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Bolia R, Safe M, Southwell BR, King SK, Oliver MR. Paediatric constipation for general paediatricians: Review using a case-based and evidence-based approach. J Paediatr Child Health 2020; 56:1708-1718. [PMID: 33197982 DOI: 10.1111/jpc.14720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/13/2022]
Abstract
Constipation is a common problem in childhood. The most common type of constipation is functional, accounting for 90-95% of all cases. The aim of this review is to provide clinical scenarios with treatment using evidence-based information, and management strategies and a clinical algorithm to guide the management of constipation in children. Recent guidelines and online information sites are detailed. Clinical red flags and organic causes of constipation are included. Four clinical scenarios are presented: case (1) 4-month-old child with constipation since birth and likely Hirschsprung disease; case (2) 6-month-old infant with infant dyschezia; case (3) 4-year old with functional constipation; and; case (4) 9-year old with treatment resistant constipation. Children with functional constipation need a thorough history and physical exam to rule out the presence of any 'red flags' but do not require laboratory investigations. Management includes education and demystification, disimpaction followed by maintenance therapy with oral laxatives, dietary counselling and toilet training. Treatment options differ between infants and children. Disimpaction and maintenance regimens for common laxatives are presented. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. The radionuclide intestinal transit study (scintigraphy) is a useful modality for evaluation and planning of management in treatment-resistant children. Treatment options for treatment-resistant patients are presented. High-level evidence (meta-analyses) for pharmalogical and non-pharmalogical treatment modalities are reviewed and an algorithm for assessment and treatment are presented.
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Affiliation(s)
- Rishi Bolia
- Division of Paediatric Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Mark Safe
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Bridget R Southwell
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Urology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Sebastian K King
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatric Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Yik YI, Hutson J, Southwell B. Home-Based Transabdominal Interferential Electrical Stimulation for Six Months Improves Paediatric Slow Transit Constipation (STC). Neuromodulation 2017; 21:676-681. [PMID: 29164818 DOI: 10.1111/ner.12734] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 09/19/2017] [Accepted: 10/05/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transcutaneous electrical stimulation (TES) for one to two months has produced some improvement in treatment-resistant slow-transit constipation (STC) in children. Optimal parameters for treatment are not known. It is possible that more improvement would occur with stimulation for longer. This study examined the effectiveness of stimulation for six months. METHODS Children with STC confirmed by nuclear transit study (NTS) were enrolled prospectively. All had chronic constipation for greater than two years and had failed medical treatment. TES was performed for one hour/day for six months using the INF 4160 (Fuji Dynamics) portable stimulator and 4 cm × 4 cm electrodes near the belly button and on the back. Families kept bowel diaries and completed PEDSQLCore QOL (4.0) questionnaires before and at end of treatment. RESULTS Sixty-two children (34 females; seven years, 2-16 year) with STC were studied. Defecation frequency increased in 57/62 (91%, mean ± SEM pre- 1.49 ± 0.20 vs. post- 3.25 ± 0.25 defecation/week, p < 0.0001) with the number with ≥3BA increasing from 6 to 37 (10-59%). Soiling frequency decreased from 4.8 to 1.1 days/week (p <0.001). Abdominal pain decreased from 1.7 to 0.3 days/week (<0.0001), and spontaneous urge to defecate improved. Quality of life (p < 0.01), mean transit index and gastric emptying on NTS improved (p < 0.005). CONCLUSION Treatment-resistant STC responds to TES using interferential current across the abdomen when given daily for many months. Battery operated stimulators allowed stimulation at home for an hour each day. Stimulation for six months produced clinically significant improvement in defecation frequency, soiling, abdominal pain, urge to defecate, and quality of life in half of these chronic patients.
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Affiliation(s)
- Yee Ian Yik
- Gut Motility Laboratory, Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - John Hutson
- Gut Motility Laboratory, Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Bridget Southwell
- Gut Motility Laboratory, Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Yabunaka K, Nakagami G, Komagata K, Sanada H. Ultrasonographic follow-up of functional chronic constipation in adults: A report of two cases. SAGE Open Med Case Rep 2017; 5:2050313X17694234. [PMID: 28250918 PMCID: PMC5317036 DOI: 10.1177/2050313x17694234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/23/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic constipation is a disorder frequently encountered in clinical practice. Here, we describe the use of ultrasonography as a new approach to the follow-up of adult patients with functional chronic constipation. Specifically, we report two cases of functional chronic constipation: fecal retention in the rectum and not fecal retention in the rectum. In the not fecal retention in the rectum patient, ultrasonography showed no evidence of fecal retention in the rectum, including no rectal fecaloma, whereas in the fecal retention in the rectum patient, fecal retention in the rectum was clearly recognized. Moreover, ultrasonography can guide the choice of laxative, enema, or appropriate manual maneuver to treat chronic constipation. As a simple and noninvasive method for assessing functional chronic constipation in adults, ultrasonography not only provides important clinical information but can also aid in determining the location of fecal retention.
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Affiliation(s)
- Koichi Yabunaka
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunori Komagata
- Department of Nursing Administration and Advanced Clinical Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kearsey I, Hutson JM, Southwell BR. The effect of food withdrawal in children with rapid-transit constipation. Pediatr Surg Int 2016; 32:683-9. [PMID: 27245164 DOI: 10.1007/s00383-016-3899-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Rapid proximal colonic transit with anorectal holdup is a subtype of chronic constipation linked to food intolerance. We aimed to determine the effectiveness of dietary exclusion as a treatment for constipated children with rapid-transit constipation by scintigraphy. METHODS Questionnaires on diet and symptoms were mailed out to 125 children with chronic constipation and rapid proximal colonic transit on nuclear transit study at our institute between 1998 and 2014 years. Patients were given instructions and encouraged to undertake a six-food elimination diet targeting common protein allergens (dairy, wheat, soy, eggs, nuts, seafood). Answers were completed by circling an option or on visual analogue scale. Results were evaluated statistically using GraphPad Prism 6 by a Wilcoxon matched-pairs rank test. P < 0.05 was considered significant. RESULTS We received 44/125 responses, 26 patients [mean age 11 years (5-21)] had attempted elimination diet and 18 had not. Dairy and wheat were the most common foods eliminated and symptomatic improvement was greater for patients who had completely eliminated foods. Constipation, abdominal pain and pain on defecation were reduced (p < 0.01). Laxative usage decreased, although this was not statistically significant. Families encountered problems with dietary exclusion, particularly expense. Assistance from a dietician or nutritionist was sought by >50 % of families. CONCLUSION Dietary exclusion is a promising strategy to treat constipation in children with rapid proximal colonic transit. However, it was hard for many families, demonstrating the need for identifying the cause more specifically and a better set of instructions for the family and/or dietitian to follow.
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Affiliation(s)
- I Kearsey
- FD Stephens Surgical Research Group, Murdoch Childrens Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - J M Hutson
- FD Stephens Surgical Research Group, Murdoch Childrens Research Institute, Melbourne, Australia. .,Urology Department, The Royal Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, University of Melbourne, Melbourne, Australia.
| | - B R Southwell
- FD Stephens Surgical Research Group, Murdoch Childrens Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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5
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Chu H, Hou X. Understanding of Constipation Symptoms and the Diagnosis and Management of Constipation in Chinese Physicians. PLoS One 2016; 11:e0152801. [PMID: 27031865 PMCID: PMC4816533 DOI: 10.1371/journal.pone.0152801] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/18/2016] [Indexed: 01/03/2023] Open
Abstract
Background and Aims Although a range of guidelines for the diagnosis and treatment of chronic constipation has been carried out, there was very little information about the understanding on constipation. The aim of the present study was to estimate the understanding of constipation symptoms and the diagnosis and management of constipation by clinical physicians in China. Methods Participants were physicians and researchers in the field of gastroenterology in China who were scheduled to attend the National Conference on gastrointestinal motility(Constipation). Based on the recommendation of the Rome Foundation Board, the self-reported questionnaire was constructed. Findings Although most of the opinions on symptoms of constipation were consistent, there were still some differences. Opinions on the Bristol stool form during constipation were discordant, 34% of the doctors thought that it was type 1 and type 2, while 46%of the doctors suggested that type 3 should also be considered constipation. There was no significant difference between them(P = 0.05); We investigated the interpretation on the duration of defecation prolonged, 27% of the doctors suggested it should be longer than 10 minutes, 22% of the doctors suggested it should be longer than 20 minutes, and other 22% of the doctors suggested it should be time of defecation became longer compared to previously bowel habits, there was no significant difference among them(P = 0.38).Only 36% of the doctors thought that psychotherapy was most important in the treatment of severe constipation, while 37% of the doctors thought that medication treatment was most important in the treatment of severe constipation, there was no significant difference between them(P = 0.895). Conclusion We were able to obtain valuable information about current views on symptoms of constipation and the diagnosis and treatment of constipation among Chinese doctors. Although most of the opinions were consistent there were still some differences. This study indicated that in practice in China there was a need for further study on the role of constipation symptoms and there may also be a need for better establishment of consensus guidelines for constipation.
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Affiliation(s)
- Huikuan Chu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, China
- * E-mail:
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6
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Mehra R, Sodhi KS, Saxena A, Thapa BR, Khandelwal N. Sonographic evaluation of gallbladder motility in children with chronic functional constipation. Gut Liver 2016; 9:388-94. [PMID: 25167798 PMCID: PMC4413973 DOI: 10.5009/gnl13414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background/Aims Studies in adults suggest that constipation may not be a purely colonic pathology and may be a component of a generalized gastrointestinal (GI) motor disorder in which proximal GI motility can be impaired. Pediatric data are scarce, and the natural history of the disorder remains undefined. We aimed to evaluate gallbladder motility in a subset of Asian children with chronic functional constipation. Methods Abdominal ultrasound was performed on 105 children, including 55 patients (aged 3 to 13 years) with chronic functional constipation who met the inclusion criteria and 50 age- and gender-matched controls. The gallbladder contractility index was calculated based on the preprandial and postprandial gallbladder areas. Preprandial and postprandial values for gallbladder volume and wall thickness were evaluated. Results The mean value of the contractility index for the patients (15.77±24.68) was significantly lower than the mean value for the controls (43.66±11.58) (p=0.001). The mean postprandial gallbladder volumes and areas were larger in children with gallbladder hypomotility (p<0.05). The mean duration of constipation (4.8 months) was significantly higher (p=0.004) in the children with gall-bladder hypomotility. Conclusions Gallbladder motility is significantly impaired in children with chronic functional constipation. This study contributes to the understanding of the underlying pathophysiology, which will enable advancement in and improved management of children with chronic constipation and associated gallbladder hypomotility.
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Affiliation(s)
- Rakesh Mehra
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kushaljit Singh Sodhi
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Akshay Saxena
- Department of Postgraduate, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B R Thapa
- Department of Gastroenterology, Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio Diagnosis, Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Carmo RL, Oliveira RP, Ribeiro AE, Lima MC, Amorim BJ, Ribeiro AF, Ramos CD, Bustorff‐Silva JM, Lomazi EA. Colonic transit in children and adolescents with chronic constipation. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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8
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Carmo RLML, Oliveira RPM, Ribeiro AEA, Lima MCL, Amorim BJ, Ribeiro AF, Ramos CD, Bustorff-Silva JM, Lomazi EA. Colonic transit in children and adolescents with chronic constipation. J Pediatr (Rio J) 2015; 91:386-91. [PMID: 25986613 DOI: 10.1016/j.jped.2014.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/17/2014] [Accepted: 10/22/2014] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess clinical features and colonic transit patterns in Brazilian children with refractory constipation. METHODS From 2010 to 2013, 79 constipated patients received follow-up care in a tertiary hospital. Of these patients, 28 (aged 8-14 years) were refractory to conventional therapy and underwent a simplified visual method of nuclear colonic transit study, by ingestion of a liquid meal containing 9.25 MBq/kg of (99m)Tc-phytate. Abdominal static images were taken immediately and at two, six, 24, 30, and 48h after ingestion for qualitative analysis of the radio marker progression through the colon. RESULTS Two patterns of colonic transit were found: slow colonic transit (SCT, n=14), when images at 48h showed a larger part of the tracer remained in proximal and transverse colon, and distal retention (DR, n=14), when after 30h, the radio isotope passed the transverse colon and was retained in the rectosigmoid up to 48h. The SCT and DR group included, respectively, nine and ten males; median ages in the nuclear study of 11 and 10 years, p=0.207; median duration of constipation of seven and six years, p=0.599. Constipation appearing during first year age (p=0.04) and report of soft stools (p=0.02) were more common in SCT patients. Palpable abdominal fecal impaction was found only in DR group. Appendicostomy for antegrade continence enema was successful in 4/12 (30%) of SCT patients (median follow-up: 2.4 years). CONCLUSION Nuclear transit study distinguished two colonic dysmotility patterns and was useful for guiding refractory patients to specific therapies.
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Affiliation(s)
- Rafael L M L Carmo
- School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Raquel P M Oliveira
- School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Antonio E A Ribeiro
- School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Mariana C L Lima
- Department of Radiology, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Bárbara J Amorim
- Department of Radiology, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Antonio Fernando Ribeiro
- Department of Pediatrics, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Celso D Ramos
- Department of Radiology, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Joaquim M Bustorff-Silva
- Department of Surgery, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Elizete A Lomazi
- Department of Pediatrics, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.
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Hutson JM, Dughetti L, Stathopoulos L, Southwell BR. Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC). Pediatr Surg Int 2015; 31:445-51. [PMID: 25672282 DOI: 10.1007/s00383-015-3681-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 12/14/2022]
Abstract
Slow-transit constipation (STC) is a newly described subtype of intractable constipation in children which we originally identified with deficiency of substance P in axons supplying the proximal colonic muscle. When nuclear transit studies became available, the patients were found to have slow proximal colonic transit, and responded to antegrade enemas. Using the appendicostomy, we found that there was reduced frequency in propagating sequences throughout the colon. We began testing whether transcutaneous electrical stimulation (TES) could improve motility and symptoms, and over several trials have now shown that TES is remarkably effective in treating children with STC, with long-lasting effects. TES holds promise for treating STC, as well as a range of gastrointestinal motility disorders.
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Affiliation(s)
- John M Hutson
- Murdoch Childrens Research Laboratory, F Douglas Stephens Surgical Research Group, Melbourne, Australia,
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10
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Lu ML, He J, Lu S. Electrical stimulation therapy for slow transit constipation in children: a systematic review. Int J Colorectal Dis 2015; 30:697-702. [PMID: 25772272 DOI: 10.1007/s00384-015-2180-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Slow transit constipation is a common disorder in children, which often does not respond well to ordinary treatments. We have conducted a systematic review of reported studies in order to better define the current state of knowledge about electrical stimulation treatment of slow transit constipation in children. METHODS We searched PubMed, Embase, Cochrane Library, BioMed Central, and ISI Web of Knowledge with relevant terms; six studies, all from one center, met the criteria for inclusion. Two trials were randomized clinical trials, and four were prospective studies. The number of subjects included in the studies was 8 to 39, with ages 3 to 18 years. RESULTS Treatment sessions varied from 20 to 30 min 3 times per week to 1 h daily, and duration of therapy varied from 3 weeks to 6 months. Statistically significant improvements after electrical stimulation therapy were recorded in one to four outcome measures in each of the studies: frequency of defecation, soiling, Bristol Stool Scale, radionuclear transit studies, and quality of life; however, the improvements were of modest degree and of uncertain clinical significance. Quality assessment of the studies found various levels of bias, with attrition bias and reporting bias in all six. CONCLUSIONS This systemic review found moderate support for the effectiveness of electrical stimulation therapy in slow transit constipation in children. However, better-designed studies, with larger and more diverse patient populations followed for longer time periods, will be needed in order to reliably determine the efficacy of electrical stimulation therapy in the treatment of this disorder.
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Affiliation(s)
- Ming-Liang Lu
- Department of Anorectal Surgery, No.117 Hospital of PLA, Hangzhou, 310004, Zhejiang, China
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11
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Abstract
PURPOSE Slow transit constipation (STC) and functional fecal retention (FFR) are two forms of severe intractable constipation in childhood diagnosed by nuclear transit studies (NTS). This retrospective study aims to identify the predicting factors for STC and FFR by looking at the association with neuropsychiatric disorders (NPD), obesity, family history of constipation and atopic disease. PATIENTS AND METHODS A retrospective chart review was conducted on children with intractable constipation referred for NTS between 1st April 2003 and 1st April 2014. Comparisons were made between STC, FFR and normal transit patients with regards to NPD, obesity (BMI z score >95th percentile), family history of constipation in first and second-degree relatives and atopic disease which included food allergy, asthma and eczema. RESULTS Between 2003 and 2014, 97 patients were referred for a NTS. Out of 36 patients with NPD, 21 (58.3 %) had STC and 13 (36.1 %) had FFR (p < 0.05). 15.8 % of patients with constipation were obese, compared to 6.4 % in the general Australian paediatric population (p < 0.05). There was no significant association between constipation and atopic disease or family history. CONCLUSION Neuropsychiatric disorders, in particular autism, are useful predictors of STC and FFR in children. Obesity may be associated with a higher risk of developing chronic constipation.
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Affiliation(s)
- Zainab Ridha
- The Australian National University, Canberra, Australia
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12
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Moeller Joensson I, Hagstroem S, Fynne L, Krogh K, Siggaard C, Djurhuus JC. Rectal motility in pediatric constipation. J Pediatr Gastroenterol Nutr 2014; 58:292-6. [PMID: 24135982 DOI: 10.1097/mpg.0000000000000203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Constipation is a common disorder in children, but little is known about its etiology. Rectal impedance planimetry determines segmental rectal cross-sectional area (CSA) and pressure, allowing detailed description of rectal motility. The aim of the present study was to compare rectal motility in healthy and constipated children. METHODS We analyzed data from 10 children (1 girl) with constipation according to the Rome III criteria, mean age 8.8 years (standard deviation ± 1.2), and 10 healthy children (5 girls), mean age 9.9 years (standard deviation ± 1.5). CSA was determined at 3 levels (4, 5.5, and 7 cm from the anal verge). The resting rectal motility was recorded for 30 minutes followed by a distension protocol to assess compliance. Runs of phasic rectal contractions were defined as changes of >10% from baseline CSA and lasting at least 2 minutes. Rectal dimensions were expressed as mean CSA. RESULTS A low-amplitude contraction pattern (3%-5% of baseline CSA) with a frequency of 6 to 8/minute was present in all of the children. There was significantly more time with phasic rectal contractions in constipated children (median 38%, range [0-100]) compared with healthy children (median 8.8%, range [0-57]) (P < 0.05). The rectal CSA was higher in constipated children (median 1802 mm [range 1106-2948]) compared with healthy children (1375 mm [range 437-1861]) (P < 0.05), but compliance did not differ (constipated: median 38 mm/H2O [range 12-86] vs healthy 33 mm/H2O [range 10-63]) (P = 30). CONCLUSIONS In children with constipation, we found phasic rectal contractions for a significantly longer period compared with healthy children, and their rectum is larger than normal.
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Affiliation(s)
- Iben Moeller Joensson
- *Institute of Clinical Medicine, University of Aarhus †Department of Pediatrics, Aarhus University Hospital, Skejby ‡Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University, Hospital, Aarhus, Denmark
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13
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Colonic manometry and colonic scintigraphy as a diagnostic tool for children with severe constipation. J Pediatr Gastroenterol Nutr 2013; 57:598-602. [PMID: 24177783 DOI: 10.1097/mpg.0b013e31829e0bdd] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In adults, colonic manometry and colonic scintigraphy are both valuable studies in discriminating normal and abnormal colonic motility. The objective of this study was to compare the diagnostic yield and tolerability of colonic manometry and colonic scintigraphy in children with severe constipation. METHODS Twenty-six children (mean age 11.4 years, 77% boys) who had received colonic manometry and colonic scintigraphy as part of a colonic motility evaluation were included. Manometry was performed as per department protocol. After swallowing a methacrylate-coated capsule containing indium-111, images were taken at 4, 24, and 48 hours, and geometric centers were calculated. Results of both tests were categorized in 3 groups: normal, abnormal function in the distal part of the colon, and colonic inertia. Cohen κ was used for the level of agreement. Patients and parents completed a questionnaire regarding their experience. RESULTS Colonic scintigraphy showed normal transit time in 20%, delay in the distal colon in 48%, and colonic inertia in 32% of patients. Colonic manometry was normal in 40%, abnormal in the distal colon in 40%, and colonic inertia was diagnosed in 20%. The κ score was 0.34. All 5 patients with colonic inertia during manometry had a similar result by scintigraphy. Eighty-eight percent of patients preferred scintigraphy over manometry and 28% of parents preferred colonic manometry over scintigraphy. CONCLUSIONS Colonic manometry and colonic scintigraphy have a fair agreement regarding the categorization of constipation. Scintigraphy is well tolerated in pediatric patients and may be a useful tool in the evaluation of children with severe constipation.
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Abstract
Varied intestinal neuromuscular pathologies are responsible for Hirschsprung disease and other forms of chronic pseudo-obstruction that are encountered in pediatrics. Pathologically distinct subtypes discussed in this review include aganglionosis, hypoganglionosis, neuronal intranuclear inclusion disease, ganglionitis, degenerative neuropathy, diffuse ganglioneuromatosis, neuronal dysplasia, malformations of the muscularis propria, degenerative leiomyopathy, leiomyositis, and mitochondriopathies. Emphasis is given to the histopathologic features that distinguish these conditions and their differential diagnoses.
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Affiliation(s)
- Raj P Kapur
- Department of Laboratories, Seattle Children's Hospital University of Washington, A6901, 4800 Sand Point Way North East, Seattle, WA 98105, USA.
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15
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Is rectal disimpact always necessary in children with chronic constipation? Evaluation with pelvic ultrasound. Pediatr Surg Int 2010; 26:601-6. [PMID: 20414661 DOI: 10.1007/s00383-010-2602-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of study was to evaluate if pelvic ultrasound can be useful in managing children with chronic idiopathic constipation. METHODS A total of 270 children with idiopathic chronic constipation were enrolled in the study. At baseline and at monthly checkups children were evaluated by clinical score and pelvic ultrasound (US). Patients have been divided in 2 groups, based on pelvic US results: group A with a rectal diameter >3 cm, group B with a rectal diameter <3 cm or rectum not visualized. Both groups were subsequently randomly divided in two subgroups (A1, A2, B1, B2) on the basis of the prescribed treatment (disimpaction for the first week and daily laxative or only daily laxative). RESULTS After 1 month of therapy all clinical features improved in group A1 and at pelvic US, rectal size reduced and became not visualized; group A2 showed poor clinical response and transverse diameter of rectum did not modify significantly; B1 and B2 groups showed significant improvement only after 2-3 months. CONCLUSIONS Rectal disimpaction is necessary only in presence of MR. Pelvic US is a useful to diagnose MR and to set up the most appropriate treatment protocol for different chronic constipation cases.
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Daily transabdominal electrical stimulation at home increased defecation in children with slow-transit constipation: a pilot study. J Pediatr Surg 2009; 44:2388-92. [PMID: 20006033 DOI: 10.1016/j.jpedsurg.2009.07.063] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 07/31/2009] [Indexed: 01/14/2023]
Abstract
PURPOSE Transcutaneous electrical stimulation (TES) (3 sessions/wk) over the abdomen stimulated bowel functions in a randomized controlled trial. This pilot study assessed whether daily TES at home with a safe, portable machine would be possible and more efficacious than trial results. METHODS Eleven patients (6 male/5 female; mean age, 14 years; range, 12-18 years) with slow-transit constipation who relapsed or responded poorly in the trial were recruited (11 +/- 5 months later). An EPM-IF-4160 (Fuji Dynamics, Hong Kong) portable machine (sine waveform, 4 kHz carrier frequency, 80-160 Hz beat frequency, intensity <33 mA) delivering interferential current (2 electrodes over epigastrium + 2 over kidneys) was applied 1 hour daily at home. Continence diaries were kept for 1 month before and 2 months during treatment. RESULTS All children completed more than 1 month of treatment after baseline recording. Defecation increased in 9 of 11 children, and soiling decreased in 4 of 11 children. There was a significant increase in total episodes of defecation per week (mean +/- SD, 2.5 +/- 2.1 vs 6.7 +/- 4.4; P = .008) and a nonsignificant decrease in soiling (3.8 +/- 1.6 vs 1.1 +/- 0.5 episodes/wk, P = .1). Daily stimulation does not affect abdominal pain. No adverse events occurred. CONCLUSIONS Daily TES at home is safe and significantly improved bowel function in children who did not respond to 3 times per week of TES. Home TES may be a novel treatment of intractable slow transit constipation, avoiding hospital visits.
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Chase JW, Stillman BC, Gibb SM, Clarke MCC, Robertson VJ, Catto-Smith AG, Hutson JM, Southwell BR. Trunk strength and mobility changes in children with slow transit constipation. J Gastroenterol Hepatol 2009; 24:1876-84. [PMID: 19686406 DOI: 10.1111/j.1440-1746.2009.05940.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM It appears that there are no published reports on childhood slow transit constipation (STC) that have considered the state of the musculoskeletal components of the trunk in these children. The present study aimed to determine whether children with STC have different trunk musculoskeletal characteristics that might be related to their defecation difficulties, compared to controls. METHODS With the aid of computer-analyzed photographs and clinical testing, 41 children with STC and 41 age-matched controls were examined for Marfanoid features, sitting posture, spinal joint mobility and trunk muscle strength. The latter was assessed by measuring maximum voluntary abdominal bulging and retraction in sitting, and active trunk extension in prone-lying. Levels of general exercise and sedentary activities were evaluated by questionnaire. RESULTS STC subjects were more slumped in relaxed sitting (P < or = 0.001), less able to bulge (P < or = 0.03) and less able to actively extend the trunk (P = 0.02) compared to controls. All subjects sat more erect during abdominal bulging (P < or = 0.03). CONCLUSION The results show that STC children have reduced trunk control and posture, which indicates that clinicians should include training of trunk muscles and correction of sitting posture. There was no evidence that children with STC exercised less than the controls.
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Affiliation(s)
- Janet W Chase
- Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Australia.
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18
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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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Hutson JM, Chase JW, Clarke MCC, King SK, Sutcliffe J, Gibb S, Catto-Smith AG, Robertson VJ, Southwell BR. Slow-transit constipation in children: our experience. Pediatr Surg Int 2009; 25:403-6. [PMID: 19396449 DOI: 10.1007/s00383-009-2363-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 02/08/2023]
Abstract
Constipation is a common problem in children, with childhood prevalence estimated at between 1 and 30%. It accounts for a significant percentage of referrals to paediatricians and paediatric gastroenterologists. It commonly runs in families, suggesting either an underlying genetic predisposition or common environmental factors, such as dietary exposure. The peak age for presentation of constipation is shortly after toilet training, when passage of hard stools can cause pain on defecation, which then triggers holding-on behaviour in the child. At the time of the next call to stool the toddler may try to prevent defecation by contraction of the pelvic floor muscles and anal sphincter. Unless the holding-on behaviour is quickly corrected by interventions to soften faeces and prevent further pain, the constipation can very rapidly become severe and chronic. Until recently, this mechanism was thought to be the only significant primary cause of constipation in childhood. In this review, we will summarise recent evidence to suggest that severe chronic constipation in children may also be due to slowed colonic transit.
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Affiliation(s)
- John M Hutson
- Department of Surgery, Royal Children's Hospital, Melbourne, Australia.
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20
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King SK, Catto-Smith AG, Stanton MP, Sutcliffe JR, Simpson D, Cook I, Dinning P, Hutson JM, Southwell BR. 24-Hour colonic manometry in pediatric slow transit constipation shows significant reductions in antegrade propagation. Am J Gastroenterol 2008; 103:2083-91. [PMID: 18564112 DOI: 10.1111/j.1572-0241.2008.01921.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The physiological basis of slow transit constipation (STC) in children remains poorly understood. We wished to examine pan-colonic motility in a group of children with severe chronic constipation refractory to conservative therapy. METHODS We performed 24 h pan-colonic manometry in 18 children (13 boys, 11.6 +/- 0.9 yr, range 6.6-18.7 yr) with scintigraphically proven STC. A water-perfused, balloon tipped, 8-channel, silicone catheter with a 7.5 cm intersidehole distance was introduced through a previously formed appendicostomy. Comparison data were obtained from nasocolonic motility studies in 16 healthy young adult controls and per-appendicostomy motility studies in eight constipated children with anorectal retention and/or normal transit on scintigraphy (non-STC). RESULTS Antegrade propagating sequences (PS) were significantly less frequent (P < 0.01) in subjects with STC (29 +/- 4 per 24 h) compared to adult (53 +/- 4 per 24 h) and non-STC (70 +/- 14 per 24 h) subjects. High amplitude propagating sequences (HAPS) were of a normal frequency in STC subjects. Retrograde propagating sequences were significantly more frequent (P < 0.05) in non-STC subjects compared to STC and adult subjects. High amplitude retrograde propagating sequences were only identified in the STC and non-STC pediatric groups. The normal increase in motility index associated with waking and ingestion of a meal was absent in STC subjects. CONCLUSIONS Prolonged pancolonic manometry in children with STC showed significant impairment in antegrade propagating motor activity and failure to respond to normal physiological stimuli. Despite this, HAPS occurred with normal frequency. These findings suggest significant clinical differences between STC in children and adults.
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Affiliation(s)
- Sebastian K King
- Department of General Surgery, Royal Children's Hospital, Melbourne, Australia
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21
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Reilly DJ, Chase JW, Hutson JM, Clarke MC, Gibb S, Stillman B, Southwell BR. Connective tissue disorder--a new subgroup of boys with slow transit constipation? J Pediatr Surg 2008; 43:1111-4. [PMID: 18558192 DOI: 10.1016/j.jpedsurg.2008.02.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 02/09/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls. METHODS Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more = hypermobile). This project received ethical approval by the human research ethics committee. RESULTS Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls (P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile (P < .01). CONCLUSIONS These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.
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Affiliation(s)
- Daniel J Reilly
- School of Medicine, University of Melbourne, Melbourne, Victoria 3052, Australia
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Abstract
Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.
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Affiliation(s)
- Alexander von Gontard
- Klinik für Kinder- und Jugendpsychiatrie und Psychoterapie, Universitätsklinikum des Saarlandes, Homburg/Saar.
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Abstract
General localization of gastrointestinal bleeding through the use of labeled red blood cells may be performed in children, or (99m)Tc-pertechnetate may be used if a Meckel's diverticulum is suspected. As in adults, cholecystitis and biliary leak may be assessed in children via (99m)Tc-IDA derivatives. Gastroesophageal reflux can be evaluated by oral consumption of the child's usual diet labeled with (99m)Tc sulfur colloid. For the scintigraphic determination of pulmonary aspiration, a relatively high concentration of tracer within a drop of liquid is placed beneath the child's tongue followed by dynamic imaging of the respiratory tract. Colonic transit scintigraphy can aid in the identification and therapeutic decision-making in patients with functional fecal retention, the most common cause of chronic constipation in children. (18)F-DOPA positron emission tomography is useful for classifying pancreatic involvement in infantile hyperinsulinism as focal or diffuse, thereby differentiating between patients who should receive curative focal pancreatic resection versus those who should receive medical management. Assessment of protein-losing enteropathy can be conducted scintigraphically and, compared with fecal alpha-1 antitrypsin collection, the scintigraphic method can detect esophageal and gastric protein loss. Also, scintigraphic quantification of protein loss can be performed without the requirement for fecal collection. Intestinal inflammation in children with inflammatory bowel disease can be evaluated using (99m)Tc white blood cells. The scintigraphic method is safe, accurate, well-tolerated by children and complementary to endoscopy in most patients.
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Rodriguez LA, Flores A, Doody DP. Evaluation and Management of Intractable Constipation in Children. SEMINARS IN COLON AND RECTAL SURGERY 2006. [DOI: 10.1053/j.scrs.2006.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Zuccarello B, Romeo C, Scalfari G, Impellizzeri P, Montalto AS, D'Oppido D, Campennì A, Formica I, Baldari S. Scintigraphic evaluation of colonic motility in patients with anorectal malformations and constipation. J Pediatr Surg 2006; 41:310-3. [PMID: 16481241 DOI: 10.1016/j.jpedsurg.2005.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Constipation is one of the major sequelae in patients after correction of anorectal anomalies (ARAs). The aim of the present work has been to assess the colonic transit time, using radioisotope scintigraphy, in patients operated for ARA and experiencing constipation in the follow-up. The results were compared with transit time from children with true functional constipation. METHODS Twelve or 32 patients operated for ARA during the period 1994-2003 experienced mild or severe constipation (6 with high or intermediate form of ARA and 6 with low type) at follow-up. The mean age of this group was 5.8 years. Eighteen patients, mean age 6.7 years, with true functional constipation were studied as well. Colonic transit times were investigated using radioisotope scintigraphy. Normal values for colonic transit time were derived from historical controls. Radioisotope diethylenetriamine pentaacetic acid labelled with indium 111 was administered orally to determine a segmental colonic transit. Images of the abdomen have been taken at 6, 24, 48, and again at 72 hours, if radioactivity was not cleared from the colon. To quantify colonic transit, we calculated the geometric centre (GC) dividing the colon into anatomic regions. RESULTS According to normal controls, 2 different type of delayed transit can be observed: (a) slow-transit constipation if GC at 48 hours is less than 4.1; (b) functional rectosigmoid obstruction (FRSO) if GC at 48 hours is 4.1 or more but less than 6.1 at 72 hours. Patients with functional constipation were divided into 2 groups: (a) slow-transit constipation in 12 patients with a GC at 48 hours of 3.7 +/- 0.5; (b) FRSO in 6 patients with a GC of 4.7 +/- 0.04 and 5.02 at 48 and 72 hours, respectively. Patients operated for high ARA had values characteristic of FRSO with GC at 48 hours of 5.1 +/- 0.8 and 4.75 +/- 0.5 at 72 hours. In low ARA, the transit times were similar to the ones observed in patients with high ARA at 48 hours with a GC of 4.9 +/- 0.5. CONCLUSIONS Patients with ARA frequently have functional sequelae in the postoperative period such as constipation. According to our results, constipation seems to be secondary to segmental motility disorders limited to the rectosigmoid area, similar to constipated children with FRSO. No evidence of more generalised motility disturbance, as previously postulated, could be recorded.
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Affiliation(s)
- Biagio Zuccarello
- Department of Medical and Surgical Pediatric Sciences, University of Messina, 98125 Messina, Italy.
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Chase J, Robertson VJ, Southwell B, Hutson J, Gibb S. Pilot study using transcutaneous electrical stimulation (interferential current) to treat chronic treatment-resistant constipation and soiling in children. J Gastroenterol Hepatol 2005; 20:1054-61. [PMID: 15955214 DOI: 10.1111/j.1440-1746.2005.03863.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Chronic constipation in children may have organic or behavioral causes. The purpose of the present study was to investigate the effect of treatment with transcutaneous electrical stimulation (using interferential current) in children with chronic treatment-resistant constipation with proven organic disorders. METHODS Eight children (7-16 years) with at least 4 years of chronic treatment-resistant constipation and soiling, who had failed diet, laxative treatment and behavioral therapy were given 1 month of transcutaneous electrical stimulation. The three most severe cases had appendicostomies with antegrade washouts every 2-3 days to prevent impaction and reduce their soiling. Children and carers kept a daily diary of bowel habits, recording number of spontaneous defecations, episodes of soiling, use of bowel washouts and medications. Transcutaneous stimulation using interferential current was applied three times per week for 3-4 weeks using four surface electrodes, two to the paraspinal area of T9-10 to L2 and one to either side of the anterior abdominal wall beneath the costal margin. Diaries were recorded for 1 month before, during, and after stimulation and for 2 weeks 3 months later. RESULTS Transcutaneous electrical stimulation using interferential current stopped soiling in 7/8 children and increased the frequency of spontaneous defecations in 5/8. Defecations remained high and soiling low for 3 months in 3/6 children (with data). CONCLUSIONS These results suggest that transcutaneous electrical stimulation using interferential current has a beneficial effect for children with chronic treatment-resistant constipation. Further trials using larger series of patients are needed to confirm this benefit, to determine the ideal stimulation parameters and to investigate why electrical stimulation might be effective.
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Affiliation(s)
- Janet Chase
- School of Physiotherapy, The University of Melbourne, Victoria, Australia.
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Sutcliffe JR, King SK, Southwell BR, Hutson JM. Paediatric constipation for adult surgeons--article 1: targeting the cause. ANZ J Surg 2005; 74:777-80. [PMID: 15379810 DOI: 10.1111/j.1445-1433.2004.03149.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Constipation is very common in all age groups and can be resistant to standard therapies, producing chronic morbidity. Childhood onset constipation frequently produces symptoms that persist into adulthood. Recent advances have been made in the diagnosis and treatment of childhood constipation that could have application in adult practice. In the first part of the present review, the methods of differentiation of patients with a disorder of colonic motility from those with an anorectal hold-up are discussed. Slow transit constipation, with distinct features on colonic manometry and scintigraphy, has only recently been recognized in children. This diagnosis, together with a novel method of placement of a manometric catheter, is described. While the cause of slow transit constipation remains unclear, clinical features that differ between children and adults may provide an insight into the aetiology. The diagnosis of intestinal neuronal dysplasia is explained and the controversy surrounding the diagnosis outlined. We propose that the traditional histological criteria exclude many other clinically significant forms of dysplasia of the enteric nervous system and should be extended.
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Affiliation(s)
- Jonathan R Sutcliffe
- Department of General Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
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King SK, Sutcliffe JR, Hutson JM, Southwell BR. Paediatric constipation for adult surgeons - article 2: new microscopic abnormalities and therapies. ANZ J Surg 2005; 74:890-4. [PMID: 15456440 DOI: 10.1111/j.1445-1433.2004.03202.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic constipation is a common condition in both adults and children. Children with chronic constipation frequently have symptoms that continue into adulthood. In the second part of the review we describe advances in the identification of abnormalities in the control of motility. The role of neurotransmitters in both paediatric and adult constipation is examined and the radical rethink of colonic dysmotility caused by the re-emergence of interstitial cells of Cajal is discussed. The recognition of chronic constipation as an heterogenous condition has led to the introduction of new therapies. Antegrade washouts through appendix stomas and an exciting new treatment with electrical interferential therapy may, in the future, result in a less invasive approach to the management of chronic constipation. An improved understanding of the assessment and management of chronic constipation in childhood is also likely to reduce the frequency and morbidity of chronic constipation in adults.
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Affiliation(s)
- Sebastian K King
- Department of General Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
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Abstract
Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.
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Affiliation(s)
- B R Southwell
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
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30
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Hutson JM, Catto-Smith T, Gibb S, Chase J, Shin YM, Stanton M, King S, Sutcliffe J, Ong SY, Djaja S, Farmer P, Southwell B. Chronic constipation: no longer stuck! Characterization of colonic dysmotility as a new disorder in children. J Pediatr Surg 2004; 39:795-9. [PMID: 15185198 DOI: 10.1016/j.jpedsurg.2004.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- John M Hutson
- Department of Surgery, Royal Children's Hospital, Melbourne, Australia
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Woodward MN, Foley P, Cusick EL. Colostomy for treatment of functional constipation in children: a preliminary report. J Pediatr Gastroenterol Nutr 2004; 38:75-8. [PMID: 14676599 DOI: 10.1097/00005176-200401000-00017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Surgery is indicated in very few children with intractable functional constipation. A number of operations have been described with unpredictable outcome and significant morbidity. The authors present a series of 10 children who underwent a Hartmann procedure with end colostomy formation. METHOD Preoperative management, in addition to maximum conservative measures, included psychologic referral, rectal biopsy, transit studies, and contrast enemas. A standard Hartmann procedure was performed with on-table rectal washout, formation of a proximal sigmoid colostomy, limited anterior resection of hypertrophic proximal rectosigmoid, and oversewing of the rectal stump. RESULTS The series includes 10 pediatric patients (4 female, 6 male), in whom constipation was first reported at a median age of 3 years (range, 2 months-7 years) and surgical referral was made at 8 years (range, 1-14 years). Surgery was performed at a median age of 9.5 years (range, 2-15 years), and the median postoperative stay was 5 days (range, 4-9 days). Complications occurred in four patients (transient mild rectal discharge in 2, stomal prolapse in 1, and an unrelated small bowel obstruction in 1 patient with an additional Mitrofanoff stoma). Median postoperative follow-up was 31 months (range, 9-56 months), and the children and parents were all completely satisfied with the stoma. CONCLUSION Colostomy formation is a potential surgical option for severe functional constipation with low associated morbidity and high patient satisfaction.
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Affiliation(s)
- Mark N Woodward
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, United Kingdom.
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