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Srinivas S, Trimble C, Driesbach S, Zahora P, Gasior A, Wood RJ, Halaweish I. Laxative Weaning Protocol for Patients With Functional Constipation: A Pilot Study. J Pediatr Surg 2024:S0022-3468(24)00263-X. [PMID: 38760307 DOI: 10.1016/j.jpedsurg.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Children with functional constipation require prolonged laxative administration for proper emptying. Whether these laxatives can be weaned after better functioning is achieved is unknown. We aim to describe a standardized protocol for stimulant laxative weaning and its early outcomes. METHODS Patients were candidates for weaning if they had been on a stable laxative dose for six months, defined as one bowel movement per day with no soiling, impaction, or enemas. Laxative dose was decreased by 10-25% with re-evaluation every two weeks. If patients remained well without constipation, dose was weaned further by 10-25%. If there were worsening of symptoms, lower dose was maintained for 3-6 months until re-evaluation. RESULTS There were a total of sixteen patients evaluated. Median age was 12.7 years [IQR: 11.7-15.3] with laxative duration of 8.0 years [IQR: 5.4-10.7]. All patients were on senna; some were on fiber. Median starting senna dose was 71.3 mg [IQR: 54.3-75.0] and median fiber dose was 5.5 g [IQR: 4.0-6.0]. As of most recent follow up, nine patients (56.3%) had weaned off laxatives in 3.7 months [IQR: 1.3-11.6]. For those still on laxatives, median reduction in dose was 41.4 mg [30.0-75.0], and over half weaned their dose by >50%. Almost all (90.9%) of those on high doses were able to wean. CONCLUSION A standardized laxative weaning process can be successful in patients with functional constipation, especially on high doses. Further prospective studies will be necessary to confirm the success of this protocol. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shruthi Srinivas
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Casey Trimble
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Sarah Driesbach
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Pooja Zahora
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Alessandra Gasior
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Richard J Wood
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Ihab Halaweish
- Department of Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Di Nardo G, Barbara G, Borrelli O, Cremon C, Giorgio V, Greco L, La Pietra M, Marasco G, Pensabene L, Piccirillo M, Romano C, Salvatore S, Saviano M, Stanghellini V, Strisciuglio C, Tambucci R, Turco R, Zenzeri L, Staiano A. Italian guidelines for the management of irritable bowel syndrome in children and adolescents : Joint Consensus from the Italian Societies of: Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP), Pediatrics (SIP), Gastroenterology and Endoscopy (SIGE) and Neurogastroenterology and Motility (SINGEM). Ital J Pediatr 2024; 50:51. [PMID: 38486305 PMCID: PMC10938778 DOI: 10.1186/s13052-024-01607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 03/18/2024] Open
Abstract
The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), whose prevalence has widely increased in pediatric population during the past two decades. The exact pathophysiological mechanism underlying IBS is still uncertain, thus resulting in challenging diagnosis and management. Experts from 4 Italian Societies participated in a Delphi consensus, searching medical literature and voting process on 22 statements on both diagnosis and management of IBS in children. Recommendations and levels of evidence were evaluated according to the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was reached for all statements. These guidelines suggest a positive diagnostic strategy within a symptom-based approach, comprehensive of psychological comorbidities assessment, alarm signs and symptoms' exclusion, testing for celiac disease and, under specific circumstances, fecal calprotectin and C-reactive protein. Consensus also suggests to rule out constipation in case of therapeutic failure. Conversely, routine stool testing for enteric pathogens, testing for food allergy/intolerance or small intestinal bacterial overgrowth are not recommended. Colonoscopy is recommended only in patients with alarm features. Regarding treatment, the consensus strongly suggests a dietary approach, psychologically directed therapies and, in specific conditions, gut-brain neuromodulators, under specialist supervision. Conditional recommendation was provided for both probiotics and specific fibers supplementation. Polyethylene glycol achieved consensus recommendation for specific subtypes of IBS. Secretagogues and 5-HT4 agonists are not recommended in children with IBS-C. Certain complementary alternative therapies, antispasmodics and, in specific IBS subtypes, loperamide and rifaximin could be considered.
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Affiliation(s)
- Giovanni Di Nardo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Osvaldo Borrelli
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Valentina Giorgio
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luigi Greco
- General Pediatrician, Heath Care Agency of Bergamo, Bergamo, Italy
| | | | - Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, Magna Graecia University, Catanzaro, Italy
| | - Marisa Piccirillo
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Silvia Salvatore
- Pediatric Department, "F. Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Michele Saviano
- General Pediatrician, Heath Care Agency of Naples, Naples, Italy
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, 40126, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, 40126, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rossella Turco
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Letizia Zenzeri
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University Federico II, Via S. Pansini 5, Naples, 80131, Italy.
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Barbara G, Cremon C, Bellini M, Corsetti M, Di Nardo G, Falangone F, Fuccio L, Galeazzi F, Iovino P, Sarnelli G, Savarino EV, Stanghellini V, Staiano A, Stasi C, Tosetti C, Turco R, Ubaldi E, Zagari RM, Zenzeri L, Marasco G. Italian guidelines for the management of irritable bowel syndrome: Joint Consensus from the Italian Societies of: Gastroenterology and Endoscopy (SIGE), Neurogastroenterology and Motility (SINGEM), Hospital Gastroenterologists and Endoscopists (AIGO), Digestive Endoscopy (SIED), General Medicine (SIMG), Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP) and Pediatrics (SIP). Dig Liver Dis 2023; 55:187-207. [PMID: 36517261 DOI: 10.1016/j.dld.2022.11.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 01/29/2023]
Abstract
The irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction. IBS is still associated with areas of uncertainties, especially regarding the optimal diagnostic work-up and the more appropriate management. Experts from 7 Italian Societies conducted a Delphi consensus with literature summary and voting process on 27 statements. Recommendations and quality of evidence were evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was defined as >80% agreement and reached for all statements. In terms of diagnosis, the consensus supports a positive diagnostic strategy with a symptom-based approach, including the psychological comorbidities assessment and the exclusion of alarm symptoms, together with the digital rectal examination, full blood count, C-reactive protein, serology for coeliac disease, and fecal calprotectin assessment. Colonoscopy should be recommended in patients with alarm features. Regarding treatment, the consensus strongly supports a dietary approach for patients with IBS, the use of soluble fiber, secretagogues, tricyclic antidepressants, psychologically directed therapies and, only in specific IBS subtypes, rifaximin. A conditional recommendation was achieved for probiotics, polyethylene glycol, antispasmodics, selective serotonin reuptake inhibitors and, only in specific IBS subtypes, 5-HT3 antagonists, 5-HT4 agonists, bile acid sequestrants.
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Affiliation(s)
- Giovanni Barbara
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy.
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010 Pisa, Italy
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham Digestive Diseases Biomedical Research Centre, Nottingham, United Kingdom
| | - Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; Gastroenterology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy
| | - Francesca Galeazzi
- Gastroenterology Unit, Azienda Ospedale Università di Padova, 35128 Padua, Italy
| | - Paola Iovino
- Gastrointestinal Unit Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Annamaria Staiano
- Department of Translational Medical Sciences-Section of Pediatric, University Federico II, 80100 Naples, Italy
| | - Cristina Stasi
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | | | - Rossella Turco
- Department of Translational Medical Sciences-Section of Pediatric, University Federico II, 80100 Naples, Italy
| | - Enzo Ubaldi
- Primary Care, Health Care Agency of Ascoli Piceno, Ascoli Piceno, Italy
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; Gastroenterology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy
| | - Letizia Zenzeri
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero Universitaria di Bologna, 40126 Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
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Colonic Function Investigations in Children: Review by the ESPGHAN Motility Working Group. J Pediatr Gastroenterol Nutr 2022; 74:681-692. [PMID: 35262513 DOI: 10.1097/mpg.0000000000003429] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
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Dyssynergic Defecation and Anal Sphincter Disorders in Children in High-Resolution Anorectal Manometry Investigation. J Pediatr Gastroenterol Nutr 2020; 71:484-490. [PMID: 32960538 DOI: 10.1097/mpg.0000000000002819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Dyssynergic defecation is a common disorder in children with functional constipation (FC) because of relaxation disorders of the sphincter apparatus and intra-rectal pressure during defecation. The aim of the study was to determine frequency and type of dyssynergic defecation and to assess pressure in the anal canal poles during simulated evacuation and function of puborectalis muscle in defecation in children with FC. METHODS Three-dimensional (3D) high-resolution anorectal manometries (3D HRAM) were performed in 131 children with FC. In the manometric test, resting pressure measurements were assessed in 4 measuring poles of the anal canal. RESULTS One hundred thirty-one children ages 5 to 17 years (mean age 10.2; SD ± 3.8; median 10) were involved in the study (69 girls and 62 boys). Dyssynergic defecation was shown in 106/131 (80.9%) examined children. A statistically significant difference between the age of examined children (P < 0.02) and intrarectal pressures at the anal canal measuring points (left P < 0.009, right P < 0.005, anterior P < 0.01) was found. Correlation between the residual pressure values in lateral anal canal measurement poles and intrarectal pressure was demonstrated in all types of dyssynergy (left: r = 0.69, P < 0.0005; right: r = 0.74, P < 0.0005). In a group of 53/131 (40.5%) children, 3D HRAM showed a rectal pressure increase during simulated defecation, because of the dysfunction of the puborectalis muscle. CONCLUSION The increase in sphincter pressure in lateral and posterior poles in I and II types of dyssynergia and in lateral poles in other types of dyssynergia may depend on relaxation disorders of the puborectalis muscle during defecation.
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Lu PL, Saps M. Advances in the Evaluation and Management of Childhood Functional Abdominal Pain. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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7
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Ghoshal UC, Sachdeva S, Pratap N, Verma A, Karyampudi A, Misra A, Abraham P, Bhatia SJ, Bhat N, Chandra A, Chakravartty K, Chaudhuri S, Chandrasekar TS, Gupta A, Goenka M, Goyal O, Makharia G, Mohan Prasad VG, Anupama NK, Paliwal M, Ramakrishna BS, Reddy DN, Ray G, Shukla A, Sainani R, Sadasivan S, Singh SP, Upadhyay R, Venkataraman J. Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology. Indian J Gastroenterol 2018; 37:526-544. [PMID: 30617919 PMCID: PMC6339668 DOI: 10.1007/s12664-018-0894-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/18/2018] [Indexed: 02/06/2023]
Abstract
The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.
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Affiliation(s)
- Uday C. Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | | | | | - Abhai Verma
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Arun Karyampudi
- Asian Institute of Gastroenterology, Hyderabad, 500 082 India
| | - Asha Misra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Philip Abraham
- P D Hinduja Hospital and MRC, and Hinduja Heathcare Surgical, Mumbai, 400 016 India
| | | | - Naresh Bhat
- Aster CMI Hospital, Bangalore, 560 092 India
| | | | | | - Sujit Chaudhuri
- Advanced Medicare Research Institute, Salt Lake, Kolkata, 700 091 India
| | - T. S. Chandrasekar
- Department of Gastroenterology, Medindia Hospitals, Nungambakkam, Chennai, 600 034 India
| | - Ashok Gupta
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014 India
| | - Mahesh Goenka
- Appollo Gleneagles Hospitals, Kolkata, 700 054 India
| | - Omesh Goyal
- Dayanand Medical College, Ludhiana, 141 001 India
| | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029 India
| | | | | | | | | | - D. N. Reddy
- Asian Institute of Gastroenterology, Hyderabad, 500 082 India
| | - Gautam Ray
- B R Singh Railway Hospital, Kolkata, 700 014 India
| | - Akash Shukla
- Lokmanya Tilak Municipal General Hospital and Medical College, Sion, Mumbai, 400 022 India
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Rectal Gas Volume Measured by Computerized Tomography Identifies Evacuation Disorders in Patients With Constipation. Clin Gastroenterol Hepatol 2017; 15:543-552.e4. [PMID: 27856363 PMCID: PMC5362281 DOI: 10.1016/j.cgh.2016.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Approximately one third of patients who present to gastroenterology care with constipation have rectal evacuation disorders. We aimed to compare rectal gas volume, measured by computerized tomography (CT), in constipated patients with and without rectal evacuation disorders. METHODS In a retrospective study, we collected data from 1553 patients with constipation, evaluated over 20 years. We analyzed data from 141 patients evaluated by anorectal manometry, balloon expulsion tests, and colon transit tests, collecting records of abdominal and pelvic CT examinations. Patients were classified into 3 subgroups: those with rectal evacuation disorders, slow-transit constipation, or normal-transit constipation. Two observers used standard CT software to identify variable regions of interest on each cross-sectional CT image that contained rectum and measured areas of gas in each slice; they then summated entire volumes of rectal gas. For the 3 groups, we compared rectal gas volume, maximal rectal gas transaxial area (measured by CT), and area of rectal gas (vertical) on the 2-dimensional abdominal film (scout) using the Kruskal-Wallis test. RESULTS The intraclass correlation coefficient between 2 observers' measurements of rectal gas volume was 0.99 (P < .001). There were overall group differences in rectal gas volume and the maximal rectal gas transaxial area (both P < .001). The median rectal gas volume was higher in patients with rectal evacuation disorders (13.84 cm3) than in patients with slow-transit (2.51 cm3) or normal-transit constipation (1.33 cm3, both P < .05). Similarly, the area of rectal gas, which correlated with the maximal rectal gas transaxial area (Spearman correlation coefficient, 0.7; P < .001), showed overall 3-group differences (P = .033), with greater areas of rectal gas on the abdominal scout film in patients with rectal evacuation disorders than in those with normal-transit constipation. CONCLUSIONS In an analysis of patients with constipation, we found rectal gas volume, determined by abdominal CT imaging, to be greater in patients with than without rectal evacuation disorders.
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Ghoshal UC, Verma A, Misra A. Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India. Indian J Gastroenterol 2016; 35:83-90. [PMID: 27041380 DOI: 10.1007/s12664-016-0631-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 03/01/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Data on fecal evacuation disorder (FED) causing chronic constipation (CC) is scanty in India. METHODS Prospectively maintained data of 249 consecutive patients with CC (Rome III) referred for investigations were retrospectively analyzed. RESULTS Of 249 patients (43.7 ± 16.2 years, 174 males), 135/242 (55.8 %), 57/249 (22.9 %), and 83/136 (61.0 %) had abnormal balloon expulsion test (>200 g), anorectal manometry [>100 mmHg resting pressure (n = 4), >167 mmHg squeeze pressure (n = 46), and both (n = 7)], and defecography (anorectal angle not opening by >15° during defecation, perineal descent ≥4 cm, and/or rectocele), respectively. Though 181/249 (72.6 %) had one test abnormality, 86/249 (34 %) had FED (greater than or equal to two abnormalities), 44/65 (67.6 %) of whom had a defecation index ≤1.4. Rome III criteria for irritable bowel syndrome were equally fulfilled by patients with and without FED [74/83 (89 %) vs. 117/144 (81.2 %); p = ns]. On univariate analysis, straining duration, prolonged straining [≥30 min; 21/39 (53.8 %) vs. 15/65 (23.1 %); p = 0.002], incomplete evacuation [75/77 (97.4 %) vs. 95/114 (83.3 %); p = 0.004], and >3 stools/week [60/75 (80 %) vs. 76/128 (60 %); p = 0.004] were commoner among the FED patients though age, gender, symptom duration, mucus, manual evacuation, and stool forms were comparable. Resting and squeeze pressures and balloon volume at maximum tolerable limit were higher, and the sphincter tended to be shorter in FED. Prolonged straining, incomplete evacuation, and squeeze pressure were significant on multivariate analysis. Manometry and defecography abnormalities were commoner among the female FED patients. CONCLUSION FED is not uncommon, which fulfills the Rome III criteria for IBS, and prolonged straining may be suggestive; abnormal defecography and manometry are commoner in female.
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Affiliation(s)
- Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India.
| | - Abhai Verma
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Asha Misra
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
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Arbuckle RA, Carson RT, Abetz-Webb L, Hyams J, Di Lorenzo C, Lewis BE, Gargon E, Kurtz C, Shiff SJ, Johnston JM. Measuring the symptoms of pediatric constipation and irritable bowel syndrome with constipation: expert commentary and literature review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2015; 7:343-64. [PMID: 24965712 DOI: 10.1007/s40271-014-0070-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Symptom measurement in pediatric chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) trials requires appropriately developed clinical outcome assessments (COAs). METHODS Literature was reviewed to identify symptom COAs meeting regulatory standards. Searches were conducted in Pubmed/Medline, EMBASE, and PsychINFO. Title/abstracts were reviewed to identify qualitative studies and those using COAs to measure pediatric CIC/IBS symptoms. Pediatric functional gastrointestinal experts provided input on relevant symptom-concepts to measure. RESULTS Review of 1,105 abstracts identified 1 relevant qualitative article and 113 articles including COAs. Symptoms most frequently measured in CIC studies were frequency of bowel movements, fecal incontinence/encopresis, abdominal pain, stool consistency, and painful defecation. Symptoms most frequently measured in IBS were abdominal pain, abdominal distention/bloating, stool consistency, frequency of bowel movements, and gas. Evidence of development/validity of COAs was limited. Expert feedback was broadly consistent with the literature. CONCLUSION Findings demonstrate consistency in the literature on key CIC/IBS symptoms to measure in pediatric trials, but existing COAs do not meet regulatory standards.
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Zhang SC, Wang WL, Su PJ, Jiang KL, Yuan ZW. Decreased enteric fatty acid amide hydrolase activity is associated with colonic inertia in slow transit constipation. J Gastroenterol Hepatol 2014; 29:276-83. [PMID: 23926887 DOI: 10.1111/jgh.12346] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Constipation is one of the most common chronic digestive complaints. Gastrointestinal transit studies have divided it into three patterns: normal transit, slow transit constipation (STC), and outlet obstruction. It has been demonstrated that STC patients respond poorly to standard therapies, and the etiology of STC remains poorly understood. Animal studies have also shown that fatty acid amide hydrolase (FAAH) controls intestinal motility through its putative receptors or non-receptor-mediated pathways. However, the role of FAAH in STC has not been elaborated. METHODS A case series was carried out on thirty-two STC patients fulfilling the Rome II criteria and on 24 controls. All of the subjects underwent a laparotomy in Shengjing Hospital. Colonic specimens were obtained and used for FAAH expression analysis, enzyme activity assay, and cannabinoid detection. RESULTS FAAH immunoreactivity occurred in the enteric neurons and in the surface epithelial and glands. The expression level and enzyme activity of FAAH in the STC group were both significantly lower than those in the control group (P < 0.05). The amounts of anandamide, 2-arachidonylglycerol, and palmitoylethanolamide, which are negatively correlated with enzyme activity, were significantly higher in the constipation group than that in the control group. In the STC group, cannabinoid receptor type 1 immunoreactivity occurred predominantly in the submucosal and myenteric fibers that were obviously strong and wave-like in their appearance. Enteric ganglions decreased or disappeared. CONCLUSIONS The tone of the enteric cannabinoids system is disturbed in STC, and the decreased enteric FAAH activity contributes to colonic inertia in STC.
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Affiliation(s)
- Shu-Cheng Zhang
- Department of Pediatric Surgery, Major Laboratory of Chinese Health Ministry for Congenital Malformations, Shengjing Hospital of China Medical University, Shenyang, China
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12
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The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial. BMC Pediatr 2013; 13:112. [PMID: 23914827 PMCID: PMC3750818 DOI: 10.1186/1471-2431-13-112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 06/17/2013] [Indexed: 12/13/2022] Open
Abstract
Background Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking. Methods/design A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria. Discussion This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care. Trial registration Current Controlled Trials NL30551.068.09
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13
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Nicolai MPJ, Fidder HH, Bekker MD, Putter H, Pelger RCM, Elzevier HW. Pelvic floor complaints in gastroenterology practice: results of a survey in the netherlands. Frontline Gastroenterol 2012; 3:166-171. [PMID: 24124626 PMCID: PMC3793542 DOI: 10.1136/flgastro-2012-100133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 02/28/2012] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The pelvic floor is an integrated structure; dysfunctions may lead to a wide range of symptoms, involving voiding, defecation and sexual functioning (SF). Functional symptoms such as constipation and lower abdominal pain are often caused by pelvic floor dysfunction (PFD), and they highly impact the quality of life. Multiple specialists are responsible for a specific part of the pelvic floor, but its treatment asks for a holistic approach. The authors are still unaware of gastroenterologists' knowledge on PFD or whether they are addressing pelvic floor complaints in their daily practice. DESIGN A 42-itemed anonymous questionnaire was mailed to all 402 members of the Dutch Society of Gastroenterology (gastroenterologists and residents-in-training). RESULTS 169 (42%) questionnaires were analysed. Most gastroenterologists address lower urinary tract symptoms in their history-taking, 92% in female patients and 84% in male patients. When patients indicate irritable bowel syndrome-like complaints, more than 60% of the physicians inquire about SF to their female patients, compared with 38% inquiries to male patients (p<0.001). A reason not to inquire about SF is a lack of knowledge about female and male sexuality (19% and 23%, respectively). Forty-six per cent of the respondents regard it rather important to receive more training on PFD in male patients versus 61% in female patients. CONCLUSION Awareness of PFD is not yet routinely integrated into the history taken by gastroenterologists.
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Affiliation(s)
| | - Herma H Fidder
- Department of Gastroenterology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Milou D Bekker
- Department of Surgery, Haaglanden Medical Center, the Hague, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob C M Pelger
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk W Elzevier
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
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Camilleri M. Inclusion criteria for pharmacodynamic and clinical trials in chronic idiopathic constipation: pitfalls in using Rome III for functional constipation. Therap Adv Gastroenterol 2011; 4:159-63. [PMID: 21694799 PMCID: PMC3105610 DOI: 10.1177/1756283x11401773] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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15
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King SK, Sutcliffe JR, Ong SY, Lee M, Koh TL, Wong SQ, Farmer PJ, Peck CJ, Stanton MP, Keck J, Cook DJ, Chow CW, Hutson JM, Southwell BR. Substance P and vasoactive intestinal peptide are reduced in right transverse colon in pediatric slow-transit constipation. Neurogastroenterol Motil 2010; 22:883-92, e234. [PMID: 20529207 DOI: 10.1111/j.1365-2982.2010.01524.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Slow-transit constipation (STC) is recognized in children but the etiology is unknown. Abnormalities in substance P (SP), vasoactive intestinal peptide (VIP) and nitric oxide (NO) have been implicated. The density of nerve fibers in circular muscle containing these transmitters was examined in colon from children with STC and compared to other pediatric and adult samples. METHODS Fluorescence immunohistochemistry using antibodies to NO synthase (NOS), VIP and SP was performed on colonic biopsies (transverse and sigmoid colon) from 33 adults with colorectal cancer, 11 children with normal colonic transit and anorectal retention (NAR) and 51 with chronic constipation and slow motility in the proximal colon (STC). The percentage area of nerve fibers in circular muscle containing each transmitter was quantified in confocal images. KEY RESULTS In colon circular muscle, the percentage area of nerve fibers containing NOS > VIP > SP (6 : 2 : 1). Pediatric groups had a higher density of nerve fibers than adults. In pediatric samples, there were no regional differences in NOS and VIP, while SP nerve fiber density was higher in sigmoid than proximal colon. STC children had lower SP and VIP nerve fiber density in the proximal colon than NAR children. Twenty-three percent of STC children had low SP nerve fiber density. CONCLUSIONS & INFERENCES There are age-related reductions in nerve fiber density in human colon circular muscle. NOS and VIP do not show regional variations, while SP nerve fiber density is higher in distal colon. 1/3 of pediatric STC patients have low SP or VIP nerve fiber density in proximal colon.
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Affiliation(s)
- S K King
- Department of General Surgery, Royal Children's Hospital, Melbourne, Australia
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Bower W, Swithinbank L, de Jong T, de Kort L, Marschall-Kehrel D. Assessment of non-neurogenic incontinence and lower urinary tract symptoms in adolescents and young adults. Neurourol Urodyn 2010; 29:702-7. [DOI: 10.1002/nau.20829] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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17
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Abstract
This review details our contemporary knowledge of the mechanisms underlying evacuatory disorders. There is confusion concerning terminology and classification, which is based upon both an incomplete understanding of the multiple mechanisms involved in evacuation, and that current tests to investigate it are not physiological. Nevertheless, despite the need for more research, significant advances have been made and current assessments can direct therapy.
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Affiliation(s)
- P J Lunniss
- Queen Mary University London, Barts and the London School of Medicine and Dentistry, London, UK.
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18
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van den Berg MM, Bongers MEJ, Voskuijl WP, Benninga MA. No role for increased rectal compliance in pediatric functional constipation. Gastroenterology 2009; 137:1963-9. [PMID: 19699738 DOI: 10.1053/j.gastro.2009.08.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 07/30/2009] [Accepted: 08/13/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Increased rectal compliance has been proposed to contribute to pediatric functional constipation (FC). We evaluated the clinical relevance of increased rectal compliance and assessed whether regular use of enemas improves rectal compliance in children with FC. METHODS A prospective longitudinal study was conducted on children (8-18 years old) with FC. Pressure-controlled rectal distensions were performed at baseline and at 1 year. Rectal compliance was categorized into 3 groups: normal, moderately increased, or severely increased. Patients were randomly assigned to groups given conventional therapy or rectal enemas and conventional therapy. Clinical success was defined as >or=3 spontaneous defecations per week and fecal incontinence <1 per week. RESULTS Baseline measurements were performed in 101 children (11.0 +/- 2.1 years); rectal compliance was normal in 36%, moderately increased in 40%, and severely increased in 24%. Patients with severely increased rectal compliance had lower defecation frequency (P = .03), more fecal incontinence (P = .04), and more rectal fecal impaction (P < .001). After 1 year, success values were similar between groups: 42% normal, 41% moderately increased, and 40% with severely increased compliance. Barostat studies performed after 1 year in 80 children (37 conventional therapy and 43 rectal enemas in addition to conventional therapy) revealed that rectal compliance had not changed in either group and had not improved in successfully treated patients. CONCLUSIONS Constipated children with severely increased rectal compliance have severe symptoms. However, increased rectal compliance is not related to treatment failure. Regular use of enemas to avoid rectal fecal impaction does not improve rectal compliance in pediatric FC.
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Affiliation(s)
- Maartje M van den Berg
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands.
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Southwell BR, Clarke MCC, Sutcliffe J, Hutson JM. Colonic transit studies: normal values for adults and children with comparison of radiological and scintigraphic methods. Pediatr Surg Int 2009; 25:559-72. [PMID: 19488763 DOI: 10.1007/s00383-009-2387-x] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2009] [Indexed: 12/17/2022]
Abstract
The sitz or plastic marker study for colonic transit has been around for many years. It is applicable where an X-ray machine exists, is widely used and is accepted as the gold standard for diagnosing constipation. Recently, radiopharmaceutical methods have been developed. The theme of this review is their possible roles in the assessment of paediatric bowel motility disorders in patients presenting to paediatric surgeons. This review presents data on total and segmental transit in normal adults and children and comparing the two techniques in adults. Reliability and reproducibility are presented. Normative data for colonic transit in adults and children are discussed and parameters for assessing abnormal transit are reviewed. Normal colonic transit takes 20-56 h. Plastic marker studies are more readily accessible, but the assessment may be misleading with current methods. Plastic markers show faster transit than scintigraphy. It is difficult to compare the two techniques because methods of reporting are different. Using scintigraphy, repeatability is good. Separation of normal from slow transit in the ascending colon is apparent at 24 and 48 h, but the determination of transit through the distal colon/rectum in adults may require studies of more than 7 days. In conclusion, plastic marker studies and scintigraphy show similar transit rates in young adults and children. However, scintigraphy has advantages of allowing transit through the stomach and small intestine to be measured and has proved useful in the diagnostic workup of children with intractable constipation.
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Affiliation(s)
- Bridget R Southwell
- Surgical Research Group, Gut Motility Laboratory, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC 3052, Australia.
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20
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Sutcliffe JR, King SK, Hutson JM, Cook DJ, Southwell BR. Gastrointestinal transit in children with chronic idiopathic constipation. Pediatr Surg Int 2009; 25:465-72. [PMID: 19418059 DOI: 10.1007/s00383-009-2374-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2009] [Indexed: 12/18/2022]
Abstract
UNLABELLED Chronic constipation in children is common and produces significant morbidity. Identification of the site of dysmotility in constipation may determine the cause and permit directed management. Scintigraphy differentiates constipated patients with anorectal hold-up from those with colonic slowing. Adults with colonic slowing demonstrate variation in the site of hold-up. However, in children with colonic slowing, variability in the site of hold-up has not been investigated. PURPOSE The current study aimed to characterise colonic transit patterns in 64 children with chronic idiopathic constipation. METHODS Scintigraphic images were grouped visually by their transit patterns. Intra-observer variation was assessed. Scintigraphic data were analysed quantitatively. RESULTS Visual analysis of scintigraphy studies demonstrated normal transit (11/64), anorectal hold-up (7/64) and slow colonic transit (46/64). Transit characteristics in the slow transit group demonstrated three possible subgroups: pancolonic slowing (28/46), discrete hold-up in the transverse colon (10/46) and abnormal small and large bowel transit (8/46). Kappa testing demonstrated consistent characterisation (k = 0.79). Statistical analysis of scintigraphic data demonstrated highly significant differences from normal (P < 0.001) in the subgroups. CONCLUSION Scintigraphy demonstrates three possible transit patterns in children with chronic constipation secondary to slow colonic transit.
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21
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Abstract
PURPOSE The aim of our study was to evaluate patients referred for care of chronic constipation. We compared results of the anorectal manometry studies with a patient/guardian questionnaire about the patients' constipation. PATIENTS AND METHODS From patients seen for constipation in the department of pediatric gastroenterology, 123 were prospectively enrolled and they completed symptom questionnaires. These patients already were treated with stool softeners, either by the referring primary care physician or by the referring gastroenterologist. Anorectal manometry was performed per standard protocol. RESULTS Of the 123 patients enrolled in the study, 57.7% were male. Patient age ranged from 0.2 to 17.8 years, and the mean age was 7.5 years. The average duration of constipation was 4.84 years. The average number of stools per week was 3.6. Average time spent in the defecation process was 13.3 minutes. The incidence of hematochezia was 30%. Delayed passage of meconium was reported in 45 of 99 patients (45.5%). Significant correlation was found between frequency of soiling and threshold for rectoanal inhibitory reflex (P = 0.029). The volume of first urge also was positively correlated with frequency of soiling (P = 0.034). There was significant correlation of withholding behavior and the maximum volume tolerated (P = 0.020). The presence of blood in stool was inversely correlated with the maximum volume tolerated (P = 0.004). No correlation was found between severity of complaints and the presence of paradoxical puborectalis contraction. Of the patients, 90.5% had paradoxical puborectalis contraction. CONCLUSIONS Significant correlation was found between frequency of soiling and rectoanal inhibitory reflex, as well as soiling and volume of first urge. There was correlation between withholding behaviors and maximum volume tolerated. The presence of blood inversely correlated with maximum volume tolerated. Anorectal manometry continues to provide additional new information and to assist in managing patients with this common chronic pediatric affliction.
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Chao HC, Chen SY, Chen CC, Chang KW, Kong MS, Lai MW, Chiu CH. The impact of constipation on growth in children. Pediatr Res 2008; 64:308-11. [PMID: 18414138 DOI: 10.1203/pdr.0b013e31817995aa] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The observation on the impact of constipation on nutritional and growth status in healthy children was never reported. During a 4-y period, we evaluated the consequence of constipation on growth in children. The enrolled children were aged between 1 and 15 y with constipation. Medical response of constipation to treatment was evaluated by the scoring of constipation symptoms. The correlation of therapeutic effect of constipation with growth status at 12 wk and 24 wk was statistically evaluated. About 2426 children (1284 boys, 1142 girls) with a mean age of 7.31 +/- 3.65 (range 1.1-14.9) y were enrolled. After 12-wk treatment, significant increase of z-scores of height-for-age, weight-for-age, and body mass index-for-age were all found in patients with good medical responses (1377 cases) than in those with poor medical responses (1049 cases). The 1049 patients with poor medical response received advanced medications; significant increase of z-scores of height-for-age, weight-for-age, and body mass index were also found in these patients. A marked increase of appetite was significantly correlated with better gain on height and weight after treatment. We conclude that chronic constipation may retard growth status in children, and a long-term medication for constipation in children appears beneficial to their growth status.
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Affiliation(s)
- Hsun-Chin Chao
- Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Kweishan, Taoyuan 33305, Taiwan.
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Chitkara DK, Talley NJ, Locke GR, Weaver AL, Katusic SK, De Schepper H, Rucker MJ. Medical presentation of constipation from childhood to early adulthood: a population-based cohort study. Clin Gastroenterol Hepatol 2007; 5:1059-64. [PMID: 17632040 DOI: 10.1016/j.cgh.2007.04.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Constipation is a common disorder in children and adults, but the role of gender and early life risk factors remains undefined. The aims of the study were as follows: (1) to estimate the incidence of medical presentation for constipation in a population-based birth cohort, and (2) to examine factors associated with constipation presentation from childhood to adulthood. METHODS A birth cohort of all children born between 1976 and 1982 to mothers who were residents of Rochester, Minnesota, and who remained in the community until age 5 was used for this study. Medical visits for constipation were identified by diagnoses codes and chart review. Subjects were followed up based on their diagnoses accumulated while younger than 21 years old, and 80% of subjects remained in the area until 18 years of age. RESULTS Of 5299 birth cohort members without constipation presentation before age 5, the overall age- and sex-adjusted incidence was 3.9 per 1000 person-years. A higher incidence for constipation in females occurred beginning at 13 years to early adulthood (rate ratio, 2.6 for 13-16 y and 4.2 for 17 to <21 y). Children with a diagnosis for constipation at younger than 5 years of age had a significantly higher incidence for subsequent medical visits for constipation through adolescence and early adulthood compared with the incidence rate of children without an early medical presentation (rate ratio, 4.5 for 5-8 y, 2.5 for 9-12 y, and 3.9 for 17-20 y). CONCLUSIONS Early medical presentation and female sex influence incident and repeat medical visits for constipation from childhood to early adulthood.
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Affiliation(s)
- Denesh K Chitkara
- University of North Carolina Center for Functional GI and Motility Disorders, Division of Pediatric Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Chu WCW, Tam YH, Lam WWM, Ng AWH, Sit F, Yeung CK. Dynamic MR assessment of the anorectal angle and puborectalis muscle in pediatric patients with anismus: technique and feasibility. J Magn Reson Imaging 2007; 25:1067-72. [PMID: 17410575 DOI: 10.1002/jmri.20914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To assess the feasibility of dynamic breath-hold MRI for evaluating changes in the anorectal angle and movements of the pelvic-floor musculature (puborectalis) during resting and straining states in pediatric patients presenting with anismus. MATERIALS AND METHODS Six pediatric patients (7-13 years old) with chronic constipation and manometric evidence of anismus were assessed by dynamic breath-hold MRI. Changes in the anorectal angle, the degree of pelvic-floor descent, and the thickness and length of the puborectalis muscles were measured during rest and straining. The findings were compared with those obtained in six age- and sex-matched controls. RESULTS The children with anismus had a smaller anorectal angle during straining, and the angle decreased from rest to defecation. The puborectalis also became paradoxically shortened and thickened during straining in the anismus group. There were significant differences between the two groups in terms of the change of degree of the anorectal angle, and the thickness and length of the puborectalis muscle during straining. CONCLUSION Fast dynamic MRI is feasible for evaluating pelvic-floor movement in pediatric patients. Preliminary results suggest that children with anismus have a smaller anorectal angle and a different puborectalis configuration compared to controls.
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Affiliation(s)
- Winnie C W Chu
- Department of Diagnostic Radiology and Organ Imaging, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.
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Abstract
A practical approach to the management of chronic abdominal pain is needed, given the high prevalence and impact of this problem. This article describes an approach that has evolved based on clinical experience and review of the literature: identifying predominant bloaters and abdominal wall pain; exclusion of organic disease, including consideration of laparoscopy for diagnosis; consideration of chronic functional abdominal pain and the first and second line pharmacotherapies; and seeking specialist care in a pain clinic, psychiatry, or behavioural therapy.
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Affiliation(s)
- M Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Chitkara DK, Di Lorenzo C. From the bench to the 'crib'-side: implications of scientific advances to paediatric neurogastroenterology and motility. Neurogastroenterol Motil 2006; 18:251-62. [PMID: 16553581 DOI: 10.1111/j.1365-2982.2005.00751.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Paediatric gastrointestinal motility disorders may present in the neonatal period as the result of a congenital insult that occurred during embryonic development or as a manifestation of an abnormal genetic background. Functional gastrointestinal and motility disorders may also be acquired and present during childhood as the first presentation of a condition that can persist or re-occur throughout adolescence and adulthood. These disorders can have a significant psychological and financial impact on the lives of the affected children and their families. Recently, enteric neuroscience research has advanced the understanding of the pathogenesis and treatment of uncommon congenital or developmental gastrointestinal motility disorders such as Hirschsprung disease and chronic intestinal pseudo-obstruction. In addition, research has contributed to improvements in the understanding of more prevalent functional gastrointestinal disorders in children, such as chronic constipation and functional abdominal pain syndromes. The purpose of this review is to highlight these advances with particular regard to the clinical impact they have in the understanding and management of disorders in the field of paediatric neurogastroenterology and motility.
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Affiliation(s)
- D K Chitkara
- UNC Center for Functional GI and Motility Disorders, Division of Pediatric Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, 27599, USA.
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Eckardt VF. Is biofeedback therapy an effective treatment for patients with constipation? ACTA ACUST UNITED AC 2006; 3:198-9. [PMID: 16582960 DOI: 10.1038/ncpgasthep0448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 01/11/2006] [Indexed: 02/05/2023]
Affiliation(s)
- Volker F Eckardt
- Department of Gastroenterology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany.
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Bennani M, Belarbi N, Acharki M, Mouline H, Kanouni N, Amrani N. La place de la manométrie anorectale dans la démarche diagnostique et thérapeutique de la constipation rebelle. ACTA ACUST UNITED AC 2005. [DOI: 10.1007/bf03003926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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