Empty Rectum Research Articles

Colonic transit time in constipated children: does pediatric slow-transit constipation exist?

In adults, slow-transit constipation is a well-established form of constipation with abdominal pain and an empty rectum on examination. Marker studies in these patients, mainly women, show a markedly slowed transit time in all colonic segments. No studies in constipated children are available that assess the existence of slow-transit constipation. In a prospective study, a total of 94 referred constipated pediatric patients, 63 boys and 31 girls (median age, 8.0 years), underwent colonic-transit-time measurements using radioopaque markers to evaluate the pattern of transit. In addition, orocecal-transit-time measurements using the hydrogen breath (lactulose) test, anorectal manometry, and behavior studies using the Child Behavior Checklist were performed in all children. Based on the upper limit (mean + 2 SD) of total colonic transit time (CTT) in constipated children, we arbitrarily separated patients into two groups. Children with CTTs > 100 h were said to have pediatric slow-transit constipation (PSTC), while patients with CTTs < 100 h were said to have normal- or delayed-transit constipation (NDTC). In 94 constipated children, PSTC was found in 24 children; in 70 children, total CTT was < 100 h (NDTC). Total and segmental CTTs were significantly prolonged in PSTC (median, 189 h; range, 104.4-384) versus NDTC (median, 46.8 h; range, 3.6-99.4) hours. No significant differences were found in orocecal transit time. Significant clinical differences in children with PSTC versus those with NDTC existed regarding nighttime soiling (71 vs. 11%); daytime soiling episodes (14 vs. 7 each week, median), and nighttime soiling episodes (5 vs. 0 each week, median); absent urge to defecate (33 vs. 14%); and palpable abdominal (71 vs. 39%) and/or rectal (71 vs. 13%) masses. All manometric parameters were comparable in the two groups, except for a significantly lower maximal squeeze pressure with PSTC. Using the Child Behavior Checklist, both groups differed significantly from controls (26 and 43%, respectively), with no significant differences in behavior problems found between the NDTC and the PSTC groups. In conclusion, based on objective marker studies, our findings suggest the existence of pediatric slow-transit constipation. This entity can be recognized by clinical features, most importantly nighttime soiling and a palpable rectal mass. The probability of PSTC with both of these symptoms was 0.82; in the absence of these two symptoms, it was 0.07. It is of interest that CTTs in PSTC are comparable with CTTs in adults with slow-transit constipation, although the clinical presentation is clearly different. Further studies are needed to investigate whether the prolonged CTT characterizes a distinct form of constipation in children or is an epiphenomenon of the underlying constipation itself. The mechanisms responsible for the slow transit in these children and the appropriate therapeutic approach need to be studied.

The empty rectum on plain X-ray. Does it have a significance in the neonate? : M.J. Bradley and D. Pilling. Clin Radiol 43:265–267, (April), 1991

The empty rectum on plain X-ray. Does it have a significance in the neonate? : M.J. Bradley and D. Pilling. Clin Radiol 43:265–267, (April), 1991

The empty rectum on plain X-ray. Does it have any significance in the neonate?

The absence of rectal gas is said to be a sign of Hirschsprung's disease, especially when there is also gaseous distension of the bowel proximally. This paper reviews 136 neonates who had plain abdominal radiographs. There were 83 patients with multiple examinations, of which 52 (63%) showed variability in the presence of rectal gas on the radiographs. Fifty-seven of the total babies (42%) had significant bowel distension and of these 42 (74.5%) had absence of rectal gas. Only one of these cases had Hirschsprung's disease, most of the remaining having either generalized sepsis (42%) or necrotizing enterocolitis (25.5%).

Defecometry. A new method for determining the parameters of rectal evacuation.

The parameters of defecation, i.e., maximum rectal pressure increase during straining, duration of effective evacuation, and the work performed to evacuate a simulated stool, can be quantified by defecometry, a new method to evaluate the defecation act. Simultaneous anal pressure records demonstrate the nature of the sphincter activity during simulated defecation. The test was performed on 19 patients with constipation and on 14 controls. Five patients could not evacuate the simulated stool, while five others could, but more laboriously than the remaining nine patients whose defecation was comparable with the controls. Laborious defecation is characterized by longer duration and more performed work during evacuation. Every patient with difficult or ineffective evacuation had sphincter contraction during defecation, whereas this phenomenon was not observed in patients with normal defecation. Defecometry permits more adequate identification and characterization of the outlet-obstruction-type constipated patients than the simple balloon expulsion test and the analysis of sphincter activity during straining with empty rectum in lateral decubitus. Early diagnosis and treatment of patients with outlet obstruction is important to avoid late neuromuscular damage to the pelvic floor.

Hirschsprung Disease

Intestinal aganglionosis (Hirschsprung disease) has an incidence of one in 5,000 live births. It is being recognized with greater frequency during the neonatal period when it must be distinguished from other causes of intestinal obstruction. The diagnosis of Hirschsprung disease is most often considered in the infant or child with chronic constipation since birth. A history of delayed passage of meconium may be obtained, and the infant may have no spontaneous evacuation of feces without stimulation. Less commonly, intractable diarrhea secondary to enterocolitis may be the finding.Clinical features suggestive of Hirschsprung disease include increased anal sphincter tone and empty rectum despite the presence of fecal impaction.

Hirschsprung Disease

Intestinal aganglionosis (Hirschsprung disease) has an incidence of one in 5,000 live births. It is being recognized with greater frequency during the neonatal period when it must be distinguished from other causes of intestinal obstruction. The diagnosis of Hirschsprung disease is most often considered in the infant or child with chronic constipation since birth. A history of delayed passage of meconium may be obtained, and the infant may have no spontaneous evacuation of feces without stimulation. Less commonly, intractable diarrhea secondary to enterocolitis may be the finding. Clinical features suggestive of Hirschsprung disease include increased anal sphincter tone and empty rectum despite the presence of fecal impaction.

Colonic and anorectal motility in young women with severe idiopathic constipation

Forty-four severely constipated women and 16 (8 female, 8 male) asymptomatic volunteers underwent assessment of colon function by (a) clinical examination, (b) rectosigmoid intraluminal pressure recording, (c) colonic transit utilizing radiopaque markers, (d) anorectal manometry, and (e) rectosigmoid electrical activity. Constipated patients were characterized by (a) a greater volume and pressure of rectal distention required for both sensation and sphincter relaxation, (b) diminished basal and postmorphine motility indices only in the distal rectum, (c) delayed transit, and (d) an empty rectum when severely constipated. A neural abnormality affecting afferent nerves may be present in the rectum of female patients with severe idiopathic constipation. Delivery of stool to the rectum is impaired in these patients.

Radiographic spectrum of rectocolonic calcification from schistosomiasis.

Rectocolonic calcification was detected radiographically in 17 sites in 14 patients undergoing excretory urography for the assessment of urinary schistosomiasis. The right colon was involved in 11 sites, the rectum in four, and the left colon in two. The pattern of calcification varied according to the degree of bowel distension. A laminar pattern was common to all sites and occurred when the rectum or colon was distended with air, feces, or barium. A laminar or irregular amorphous density was found in the empty colon, whereas the calcified, empty rectum had a corrugated pattern. Rectocolonic calcification is probably the most common radiographic manifestation of schistosomal infestation of the gastrointestinal tract.

Two-stage abdominoperineal removal of cancer of the rectum.

We have employed the operative plan described upon 7 patients with cancer of the rectum. This method is itself not without undesirable features but, as a two-stage operation, has so far appeared to offer a nearer approach to the ideal one-stage abdominosacral removal of cancer of the rectum than have other procedures. As much delay and preparation as desired are possible between the first and second stages of the operation. The duration of the steps is better divided, the greater part being done in the second stage when the patient is in the best state of preparation. The necessity of implanting dead bowel in the pelvis is overcome, The second stage involves the removal of a clean, empty rectum. Good posterior drainage is established immediately after the extensive pelvic dissection.

Comparison of proximal and distal ligation of mesenteric vessels in restorative colorectal surgery

N MANY OPERATIONS in which colon and/or rectal resection is followed by sphincter-saving anastomosis, such as in Hirschsprung's disease, one of the problems facing the surgeon is the best point at which to divide the mesenteric vessels in order to preserve the blood supply to the distal end of the mobilized bowel. The marginal vessels should certainly be maintained but it was not clear whether the preservation of arcades toward the root of the mesentery would be beneficial or produce a lower-pressure by-pass. COMPARATIVE ANATOMICAL OBSERVATIONS The rabbit was chosen as suitable for the experiment in view of its distal colonic vascular pattern. Although the anatomical features of the large bowel are rather different with a relatively lengthy the vascular supply of the rabbit's is very similar to the one seen in the human from the splenic flexure downward to the as to the inferior mesenteric artery, left colic artery, and sigmoid arteries. The main trunk in the rabbit is called the posterior mesenteric artery (Fig. 1). The resection of roughly the distal half of the rabbit's rectum is, in relation to the ligated vessels, similar to resection of distal third of the left colon, sigmold and down to the anal canal in the human. The rabbit's rectum, like the human colon, has a definite marginal artery giving some justification for comparisons. MATERIAL AND METHODS Ten rabbits were used in the experiment, four males and six females, with an average weight of 2,150 g (I,800 2,850 g): all of them were starved for 24 hr before operation in order to have a reasonably empty rectum, not distended with fecal pellets. The experiments were conducted under general anesthesia induced by intravenous Nembutal and maintained by chloroform inhalation. One animal had a cardiac arrest soon after laparotomy and died after several attempts to massage the heart. The peritoneal cavity was opened by a left paramedian incision: none of the rabbits had visible abdominal abnormality. In four of the animals, the main arterial trunk to the rectum, the posterior mesenteric artery, was divided and ligated with 3-0 silk (Fig. 2A) so as to preserve continuity through the proximal arcades. In the remaining five, all of the vessels branching from the posterior mesenteric artery were individually divided and ligated, leaving intact only the marginal artery (Fig. 2B). A segment of bowel, from the middle of the rectum downward was then resected, extending down as low as possible. Continuity was restored by end-to-end anastomosis in one layer with

Office Treatment of Rectal and Anal Diseases

Considering the role of the rectum and anus as a conduit for excretion of gaseous, liquid, or solid waste with high concentrations of infective bacteria, their functions are remarkably efficient and trouble-free. In fact, discrimination, continence, and defecation are accomplished largely at reflex levels with acute consciousness of anorectal function being reserved for states of deliberate continence of defecation, malfunction, or disease.^1,2 <h3>Normal Physiology</h3> In the resting state, anus and rectum are empty and collapsed with their side walls closely approximated. The sigmoid colon, a narrowed segment with relatively high intraluminal pressure, functions as a partial sphincter to retain bowel content in the proximal reservoir of descending colon. Increased intra-abdominal pressure with muscular exertion or straining tends to collapse even more tightly the walls of the empty rectum above the levator muscles to reinforce the mechanisms of continence. In addition, the internal sphincter of the anus maintains a state

PSYCHOGENIC MEGACOLON MANIFESTED BY FECAL SOILING

The results of surgical therapy in cases of aganglionic megacolon have tended to create the impression that all cases of megacolon can be benefited by surgery. The authors have described six patients in whom megacolon had a psychogenic origin; this group has been previously described as "functional" or "idiopathic," and its psychogenic origin has not been clearly recognized. Psychogenic megacolon may be diagnosed by the following clinical findings without the necessity of a detailed psychiatric history: admitting complaint of fecal soiling, onset in the second year of life or later, infrequent use of the toilet for defecation, defecation in the standing or supine position, inhibition of the stool, periodic voluminous stools, absence of episodes of intestinal obstruction, a feces-packed rectum, absence of a spastic segment of rectum or rectosigmoid using Neuhauser's fluoroscopic technic and a relatively benign course insofar as physical status is concerned. A sharp clinical distinction is apparent when the following findings of the aganglionic group are considered: admitting complaint of constipation without fecal soiling, onset at birth or in the first few weeks of life, use of the toilet for defecation, defecation in the sitting position, pellet-like or ribbon-like stools, frequent episodes of intestinal obstruction, an empty rectum, and the presence of a spastic segment of rectum or rectosigmoid using Neuhauser's fluoroscopic technic. A small additional group of cases has been described by others in which megacolon is due to anatomic obstruction; these cases can usually be diagnosed by digital examination of the rectum. The authors have classified the symptom of megacolon into three groups and have given them the following generic designations: psychogenic, neurogenic and anatomic. Only the neurogenic and anatomic groups are benefited by surgery.

The peritoneum of the pelvic cavity

The peritoneum of the pelvic cavity