Functional Constipation and Dyssynergic Defecation in Children

Use of Digital Rectal Exam Compared With High-Resolution Anorectal Manometry in the Diagnosis of Dyssynergic Defecation in Pediatrics

BACKGROUND

Currently, high-resolution anorectal manometry (HRAM) is the only way to confirm the diagnosis of defecatory dyssynergia; however, it has limitations in pediatric patients. Digital rectal examination (DRE) may suggest the presence of defecatory dyssynergia based on clinical findings, but it is not a definitive diagnostic method. Its role in pediatric patients remains unexplored. The objective of this study was to determine the usefulness of DRE as a diagnostic test for dyssynergic defecation in pediatric patients compared with HRAM.

METHODS

Patients aged 5-18 years who were referred for HRAM in a third-level hospital in Mexico City between March 2022 and September 2022 were included. Altered propulsion or impaired push effort was considered a suggestive diagnosis of dyssynergia by DRE. The results were compared with those obtained using HRAM.

RESULTS

Forty-two patients were included, of whom 50% were male, with a median age of 10.68 years (standard deviation [SD] 3.23). Dyssynergia was diagnosed by DRE in 21 patients (50%) and by HRAM in 21 patients (50%). A sensitivity of 66% and a specificity of 66% were calculated for the alteration of rectal propulsion in DRE as suggestive of dyssynergia when compared to HRAM. A positive predictive value of 66% and a negative predictive value of 66% were calculated.

CONCLUSIONS AND INFERENCES

The sensitivity and specificity of DRE for the diagnosis of dyssynergic defecation were lower than those reported for adults (75% and 85%, respectively). In some cases, DRE would be useful, especially in low-resource scenarios where HRAM is not available, and we recommend DRE prior to HRAM as a complementary approach to dyssynergic defecation.

Functional constipation in children: What physicians should know

Functional constipation (FC) is considered the most common functional gastrointestinal disorder in children with a pooled global prevalence of 14.4% (95% confidence interval: 11.2-17.6) when diagnosed based on the Rome IV criteria. Its pathophysiological mechanisms are thought be multifactorial and complicated, resulting in difficult management. Currently, the most effective medication, when used in parallel with toilet training, is osmotic laxatives. Children's adherence to medication and parental concern regarding long-term laxative use are the main contributors to treatment failure. Recently, novel therapies with a high safety profile have been developed, such as probiotics, synbiotics, serotonin 5-hydroxytryptamine 4 receptor agonists, chloride channel activators, and herbal and transitional medicines; nonetheless, well-designed research to support the use of these therapies is needed. This review aims to focus on multiple aspects of FC in children, including global prevalence, pathogenesis, diagnostic criteria, tools, as well as conventional and novel treatment options, such as non-pharmacological management, including adequate fiber and fluid intake, physiotherapy, or neuromodulators. We also report that in very difficult cases, surgical intervention may be required.

Current use of complementary and conventional medicine for treatment of pediatric patients with gastrointestinal disorders

Infants, children, and adolescents are at risk of experiencing a multitude of gastrointestinal disorders (GID). These disorders can adversely affect the quality of life or be life-threatening. Various interventions that span the conventional and complementary therapeutic categories have been developed. Nowadays, parents increasingly seek complementary options for their children to use concurrently with conventional therapies. Due to the high prevalence and morbidity of diarrhea, constipation, and irritable bowel syndrome (IBS) in children, in this review, we decided to focus on the current state of the evidence for conventional and complementary therapies used for the treatment of these diseases in children. Diarrhea treatment focuses on the identification of the cause and fluid management. Oral rehydration with supplementation of deficient micronutrients, especially zinc, is well established and recommended. Some probiotic strains have shown promise in reducing the duration of diarrhea. For the management of constipation, available clinical trials are insufficient for conclusive recommendations of dietary modifications, including increased use of fruit juice, fiber, and fluid. However, the role of laxatives as conventional treatment is becoming more established. Polyethylene glycol is the most studied, with lactulose, milk of magnesia, mineral oil, bisacodyl, and senna presenting as viable alternatives. Conventional treatments of the abdominal pain associated with IBS are poorly studied in children. Available studies investigating the effectiveness of antidepressants on abdominal pain in children with IBS were inconclusive. At the same time, probiotics and peppermint oil have a fair record of benefits and safety. The overall body of evidence indicates that a careful balance of conventional and complementary treatment strategies may be required to manage gastrointestinal conditions in children.

Colonic pseudo-obstruction in a patient with dyssynergic defecation: A case report

Introduction and importance: Colonic pseudo-obstruction (CPO) is characterized by massive colonic dilatation of the large intestine without mechanical obstruction. In this study, we report our surgical experience in treating refractory CPO with increased anal sphincter tone, suggested as type IV dyssynergia.

Case presentation

A 48-year-old man with intellectual disability, depression, heart failure, and end-stage renal disease presented with acute exacerbation of CPO. He had a history of chronic constipation and abdominal distension. Colonic dilatation and defecation difficulty persisted despite medication and repeated colonoscopic decompression. Anal manometry results indicated type IV dyssynergia with increased rectal pressure. Hartmann′s operation was performed to resect the redundant megacolon and to avoid increased anal sphincter pressure during defecation. Hypoganglionosis was observed in the resected colon, which could worsen the chronic process of CPO.

Clinical discussion

Meticulous evaluation and careful management are required to treat CPO patients because the pathophysiology of CPO has not yet been clearly identified. Proper surgical treatment is needed for patients with refractory CPO.

Conclusion

CPO requires meticulous evaluation and careful management owing to the risk of bowel perforation. Precise evaluation to identify other factors affecting defecation problems accompanied by CPO is required to make appropriate treatment decisions.

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Colonic pseudo-obstruction is defined as massive colonic dilatation of the large intestine without mechanical obstruction.

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Dyssynergic defecation results from an abnormality for defecations and discordance for contraction of anal sphincter.

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Surgical resection is considered in patients with refractory colonic pseudo-obstruction and colonic aganglinosis.