Is there a role for surgery beyond colonic aganglionosis and anorectal malformations in children with intractable constipation?

PURPOSE

The aim of this study was to assess benefit of surgery in the treatment of childhood constipation in children without aganglionosis or anorectal malformations.

METHODS

Retrospective chart review and follow-up questionnaire of 19 children (10 girls, age 7.6 +/- 3.9 years) who underwent surgery after colonic and anorectal manometry had documented abnormal motility. Children at the time of manometric evaluation had symptoms of intractable constipation a mean of 5.1 +/- 2.5 years. Follow-up questionnaires were administered to caregivers a mean of 11.4 +/- 9.3 months after surgical intervention.

RESULTS

Proximal colonic abnormalities were seen in 2 patients, abnormalities involving the distal colon and rectosigmoid region in 13 patients, pancolonic abnormalities in 2 patients, and incomplete relaxation of the internal anal sphincter in 2 patients. Surgery led to increase in frequency of bowel movements per week (8.1 v 1.9; P <.005), decrease in soiling episodes per week (2.20 v 4.7; P <.01), and decrease in daily use of medications for constipation (0.8 v 2.3; P <.05). Adverse events included skin breakdown at site of ostomy (9%), fecal incontinence after pull-through procedure (13%), and persistent constipation (4.5%). Parents felt that the symptoms after surgery were completely resolved in 89% of patients.

CONCLUSIONS

Surgery may be beneficial in the management children with chronic intractable constipation and documented abnormalities in motility.

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.

Clostridium difficile colitis associated with infant botulism: near-fatal case analogous to Hirschsprung's enterocolitis

We present the first five reported cases of Clostridium difficile-associated diarrhea (CDAD) in children with infant botulism caused by Clostridium botulinum. We compare two fulminant cases of colitis in children with colonic stasis, the first caused by infant botulism and the second caused by Hirschsprung's disease. In both children, colitis was accompanied by hypovolemia, hypotension, profuse ascites, pulmonary effusion, restrictive pulmonary disease, and femoral-caval thrombosis. Laboratory findings included pronounced leukocytosis, hypoalbuminemia, hyponatremia, coagulopathy, and, when examined in the child with infant botulism, detection of C. difficile toxin in ascites. CDAD recurred in both children, even though difficile cytotoxin was undetectable in stool after prolonged initial therapy. Four children who had both infant botulism and milder CDAD also are described. Colonic stasis, whether acquired, as in infant botulism, or congenital, as in Hirschsprung's disease, may contribute to the susceptibility to and the severity of CDAD.

A STUDY OF THE VESICAL GANGLIA IN CHILDREN AND THE RELATIONSHIP TO THE MEGAURETER MEGACYSTIS SYNDROME AND HIRSCHSPRUNG'S DISEASE

A method for the assay of vesical ganglion cells is described and the number and distribution of the neurones in three normal bladders was studied. Vesical ganglion counts were done in cases of the megaureter-megacystis syndrome, megaureter, bladder neck obstruction, megacystis associated with absent abdominal muscles, Hirschsprung's disease, and lumbar myelomeningocoele. A normal complement of neurones was found in each case. No evidence was found that the megaureter-megacystis syndrome is due to an agenesis of the peripheral autonomic ganglia similar to that in Hirschsprung's disease. Vesical ganglia were normal in the two cases examined and no clinical association was found between the two conditions in a large series of cases. Moreover, a study of the cell counts suggests that at least some of the reports of such a lesion are based upon an inadequate appreciation of the number and distribution of neurones in the normal urinary tract.

Altered expression of alpha-smooth muscle isoactin in Hirschsprung's disease

OBJECTIVE

To analyze the expression of smooth muscle actin (SMA) contractile proteins in the intestinal muscle of patients with Hirschsprung's disease.

DESIGN

A total of 56 colonic whole-wall specimens were tested with immunohistochemistry and monoclonal antibodies directed against, respectively, alpha and pan (alpha and gamma) SMA.

PATIENTS

The study included both aganglionic and dilated normoganglionic colonic samples from 29 children who had undergone definitive surgery for Hirschsprung's disease. Morphologically normal (n = 6) and dilated colons (n = 5) from 11 patients suffering from conditions unrelated to Hirschsprung's disease served as controls.

RESULTS

The alphaSMA immunostaining showed a pattern identical to normal controls in all the aganglionic areas and in 70% of the normoganglionic segments. In contrast, a lack of alphaSMA expression confined to the circular muscle cells was observed in 30% of the normoganglionic specimens and in the five dilated control specimens. The same areas showed a faintly reduced immunoreactivity with the antibody to pan SMA, consistent with the absence of alpha-isoactin, but implying the presence of gamma-isoactin. In the Hirschsprung's disease cases, the absence of alphaSMA expression at the time of surgery was associated with the occurrence of long-term postoperative motility problems (p<.01).

CONCLUSION

These data suggest that alphaSMA expression defect in Hirschsprung's disease may be acquired and related to chronic colonic obstruction and subsequent dilatation. The observed changes correlate with disturbances of peristalsis and could be used to assess the risk of intestinal dysmotility frequently reported after surgical removal of the aganglionic bowel.

Autosomal-recessive neural crest syndrome with albinism, black lock, cell migration disorder of the neurocytes of the gut, and deafness: ABCD syndrome

We report on a macrosomic newborn girl with albinism, a black lock at the right temporo-occipital region, and retinal depigmentation. Bilateral deafness was confirmed by brainstem auditory-evoked potentials. In addition, the infant had a severe defect of intestinal innervation. Biopsy showed aganglionosis of the large intestine, and total absence of neurocytes and nerve fibers in the small intestine, indicating a total lack of sympathetic and parasympathetic innervation. The infant died of intestinal dysfunction at 5 weeks. She was the 14th child of consanguineous Kurdish parents. Four sibs of our patient had the same syndrome and died a few days after birth. The other 9 sibs are well, with an unremarkable phenotype. A syndrome of albinism, black lock, deafness, and a total lack of intestinal neural innervation has not yet been reported. It represents a new neural crest syndrome with autosomal-recessive inheritance.