Normal Stool Pattern Research Articles

Association between stool consistency and clinical variables among infants with cystic fibrosis: Findings from the BONUS study

Background: Concerns related to stool consistency are common in the first year of life among children with cystic fibrosis (CF). However, normal stool patterns for infants with CF have not been described.Methods: Secondary analysis was completed from the previously described BONUS cohort which followed 231 infants with CF through the first 12 months of life. Pain, stool category, stool frequency, feeding type, PERT dose, acid suppression medication, antibiotics usage, stool softener usage and fecal calprotectin were described at 3, 6, and 12 months. Repeated measure ANOVA was used to test the difference in mean stool number. Generalized linear mixed models were used to investigate the relationship between stool characteristics and various factors.Results: The frequency of constipation was stable throughout the first year of life (10–13%) while watery stool significantly decreased from 21.3% at 3 months to 5.8% at 12 months (p=<0.001). The number of stools at months 6 (mean=2.40) and 12 (mean=2.50) are significantly lower than in month 3 (mean=2.83), p<0.025. Exclusive breast feeding was associated with an increased risk for constipation (OR=2.64 [1.60–4.37], p = 0.002) while exclusive formula feeding and acid suppression was associated with decreased risk for constipation (OR=0.40 [0.26–0.61], p=<0.0001 and OR=0.59 [0.39–0.89], p = 0.01 respectively). Pain was not significantly associated with stool consistency.Conclusion: Stool frequency and consistency evolves in infant with CF in a fashion similar to that reported in non-CF infants over the first year. Constipation was not associated with pain and was less common among infants receiving acid suppression or exclusively formula feeding.

Effectiveness of different therapy protocols in preemies with intestinal hypomotility.

Intestinal hypomotility delays achievement of full enteral feeds and normalization of stooling patterns in preemies. We hypothesized that introduction of prokinetic drug in addition to enemas would improve intestinal motility. time needed to achieve full enteral feeds and normal stooling pattern. Secondary outcome: day when start of minimal enteral feeding was feasible, necrotizing enterocolitis incidence, length of hospitalization and whether daily meconium evacuation is more effective than evacuation in presence of clinical symptoms only. A randomized controlled trial was conducted from December 1st, 2015. until December 1st, 2016. in level III neonatal unit on 67 preterm infants ≤ 32 gestational weeks and intestinal hypomotility. Infants were allocated to: Group 1 - treated with saline enemas twice daily until normal stooling pattern was achieved; and Group 2 - treated with erythromycin and enemas. Infants with intestinal hypomotility, hospitalized from December 1st, 2014. to December 1st, 2015. were assigned to group 3, and were treated with enemas only when symptoms of abdominal distension or absence of stool for 48 hours were observed. Total of 127 neonates was included in this study; 33 were assigned to Group 1, 34 to Group 2, and 60 to Group 3. There was no significant difference in number of days needed to reach full enteral feeds: 25 vs. 26 days and normal stooling pattern: 18 vs. 15 between groups 1 and 2. Time needed to achieve full enteral feeds and normal stooling pattern in groups 1 and 2 were significantly shorter when compared to group 3. No difference in length of hospitalization between the groups was observed. Erythromycin did not improve the patient outcome, although therapy protocol in group 1 and group 2 were more effective than therapy used in patients in group 3.

2878 Assessment of Mobile APP for Constipation and Incontinence: Randomized Crossover Study in Healthy Subjects

INTRODUCTION: An accurate history is important for diagnosis, treatment and clinical decision making but patients with bowel problems cannot accurately recall or quantify stool habit. We determined whether an electronic mobile phone APP can reliably and accurately records bowel symptoms of constipation and fecal incontinence (FI), when compared to paper form stool diary in healthy subjects. METHODS: Healthy subjects were randomly assigned to complete either a paper diary or 2 mobile phone APPs (separate for FI and constipation) for 2 weeks each, in a crossover study. The APP has approximately 10 questions each that assess severity of symptoms, bowel habit, stool consistency etc. Usability of APP versus paper form diary was assessed after 4 weeks. Intraclass correlation coefficients (ICC) assessed equivalence. RESULTS: Ten healthy subjects (34.7 ± 4.1 years, F/M = 6/4) participated. The number of BM, spontaneous (SBM), and complete spontaneous bowel movement (CSBM), over 2 weeks showed strong correlation between APP and paper form diaries, and for all questions related to either FI or constipation (ICC &gt;0.79) (Table 1). Although mean stool consistency was strongly correlated with paper diary, the number of hard (BSFS1-2) and normal (BSFS3-4) stools were moderately significantly correlated with paper diary, possibly because of day to day variability in normal stool pattern. No leakage episodes were recorded in both FI APP and paper diary. The urgency of BM in FI APP was significantly associated with paper diary. The number of gas and bloating episodes ranged rom 0.8 to 2.5 in both APPs and paper diary. The VAS scores for functionality and usability for electronic APP were significantly higher (P &lt; 0.027) compared to paper diary, and 90% of subjects preferred (P &lt; 0/001) the APP (Table 2). CONCLUSION: The mobile APPs for FI and constipation were reliable, reproducible and useful and strongly correlated with paper diary. However they were strongly preferred by the subjects over paper form. These APPs could aid screening and assessment of bowel function in patients with FI and constipation but require validation for clinical or research use.

Defining Pediatric Diarrhea in Low-Resource Settings.

Differences in definitions of acute pediatric diarrhea result in variable estimates of morbidity and mortality, treatment coverage, and associations with risk factors and outcomes. We reviewed published literature and guidelines focused on acute pediatric diarrhea in low- and middle-income countries. Clinical guidelines most commonly defined diarrhea in terms of quantity of loose or watery stool with consideration of normal stool patterns, whereas research studies often relied exclusively on a quantitative definition. The most commonly used quantitative definition, ≥3 loose or watery stools in a 24-hour period, has been compared to gold standards of caregiver perception and visual inspection of stool, with variable agreement. Age, breast-feeding status, and setting (facility vs household-based) influence the performance of quantitative diarrhea definitions in children. Universal adoption of a set of valid gold standard definitions specifically aligned with various programmatic and research goals will lead to more accurate coverage estimates and better-informed resource prioritization.

P-124 YI Severe Colonic Stricture in Immunosuppressed Patient with Chronic Cytomegalovirus Colitis

Chronic granulomatous disease (CGD) is a primary immunodeficiency due to a defect in phagocyte NADPH oxidase resulting in recurrent life-threatening bacterial and fungal infections, commonly with catalase positive organisms. These patients may present with an inflammatory bowel disease phenotype and frequently have severe intestinal disease. Bone marrow transplantation is curative for CGD, but chronic immunosuppression places patients at higher risk for disseminated infections including cytomegalovirus (CMV). We present a case of CMV colitis resulting in severe stricture formation in a post-transplant patient. A 6 year old boy with history of CGD diagnosed at age 21 months after presenting with multiple infections and colitis underwent 2 autologous bone marrow transplantations. He later developed several months of bloody diarrhea, intermittent fever, and severe abdominal pain. Infectious stool studies were negative. EGD and flexible sigmoidoscopy revealed epithelial damage in his antrum, duodenum, and colon with increased apoptosis and cytopathic changes in his colon with positive CMV tissue PCR and immunostain. Initial differential diagnosis included Graft versus Host disease and CMV colitis. Imaging at the time revealed diffuse circumferential bowel wall thickening with pericolonic fat. He continued to have profuse bloody diarrhea as well as diffuse abdominal pain. Subsequently, he was treated with IV Ganciclovir and Foscarnet, as well as bowel rest. Follow up flexible sigmoidoscopy biopsies remained CMV tissue PCR positive. With antiviral treatment, his symptoms resolved, and he tolerated enteral feeds with a normal stooling pattern again. Two months following therapy, he returned with progressive, severe distinct episodes of diffuse abdominal pain. The pain was worse with defecation and passing flatus and pain improved on Miralax. CT scan demonstrated a long segment of submucosal bowel wall thickening involving the descending colon. Subsequent barium enema reproduced the patient's episodic pain symptoms and revealed a pinpoint focal colonic stricture at the level of the splenic flexure. Ultimately, surgical resection of 20cm of colon revealed ulceration with chronic inflammation and granulation tissue with scattered capillary endothelial cells with viral cytopathic changes consistent with CMV and highlighted by immunohistochemical stains. CMV is an opportunistic pathogen that results in systemic disease through blood circulation and subsequent invasion of endothelial cells of several organ tissues. CMV infection typically remains latent in immunocompetent individuals, however, it is critical to evaluate for the virus in the immunosuppressed patient, where the infection can be reactivated. The GI tract is a common site for CMV disease, often resulting in esophagitis or colitis. Typical symptoms include watery diarrhea that progresses to rectal bleeding, abdominal pain, fatigue, fever, or even toxic megacolon. While CMV has been previously implicated in complicating severe steroid-refractory inflammatory bowel disease, this is the first report of colonic stricture secondary to chronic CMV infection in an immunosuppressed patient.

Variation in Bowel Habits of Healthy Indian Children Aged up to Two Years

To study the normal bowel habits of healthy Indian children up to 2y of age. This cross sectional study was conducted in medical college associated teaching hospital in Delhi. Ethical clearance was obtained from Institutional Ethical Committee. A total of 500 infants and toddlers up to 2y of age were recruited for the study. Data were collected by interviewing parents of the eligible children who came for immunisation using pre designed Performa. There was steady decline in stool frequency with increasing age. Maximum decline in stool frequency was noted after 1mo of age. Variation in stool frequency between children was maximum in 0-3mo of age and decreased with increasing age. Stools at 4wk were usually semiliquid, watery and semisolid. By 6mo of age 55% infants were passing semisolid stools and 40% were passing formed stools. At 24mo of age, 89.2% children usually passed formed stools. This is the first study in India to date documenting the frequency and consistency of the stools of young children. These results make an important contribution to defining normal stool patterns in young Indian children.

Acquisition of full enteral feeds may depend on stooling pattern in very premature infants

The objective of this study was to determine whether acquisition of normal stooling pattern is associated with full enteral feeding and growth. This is a prospective observational study of infants with a gestational age of <28 weeks (n=121). All infants admitted to our unit during the study period were managed using the same protocol for rectal stimulation and enemas: we used rectal stimulation if abdominal distension and no defecation occurred in the previous 24 h; enema administration was practiced if abdominal distension persists and no defecation had occurred after rectal stimulation. Age of normal bowel habit (T-NBH) is defined as days when two stools passed each day without enemas or stimulation for three consecutive days. Full enteral feeding is measured by time to receive 120 mL/kg/day (T-120). Multivariable linear regression estimated the contribution of T-NBH on T-120 and the effect of tolerance on growth. T-NBH was 16 days (12, 24 days) and T-120 was 16 days (12, 24 days). T-120 decreased with earlier normal bowel habit (r=0.625, P<0.0001). Change in weight z-score between 36 weeks postmenstrual age and birth was less pronounced with earlier full enteral feeding (r=-0.446, P<0.0001). Normalization of bowel habit is an important determinant of full enteral feeding of very immature infants. Earlier full enteral feeding is associated with less postnatal growth failure.

Case 1: Going forward in lack of movement

A 12-year-old girl was referred to the paediatric gastroenterology service with a history of chronic constipation and fecal incontinence. The symptoms were present for seven years, with frequent passage of stools in the clothes. She also experienced intermittent nocturnal enuresis. There was no abdominal pain, bloating, nausea, vomiting, diarrhea, rectal bleeding, dysuria, chronic cough, fatigue or weight loss. Her history was otherwise unremarkable, with no problem passing meconium after birth and a normal stool pattern in infancy. Her growth and development were normal. The child was in foster care and a family history was not available. The patient was tried on a variety of laxative therapies including lactulose, oral polyethylene glycol and repeated rectal enemas. The patient had a difficult and protracted course over several years, with frequent stool incontinence. Cognitive behavioural therapy was provided by a professional psychologist. Due to uncertain compliance with oral therapy, lavage with polyethylene glycol via a nasogastric tube had been tried several times for fecal disimpaction. Investigations included normal thyroid function tests, serum calcium and urinalysis. An abdominal radiograph had revealed fecal loading in the distal colon. On examination, she was obese with a weight between the 90th and 95th percentiles, and a height between the 10th and 25th percentiles. Her body mass index was 29.8 kg/m2 (greater than the 97th percentile). There was no pallor, clubbing or thyromegaly. The abdomen was soft and nondistended, with no tenderness, organomegaly or masses. (A previous rectal examination conducted by the referring physician revealed stool in the rectum.) Examination of the nervous system and spine was normal. A diagnostic laboratory test was performed, which revealed the diagnosis.

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

Purpose The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT). Method The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007. Results Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 ± 216 days, and the mean body weight at TERPT was 4.5 ± 2.8 kg. The average operating time was 189 ± 49 minutes, and mean length of bowel resection was 11.1 ± 3.2 cm. The mean postoperative hospital stay was 8.0 ± 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 ± 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 ± 6.9 weeks vs 7.3 ± 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased ( P = .018). Conclusion Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.

The variation in stool patterns from 1 to 42 months: a population-based observational study

Objective:To document the normal stool patterns of young children.Design:Prospective population-based longitudinal study.Setting:Avon Longitudinal Study of Parents and Children (ALSPAC).Subjects:12 984 children, whose parents completed questionnaires at 4 weeks, 6, 18,...

Redo-endorectal pull through following various pull through procedures in Hirschsprung's disease

The purpose of this study was to analyse the outcome of redo-endorectal pull through in Hirschsprung's disease following different original pull through procedures. In the past, redo-endorectal pull through was mainly performed following endorectal pull through, but not following the Duhamel procedure. We present the outcome of eight patients after redo-endorectal pull through, including five who underwent Duhamel pull through as original procedure. Between 2002 and 2004, eight patients underwent redo-endorectal pull through following the Duhamel procedure (five), Rehbein procedure (one) and endorectal pull through (two). A retrospective study was performed to evaluate the clinical course after redo-endorectal pull through, reviewing inpatients' and outpatients' charts and performing standardised interviews. Four of eight patients had normal stool pattern after redo-endorectal pull through. In two patients mild and in another two patients severe chronic constipation occurred after redo-surgery. Constipation-associated incontinence was noted in four patients, which is terminated after initiation of laxative treatment in three. Enterocolitis occurred in one patient and recurrent ileitis in another child with total colonic aganglionosis. No impairment of bladder function was observed after redo-endorectal pull through. Redo-endorectal pull through proved to be a safe technique and feasible even after prior Duhamel pull through, resulting in good clinical outcome.

Nature’s Therapy for RecurrentClostridium DifficileDiarrhea

Nature’s Therapy for Recurrent<i>Clostridium Difficile</i>Diarrhea

Case 2: You look like you've seen a goat

A five-month-old, white female presented to the hospital with a three-week history of pallor and lethargy. The infant was born at term with a birth weight of 3.15 kg. She was bottlefed every 2 h to 4 h on demand with a normal stool and urine pattern. Her 26-year-old mother consumed a vegan diet. The infant was not taking any medications and all immunizations had been declined. On examination, she was pale and lethargic; vital signs included a temperature of 37.8°C, a pulse of 145 beats/min, a blood pressure of 80 mmHg and a respiratory rate of 35 breaths/min. Her weight was 6.37 kg (in the 25th percentile for age). A grade 2/6 systolic ejection murmur was detected at the left sternal border in addition to a palpable spleen. The remainder of her physical examination was normal. On investigation, her hemoglobin level was 30 g/L (normal 100 g/L to 140 g/L), with a mean corpuscular volume (MCV) of 94.3 fL (normal 73 fL to 85 fL) and an absolute reticulocyte count of 41.3×109/L (normal 5×109/L to 250×109/L). Her platelet count was 57×109/L (normal 150×109/L to 400×109/L) and white blood cell count was 5.7×109/L (normal 5×109/L to 15×109/L), with 1.83×109/L of neutrophils. Her blood smear showed hypersegmented neutrophils. Electrolytes, renal function tests and liver enzymes were normal. Her chest x-ray showed mild cardiomegaly and abdominal ultrasound showed mild splenomegaly (6.6 cm). Bone marrow aspirate revealed increased erythropoiesis, and bone marrow biopsy reported hypercellular marrow and megaloblastic changes with no evidence of leukemia. Further history and laboratory tests revealed the etiology of her anemia.

Diarrhoea in Childhood

Abstract Diarrhoea may be defined as frequent passage of loose stools or, more accurately, passage of an increased volume of stool water. A stool volume of more than 200 ml/m2/day indicates diarrhoea, as does a stool weight of more than 150-200 g watery stool/m2/day. Such precise measurements are difficult to achieve in children, and infants would have to be admitted to a metabolic unit. Therefore, more practical definitions are required. • Diarrhoea in infancy and early childhood may be defined as an increase in stool frequency associated with a change to loose or watery stools. • It must be remembered that normal breast-fed infants may pass frequent loose stools. Diarrhoea in a breast-fed infant is defined as a departure from the normal stool pattern with increased volume and frequency. • Acute diarrhoea may be defined as diarrhoea of less than 2 weeks' duration. • Chronic diarrhoea is that of more than 2 weeks' duration. Diarrhoea in infancy and childhood has many causes, which vary geographically. Repeated bacterial infection is important in chronic diarrhoea in the developing world, but an uncommon cause in developed countries in the absence of underlying immunodeficiency. Rare intractable diarrhoea syndromes may require long-term parenteral nutrition, or even small intestinal transplantation.

HIV disease: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

HIV disease: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Educating parents about normal stool pattern changes in infants

Educating parents about normal stool pattern changes in infants

Educating parents about normal stool pattern changes in infants

J Pediatr Health Care. (2001). 15, 269-274.

Repeat pull-through surgery for complicated Hirschsprung's disease: Indications, techniques, and results

Background: Most children with Hirschsprung's disease (HD) do well after a pull-through procedure. In the occasional child in which the operation fails, a repeat procedure may be necessary. Methods: Nine children with HD aged 20 months to 9 years underwent repeat pull-through over a 4-year period. Original pull-throughs (six Soave, two Swenson, one Duhamel) were performed elsewhere 12 to 95 months earlier (median, 36 months). Indications for revision were stricture unresponsive to dilatation (n = 3) and acquired aganglionosis (n = 6). One of the latter had associated segmental intestinal neuronal dysplasia. One child with a stricture after a Swenson procedure underwent a repeat Swenson. The other eight underwent reconstruction using a Duhamel technique. Five had a defunctioning stoma before or at the time of repeat surgery. Results: Median follow-up was 15 months (range, 4 to 40 months). Complications included wound infection (n = 2), anastomotic bleeding (n = 2), stoma leak (n = 1) or stenosis (n = 1), “kinking” at the top of the Duhamel (n = 1), and persistent septum (n = 1). Three patients have had a good outcome with normal stool patterns. One has intermittent soiling, and one has what is believed to be stool-holding behavior. Four have persistent obstructive symptoms caused by sphincter hypertonicity, which are being successfully managed nonoperatively. Conclusions: Repeat pull-through surgery can be performed safely in appropriately selected patients. Duhamel reconstruction usually is preferred for technical reasons, and a stoma is not always necessary. Outcome is generally favorable, but anal sphincter hypertonicity may cause persistent symptoms in some patients.

Rotavirus infection and diarrhea in healthy and HIV-infected children: a cohort study.

Rotavirus infection and diarrhea in healthy and HIV-infected children: a cohort study.

Hirschsprung's disease, imperforate anus, and Down's syndrome: A case report

Patients with trisomy 21 have a higher incidence of several gastrointestinal anomalies. However, the coexistence of imperforate anus, Hirschsprung's disease, and trisomy 21 had not been reported previously. This report describes the case of an infant girl born with trisomy 21 and imperforate anus, without a fistula, who presented with bowel obstruction 3 months after anoplasty. The obstruction was attributable to Hirschsprung's disease. This was managed by a leveling colostomy in the descending colon, followed by an endorectal pull-through after 4 weeks. She has a normal stooling pattern 11 months after colostomy closure. Hirschsprung's disease should be suspected in infants with trisomy 21 who have constipation after repair of imperforate anus. The authors believe that the endorectal pull-through is the safest technique to use for Hirschsprung's disease after a previous anoplasty.