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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Anorectal Manometry Profile among Patients with Chronic Constipation and Faecal Incontinence in Western India: A Retrospective Study
Correspondence Address :
Shankar Lal Jat,
10A, North Part, Nemi Nagar Vistar, Vaishali Nagar, Jaipur, Rajasthan, India.
E-mail: drshankar02@gmail.com
Introduction: About 50% of patients referred to tertiary care centre for constipation in the western countries have faecal evacuation disorder. A diagnosis of faecal evacuation disorder requires specialised investigations such as anorectal manometry. Anorectal manometry is a method to measure pressure exerted by the muscles in anus and rectum.
Aim: To evaluate the characteristics of anorectal pressure in a cohort of western Indian patients with chronic constipation and faecal incontinence. Also, to evaluate the types of faecal evacuation disorders in patients with chronic constipation.
Materials and Methods: The present retrospective study was conducted from January 2020 to May 2022 at Department of Gastroenterology, National Institute of Medical College and Research, Jaipur, Rajasthan. Total of 115 patients presented with chronic constipation and faecal incontinence, were included in the study. Sigmoidoscopy or full-length colonoscopy, Balloon Expulsion Test (BET) and anorectal manometry test were done in all the patients. Mean resting and squeeze pressure were measured by anorectal manometry. Continuous variables were summarised using means and standard deviations for normally distributed data. Statistical analysis was performed using Statistical Package for Social Sciences software (SPSS) version 20.0 (IBM Corp, Armonk, NY, USA).
Results: Among 115, 62 were (53.9%) males and 53 (46.1%) females with mean age 51.9±16.2 years. In High Resolution Anorectal Manometry (HRAM), the mean resting anal pressure was 67.2±34.24 mmHg (range 14-183 mmHg) and mean squeeze pressure was 113.4±60.9 mmHg (range 30-290 mmHg). In present study type I dyssynergic defecations was most common with 20 (17.4%) patients.
Conclusion: The present study showed that almost half of the patients had defecation disorders and type I dyssynergic defecations was most common, followed by type IV.
Balloon expulsion test, Dyssynergic defecation, Solitary Rectal Ulcer Syndrome
Anorectum has an important role in regulation of defecation and in maintenance of continence (1). During defecation either incomplete relaxation or paradoxical contractions of pelvic floor muscles are considered as dyssynergic defecation (2). In various community-based surveys chronic constipation was reported between 12% to 30% (3),(4). Prevalence of constipation is 14-29 % in adults of the western countries (5),(6). About 50% of patients referred to tertiary care centre for constipation in the west have faecal evacuation disorders (7),(8).
A study by Rajput M and Saini SK from North India showed prevalence of self-reported constipation within 1 year was 24.8%. This study also showed prevalence of constipation was more in female and non working (9). A study by Baijal R and Jain M from India in 178 chronic constipation patients showed half of the patients of chronic constipation had normal study while 47% patient had pelvic floor dyssynergia (10). A study by Ghoshal UC et al., in 249 chronic constipation found 86 patients (34%) had faecal evacuation disorder (11).
A diagnosis of defecatory dyssynergia requires specialised investigations such as anorectal manometry, Balloon Expulsion Test (BET), defecography. BET is used as screening test. High Resolution Anorectal Manometry (HRAM) is considered a first line diagnostic tool for diagnosis and subtyping of chronic constipation and defecatory disorders (12),(13),(14). HRAM test is used in diagnosis of chronic constipation, faecal incontinence, anal sphincter tone and pelvic floor dyssynergia. Clinical data on HRAM used in constipation patients from the Asian countries are limited (12).
Hence, this present study was done in this part of the world because the data is not available about western India in literature as per the best knowledge of authors. This will help in better understanding and may improve the treatment protocol in routine clinical practice and will also allow to understand the details. The present study aimed to evaluate the characteristics of anorectal pressure in a cohort of western Indian patients with chronic constipation.
In this retrospective study, data were collected from January 2020 to March 2022 and were analysed from April 2022 to May 2022 at Department of Gastroenterology, National Institute of Medical College and Research, Jaipur, Rajasthan, India. This study was approved by the Institutional Ethical Committee (IEC-NO NIMSUNI/IEC218/22) and informed consent was taken.
Inclusion criteria: Patients with chronic constipation diagnosed according to the Rome IV Criteria (15) and with faecal incontinence were included in study.
Exclusion criteria: Patients with history of prior anorectal surgery, inflammatory bowel disease or anorectal malignancy were excluded from study.
Sample size calculation: Sample size was calculated at 80% study power and α error of 0.05 by using statcalc of Epi info 7 software. Final calculated sample size was 113, hence for the present study 115 patients were included.
Procedure
Baseline characteristics (e.g. age, gender), relevant clinical and laboratory data (duration of symptoms, presence of pain abdomen, feeling of incomplete evacuation, history of digital evacuation, history of enema, painful evacuation efforts, history of bleeding per rectum) were taken from all patients. All patients underwent flexible sigmoidoscopy or full-length colonoscopy either in the study centre or elsewhere to rule out colonic malignancy, ulcerative colitis and rectal ulcerations. Mean resting and squeeze anal pressure was measured in all the patients.
Balloon Expulsion Test (BET): BET was done in all patients. For BET, a latex balloon was tied on tip of manometry catheter. Balloon was filled with 50 mL water, the patient was asked to evacuate, if patient was unable to evacuate in one-two minutes, then gradually increase in weight at another end of catheter to support evacuation (maximum weight up to 200 g) was done. A normal person is able to expel the balloon (condom) without addition or at most 200 g added weight. If patient was unable to evacuate despite 200 g weight, then was considered as abnormal BET (13),(14).
During balloon inflation, balloon was inflated with 60 mL air and recto-anal inhibitory reflux was checked whether present or absent. The patient was also asked to report about feel for the first-time sensation, urge or desire to defecate and at that point maximum tolerable limit was measured. Anorectal Manometry (ARM) signal was analysed by using Trace 2.1 software from G S Hebbard (Australia).
High Resolution Anorectal Manometry Procedure (HRAM): Anorectal manometry was performed in all patients by using The Royal Melbourne Hospital High Resolution Manometry and 16 channel water perfusion system. An anorectal manometry catheter was of 4.2 mm in diameter and 16 radial ports. A latex balloon was tied at tip of manometry catheter, was used for BET and rectal sensory testing. No bowel preparation was given and all patients were studied in left lateral position with knee and hips flexed. Resting, squeeze and bear down was explained to patient before catheter was inserted into anorectum. Manometry catheter was inserted deep inside the rectum and then it pulled slowly till it was positioned in sphincter zone which is high pressure zone should be in middle, low-pressure area of rectum and exterior above and below that high pressure zone (Table/Fig 1)a-d. Length of high-pressure zone and basal anal sphincter pressure was measured. All maneuvers were performed in accordance to published international minimal standards using a previously published protocol (15),(16). After five minutes of rest to make patient comfortable, the resting or basal anal pressure (denotes internal anal sphincter activity) was measured, the patient was asked to squeeze the sphincter (denotes external anal sphincter activity) and squeeze sphincter pressure was measured. The patient was asked to bear down as done during defecation.
Defecation disorder was classified into Rao’s types (16),(17) (Table/Fig 2). Both intra-rectal and intra-anal pressure were measured by anorectal manometry during BET.
Analysis of Manometry Signal: ARM signal was analysed by using Trace 2.1 software from G S Hebbard (Australia). According to standard criteria, a resting anal pressure more than 68 mmHg, squeeze pressure more than 164 mmHg and length of anal high pressure zone (denotes sphincter) more than 3.6 cm in female and more 4 cm in male were considered abnormal. Threshold volume for first sensation at >20 mL in both gender, an urge to defecate at >80 mL in male and >60 mL in female and maximum tolerable volume of >126 mL were taken as abnormal (high) (10),(17),(18),(19).
Statistical Analysis
Continuous variables were summarised using means and standard deviations for normally distributed data. Pearson’s correlation test used to analyse the data. The medians and inter-quartile ranges were used to describe non nominal data. Statistical analysis was performed using SPSS version 20.0 (IBM Corp, Armonk, NY, USA). A p-value <0.05 was considered significant.
A total 115 patients underwent anorectal manometry during the study period. Mean age of patients was 51.9±16.2 years (range, 15-76 years). The cohort included 62 (53.9%) males and 53 (46.1%) females (Table/Fig 3).
Indications of anorectal manometry was chronic constipation in 68 (59.1%), faecal incontinence in 36 (31.3%) and bleeding per rectum in 11(9.6%) patients (Table/Fig 3), (Table/Fig 4). Sigmoidoscopy was normal in 86 (74.8%) patients, Solitary Rectal Ulcer Syndrome (SRUS) in 23 (20%) and rectal ulcerations in 6 (5.2%) patients (Table/Fig 4).
In HRAM, the mean resting anal pressure was 67.2±34.24 mmHg (range 14-183 mmHg). Mean squeeze pressure was 113.4±60.9 mmHg (range 30-290 mmHg). High Pressure Zone (HPZ) length was 3.2±1.0 cm. Mean volume of first sensation was 40 mL, mean volume for urgency was 75 mL and maximum tolerable volume was 125 mL (Table/Fig 5).
In attempted defecation, anorectal manometry was normal in 32 (27.8%) patients and abnormal anorectal manometry was present in 83 (72.2%) patients. Type I was the most common 20 (17.4%) present on HRAM according to Rao’s classification followed by type IV in 16 (13.9%), type II in 14 (12.2%) and type III in 3 (2.6%) patients (Table/Fig 6).
BET were abnormal in 53 (46.1%) patients in which faecal evacuation disorders were present while rest 62 (53.9%) patients were normal. Recto-Anal Inhibitory Reflux (RAIR) was present in all patients. Weak anal sphincter was present in 30 (26.1%) patients. Rectal ulcerations and SRUS were more common in defecatory disorder. SRUS and rectal ulcerations were significantly positive correlations with defecatory disorder (correlation coefficient, r=0.41, p-value <0.001 and r=0.25, p-value=0.006 respectively).
The present study showed that in 83 (72.2%) patients with chronic constipation had abnormal anorectal manometry. Out of these abnormal manometry, type I dyssynergia was the most commonly present on anorectal manometry according to Rao’s classification followed by type IV, type II and least was type III. Weak anal sphincter was present in almost 1/3rd patients presented for anorectal manometry in present study.
Prevalence of defecation disorders in patients with chronic constipation is 10-30% depending on patient population (3),(4). Prevalence of constipation is 14-29% of adults in the western countries (5),(6). A study by Rajput M and Saini SK showed prevalence of 24.8% in constipation and was significantly more frequent in females than in males (20% vs. 13%) and in non working population than in working population (20% vs. 12%) (9). A study by Baijal R and Jain M that 47% patient had pelvic floor dyssynergia (10). It is important to diagnose defecatory disorder patient with chronic constipation because these patient responds by anorectal biofeedback therapy. HRAM is a gold standard test to diagnosed defecatory disorders. A study from Surrenti E et al., showed pelvic floor dysfunction as most common cause of severe constipation among the 70 patients presenting to tertiary referral motility clinic, further slow transit constipation and irritable bowel syndrome occurred equally (20). Defecatory disorders is a common cause of chronic constipation in tertiary care practice in the west (21). Ghoshal UC et al., showed that 86 patients (34%) had faecal evacuation disorder (11).
Another study from India by Baijal R and Jain M in 178 patients presenting with anorectal disorders showed faecal incontinence in 11 (6.7%), dyssynergic defecation in 104 (58.4%), Irritable Bowel Syndrome (IBS) type constipation in 53 (29.7%), Hirschsprung’s disease 4 (2.24%) and IBS with pain 4 (2.24%) patients (10). In a study Gonlachanvit S and Patcharatrakul T, 103 patients of chronic constipation from Thailand, 40% had faecal evacuation disorder and 11% also had associated slow transit constipation (22). In current study, type I dyssynergic defecations is most common 20 (17.4%) followed by type IV in 16 (13.9%), type II in 14 (12.2%) and type III in 3 (2.6%) patients. These findings were supported by study published in Zhao Y et al., from China in 82 chronic constipation patients. In this study type I was the most common (n=24) presented on HRAM according to Rao classification’s, followed by type IV (n=13), type II (n=12) and type III (n=11) (23). SRUS and rectal ulcerations were significantly positive correlations with defecatory disorder (correlation coefficient, r=0.41, p-value <0.001 and r=0.25, p-value=0.006 respectively). Present result supported by a study by Ghoshal UC et al., SRUS patients more often 17/40 (43%) had defecation disorder as compare to healthy. Patient with SRUS with abnormal BET had thicker internal anal sphincter (24).
In a population study from Turkey in 4002 subjects, 67.5% patients had pelvic floor disorders including faecal incontinence, constipation and faecal evacuation disorder (25). The present study showed that in 83 (72.2%) patients had abnormal anorectal manometry and almost half (46%) patients had defecatory disorders.
Limitation(s)
This study is important in clinical perspective but has a few limitations such as retrospective design, did not include healthy subjects for HRAM test as a control group. BET in left lateral position has been thought to be non physiological as compare to that in seated position. Another limitation of our study is lack of data on defecatory index in all the patients.
The present study showed that almost half (46%) patients had defecation disorders and type I dyssynergia was most common. Rectal ulcerations and SRUS were more common in patients with defecatory disorders. Type of dyssynergia is helpful for treatment because these patients respond to biofeedback therapy along with laxatives. More prospective studies are needed on this issue.
The authors thank to Mr. Vikas, Mr. Kaushal and Mr. Shri Chand, Technicians of Gastrointestinal Pathophysiology and Manometry Laboratory.
DOI: 10.7860/JCDR/2022/58112.16731
Date of Submission: May 30, 2022
Date of Peer Review: Jun 25, 2022
Date of Acceptance: Jul 26, 2022
Date of Publishing: Aug 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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