ANO RECTAL MANUAL.docx
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ANO RECTAL MANUAL.docx
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ANORECTALMANUAL
USER’SMANUAL
ANO-RECTALMANOMETRY
TableofContents
PageNumber
Introduction2
Investigationspossiblewithyourinstrument2-3
Unpackingandsettingupyourinstrument3
Calibratingtheinstrument3
Usingyourinstrument3-10
Takingcareofyourinstrument11
1
INTRODUCTION
Indicationsforanorectalmanometry
Althoughvariousinnovativetechniqueshavebeenusedtoassessanorectalfunction,manometryremainsthekeyinvestigativetoolinitsoverallassessment.
TheClinicalindicationsforanorectalmanometryinclude
(1)Faecalincontinence
(2)Constipation
(3)Ulcerativecolitiswithlieoanalanastomosisbeforeandafteroperation
(4)Hirschprung’sdisease
(5)Haemorrhoids
(6)Analfissure
(7)Analfistula
Inadditionanorectalmanometryisanimportantresearchtoolinvariousotherdiseasestatessuchasspinalcordinjuryandanorectaldysfunction.
TheInstrument
Yourportablemicroprocessorbasedanorectalmanometrysysteminacomprehensiveplatformforperformingallroutineanorectalmanometryinvestigations.ItwasdevelopedbyresearchersattheAllIndiaInstituteofMedicalSciences,NewDelhi,andhasundergoneextensiveclinicaltrialsatthisinstitution.Duringdevelopmenttheneedsofpracticingclinicianwerekeptforemostandtheresultisacompact,portable,table-topinstrumentwhichisveryeasytooperate.Itaddressestherequirementsofgastrointestinalsurgeonsandgastroenterologistsindifferentpartsofthecountry,particularlythoseinofficepracticeandinsmallandmedium=sizedhospitals.Thesepractitionershavehithertobeendeniedaccesstotheexpensiveimportedequipmentpresentlyinuseinsomebiginstitutions.Thismanualdescribeshowyoumightusethisvaluableinstrument.
Investigationspossiblewithyourinstrument
Thefollowingisalistofinvestigationspossiblewithyourinstrument.
(1)AnalCanalPressure
(a)MinimumBasalPressure
(b)MaximumBasalPressure
(c)MeanBasalPressure
(d)MaximumSqueezePressure
(e)DurationofMaximalContraction.
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(2)LengthofHighPressureZoneintheAnalCanal
(3)RectoAnalReflex
(4)RectalCompliance
(a)Volumeatfirstsensation
(b)Complianceatfirstsensation
(c)VolumeatTotalPouchCapacity
(d)ComplianceatTotalPouchCapacity
TheInstrumentcanalsobeusedfor
(5)Biofeedbacktrainingtoincreasesphinctertone.
Unpackingandsettingupyourinstrument
1.Connectthepowercordsuppliedwiththemachinetothereceptacleandtheotherendtothemains.The
Switchtowardsthefrontisthemainpowerswitch,theotherisforpumpcontrol.
2.Putthepowerswitchofthe“ON”position.
AtthefrontoftheSystemisanLCDpanel(h)forrealtimepressuredisplayincmofwater.Whenthe
Systemisswitchedon,digitsappearonthisdisplay.OntopoftheSystemBoxisanotherwindow.
Whenthepowerison,thiswindowplaysthemessage“RDY”,indicatingthatthesystemisreadyfor
Use.
Caliberatingtheinstrument
Yourinstrumentwillcometoyoufactorycalibratedanditmaybeunnecessaryforyoutocalibratetheinstrumentinitially.Howeveritisgoodpracticetocheckthecalibrationofyourinstrumentpriortoeverymanometricevaluation.Thiscanbedoneverysimplybyconnectingtheperfusioncathetertothetransducerandfillingthecatheterwiththeperfusate,eitherbyrunningthepump,orbyinfusingdistilledwaterintothesystemthroughthesideportofthethree-waystopcockuntilthewaterexitsfromtherecordingpostofthecatheter.Theperfusioncatheteristhenraisedverticallyandthereadingonthefrontpaneldisplayobserved.Itshouldread100,sincetheperfusioncatheterisexactly100cmlong.Ifitdoesnot,thenalterationswillhavetobemade.
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UsingYourInstrument
Asindicatedearlieryourinstrumentcanbeusedforperformingmanymanometricevaluations.Thefollowingisaguidetotheseinvestigations.
(1)AnalCanalPressure
(i)Patientpreparation:
Nospecificpatientpreparationisrequired.Donotgivelaxativesbecausetheyalterbowelmotilityandmaycausediscomforttopatientswhoalreadysufferfromdiarrhea.Likewisethereshouldbenorestrictionondiet.Howevertheoccasionalpatientwithboweldiseasemayhaveanexaggerateddefaecatoryurgeimmediatelyaftermealsandmaywishtovisitthetoiletduringaninvestigation,causingproblemsduringthestudy.Theyshouldbeadvisednottoeatfor2-3hourspriortoevaluation.
(ii)Patientposition:
Theleftlateralpositionisprobablythemostconvenienttobothpatientandoperator.Thepatientmustbetoldtobestillwhilethetestintheprogressbecausemovementmaycausechangesintheanalcanalpressures.Theinstrumentissupportedattheleveloftheanus,asthisensuresthatthereisnopressuredifferentialbetweentheanalcanalandthetransducer.If,forunavoidablereasons,ithastobeplacedatalowerlevel,thedifferencein
heightshouldbesubtractedfromtherecordedpressures.Undernocircumstancesshoulditbe
atahigherlevelthantheanus.
(iii)Switchonthemachine.
(iv)Thecatheterisloadedwithdistilledwaterasdescribedpreviously,andtheinstrumentcalibrated.Theevaluationmaynowstart.
(v)Wearglovesorafingerstallwithlubricatingjellyandperformarectalexamination.Makessubjectiveassessmentofthetoneofthesphincter.Doesthesphincterfeelhypertonicorpatulous?
Notealsotheexistenceofanystructuralabnormalitiesthatmaycauseproblemsduringtheevaluation.Istherectumorpouchtender?
Forinstance,ifonrectalexaminationastrictureisdetected,determinewhetheritwilladmitanindexfinger.Thisisimportantbecauserectalcompliancetestinginvolvestheintroductionofarubberballoonwithmount,theconicalportionofwhichwillliewithintherectum.Theballoonmounthasadiameteraboutthesameastheindexfingeranditmustbeabletoenterastricturedrectum.Recordingofanalcanalpressureisusuallyproblem–free.
(vi)Askthepatienttocontractthesphincterandmakearoughassessmentofthesphinctertoneduringcontraction.Itmaytakerepeatedattemptsforthepatienttogetitright,sincehemaynotunderstandwhatisrequired.Acommonerroristobeardownbyincreasingabdominalpressureasduringdefaecation,withoccasionalpassageofflatus.Thepatientshouldbecorrectedandinstructedtomakeanefforttoholdtheoperatorsindexfingerwiththeanalsphincterortomakeanefforttoresistadefaectoryurge.Ifsuccessful,thepatientisrequestedtorepeattheeffortduringthestudy.
(vii)Thecatheterisfilledwithdistilledwaterandallairbubblesevacuatedbyrunningthepump.Itisinsertedintotheanussothattherecordingportliesintherectum.Thepressuredisplayedshouldbeabout5–10cmwaterhigherthanatmosphericpressure.
(viii)Nowwithdrawthecatheterveryslowlynotingthepressuresimultaneously.Ataparticularposition,thepressurewillstarttoincrease.Withdrawthecatheterby5mmandallowtimeforthepressurereadingtostabilizeattheposition.Continuein5mmstepsuntilthereadingsbegintodecrease.Thistechniqueiscalled‘stationpullthrough’.Theportisnowexitingtheanalcanal.Notethehighestpressurerecordedduringthepassageoftherecordingportthroughtheanalcanal.
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(ix)Nowreintroducethecatheterandplaceitinthepositionwhichrecordedthehighestpressure.Allowtimeforthereadingtostabilizeafteraskingthepatienttorelax.Oneshouldnot,however,waittoolong,becausethesyringemaynothaveenoughperfusatelefttocompletethetest.Pressthekey“ANALPRES”.Abeepwillbeheardandpressuredataacquisitionwillstart.
(x)Afterabout4minutesanotherbeepwillbeheard.Thismarkstheendofbasalpressureacquisition.Nowaskthepatienttocontractthesphincter.NotethepressureontheLCD.Encouragethepatienttosqueezeashardaspossible,andtomaintaintheeffortforaslongaspossible.Ifthepatientcanmaintainasqueezeeffortformorethan30sechecanbeadvisedtorelax.Ifthemaximumpressuredisplayedismorethan200cmwater,nofurthereffortisrequired,sincethedisplayofcumulativeparametersattheterminationofthetestdisplaysallvalues>200cmwater,as199.Iftheeffortwasunsatisfactory,i.e.lessthan100cmwater,thesqueezeshouldberepeatedanytimewithinthenext3mins.Howeverifcorrectlyperformedthefirsteffortusuallygeneratesthehighestpressure.
(xi)Afterabout9minutesalongbeepwillbeheardandtheresultsdisplayed.Theorderofappearanceofnumbersisasfollows.
(a)Maximumsqueezepressure
(b)Minimumbasalpressure
(c)Meanbasalpressure
(d)Maximumbasalpressure
(xii)Ifafurtherdisplayofthesameparametersisrequired,press“EXAM”,whenthedisplaywillberepeated
(xiii)Isthereaneedtorepeatthetestandobtainanothersetofreadings?
Iftheresultsareunequivocal,thenfurthertestingofanalcanalpressureisnotrequired.Thismeansthatifthevaluesprovidedbytheinstrumentagreewiththeoperator’ssubjectiveassessmentofsphinctertoneorifthevaluesareclearlyinthenormalrangeorareclearlyabnormalthenthetestneednotberepeated.Howeveriftherecordedpressuresdonotagreewithoperatorassessmentorifthemeanbasalpressureisborderline,repeatevaluationmaybeinorder.Awordofcautionhereaboutrecordedlowpressures.Sincethepressuresrecordedvarywiththeportposition,itisnecessarytoensurethatthecatheterhasnotslippedoutofitsmaximalpressureposition,inwhichcasespuriouslowpressureswillberecorded.Thismayhappednifanexcessoflubricantsisusedtoeasepassageofthecatheter.
Ifinordinatelyhigh
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