The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children

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.

Dyssynergic Defecation in Chronically Constipated Children in Korea

Purpose

Dyssynergic defecation (DSD) is one of the important causes of chronic constipation in children. We aimed to analyze the clinical features, diagnostic test results, and treatments for DSD in children.

Methods

Children diagnosed with DSD using fluoroscopic defecography were enrolled in this study. Clinical data, including the results of colon transit time (CTT) test and biofeedback (BF) therapy, were collected from medical records retrospectively.

Results

Nineteen children were enrolled. The median age was 9 years (6-18 years), the median frequency of bowel movement was 1/7 days (1-10 days), the median duration of constipation was 7.0 years (2-18 years), the median age of onset of constipation was 2.5 years (1-11 years). In the CTT test, outlet obstruction type was noted in 10/18 (55.6%), slow transit type in 5/18 (27.8%), and normal transit in 1/18 (5.6%). The median CTT was 52 hours (40-142 hours). Initial medical therapy was performed with the polyethylene glycol 4000, and the response was good in 9/19 (47.4%), fair in 9/19 (47.4%), and poor in 1/19 (5.0%). BF was performed in 8/19, with good results in 6/8 (75.0%) children and failure in 2/8 (25.0%) children. After long-term medical therapy (11/19), 3/5 showed good response with medication alone, 6/8 showed good response with BF and medication combined.

Conclusion

DSD should be considered as a cause of chronic constipation in children, especially in those with abnormal CTT test results. BF combined with medical therapy is effective even with age-limited cooperation.

Comparison of Anorectal Function as Measured with High-Resolution and High-Definition Anorectal Manometry

INTRODUCTION

Anorectal manometry (ARM) provides comprehensive assessment of pressure activity in the rectum and anal canal. Absolute pressure values might depend on the catheter used.

OBJECTIVE

Our aim was to compare the results obtained by different anorectal catheters in children with functional anorectal disorders.

METHODS

Children diagnosed with functional defecation disorders based on the Rome IV criteria were prospectively enrolled. ARM was performed in the supine position successively using 2 different probes in each patient in random order. Resting, squeeze pressures, and bear-down maneuver variables obtained by high-resolution (2-dimensional [2D]) and high-definition (3-dimensional [3D]) catheters were compared.

RESULTS

We prospectively included 100 children {mean age 7.5 [standard deviation (SD) ± 4.3] years; 62 boys}. Mean resting pressures were significantly higher when measured with the 3D than with the 2D catheter (71 [SD ± 19.4] vs. 65 [SD ± 20.1] mm Hg, respectively; p = 0.000). Intrarectal pressure measured by 3D and 2D catheters was similar (35 vs. 39 mm Hg, respectively; p = 0.761), but the percent of anal relaxation appeared to be higher for the 3D than for the 2D probe (12 vs. 5%, respectively; p = 0.002). Dyssynergic defecation (DD) was diagnosed in 41/71 patients (57.7%) using the 3D probe and in 51/71 children (71.8%) using the 2D probe (p = 0.044). Cohen's kappa showed only fair agreement between the catheters (κ = 0.40) in diagnosis of DD.

CONCLUSIONS

Our study demonstrated significantly different values of pressures obtained with different types of catheters. Normal ranges for conventional manometry cannot be applied to high-resolution systems, and results obtained by different types of manometry cannot be compared without adjustments (NCT02812823).

Value of Fluoroscopic Defecography in Constipated Children With Abnormal Colon Transit Time Test Results

Background/Aims

Colon transit time (CTT) test is regarded as the gold standard for evaluating colon transit function. Fluoroscopic defecography (FD) is a dynamic radiologic test to assess anorectal function. The aim is to evaluate the value of FD in constipated children with abnormal CTT test results.

Methods

Fifty-one children (27 girls) with a mean age of 9.8 ± 3.2 years who met Rome III criteria for constipation and older than 5 years with abnormal CTT test results underwent FD.

Results

Of 51 children, 27 (52.9%) showed positive findings on FD, including pelvic floor dyssynergia (PFD) (10/27, 37.0%), structural abnormality (15/27, 55.6%) (rectocele 53.3%, intussusception 33.3%, and both 13.4%), and both PFD and rectocele (2/27, 7.4%). In terms of CTT test subtype, of 35 children who had outlet obstruction type in CTT test, 19 (54.2%) had positive findings, including PFD (8/19, 42.1%), structural abnormality (9/19, 47.4%) (rectocele 55.6%, intussusception 22.2%, and both 22.2%), and both PFD and rectocele (2/19, 10.5%). Of the 16 children who had slow transit type of CTT test, 8 (50.0%) had positive findings, including PFD (2/8, 25.0%) and structural abnormality (6/8, 75.0%). Of the 6 children who had structural abnormality, 3 (50.0%) had rectocele and 3 (50.0%) had intussusception. For the 2 children (2/16, 12.5%) who had PFD, puborectalis muscle relax failure was found on FD. Puborectalis muscle relax failure was treated with biofeedback and medication. In the minor abnormalities, medication continued without additional therapeutic modalities.

Conclusions

FD was valuable for both diagnoses of underlying causes and interpretation of CTT test results in children with abnormal CTT test results. Therefore, this study suggests that FD and CTT tests should be incorporated into logical thinking for constipation in children.

Constipation: Beyond the Old Paradigms

Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.

Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation

Background/Aims

Chronic constipation is a common gastrointestinal disorder diagnosed using Rome III criteria. Defecography is a radiographic method used to identify anatomic abnormalities of anorectum. The present study aimed to evaluate the defecographic findings in patients with severe idiopathic chronic constipation.

Methods

One hundred patients, who complained of severe idiopathic chronic constipation with abnormal balloon expulsion test, underwent defecography after injection of barium. An analysis of radiographs was performed by an expert radiologist for the diagnosis of descending perineum syndrome, rectocele, enterocele, rectal ulcer, rectal prolapse, fecal residue of post defecation, and etc. Then, they were compared between the two sexes.

Results

Normal defecography was only observed in two participants. Descending perineum syndrome was the most common abnormality (73.3%). The results showed that rectocele (80.8%) and descending perineum syndrome (69.2%) were most frequent in women. In males, descending perineum syndrome and rectal prolapse were more prevalent (87% and 43.5%, respectively). Compared with men, rectocele and rectal ulcer were more frequently observed in women (p<0.001, and p=0.04, respectively), while men were more affected by descending perineum syndrome (p=0.04). In total, women had a greater incidence of abnormal defecographic findings compared with men (p=0.02).

Conclusions

Defecography can be performed to detect anatomic abnormalities in patients with severe idiopathic chronic constipation and abnormal balloon expulsion test. This technique can assist physicians in making the most suitable decision for surgical procedure.

Selecting appropriate gastroenteric contrast media for diagnostic fluoroscopic imaging in infants and children: a practical approach

In our experience, questions about the appropriate use of enteric contrast media for pediatric fluoroscopic studies are common. The purpose of this article is to provide a comprehensive review of enteric contrast media used for pediatric fluoroscopy, highlighting the routine use of these media at a large tertiary care pediatric teaching hospital.