Functional Fecal Retention Research Articles

Predictors of slow colonic transit in children.

Slow transit constipation (STC) and functional fecal retention (FFR) are two forms of severe intractable constipation in childhood diagnosed by nuclear transit studies (NTS). This retrospective study aims to identify the predicting factors for STC and FFR by looking at the association with neuropsychiatric disorders (NPD), obesity, family history of constipation and atopic disease. A retrospective chart review was conducted on children with intractable constipation referred for NTS between 1st April 2003 and 1st April 2014. Comparisons were made between STC, FFR and normal transit patients with regards to NPD, obesity (BMI z score>95th percentile), family history of constipation in first and second-degree relatives and atopic disease which included food allergy, asthma and eczema. Between 2003 and 2014, 97 patients were referred for a NTS. Out of 36 patients with NPD, 21 (58.3%) had STC and 13 (36.1%) had FFR (p<0.05). 15.8% of patients with constipation were obese, compared to 6.4% in the general Australian paediatric population (p<0.05). There was no significant association between constipation and atopic disease or family history. Neuropsychiatric disorders, in particular autism, are useful predictors of STC and FFR in children. Obesity may be associated with a higher risk of developing chronic constipation.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction

PurposeTo evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group). Patients and methodsOne-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit. ResultsFFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections. ConclusionsFFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

Role of Probiotics and Prebiotics in Functional Gastrointestinal Disorders in Children

Introduction: Functional gastrointestinal disorders (FGID) are non-fatal, unknown etiology disorders with absence of a structural or biochemical explanation and accounting for up to 50% of gastroenterology referrals. Infant regurgitation, rumination and cyclic vomiting constitute the vomiting disorders. Abdominal pain disorders are classified as: functional dyspepsia, irritable bowel syndrome (IBS), functional abdominal pain, abdominal migraine and aerophagia. Disorders of defecation include: infant dyschezia, functional constipation, functional fecal retention and functional non-retentive fecal soiling. Current researches suggest a role of gut microbiota in pathogenesis of FGID and qualitative and quantitative alterations in the normal gut flora in some functional disorder such as IBS, chronic constipation and formula-fed infants which suffering colic or regurgitation have been described. Probiotics are nonpathogenic microorganisms, when they are ingested, have positive effects on the host’s health. They influence intestinal physiology by different ways. Prebiotics are non-digestible carbohydrates which promote the growth and/or activity of probiotic bacteria. Evidences for the therapeutic or preventive effect of particular probiotic strains with or without prebiotics in FGID are available in many of articles. Results are encouraging in symptomatic alleviation and improvement in quality of life in IBS, functional constipation, functional abdominal pain, infantile colic, aerophagia and infantile regurgitation. Conclusion: Different probiotic strains have different effects, so selection of strains with specific health benefits is important. In general according to review of articles, although some of specific probiotic strains can provide a health benefit in these disorders, it seems, more high-quality and long-duration placebo-con-trolled trials are required. Keywords: Functional gastrointestinal disorders, Probiotic.

Gastric emptying of water in children with severe functional fecal retention

The objective of this study was to evaluate gastric emptying (GE) in pediatric patients with functional constipation. GE delay has been reported in adults with functional constipation. Gastric emptying studies were performed in 22 children with chronic constipation, fecal retention and fecal incontinence, while presenting fecal retention and after resuming regular bowel movements. Patients (18 boys, median age: 10 years; range: 7.2 to 12.7 years) were evaluated in a tertiary pediatric gastroenterology clinic. Gastric half-emptying time of water (reference range: 12 ± 3 min) was measured using a radionuclide technique immediately after first patient evaluation, when they presented fecal impaction (GE1), and when they achieved regular bowel movements (GE2), 12 ± 5 weeks after GE1. At study admission, 21 patients had reported dyspeptic symptoms, which were completely relieved after resuming regular bowel movements. Medians (and interquartile ranges) for GE1 and GE2 were not significantly different [27.0 (16) and 27.5 (21) min, respectively (P = 0.10)]. Delayed GE seems to be a common feature among children with chronic constipation and fecal retention. Resuming satisfactory bowel function and improvement in dyspeptic symptoms did not result in normalization of GE data.

Functional Defecation Disorders in Children: Comparing the Rome II with the Rome III Criteria

To evaluate the prevalence of pediatric functional defecation disorders (FDD) using the Rome III criteria and to compare these data with those obtained using Rome II criteria. A chart review was performed in patients referred to a tertiary outpatient clinic with symptoms of constipation and/or fecal incontinence. All patients received a standardized bowel questionnaire and physical examination, including rectal examination. The prevalence of pediatric FDD according to both Rome criteria sets was assessed. Patients with FDD (n = 336; 61% boys, mean age 6.3 ± 3.5 SD) were studied: 39% had a defecation frequency ≤ 2/wk, 75% had fecal incontinence, 75% displayed retentive posturing, 60% had pain during defecation, 49% passed large diameter stools, and 49% had a palpable rectal fecal mass. According to the Rome III criteria, 87% had functional constipation (FC) compared with only 34% fulfilling criteria for either FC or functional fecal retention based on the Rome II definitions (P < .001). Of the patients with a rectal fecal mass, 95% would also have been correctly identified as having FC without a rectal examination. Twenty-nine patients (11%) fulfilled the criteria for functional nonretentive fecal incontinence according to both the Rome II and Rome III criteria. The pediatric Rome III criteria for FC are less restrictive than the Rome II criteria. The Rome III criteria are an important step forward in the definition and recognition of FDD in children.

Colon lengthening slows transit: is this the mechanism underlying redundant colon or slow transit constipation?

The study by Heredia et al. (2010) in a recent issue of The Journal of Physiology shows that elongation of colon longitudinal muscle results in slow colonic transit. This study was performed in mice, but the results are probably applicable to humans. The study by Heredia et al. presents a new mechanism that may explain the association of elongated colon and poor motility and might be manipulated to overcome bowel lengthening and stasis. Their study shows that elongation of the longitudinal muscle triggers inhibition of the colonic migrating motor complex (CMMC), resulting in slow colonic transit. In humans, slow colonic transit occurs in patients with chronic constipation and is known as slow transit constipation (STC) (Hutson, 2009). Interestingly, we have observed that many patients with slow transit constipation have an elongated transverse colon (Fig. 1). The results from Heredia et al. suggest this elongation would inhibit colonic motility. Differences in colon length in children with constipation A, normal length colon; B, elongated transverse colon. Both images are from radioisotope transit studies with gamma camera images taken 24 h after ingesting a radioactive milk drink (Southwell et al. 2009). Note the large loop of transverse colon in B. The elongated colon is also narrower than the colon in A. Image provided by Dr Ian Yik (Surgical Research Group, Murdoch Childrens Research Institute, Royal Childrens Hospital, Melbourne, Australia). Elongated (called redundant) colon often occurs in patients with constipation. These patients are notable during colonic endoscopy because it is very hard to get along the length of the colon (Rex et al. 2007). Both colonic transit time and constipation symptoms increase with the number of redundancies and these are the patients that are least likely to respond to treatments (Raahave et al. 2009). Redundant bowel is often removed surgically. Propagating contractions in the proximal colon are highly propulsive and are a major determinant of proximal colonic flow in normal human colon (Dinning et al. 2008). High amplitude propagating contractions (HAPCs) underlie mass movements along the colon and may be similar to CMMC. Children with STC have reduced numbers of propagating contractions in the proximal colon (King, 2008) and lack of HAPC in constipated patients is associated with poor outcomes (van den Berg et al. 2006). Heredia et al. show that lengthening the colon inhibits CMMC in mice. Possibly the same is occurring in humans with colonic lengthening inhibiting HAPCs and so reducing colonic motility and slowing transit. STC can be associated with abnormal recto/sigmoid function (outlet obstruction, anorectal retention or functional fecal retention) or occur with normal recto/sigmoid function (Southwell et al. 2009). There is a lot of discussion about whether the defect is primarily at the outlet (ano-rectum) producing slowing of motility upstream as a secondary effect or if a defect can occur in the proximal colon without an outlet defect. Heredia et al.'s study shows the effects of elongation are different in the proximal and distal colon, and provides evidence that the proximal colon can inhibit motility in the distal colon. Thus it is possible that elongation can inhibit motility in the proximal colon primarily and this can then affect the distal colon. Heredia et al. also investigated the mechanism and showed that nitric oxide was released and activated inhibitory neurons reducing pellet propulsion and amplitude of colonic migrating motor complex (CMMC). Ileus (lack of movement of the bowel) develops after surgery and has been shown to be due to release of nitric oxide that then activates inhibitory neurons. Removal of the tonic nitrergic inhibition is a potent stimulus for human proximal colonic propagating sequences (Dinning et al. 2006). STC often develops after childbirth and there may be a connection between surgery (anaesthesia and caesarean) inducing nitric oxide release within the bowel and then leading to stasis in the ileum and in the colon. This study reveals a previously unrecognised mechanism for control of colonic motility: lengthening of the longitudinal muscle. If this mechanism can be manipulated in people, we may have a treatment for a currently poorly treated condition. Further detailed physiological studies of the effects of longitudinal muscle lengthening on migrating motor complexes in proximal and distal colon in other species should be helpful.

848 An Open Label Follow-Up Study of Prucalopride Solution in Pediatric Subjects with Functional Fecal Retention

848 An Open Label Follow-Up Study of Prucalopride Solution in Pediatric Subjects with Functional Fecal Retention

T1148 A Single-Dose Pharmacokinetic Trial of Prucalopride Solution in Pediatric Subjects with Functional Fecal Retention

T1148 A Single-Dose Pharmacokinetic Trial of Prucalopride Solution in Pediatric Subjects with Functional Fecal Retention

Avaliação da qualidade de vida relacionada à saúde em crianças com distúrbios funcionais da defecação

OBJECTIVE: To evaluate the health-related quality of life in children with functional defecation disorders. METHODS: One hundred children seen consecutively were enrolled and subdivided into three subsets according to the Roma II classification criteria: functional constipation (n = 57), functional fecal retention (n = 29) and nonretentive functional soiling (n = 14). The generic instrument Child Health Questionnaire - Parent Form 50 (CHQ-PF50®), was used to measure quality of life and to assess the impact of these disorders from the point of view of parents. The instrument measures physical and psychosocial wellbeing in 15 health domains, each of which is graded on a scale from 0 to 100, with higher values indicating better health and greater wellbeing. Ten of these are then used to obtain two aggregated and summary scores: the physical and psychosocial scores. RESULTS: No statistically significant differences were detected between subsets in terms of demographic or anthropometric characteristics. In 14 domains, children with defecation disorders scored lower than healthy children. When subsets were compared, statistically significant differences were detected between children with nonretentive functional soiling (lower scores) and those with functional constipation. Physical and psychosocial scores for the entire sample were lower than those for the group of healthy children used as controls. CONCLUSIONS: The CHQ-PF50® was considered adequate for demonstrating compromised quality of life in children with functional defecation disorders, as has been reported for other diseases, being a useful tool for making treatment decisions and for patient follow-up.

DIAGNOSIS OF FUNCTIONAL GASTROINTESTINAL DISORDERS ACCORDING TO ROMA II CRITERIA

Introduction: Functional Gastrointestinal Disorders (FGIDs) are a frequent motive for health care need during infancy and adolescence thus causing serious problems socially and in family dynamics. Objective: To know the frequency of FGIDs and to identify and validate its clinical characteristics according to Roma II criteria. Methods: Within a 2 year period 227 consecutive patients less than 17 years of age diagnosed as having a functional disorder were given a questionnaire for symptoms to be filled out by them and/or parents or tutors and were subject of a complete physical examination in their first visit. These data was loaded into an Epinfo-6 Program. Percentual distribution was the selected statistic method. Results: Cyclic vomiting syndrome 19 (8,4%), 2-10 years, mean 5. Female 57,9 %, Migraine 6 (31,5%), Irritable bowel syndrome as accompanying disease 2 (10,5%). Abdominal pain 90 (39,6%), 5-16 years, mean 10: Functional dyspepsia 31 (34,5%,) 6,5-16 years, mean 12. Male 64,5%. Irritable bowel syndrome 32 (35,6%, 5-15 years, mean 9,5. Female 53,2%. Functional abdominal pain 17 (18,8%, 5-14 years, mean 8. Female 76,5%. Abdominal migraine 9 (10%), 6,5-11 years, mean 8,5. Female 55,6%. Aerophagia 1 (1,1%), 15 years, male. Functional diarrhea 44 (19,4%), (6-36 months, mean 17). From these (44,7%) 6-12 months. 59,1% Male. 43,1% started after an acute diarrhea episode. Undernurished 11,4%. History of Giardia 18,8%. Disorders of defecation 74 (32,6%): Infant dyschezia 5 (6,8%), (15-30 days, mean 22). Male 60%. Functional Constipation 21(28,4%), 2-5 years, mean 3,5. Female 52,4%. Functional fecal retention 45 (60,8%), 1,5-12, mean 5,5. Male 60%. Non-retentive fecal soiling 3 (4%), 9-13,5 years, mean 12. Male 100%. Conclusions: FGIDs are frequent in our children and adolescents. Diagnosis based in clinical symptoms according to Roma II criteria showed to be useful for them as a diagnosis method and for their following, though age restrictions are an inconvenience specially in defecation disorders.

Assessment of health-related quality of life in children with functional defecation disorders

To evaluate the health-related quality of life in children with functional defecation disorders. One hundred children seen consecutively were enrolled and subdivided into three subsets according to the Roma II classification criteria: functional constipation (n = 57), functional fecal retention (n = 29) and nonretentive functional soiling (n = 14). The generic instrument Child Health Questionnaire - Parent Form 50 (CHQ-PF50), was used to measure quality of life and to assess the impact of these disorders from the point of view of parents. The instrument measures physical and psychosocial wellbeing in 15 health domains, each of which is graded on a scale from 0 to 100, with higher values indicating better health and greater wellbeing. Ten of these are then used to obtain two aggregated and summary scores: the physical and psychosocial scores. No statistically significant differences were detected between subsets in terms of demographic or anthropometric characteristics. In 14 domains, children with defecation disorders scored lower than healthy children. When subsets were compared, statistically significant differences were detected between children with nonretentive functional soiling (lower scores) and those with functional constipation. Physical and psychosocial scores for the entire sample were lower than those for the group of healthy children used as controls. The CHQ-PF50 was considered adequate for demonstrating compromised quality of life in children with functional defecation disorders, as has been reported for other diseases, being a useful tool for making treatment decisions and for patient follow-up.

Childhood Functional Gastrointestinal Disorders: Neonate/Toddler

Recognizing the importance of childhood functional gastrointestinal disorders in understanding adult functional gastrointestinal disorders, and encouraging clinical and research interest, the Rome Coordinating Committee added a pediatric working team to Rome II in 1999. For Rome III, there was an increase from 1 to 2 pediatric working teams. This report summarizes the current consensus concerning functional disorders in infants and toddlers. Another report covers disorders diagnosed more often in school-aged children and adolescents. The symptoms from functional gastrointestinal disorders in children younger than 5 years depend on maturational factors in anatomy, gastrointestinal physiology, and intellectual and affective functioning. There has been little or no change for infant regurgitation, infant rumination syndrome, or infant dyschezia. Cyclic vomiting syndrome may be diagnosed after 2 rather than 3 episodes. The description of infant colic has been expanded, although there was consensus that infant colic does not reflect gastrointestinal malfunction. The greatest change was in functional constipation. Functional constipation and functional fecal retention in the 1999 report were merged into a single entity: functional constipation. Data-driven changes in diagnostic criteria for functional constipation appear to be less rigid and more inclusive than previous criteria.

Childhood Functional Gastrointestinal Disorders: Child/Adolescent

The Rome II pediatric criteria for functional gastrointestinal disorders (FGIDs) were defined in 1999 to be used as diagnostic tools and to advance empirical research. In this document, the Rome III Committee aimed to update and revise the pediatric criteria. The decision-making process to define Rome III criteria for children aged 4-18 years consisted of arriving at a consensus based on clinical experience and review of the literature. Whenever possible, changes in the criteria were evidence based. Otherwise, clinical experience was used when deemed necessary. Few publications addressing Rome II criteria were available to guide the committee. The clinical entities addressed include (1) cyclic vomiting syndrome, rumination, and aerophagia; 2) abdominal pain-related FGIDs including functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain; and (3) functional constipation and non-retentive fecal incontinence. Adolescent rumination and functional constipation are newly defined for this age group, and the previously designated functional fecal retention is now included in functional constipation. Other notable changes from Rome II to Rome III criteria include the decrease from 3 to 2 months in required symptom duration for noncyclic disorders and the modification of the criteria for functional abdominal pain. The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs. The future availability of additional evidence-based data will likely continue to modify pediatric criteria for FGIDs.

Functional Gastrointestinal Disorders in African American Children in Primary Care

To determine the prevalence of functional gastrointestinal disorders (FGIDs) in a primary care setting and to assess the usefulness of pediatric Rome criteria. The Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) assessing the pediatric Rome criteria was administered to 243 school-age children visiting a general pediatric clinic for annual school physicals. Pearson chi statistics were used to determine the association of various demographic factors with FGIDs. All children were African American, 47.7% were girls, and the mean +/- standard deviation age of the group was 10.7 +/- 3.9 years. QPGS detected 52 children (21.4%) with FGID. Diagnoses included aerophagia (6), abdominal migraine (1), cyclic vomiting syndrome (2), functional dyspepsia (2), functional abdominal pain syndrome (1), functional constipation (39) and functional fecal retention (1). Thorough clinical evaluation identified 47 (19.3%) children with FGIDs. Five of the children (2.1%) identified as having FGID on QPGS were felt not to have FGID by the examining physician. Children with FGIDs were not different from healthy children in age, insurance, parent's education, employment or number of children in the family. FGIDs were more common in girls (29/47 girls, P = 0.028). Children with FGIDs tended to live in single-parent households and miss school more often than children without FGIDs (P = 0.08). Functional gastrointestinal disorders are common among African American children and adolescents in a primary care setting and predominantly affect girls. Symptom-based criteria are useful in the diagnosis of pediatric FGIDs.

Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation

Purpose It has not been possible so far to differentiate slow transit constipation from functional fecal retention because the existing medical literature lacks data on rectal dimensions for healthy children or children with chronic idiopathic constipation (CIC). We, for the first time, describe the use of pelvic ultrasound (US) to achieve this. Methods A pelvic US was carried out on 82 children with a full or partially full bladder and with no history of bowel problems and on 95 children with CIC. The rectal crescent seen behind the bladder was measured. All children also had documentation of their age, weight, and height. Results The median age, weight, and height for the healthy children were comparable with those of the children with CIC. The median rectal crescent size in children with constipation was 3.4 cm (range, 2.10-7.0; IQR, 1.0), as compared with 2.4 cm (range, 1.3-4.2; IQR, 0.72) in the healthy children, and this difference is statistically significant on multiple regressions of log for rectal diameter, adjusted for height, weight, and age ( P value< .001). Conclusion Pelvic US is a quick child-friendly investigation, which can be used to document the presence of megarectum. It should be the first line investigation for all the children with CIC.

Comorbidities Associated with Constipation in Children Referred for Colon Manometry May Mask Functional Diagnoses

In children with prolonged constipation of unclear pathogenesis or unresponsive to treatment, colon manometry can discriminate between functional fecal retention (FFR) and colon neuromuscular diseases. To identify the clinical features precipitating referral for colon manometry in children with functional constipation. Retrospective medical record review of 173 constipated children (116 male, mean age 6.9 years, range 1-17 years) referred for colon manometry. Manometry was normal in 121 (70%). In those with normal manometry, FFR was identified in 96, irritable bowel syndrome (IBS) in 10, and functional constipation in 15. Of the 96 children FFR, 72 (76%) had comorbid conditions that might have interfered with the clinician's ability to diagnose FFR. Of 52 children with colon neuromuscular disease, only 12 (23%) had comorbid conditions (P < 0.001 compared with FFR). Of children more than 4 years, those with FFR were more likely to have fecal incontinence (44 of 62; 71%) than those with other functional disorders (2 of 19; 10%; P < 0.001) or neuromuscular disease (6 of 23; 26%; P < 0.001). Two thirds of children referred for colon manometry had normal studies and met criteria for a functional diagnosis. Three quarters of those with functional constipation had a comorbid condition that might alter the history sufficiently to obscure the diagnosis.

GASTRIC EMPTYING IN CHILDREN WITH FUNCTIONAL FECAL RETENTION.

Introduction: Gastrointestinal motility disorders are considered as an underlying mechanism of chronic constipation in children. Methods: Twenty-eight children (median age 11.2 years) with chronic constipation, fecal retention and soiling at presentation (from January to December, 2002) were seen in a tertiary outpatient clinic. Twenty-three patients were followed up to complete recovery (mean period = 16.7 ± 7.6 months). Gastric emptying time (GE) and colonic transit time (CTT) studies were performed to assess gastrointestinal motility. Gastric emptying studies were performed before fecal impaction removal (GE1, N = 28) and repeated (GE2, N = 23) when patients recovered regular bowel movements (mean period: 12 ± 5 weeks after GE1). Gastric emptying time was evaluated using a radionuclide technique, patients ingested 300 ml/m2 of water added to 99mTc-sulfur colloid (1.0mCi), after an overnight fast. The reference value for young adults, t 1/2 for gastric emptying of water, established in our laboratory, is 12 ± 3 minutes. Metcalf radio-opaque marker method was performed to measure colonic transit time and the procedure was performed with no cleansing of the colon (N = 10). Results: Twenty-five children had symptoms related to food ingestion as nausea, poor appetite and early satiety, which disappeared after recovering regular bowel movements. GE1 median, maximum and minimum values, in minutes, were 27.5, 183 and 7, respectively. For GE2, values were 28, 53 and 10. GE1 value was higher than GE2 in 13 patients, GE1 value was lower than GE2 in 9 patients and GE1 was equal to GE2 in one patient. There was significant correlation (Spearman's) between mean time for completing treatment and gastric emptying values: GE1 (R = 0.63, P = 0.001) and GE2 (R = 0.66, p = 0.001). CTT was >100 hours in all patients who underwent this evaluation. Conclusion: Post-prandial symptoms may be associated to the gastric emptying delay. The gastric emptying time of a liquid test meal was correlated with time for constipation recovery in a group of constipated children with functional fecal retention.

Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation

Purpose Chronic idiopathic constipation (CIC) with soiling in children may result from slow colonic transit (SCT) or anorectal dysfunction and/or psychological problems known as functional fecal retention (FFR). Evidence is accumulating that SCT and FFR need different treatments, but they are poorly distinguished by solid marker studies. The authors used radionuclear transit scintigraphy to categorize children with CIC as having either FFR or SCT. Methods Children (N = 101) with CIC (and soiling) who were referred for further investigation after failure of standard treatments (diet, laxatives) received radiolabeled colloid orally, and scintillation images were collected at 0 to 2, 6, 24, 30 and 48 hours (total radiation dosage = 2 standard x-rays). Radioactivity in 6 regions (precolonic, ascending, transverse, descending, rectosigmoid, and evacuated feces) was measured, and the median position (geometric center) of radioactivity at each time was determined. Results In children, meals normally reach the cecum at 6 hours and are evacuated in 30 to 58 hours. Fifty patients had retention of radioactivity in the proximal colon at 48 hours, indicating SCT. Analysis of the images and the geometric center showed that passage through the ascending colon and transverse colon was delayed in SCT. In 24 patients, radioactivity was passed by 30 hours, indicating normal transit or possible FFR. Twenty-two patients had retention in the rectum, indicating definite FFR. Five studies were borderline. Conclusions Radionuclear transit scintigraphy is useful for categorizing patients with CIC as having either FFR or SCT, allowing for different treatments. Radionuclear transit scintigraphy provides more detail and greater sensitivity than solid marker studies in diagnosing CIC. Radionuclear transit scintigraphy showed that half of our patients had SCT.

Management of Fecal Incontinence in Children Without Functional Fecal Retention.

The management of the fecal incontinence in children is difficult, and its social consequences are usually devastating. The general objectives of any bowel program are to produce social continence, predictability, and eventually independence. How to achieve those goals depends in part on the underlying condition. In children, fecal incontinence can occur from a variety of conditions. The most common is overflow incontinence from functional fecal retention, but it can also occur in otherwise healthy children with functional nonretentive fecal soiling or in children with organic causes of fecal incontinence, such as congenital malformations, or any other condition affecting the anorectum, anal sphincters, or the spinal cord. The therapeutic regimen that is recommended in patients with nonretentive fecal soiling consists of explanation and support for the child and parents, a nonaccusatory approach, and a toilet training program with a rewarding system. Biofeedback does not play an important role, and laxatives need to be used with caution, as they may exacerbate the incontinence. For those patients with congenital/neuropathic incontinence a combination of maneuvers to change stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation is used. Stool consistency can be changed with the use of dietary interventions or medications. Stool transit can be slowed (antimotility agents) or accelerated (laxatives) with the use of medications. Anorectal function can be improved with the use of biofeedback or procedures to alter sphincter pressure, and the production of a bowel movement can be induced with maneuvers to empty the sigmoid (suppositories, enemas). With the recent advent of the Antegrade Colonic Enema (ACE), the patient is then able to be predictable and independent. This procedure creates a continent conduit from the skin to the cecum that can be catheterized or accessed for self-administration of enemas. The ACE has revolutionized the treatment of children with fecal incontinence.

The role of pelvic floor dysfunction and slow colonic transit in adolescents with refractory constipation.

Although pelvic floor dysfunction (PFD) is recognized as a cause of refractory constipation in adults, this diagnosis is not frequently considered in children and adolescents with refractory constipation. The purpose of this study was to examine the symptoms and colonic transit in adolescents with constipation evaluated for a disorder in pelvic floor function. Adolescents with refractory constipation who had undergone anorectal manometry (ARM) and balloon expulsion test (BET) were identified by retrospective review of records. Initial symptoms and the clinician's assessment were used to categorize patients by pediatric Rome II criteria, that is, functional constipation (FC), constipation-predominant irritable bowel syndrome (C-IBS) or functional fecal retention (FFR). Results of scintigraphic colonic transit studies were evaluated. A chi2 test was used to assess the association between individual clinical symptoms and Rome II criteria. Sixty-seven adolescents underwent evaluation of pelvic floor function by tests for PFD: BET was abnormal in 42%. There was no underlying disease or alternative diagnosis to account for the constipation in these patients. Among the 41 patients who also underwent scintigraphic colonic transit, 30% had slow transit constipation and 12% had both slow colonic transit and abnormal BET. Patients classified as C-IBS were more likely to report weight loss (p = 0.03), bloating (p = 0.04), and incomplete rectal evacuation (p = 0.03). Abnormal pelvic floor function and delayed colonic transit are demonstrable as single or combined problems in adolescents with refractory constipation.