RE: CHRONIC CONSTIPATION IN CHILDREN: ORGANIC DISORDERS ARE A MAJOR CAUSE

Abstract

27 April 2005 Dear Editor, In the recent review article: ‘Chronic constipation in children: Organic disorders are a major cause’, the authors suggest that 50% of children with severe constipation have an organic cause, where surgical management has a major role.1 They pose the question: ‘Why are some paediatricians and gastroenterologists sceptical?’. We suggest that there are many good reasons for our scepticism. First, the authors are confused about the term ‘functional’. They use it as a synonym for behavioural/psychological and suggest that any demonstration of a physiological difference from control subjects results in a diagnostic ‘paradigm’ shift to an organic pathology, that ‘completely change(s) the way they are treated’. However, the term ‘functional’ as originally used, implied that ‘morbid manifestations may be independent of anatomic change’.2 The term has now been expanded to encompass a broad range of syndromes that cannot be accounted for by observed abnormalities, but which are frequently associated with physiologic and anatomic (histologic) alterations.3 It is certainly not appropriate to assume that demonstration of slow transit constipation (STC), or of changes in neurotransmitter levels, or of impaired rectal sensation, equates with organic pathology. Second, the scientific evidence that many children with STC have a primary abnormality in intestinal innervation is weak. Yes, one can show differences in levels of an increasing number of neurotransmitters, when one compares children with STC to adults with colon cancer; but is this real or just a problem with selection of controls? Even if it is a real observation, there is almost no evidence suggesting that the abnormalities are causal rather than secondary to the constipation itself, or even its treatment. Third, we disagree with the suggestion that demonstration of any alteration of intestinal neurotransmitter levels automatically means that the condition is permanent, therefore unresponsive to conservative treatment, and therefore requires surgery. Both functional and organic diseases of the intestine are frequently both self-limiting and responsive to non-surgical treatment. This is our experience in almost all children with constipation. Finally, many of the facts and logic presented in the article are either wrong or defy comprehension (or both). In the interests of space we can only point out a few of these. (i) The statement: ‘The colon is the site of water absorption’ shows a gross misunderstanding of basic intestinal physiology. (ii) If STC is a permanent organic condition, then what is the logic of submitting a child to an end-ileostomy with retention of the colon to allow for future reconnection if recovery occurs and (iii) how is one to show recovery of colonic function in a disconnected colon? (iv) We also reject the implication that surgical management has become less invasive. Colectomy for constipation was always a rare operation in children, as opposed to the current situation in the authors' unit where they state that they have more than 50 children with colostomy for management of constipation, many of whom have also been subjected to laparoscopic full-thickness intestinal biopsy at multiple sites. Overall, the level of surgical invasion seems to have dramatically increased, at least in their unit. The editor's decision to present the paper as a review article incorrectly suggests that its content is well accepted. The reality, as the authors correctly identify, is that most paediatricians and gastroenterologists remain unconvinced by their arguments – for many good reasons.