Dyssynergic Defecation in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Introduction: Patients with inflammatory bowel disorder (IBD) often continue to experience non-specific gastrointestinal (GI) symptoms despite quiescent disease. Dyssynergic defecation (DD) is an important and treatable cause of GI symptoms in IBD patients that is not well recognized in practice. Unlike non-IBD patients, IBD patients with dyssynergia can present with various presentations such as diarrhea, fecal incontinence, constipation, incomplete evacuation and rectal discomfort. Thus, we conducted a systematic review and meta-analysis on the prevalence, diagnosis, and management of DD in IBD patients. Methods: We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews (from 1966 through February 2017) to identify studies on prevalence, diagnostic methods or management of DD in IBD patients with and without ileal pouch-anal anastomoses (IPAA). Random effect model was used to calculate the pooled prevalence rate of DD and pooled response rate to biofeedback therapy in IBD patients with and without IPAA with 95% confidence interval (CI). Heterogeneity was assessed with I2 statistics, Cochran Q statistic, and sensitivity analyses. Results: Seven studies met inclusion criteria (Table 1). Among patients with IBD who have persistent GI symptoms, the pooled prevalence of DD in those without IPAA was 76% (95%CI 35-100%, I2=95%, p < 0.01; Figure 1) and 62% (95%CI 38-84%, I2=93%, p < 0.01; Figure 1) in those with IPAA. The pooled prevalence of DD in IPAA patients with pouchitis (56%, 95%CI 23-89%, I2=96%, p < 0.01) was similar to those without pouchitis (49%, 95%CI 25-72%, I2=80%, p < 0.01). Diagnostic studies utilized include anorectal manometry, balloon expulsion test, electromyography, and defecography. The pooled response rate to biofeedback therapy in IBD patients without IPAA was 70% (95% CI 55-84%, I2=95%, p < 0.01; Figure 2) and 86% (95% CI 67-98%, I2=61%, p=0.05; Figure 2) in those with IPAA patients.Figure: Pooled prevalence of dyssynergic defecation (DD) in IBD patients without IPAA (top) and with IPAA (bottom). There was significant heterogeneity that was not explained by sensitivity analysis.Figure: Pooled response rate of dyssynergic defecation to biofeedback therapy in patients with and without IPAA. There was significant heterogeneity that was not explained by sensitivity analysis.Table: Table. Summary of studies describing prevalence, diagnostics, and management of dyssynergic defecation in IBD patients with and without IPAAConclusion: Although literature describing DD in IBD patients is limited, emerging data suggests that DD is highly prevalent in IBD patients in active and quiescent IBD patients with ongoing GI symptoms and is responsive to biofeedback therapy. Hence, DD must be considered in IBD patients with persistent defecatory symptoms. Further studies with larger sample sizes are warranted to further characterize the prevalence and management of DD in IBD patients.