reduction of at least 5 points in the Wexner Constipation score and/or of at least 9 points in the Wexner Incontinence score were considered responders (18 patients, 46%). They showed a greater improvement of only 5-second endurance squeeze pressure (23.5 (7.5/32.75) mmHg responders vs 4 (-6/20) mmHg nonresponders, P = .008); no difference was observed in the comparison of baseline variables with nonresponders. Significant negative relationship existed between the change in the Wexner Constipation score (-2 (-5/0)) and the pretreatment Wexner Constipation score (12 (5/19), β = -0.463, P < .001), and the change in the Wexner Incontinence score (-3 (-9/0)) with the pretreatment Wexner Incontinence score (12 (3/15), β = -0.590, P < .001). So, the higher the initial bowel symptom score, the greater the improvement. LIMITATIONS This study was limited by the lack of a control group. CONCLUSIONS Biofeedback improves bowel symptoms, depression, and 5-second endurance squeeze pressure in patients with multiple sclerosis.

Introduction Resistance to bolus flow across the lower esophageal sphincter (LES) is a hallmark of achalasia. Presently the gold standard of diagnosis is by high-resolution manometry (HRM) demonstration of raised integrated relaxation pressure (IRP) following ten 5 mL water swallows; however, this does not replicate normal swallowing behaviour. It has been demonstrated that the addition of adjunctive tests improves sensitivity of identifying relevant dysmotility. Such tests include multiple water swallows (MWS; 200 mL water drunk freely) and solid swallows. In addition, the timed barium esophagram (TBE) measures esophageal emptying. This study describes a cohort of patients who have been treated as having achalasia based on resistance to flow not exhibited with single water swallows. Method Inclusion criteria were all patients between October 2014–2016 with normal mean and median IRP with 5 mL water swallows but considered to have achalasia due to resistance to flow demonstrated by pan-esophageal pressurisation (PEP) during MWS or solid swallows and/or a persistent column at 5 min during TBE. Outcome post-treatment was based on Eckardt score (ES). Results 14 patients (9 male) fulfilled inclusion criteria. 7 were treatment-naive and 7 treatment-experienced (3 myotomy, 4 dilatation). Mean resting LES pressure was 14.6±7.4 mmHg. In all patients, mean and median IRP values for ten 5 mL water swallows were non-raised (mean 9.1±4.3 and 8.7±4.5 mmHg respectively). Of the 7 treatment-naive patients, 5 demonstrated PEP on MWS, 3 on solid swallows and 6 had a positive TBE at 5 min. In treatment-experienced patients, 5 had PEP on MWS, 1 on solid swallows and all had a positive TBE. Of the 13 who had resistance to flow on TBE, 10 (77%) also had resistance demonstrated during MWS and/or solid swallows. Mean height of the 5 min column of barium at baseline was 16.5±8.9 cm. 8 patients underwent therapy based on these findings; one POEM and 7 pneumatic dilatations. Median baseline ES was 7.5 (IQR 5–8). Median ES at minimum 3 months following treatment was 1 (IQR 0–2.5; p Conclusion A normal IRP for water swallows does not preclude a diagnosis of achalasia. The addition of free drinking/solids during HRM or the TBE can identify pathology that might have been missed with standard 5 mL water swallows alone. Patients treated based on this algorithm exhibit excellent treatment outcomes, validating this approach. Disclosure of Interest None Declared

Introduction Constipation affects up to 80% of spinal cord injury (SCI) patients and is cause of significant reduction of quality of life. Rectal compliance is determined by the rectal wall properties and by the supra-spinal modulation of the thoracic sympathetic and para-sympathetic lumbosacral efferents; it is increased in SCI patients with injury level above T5. Often this patient group has associated bladder dysfunction, and requires antimuscarinic agents (Tolterodine or Solifenacin), which are known to cause constipation. The authors aimed to assess the physiological effect of antimuscarinic agents on the anorectal function of patients with SCI above T5. Methods The authors prospectively collected data from 17 SCI patients (11 males, mean age 41, mean disease duration 13 months) attending a neuro-gastroenterology clinic at a tertiary centre. All had an established SCI above T5, and 11 had a complete injury. Anal manometry, assessment of rectoanal inhibitory reflex (RAIR) and rectal compliance were measured at baseline, and after antimuscarinic treatment was started (mean follow-up 12 weeks). Results Anal sphincter function parameters of squeeze and cough pressure were unchanged after antimuscarinic treatment (pre vs post 123±40 vs 122±36 p=0.827; 88±24 vs 87±26 p=0.859 respectively). However, resting anal pressure and rectal compliance were significantly raised after antimuscarinic treatment (82±18 vs 88±16 p=0.058; 19.2±5.0 vs 24.2±4.1 p Conclusion In SCI patients the use of antimuscarinic agents causes increased rectal compliance, reduced reflex relaxation of the anal sphincter and delayed latency of this reflex. These physiological changes all predispose towards constipation. In the absence of cortical modulation, in patients with a SCI level above T-5, sympathetic activity is effectively enhanced. The effect of these drugs underlines the importance of tonic parasympathetic input to rectal compliance and anorectal reflex function.