Defaecation disorders in children, colonic transit time versus the Barr-score

Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement

Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.

Imaging in pediatric disorders of the gut-brain interactions: current best practice and future directions

INTRODUCTION

Disorders of Gut-Brain Interactions (DGBI) are a common clinical problem in children and pose significant challenges to the attending pediatrician. Radiological investigations are commonly ordered to evaluate these children.

AREA COVERED

This review focuses on the current best practice of using radiological investigations in DGBIs and how novel radiological investigations could revolutionize the assessment and therapeutic approach of DGBI in children.

EXPERT OPINION

We believe imaging in DGBI is still in its early stages, but it has the potential to revolutionize how we diagnose and treat children with DGBI. As the understanding of the gut-brain axis continues to grow, we can expect to see the disappearance of conventional imaging techniques and the emergence of more sophisticated imaging techniques with less radiation exposure in the future which provide more clinically meaningful information regarding the gut-brain axis and its influence on intestinal function. Some of the novel imaging modalities will be able to broaden our horizon of understanding DGBI in children providing more useful therapeutic options to minimize their suffering.

Inter and Intraobserver Variation in Interpretation of Fecal Loading on Abdominal Radiographs

OBJECTIVES

The current gold standard for the diagnosis of functional constipation is the ROME IV criteria. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN) guidelines do not support the use of abdominal X-rays in establishing the diagnosis of constipation. Despite these recommendations, abdominal radiography is frequently performed to diagnose constipation. The objective of our study is to evaluate inter and intraobserver variation in interpretation of fecal loading on abdominal radiographs.

METHODS

Electronic records of 100 children seen in the emergency room for gastrointestinal symptoms who had an abdominal radiograph performed were included. Four physicians from each specialty including gastroenterology, radiology, and emergency medicine interpreted the radiographs independently. Initially, subjective interpretations, followed by interpretations for intraobserver variation were obtained. Subsequently, all physicians were trained and asked to score the X-rays objectively using Barr and Blethyn scoring systems. Consistency between inter and intraobserver ratings of radiographic interpretation was evaluated using the Kappa coefficient ( k ) which ranges from 0 (no agreement) to 1.0 (perfect agreement).

RESULTS

For subjective interpretations, k values showed a fixed margin k of 0.18 indicating poor agreement among 12 observers. Intraobserver k to look for reproducibility showed significant variability ranging from 0.08 (poor) to 0.61 (fair) agreement. Objective scoring results for Blethyn showed a k of 0.14 indicating poor agreement among 12 providers.

CONCLUSIONS

Reliability and reproducibility of X-rays for diagnosis and grading of constipation is questionable given poor to fair agreement for both inter and intraobserver comparisons. Our study supports the current recommendation of ESPGHAN and NASPGHAN to not use abdominal X-rays to diagnose constipation.

Colonic Function Investigations in Children: Review by the ESPGHAN Motility Working Group

Disorders of colonic motility, most often presenting as constipation, comprise one of the commonest causes of outpatient visits in pediatric gastroenterology. This review, discussed and created by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Motility Working Group, is a practical guide, which highlights the recent advances in pediatric colonic motility testing including indications, technical principles of the tests, patient preparation, performance and basis of the results' analysis of the tests. classical methods, such as colonic transit time (cTT) with radiopaque markers and colonic scintigraphy, as well as manometry and novel techniques, such as wireless motility capsule and electromagnetic capsule tracking systems are discussed.

Bowel transit studies in children: evidence base, role and practicalities

Constipation is common in children and adults with varied worldwide prevalence. The majority of children have functional constipation as defined by Rome clinical criteria and respond favourably to standard medical therapy; up to one-third can develop difficult-to-treat constipation requiring investigation and specialist treatment. Colon function tests aim to assess the neuromuscular integrity, the movement of faeces across the colon and evaluate/predict response to the therapy. The 'ideal' test should be practical, non-invasive, widely available and cost-effective. None of the available diagnostic tools is designed to provide a comprehensive assessment of colon function and clinicians often have to combine more than one test to answer different questions. In this review, we aim to assess the strengths and limitations of the commonly available diagnostic investigations (radiopaque marker studies, scintigraphy, wireless motility capsule and colonic manometry) used to assess colon transit in children and to provide guidance on the most appropriate test for particular clinical settings.

Can unrecognized fecal loading without infrequent bowel movements be a cause of symptoms in a subset of patients with functional bowel disorders?

Infrequent bowel movements are a common feature of constipation, but fecal loading as a cause of symptoms in patients with regular bowel movements has not previously been evaluated. The aim of this preliminary study was to assess prospectively if fecal loading may be a cause of bowel symptoms in patients with regular bowel movements. Consecutive patients attending a gastroenterology clinic for functional bowel symptoms (FBD) not including infrequent bowel movements and who did not fulfil the criteria for constipation-predominant irritable bowel syndrome or functional constipation underwent plain abdominal radiography. Those with fecal loading received dietary advice and laxative treatment. The reproducibility of determination of fecal loading using the Leech score was assessed 'blindly' by a consultant radiologist. Twenty-six of 74 patients with FBD but not infrequent bowel movements had fecal loading demonstrated on abdominal radiology. Their Leech scores were significantly higher than those of control patients matched for age, sex and hospital (median 6 vs. 4, IQR 5-7 vs. 3.5-5, p < 0.001). Three out of 20 patients (15%) who returned for review after dietary advice and laxatives were asymptomatic and 17/20 (85%) had improved. Fecal loading may therefore cause bowel symptoms in patients who move their bowels regularly and dietary and laxative treatment may then improve these symptoms. This approach may prove cost-effective as an empirical interim measure especially where healthcare resources are limited and where sophisticated imaging is not readily available.

Diagnostic and clinical utility of the wireless motility capsule in children: A study in patients with functional gastrointestinal disorders

BACKGROUND

The wireless motility capsule (WMC) evaluates gastrointestinal motility and transit simultaneously. We evaluated the utility of the WMC in children with functional gastrointestinal symptoms.

METHODS

Study in children comparing WMC transit and motility parameters between those with upper (UGI) or lower (LGI) gastrointestinal symptoms, nuclear medicine gastric emptying time (NMGET) and/or a colonic radiopaque marker (CROM) study.

KEY RESULTS

We prospectively recruited 57 children (median age 16.45y, range 8.78-17.8y, 44 Female) and 50 completed the study (24 UGI/26 LGI). We found no association between WMC study interpretation, motility and transit parameters and symptoms. WMC and NMGET interpretation agreement observed in 24/34 (70%) (κ = 0.351, p = 0.026) and with CROM in 17/21 (81%) patients (κ = 0.576, p = 0.007). WMC detected abnormal gastric transit in 41% vs. 24% with NMGET (p = 0.04) and abnormal colon transit in 62% vs. 71% of patients by CROM (p = 0.01). We found significant correlation (r = 0.574, p = 0.01) and no difference in median colon transit (p = 0.421) by WMC and CROM. A single WMC motility parameter, mean peak amplitude, was associated with NMGET (p = 0.04), none with CROM. Capsule retention >5 days (n = 9, all passed <2 weeks) was associated with prolonged colon transit, not with symptoms, age and gender.

CONCLUSIONS

WMC is well tolerated in children as young as 8 years old. We found no association between WMC and symptoms, fair agreement with NMGET and strong agreement with CROM. WMC increases the yield of finding gastrointestinal transit abnormalities. Capsule retention in children is associated to prolonged colon transit. Larger studies are needed to further validate these findings.

Colonic stool burden on computed tomography does not correlate with bowel habit: a cross-sectional study

PURPOSE

Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function.

METHODS

Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians.

RESULTS

The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice.

CONCLUSIONS

Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis

BACKGROUND

functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods, including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of wireless motility capsules, and emerging magnetic resonance imaging (MRI) approaches.

OBJECTIVES

to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs.

METHODS

a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI.

CONCLUSIONS

emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs.

Diagnostic Tests in Pediatric Constipation

Constipation is one of the most common gastrointestinal symptoms in children. With a median reported prevalence of 12%, it accounts for about 25% of all pediatric gastroenterology consultations. The majority of children experiences functional constipation and do not usually require any diagnostic testing. For those children not responding to conventional medical treatment or in the presence of a more significant clinical picture, however, an accurate instrumental assessment is usually recommended to evaluate either the underlying pathophysiologic mechanisms or a possible organic etiology. The present review analyzes the possible diagnostic investigations for severely constipated children, focusing on their actual indications and their utility in clinical practice. During the last decade, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed and are discussed in this narrative review.

Home-Based Transabdominal Interferential Electrical Stimulation for Six Months Improves Paediatric Slow Transit Constipation (STC)

BACKGROUND

Transcutaneous electrical stimulation (TES) for one to two months has produced some improvement in treatment-resistant slow-transit constipation (STC) in children. Optimal parameters for treatment are not known. It is possible that more improvement would occur with stimulation for longer. This study examined the effectiveness of stimulation for six months.

METHODS

Children with STC confirmed by nuclear transit study (NTS) were enrolled prospectively. All had chronic constipation for greater than two years and had failed medical treatment. TES was performed for one hour/day for six months using the INF 4160 (Fuji Dynamics) portable stimulator and 4 cm × 4 cm electrodes near the belly button and on the back. Families kept bowel diaries and completed PEDSQLCore QOL (4.0) questionnaires before and at end of treatment.

RESULTS

Sixty-two children (34 females; seven years, 2-16 year) with STC were studied. Defecation frequency increased in 57/62 (91%, mean ± SEM pre- 1.49 ± 0.20 vs. post- 3.25 ± 0.25 defecation/week, p < 0.0001) with the number with ≥3BA increasing from 6 to 37 (10-59%). Soiling frequency decreased from 4.8 to 1.1 days/week (p <0.001). Abdominal pain decreased from 1.7 to 0.3 days/week (<0.0001), and spontaneous urge to defecate improved. Quality of life (p < 0.01), mean transit index and gastric emptying on NTS improved (p < 0.005).

CONCLUSION

Treatment-resistant STC responds to TES using interferential current across the abdomen when given daily for many months. Battery operated stimulators allowed stimulation at home for an hour each day. Stimulation for six months produced clinically significant improvement in defecation frequency, soiling, abdominal pain, urge to defecate, and quality of life in half of these chronic patients.

Delayed Diagnoses in Children with Constipation: Multicenter Retrospective Cohort Study

OBJECTIVE

The use of abdominal radiographs contributes to increased healthcare costs, radiation exposure, and potentially to misdiagnoses. We evaluated the association between abdominal radiograph performance and emergency department (ED) revisits with important alternate diagnosis among children with constipation.

STUDY DESIGN

Retrospective cohort study of children aged <18 years diagnosed with constipation at one of 23 EDs from 2004 to 2015. The primary exposure was abdominal radiograph performance. The primary outcome was a 3-day ED revisit with a clinically important alternate diagnosis. RAND/University of California, Los Angeles methodology was used to define whether the revisit was related to the index visit and due to a clinically important condition other than constipation. Regression analysis was performed to identify exposures independently related to the primary outcome.

RESULTS

A total of 65.7% (185 439/282 225) of children with constipation had an index ED visit abdominal radiograph performed. Three-day revisits occurred in 3.7% (10 566/282 225) of children, and 0.28% (784/282 225) returned with a clinically important alternate related diagnosis. Appendicitis was the most common such revisit, accounting for 34.1% of all 3-day clinically important related revisits. Children who had an abdominal radiograph performed were more likely to have a 3-day revisit with a clinically important alternate related diagnosis (0.33% vs 0.17%; difference 0.17%; 95% CI 0.13-0.20). Following adjustment for covariates, abdominal radiograph performance was associated with a 3-day revisit with a clinically important alternate diagnosis (aOR: 1.39; 95% CI 1.15-1.67). Additional characteristics associated with the primary outcome included narcotic (aOR: 2.63) and antiemetic (aOR: 2.35) administration and underlying comorbidities (aOR: 2.52).

CONCLUSIONS

Among children diagnosed with constipation, abdominal radiograph performance is associated with an increased risk of a revisit with a clinically important alternate related diagnosis.

Approach to Constipation in Children

PURPOSE

There is a scarcity of literature, and prevalent misconceptions about constipation in India.

METHODS

A literature search in PubMed was conducted with regard to epidemiology, clinical features, and management of constipation. Special emphasis was paid to functional constipation and refractory constipation. English language studies available full text over the last 25 years were considered and relevant information was extracted.

CONCLUSIONS

Estimated prevalence of constipation is 3% among toddlers and pre-school children worldwide and 95%, of them are considered functional. A careful history and thorough physical examination is all that is required to diagnose functional constipation. Management includes disimpaction followed by maintenance therapy with oral laxative, dietary modification and toilet training. A close and regular follow-up is necessary for successful treatment. In most of the cases laxative needs to be continued for several months and sometimes years. Early withdrawal of laxative is the commonest cause of recurrence. Refractory constipation is less common in primary care set up. Radiological colon transit study is useful in picking up Slow transit constipation. Antegrade continence enema plays an important role in the management of slow transit constipation.

RELIABILITY OF BARR, LEECH, AND BLETHYN SCORE IN USING OF PLAIN RADIOGRAPHY IN DETERMINING FECAL IMPACTION IN CHILDREN WITH AND WITHOUT CONSTIPATION

BACKGROUND

- Several scoring was developed for evaluation of children with fecal retention using plain radiograph. There are controversies about specificity and sensitivity of these scoring system.

OBJECTIVES

- The aim of this study was to evaluate Barr, Blethyn, and Leech score in evaluation of fecal load in plain radiograph.

METHODS

- This case control study was conducted on children aged 2-14 years old with abdominal pain who visited Abuzar children's Hospital of Ahvaz University of Medical Sciences. This study was conducted in fall season. Children with history of previous abdominal surgery, any systemic illness including sickle cell anemia were excluded. Children with constipation were placed in case group. Subjects without constipation were placed in control group. Subjects without exclusion criteria were examined by physician who is blind to aim of the study. Careful history and physical examination was done. Demographic features, history of gastrointestinal problem, duration of abdominal pain, defecation habit, stool consistency (loose, hard), and results of physical examination were recorded. Rome III criteria was used for definition of constipation. Abdominal x-ray was ordered for each patients. Abdominal radiography was reviewed by radiologist. Barr, Leach, and Blethyn scores were calculated for each case.

RESULTS

- In this study 102 children with functional constipation and 102 children without constipation as a control were included. Mean ±SD for case and control group was 68.39±34.88 and 69.46±32.60 (P=0.82).Leech score (mean ±SD) was 11.05±2.177 and 5.67±3.228 for case and control group respectively (P<0.0001). Barr score (mean ±SD) was 14.86±3.54 and 7.16±5.59 for case and control group respectively (P=<0.0001). Blethyn (mean ±SD) score was 1.97±0.667 and 1.04±0.900 for case and control group respectively (P=0.000). Sensitivity and specificity of Barr score was 83% and 79% respectively. Sensitivity and specificity of Leech score was 92% and 80% respectively. Sensitivity and specificity of Blethyn score was 79% and 92% respectively.

CONCLUSION

- Barr, Blethyn and Leech scores were significantly higher in children with abdominal pain and constipation in contrast to children with abdominal pain and without constipation. Sensitivity of Leech score was more than Barr and Blethyn scoring systems. Specificity of Blethyn score was more than Barr and Leech score.

How to use a plain abdominal radiograph in children with functional defecation disorders

Defecation-related functional gastrointestinal disorders (FGIDs), such as infant dyschezia, functional constipation and functional non-retentive faecal incontinence, as defined by the Rome IV criteria, are common problems in childhood. The symptomatology varies from relatively mild, such as crying before passage of soft stools or infrequent defecation to severe problems with faecal impaction and the daily involuntary loss of faeces in the underwear. Conventional radiography is widely available, relatively cheap and is non-invasive. The drawback however, is radiation exposure. This review describes and evaluates the value of different existing scoring methods to assess faecal loading on an abdominal radiograph with or without the use of radio-opaque markers, to measure colonic transit time, in the diagnosis of these defecation-related FGIDs. Insufficient evidence exists for a diagnostic association between clinical symptoms of functional constipation or functional nonretentive faecal incontinence and faecal loading on an abdominal radiograph. Furthermore, evidence does not support the routine use of colonic transit studies to diagnose functional constipation. Colonic transit time measurement may be considered in discriminating between functional constipation and functional non-retentive faecal incontinence and in patients in which the diagnosis is not clear such as having an unreliable medical history. In children with the suspicion of defecation-related FGIDs, the diagnosis should be made based on the Rome IV criteria.

Functional Disorders: Children and Adolescents

Characterization of childhood and adolescent functional gastrointestinal disorders (FGIDs) has evolved during the two decade long Rome process now culminating in Rome IV. The era of diagnosing a FGID only when organic disease has been excluded is waning,as we now have evidence to support symptom-based diagnosis. In child/adolescent Rome IV we extend this concept by removing the dictum that there was "no evidence for organic disease" in all definitions and replacing it with "after appropriate medical evaluation the symptoms cannot be attributed to another medical condition". This change allows the clinician to perform selective or no testing to support a positive diagnosis of a FGID. We also point out that FGIDs can coexist with other medical conditions that themselves result in gastrointestinal symptoms (e.g., inflammatory bowel disease). In Rome IV functional nausea and functional vomiting are now described. Rome III "abdominal pain related functional gastrointestinal disorders" (AP-FGID) has been changed to functional abdominal pain disorders (FAPD) and we have derived a new term, "functional abdominal pain -not otherwise specified", to describe children who do not fit a specific disorder such as irritable bowel, functional dyspepsia, or abdominal migraine. Rome IV FGID definitions should enhance clarity for both clinicians and researchers.

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).

OBJECTIVE

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

RECOMMENDATIONS

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Management of Functional Constipation in Children: Therapy in Practice

Functional constipation is a common healthcare problem among children worldwide and accounts for high healthcare usage and costs. Functional constipation is a clinical diagnosis; the evaluation primarily consists of a thorough medical history and a complete physical examination. Additional investigations are not necessary in most cases. Treatment consists of non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training (with a reward system), and a defecation diary. Pharmacological treatment comprises three steps: disimpaction, maintenance treatment, and weaning. The treatment of first choice is oral laxatives, preferably polyethylene glycol. When this is insufficient, other therapeutic agents are available. This review discusses the evaluation and management of functional constipation in the pediatric population and provides a summary of drug treatment options.

Transabdominal ultrasound measurement of rectal diameter is dependent on time to defecation in constipated children

AIM

To study whether diurnal variations and time in relation to defecation has to be taken into account when measurements of rectal diameter are used to determine faecal impaction in constipated children.

METHODS

Repeated ultrasound measures of rectal diameter were performed in 28 children (14 constipated/14 healthy, aged between 4 and 12 years) every third hour during 24 h. After defecation, three additional scans were performed at 1-h intervals.

RESULTS

No diurnal variation in rectal diameter was found in the healthy group. In the constipated group, mean rectal diameter was significantly larger at 2 pm (P = 0.038) and 5 pm (P = 0.006). There were significant differences between rectal diameter in the healthy group and the constipated group at 2 pm (P = 0.016) and 5 pm (P = 0.027). When we omitted the rectal diameter of five constipated children who had their first bowel movement after 5 pm, there were no difference between groups (2 pm (P = 0.103)/5 pm (P = 0.644) ). Only in the constipated group, rectal diameter exceeded 3 cm without the patients feeling the urge to defecate.

CONCLUSION

We found no independent daily variation in either group without relation to defecation. There was a relation between defecation and changes in rectal diameter in both healthy children and constipated children during maintenance treatment.Asking for defecation signals before scanning should be considered a routine question, and a positive answer should cause postponement of the scan.

Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC)

Slow-transit constipation (STC) is a newly described subtype of intractable constipation in children which we originally identified with deficiency of substance P in axons supplying the proximal colonic muscle. When nuclear transit studies became available, the patients were found to have slow proximal colonic transit, and responded to antegrade enemas. Using the appendicostomy, we found that there was reduced frequency in propagating sequences throughout the colon. We began testing whether transcutaneous electrical stimulation (TES) could improve motility and symptoms, and over several trials have now shown that TES is remarkably effective in treating children with STC, with long-lasting effects. TES holds promise for treating STC, as well as a range of gastrointestinal motility disorders.

Predictors of slow colonic transit in children

PURPOSE

Slow transit constipation (STC) and functional fecal retention (FFR) are two forms of severe intractable constipation in childhood diagnosed by nuclear transit studies (NTS). This retrospective study aims to identify the predicting factors for STC and FFR by looking at the association with neuropsychiatric disorders (NPD), obesity, family history of constipation and atopic disease.

PATIENTS AND METHODS

A retrospective chart review was conducted on children with intractable constipation referred for NTS between 1st April 2003 and 1st April 2014. Comparisons were made between STC, FFR and normal transit patients with regards to NPD, obesity (BMI z score >95th percentile), family history of constipation in first and second-degree relatives and atopic disease which included food allergy, asthma and eczema.

RESULTS

Between 2003 and 2014, 97 patients were referred for a NTS. Out of 36 patients with NPD, 21 (58.3 %) had STC and 13 (36.1 %) had FFR (p < 0.05). 15.8 % of patients with constipation were obese, compared to 6.4 % in the general Australian paediatric population (p < 0.05). There was no significant association between constipation and atopic disease or family history.

CONCLUSION

Neuropsychiatric disorders, in particular autism, are useful predictors of STC and FFR in children. Obesity may be associated with a higher risk of developing chronic constipation.

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

BACKGROUND

Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.

METHODS

Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

RESULTS

This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.

CONCLUSIONS

This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Pediatric abdominal radiograph use, constipation, and significant misdiagnoses

OBJECTIVE

To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses.

STUDY DESIGN

We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score.

RESULTS

3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85).

CONCLUSIONS

Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.

Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review

OBJECTIVE

To perform a systematic review evaluating the value of abdominal radiography, colonic transit time (CTT), and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children.

STUDY DESIGN

Eligible studies were those assessing diagnostic accuracy of abdominal radiography, CTT, or rectal ultrasound scanning in children suspected for idiopathic constipation. Methodological quality of the included studies was assessed with the Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews checklist.

RESULTS

One systematic review summarized 6 studies on abdominal radiography until 2004. The additional 9 studies evaluated abdominal radiography (n = 2), CTT (n = 3), and ultrasound scanning (n = 4). All studies except two used a case-control study design, which will lead to overestimation of test accuracy. Furthermore, none of the studies interpreted the results of the abdominal radiography, ultrasound scanning, or CTT without knowledge of the clinical diagnosis of constipation. The sensitivity of abdominal radiography, as studied in 6 studies, ranged from 80% (95% CI, 65-90) to 60% (95% CI, 46-72), and its specificity ranged from 99% (95% CI, 95-100) to 43% (95% CI, 18-71). Only one study presented test characteristics of CTT, and two studies presented test characteristics of ultrasonography.

CONCLUSION

We found insufficient evidence for a diagnostic association between clinical symptoms of constipation and fecal loading on abdominal radiographs, CTT, and rectal diameter on ultrasound scanning in children.

Constipation and colonic transit times in children with morbid obesity

OBJECTIVES

The aim of the study was to determine the frequency of functional constipation according to the Rome III criteria in children with morbid obesity and to evaluate by measuring colonic transit times (CTTs) whether decreased colonic motility is present in these children.

PATIENTS AND METHODS

Ninety-one children with morbid obesity ages 8 to 18 years, entering a prospective, randomized controlled study evaluating the effect of an outpatient versus inpatient treatment program of obesity, participated. All of the children filled out a standardized questionnaire regarding their bowel habits, and CTTs were measured using radioopaque markers. Food diaries were also recorded to evaluate their diet.

RESULTS

A total of 19 children (21%) had functional constipation according to the Rome III criteria, whereas 1 child had functional nonretentive fecal incontinence. Total CTT exceeded 62 hours in only 10.5% of the children with constipation, and among them, 2 had a total CTT of >100 hours. In the nonconstipated group 8.3% had a delayed CTT. Furthermore, no difference was found between the diet of children with or without constipation, specifically not with respect to fiber and fat intake.

CONCLUSIONS

Our study confirms a high frequency of functional constipation in children with obesity, using the Rome III criteria. However, abnormal colonic motility, as measured by CTT, was delayed in only a minority of patients. No relation was found between constipation in these children and fiber or fat intake.

Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods

BACKGROUND AND AIM

Abdominal x-rays are used diagnostically in the evaluation of children with constipation. However, their clinical utility has not been established. The aim of the study was to assess the accuracy of different methods in identifying children with functional constipation (FC) or nonretentive fecal incontinence (NRFI).

PATIENTS AND METHODS

Retrospective review of abdominal x-rays in which colonic transit (CT), Barr, Leech, and fecal loading (FL) scores were blindly measured by blinded pediatric gastroenterologists and a radiologist. Children were classified a priori as FC or NRFI.

RESULTS

One hundred sixty patients (125 FC, 35 NRFI) were studied. There were significant differences (P < 0.05) when comparing those with FC and those with NRFI: CT: 51 +/- 18 vs 40 +/- 21 hours; Barr: 14 +/- 5 vs 11 +/- 4; Leech: 10 +/- 2 vs 8 +/- 2; FL: 2 +/- 0.5 vs 1.7 +/- 0.4. More than 20% of FC had normal Barr and Leech scores, whereas >50% of NRFI had abnormal scores. CT discriminated better between FC and NRFI. There was a significant correlation (P < 0.05) between CT and Barr (0.45), Leech (0.41) and FL scores (0.36), and between Barr and Leech scores (r = 0.94). There was good intraobserver correlation between Barr, Leech, and FL scores but poor interobserver reproducibility.

CONCLUSIONS

Although significant differences in overall FC and NRFI scores exist, the discriminative value is low for all scores. There is poor interobserver reproducibility of the Barr, Leech, and FL scores. These findings confirm the limited value of the plain abdominal x-ray in the evaluation of children with constipation.

Simple diagnostic approach to childhood fecal retention using the Leech score and Bristol stool form scale in medical practice

BACKGROUND AND AIM

To assess fecal retention, plain abdominal radiography is frequently used to complement the clinical history and physical examination, and three scoring systems have been proposed by Barr, Blethyn, and Leech on a single abdominal radiography. The aim of the present study was to find simple and useful diagnostic tools for an approach to fecal retention by correlation of the three scoring systems with the clinical characteristics.

METHODS

This study included 76 children (5.6-15.4 years, male : female = 33:43) who presented with various gastrointestinal complaints and 20 healthy children from the years 2004-2008. Defecation characteristics, abdominal pain, anorexia and nausea, the Bristol stool form scale, and colonic transit time were studied. Plain abdominal radiographs were independently scored with the three scoring systems by a pediatrician and a radiologist.

RESULTS

The k-value of the Leech score (0.912) between two of the observers was higher than the others (Barr 0.870 and Blethyn 0.670), and the correlation coefficients of the Leech scoring system by a pediatrician in relation to the colonic transit time (r = 0.861, P < 0.001) and the Bristol stool form scale (r = -0.818, P < 0.001) were highest in the constipated children. Furthermore, there were statistically significant associations between the Leech scoring system and the defecation frequency per week (r = -0.569 and -0.625 in two observers) or abdominal pain (r = 0.574 and 0.567).

CONCLUSIONS

The Leech score and the Bristol stool form scale may be simple and useful diagnostic tools for pediatricians to access childhood fecal loading in outpatient clinics along with a thorough clinical history.

Starreveld scoring method in diagnosing childhood constipation

BACKGROUND

Four scoring methods exist to assess severity of fecal loading on plain abdominal radiographs in constipated patients (Barr-, Starreveld-, Blethyn- and Leech). So far, the Starreveld score was used only in adult patients.

OBJECTIVE

To determine accuracy and intra- and inter-observer agreement of the Starreveld scoring method in the diagnosis of functional constipation among pediatric patients. In addition, we compared the Starreveld with the Barr scoring method.

MATERIALS AND METHODS

Thirty-four constipated and 34 non-constipated children were included. Abdominal radiographs, obtained before treatment, were rated (Starreveld- and Barr) by 4 observers. A second observation after 4 weeks was done by 3 observers. Cut-off level for the Starreveld score, accuracy as measured by the area under the receiver operator characteristics curve, and inter- and intra-observer agreement were calculated.

RESULTS

Cut-off value for the Starreveld score was 10. AUC for Starreveld score was 0.54 and for Barr score 0.38, indicating poor discriminating power. Inter-observer agreement was 0.49-0.52 4 (Starreveld) and 0.44 (Barr), which is considered moderate. Intra-observer agreement was 0.52-0.71 (Starreveld) and 0.62- 0.76 (Barr).

CONCLUSION

The Starreveld scoring method to assess fecal loading on a plain abdominal radiograph is of limited value in the diagnosis of childhood constipation.

Constipation in pediatric cystic fibrosis patients: an underestimated medical condition

BACKGROUND

The aims of this study were to determine prevalence, risk factors and treatment of constipation in patients with Cystic Fibrosis (CF), as well as the diagnostic value of abdominal radiography.

METHODS

A cohort of 214 pediatric CF patients was investigated. Furthermore, 106 abdominal radiographs of CF patients with or without constipation were independently assessed by three observers on two separate occasions using the Barr and Leech scores.

RESULTS

The prevalence of constipation was 47%. Low total fat absorption and meconium ileus were independent risk factors for constipation in CF, while fiber and fluid intake were not associated. In CF patients the inter and intraobserver variabilities of the Barr and Leech scores were poor to moderate.

CONCLUSION

Constipation is a significant medical issue in CF and was associated with low total fat absorption and a history of meconium ileus. Finally, abdominal radiography seems of little value in the regular follow-up of CF patients.

Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG

OBJECTIVE

We hypothesized that enemas and polyethylene glycol (PEG) would be equally effective in treating rectal fecal impaction (RFI) but enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.

METHODS

Children (4-16 years) with functional constipation and RFI participated. One week before disimpaction, a rectal examination was performed, symptoms of constipation were recorded, and the first CTT measurement was started. If RFI was determined, then patients were assigned randomly to receive enemas once daily or PEG (1.5 g/kg per day) for 6 consecutive days. During this period, the second CTT measurement was started and a child's behavior questionnaire was administered. Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed.

RESULTS

Ninety-five patients were eligible, of whom 90 participated (male, n = 60; mean age: 7.5 +/- 2.8 years). Forty-six patients received enemas and 44 PEG, with 5 dropouts in each group. Successful disimpaction was achieved with enemas (80%) and PEG (68%; P = .28). Fecal incontinence and watery stools were reported more frequently with PEG (P < .01), but defecation frequency (P = .64), abdominal pain (P = .33), and behavior scores were comparable between groups. CTT normalized equally (P = .85) in the 2 groups.

CONCLUSION

Enemas and PEG were equally effective in treating RFI in children. Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI.

Diagnostic accuracy of the Barr and Blethyn radiological scoring systems for childhood constipation assessed using colonic transit time as the gold standard

BACKGROUND

Constipation is a common childhood symptom and abdominal radiography is advocated in diagnosis and management.

OBJECTIVE

To assess the reproducibility and diagnostic accuracy of the Barr and Blethyn systems for quantifying constipation on abdominal radiographs in children.

MATERIALS AND METHODS

Radiographs were scored by three observers of increasing radiological experience (student, junior doctor, consultant). Abdominal radiographs produced during measurement of colonic transit time (CTT) were classified as constipated or normal based on the value of the transit time, and were scored using both systems by observers blinded to the CTT. Abdominal radiographs obtained in children for reasons other than constipation were classed as normal and similarly scored. Reproducibility was measured using the kappa statistic. Diagnostic accuracy was measured using the area under the curve (AUC) for the receiver operator characteristic (ROC) curve.

RESULTS

Using either system, scores were higher for constipated children (P<0.01). The consultant produced higher scores than the other observers (P<0.01). Interobserver reproducibility was moderate with the best kappa value only 0.48. The best correlation between score and CTT was 0.51 (junior doctor scores). Diagnostic accuracy of the scores was only moderate, with the largest AUC for a ROC curve of 0.84 for the consultant using the Barr score.

CONCLUSIONS

Scoring of abdominal radiographs in the assessment of childhood constipation should be abandoned because it is dependent on the experience of the observer, is poorly reproducible, and does not accurately discriminate between constipated children and children without constipation.

The nervous system and gastrointestinal function

The enteric nervous system is an integrative brain with collection of neurons in the gastrointestinal tract which is capable of functioning independently of the central nervous system (CNS). The enteric nervous system modulates motility, secretions, microcirculation, immune and inflammatory responses of the gastrointestinal tract. Dysphagia, feeding intolerance, gastroesophageal reflux, abdominal pain, and constipation are few of the medical problems frequently encountered in children with developmental disabilities. Alteration in bowel motility have been described in most of these disorders and can results from a primary defect in the enteric neurons or central modulation. The development and physiology of the enteric nervous system is discussed along with the basic mechanisms involved in controlling various functions of the gastrointestinal tract. The intestinal motility, neurogastric reflexes, and brain perception of visceral hyperalgesia are also discussed. This will help better understand the pathophysiology of these disorders in children with developmental disabilities.

Blinded comparison of faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation

AIM

To compare faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation.

METHODS

The study group was a convenience sample of patients attending the Durham Constipation Clinic. All patients underwent transit studies according to an established protocol, and severity of constipation was assessed contemporaneously using a validated questionnaire (PAC-SYM). Transit studies were performed using radio-opaque markers that were ingested over 3 consecutive days, with a radiograph taken on the fourth day. Digital images of the radiograph were digitally altered to remove all traces of the transit markers without affecting the underlying pattern of faecal loading. Four observers assessed faecal loading independently; two clinicians (C1 and C2) and two radiologists (R1 and R2). C1 and R1 used a previously described formal scoring method of assessing faecal loading, whereas C2 and R2 assessed the images as if they were in a clinic or reporting session, grading the faecal loading as mild, moderate, or severe.

RESULTS

One hundred patients were recruited out of 186 presenting in a 2-year period. All patients completed assessments. The correlation between observers was only fair to moderate (r ranging from 0.34-0.51). There were some surprisingly marked disagreements in 10-18% of assessments. The correlation between faecal loading and transit was weak for all observers (r ranging from 0.261-0.311). Symptom severity did not correlate with faecal loading.

CONCLUSION

These results suggest that there is considerable inter-observer variation in the radiological assessment of faecal loading, irrespective of the training or method used by the observer, and that there is very poor correlation with colonic transit. The diagnosis of constipation, and the assessment of severity, is best performed clinically.

The usefulness of ultrasound examination of the bowel as a method of assessment of functional chronic constipation in children

BACKGROUND

Ultrasonographic assessment of stool retention in children with chronic constipation requires the diagnosis of megarectum.

OBJECTIVE

The aim of the study was to evaluate an atypical method of US assessment of megarectum, fecal impaction and enlarged colon in order to decide whether it can be used as an assessment method for children with functional chronic constipation.

MATERIALS AND METHODS

A total of 120 children with a positive diagnosis of chronic constipation were included in the study. All patients fulfilled the ROME II diagnostic criteria for defecation disorders. The control group comprised 105 patients with a normal defecation pattern. Children with a US diagnosis of megarectum, fecal impaction and enlarged colon were referred for proctoscopy and measurement of colonic transit time.

RESULTS

The transverse diameter of the rectal ampulla increases with age and thus influenced the US measurements in both the patient and control groups. The numerical values of this parameter differed significantly between patients and controls in all age groups. The rectopelvic ratio is the ratio of the width of the rectal ampulla (as seen by US) to the distance between the anterior superior iliac spines (measured externally using a measuring tape). This allows the definition of megarectum. In the diagnosis of fecal impaction, US showed a sensitivity of 88.3% relative to proctoscopy. In children with fecal impaction the colonic transit time, average segmental transit time for the rectum and sigmoid colon, and average segmental transit time for the left colon were significantly longer. There was no statistically significant difference for the right side of the colon.

CONCLUSION

US assessment of stool retention and overfilling of the colon in children with functional chronic constipation has a high correlation with proctoscopy findings and colonic transit time. The rectopelvic ratio can be used to diagnose megarectum in children with functional chronic constipation with a cut-off value of 0.189.

Gastrointestinal motility disorders in adolescent patients: transitioning to adult care

A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.

Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has formulated a clinical practice guideline for the management of pediatric constipation. The Constipation Guideline Committee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Guideline Committee also provided recommendations for management by the pediatric gastroenterologist.

The value of the abdominal radiograph in children with functional gastrointestinal disorders

Functional gastrointestinal disorder is a common problem in childhood. The symptoms vary from a relative mild gastrointestinal problem such as abdominal pain or infrequent defecation to severe problems with fecal impaction and fecal incontinence. The aim of this review is to describe and evaluate the value of the different existing methods to assess fecal loading on an abdominal radiograph with or without the use of radio-opaque markers in the diagnosis of functional abdominal pain, functional constipation and functional non-retentive fecal incontinence. In our opinion, the abdominal radiograph has limited value in the diagnostic work-up of children with functional gastrointestinal disorders.

Systematic assessment of constipation on plain abdominal radiographs in children

BACKGROUND

Constipation in childhood is common and its clinical assessment is often difficult. Plain abdominal radiography is simple and used to quantify constipation. Three scoring systems, those of Barr et al., Leech et al. and Blethyn et al., have been developed to quantify fecal loading on the abdominal radiograph.

OBJECTIVE

In order to determine which method is the most useful in clinical practice, we assessed the reproducibility of the three scoring systems.

MATERIALS AND METHODS

Plain abdominal radiographs from 40 clinically constipated children were retrospectively reviewed by two paediatric radiologists on two separate occasions. The radiographs were scored according to three different systems developed by Barr et al., Leech et al., Blethyn et al. Intraobserver variability and interobserver reproducibility were determined for each system. Kappa coefficients were calculated as indicators of inter- and intraobserver agreement for categorical outcome variables.

RESULTS

The Leech score showed the highest reproducibility: the intraobserver agreement was high for both observers (kappa values of 0.88 and 1.00, respectively, P<0.05). Furthermore, the interobserver agreement was also high: kappa 0.91 in the first round and 0.84 in the second.

CONCLUSIONS

The Leech score proved to be a highly reproducible tool for assessment of childhood constipation and is of value in clinical practice for systematic assessment of constipation on plain abdominal radiographs in children.

The Leech method for diagnosing constipation: intra- and interobserver variability and accuracy

BACKGROUND

The data concerning the value of a plain abdominal radiograph in childhood constipation are inconsistent. Recently, positive results have been reported of a new radiographic scoring system, "the Leech method", for assessing faecal loading.

OBJECTIVE

To assess intra- and interobserver variability and determine diagnostic accuracy of the Leech method in identifying children with functional constipation (FC).

MATERIALS AND METHODS

A total of 89 children (median age 9.8 years) with functional gastrointestinal disorders were included in the study. Based on clinical parameters, 52 fulfilled the criteria for FC, six fulfilled the criteria for functional abdominal pain (FAP), and 31 for functional non-retentive faecal incontinence (FNRFI); the latter two groups provided the controls. To assess intra- and interobserver variability of the Leech method three scorers scored the same abdominal radiograph twice. A Leech score of 9 or more was considered as suggestive of constipation. ROC analysis was used to determine the diagnostic accuracy of the Leech method in separating patients with FC from control patients.

RESULTS

Significant intraobserver variability was found between two scorers (P=0.005 and P<0.0001), whereas there was no systematic difference between the two scores of the other scorer (P=0.89). The scores between scorers differed systematically and displayed large variability. The area under the ROC curve was 0.68 (95% CI 0.58-0.80), indicating poor diagnostic accuracy.

CONCLUSIONS

The Leech scoring method for assessing faecal loading on a plain abdominal radiograph is of limited value in the diagnosis of FC in children.

Breath hydrogen test after a bean meal demonstrates delayed oro-cecal transit time in children with chronic constipation

OBJECTIVE

To evaluate oro-cecal transit time in children with chronic constipation.

METHODS

34 patients with chronic functional constipation age 3 to 13 years and 15 controls without constipation. Oro-cecal transit time was evaluated using the hydrogen breath test after ingestion of lactulose and after a standard meal of cooked beans. Total and segmental colonic transit times were measured with radiopaque markers.

RESULTS

Of 34 patients with chronic constipation 61.8% had increased total colonic transit time (>62 hours). Oro-cecal transit time measured with lactulose as substrate was similar (p=0.727) in constipated patients with increased colonic transit time (63.8+/-16.3 minutes), in constipated patients with normal colonic transit time (66.9+/-22.9 minutes), and in controls (65.3+/-15.5 minutes). Using a test meal of beans, the hydrogen breath test showed that oro-cecal transit time of constipated patients with increased total colon transit time was higher (252.4+/-23.2 minutes) than oro-cecal transit time of constipated patients with normal colonic transit time (227.7+/-39.6 minutes) or controls (205.3+/-23.3 minutes) (p<.05).

CONCLUSION

Hydrogen excretion in breath after a bean test meal showed delayed oro-cecal transit time in children with chronic constipation with abnormal total colonic transit time.

Prognosis of constipation: clinical factors and colonic transit time

BACKGROUND

Measurement of colonic transit time (CTT) is sometimes used in the evaluation of patients with chronic constipation.

AIM

To investigate the relation between symptoms and CTT, and to assess the importance of symptoms and CTT in predicting outcome.

METHODS

Between 1995 and 2000, 169 consecutive patients (median age 8.4 years, 65% boys) fulfilling the criteria for constipation were enrolled. During the intervention and follow up period, all kept a diary to record symptoms. CTT was measured at entry to the study.

RESULTS

At entry, defecation frequency was lower in girls than in boys, while the frequency of encopresis episodes was higher in boys. CTT values were significantly higher in those with a low defecation frequency (< or =1/week) and a high frequency of encopresis (> or =2/day). However, 50% had CTT values within the normal range. Successful outcome occurred more often in those with a rectal impaction. CTT results <100 hours were not predictive of outcome. However, those with CTT >100 hours were less likely to have had a successful outcome.

CONCLUSION

The presence of a rectal impaction at presentation is associated with a better outcome at one year. A CTT >100 hours is associated with a poor outcome at one year.

Total and segmental colonic transit time and anorectal manometry in children with chronic idiopathic constipation

BACKGROUND

Constipation is a frequent symptom in pediatric clinical practice, although the underlying pathogenesis is not fully understood. Estimating the colonic transit time may help identify subgroups of patients with different physiopathologic mechanisms.

METHODS

Thirty children with normal bowel habits and 38 children with chronic idiopathic constipation, aged 2 to 14 years, were studied. The total and segmental colonic transit times were estimated by administering multiple radiopaque markers for 6 days and performing a single abdominal radiograph on day 7. Anorectal function was evaluated using manometry with an Arhan probe.

RESULTS

The observed upper reference values were 19.02 hours for the right colon, 19 hours for the left colon, 32 hours for the rectosigmoid colon, and 45.7 hours for the total colon. Fifty percent of the children with chronic idiopathic constipation had colonic transit times within reference values, whereas 37% had left colonic and rectosigmoid delays and 13% had global delay in all colonic segments (colonic inertia). Paradoxic anal contraction was observed in 64% of the constipated children with distal delay but in none of the subjects with colonic inertia.

CONCLUSIONS

Estimating colonic transit time is a simple and noninvasive technique for classifying patients with constipation. Colonic inertia may be a manifestation of global motility dysfunction. Children with delayed distal colonic transits are more likely to have abnormal defecation dynamics.

Megarectum in constipation

BACKGROUND

Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding.

AIM

To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum.

METHODS

All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination.

RESULTS

A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls.

CONCLUSIONS

We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition

BACKGROUND

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers.

METHODS

The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method.

RESULTS

The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist.

CONCLUSIONS

This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Colonic transit time in constipated children: does pediatric slow-transit constipation exist?

In adults, slow-transit constipation is a well-established form of constipation with abdominal pain and an empty rectum on examination. Marker studies in these patients, mainly women, show a markedly slowed transit time in all colonic segments. No studies in constipated children are available that assess the existence of slow-transit constipation. In a prospective study, a total of 94 referred constipated pediatric patients, 63 boys and 31 girls (median age, 8.0 years), underwent colonic-transit-time measurements using radioopaque markers to evaluate the pattern of transit. In addition, orocecal-transit-time measurements using the hydrogen breath (lactulose) test, anorectal manometry, and behavior studies using the Child Behavior Checklist were performed in all children. Based on the upper limit (mean + 2 SD) of total colonic transit time (CTT) in constipated children, we arbitrarily separated patients into two groups. Children with CTTs > 100 h were said to have pediatric slow-transit constipation (PSTC), while patients with CTTs < 100 h were said to have normal- or delayed-transit constipation (NDTC). In 94 constipated children, PSTC was found in 24 children; in 70 children, total CTT was < 100 h (NDTC). Total and segmental CTTs were significantly prolonged in PSTC (median, 189 h; range, 104.4-384) versus NDTC (median, 46.8 h; range, 3.6-99.4) hours. No significant differences were found in orocecal transit time. Significant clinical differences in children with PSTC versus those with NDTC existed regarding nighttime soiling (71 vs. 11%); daytime soiling episodes (14 vs. 7 each week, median), and nighttime soiling episodes (5 vs. 0 each week, median); absent urge to defecate (33 vs. 14%); and palpable abdominal (71 vs. 39%) and/or rectal (71 vs. 13%) masses. All manometric parameters were comparable in the two groups, except for a significantly lower maximal squeeze pressure with PSTC. Using the Child Behavior Checklist, both groups differed significantly from controls (26 and 43%, respectively), with no significant differences in behavior problems found between the NDTC and the PSTC groups. In conclusion, based on objective marker studies, our findings suggest the existence of pediatric slow-transit constipation. This entity can be recognized by clinical features, most importantly nighttime soiling and a palpable rectal mass. The probability of PSTC with both of these symptoms was 0.82; in the absence of these two symptoms, it was 0.07. It is of interest that CTTs in PSTC are comparable with CTTs in adults with slow-transit constipation, although the clinical presentation is clearly different. Further studies are needed to investigate whether the prolonged CTT characterizes a distinct form of constipation in children or is an epiphenomenon of the underlying constipation itself. The mechanisms responsible for the slow transit in these children and the appropriate therapeutic approach need to be studied.