Rectal Enema Research Articles

The usefulness of fleet rectal enemas on high-dose-rate intracavitary cervical cancer brachytherapy. A prospective trial.

PurposeTo evaluate the effects of rectal enemas on rectal doses during radical high-dose-rate (HDR) intracavitary cervical brachytherapy (BT).Material and methodsTwenty patients suffering from cervical cancer and treated with external beam radiotherapy and HDR-BT were included in a prospective trial. The first brachytherapy fraction was considered the basal status, and patients were instructed to self-administer two rectal cleansing enemas before the second fraction. Dose-volume histogram (DVH) values were generated for the rectum and correlated with rectal volume variation. Brachytherapy was carried out with a Fletcher or Utrecht applicator.ResultsNo significant rectal volume differences were observed between fractions with or without rectal enemas (without, 52.64 ± 15.92 cc; with, 53.16 ± 19.28 cc). There was a significant correlation between both rectal volumes (r = 0.722, p = 0.001). No significant differences were observed in analyzed DVH parameters (median values: ΔD0.1cc, 4.17 vs. 3.61 Gy; ΔD1cc, 3.23 vs. 2.87 Gy; ΔD2cc, 2.9 vs. 2.54 Gy; ΔD5cc, 2.35 vs. 2.05 Gy, for no enema and enema fraction, respectively). No significant rectal volume differences nor DVH parameter differences were observed according the applicator type.ConclusionsOur rectal enemas protocol prior to HDR-BT was ineffective in significantly modifying rectal DVH parameters. No differences were observed according to the type of applicator used.

Comparison of three different application routes of butyrate to improve colonic anastomotic strength in rats

IntroductionDespite extensive research, anastomotic leakage (AL) remains one of the most dreaded complications after colorectal surgery. Since butyrate enemas are known to enhance anastomotic healing, several administration routes have been explored in this study.MethodsThree intraluminal approaches involving butyrate were investigated: (1) butyrin-elucidating patch, (2) a single injection of hyaluronan-butyrate (HA-But) prior to construction of the proximal anastomosis and (3) rectal hyaluronan-butyrate (HA-But) enemas designed for distal anastomoses. The main outcome was AL and secondary outcomes were bursting pressure, histological analysis of the anastomosis, zymography to detect MMP activity and qPCR for gene expression of MMP2, MMP9, MUC2 and TFF3.ResultsNeither the patches nor the injections led to a reduction of AL in experiments 1 and 2. In experiment 3, a significant reduction of AL was accomplished with the (HA-But) enema compared to the control group together with a higher bursting pressure. Histological analysis detected only an increased inflammation in experiment 2 in the hyaluronan injection group compared to the control group. No other differences were found regarding wound healing. Zymography identified a decreased proenzyme of MMP9 when HA-But was administered as a rectal enema. qPCR did not show any significant differences between groups in any experiment.ConclusionButyrate enemas are effective in the enhancement of colonic anastomosis. Enhanced butyrate-based approaches designed to reduce AL in animal models for both proximal and distal anastomoses were not more effective than were butyrate enemas alone. Further research should focus on how exogenous butyrate can improve anastomotic healing after gastrointestinal surgery.

Transient Descending Colo-Colonic Intussusception Due to a Large Fecaloma in an Adult: A Rare Case Report

Introduction: Adult intussusception represents 5% of all cases of intussusception and accounts for only 1%-5% of intestinal obstructions in adults, and 0.003-0.02% of all hospital admissions. Transient nonobstructing intussusception is frequently idiopathic and resolves spontaneously without any specific treatment. We describe a case of transient non-obstructing colo-colonic intussusception due to a large fecaloma. Case Report: 53 years old African American lady presented to Emergency Department with severe progressive lower abdominal cramping pain of 12 hours' duration. Abdominal examination was significant for bilateral lower abdominal tenderness with hypoactive bowel sounds. CT scan of the abdomen and pelvis demonstrated a “colocolonic intussusception” in the descending colon extending over a length of 3.5 cm. Subsequently she underwent an emergent colonoscopy for possible reduction of the intussusception. On colonoscopy, in mid-descending colon, solid stool was found which was packing the entire lumen and it was deemed not safe to advance further so procedure was aborted. Patient was managed conservatively in the absence of peritoneal signs and underwent a water-soluble rectal enema next day that showed a filling defect in the mid descending colon. She was subsequently prepped for an elective colonoscopy for further evaluation of colonic mucosa. Colonoscopy demonstrated the presence of a large stool ball (fecaloma) in left colon even after colonic prep with polyethylene glycol. She was started on round the clock laxatives and she continued to have multiple bowel movements in hospital and her abdominal pain subsided.Figure 1Figure 2Figure 3Discussion: The incidence of intussusception is low in adults, particularly in the descending colon, due to the anatomical attachment of the descending colon to the retroperitoneum. Primary or idiopathic intussusception is usually transient while secondary intussusception due to a lead point is usually permanent or recurrent. In our patient, Intussusception was secondary to a fecaloma that served as a lead point but was transient. Abdominal computed tomography (CT) is currently considered as the most sensitive radiologic method to confirm intussusception. 70 to 90% of adult cases of intussusception require definitive treatment and often surgical resection is the treatment of choice. However, an isolated episode of transient non-obstructive intussusception can be managed conservatively.

Systematic Review and Meta-Analysis of Randomized Trials: Curcumin Treatment for Clinical Remission Induction in Patients with Mild to Moderate Ulcerative Colitis

Introduction: Curcumin is a phytochemical compound with anti-inflammatory properties. There is limited data regarding the utility of such alternative medicines in treatment of Ulcerative colitis (UC). A few recent randomized trials looked at the role of curcumin in achieving remission induction in patients with mild - moderate UC. This has never been systematically reviewed. Aims: Primary outcome was to evaluate the efficacy of curcumin in achieving clinical remission induction [SCCAI (simple clinical colitis activity index) score 3) and safety profile. Methods: Study Selection Criteria: Randomized controlled trials comparing the efficacy of curcumin (2-3gms oral capsules daily or 140mg rectal enema daily) plus mesalamine (1600-4000mg daily) (CM group) versus placebo plus mesalamine (PM group) in patients with mild to moderate UC. Data collection & extraction: Articles were searched in Medline, Pubmed, and Ovid journals. Two authors independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Methods: Pooled proportions were calculated using both fixed and random effects model. The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 142 reference articles, of which 24 were selected and reviewed. Three studies (N=184) that met the inclusion criteria were included in this analysis. Median age of the patients was 41 years, predominantly male population (62.5%). The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. At a mean follow up period of 6 weeks (ranged 4-8 weeks), the pooled odds ratio for clinical remission induction in CM group versus PM group was 6.78 (95% CI = 2.39 to 19.23) after a mean treatment period of 6 weeks. Odds ratio for clinical improvement in CM group versus PM group was 4.83 (95% CI = 2.00 to 11.65). Adverse events (mild nausea, transient increase in stool frequency, and abdominal bloating) in both the group were similar, with an odds ratio of 1.13 (95% CI = 0.34 to 3.70) in CM group versus PM group. Conclusion: In patients with mild to moderate UC, 4-8 weeks of curcumin treatment along with mesalamine is superior to placebo plus mesalamine. It is a safe and promising agent for the treatment of ulcerative colitis.

Developing hyperpolarized silicon particles for in vivo MRI targeting of ovarian cancer.

Silicon-based nanoparticles are ideally suited for use as biomedical imaging agents due to their biocompatibility, biodegradability, and simple surface chemistry that facilitates drug loading and targeting. A method of hyperpolarizing silicon particles using dynamic nuclear polarization, which increases magnetic resonance imaging signals by several orders-of-magnitude through enhanced nuclear spin alignment, has recently been developed to allow silicon particles to function as contrast agents for in vivo magnetic resonance imaging. The enhanced spin polarization of silicon lasts significantly longer than other hyperpolarized agents (tens of minutes, whereas [Formula: see text] for other species at room temperature), allowing a wide range of potential applications. We report our recent characterizations of hyperpolarized silicon particles, with the ultimate goal of targeted, noninvasive, and nonradioactive molecular imaging of various cancer systems. A variety of particle sizes (20nm to [Formula: see text]) were found to have hyperpolarized relaxation times ranging from [Formula: see text] to 50min. The addition of various functional groups to the particle surface had no effect on the hyperpolarization buildup or decay rates and allowed in vivo imaging over long time scales. Additional in vivo studies examined a variety of particle administration routes in mice, including intraperitoneal injection, rectal enema, and oral gavage.

Primary sigmoidectomy and appendicostomy for chronic idiopathic constipation.

To present our experience in patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence who underwent a primary sigmoidectomy and appendicostomy. We reviewed eight patients referred to the Colorectal Center from 2014 to 2016 with chronic idiopathic constipation and undergoing a sigmoidectomy and appendicostomy. We analyzed the previous medical treatment, indications for the surgical procedure, and outcomes. Age at operation was 5-19years. Time with constipation was 4-15years. All patients received multiple laxatives, mainly polyethylene glycol, and all had severe social problems. Four patients have autism. The indication for surgery was an unsuccessful laxative trial, refusal to continue with rectal enemas or both, and social fear of continued fecal incontinence. Post-operatively, all patients were having daily bowel movements without fecal accidents. Selected patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence can obtain great benefit from primary sigmoidectomy and appendicostomy.

Rectal budesonide and mesalamine formulations in active ulcerative proctosigmoiditis: efficacy, tolerance, and treatment approach.

Ulcerative colitis (UC) is an immune-mediated disease of the colon that is characterized by diffuse and continuous inflammation contiguous from the rectum. Half of UC patients have inflammation limited to the distal colon (proctitis or proctosigmoiditis) that primarily causes symptoms of bloody diarrhea and urgency. Mild-to-moderate distal UC can be effectively treated with topical formulations (rectal suppositories, enemas, or foam) of mesalamine or steroids to reduce mucosal inflammation and alleviate symptoms. Enemas or foam formulations adequately reach up to the splenic flexure, have a minimal side-effect profile, and induce remission alone or in combination with systemic immunosuppressive therapy. Herein, we compare the efficacy, cost, patient tolerance, and side-effect profiles of steroid and mesalamine rectal formulations in distal UC. Patients with distal mild-to-moderate UC have a remission rate of approximately 75% (NNT =2) after treatment for 6 weeks with mesalamine enemas. Rectal budesonide foam induces remission in 41.2% of patients with mild-to-moderate active distal UC compared to 24% of patient treated with placebo (NNT =5). However, rectal budesonide has better patient tolerance profile compared to enema formulations. Despite its favorable efficacy, safety, and cost profiles, patients and physicians significantly underuse topical treatments for treating distal colitis. This necessitates improved patient education and physician familiarity regarding the indications, effectiveness, and potential financial and tolerability barriers in using rectal formulations.

Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology

ObjectiveThe objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease. MethodsEach recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines). ResultsHysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (gradeC). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (gradeC). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (gradeC). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (gradeC) or in women with previous cesarean section (gradeC). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (gradeC). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B). ConclusionThe application of these recommendations should minimize risks associated with hysterectomy.

Effect of rectal enemas on rectal dosimetric parameters during high-dose-rate vaginal cuff brachytherapy: A prospective trial.

To evaluate the effects of rectal enemas on rectal doses during postoperative high-dose-rate (HDR) vaginal cuff brachytherapy (VCB). This prospective trial included 59patients. Two rectal cleansing enemas were self-administered before the second fraction, and fraction1 was considered the basal status. Dose-volume histogram (DVH) values were generated for the rectum and correlated with rectal volume variation. Statistical analyses used paired and unpaired t-tests. Despite a significant 15 % reduction in mean rectal volume (44.07 vs. 52.15cc, p = 0.0018), 35.6 % of patients had larger rectums after rectal enemas. No significant rectal enema-related DVH differences were observed compared to the basal data. Although not statistically significant, rectal cleansing-associated increases in mean rectal DVH values were observed: D0.1cc: 6.6 vs. 7.21Gy; D1cc: 5.35 vs. 5.52Gy; D2cc: 4.67 vs. 4.72Gy, before and after rectal cleaning, respectively (where Dxcc is the dose to the most exposed xcm(3)). No differences were observed in DVH parameters according to rectal volume increase or decrease after the enema. Patients whose rectal volume increased also had significantly larger DVH parameters, except for D5 %, D25 %, and D50 %. In contrast, in patients whose rectal volume decreased, significance was only seen for D25 % and D50 % (Dx % dose covering x % of the volume). In the latter patients, nonsignificant reductions in D2cc, D5cc and V5Gy (volume receiving at least 5Gy) were observed. The current rectal enemas protocol was ineffective in significantly modifying rectal DVH parameters for HDR-VCB.

Synergic Interaction of Rifaximin and Mutaflor (Escherichia coli Nissle 1917) in the Treatment of Acetic Acid-Induced Colitis in Rats.

Background. Inflammatory bowel disease results from the dysregulation of immune response to environmental and microbial agents in genetically susceptible individuals. The aim of the present study was to examine the effect of rifaximin and/or Mutaflor (Escherichia coli Nissle 1917, EcN) administration on the healing of acetic acid-induced colitis. Methods. Colitis was induced in male Wistar rats by rectal enema with 3.5% acetic acid solution. Rifaximin (50 mg/kg/dose) and/or Mutaflor (109 CFU/dose) were given intragastrically once a day. The severity of colitis was assessed at the 8th day after induction of inflammation. Results. Treatment with rifaximin significantly accelerated the healing of colonic damage. This effect was associated with significant reversion of the acetic acid-evoked decrease in mucosal blood flow and DNA synthesis. Moreover, administration of rifaximin significantly reduced concentration of proinflammatory TNF-α and activity of myeloperoxidase in colonic mucosa. Mutaflor given alone was without significant effect on activity of colitis. In contrast, Mutaflor given in combination with rifaximin significantly enhanced therapeutic effect of rifaximin. Moreover, Mutaflor led to settle of the colon by EcN and this effect was augmented by pretreatment with rifaximin. Conclusion. Rifaximin and Mutaflor exhibit synergic anti-inflammatory and therapeutic effect in acetic acid-induced colitis in rats.

Fecaloma mimicking acute abdomen: a diagnostic challenge

Fecaloma can occur as a result of several causes and may present as a challenging diagnostic and therapeutic problem. In this case report, we would like to present the case of a 37-year-old male who presented with abdominal distention and pain. His previous medical history was significant for catatonic disorder due to psychiatric conditions. Physical examination showed a distended abdomen with focal tenderness in the lower quadrant regions. Bowel sounds were decreased and fecal materials were palpable on digital rectal examination. Upon further clinical interrogation, the patient admitted to constipation for the past three months. Except for leukocytosis (28,000/mm3 (normal range 4.5-10.5/mm3) and elevated C reactive protein (304mg/L) levels, all other laboratory findings were normal. Abdominal plain x-ray demonstrated a predominantly feces-filled colon. This was confirmed on abdominal computed tomography (CT) scan as a giant sigmoid colon, measuring 25 cm in diameter and lateralized bladder. The patient was initially treated with oral laxatives and rectal enema, which were ineffective. He was then treated with evacuation of the feces under general anesthesia. After then, patient’s symptoms were relieved. Post-operative CT imaging confirmed a decrease in the size of the sigmoid colon to an acceptable measure. No mass or polypoid lesions were seen on colonoscopy. This report attracts the attention how sigmoid colon can be a long-term reservoir for fecal contents without serious symptoms but only abdominal distention. Evacuation of fecal contents under general anesthesia may help to relieve fecaloma without surgery.

Postpartum urinary retention mimicking Fowler's syndrome: A case report

Urinary retention (UR) is relatively uncommon in women; however, it may occur following childbirth and is termed as postpartum urinary retention (PPUR). PPUR has been variably defined as the abrupt onset of painful or painless inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or unable to void spontaneously within 6 hours of vaginal delivery. This is a case of a 22-year-old woman presenting with 12 days history of intractable UR following spontaneous vaginal delivery and repair of episiotomy. The UR persisted despite repeated trial without catheter (TWOC) and bladder training. The absence of an identifiable cause and the failure of the bladder neck to open on micturating cystourethrogram (MCUG) lead to the suspicion of Fowler's syndrome thus the patient was referred to our urology unit. She was seen with an indwelling urethral catheter and there was no significant finding on evaluation except the presence of hard, impacted feces in the rectum. She had rectal enema with evacuation of feces and was able to void spontaneously without catheter. Normal voiding was maintained at 2 months of follow-up.

Obestatin Accelerates the Healing of Acetic Acid-Induced Colitis in Rats.

Obestatin, a 23-amino acid peptide derived from the proghrelin, has been shown to exhibit some protective and therapeutic effects in the gut. The aim of present study was to determine the effect of obestatin administration on the course of acetic acid-induced colitis in rats. Materials and Methods. Studies have been performed on male Wistar rats. Colitis was induced by a rectal enema with 3.5% acetic acid solution. Obestatin was administered intraperitoneally twice a day at a dose of 8 nmol/kg, starting 24 h after the induction of colitis. Seven or 14 days after the induction of colitis, the healing rate of the colon was evaluated. Results. Treatment with obestatin after induction of colitis accelerated the healing of colonic wall damage and this effect was associated with a decrease in the colitis-evoked increase in mucosal activity of myeloperoxidase and content of interleukin-1β. Moreover, obestatin administration significantly reversed the colitis-evoked decrease in mucosal blood flow and DNA synthesis. Conclusion. Administration of exogenous obestatin exhibits therapeutic effects in the course of acetic acid-induced colitis and this effect is related, at least in part, to the obestatin-evoked anti-inflammatory effect, an improvement of local blood flow, and an increase in cell proliferation in colonic mucosa.

Anal Douche Practices and Willingness to Use a Rectal Microbicide Enema for HIV Prevention and Associated Factors Among an Internet Sample of HIV-Negative and HIV-Discordant Male Couples in the US.

A significant proportion of MSM acquire HIV from their primary relationship partners. Rectal microbicides are currently being studied to determine their efficacy for HIV prevention, yet willingness to use rectal microbicides among male couples is largely unknown. Dyadic data from 333 HIV-negative and HIV-discordant male couples, representing 631 HIV-negative men, were used to assess anal douching practices and willingness to use a rectal microbicide for HIV prevention. 17% of men douched 100% of the time before having anal sex within their primary partner. Among those who had sex outside of their relationship, 36% had douched 100% of the time before having anal sex with a casual MSM partner. Most men (63%) indicated a willingness to use a theoretically effective rectal microbicide prior to anal sex for HIV prevention. If found effective, rectal microbicides delivered as an anal douche may be an acceptable format for HIV prevention to some MSM who already engage in anal douching. Understanding current douching practices will be important in successfully promoting the uptake of rectal microbicides.

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Rectal enema is an alternative to full mechanical bowel preparation for primary rectal cancer surgery.

According to the French GRECCAR III randomized trial, full mechanical bowel preparation (MBP) for rectal surgery decreases the rate of postoperative morbidity, in particular postoperative infectious complications, but MBP is not well tolerated by the patient. The aim of the present study was to determine whether a preoperative rectal enema (RE) might be an alternative to MBP. An analysis was performed of 96 matched cohort patients undergoing rectal resection with primary anastomosis and protective ileostomy at two different university teaching hospitals, whose rectal cancer management was comparable except for the choice of preoperative bowel preparation (MBP or RE). Prospective databases were retrospectively analysed. Patients were well matched for age, gender, body mass index and Charlson index. The surgical approach and cancer characteristics (level above anal verge, stage and use of neoadjuvant therapy) were comparable between the two groups. Anastomotic leakage occurred in 10% of patients having MBP and in 8% having RE (P = 1.00). Pelvic abscess formation (6% vs 2%, P = 0.63) and wound infection (8% vs 15%, P = 0.55) were also comparable. Extra-abdominal infection (13% vs 13%, P = 1.00) and non-infectious abdominal complications such as ileus and bleeding (27% and 31%, P = 0.83) were not significantly different. Overall morbidity was comparable in the two groups (50% vs 54%, P = 0.83). A simple RE before rectal surgery seems not to be associated with more postoperative infectious complications nor a higher overall morbidity than MBP.

Treatment of First-Time Clostridium difficile Infection With Fecal Microbiota Transplantation

Introduction:Clostridium difficile infection (CDI) is treated with Fecal Microbiota Transplantation (FMT) after two failed treatments with antibiotics, e.g. vancomycin(V) or metronidazole(M). To date, however, there have been no reports of FMT in CDI as a first line treatment. Success rate of FMT in relapsing CDI is close to 90%. Given CDI often follows antibiotic use which may result in depleted bacterial classes; it is irrational to use further antibiotics then await relapse to access FMT. It makes sense to treat with FMT to eradicate CDI and replace missing flora components simultaneously. Hence, we offered FMT to patients with initial diagnosis of CDI. To maintain uniform approach we used pre-FMT antibiotics. No patients with inflammatory bowel disease were included in this study. Methods: Consecutive patients were recruited with toxin-positive CDI (toxin assay or PCR) upon stool test analysis for transcolonoscopic FMT as an initial infusion, followed next day by rectal enema. Patients reported general irritable bowel syndrome (IBS) symptoms including; bloating, abdominal pain, excessive flatulence and nausea. Symptom data was recorded at initial presentation on a scale of mild, moderate or severe. Symptom data recorded again at 8/52 and 6/12 post FMT. For pre-treatment 15 had V 500mg BD, 6 had V 500mg BD + Rifaximin(R) 1000mg BD, 4 had V 500mg BD + M 200mg BD, 2 had V 250mg mane 500 nocte, 1 had 500mg R daily and the final patient had no pre-treatment (consultant driven choice). Stool cultures and toxin assays were repeated after 4 weeks. Patients were seen in clinic approximately 8 weeks after FMT as part of standard-of-care follow-up. Treatment success defined as negative stool culture and toxin assay. Results: All 29 patients recruited and treated achieved eradication of CDI. 26% reported transient bloating and flatulence immediately after FMT. 34% reported a decline in bowel motions from an average of 5.9 BM to 1.6 BM per day. 17% of patients reported constipation initially. Globally initial symptoms lessened in severity with 55%. Hence the majority of these patients had co-existing (IBS) for many months or years and most continued to have some components of their IBS after their FMT-eradication of CDI. Conclusion: - In these patients with initial diagnosis of CDI, FMT was a safe and 100% effective treatment of CDI. - Transient adverse effects of bloating / flatulence were noted. - Accompanying IBS can persist after CDI cure in this cohort albeit moderate improvement occurs in some.

OP‐10 EFFICACY AND SAFETY OF ENEMAS ADMINISTERED HIGH IN THE RECTUM FOR FECAL DISIMPACTION IN CHILDREN.

Aim:Efficacy and safety of enemas administered high in the rectum for fecal disimpaction in children was evaluated by a retrospective cohort study.Methods:Between January 1, 2012 and January 1, 2014 all procedures were evaluated. All enemas were administered, using a standardized in‐house protocol, so all procedures were performed in the same way. An enema high in the rectum was considered effective, if stool production exceeded the amount of stools that is regarded normal for the age and weight of the patient, and if the patient felt relieved after the production of stools.A qualitative scale was used by the nursing staff to estimate the amount of stools produced by the patient (‘none’, ‘little’, ‘normal’, ‘many’). Stool consistency was scored, using Bristol Stool Scale. Total stool production within 12 hours after enema was scored. Literature review was performed on efficacy and safety of enemas high in the rectum.Results:N = 77 procedures were evaluated in which all data were documented. Enemas were administered in N = 75 children (36 girls/39 boys: mean age: 9.8 yr (3.6 ‐ 19)(range)). Fecal impaction was present, defined as: palpable mass in abdomen or in rectum and a history of low stool frequency. N = 25 children were treated with more than one enema during the studied period. 68 % of enemas were effective for acute disimpaction. In 30 (45%) procedures, many stools were evacuated, in 15 (23%) procedures the amount was normal; in 18 (27%) procedures there was little stool production and in 3 (5%) procedures no stools were produced. In N = 11 procedures the amount of stools produced was documented insufficiently. Procedure‐ related complications were not seen. In literature no data were found on the efficacy or on safety of enemas administered high up in the rectum. Literature shows equal efficacy of high dose (oral) macrogol as compared to standard rectal enemas (not high up).Conclusions:Enemas administered high up in the rectum are safe in all, and effective in a majority of patients for the management of fecal impaction in children. Prospective studies are needed to evaluate efficacy of enemas high up in the rectum as compared to high doses of macrogol for fecal disimpaction in children.

Maladie de Hirschsprung, diagnostic et prise en charge actuelle

Hirschsprung disease is a congenital malformation in which, due to lack of neural crest cell migration, the distal part of the bowel has no innervation, leading to functional obstruction. This rare disease (1/5000 live birth) has a complex genetic and physiopathologic background. Depending on the disease level, symptoms vary from distal obstruction to short bowel syndrome. Diagnosis is based on suction rectal biopsy examination and contrast enema. After the obstruction relief, surgical cure aim to remove the aganglionic bowel and to perform laparoscopic or transanal pullthrough. Enterocolitis or anal soiling in childhood can disturb follow up.

Diffusion-weighted magnetic resonance imaging is effective to detect ileocolonic ulcerations in Crohn's disease.

Magnetic resonance entero-colonography enables accurate assessment of ileocolonic Crohn's disease, but the need for bowel cleansing and rectal enema limits considerably its use in daily practice. We evaluated the accuracy of diffusion-weighted magnetic resonance entero-colonography with neither bowel cleansing nor rectal enema to assess endoscopic activity. Forty-four Crohn's disease patients underwent prospectively and consecutively diffusion-weighted magnetic resonance entero-colonography [with apparent diffusion coefficient (ADC) and Clermont score calculation] and ileocolonoscopy [with Crohn's Disease Endoscopic Index of Severity (CDEIS) and Simplified Endoscopic score for Crohn's Disease (SES-CD) calculation]. Mean ADC was inversely correlated with total CDEIS (ρ = -0.40; P = 0.0067) and total SES-CD (ρ = -0.33; P = 0.032). Considering the 194 segments, ADC was inversely correlated with segmental CDEIS (-0.48; P < 0.001) and segmental SES-CD (-0.44; P < 0.001). ADC values were lower in segments with deep ulcers (1.30 ± 0.23) or superficial ulcerations (1.75 ± 0.64) than in non-ulcerated segments (2.15 ± 0.5) (P = 0.001). Using a receiver operating curve, we determined that segmental ADC <1.42 detected endoscopic deep ulcerations with sensitivity = 0.91 and specificity = 0.83 (Area under the curve = 0.84; P < 0.001). Segmental ADC <1.88 detected endoscopic superficial ulcerations with sensitivity = 0.64 and specificity = 0.75. The segmental ADC values decreased when the ulcerations size increased (P = 0.0001). Clermont score correlated with ileal CDEIS (0.63; P < 0.05) and ileal SES-CD (0.58; P < 0.05). Clermont score was higher in ulcerated segments (23.3 ± 8.4) than in non-ulcerated segments (12.4 ± 10.0) (P = 0.006) and increased with ulcers size (P = 0.012). Clermont score >18.9 detected ulcerations with sensitivity = 0.79 and specificity = 0.73. Diffusion-weighted magnetic resonance entero-colonography using apparent diffusion coefficient and Clermont score was effective to indirectly detect endoscopic ulcerations in ileocolonic Crohn's disease.