Gastrointestinal motility disorders in children

Future horizons in the treatment of enteric neuropathies

Enteric neuropathies comprise a vast and disparate array of congenital and acquired disorders of the enteric nervous system (ENS), reflecting both the complexity of its neuronal composition and the many interactions that modulate its function. Although present therapeutic strategies, largely limited to surgery and the provision of artificial nutrition, have transformed the early survival and life of sufferers, levels of morbidity and mortality remain unacceptably high. This highlights the need to develop new treatments for enteric neuropathies. In the last decade, the tremendous advances in molecular biology and genetics have significantly enhanced our understanding of ENS development and function. Coupled with equivalent progress in the fields of pharmacology and stem-cell biology, this has led to the identification of novel tools and targets for therapy, which either aim to optimise the function of the intrinsic ENS or replace/replenish components of an inadequate or dysfunctional ENS. This article reviews current work on a number of these interventions with a particular focus on the use of ENS stem cells as potential therapeutic tools for enteric neuropathies.

Gastric emptying in infants: epigastric impedance versus scintigraphy

AIM

To compare epigastric impedance versus scintigraphy in monitoring the gastric emptying of the same adapted milk formula in infants.

METHODS

Seven infants with clinical symptoms of gastric motility disease underwent scintigraphy with 99mTc sulphur colloid for the 90 min following the ingestion of the same adapted milk formula, in order to evaluate gastric emptying. A bio-impedance device, connected to a PC, was prepared for this purpose with four standard electrodes placed anteriorly on the upper part of the body. The obtained graphs were compared to those of the scintigraphic method. Statistical analysis was performed using Pearson correlation. The confidence limits were set at 95%. Parental consent was obtained before each analysis.

RESULTS

The gastric emptying patterns obtained with epigastric impedance were closely correlated to those shown by the scintigraphy (r = 0.86 +/- 0.08; p < 0.05). A significant correlation between the gastric emptying velocity measured by the two techniques was found (r = 0.94; p = 0.002).

CONCLUSIONS

Epigastric impedance in infants provided estimates of gastric emptying that were closely correlated with scintigraphy. However, the limits derived from the epigastric impedance suggest that, at the moment, the two methods should not be used interchangeably.

Total colonic aganglionosis: a case study

Total colonic aganglionosis (TCA) is a rare, hybrid form of Hirschsprung's disease. It is a functional rather than mechanical obstruction, characterized by the absence of intrinsic ganglion cells in the myenteric and submucosal plexuses of the bowel wall. Ganglion cells regulate normal colonic peristaltic activity. Paucity of ganglion cells results in an aganglionic segment of bowel that is functionally abnormal and does not propagate the normal peristaltic wave that moves to it from the proximal ganglionic bowel. The lesion originates in the rectum and extends proximally over a variable distance of the bowel. The further the lesion extends, the more difficult the management becomes. Clinical and radiologic findings can be useful in diagnosis, but they are not pathognomonic. The definitive diagnosis is made following suction biopsy of the rectum, colon, and ileum. Ultimate treatment for TCA is surgical, although no single surgical procedure has been proven superior. Total parenteral nutrition during the postoperative period is essential to ensure appropriate fluid and electrolyte status. Improvements in supportive care and earlier recognition and diagnosis of TCA in infants have led to a significantly increased rate of survival since the lesion was first recognized. The embryology, pathogenesis, clinical presentation, diagnosis, management prognosis, and outcome of TCA are discussed. A case study is presented.

Chronic intestinal pseudo-obstruction: treatment and long term follow up of 44 patients

AIMS

To document the long term course of chronic idiopathic intestinal pseudo-obstruction syndrome (CIIPS) in children with defined enteric neuromuscular disease, and the place and type of surgery used in their management; in addition, to identify prognostic factors.

METHODS

Children with CIIPS were investigated and treated prospectively.

RESULTS

Twenty four children presented congenitally, eight during the 1st year of life, and 10 later. Twenty two had myopathy and 16 neuropathy (11 familial). Malrotation was present in 16 patients, 10 had short small intestine, six had non-hypertrophic pyloric stenosis, and 16 had urinary tract involvement. Thirty two patients needed long term parenteral nutrition (TPN): for less than six months in 19 and for more than six months in 13, 10 of whom are TPN dependent; 14 are now enteral feeding. Prokinetic treatment improved six of 22. Intestinal decompression stomas were used in 36, colostomy relieved symptoms in five of 11, and ileostomy in 16 of 31. A poor outcome (death (14) or TPN dependence (10)) was seen with malrotation (13 of 16), short small bowel (eight of nine), urinary tract involvement (12 of 16), and myopathic histology (15 of 22).

CONCLUSIONS

In CIIPS drugs are not helpful but decompression stomas are. Outcome was poor in 24 of 44 children (15 muscle disorder, 10 nerve disease).

Recurrent abdominal pain in children: a review of psychological factors and treatment

This paper reviews current knowledge regarding recurrent abdominal pain (RAP) and the physiological, dietary, and psychological variables that may have some influence in pain episodes. Emphasis is placed on psychological factors and studies that have investigated psychological treatment modalities. There is some limited evidence of physiological dysfunction in RAP patients, and while some researchers have asserted that RAP may be a dietary disorder, results of several studies do not support this assertion. Studies examining psychological variables in RAP patients show elevated anxiety levels; however, elevated anxiety is also associated with organic abdominal pain. Psychological treatments focusing on cognitive-behavioral methods have demonstrated success in treating RAP. Follow-up studies are needed to determine the long-term success of these treatments, and continued research examining which children benefit from treatment would also be beneficial.