Physiological and structural anorectal abnormalities in patients with systemic sclerosis and fecal incontinence

Abstract

Objective. Fecal incontinence is common in systemic sclerosis (SSc), but the underlying mechanisms are not fully understood. The objectives of this study were to characterize anorectal physiological and morphological defects in SSc patients and to correlate the results with incontinence symptoms. Materials and methods. Twenty-five SSc patients underwent anorectal neurophysiological investigations, anal manometry, and ultrasound. Results. Eleven patients (44%) reported incontinence to solid or liquid feces, but no patient reported diarrhea. Increased fiber density (FD) was recorded in 78% of patients with and in 86% of patients without fecal incontinence not significant (NS). Incontinent patients had lower squeeze pressure (SP; median 49.5 mm Hg) in the high-pressure zone (HPZ) than continent patients (median 72 mm Hg; p = 0.01). In two of the incontinent patients, sonographic abnormalities of the internal anal sphincter (IAS) and the external anal sphincter (EAS) were present, whereas in another two patients isolated IAS abnormalities were seen. These four individuals had lower resting pressure at 1 cm and in the HPZ, and lower SP at 2 cm than patients with normal anorectal sonographic findings (p < 0.05). Conclusion. Lower voluntary SP in incontinent patients and EAS sonographic abnormalities only in patients with incontinence suggest that the EAS is more important in maintaining fecal continence in SSc patients than has previously been reported. The finding of increased FD in most patients further supports involvement of the EAS function in SSc and could indicate previous nerve injury with consequent incomplete reinnervation.

Key Words::

• fecal incontinence
• manometry
• neurophysiology
• systemic sclerosis
• ultrasound

Acknowledgment

The authors thank Elsy Söder for excellent assistance with the manometry examinations.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The study was supported by grants from Uppsala University, Uppsala, Sweden.