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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Papadopoulos M, Mutalib M, Nikaki K, Volonaki E, Rybak A, Thapar N, Lindley K, Borrelli O, Das A, Crespi D, Cleeve S, Athanasakos E. Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement. Neurogastroenterol Motil 2024; 36:e14776. [PMID: 38454312 DOI: 10.1111/nmo.14776] [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: 08/28/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.
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Affiliation(s)
- M Papadopoulos
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, St Thomas' Hospital, London, UK
| | - M Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, St Thomas' Hospital, London, UK
| | - K Nikaki
- Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - E Volonaki
- Department of Paediatric Gastroenterology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - A Rybak
- Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - N Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Queensland, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - K Lindley
- Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - O Borrelli
- Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - A Das
- Paediatric Department, Broomfield Hospital, Broomfield, UK
| | - D Crespi
- Department of Paediatric Surgery, The Royal London Hospital, Barts Health NHS, London, UK
| | - S Cleeve
- Department of Paediatric Surgery, The Royal London Hospital, Barts Health NHS, London, UK
| | - E Athanasakos
- Department of Paediatric Surgery, The Royal London Hospital, Barts Health NHS, London, UK
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3
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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: 5] [Impact Index Per Article: 1.3] [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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4
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Heitmann PT, Wiklendt L, Thapar N, Borrelli O, Di Lorenzo C, Yacob DT, Baaleman DF, Vriesman MH, Nurko S, El-Chammas K, Kaul A, Benninga MA, Koppen IJN, Wattchow DA, Brookes SJH, Dinning PG. Characterization of the colonic response to bisacodyl in children with treatment-refractory constipation. Neurogastroenterol Motil 2020; 32:e13851. [PMID: 32281199 DOI: 10.1111/nmo.13851] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonic manometry with intraluminal bisacodyl infusion can be used to assess colonic neuromuscular function in children with treatment-refractory constipation. If bisacodyl does not induce high-amplitude propagating contractions (HAPCs), this can be an indication for surgical intervention. A detailed characterization of the colonic response to intraluminal bisacodyl in children with constipation may help to inform clinical interpretation of colonic manometry studies. METHODS Studies were performed in five pediatric hospitals. Analysis included identification of HAPCs, reporting HAPCs characteristics, and an area under the curve (AUC) analysis. Comparisons were performed between hospitals, catheter type, placement techniques, and site of bisacodyl infusion. RESULTS One hundred and sixty-five children were included (median age 10, range 1-17 years; n = 96 girls). One thousand eight hundred and ninety-three HAPCs were identified in 154 children (12.3 ± 8.8 HAPCs per child, 0.32 ± 0.21 HAPCs per min; amplitude 113.6 ± 31.5 mm Hg; velocity 8.6 ± 3.8 mm/s, propagation length 368 ± 175 mm). The mean time to first HAPC following bisacodyl was 553 ± 669 s. Prior to the first HAPC, there was no change in AUC when comparing pre- vs post-bisacodyl (Z = -0.53, P = .60). The majority of HAPCs terminated in a synchronous pressurization in the rectosigmoid. Defecation was associated with HAPCs (χ2 (1)=7.04, P < .01). Site of bisacodyl administration, catheter type, and hospital location did not alter the response. CONCLUSIONS AND INFERENCES Intraluminal bisacodyl induced HAPCs in 93% of children with treatment-refractory constipation. The bisacodyl response is characterized by ≥1 HAPC within 12 minutes of infusion. The majority of HAPCs terminate in a synchronous pressurization in the rectosigmoid. Optimal clinical management based upon colonic manometry findings is yet to be determined.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Lukasz Wiklendt
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Nikhil Thapar
- Division of Neurogastroenterology & Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital, and Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Osvaldo Borrelli
- Division of Neurogastroenterology & Motility, Department of Paediatric Gastroenterology, Great Ormond Street Hospital, and Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | | | | | | | - Mana H Vriesman
- Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, MA, USA
| | - Khalil El-Chammas
- Neurogastroenterology and Motility Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ajay Kaul
- Neurogastroenterology and Motility Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - David A Wattchow
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Simon J H Brookes
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
| | - Phil G Dinning
- College of Medicine and Public Health & Centre for Neuroscience, Flinders University, Bedford Park, SA, Australia
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5
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Dranove J, Fleishman N, Reddy S, Teich S. Does the Oral-Anal Transit Test Correlate with Colonic Manometry Findings in Children with Refractory Constipation? Pediatr Gastroenterol Hepatol Nutr 2020; 23:137-145. [PMID: 32206626 PMCID: PMC7073376 DOI: 10.5223/pghn.2020.23.2.137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The Oral-anal Transit Test (OTT) is a simple method of obtaining information about colonic transit. We aim to assess the correlation of OTT with the neuromuscular integrity of the colon determined by colonic manometry (CM). METHODS All patients who had OTT followed by CM were evaluated. Less than 6 of 24 markers remaining on OTT was considered normal. CM was performed per previously published guidelines. A normal CM was defined as at least one High Amplitude Propagating Contraction progressing from the most proximal sensor through the sigmoid colon. RESULTS A total of 34 patients underwent both OTT and CM (44% male, age 4-18 years, mean 11.5 years, 97% functional constipation +/- soiling, Hirschsprung's Disease). Of normal and abnormal OTT patients, 85.7% (6/7) and 18.5% (5/27) respectively had normal CM. When all markers progressed to at least the sigmoid colon, this was 100% predictive against colonic inertia. Greater than 50% of patients with manometric isolated sigmoid dysfunction had markers proximal to the recto-sigmoid. CONCLUSION OTT and CM are both valuable studies that assess different aspects of colonic function. OTT can be used as a screening test to rule out colonic inertia. However, the most proximal extent of remaining markers does not predict the anatomical extent of the manometric abnormality, particularly in isolated sigmoid dysfunction.
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Affiliation(s)
- Jason Dranove
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Nathan Fleishman
- Department of Pediatric Gastroenterology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Saigopala Reddy
- Department of Public Health, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Steven Teich
- Division of Pediatric Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
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6
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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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7
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Corsetti M, Costa M, Bassotti G, Bharucha AE, Borrelli O, Dinning P, Di Lorenzo C, Huizinga JD, Jimenez M, Rao S, Spiller R, Spencer NJ, Lentle R, Pannemans J, Thys A, Benninga M, Tack J. First translational consensus on terminology and definitions of colonic motility in animals and humans studied by manometric and other techniques. Nat Rev Gastroenterol Hepatol 2019; 16:559-579. [PMID: 31296967 PMCID: PMC7136172 DOI: 10.1038/s41575-019-0167-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 12/19/2022]
Abstract
Alterations in colonic motility are implicated in the pathophysiology of bowel disorders, but high-resolution manometry of human colonic motor function has revealed that our knowledge of normal motor patterns is limited. Furthermore, various terminologies and definitions have been used to describe colonic motor patterns in children, adults and animals. An example is the distinction between the high-amplitude propagating contractions in humans and giant contractions in animals. Harmonized terminology and definitions are required that are applicable to the study of colonic motility performed by basic scientists and clinicians, as well as adult and paediatric gastroenterologists. As clinical studies increasingly require adequate animal models to develop and test new therapies, there is a need for rational use of terminology to describe those motor patterns that are equivalent between animals and humans. This Consensus Statement provides the first harmonized interpretation of commonly used terminology to describe colonic motor function and delineates possible similarities between motor patterns observed in animal models and humans in vitro (ex vivo) and in vivo. The consolidated terminology can be an impetus for new research that will considerably improve our understanding of colonic motor function and will facilitate the development and testing of new therapies for colonic motility disorders.
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Affiliation(s)
- Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Marcello Costa
- Human Physiology and Centre of Neuroscience, College of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Gabrio Bassotti
- Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children, London, UK
| | - Phil Dinning
- Human Physiology and Centre of Neuroscience, College of Medicine, Flinders University, Bedford Park, South Australia, Australia
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Carlo Di Lorenzo
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Jan D Huizinga
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marcel Jimenez
- Department of Cell Physiology, Physiology and Immunology and Neuroscience Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Satish Rao
- Division of Gastroenterology/Hepatology, Augusta University, Augusta, GA, USA
| | - Robin Spiller
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nick J Spencer
- Discipline of Human Physiology, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Roger Lentle
- Digestive Biomechanics Group, College of Health, Massey University, Palmerston North, New Zealand
| | - Jasper Pannemans
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Alexander Thys
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Marc Benninga
- Translational Research Center for Gastrointestinal disorders (TARGID), Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands.
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8
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Koppen IJN, Wiklendt L, Yacob D, Di Lorenzo C, Benninga MA, Dinning PG. Motility of the left colon in children and adolescents with functional constpation; a retrospective comparison between solid-state and water-perfused colonic manometry. Neurogastroenterol Motil 2018; 30:e13401. [PMID: 30039585 DOI: 10.1111/nmo.13401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/28/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Using water-perfused (WP) high-resolution manometry, we recently demonstrated that children with functional constipation (FC) lacked the postprandial increase in distal colonic cyclic motor patterns that was observed in healthy adults. Our aim was to determine if similar results could be detected using a solid-state (SS) manometry catheter. METHODS We performed a retrospective analysis of 19 children with FC (median age 11.1 years, 58% male) who underwent colonic manometry with a SS catheter (36 sensors, 3 cm apart). Data were compared with previously published data using a WP catheter (36 sensors, 1.5 cm apart) recorded from 18 children with FC (median age 15 years; 28% male). KEY RESULTS The cyclic motor patterns recorded by the SS catheter did not differ from those previously recorded by the WP catheter. There was no detected increase in this activity in response to the meal in either group. Long-single motor patterns were recorded in most patients (n = 16, 84%) with the SS catheter. The number of these events did not differ from the WP recordings. In the SS data, HAPCs were observed in 4 children prior to the meal, in 5 after the meal. This did not differ significantly from the WP data. CONCLUSIONS & INFERENCES These data recorded by SS manometry did not differ from WP manometry data. Regardless of the catheter used, both studies revealed an abnormal colonic response to a meal, indicating a pathology which is not related to the catheter used to record these data.
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Affiliation(s)
- I J N Koppen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - L Wiklendt
- Department of Human Physiology, Flinders University, Adelaide, SA, Australia
| | - D Yacob
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - C Di Lorenzo
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - P G Dinning
- Department of Human Physiology, Flinders University, Adelaide, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, SA, Australia
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9
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King SK. Constipation—Surgical Aspects, Investigations, and Therapies. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Rodriguez L, Sood M, Di Lorenzo C, Saps M. An ANMS-NASPGHAN consensus document on anorectal and colonic manometry in children. Neurogastroenterol Motil 2017; 29. [PMID: 27723185 DOI: 10.1111/nmo.12944] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the last few years, the study of the colon and anorectal function has experienced great technical advances that have facilitated the performance of the tests and have allowed a more detailed characterization of reflexes and motor patterns. As a result, we have achieved a much better understanding of the pathophysiology of children with defecation problems. Anorectal and colonic manometry are now commonly used in all major pediatric referral centers as diagnostic tools and to guide the management of children with intractable constipation and fecal incontinence, particularly when a surgical intervention is being considered. PURPOSE This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).
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Affiliation(s)
- L Rodriguez
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - M Sood
- Department of Pediatric Gastroenterology, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - C Di Lorenzo
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - M Saps
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
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11
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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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12
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Abstract
PURPOSE OF REVIEW Constipation is a very common problem in pediatrics with both the severity of presentations and treatments varying across a broad spectrum. The majority of children with functional constipation are managed successfully without the need for specialized testing and surgical intervention. Those who present with intractable constipation, with or without fecal soiling, require referrals for motility testing that helps determine both medical and surgical management, and interventions. The literature was reviewed for publications on surgical approaches to children with severe constipation, including assessing the quality and levels of evidence and the use of objective measures to determine outcomes. RECENT FINDINGS There is very little in the way of recent studies evaluating surgical indications or treatment approaches for functional constipation, apart from one systematic review and one recent expert review. Although the systematic review was published in the last year, most of the studies it analyzes are older. The vast majority of studies comprise level 4 and 5 evidence. SUMMARY The indication for most surgical procedures is 'failed' medical management, yet no standardized definition for this exists. Many surgical procedures are proposed with little evidence to show outcomes. We recommend that the surgical evaluation and treatment of children with constipation needs to be protocolized and studied in a prospective manner using validated outcomes measures. Our center's current protocol is described.
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Wessel S, Koppen IJN, Wiklendt L, Costa M, Benninga MA, Dinning PG. Characterizing colonic motility in children with chronic intractable constipation: a look beyond high-amplitude propagating sequences. Neurogastroenterol Motil 2016; 28:743-57. [PMID: 26867952 DOI: 10.1111/nmo.12771] [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] [Received: 09/11/2015] [Accepted: 12/14/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Children with chronic intractable constipation experience severe and long-lasting symptoms, which respond poorly to conventional therapeutic strategies. Detailed characterization of colonic motor patterns in such children has not yet been obtained. METHODS In 18 children with chronic intractable constipation, a high-resolution water-perfused manometry catheter (36 sensors at 1.5-cm intervals) was colonoscopically placed with the tip at the distal transverse colon. Colonic motor patterns were recorded for 2 h prior to and after a meal and then after colonic infusion of bisacodyl. These data were compared with previously published colonic manometry data from 12 healthy adult controls and 14 adults with slow-transit constipation. KEY RESULTS The postprandial number of the retrograde cyclic propagating motor pattern was significantly reduced in these children compared with healthy adults (children, 3.1 ± 4.7/h vs healthy adults, 34.7 ± 45.8/h; p < 0.0001) but not constipated adults (4.5 ± 5.6/h; p = 0.9). The number of preprandial long-single motor patterns was significantly higher (p = 0.003) in children (8.0 ± 13.2/h) than in healthy adults (0.4 ± 0.9/h) and in constipated adults (0.4 ± 0.7/h). Postprandial high-amplitude propagating sequences (HAPSs) were rarely observed in children (2/18), but HAPS could be induced by bisacodyl in 16 of 18 children. CONCLUSIONS & INFERENCES Children with chronic intractable constipation show a similar impaired postprandial colonic response to that seen in adults with slow-transit constipation. Children may have attenuated extrinsic parasympathetic inputs to the colon associated with an increased incidence of spontaneous long-single motor patterns.
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Affiliation(s)
- S Wessel
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - I J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - L Wiklendt
- Department of Human Physiology, Flinders University, Adelaide, SA, Australia
| | - M Costa
- Department of Human Physiology, Flinders University, Adelaide, SA, Australia
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - P G Dinning
- Department of Human Physiology, Flinders University, Adelaide, SA, Australia.,Departments of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, SA, Australia
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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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15
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Abstract
OBJECTIVES Colonic manometry is a test used in the evaluation of children with defecation disorders unresponsive to conventional treatment. The most commonly reported protocol in pediatrics consists of a study that lasts approximately 4 hours. Given the wide physiological variations in colonic motility throughout the day, longer observation may detect clinically relevant information. The aim of the present study was to compare prolonged colonic manometry studies in children referred for colonic manometry with the more traditional short water-perfused technology. METHODS Colonic manometry studies of 19 children (8 boys, mean age 9.4 ± 0.9, range 3.9-16.3) with severe defecation disorders were analyzed. First, a "standard test" was performed with at least 1-hour fasting, 1-hour postprandial, and 1-hour postbisacodyl provocation recording. Afterwards, recordings continued until the next day. RESULTS In 2 of the 19 children, prolonged recording gave us extra information. In 1 patient with functional nonretentive fecal incontinence who demonstrated no abnormalities in the short recording, 2 long clusters of high-amplitude contractions were noted in the prolonged study, possibly contributing to the fecal incontinence. In another patient evaluated after failing use of antegrade enemas through a cecostomy, short recordings showed colonic activity only in the most proximal part of the colon, whereas the prolonged study showed normal motility over a larger portion of the colon. CONCLUSIONS Prolonged colonic measurement provides more information regarding colonic motor function and allows detection of motor events missed by the standard shorter manometry study.
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Wiklendt L, Mohammed SD, Scott SM, Dinning PG. Classification of normal and abnormal colonic motility based on cross-correlations of pancolonic manometry data. Neurogastroenterol Motil 2013; 25:e215-23. [PMID: 23360122 DOI: 10.1111/nmo.12077] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Manual analysis of data acquired from manometric studies of colonic motility is laborious, subject to laboratory bias and not specific enough to differentiate all patients from control subjects. Utilizing a cross-correlation technique, we have developed an automated analysis technique that can reliably differentiate the motor patterns of patients with slow transit constipation (STC) from those recorded in healthy controls. METHODS Pancolonic manometric data were recorded from 17 patients with STC and 14 healthy controls. The automated analysis involved calculation of an indicator value derived from cross-correlations calculated between adjacent recording sites in a manometric trace. The automated technique was conducted on blinded real data sets (observed) and then to determine the likelihood of positive indicator values occurring by chance, the channel number within each individual data set were randomized (expected) and reanalyzed. KEY RESULTS In controls, the observed indicator value (3.2 ± 1.4) was significantly greater than that predicted by chance (0.8 ± 1.5; P < 0.0001). In patients, the observed indicator value (-2.7 ± 1.8) did not differ from that predicted by chance (-3.5 ± 1.6; P = 0.1). The indicator value for controls differed significantly from that of patients (P < 0.0001), with all individual patients falling outside of the range of indicator values for controls. CONCLUSIONS & INFERENCES Automated analysis of colonic manometry data using cross-correlation separated all patients from controls. This automated technique indicates that the contractile motor patterns in STC patients differ from those recorded in healthy controls. The analytical technique may represent a means for defining subtypes of constipation.
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Affiliation(s)
- L Wiklendt
- St. George Clinical School, University of New South Wales, Sydney, NSW, Australia
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17
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Giorgio V, Borrelli O, Smith VV, Rampling D, Köglmeier J, Shah N, Thapar N, Curry J, Lindley KJ. High-resolution colonic manometry accurately predicts colonic neuromuscular pathological phenotype in pediatric slow transit constipation. Neurogastroenterol Motil 2013; 25:70-8.e8-9. [PMID: 23030503 DOI: 10.1111/nmo.12016] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe pediatric slow transit constipation (STC) is commonly due to intrinsic colonic neuromuscular disease. We sought to correlate neuromuscular histological phenotypes in pediatric STC with colonic manometric phenotypes using high-resolution manometry (HRM). We tested the hypothesis that failure of motor quiescence (FQ) between bisacodyl-induced high amplitude propagating sequences (HAPSs) might predict neuromuscular pathology. METHODS Eighteen children (10 males, median age: 7.5 years) with refractory STC underwent stationary colonic HRM before segmental colonic resection. Six age-matched constipated children with normal colonic transit served as controls. Colonic resection specimens underwent histopathological analysis. Conventional manometric parameters and area under the curve (AUC) during a 1-min period following bisacodyl-induced HAPSs [PBAUC(1) ], as measure of FQ, were calculated. KEY RESULTS Numbers of postbisacodyl HAPSs in descending and sigmoid segments were lower in patients than controls (P < 0.01, respectively). Low amplitude propagating sequences (LAPSs) were common prebisacodyl in controls and rare in STC (P < 0.001), whereas postbisacodyl LAPS were more common in STC (P < 0.001). Postbisacodyl, both retrograde propagating contractions and bursts of contractions were present in STC patients only (P < 0.001 and P < 0.01). Postbisacodyl simultaneous pressurization was seen only in STC (P < 0.05 and P < 0.001, in descending and rectosigmoid segments). Histological abnormalities were present in 17/18. Fourteen were neurogenic, one neuro-myogenic, and two myogenic. In segments with HAPS, PBAUC(1) was predictive of colonic neuropathy using a cutoff of 205 mmHg.s(-1) (Sensitivity 100%, specificity 86%, PPV92%, NPV100%). CONCLUSIONS & INFERENCES PBAUC(1) is increased in multiple colonic segments in neuropathic pediatric STC and constitutes a sensitive and specific biomarker of neuropathy.
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Affiliation(s)
- V Giorgio
- Division of Neurogastroenterology & Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital and UCL, London, UK
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Transabdominal electrical stimulation increases colonic propagating pressure waves in paediatric slow transit constipation. J Pediatr Surg 2012; 47:2279-84. [PMID: 23217889 DOI: 10.1016/j.jpedsurg.2012.09.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/01/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children. METHODS Eight children (8-18 years) with confirmed STC had 24-h colonic manometry using a water-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas. They then received 12 sessions (20 min/3× per week) of IFC stimulation (2 paraspinal and 2 abdominal electrodes), applied at a comfortable intensity (<40 mA, carrier frequency 4 kHz, varying beat frequency 80-150 Hz). Colonic manometry was repeated 2 (n=6) and 7 (n=2) months after IFC. RESULTS IFC significantly increased frequency of total PS/24h (mean ± SEM, pre 78 ± 34 vs post 210 ± 62, p=0.008, n=7), antegrade PS/24h (43 ± 16 vs 112 ± 20, p=0.01) and high amplitude PS (HAPS/24h, 5 ± 2:10 ± 3, p=0.04), with amplitude, velocity, or propagating distance unchanged. There was increased activity on waking and 4/8 ceased using antegrade continence enemas. CONCLUSIONS AND INFERENCES Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2-7 months. IFC may provide a treatment for children with treatment-resistant STC.
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Abstract
While most colonic motor activity is segmental and non-propulsive, colonic high amplitude propagated contractions (HAPC) can transfer colonic contents over long distances and often precede defecation. High amplitude propagated contractions occur spontaneously, in response to pharmacological agents or colonic distention. A subset of patients with slow transit constipation have fewer HAPC. In this issue of Neurogastroenterology and Motility, Rodriguez et al. report that anal relaxation during spontaneous and bisacodyl-induced HAPC exceeds anal relaxation during rectal distention in constipated children undergoing colonic manometry. Moreover, and consistent with a neural mechanism, anal relaxation often precedes arrival of HAPC in the left colon. High amplitude propagated contractions are also used to evaluate the motor response to a meal and pharmacological stimuli (e.g., bisacodyl, neostigmine) and to identify colonic inertia during colonic motility testing in chronic constipation. This editorial comprehensively reviews the characteristics, physiology and pharmacology of HAPC, their assessment by manometry, and relevance to constipation and diarrhea.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN
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20
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Yik YI, Cook DJ, Veysey DM, Tudball CF, Cain TM, Southwell BR, Hutson JM. How common is colonic elongation in children with slow-transit constipation or anorectal retention? J Pediatr Surg 2012; 47:1414-20. [PMID: 22813806 DOI: 10.1016/j.jpedsurg.2012.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 01/06/2012] [Accepted: 01/06/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE Colonic elongation is reported as a possible cause for slow colonic transit, as it is observed in patients with slow-transit constipation (STC). This study aimed to determine the frequency of colonic elongation in children with STC or anorectal retention using radioimaging. We hypothesized that transverse colon elongation may occur in patients with STC, whereas sigmoid colon elongates in patients with anorectal retention. METHODS Nuclear transit scintigraphy performed for chronic constipation (1999-2011) was analyzed qualitatively for elongated transverse colon or sigmoid colon. Three major colonic transit patterns were identified: slow transit in the proximal colon (STC), normal proximal colonic transit with anorectal retention (NT-AR), and rapid proximal transit ± anorectal retention (RT). χ(2) Test was used for statistical analysis (P < .05 significant). RESULTS From 1999 to 2011, 626 children had nuclear transit scintigraphy. Transverse colon elongation occurred more frequently in STC (73/322, or 23%) compared with NT-AR (9/127, or 7%) and RT (5/177, or 3%; P < .0001). Sigmoid colon elongation was equally common in NT-AR (8/127, or 6%) compared with RT (10/177, or 6%) and STC (14/322, or 4%; P < .9). CONCLUSION Transverse colon elongation is more common in STC (23%), whereas sigmoid colon elongation is not more common in anorectal retention. Colonic elongation may be the cause or the result of the underlying slow colonic transit.
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Affiliation(s)
- Yee Ian Yik
- F Douglas Stephens Surgical Research and Gut Motility Laboratories, Murdoch Children's Research Institute, Melbourne, Australia
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21
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Do oro-anal transit markers predict which children would benefit from colonic manometry studies? J Pediatr Gastroenterol Nutr 2012; 54:258-62. [PMID: 21734599 DOI: 10.1097/mpg.0b013e31822bbcd8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study was to compare oro-anal transit time (OTT) measured by radio-opaque markers with colon motility (CM) findings in children with chronic constipation and to assess clinical outcomes in children with chronic constipation evaluated by OTT and CM studies. METHODS Twenty-four children with chronic constipation (12 girls; median age 12 years [3-18 years]; median symptoms 87 months [6-186 months]) who underwent OTT and CM studies were reviewed. The OTT was determined using commercially available Sitzmarks. Patients were studied for a median of 23 months (4-60 months) and outcomes reviewed. RESULTS All 5 children with normal OTT had normal CM; however, only 47% (9/19) of children with slow OTT had an abnormal CM. The abnormal CM findings were total colonic pseudo-obstruction in 3 and left colonic pseudo-obstruction in 6 children. Of the 9 children with abnormal CM, 5 were managed surgically, 1 with medicine escalation, and 3 were lost to follow-up; all 6 children with known follow-up have more bowel movements and less soiling. Of the 15 children with normal CM, 10 were managed with medication escalation, 3 with behavioral intervention, and 2 surgically. Of these 15 children, 8 improved, 1 did not change, 2 worsened, and 4 were lost to follow-up. CONCLUSIONS OTT studies may be helpful to predict which children should be referred for CM studies. Normal OTT studies may predict normal colon manometry; however, abnormal OTT studies may not predict abnormalities in colonic manometry in children with chronic constipation. Therefore, patients with slow transit marker studies should be assessed by colon manometry to evaluate colon neuromuscular integrity.
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Spencer NJ, Kyloh M, Wattchow DA, Thomas A, Sia TC, Brookes SJ, Nicholas SJ. Characterization of motor patterns in isolated human colon: are there differences in patients with slow-transit constipation? Am J Physiol Gastrointest Liver Physiol 2012; 302:G34-43. [PMID: 21960519 DOI: 10.1152/ajpgi.00319.2011] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The patterns of motor activity that exist in isolated full-length human colon have not been described. Our aim was to characterize the spontaneous motor patterns in isolated human colon and determine whether these patterns are different in whole colons obtained from patients with slow-transit constipation (STC). The entire colon (excluding the anus), was removed from patients with confirmed STC and mounted longitudinally in an organ bath ∼120 cm in length, containing oxygenated Krebs' solution at 36°C. Changes in circular muscle tension were recorded from multiple sites simultaneously along the length of colon, by use of isometric force transducers. Recordings from isolated colons from non-STC patients revealed cyclical colonic motor complexes (CMCs) in 11 of 17 colons, with a mean interval and half-duration of contractions of 4.0 ± 0.6 min and 51.5 ± 15 s, respectively. In the remaining six colons, spontaneous irregular phasic contractions occurred without CMCs. Interestingly, in STC patients robust CMCs were still recorded, although their CMC pacemaker frequencies were slower. Intraluminal balloon distension of the ascending or descending colon evoked an ascending excitatory reflex contraction, or evoked CMC, in 8 of 30 trials from non-STC (control) colons, but not from colons obtained from STC patients. In many control segments of descending colon, spontaneous CMCs consisted of simultaneous ascending excitatory and descending inhibitory phases. In summary, CMCs can be recorded from isolated human colon, in vitro, but their intrinsic pacemaker frequency is considerably faster in vitro compared with previous human recordings of CMCs in vivo. The observation that CMCs occur in whole colons removed from STC patients suggests that the intrinsic pacemaker mechanisms underlying their generation and propagation are preserved in vitro, despite impaired transit along these same regions in vivo.
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Affiliation(s)
- Nick J Spencer
- Dept. of Human Physiology, School of Medicine, Flinders Univ., South Australia, Australia.
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Long-term effects of transabdominal electrical stimulation in treating children with slow-transit constipation. J Pediatr Surg 2011; 46:2309-12. [PMID: 22152871 DOI: 10.1016/j.jpedsurg.2011.09.022] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 09/03/2011] [Indexed: 11/22/2022]
Abstract
AIMS Transcutaneous electrical stimulation (TES) was used to treat children with slow-transit constipation (STC) for 1 to 2 months in a randomized controlled trial during 2006 to 2008. We aimed to determine long-term outcomes, hypothesizing that TES produced sustained improvement. METHODS Physiotherapists administered 1 to 2 months of TES to 39 children (20 minutes, 3 times a week). Fifteen continued to self-administer TES (30 minutes daily for more than 2 months). Mean long-term follow-up of 30 of 39 patients was conducted using questionnaire review 3.5 years (range 1.9-4.7 years) later. Outcomes were evaluated by confidence intervals or paired t test. RESULTS Seventy-three percent of patients perceived improvement, lasting more than 2 years in 33% and less than 6 months in 25% to 33%. Defecation frequency improved in 30%. Stools got wetter in 62% after stimulation and then drier again. Soiling improved in 75% and abdominal pain in 59%. Laxative use stopped in 52%, and 43% with appendicostomies stopped washouts. Soiling/Holschneider continence score improved in 81% (P = .0002). Timed sits switched to urge-initiated defecations in 80% patients. Eighty percent of relapsed patients elected to have home stimulation. CONCLUSION TES holds promise for STC children. Improvement occurred in two thirds of children, lasting more than 2 years in one third, whereas symptoms recurred after 6 months in one third of children.
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Yik YI, Farmer PJ, King SK, Chow CW, Hutson JM, Southwell BR. Gender differences in reduced substance P (SP) in children with slow-transit constipation. Pediatr Surg Int 2011; 27:699-704. [PMID: 21287181 DOI: 10.1007/s00383-011-2852-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2011] [Indexed: 12/20/2022]
Abstract
PURPOSE Adult slow-transit constipation (STC) occurs predominantly in females and is associated with low numbers of substance P (SP)-containing nerves in colonic circular muscle. AIM To determine if reduced SP nerves is female predominant in paediatric STC. METHODS Children with STC were identified from records of more than 600 nuclear transit studies (NTS) and intestinal biopsies done for intractable chronic constipation between November 1998 and March 2009. Colonic seromuscular biopsies collected from hepatic and splenic flexures, and sigmoid colon were processed for immunohistochemistry. Nerve fibre density in circular muscle containing SP was measured qualitatively by a pathologist. RESULTS Eighty-eight children with chronic constipation had both NTS and intestinal biopsies. Seventy-eight children (52 M; age 2-15.5 years; mean 7.7 years) had STC diagnosed by NTS. SP was reduced in 10/26 girls, but only 11/52 boys. CONCLUSION In this sample, STC was more common in boys than girls. However, in girls with STC, SP deficiency occurred in 40%, when compared with 20% of boys. During puberty, the percentage of girls with reduced SP decreased, whilst the percentage of boys increased. These results suggest that STC is heterogeneous and that there are some gender differences, the implication of which requires further investigation.
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Affiliation(s)
- Yee Ian Yik
- F Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia.
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25
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Dinning PG, Di Lorenzo C. Colonic dysmotility in constipation. Best Pract Res Clin Gastroenterol 2011; 25:89-101. [PMID: 21382581 DOI: 10.1016/j.bpg.2010.12.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 11/23/2010] [Accepted: 12/13/2010] [Indexed: 01/31/2023]
Abstract
Constipation is a common and distressing condition with major morbidity, health care burden, and impact on quality of life. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in the most severe cases of chronic constipation and physiological testing plays a role in identifying the colonic dysmotility and the subsequent patient management. Measurement of colonic motor patterns and transit has enhanced our knowledge of normal and abnormal colonic motor physiology. The scope of this review encompasses the latest findings that improve our understanding of the motility disorders associated with colonic dysfunction in both the paediatric and adult population suffering from constipation.
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Affiliation(s)
- Philip G Dinning
- Department of Gastroenterology, University of New South Wales, St George Hospital, Gray St, Kogarah, NSW 2217, Sydney, Australia.
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Chronic constipation: lessons from animal studies. Best Pract Res Clin Gastroenterol 2011; 25:59-71. [PMID: 21382579 DOI: 10.1016/j.bpg.2010.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 11/23/2010] [Accepted: 12/15/2010] [Indexed: 01/31/2023]
Abstract
Chronic constipation is a highly debilitating condition, affecting a significant proportion of the community. The burden to the health care system and impact on individual patients quality of life is immense. Unfortunately, the aetiology underlying chronic constipation is poorly understood and animal models are being used increasingly to investigate possible intrinsic neurogenic and myogenic mechanisms leading to relevant colonic sensori-motor dysfunction. Recently, major advances have been made in our understanding of the mechanisms that underlie propagating contractions along the large intestine, such as peristalsis and colonic migrating motor complexes in laboratory animals, particularly in guinea-pigs and mice. The first recordings of cyclical propagating contractions along the isolated whole human colon have now also been made. This review will highlight some of these advances and how impairments to these motility patterns may contribute to delayed colonic transit, known to exist in a proportion of patients with chronic constipation.
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Southwell BR. Colon lengthening slows transit: is this the mechanism underlying redundant colon or slow transit constipation? J Physiol 2011; 588:3343. [PMID: 20843833 DOI: 10.1113/jphysiol.2010.196121] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Bridget R Southwell
- Gut Motility Laboratory, Surgical Research Group, Murdoch Childrens Research Institute, Royal Childrens Hospital and Department of Paediatrics, University of Melbourne, Australia.
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Dinning PG, Benninga MA, Southwell BR, Scott SM. Paediatric and adult colonic manometry: A tool to help unravel the pathophysiology of constipation. World J Gastroenterol 2010; 16:5162-72. [PMID: 21049550 PMCID: PMC2975087 DOI: 10.3748/wjg.v16.i41.5162] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colonic motility subserves large bowel functions, including absorption, storage, propulsion and defaecation. Colonic motor dysfunction remains the leading hypothesis to explain symptom generation in chronic constipation, a heterogeneous condition which is extremely prevalent in the general population, and has huge socioeconomic impact and individual suffering. Physiological testing plays a crucial role in patient management, as it is now accepted that symptom-based assessment, although important, is unsatisfactory as the sole means of directing therapy. Colonic manometry provides a direct method for studying motor activities of the large bowel, and this review provides a contemporary understanding of how this technique has enhanced our knowledge of normal colonic motor physiology, as well as helping to elucidate pathophysiological mechanisms underlying constipation. Methodological approaches, including available catheter types, placement technique and recording protocols, are covered, along with a detailed description of recorded colonic motor activities. This review also critically examines the role of colonic manometry in current clinical practice, and how manometric assessment may aid diagnosis, classification and guide therapeutic intervention in the constipated individual. Most importantly, this review considers both adult and paediatric patients. Limitations of the procedure and a look to the future are also addressed.
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Pan C, Tian SP, Yan GZ, Wang KD. Colonic pressure data processing based on independent component analysis. J Med Eng Technol 2010; 34:415-21. [DOI: 10.3109/03091902.2010.514973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Constipation is one of the most common digestive problems in North America with significant psychosocioeconomic implications. It is caused by either a primary disorder of colonic and anorectal function or by many secondary conditions such as constipating drugs, metabolic disorders and other colorectal problems. Given the heterogeneity of problems that cause constipation, defining the underlying pathophysiology is increasingly being recognized as a key step toward optimal management. Colonic manometry with sensation and tone assessment (barostat) and anorectal manometry with rectal sensation and compliance assessment and balloon expulsion test can provide a comprehensive evaluation of colonic and anorectal sensorimotor function and facilitate a diagnosis of slow transit constipation, dyssynergic defecation or irritable bowel syndrome, or an overlap of these disorders. This review provides a critical appraisal of the role of manometric techniques toward augmenting our understanding of colonic and anorectal physiology, both in health and constipation and discussing their clinical utility in the diagnosis and management of chronic constipation.
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31
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King SK, Sutcliffe JR, Ong SY, Lee M, Koh TL, Wong SQ, Farmer PJ, Peck CJ, Stanton MP, Keck J, Cook DJ, Chow CW, Hutson JM, Southwell BR. Substance P and vasoactive intestinal peptide are reduced in right transverse colon in pediatric slow-transit constipation. Neurogastroenterol Motil 2010; 22:883-92, e234. [PMID: 20529207 DOI: 10.1111/j.1365-2982.2010.01524.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Slow-transit constipation (STC) is recognized in children but the etiology is unknown. Abnormalities in substance P (SP), vasoactive intestinal peptide (VIP) and nitric oxide (NO) have been implicated. The density of nerve fibers in circular muscle containing these transmitters was examined in colon from children with STC and compared to other pediatric and adult samples. METHODS Fluorescence immunohistochemistry using antibodies to NO synthase (NOS), VIP and SP was performed on colonic biopsies (transverse and sigmoid colon) from 33 adults with colorectal cancer, 11 children with normal colonic transit and anorectal retention (NAR) and 51 with chronic constipation and slow motility in the proximal colon (STC). The percentage area of nerve fibers in circular muscle containing each transmitter was quantified in confocal images. KEY RESULTS In colon circular muscle, the percentage area of nerve fibers containing NOS > VIP > SP (6 : 2 : 1). Pediatric groups had a higher density of nerve fibers than adults. In pediatric samples, there were no regional differences in NOS and VIP, while SP nerve fiber density was higher in sigmoid than proximal colon. STC children had lower SP and VIP nerve fiber density in the proximal colon than NAR children. Twenty-three percent of STC children had low SP nerve fiber density. CONCLUSIONS & INFERENCES There are age-related reductions in nerve fiber density in human colon circular muscle. NOS and VIP do not show regional variations, while SP nerve fiber density is higher in distal colon. 1/3 of pediatric STC patients have low SP or VIP nerve fiber density in proximal colon.
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Affiliation(s)
- S K King
- Department of General Surgery, Royal Children's Hospital, Melbourne, Australia
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32
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Rao SSC, Singh S, Mudipalli R. Day-to-day reproducibility of prolonged ambulatory colonic manometry in healthy subjects. Neurogastroenterol Motil 2010; 22:640-e178. [PMID: 20345373 PMCID: PMC2902872 DOI: 10.1111/j.1365-2982.2010.01492.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although colonic manometry provides useful information regarding colonic physiology, considerable variability has been reported both for regional motility and manometric patterns. Whether colonic manometry is reproducible is not known. METHODS Seven healthy volunteers (three men, four women, mean age = 34 years) underwent two studies of 24-h ambulatory colonic manometry, each 2 weeks apart. Manometry was performed by placing a six-sensor solid-state probe, up to the hepatic flexure and anchored to colonic mucosa. Colonic motility was assessed by the number and area-under-curve (AUC) of pressure waves and motility patterns such as high-amplitude propagating contractions (HAPC). Waking and meal-induced gastrocolonic responses were also assessed. Paired t-test was used to examine the reproducibility and intra and interindividual variability. KEY RESULTS The number of pressure waves and propagating pressure waves and HAPC, and AUC were similar between the two studies. Diurnal variation, waking and meal-induced gastrocolonic responses were also reproducible. There was some variability in the incidence of individual colonic motor patterns. CONCLUSIONS & INFERENCES Colonic manometry findings were generally reproducible, particularly for the assessment of key physiologic changes, such as meal-induced gastrocolonic, HAPC, and waking responses.
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Affiliation(s)
- S S C Rao
- Division of Neurogastroenterology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa city, IA 52242, USA.
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33
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Abstract
The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.
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Affiliation(s)
- Shawn J Rangel
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02210, USA.
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34
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Sutcliffe JR, King S, Hutson JM, Southwell B. What is new in radiology and pathology of motility disorders in children? Semin Pediatr Surg 2010; 19:81-5. [PMID: 20307844 DOI: 10.1053/j.sempedsurg.2009.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Disorders affecting colorectal motility lead to significant morbidity in children with surgical conditions. Etiology is frequently unknown, which in turn makes treatment empiric and compromises outcome. A thorough understanding of the normal mechanisms of control and the ability to recognize and manage defects is an important goal for clinicians. This article reviews recent advances made in the investigation of children with colorectal motility disorders, including the role of transit studies (marker studies and scintigraphy), options for assessing anatomy (ultrasound, contrast enema, and sectional imaging) and the use of manometry, both anorectal and colonic. Current concepts in microscopic evaluation are outlined.
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Affiliation(s)
- Jonathan R Sutcliffe
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom.
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35
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Liem O, van den Berg MM, Mousa HM, Youssef NN, Langseder AL, Benninga MA, Di Lorenzo C. Distention of the colon is associated with initiation of propagated contractions in children. Neurogastroenterol Motil 2010; 22:19-23, e1. [PMID: 19706068 DOI: 10.1111/j.1365-2982.2009.01383.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The presence of high-amplitude propagating contractions (HAPCs) has been identified as a marker of colonic neuromuscular integrity. The physiologic mechanisms of HAPCs initiation have yet to be determined. Distention secondary to colonic filling has been hypothesized as physiologic initiator. The aim of this study was to study the effect of intraluminal balloon distention in the colon of children with defecatory disorders. Colonic manometry was performed with a polyethylene balloon situated at the proximal end of the catheter, which was placed in the most proximal colonic segment reached during colonoscopy. A stepwise pressure controlled distention of the balloon was performed using barostat computer (10-50 mmHg). Propagated contractions were defined as those that migrated over at least three recording sites. They were divided into HAPCs, amplitude >60 mmHg and low-amplitude propagating contractions (LAPCs), amplitude <60 mmHg. Children with spontaneous HAPCs or HAPCs after bisacodyl provocation were considered to have normal motility. Twenty children completed the study. Among the 14 children with normal colonic motility, balloon distention elicited HAPCs in four and LAPCs in 10 children. No HAPC were elicited in six children with abnormal motility and LAPCs were seen in four of them. The balloon-induced propagated contractions had similar characteristics as those occurring spontaneously and after bisacodyl provocation but the pressure needed to elicit them and their amplitude was inconsistent. These findings suggest that intraluminal distention can trigger propagated contractions in children. This mechanism of action for induction of propagated contractions is not as consistent as the motor response found in response to bisacodyl administration.
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Affiliation(s)
- O Liem
- Emma Children's Hospital, Amsterdam Medical Centre, Amsterdam, The Netherlands.
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36
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Abstract
PURPOSE OF REVIEW Disorders of colonic motor and sensory function are common among children and adults and pose significant diagnostic and therapeutic challenges; the purpose of this review, therefore, was to critically assess the recent literature on this topic. RECENT FINDINGS Considerable progress has been made at the ultrastructural, molecular and electrophysiological level in understanding the normal functions of the muscles, nerves and interstitial cells that generate and control colonic motility. Furthermore, abnormalities in these cell types and in the interstitial cells of Cajal, in particular, have been identified in a number of disease states. Testing of colonic motor and sensory function in clinical practice continues to be a challenge due, in part, not only to the technical issues presented by accessing the organ but also to the intrinsic variability of its physiology. These have not been auspicious times for advances in the therapy of disturbed colonic motility; new agents or new applications for 'old' agents continue to be explored as are more innovative approaches such as those based on neural stimulation and cell therapy. SUMMARY Considerable progress has been made in understanding the basic pathophysiology of colonic dysmotility; clinical diagnostics and therapeutics continue to lag behind.
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37
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Abstract
Colonic sensorimotor dysfunction is recognized as the principal pathophysiological mechanism underpinning chronic constipation. This review addresses current understanding derived from both human and animal studies, with particular reference made to methods of investigation.
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Affiliation(s)
- P. G. Dinning
- Department of Medicine, University of New South Wales, St George Hospital, Sydney, Australia
| | - T. K. Smith
- Department of Physiology and Cell Biology, University of Nevada School of Medicine, Reno, NV, USA
| | - S. M. Scott
- Queen Mary University London, Barts and the London School of Medicine & Dentistry, London, UK
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38
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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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39
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Abstract
When the Gastroenterological Society of Australia (GESA) began 50 years ago there were very few pediatric gastroenterologists in the world. The 'Mother' of Paediatric Gastroenterology was Australian Charlotte ('Charlo') Anderson who established one of the world's first pediatric gastroenterology units in Melbourne in the early 1960s. Her earlier work in Birmingham had identified gluten as the component of wheat responsible for celiac disease and helped separate maldigestion (cystic fibrosis) and mucosal malabsorption. The first comprehensive textbook of Paediatric Gastroenterology was edited by Charlotte Anderson and Valerie Burke in 1975. Rudge Townley succeeded Charlotte Anderson in Melbourne and went on to further develop small bowel biopsy techniques making it a safe, simple, and quick procedure that led to much greater understanding of small bowel disease and ultimately the discovery of Rotavirus by Ruth Bishop et al. and subsequently to Rotavirus immunization. Australian Paediatric Gastroenterology subsequently developed rapidly with units being established in all mainland capital cities by the end of the 1970s. The Australian Society of Paediatric Gastroenterology Hepatology and Nutrition (AuSPGHAN) was established in the 1980s. Australians have contributed significantly in many areas of gastroenterology in infants, children, and adolescents including celiac disease, cystic fibrosis, liver disease, transplantation, gastrointestinal infection, allergy, indigenous health, inflammatory bowel disease, gastrointestinal motility, and the development of novel tests of gastrointestinal function and basic science. There have also been major contributions to nutrition in cystic fibrosis, end-stage liver disease, and intestinal failure. The future of Australian Paediatric Gastroenterology is in good hands.
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Affiliation(s)
- Don Cameron
- Monash University and Southern Health, Parkville, Victoria, Australia.
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40
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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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41
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Abstract
The colon is an organ of conservation that salvages water, electrolytes, and energy. The organization of colonic function is determined by the roles played by the luminal flora, the function of the different mucosal epithelial cell types, immunocompetent cells, and the neuromusculature. These different components of the colon interact with one another and with the colonic flora, and different areas of the colon serve different functions. In the normal adult during the course of a day the colon absorbs approximately 1.5 L of fluid, but under the influence of aldosterone increases up to 5 to 6 L. Diarrhoea occurs when secretion exceeds absorptive processes by either small intestinal secretion overwhelming colonic salvage or salvage being impaired by reduced colonic absorption or increased colonic secretion.
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42
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Camilleri M, Bharucha AE, di Lorenzo C, Hasler WL, Prather CM, Rao SS, Wald A. American Neurogastroenterology and Motility Society consensus statement on intraluminal measurement of gastrointestinal and colonic motility in clinical practice. Neurogastroenterol Motil 2008; 20:1269-82. [PMID: 19019032 DOI: 10.1111/j.1365-2982.2008.01230.x] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tests of gastric, small intestinal and colonic motor function provide relevant physiological information and are useful for diagnosing and guiding the management of dysmotilities. Intraluminal pressure measurements may include concurrent measurements of transit or intraluminal pH. A consensus statement was developed and based on reports in the literature, experience of the authors, and discussions conducted under the auspices of the American Neurogastroenterology and Motility Society in 2008. The article reviews the indications, methods, performance characteristics, and clinical utility of intraluminal measurements of pressure activity and tone in the stomach, small bowel and colon in humans. Gastric and small bowel motor function can be measured by intraluminal manometry, which may identify patterns suggestive of myopathy, neuropathy, or obstruction. Manometry may be most helpful when it is normal. Combined wireless pressure and pH capsules provide information on the amplitude of contractions as they traverse the stomach and small intestine. In the colon, manometry assesses colonic phasic pressure activity while a barostat assesses tone, compliance, and phasic pressure activity. The utility of colonic pressure measurements by a single sensor in wireless pressure/pH capsules is not established. In children with intractable constipation, colonic phasic pressure measurements can identify patterns suggestive of neuropathy and predict success of antegrade enemas via cecostomy. In adults, these assessments may be used to document severe motor dysfunction (colonic inertia) prior to colectomy. Thus, intraluminal pressure measurements may contribute to the management of patients with disorders of gastrointestinal and colonic motility.
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Affiliation(s)
- M Camilleri
- CENTER Program, Mayo Clinic, Rochester, MN 55905, USA.
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