ANO RECTAL MANUALWord下载.docx

ANO RECTAL MANUALWord下载.docx

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Unpackingandsettingupyourinstrument3

Calibratingtheinstrument3

Usingyourinstrument3-10

Takingcareofyourinstrument11

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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.

（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