1
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Rodriguez L. Testing in functional constipation-What's new and what works. Aliment Pharmacol Ther 2024; 60 Suppl 1:S30-S41. [PMID: 38940015 DOI: 10.1111/apt.17857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/17/2023] [Accepted: 12/14/2023] [Indexed: 06/29/2024]
Abstract
BACKGROUND Constipation is among the most common symptoms prompting a consultation with a paediatric gastroenterologist. While most patients will respond to lifestyle and dietary changes and conventional therapy, some may require diagnostic studies. AIM To review the diagnostics studies used to evaluate children with functional constipation. MATERIALS AND METHODS There is no evidence to support the routine use of abdominal X-rays in the evaluation of paediatric constipation. Colon transit by radiopaque markers (ROM) should be indicated when medical history does not match clinical findings, to guide colon manometry (CM) performance and to discriminate between faecal incontinence from functional constipation and non-retentive faecal incontinence. Colon scintigraphy may be useful as an alternative to ROM. Lumbar spine MRI may be indicated to evaluate for spinal abnormalities. The role of defecography has not been properly evaluated in children. Anorectal manometry in children is indicated primarily to evaluate anal resting pressure, presence and quality of the recto-anal inhibitory reflex and simulated defecation manoeuvres. The CM is indicated to guide surgical interventions after failing medical therapy. CONCLUSIONS The goal of these studies is to identify treatable causes of constipation. Most of these studies are designed to evaluate anatomy, transit and/or colon/rectum motility function and are primarily indicated in those who fail to respond to conventional therapy.
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Affiliation(s)
- Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
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2
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van der Zande JMJ, Lu PL. Management of the child with refractory constipation. Aliment Pharmacol Ther 2024; 60 Suppl 1:S42-S53. [PMID: 38923030 DOI: 10.1111/apt.17847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 06/28/2024]
Abstract
BACKGROUND Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely. AIMS To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience. METHODS We performed a literature review on diagnostic tests and treatment options for children with refractory constipation. RESULTS Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed. CONCLUSIONS Recent advances offer hope for children with refractory constipation.
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Affiliation(s)
- Julia M J van der Zande
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter L Lu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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3
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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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4
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Osatakul S, Benninga MA, Thapar N, Treepongkaruna S, Puetpaiboon A. The magnitude and management of functional constipation at pediatric gastroenterology clinics: A survey study of various countries. J Gastroenterol Hepatol 2022; 37:89-96. [PMID: 34425028 DOI: 10.1111/jgh.15671] [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: 04/02/2021] [Revised: 06/27/2021] [Accepted: 08/14/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM There have been no large-scale epidemiological study of functional constipation of pediatric gastroenterology services. This survey was undertaken to investigate the prevalence of functional constipation and magnitude of related problems in hospital settings of various countries as well as the practice of pediatric gastroenterologists in management of these conditions. METHODS The survey was conducted by sending questionnaires to members of Societies for Pediatric Gastroenterology Hepatology and Nutrition of various continents. RESULTS A total of 274 pediatric gastroenterologists from 41 countries participated in this study. Functional constipation accounted for overall 30% of patients attending pediatric gastroenterology outpatient clinics. In comparison with non-western countries, respondents from western countries reported significantly higher median annual numbers of new patients with intractable functional constipation (10 [4,25] vs 5 [2,10], P < 0.001), dyssynergic defecation (3 [0,15] vs 1 [0,4], P < 0.001), and colonic inertia (2 [0,5] vs 0 [0,1], P < 0.001). The use of high dose polyethylene glycol for fecal disimpaction was significantly more commonly among respondents from western countries, whereas rectal enema was significantly more favored in non-western countries. Respondents from different continents reported significant discrepancies in choices of investigations and management of patients with dyssynergic defecation and colonic inertia. CONCLUSIONS Functional constipation is a major problem for pediatric gastroenterology outpatient services worldwide. There were significant variations in the investigations of choice and therapeutic management of functional constipation, intractable functional constipation, and related problems among pediatric gastroenterologists of different geographic regions.
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Affiliation(s)
- Seksit Osatakul
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Suporn Treepongkaruna
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Areeruk Puetpaiboon
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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5
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Popescu M, Mutalib M. Bowel transit studies in children: evidence base, role and practicalities. Frontline Gastroenterol 2021; 13:152-159. [PMID: 35300467 PMCID: PMC8862445 DOI: 10.1136/flgastro-2020-101719] [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: 02/24/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 02/04/2023] Open
Abstract
Constipation is common in children and adults with varied worldwide prevalence. The majority of children have functional constipation as defined by Rome clinical criteria and respond favourably to standard medical therapy; up to one-third can develop difficult-to-treat constipation requiring investigation and specialist treatment. Colon function tests aim to assess the neuromuscular integrity, the movement of faeces across the colon and evaluate/predict response to the therapy. The 'ideal' test should be practical, non-invasive, widely available and cost-effective. None of the available diagnostic tools is designed to provide a comprehensive assessment of colon function and clinicians often have to combine more than one test to answer different questions. In this review, we aim to assess the strengths and limitations of the commonly available diagnostic investigations (radiopaque marker studies, scintigraphy, wireless motility capsule and colonic manometry) used to assess colon transit in children and to provide guidance on the most appropriate test for particular clinical settings.
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Affiliation(s)
- Mara Popescu
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mohamed Mutalib
- Faculty of Life Sciences and Medicine, King's College London, London, UK,Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
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6
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 200] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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7
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Hutson JM, Hynes MC, Kearsey I, Yik YI, Veysey DM, Tudball CF, Cain TM, King SK, Southwell BR. 'Rapid transit' constipation in children: a possible genesis for irritable bowel syndrome. Pediatr Surg Int 2020; 36:11-19. [PMID: 31673760 DOI: 10.1007/s00383-019-04587-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2019] [Indexed: 02/07/2023]
Abstract
Children with chronic idiopathic constipation (CIC) often end up at the surgeon when medical treatments have failed. This opinion piece discusses a recently described pattern of CIC called 'Rapid transit constipation (RTC)' first identified in 2011 as part of surgical workup. RTC was identified using a nuclear medicine gastrointestinal transit study (NMGIT or nuclear transit study) to determine the site of slowing within the bowel and to inform surgical treatment. Unexpectedly, we found that RTC occured in 29% of 1000 transit studies in a retrospective audit. Irritable bowel syndrome (IBS) occurs in 7-21% of the population, with a higher prevalence in young children and with constipation type dominating in the young. While 60% improve with time, 40% continue with symptoms. First-line therapy for IBS in adults is a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols which reduces symptoms in > 70% of patients. In children with functional gastrointestinal disorders, fructose intolerance occurs in 35-55%. Reducing fructose produced significant improvement in 77-82% of intolerant patients. In children with RTC and a positive breath test upon fructose challenge, we found that exclusion of fructose significantly improved constipation, abdominal pain, stool consistency and decreased laxative use. We hypothesise that positive breath tests and improvement of pain and bowel frequency with sugar exclusion diets in RTC suggest these children have IBS-C. These observations raise the possibility that many children with CIC could be treated by reducing fructose early in their diet and this might prevent the development of IBS in later life.
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Affiliation(s)
- J M Hutson
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Australia. .,Department of Urology, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, Australia. .,Department of Paediatrics, University of Melbourne, Melbourne, Australia.
| | - M C Hynes
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - I Kearsey
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Y I Yik
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - D M Veysey
- Department of Nuclear Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - C F Tudball
- Department of Nuclear Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - T M Cain
- Department of Nuclear Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - S K King
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - B R Southwell
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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8
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Li YW, Yu YJ, Fei F, Zheng MY, Zhang SW. High-resolution colonic manometry and its clinical application in patients with colonic dysmotility: A review. World J Clin Cases 2019; 7:2675-2686. [PMID: 31616684 PMCID: PMC6789394 DOI: 10.12998/wjcc.v7.i18.2675] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/26/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
The detailed process and mechanism of colonic motility are still unclear, and colonic motility disorders are associated with numerous clinical diseases. Colonic manometry is considered to the most direct means of evaluating colonic peristalsis. Colonic manometry has been studied for more than 30 years; however, the long duration of the examination, high risk of catheterization, huge amount of real-time data, strict catheter sterilization, and high cost of disposable equipment restrict its wide application in clinical practice. Recently, high-resolution colonic manometry (HRCM) has rapidly developed into a major technique for obtaining more effective information involved in the physiology and/or pathophysiology of colonic contractile activity in colonic dysmotility patients. This review focuses on colonic motility, manometry, operation, and motor patterns, and the clinical application of HRCM. Furthermore, the limitations, future directions, and potential usefulness of HRCM in the evaluation of clinical treatment effects are also discussed.
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Affiliation(s)
- Yu-Wei Li
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin 300071, China
| | - Yong-Jun Yu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin 300071, China
| | - Fei Fei
- Department of Pathology, Tianjin Union Medical Center, Tianjin 300071, China
- Nankai University School of Medicine, Nankai University, Tianjin 300071, China
| | - Min-Ying Zheng
- Department of Pathology, Tianjin Union Medical Center, Tianjin 300071, China
| | - Shi-Wu Zhang
- Department of Pathology, Tianjin Union Medical Center, Tianjin 300071, China
- Nankai University School of Medicine, Nankai University, Tianjin 300071, China
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9
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Abstract
Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.
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Affiliation(s)
- Peter L Lu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Hayat M Mousa
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, 3030 Children's Way, San Diego, CA 92123, USA
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10
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Chen JH, Parsons SP, Shokrollahi M, Wan A, Vincent AD, Yuan Y, Pervez M, Chen WL, Xue M, Zhang KK, Eshtiaghi A, Armstrong D, Bercik P, Moayyedi P, Greenwald E, Ratcliffe EM, Huizinga JD. Characterization of Simultaneous Pressure Waves as Biomarkers for Colonic Motility Assessed by High-Resolution Colonic Manometry. Front Physiol 2018; 9:1248. [PMID: 30294277 PMCID: PMC6159752 DOI: 10.3389/fphys.2018.01248] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/17/2018] [Indexed: 12/31/2022] Open
Abstract
Simultaneous pressure waves (SPWs) in manometry recordings of the human colon have been associated with gas expulsion. Our hypothesis was that the SPW might be a critical component of most colonic motor functions, and hence might act as a biomarker for healthy colon motility. To that end, we performed high-resolution colonic manometry (HRCM), for the first time using an 84-sensor (1 cm spaced) water-perfused catheter, in 17 healthy volunteers. Intraluminal pressure patterns were recorded during baseline, proximal and rectal balloon distention, after a meal and following proximal and rectal luminal bisacodyl administration. Quantification was performed using software, based on Image J, developed during this study. Gas expulsion was always associated with SPWs, furthermore, SPWs were associated with water or balloon expulsion. SPWs were prominently emerging at the termination of proximal high amplitude propagating pressure waves (HAPWs); we termed this motor pattern HAPW-SPWs; hence, SPWs were often not a pan-colonic event. SPWs and HAPW-SPWs were observed at baseline with SPW amplitudes of 12.0 ± 8.5 mmHg and 20.2 ± 7.2 mmHg respectively. The SPW occurrence and amplitude significantly increased in response to meal, balloon distention and luminal bisacodyl, associated with 50.3% anal sphincter relaxation at baseline, which significantly increased to 59.0% after a meal, and 69.1% after bisacodyl. Often, full relaxation was achieved. The SPWs associated with gas expulsion had a significantly higher amplitude compared to SPWs without gas expulsion. SPWs could be seen to consist of clusters of high frequency pressure waves, likely associated with a cluster of fast propagating, circular muscle contractions. SPWs were occasionally observed in a highly rhythmic pattern at 1.8 ± 1.2 cycles/min. Unlike HAPWs, the SPWs did not obliterate haustral boundaries thereby explaining how gas can be expelled while solid content can remain restrained by the haustral boundaries. In conclusion, the SPW may become a biomarker for normal gas transit, the gastrocolonic reflex and extrinsic neural reflexes. The SPW assessment reveals coordination of activities in the colon, rectum and anal sphincters. SPWs may become of diagnostic value in patients with colonic dysmotility.
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Affiliation(s)
- Ji-Hong Chen
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sean P Parsons
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mitra Shokrollahi
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew Wan
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Alexander D Vincent
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada.,Sun Yat-sen University, Guangdong, China
| | - Maham Pervez
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Wu Lan Chen
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mai Xue
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Kailai K Zhang
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Arshia Eshtiaghi
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - David Armstrong
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Premsyl Bercik
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Eric Greenwald
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Elyanne M Ratcliffe
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Jan D Huizinga
- Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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11
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Waingankar K, Lai C, Punwani V, Wong J, Hutson JM, Southwell BR. Dietary exclusion of fructose and lactose after positive breath tests improved rapid-transit constipation in children. JGH OPEN 2018; 2:262-269. [PMID: 30619935 PMCID: PMC6308069 DOI: 10.1002/jgh3.12079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/14/2018] [Accepted: 06/28/2018] [Indexed: 12/16/2022]
Abstract
Aims Exclusion of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) from the diet is effective in alleviating symptoms of irritable bowel syndrome (IBS) in adults. Rapid‐transit constipation (RTC) is a recently discovered subset of chronic constipation and has been linked to food intolerance. The aim of this study was to audit the effect of specific FODMAP elimination diets in children with RTC. Methods This was an audit of children presenting to a tertiary children's hospital surgeon with refractory chronic constipation who had rapid transit in the proximal colon on nuclear imaging; had hydrogen/methane breath tests for fructose, lactose, and/or sorbitol intolerance; and were advised to exclude positive sugar under clinical supervision. Patients filled in a questionnaire rating severity of constipation, abdominal pain, and pain on defecation with a visual analogue scale (VAS, 0 = none, 10 = high) and stool consistency for 6 months before and after dietary exclusion. Results In responses from 29 children (5–15 years, 21 males), 70% eliminated fructose, and 40% eliminated lactose. There was a significant reduction in the severity of constipation (VAS mean ± SEM, pre 5.8 ± 0.5 vs post 3.3 ± 0.6, P < 0.0001), abdominal pain (5.1 ± 0.6 vs 2.8 ± 0.5, P = 0.0004), pain on defecation (5.8 ± 0.6 vs 2.6 ± 0.5, P < 0.0001), and increase in stool wetness (Bristol Stool Scale pre 3.3 ± 0.3 vs post 3.9 ± 0.2, P = 0.004). Conclusion Children with RTC showed significant improvements in constipation and pain after excluding the sugar indicated by positive breath tests, suggesting that specific sugar‐exclusion diets may have a role in the management of RTC in children.
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Affiliation(s)
- Kasturi Waingankar
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia
| | - Christoper Lai
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia
| | - Vishal Punwani
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia
| | - Jeremy Wong
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia
| | - John M Hutson
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia.,Department of Urology The Royal Children's Hospital Melbourne Victoria Australia
| | - Bridget R Southwell
- Surgical Research Group Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Melbourne Victoria Australia.,Department of Urology The Royal Children's Hospital Melbourne Victoria Australia
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12
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The Role of Bowel Management in Children with Bladder and Bowel Dysfunction. CURRENT BLADDER DYSFUNCTION REPORTS 2018. [DOI: 10.1007/s11884-018-0458-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Abstract
Constipation is one of the most common gastrointestinal symptoms in children. With a median reported prevalence of 12%, it accounts for about 25% of all pediatric gastroenterology consultations. The majority of children experiences functional constipation and do not usually require any diagnostic testing. For those children not responding to conventional medical treatment or in the presence of a more significant clinical picture, however, an accurate instrumental assessment is usually recommended to evaluate either the underlying pathophysiologic mechanisms or a possible organic etiology. The present review analyzes the possible diagnostic investigations for severely constipated children, focusing on their actual indications and their utility in clinical practice. During the last decade, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed and are discussed in this narrative review.
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14
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Artifact Rejection Methodology Enables Continuous, Noninvasive Measurement of Gastric Myoelectric Activity in Ambulatory Subjects. Sci Rep 2018; 8:5019. [PMID: 29568042 PMCID: PMC5864836 DOI: 10.1038/s41598-018-23302-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/08/2018] [Indexed: 12/19/2022] Open
Abstract
The increasing prevalence of functional and motility gastrointestinal (GI) disorders is at odds with bottlenecks in their diagnosis, treatment, and follow-up. Lack of noninvasive approaches means that only specialized centers can perform objective assessment procedures. Abnormal GI muscular activity, which is coordinated by electrical slow-waves, may play a key role in symptoms. As such, the electrogastrogram (EGG), a noninvasive means to continuously monitor gastric electrical activity, can be used to inform diagnoses over broader populations. However, it is seldom used due to technical issues: inconsistent results from single-channel measurements and signal artifacts that make interpretation difficult and limit prolonged monitoring. Here, we overcome these limitations with a wearable multi-channel system and artifact removal signal processing methods. Our approach yields an increase of 0.56 in the mean correlation coefficient between EGG and the clinical "gold standard", gastric manometry, across 11 subjects (p < 0.001). We also demonstrate this system's usage for ambulatory monitoring, which reveals myoelectric dynamics in response to meals akin to gastric emptying patterns and circadian-related oscillations. Our approach is noninvasive, easy to administer, and has promise to widen the scope of populations with GI disorders for which clinicians can screen patients, diagnose disorders, and refine treatments objectively.
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Is Hydrogen Breath Test with Lactulose Feasible for Measuring Gastrocecal Transit in Critically Ill Children? Pilot Study about Modification of the Technique. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5878659. [PMID: 28246601 PMCID: PMC5299192 DOI: 10.1155/2017/5878659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/18/2016] [Accepted: 12/28/2016] [Indexed: 12/26/2022]
Abstract
Introduction. Gastrocecal transit time (GCTT) can be measured by exhaled hydrogen after lactulose intake (lactulose-eH2 test). The objectives were to assess whether it is possible to carry out this test in critically ill children with and without mechanical ventilation (MV) and to analyze whether the results are consistent with clinical findings. Methods. Patients admitted to the Pediatric Intensive Care Unit (PICU) for more than 3 days were included. Those with gastrointestinal disease prior to admission were excluded. A modified technique to obtain eH2 from the ventilator tubes was performed. Results. Sixteen patients (37.5% boys) with a median age of 19 (5-86.5) months were included. Five patients (31.2%) were breathing spontaneously but lactulose-eH2 test could not be performed while it could be performed successfully in the 11 patients with MV. Seven patients (63.3%) did not show an eH2 peak. The other 4 showed a median time of 130 min (78.7-278.7 min) from lactulose intake to a 10 ppm eH2 peak. Children with an eH2 peak had intestinal movements earlier [6.5 (1.5-38.5) versus 44 (24-72) hours p = 0.545]. Conclusion. Although the designed adaption is useful for collecting breath samples, lactulose-eH2 test may not be useful for measuring GCTT in critically ill children.
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Borrelli O, Pescarin M, Saliakellis E, Tambucci R, Quitadamo P, Valitutti F, Rybak A, Lindley KJ, Thapar N. Sequential incremental doses of bisacodyl increase the diagnostic accuracy of colonic manometry. Neurogastroenterol Motil 2016; 28:1747-1755. [PMID: 27335210 DOI: 10.1111/nmo.12876] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/09/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colonic manometry is the standard diagnostic modality for evaluating colonic motility in children. Intraluminal bisacodyl is routinely used to trigger high-amplitude propagating contractions (HAPCs), a feature of normal colonic motility. Usually, only a single dose (0.2 mg/kg) is suggested. We retrospectively explored whether the use of an additional higher (0.4 mg/kg) dose of bisacodyl increases the yield of colonic manometry. METHODS In 103 children (median age: 8.8 years, range 3.2-15.7 years) with a diagnosis of slow transit constipation, colonic motility was recorded for 1 h before and 1 h after each of two incremental doses of bisacodyl (low, L, dose: 0.2 mg/kg, max 10 mg; high, H, dose: 0.4 mg/kg, max 20 mg) and the characteristics of HAPCs analyzed. KEY RESULTS High-amplitude propagating contractions were seen in 85 children. H dose significantly increased the proportion of patients with fully propagated HAPCs (H dose: 57/103 [55%], L dose: 27/103 [26%], p < 0.001), paralleling the significant decrease in the proportion with partially propagated HAPCs (H dose: 29/103 [28%], L dose: 47/103 [46%], p < 0.01). Mean HAPC number significantly increased throughout the colon at H compared to L dose (7.2 ± 5.05 vs 5.6 ± 5.1, p < 0.05). Finally, the proportion of patients with normal pressure wave morphology of HAPCs significantly increased with higher dose (H dose: 55/85 [65%], L dose: 27/85 [32%], p < 0.001). CONCLUSIONS & INTERFERENCES An additional higher dose of bisacodyl during colonic manometry improves colonic neuromuscular function suggesting its use might improve interpretation and decision making in children with slow transit constipation.
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Affiliation(s)
- O Borrelli
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK.
| | - M Pescarin
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - E Saliakellis
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - R Tambucci
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - P Quitadamo
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - F Valitutti
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - A Rybak
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK.,Department of Gastroenterology, Hepatology, Nutrition Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - K J Lindley
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - N Thapar
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK.,Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Koppen IJN, Di Lorenzo C, Saps M, Dinning PG, Yacob D, Levitt MA, Benninga MA. Childhood constipation: finally something is moving! Expert Rev Gastroenterol Hepatol 2016; 10:141-55. [PMID: 26466201 DOI: 10.1586/17474124.2016.1098533] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.
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Affiliation(s)
- Ilan J N Koppen
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands.,b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Carlo Di Lorenzo
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Miguel Saps
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Phil G Dinning
- c Departments of Gastroenterology & Surgery , Flinders Medical Centre, Flinders University , South Australia , Australia
| | - Desale Yacob
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Marc A Levitt
- d Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Department of Surgery , The Ohio State University , Columbus , OH , USA
| | - Marc A Benninga
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
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Abstract
Ingestion and digestion of food as well as expulsion of residual material from our gastrointestinal tract requires normal propulsive, i.e. motor, function. Hypomotility refers to inherited or acquired changes that come with decreased contractile forces or slower transit. It not only often causes symptoms but also may compromise nutritional status or lead to other complications. While severe forms, such as pseudo-obstruction or ileus, may have a tremendous functional impact, the less severe forms of hypomotility may well be more relevant, as they contribute to common disorders, such as functional dyspepsia, gastroparesis, chronic constipation, and irritable bowel syndrome (IBS). Clinical testing can identify changes in contractile activity, defined by lower amplitudes or abnormal patterns, and the related effects on transit. However, such biomarkers show a limited correlation with overall symptom severity as experienced by patients. Similarly, targeting hypomotility with pharmacological interventions often alters gut motor function but does not consistently improve symptoms. Novel diagnostic approaches may change this apparent paradox and enable us to obtain more comprehensive information by integrating data on electrical activity, mechanical forces, patterns, wall stiffness, and motions with information of the flow of luminal contents. New drugs with more selective effects or more specific delivery may improve benefits and limit adverse effects. Lastly, the complex regulation of gastrointestinal motility involves the brain-gut axis as a reciprocal pathway for afferent and efferent signaling. Considering the role of visceral input in emotion and the effects of emotion on visceral activity, understanding and managing hypomotility disorders requires an integrative approach based on the mind-body continuum or biopsychosocial model of diseases.
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Affiliation(s)
- Klaus Bielefeldt
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ashok Tuteja
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Salman Nusrat
- Department of Medicine, Oklahoma University Medical Center, Oklahoma City, OK, USA
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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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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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