DDSEP® 8 Quick Quiz

Question 1

Publish date: May 28, 2021

A 37-year-old woman with no significant past medical history presents for further evaluation of chronic constipation with straining. She denies significant abdominal pain, gastrointestinal bleeding, or weight loss. There is no family history of colorectal neoplasia or inflammatory bowel disease. She has not responded to many laxatives and undergoes anorectal manometry with balloon expulsion testing.

Which of the following results suggests a diagnosis of dyssynergic defecation?

Absent rectoanal inhibitory reflex (RAIR)

Expulsion of water-filled balloon in 3 minutes

Defecation index of 2.0

Decreased anal sphincter pressure during simulated defecation

Q1. Correct answer: B. Expulsion of water-filled balloon in 3 minutes.


Rationale
The balloon expulsion test is highly suggestive of dyssynergia. A balloon expulsion time of greater than 2 minutes is abnormal. An absent RAIR can be seen in Hirschsprung's disease or megarectum. Defecation index equals maximum rectal pressure during attempted defecation divided by minimum anal residual pressure during attempted defecation. A normal defecation index is greater than 1.5. Decreased anal sphincter pressure during simulated defecation is normal and therefore not consistent with dyssynergic defecation.

References
Wald A et al. Am J Gastroenterol. 2014 Aug;109(8):1141-57.
Bharucha AE et al. Gastroenterology. 2013 Jan;144(1):218-38.

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