{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T16:39:21Z","timestamp":1785775161113,"version":"3.56.0"},"reference-count":41,"publisher":"Elsevier BV","issue":"3","license":[{"start":{"date-parts":[[2024,3,1]],"date-time":"2024-03-01T00:00:00Z","timestamp":1709251200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/tdm\/userlicense\/1.0\/"},{"start":{"date-parts":[[2024,3,1]],"date-time":"2024-03-01T00:00:00Z","timestamp":1709251200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/legal\/tdmrep-license"}],"content-domain":{"domain":["clinicalkey.com","clinicalkey.com.au","clinicalkey.es","clinicalkey.fr","clinicalkey.jp","dldjournalonline.com","elsevier.com","sciencedirect.com"],"crossmark-restriction":true},"short-container-title":["Digestive and Liver Disease"],"published-print":{"date-parts":[[2024,3]]},"DOI":"10.1016\/j.dld.2023.06.004","type":"journal-article","created":{"date-parts":[[2023,6,30]],"date-time":"2023-06-30T15:37:39Z","timestamp":1688139459000},"page":"429-435","update-policy":"https:\/\/doi.org\/10.1016\/elsevier_cm_policy","source":"Crossref","is-referenced-by-count":18,"title":["Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests"],"prefix":"10.1016","volume":"56","author":[{"given":"Giuseppe","family":"Chiarioni","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9565-5039","authenticated-orcid":false,"given":"Christian","family":"Lambiase","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William E.","family":"Whitehead","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Rettura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Riccardo","family":"Morganti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan Lucian","family":"Popa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Massimo","family":"Bellini","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"78","reference":[{"key":"10.1016\/j.dld.2023.06.004_bib0001","doi-asserted-by":"crossref","DOI":"10.1053\/j.gastro.2020.04.014","article-title":"Worldwide prevalence and burden of functional gastrointestinal disorders, results of rome foundation global study","volume":"160","author":"Sperber","year":"2021","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0002","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1007\/BF01537261","article-title":"A longitudinal survey of self-reported bowel habits in the United States","volume":"34","author":"Everhart","year":"1989","journal-title":"Dig Dis Sci"},{"key":"10.1016\/j.dld.2023.06.004_bib0003","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1001\/archinte.1996.00440030117014","article-title":"Bowel habit in relation to age and gender. Findings from the National Health Interview Survey and clinical implications","volume":"156","author":"Harari","year":"1996","journal-title":"Arch Intern Med"},{"key":"10.1016\/j.dld.2023.06.004_bib0004","doi-asserted-by":"crossref","first-page":"3530","DOI":"10.1111\/j.1572-0241.1999.01642.x","article-title":"Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features","volume":"94","author":"Stewart","year":"1999","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0005","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1111\/j.1365-2036.2007.03376.x","article-title":"The burden of constipation on quality of life: results of a multinational survey","volume":"26","author":"Wald","year":"2007","journal-title":"Aliment Pharmacol Ther"},{"key":"10.1016\/j.dld.2023.06.004_bib0006","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1111\/j.1365-2036.2007.03370.x","article-title":"Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain","volume":"26","author":"Nyrop","year":"2007","journal-title":"Aliment Pharmacol Ther"},{"key":"10.1016\/j.dld.2023.06.004_bib0007","doi-asserted-by":"crossref","DOI":"10.1053\/j.gastro.2016.02.031","article-title":"Bowel disorders","volume":"150","author":"Lacy","year":"2016","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0008","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1111\/j.1365-2982.2009.01404.x","article-title":"Conservative and behavioural management of constipation","volume":"21 Suppl 2","author":"Whitehead","year":"2009","journal-title":"Neurogastroenterol Motil"},{"key":"10.1016\/j.dld.2023.06.004_bib0009","doi-asserted-by":"crossref","first-page":"1480","DOI":"10.1053\/j.gastro.2005.11.061","article-title":"Functional bowel disorders [published correction appears in Gastroenterology. 2006 Aug;131(2):688]","volume":"130","author":"Longstreth","year":"2006","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0010","first-page":"S1","article-title":"An evidence-based approach to the management of chronic constipation in North America","volume":"100 Suppl 1","year":"2005","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0011","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1038\/ajg.2010.69","article-title":"Bowel disorders","volume":"105","author":"Spiller","year":"2010","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0012","article-title":"Towards Improving Diagnosis of Dyssynergic Defecation: a Small Step or a New Paradigm? [published online ahead of print, 2022 Aug 30]","author":"Buchanan","year":"2022","journal-title":"Clin Gastroenterol Hepatol"},{"key":"10.1016\/j.dld.2023.06.004_bib0013","doi-asserted-by":"crossref","first-page":"1510","DOI":"10.1053\/j.gastro.2005.11.064","article-title":"Functional anorectal disorders","volume":"130","author":"Bharucha","year":"2006","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0014","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1053\/j.gastro.2005.05.015","article-title":"Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation","volume":"129","author":"Chiarioni","year":"2005","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0015","series-title":"Handbook of gastroenterologic procedures","first-page":"341","article-title":"Anorectal manometry and biofeedback","author":"Scarlett","year":"2005"},{"key":"10.1016\/j.dld.2023.06.004_bib0016","doi-asserted-by":"crossref","first-page":"2049","DOI":"10.1016\/j.cgh.2014.03.013","article-title":"Validation of the balloon evacuation test: reproducibility and agreement with findings from anorectal manometry and electromyography","volume":"12","author":"Chiarioni","year":"2014","journal-title":"Clin Gastroenterol Hepatol"},{"key":"10.1016\/j.dld.2023.06.004_bib0017","doi-asserted-by":"crossref","first-page":"809","DOI":"10.14309\/ajg.0000000000001647","article-title":"Innovative Balloon Expulsion Testing for Defecation Disorders: look Before Leaping the Old Path","volume":"117","author":"Bellini","year":"2022","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0018","article-title":"Can a defecation posture modifying device correct an abnormal balloon expulsion test in chronically constipated patients?","volume":"6","author":"Koo","year":"2022","journal-title":"Clin Gastroenterol Hepatol"},{"key":"10.1016\/j.dld.2023.06.004_bib0019","doi-asserted-by":"crossref","first-page":"e13582","DOI":"10.1111\/nmo.13582","article-title":"Anorectal physiology in health: a randomized trial to determine the optimum catheter for the balloon expulsion test","volume":"31","author":"Chiarioni","year":"2019","journal-title":"Neurogastroenterol Motil"},{"key":"10.1016\/j.dld.2023.06.004_bib0020","first-page":"209","article-title":"Defecography: a practical approach","volume":"16","author":"Faccioli","year":"2010","journal-title":"Diagn Interv Radiol"},{"key":"10.1016\/j.dld.2023.06.004_bib0021","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1053\/j.gastro.2005.11.014","article-title":"Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia","volume":"130","author":"Chiarioni","year":"2006","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0022","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1111\/nmo.12859","article-title":"Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients","volume":"28","author":"Palit","year":"2016","journal-title":"Neurogastroenterol Motil"},{"key":"10.1016\/j.dld.2023.06.004_bib0023","doi-asserted-by":"crossref","first-page":"1605","DOI":"10.1111\/j.1572-0241.2005.41845.x","article-title":"Clinical utility of diagnostic tests for constipation in adults: a systematic review","volume":"100","author":"Rao","year":"2005","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0024","doi-asserted-by":"crossref","first-page":"e13762","DOI":"10.1111\/nmo.13762","article-title":"European society of neurogastroenterology and motility guidelines on functional constipation in adults","volume":"32","author":"Serra","year":"2020","journal-title":"Neurogastroenterol Motil"},{"key":"10.1016\/j.dld.2023.06.004_bib0025","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1038\/ajg.2014.18","article-title":"Chronic constipation, irritable bowel syndrome with constipation and constipation with pain\/discomfort: similarities and differences","volume":"109","author":"Rey","year":"2014","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0026","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1111\/j.1572-0241.2006.00435.x","article-title":"Differences between painless and painful constipation among community women","volume":"101","author":"Bharucha","year":"2006","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0027","doi-asserted-by":"crossref","first-page":"749","DOI":"10.1053\/j.gastro.2013.07.014","article-title":"Rome III functional constipation and irritable bowel syndrome with constipation are similar disorders within a spectrum of sensitization, regulated by serotonin","volume":"145","author":"Shekhar","year":"2013","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0028","doi-asserted-by":"crossref","first-page":"2228","DOI":"10.1038\/ajg.2010.200","article-title":"Inability of the Rome III criteria to distinguish functional constipation from constipation-subtype irritable bowel syndrome","volume":"105","author":"Wong","year":"2010","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0029","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1097\/MCG.0b013e31820c6001","article-title":"Outcome of biofeedback therapy in dyssynergic defecation patients with and without irritable bowel syndrome","volume":"45","author":"Patcharatrakul","year":"2011","journal-title":"J Clin Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0030","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1097\/MCG.0b013e3182192230","article-title":"What's in a name? Putting patients first: biofeedback for irritable bowel syndrome patients with dyssynergic defecation","volume":"45","author":"Rao","year":"2011","journal-title":"J Clin Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0031","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1136\/gut.35.6.798","article-title":"Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation","volume":"35","author":"Grotz","year":"1994","journal-title":"Gut"},{"key":"10.1016\/j.dld.2023.06.004_bib0032","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1111\/j.1365-2982.2004.00526.x","article-title":"Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)","volume":"16","author":"Rao","year":"2004","journal-title":"Neurogastroenterol Motil"},{"key":"10.1016\/j.dld.2023.06.004_bib0033","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1016\/j.bpg.2011.01.004","article-title":"Biofeedback therapy for constipation in adults","volume":"25","author":"Rao","year":"2011","journal-title":"Best Practice Res Clin Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0034","doi-asserted-by":"crossref","DOI":"10.1053\/j.gastro.2019.12.034","article-title":"Mechanisms, evaluation, and management of chronic constipation","volume":"158","author":"Bharucha","year":"2020","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0035","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1186\/s12876-016-0556-7","article-title":"ChroCoDiTE Study Group, AIGO. Chronic constipation diagnosis and treatment evaluation: the \u201cCHRO.CO.DI.T.E.\u201d study","volume":"17","author":"Bellini","year":"2017","journal-title":"BMC Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0036","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1016\/j.cgh.2010.06.031","article-title":"Digital Rectal Examination Is a Useful Tool for Identifying Patients With Dyssynergia","volume":"8","author":"Tantiphlachiva","year":"2010","journal-title":"Clin Gastroenterol Hepatol"},{"key":"10.1016\/j.dld.2023.06.004_bib0037","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1038\/ajg.2010.70","article-title":"Anorectal disorders","volume":"105","author":"Bharucha","year":"2010","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0038","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1007\/BF02066978","article-title":"Anismus: the cause of constipation? Results of investigation and treatment","volume":"16","author":"Duthie","year":"1992","journal-title":"World J Surg"},{"key":"10.1016\/j.dld.2023.06.004_bib0039","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1111\/j.1572-0241.1999.00950.x","article-title":"Manometric tests of anorectal function in healthy adults","volume":"94","author":"Rao","year":"1999","journal-title":"Am J Gastroenterol"},{"key":"10.1016\/j.dld.2023.06.004_bib0040","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1053\/j.gastro.2003.10.044","article-title":"Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation","volume":"126","author":"Minguez","year":"2004","journal-title":"Gastroenterology"},{"key":"10.1016\/j.dld.2023.06.004_bib0041","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1038\/ajg.2015.153","article-title":"The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence","volume":"110","author":"Soh","year":"2015","journal-title":"Am J Gastroenterol"}],"container-title":["Digestive and Liver Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S1590865823007004?httpAccept=text\/xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S1590865823007004?httpAccept=text\/plain","content-type":"text\/plain","content-version":"vor","intended-application":"text-mining"}],"deposited":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T04:25:27Z","timestamp":1761625527000},"score":1,"resource":{"primary":{"URL":"https:\/\/linkinghub.elsevier.com\/retrieve\/pii\/S1590865823007004"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3]]},"references-count":41,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2024,3]]}},"alternative-id":["S1590865823007004"],"URL":"https:\/\/doi.org\/10.1016\/j.dld.2023.06.004","relation":{},"ISSN":["1590-8658"],"issn-type":[{"value":"1590-8658","type":"print"}],"subject":[],"published":{"date-parts":[[2024,3]]},"assertion":[{"value":"Elsevier","name":"publisher","label":"This article is maintained by"},{"value":"Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests","name":"articletitle","label":"Article Title"},{"value":"Digestive and Liver Disease","name":"journaltitle","label":"Journal Title"},{"value":"https:\/\/doi.org\/10.1016\/j.dld.2023.06.004","name":"articlelink","label":"CrossRef DOI link to publisher maintained version"},{"value":"article","name":"content_type","label":"Content Type"},{"value":"\u00a9 2023 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.","name":"copyright","label":"Copyright"}]}}