Motility In Children Research Articles

Intestinal motility in children and adults after small bowel transplantation

Intestinal motility in children and adults after small bowel transplantation

Upper gastrointestinal motility disorders in children

This review covers progress made over the past few years in the area of gastroesophageal reflux, cyclic vomiting, intestinal pseudo-obstruction, drugs, and hormones that affect motility in children. Studies such as those reviewed not only improve our understanding of such disorders but also enhance the quality of life for children affected by them.

GASTROINTESTINAL MOTILITY IN NEONATAL AND PEDIATRIC PRACTICE

Caring for children with gastrointestinal motility disorders requires an understanding of age-related changes in gastrointestinal function and in the clinical expression of disease. Successful evaluation of the child with a gastrointestinal motility disorder necessitates an approach that takes into account not only the child's symptoms, but also the stage of development. This article reviews the ontogeny of gastrointestinal motility; the techniques available for the study of gastrointestinal motility in children; and the presentation, pathophysiology, and treatment of pediatric functional bowel diseases. Differences in children compared to adults in performing and analyzing motility testing and in evaluating motility disorders are emphasized. A more complete understanding of pediatric motility disorders may provide important insights in approaching functional bowel diseases in adults.

Manometric evaluation of gastrointestinal motility in children with chronic intestinal pseudo-obstruction syndrome

Various causes of abnormal gastrointestinal motility may account for the symptoms of chronic intestinal pseudoobstruction syndrome (CIIPS). Fasting gastrointestinal motility in humans is characterized by regular cyclic activity of the migrating motor complex (MMC), which may be used as an objective indicator of intestinal motility. The present study investigated MMC in five children with CIIPS (2 neurogenic and 3 nonneurogenic cases) using a perfusedcatheter system. The findings were compared with those for children with idiopathic constipation (9) and Hirschsprung's disease (4). The gastrointestinal MMC was found to be abnormal with CIIPS, whereas it remained normal with idiopathic constipation and Hirschsprung's disease. The four CIIPS patients without any gastrointestinal MMC activity required total pareteral nutrition. There was significant improvement of intestinal motility over time in a patient with immaturity of ganglia, and there was gradual deterioration in a patient with hypoganglionosis. In conclusion, gastrointestinal motility studies provide objective diagnostic information in patients with intestinal dysmotility and can be used as an indicator of intestinal function during the treatment of CIIPS.

Vomiting and gastroesophageal motility in children with disorders of the central nervous system

Vomiting and gastroesophageal motility in children with disorders of the central nervous system

Use of the Hydroxyapatite Ocular Implant in the Pediatric Population

There is always a hesitancy to use an ocular implant after enucleation in children, especially in cases of eyes enucleated for retinoblastoma. In this prospective study, we report our experience of 60 consecutive cases in which we used the hydroxyapatite ocular implant after enucleation in children younger than age 10 years. The mean age at the time of enucleation and hydroxyapatite placement was 27 months (range, 1 to 108 months). The histopathologic diagnoses after enucleation included retinoblastoma in 51 patients, endophthalmitis in two patients, persistent hyperplastic primary vitreous in two patients, neovascular glaucoma resulting from Coats' disease in one patient, uveal melanoma in two patients, undifferentiated intraocular neoplasm in one patient, and blind painful traumatized eye in one patient. After a mean follow-up of 19 months (range, 6 to 36 months), two cases of conjunctival erosion and five cases of conjunctival thinning were recorded. These problems were associated with a flat posterior prosthesis vault in all seven cases. There were no cases of orbital cellulitis, implant extrusion, or implant migration. All children showed good small-degree prosthesis motility despite the lack of peg placement. Only one older child underwent drilling and peg placement and she had excellent small- and large-degree prosthesis motility. We generally postpone the drilling and peg placement stage and tedious prosthesis revision in children until they are able to fully cooperate with the ocularist. The hydroxyapatite ocular implant is well tolerated and provides good prosthesis motility in children with few complications. It is critical for the ocularist to fit the prosthesis comfortably with a high posterior vault.

Effect of gastro-oesophageal reflux on upper oesophageal sphincter motility in children.

Motor events of the upper oesophageal sphincter associated with gastro-oesophageal reflux were evaluated in 53 symptomatic children (median age 13 months) who were studied recumbent and unsedated. Children were divided into four groups according to symptoms, and then into two groups according to the presence or absence of neurological deficit. No grouping had basal upper oesophageal sphincter pressure that differed significantly from any other. Oesophageal distention due to gastro-oesophageal reflux, which was recognisable as oesophageal common cavity episodes, was associated with augmentation of mean basal upper oesophageal sphincter pressure from 36.5 (SD 18) mm Hg to 48.5 (18) mm Hg (p < 0.0001), irrespective of whether gastro-oesophageal reflux caused oesophageal acidification. Abrupt relaxations of the upper oesophageal sphincter independent of swallowing and lasting up to three seconds occurred during 54% of common cavity episodes. Forty nine per cent of these relaxations occurred within four seconds after the onset of distention. The oesophageal distention caused by gastro-oesophageal reflux is a potent stimulus of transient upper oesophageal sphincter relaxations in children. These relaxations are a more likely explanation for oesophagopharyngeal reflux than defective basal upper oesophageal sphincter tone.

Upper gastrointestinal tract motility in children with progressive muscular dystrophy

Gastric emptying was evaluated in 15 children (mean age, 8.0 years) with progressive muscular dystrophy to detect early gastrointestinal smooth muscle involvement; 10 of the children also underwent esophageal manometry. Clinical evidence of skeletal muscle dysfunction was minimal in 14 of the 15 patients; 10 of them had no gastrointestinal symptoms. Gastric emptying studies were performed by using 500 muCi of technetium 99m-sulfur colloid bound to a scrambled egg, and scintigraphic measurements were made continuously for 60 to 90 minutes. Gastric emptying studies and manometric tracings were compared with those from 11 children (mean age, 8.4 years) without gastrointestinal or muscular disorders. Mean (+/- SD) percentage retention of gastric isotope was significantly greater in patients with muscular dystrophy than in control subjects. No differences were found between the two groups in distal esophageal motility or in upper and lower esophageal sphincter pressures or relaxation. Contraction amplitudes in the upper portion of the esophagus, however, were significantly lower in patients with myopathy than in control subjects. These data suggest that dysfunction of smooth muscle of the upper gastrointestinal tract is detectable in children with muscular dystrophy early in the course of the disease, even when gastrointestinal symptoms are absent and skeletal muscle symptoms are minimal.

Gut hormones and gastrointestinal motility in children with cystic fibrosis

Intestinal dysmotility may be an important factor contributing to various gastrointestinal complications associated with cystic fibrosis. Motilin, enteroglucagon, neurotensin, and peptide YY may each play a role as endocrine hormones influencing gastrointestinal motor activity. Fasting children with cystic fibrosis (N = 8) and controls (N = 18) received a liquid nutrient test meal (fat 4 g/100 ml, protein 4 g/100 ml, carbohydrate 20 g/100 ml, 125 kcal/100 ml; 200 ml/m2) containing lactulose (5 g/100 ml), and the plasma concentrations of these peptides were studied. Mouth-to-cecum transit time was simultaneously studied using the breath H2 technique. Fasting levels of peptide YY and the postprandial response of all four peptides were significantly increased in those with cystic fibrosis. In repeat studies on those with cystic fibrosis after a period of altered pancreatic enzyme supplementation, no significant changes in peptide concentrations were observed. A rise in breath H2 permitting estimation of mouth-to-cecum transit time was noted in 17 control subjects (70-220 min, median 140). In contrast, a rise occurred in only two with cystic fibrosis after low-dose enzyme (70 and 180 min), and four after high-dose enzyme replacement (120-230 min, median 155). Altered gut hormone secretion may play a role in the pathophysiology of intestinal dysmotility in patients with cystic fibrosis.

Abnormalities of gastrointestinal motility in children with nonulcer dyspepsia and in children with gastroesophageal reflux disease

In 11 children (mean age 44.2 months) with symptoms suggesting upper intestinal dysfunction (nonulcer dyspepsia), in nine children (mean age 27.3 months) with gastroesophageal reflux (GER) disease, and in seven controls (mean age 20.4 months) we investigated fasting [for 3 hr or until two migrating motor complexes (MMC) were observed] and fed (90 min) antroduodenal motility by means of perfused catheter system; furthermore, we measured both gastric emptying of a radiolabeled milk formula and fasting duodenogastric reflux during manometry by assessing bile salt concentration in gastric aspirates. No structural abnormalities of gastrointestinal tract and organic disorders were detected in the patients. In a high proportion of both groups of patients we found manometric abnormalities of interdigestive and fed motor patterns that were not seen in the controls: absence of antral phase III of MMC; significant decrease of antral and/or duodenal motor activity during fasting and/or fed periods; abnormal propagation or configuration of MMC phase III that was significantly shorter than in controls; bursts of sustained fasting and/or fed phasic duodenal activity, frequently uncoordinated with adjacent gut segments. When compared to controls, the mean intragastric concentration of bile salts during all MMC phases and the mean 1-hr percent gastric activity of the radiolabeled milk were significantly higher in the two groups of patients. We conclude that in a high proportion of children with nonulcer dyspepsia and of children with GER disease, gastrointestinal manometry may reveal significant irregularities of antral and duodenal motility, which are associated with increased duodenogastric reflux and delayed gastric emptying.

Disorders of oesophageal motility in children with psychomotor retardation and gastro-oesophageal reflux

A group of 25 children affected by different degrees of psychomotor retardation (severe (n = 13); mild-moderate (n = 12)) and symptoms suggesting gastro-oesophageal reflux (GOR) underwent oesophageal manometry and oesophageal pH monitoring. Of these patients, 21 (84%) were affected by GOR. In all children with severe brain damage and GOR (12/13), oesophageal manometry showed marked motility abnormalities that persisted after cure of GOR. In patients with minor retardation and GOR (9/12), oesophageal manometry showed normal motility or a less severe degree of oesophageal motor dysfunction which improved after curing the GOR. These results suggest that oesophageal motor dysfunction is a frequent occurrence in children affected by severe psychomotor retardation and GOR.

Overnight vesical and rectal motility in children with vesico‐ureteral reflux

AbstractThe rectum and bladder are both innervated by the sympathetic and parasympathetic nervous system and have a close anatomical relation. In order to investigate whether a correlation between rectal and vesical activity is present we undertook the following study.Overnight pressure recordings from the bladder and the rectum were analyzed in 35 children with vesico‐ureteral reflux (VUR). The rectal activity of the VUR patients was compared to the rectal activity of 22 overnight recordings from normal children. The measurement system included bladder pressure measurement by way of fluid‐filled supra‐pubic catheters and rectal pressure measurement by a perfused open‐side hole catheter. Thirty‐two of the thirty‐five investigations were suitable for later computer analysis. The analysis program contained facilities for automatic scoring of contractions, frequency analysis, and area under curve determinations.Activity in the bladder and rectum was equally distributed between the reflux grades both regarding the number of contractions and the area under curve. Overnight number of contractions and the area under curve were correlated within the individual patient (σ = 0.80, P lt; 0.01). This indicates that the two variables equally reflect pressure activity. In patients with VUR rectal activity intensity were significantly correlated to bladder activity (σ = 0.53, P &lt; 0.01). However, the number of rectal contractions in the patients were not significantly different from normals.It is concluded that the urodynamic pressure data can be analyzed using a computer‐aided method, providing a rapid and objective analysis of the data. Night‐time monitoring seems to reveal a general coherence between bladder and rectal motility in this category of patients. The nature of the relation between bladder and colo‐rectal activity needs further elucidation.

Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain: V.M. Pineiro-carrero, J.M. Anders, R.H. Davis, et al. J Pediatr 113:820–825, (November), 1988

Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain: V.M. Pineiro-carrero, J.M. Anders, R.H. Davis, et al. J Pediatr 113:820–825, (November), 1988

Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain

To determine whether motor activity of the stomach and proximal small intestine is a factor in recurrent abdominal pain in adolescents, we prospectively investigated eight patients with recurrent abdominal pain and compared them with seven normal adolescents. All patients underwent a detailed examination to exclude other known organic causes of the pain. The gastroduodenal motor activity during fasting was studied with a semiconductor recording probe. The recordings were analyzed for periodicity, duration, and propagation velocity of the activity front of the migrating motor complex. The amplitude of the antral and duodenal contractions was also determined. The patients with recurrent abdominal pain had more frequent migrating motor complexes, but these were shorter in duration and moved more slowly down the intestine (slower propagation velocities). The patients also had high-pressure duodenal contractions that were associated with abdominal pain during the study period. These studies suggest that altered intestinal motility may be the underlying mechanism of recurrent abdominal pain in some children.

Pathophysiology of gastroesophageal reflux and distal esophageal motility in children with gastroesophageal reflux disease.

We investigated the mechanisms of gastroesophageal reflux (GER) and esophageal motility during endogenous esophageal acid exposure in 17 patients with reflux disease alone (age range 3-20 months) (group A) and in 10 patients with reflux disease complicated by esophagitis (age range 4-19 months) (group B), by simultaneous recording distal esophageal sphincter relaxation was the predominant mechanism of reflux in both groups of subjects; however, it was more frequent in group B patients (Bpts), whereas reflux episodes due to appropriate sphincter relaxation were detected more frequently in group A patients (Apts). During endogenous acid exposure, primary peristalsis was the most frequent esophageal motor event in all patients; furthermore, its amplitude was significantly higher in Apts as compared with Bpts. Primary peristalsis was more efficacious (rise of intraluminal pH by at least 0.5 unit) in patients with reflux disease alone, whereas nonspecific motor irregularities were more common in children with reflux esophagitis. It is concluded that the major mechanism of GER in patients with reflux esophagitis is an inappropriate sphincter relaxation; reflux due to appropriate sphincter relaxation is associated with less severe reflux disease; and patients with esophagitis exhibit a deranged esophageal motility during spontaneous acid exposure.

Pathophysiology of Gastroesophageal Reflux and Distal Esophageal Motility in Children with Gastroesophageal Reflux Disease

SummaryWe investigated the mechanisms of gastroesophageal reflux (GER) and esophageal motility during endogenous esophageal acid exposure in 17 patients with reflux disease alone (age range 3–20 months) (group A) and in 10 patients with reflux disease complicated by esophagitis (age range 4–19 months) (group B), by simultaneous recording distal esophageal sphincter relaxation was the predominant mechanism of reflux in both groups of subjects; however, it was more frequent in group B patients (Bpts), whereas reflux episodes due to appropriate sphincter relaxation were delected more frequently in group A patients (Apts). During endogenous acid exposure, primary peristalsis was the most frequent esophageal motor event in all patients; furthermore, its amplitude was significantly higher in Apts as compared with Bpts. Primary peristalsis was more efficacious (rise of intraluminal pH by at least 0.5 unit) in patients with reflux disease alone, whereas nonspecific motor irregularities were more common in children with reflux esophagitis. It is concluded that the major mechanism of GER in patients with reflux esophagitis is an inappropriate sphincter relaxation; reflux due to appropriate sphincter relaxation is associated with less severe reflux disease; and patients with esophagitis exhibit a deranged esophageal motility during spontaneous acid exposure.

Antroduodenal motility in children with chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction describes a heterogeneous group of disorders characterized by signs and symptoms of intestinal obstruction in the absence of a mechanical lesion. We studied antroduodenal motility in 13 children with pseudo-obstruction. The diagnosis was based on radiographic evidence in all, surgery in 11, and specific pathologic features in four. Antroduodenal motility was abnormal in all 13. Qualitative abnormalities in the patterns of antroduodenal contractions permitted separation into groups: (1) postprandial hypomotility (n = 3), (2) absent migrating motor complexes, with phase 3-like activity at the start of meals (neuropathic variety) (n = 5) (3) very low amplitude or absent contractions (myopathic variety) (n = 2); the remaining patients (n = 3) had other distinctive abnormalities. Cisapride, a new gastrointestinal prokinetic drug, stimulated proximal duodenal contractions in the 30 minutes after a meal in nine of 10 patients tested. These studies indicate that antroduodenal manometry is useful for characterizing intestinal pseudo-obstruction, and cisapride stimulates postprandial duodenal contractions in patients with pseudo-obstruction.

Disorders of Upper Esophageal Sphincter Motility in Children

Dysfunction of the upper esophageal sphincter was found in five out of 44 children with gastroesophageal reflux. Three of the five children had mental retardation associated with Silver Russell syndrome, 5p syndrome, or minimal change myopathy. The five patients had swallowing disorders, vomiting, and failure to thrive; four also had pulmonary aspiration. Esophageal manometry showed incomplete upper esophageal sphincter relaxation in two patients, upper esophageal sphincter relaxation incoordinated with pharyngeal contractions in two other patients, and both incomplete and incoordinated upper esophageal sphincter relaxation in the last patient. Intensive and successful treatment of gastroesophageal reflux did not improve swallowing or symptoms of pulmonary aspiration in four children. The fifth patient underwent cricopharyngeal myotomy, with complete resolution of respiratory and swallowing symptoms. It is suggested that a dysfunction of the upper esophageal sphincter, either primary or secondary to neuromuscular disorders, may play a role in the swallowing disorders and respiratory symptoms of pediatric patients.

Anorectal motility in children with clubfoot

Anorectal motility was studied in 32 children with congenital clubfoot and 86 controls of similar age and sex. Pressure was recorded in the rectum and upper and lower anal canal at rest and after rectal distension. Six subjects had no qualitative abnormality (group 1). In 8 others, a rectonal inhibitory reflex was recorded both at the upper and lower portions of the anal canal (group II). In the 8 remaining children, the anal canal resting pressure was unstable and there were rectal contractions synchronous with spontaneous upper anal canal relaxations (group III). The presence of manometric abnormalities was associated with a sacrococcygeal dimple and/or radiological abnormalities of the spine (P < 0.02). Subjectshad an increased resting pressure in the rectum (P < 0.01) and upper anal canal (P < 0.05). There were diffenences in resting pressure between the three groups at all levels. In the upper anal canal, pressure flunctuated more than normally (P < 0.02) and to different extents in the three groups. The volume necessary to induce a rectoanal inhibitory reflex was greater than normal in group I. This study demonstrates significant functional abnormalities in the anal canal of subjects with clubfoot and indicates a possible neurologic deficit in this disorder.

TRIMEBUTINE INDUCES MIGRATING MOTOR COMPLEXES IN INFANTS

Trimebutine (TMB) induces migrating motor complexes (MMC) in dogs and in healthy adults. We have tested the effect of TMB on duodenal motility in children with severe digestive diseases requiring total parenteral nutrition, and with clinical features of dismotility. Five male children were studied (mean age 11.7 ± 6.8 months) : 2 protracted diarrhea, 2 intestinal pseudo-obstruction, one short bowel syndrome. Fasting duodenal motor activity was recorded by manometry during 3 hours, using a two channel probe. The basal recording exhibited in all cases a total absence of MMC and a marked hypomotility with motor indexes significantly lower than in control subjects (p < 0.02).Intravenous administration of TMB, 3 mg/kg in 1 min 30 sec raised a phase III-Like activity in 4 cases : mean delay of apparition after end of IV 88 ± 121 sec, mean duration of phase III 236 ± 105 sec, basal electrical rythm 12.75 ± 0.86 cycles/min. An aboral propagation of the activity front was observed in 2 cases. TMB administration was followed by signs of peristalsis in 2 cases.We conclude that TMB is able to induce MMC in unspecific motor disturbances, and may be very useful in improving the motor component of severe digestive diseases.