Digital rectal examination and the primary care physicians: a lost art?

Digital rectal examination (DRE) in children is crucial to differentiate between simple (habitual) and complicated constipation. Previous experience suggests that primary care physicians (PCPs) avoid DRE in children with constipation before referral. We evaluated the rate of DRE performance by West Virginian PCPs in patients referred to our gastroenterology clinic. Data were collected from the physicians' referral letters and parental reports. We found that the vast majority (85%) of WV-PCPs do not perform DRE before referring their patients, resulting in missed diagnoses and treatment. We concluded that the lack of DRE in children with constipation may result in unnecessary referral to the specialist. To improve standard of care for children with constipation, an educational campaign for PCPs is clearly warranted.     

Megarectum in constipation.

BACKGROUND: Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding. AIM: To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum. METHODS: All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination. RESULTS: A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls. CONCLUSIONS: We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.     

Megarectum in constipation

BACKGROUND—Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding.AIM—To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum.METHODS—All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination.RESULTS—A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls.CONCLUSIONS—We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.     

The constipated child: how likely is Hirschsprung's disease?

The incidence of Hirschsprung's disease (HD) was determined in children who presented with constipation to a specialist paediatric surgical unit. During a 5-year period, 355 rectal biopsies were performed on 182 neonates, infants and children presenting with chronic constipation or intestinal obstruction: 25 (14%) were diagnosed HD. One hundred and four patients had suction and 78 had full-thickness rectal biopsies. Haematoxylin-eosin (HE) staining and acetylcholinesterase (AChE) histochemistry was used. In 13 cases (8%) of suction and 2 cases (2.5%) of full thickness rectal biopsies, specimens were inadequate to diagnose HD. The mean age of all patients was 2.9 years and that of patients diagnosed with HD was 3.64 months. Nineteen patients with HD were diagnosed in the first month, 5 in 1-12 months and 1 at 4 years of age (Fig. 1). The authors found that along with onset of constipation convincing indications for rectal biopsy to exclude HD were as follows: those infants and children who do not pass meconium within 48 hours, have low intestinal obstruction of unknown cause, severe constipation, chronic abdominal distension and failure to thrive. A diagnostic accuracy of 94% was achieved with AChE histochemistry for suction rectal biopsy. After this review, referring paediatricians were advised that screening of other common organic causes of constipation with the least invasive investigations, including laboratory, dietary and paediatric gastroenterology advice, should be undertaken to avoid unnecessary rectal biopsy to exclude HD and related disorders.     

Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children

OBJECTIVES: To assess the clinical and biochemical safety profile of long-term polyethylene glycol 3350 (PEG) therapy in children with chronic constipation and to assess pediatric patient acceptance of PEG therapy. DESIGN: Prospective observational study. SETTING: Pediatric clinics at a referral center.Patients Eighty-three children (44 with chronic constipation, 39 with constipation and encopresis) receiving PEG therapy for more than 3 months. MAIN OUTCOME MEASURES: Clinical adverse effects related to PEG therapy and acceptance and compliance with PEG therapy. Serum electrolyte levels, osmolality, albumin levels, and liver and renal function test results were measured. RESULTS: At the time of evaluation, the mean duration of PEG therapy was 8.7 months, and the mean PEG dose was 0.75 g/kg daily. There were no major clinical adverse effects. All blood test results were normal, except for transient minimal alanine aminotransferase elevation unrelated to therapy in 9 patients. All children preferred PEG to previously used laxatives, and daily compliance was measured as good in 90% of children. CONCLUSIONS: Long-term PEG therapy is safe and is well accepted by children with chronic constipation with and without encopresis.     

Colostomy for treatment of functional constipation in children: a preliminary report

OBJECTIVES: Surgery is indicated in very few children with intractable functional constipation. A number of operations have been described with unpredictable outcome and significant morbidity. The authors present a series of 10 children who underwent a Hartmann procedure with end colostomy formation. METHOD: Preoperative management, in addition to maximum conservative measures, included psychologic referral, rectal biopsy, transit studies, and contrast enemas. A standard Hartmann procedure was performed with on-table rectal washout, formation of a proximal sigmoid colostomy, limited anterior resection of hypertrophic proximal rectosigmoid, and oversewing of the rectal stump. RESULTS: The series includes 10 pediatric patients (4 female, 6 male), in whom constipation was first reported at a median age of 3 years (range, 2 months-7 years) and surgical referral was made at 8 years (range, 1-14 years). Surgery was performed at a median age of 9.5 years (range, 2-15 years), and the median postoperative stay was 5 days (range, 4-9 days). Complications occurred in four patients (transient mild rectal discharge in 2, stomal prolapse in 1, and an unrelated small bowel obstruction in 1 patient with an additional Mitrofanoff stoma). Median postoperative follow-up was 31 months (range, 9-56 months), and the children and parents were all completely satisfied with the stoma. CONCLUSION: Colostomy formation is a potential surgical option for severe functional constipation with low associated morbidity and high patient satisfaction.     

Subspecialty referrals for pauciarticular juvenile rheumatoid arthritis

OBJECTIVES: To examine referral patterns from primary care physicians for children with pauciarticular juvenile rheumatoid arthritis (JRA) and to determine whether children with pauciarticular JRA referred to pediatric rheumatologists differ in clinical presentation from children referred to other specialists. DESIGN: A retrospective records review of 49 patients with pauciarticular jRA was performed. Records were reviewed to determine the specialty of the referring physician and whether the children referred had symptoms and signs compatible with a synovitis at the time primary care was sought. SETTING: Inner-city tertiary pediatric rheumatology referral center. PARTICIPANTS: Children with pauciarticular JRA. MAIN OUTCOME MEASURES: Identification of referral patterns of primary care physicians. Associated morbidity owing to JRA was ascertained at the time of referral. RESULTS: Most children with pauciarticular JRA (62%) were referred to orthopedic surgeons prior to referral for pediatric rheumatology care. No differences in clinical symptoms were seen between children referred to pediatric rheumatologists and those referred to orthopedic surgeons. Children referred initially to orthopedic surgeons were younger than those referred to pediatric rheumatologists. CONCLUSION: A notable number of children with pauciarticular JRA are referred to orthopedic surgeons prior to the establishment of that diagnosis, even when such children present with unequivocal signs of synovitis. This may be owing to the misconception that arthritis is rare in preschool-aged children or to the difficulty of ascertaining the presence of synovitis in younger children.     

Quantitation of defecation function using radionuclide artificial stool in children with chronic constipation.

We aimed to investigate the value of scintigraphically determined evacuation fraction (EVF) as an objective follow-up criterion in medically treated children with chronic constipation, and to evaluate the relation between patients' symptoms and rectal emptying rate. Thirty children (m: 22, f: 8, mean age: 8.9 +/- 0.9 year) suffering from chronic constipation were assessed by scintigraphic evacuation study. All patients underwent anal manometric and scintigraphic examinations before their therapy was started. During 3 months, they received conventional laxative treatment for constipation, and scintigraphic studies were repeated in 20 of 30 patients. Scintigraphic examinations consisted of instillation of artificial stool into the rectum up to the volume impending rectal evacuation, and acquisition of pre- and post-evacuation images. EVF values were then calculated from the images using a fixed region of interest. All of the patients had high resting anal canal pressure (75 +/- 12 mmHg) and had positive rectoanal inhibitory reflex. In 14/20 patients (70%) who benefited from therapy, mean EVF changed from 43.6% to 62.2% (p < 0.001), while decreasing in 6120 who did not benefit. The volume arousing rectal evacuation was significantly lower at the second scintigraphic study (261 +/- 98 ml) than the first study (354 +/- 138 ml) (p < 0.05). As a conclusion: 1) EVF was low in chronically constipated children, 2) it was improved after conventional laxative treatment and, 3) radionuclide EVF determination may be a useful method for follow-up.     

Anteriorly displaced anus: an under-recognized cause of chronic constipation

Anterior displacement of a normal anus is recognized as a cause of severe constipation in some children. We have reviewed our experience with 13 children treated for this disorder over the past 8 years at the University of Virginia Health Sciences Center. Twelve of the patients were female and the age at the time of operation ranged between 12 months and 9 years. In all patients constipation began in the first 3 to 6 months of life. Symptoms were characterized by marked straining upon passage of stool, often accompanied by perineal pain. All patients had been unsuccessfully treated with agressive use of stool softeners and cathartics. The anus had a normal appearance, although it was located anterior to its normal position in every case. There was no evidence of anal stenosis on digital examination; in each case a large posterior rectal cul-de-sac could be palpated. A barium enema examination disclosed a prominent posterior shelf of the rectum, often with enormous dilation of the colon posteriorly. All patients underwent surgical treatment using a posterior anoplasty with advancement of the posterior rectal wall. In 10 patients a posterior rectal myomectomy was added to the procedure. Pathologic evaluation of the rectal muscle was normal in each instance. Complete relief of constipation was achieved in all patients, with follow-up extending for as long as 6 years. One patient continues to require occasional use of stool softeners. Anterior displacement of the anus is a frequently overlooked, although easily corrected, cause of severe constipation in childhood. Offprint requests to: B. M. Rodgers     

核素排便造影在小儿便秘诊断中的应用价值

目的　研究核素排便造影方法在小儿便秘诊断和疾病程度判定方面的应用价值。方法　对 2 5例特发性便秘患儿和 11例正常儿进行核素排便造影检查。根据直肠肛管排空曲线可计算出残留率、排空率和半排时间等反映排便能力的客观指标 ,根据采集的直肠肛管图像可获得反映耻骨直肠肌功能的静息、收缩和排便状态下的直肠肛管角。所有患儿同时进行结肠传输实验和X线排便造影检查。结果　便秘患儿直肠肛管排空曲线平直或下降缓慢 ,而正常儿的排空曲线为快速弧形下降曲线。便秘患儿排便能力明显下降 ,正常儿半排空时间、排空率和残留率分别是 1 97± 0 86min、78 30 %± 12 0 3%和 2 0 5 0 %± 7 6 7% ,而便秘患儿这三项分别为 15 16± 3 6 7min、4 4 84 %± 14 0 0 %和 5 3 5 2 %± 15 0 2 % ,两组差异有显著意义 (P <0 0 5 )。根据结肠传输实验结果有 6例患儿为慢传输型便秘 ,17例为出口梗阻型便秘 ,出口梗阻型便秘患儿的排便能力明显低于慢传输型便秘。结论　核素排便造影可以对便秘进行准确诊断和疾病程度判定 ,同时也能对耻骨直肠肌功能进行准确评价 ,而且具有操作简单、安全、受放射线照射量很低等优点 ,是评价直肠肛管排便功能的重要客观检测方法。     

Occult constipation: faecal retention as a cause of recurrent abdominal pain in children

Recurrent abdominal pain (RAP) in children is generally believed to be functional. In practice, many children with RAP become pain-free with laxative therapy. The aims of the study were to establish the role of (occult) constipation in RAP and to investigate whether patients diagnosed with (occult) constipation could be identified by history and physical examination. During 2 years, all patients (age 4–16 years, secondary referral) fulfilling Apley criteria of RAP were included. After exclusion of gastrointestinal infections and food intolerance, laxatives were advised when pain persisted. (Occult) constipation was defined as ‘abdominal pain disappearing with laxative treatment and not reappearing within a 6 month follow up period’; ‘occult constipation’ was diagnosed in patients who did not fulfil the Rome criteria of constipation. Two hundred children (87 M; median age 8.8 years) were evaluated. (Occult) constipation was found in 92 patients (46 %). Of these, 18 had considerable relief of pain when treated for a somatic cause but experienced complete relief only after laxative measures; they were considered to have two diagnoses. Using multivariate analysis, a simple model was developed with cystitis in past history, early satiety and flatulence as predictors for (occult) constipation. The risk of (occult) constipation ranged from 18/58 if no predictor was present to 4/4 if all three were present. Conclusion: Laxatives played a pivotal role in the recovery of patients with RAP. We developed a simple model to identify patients at risk of having (occult) constipation.     

The usefulness of ultrasound examination of the bowel as a method of assessment of functional chronic constipation in children

Background Ultrasonographic assessment of stool retention in children with chronic constipation requires the diagnosis of megarectum. Objective The aim of the study was to evaluate an atypical method of US assessment of megarectum, fecal impaction and enlarged colon in order to decide whether it can be used as an assessment method for children with functional chronic constipation. Materials and methods A total of 120 children with a positive diagnosis of chronic constipation were included in the study. All patients fulfilled the ROME II diagnostic criteria for defecation disorders. The control group comprised 105 patients with a normal defecation pattern. Children with a US diagnosis of megarectum, fecal impaction and enlarged colon were referred for proctoscopy and measurement of colonic transit time. Results The transverse diameter of the rectal ampulla increases with age and thus influenced the US measurements in both the patient and control groups. The numerical values of this parameter differed significantly between patients and controls in all age groups. The rectopelvic ratio is the ratio of the width of the rectal ampulla (as seen by US) to the distance between the anterior superior iliac spines (measured externally using a measuring tape). This allows the definition of megarectum. In the diagnosis of fecal impaction, US showed a sensitivity of 88.3% relative to proctoscopy. In children with fecal impaction the colonic transit time, average segmental transit time for the rectum and sigmoid colon, and average segmental transit time for the left colon were significantly longer. There was no statistically significant difference for the right side of the colon. Conclusion US assessment of stool retention and overfilling of the colon in children with functional chronic constipation has a high correlation with proctoscopy findings and colonic transit time. The rectopelvic ratio can be used to diagnose megarectum in children with functional chronic constipation with a cut-off value of 0.189.     

Management of children with functional constipation referred to tertiary care

ObjectivesTo describe the management, to compare treatment at initial referral vs. during specialized follow-up, and to describe outcomes of children with functional constipation (FC) referred to a Brazilian tertiary care center.MethodsRetrospective study, including children (4–18 years) with FC followed at a single center from 2006 to 2019. Demographics, treatments, time of follow-up, and outcomes were analyzed. The management of FC followed an institutional protocol.Results104 patients were identified, 79 were eligible and included in the analysis: 59% male, mean age at referral was 6.4 years, and mean duration of symptoms was 4.4 years. There were significant changes in the therapy(ies) used at the time of referral compared to during follow-up, with a noticeable increase in the frequency of the use of polyethylene glycol, enemas, magnesium hydroxide, and bisacodyl; 5.1% received trans-anal irrigation, and 3.8% underwent surgery. Outcomes were favorable in more than half of the cases: 31% improved; 19.5% had complete resolution and 2.5% were transferred back to primary care. Symptoms remained unchanged in 30.4%, and no patients experienced worsening of symptoms. The mean duration of follow-up was 2.8 years. When comparing patients with favorable vs. unfavorable outcomes, the authors did not identify significant differences in gender, age, therapies used, duration of symptoms, or length of follow-up.ConclusionsChildren with FC are often referred to specialized care not receiving optimal therapy. Many patients whose FC was labeled “refractory” may be treated successfully with a well-established plan of care, and do not truly present intractable constipation.     

Comparing Oral Route Paraffin Oil versus Rectal Route for Disimpaction in Children with Chronic Constipation; a Randomized Control Trial

Objective

Functional constipation is a common and challenging problem in pediatrics. Fecal disimpaction prior to maintenance therapy is recommended to ensure successful treatment. The aim of this study was to compare the efficacy and patient''s compliance of the two methods of paraffin oil administration (oral and rectal route) with the purpose of disimpaction in treatment of children with functional constipation.

Methods

A total of 80 children (49 males and 31 females) aged 1–12 years, with functional constipation according to Rome III criteria, whose rectal examination confirmed fecal impaction were divided into two groups randomly. Group I received 3 ml/kg/day paraffin oil orally and group II received 3ml/kg/day paraffin oil rectally during 3 consequent days. Successful treatment was defined as no detectable fecal impaction in rectal examination after at most 72 hours. Patient compliance and family satisfaction also was evaluated using a scored questionnaire.

Findings

Response to the treatment in both groups was with 92.5% and 82.5% in group I and II, respectively. So, there was no significant difference between the two methods of therapy. Family satisfying and compliance were obviously more achieved in group 1 (87.5% vs 57.5%) than in Group 2 (P<0.001). No parents in group I complained about type of treatment while 12.5% of parents in group II were unsatisfied with the mode of paraffin oil administration. The most common side effect of paraffin oil in both groups was anal oil seepage (27.5%). Nausea and abdominal pain were more common side effects in group 1 and 2 respectively.

Conclusion

It seems that using paraffin oil per oral route in comparison with rectal route could be a preferred option for disimpaction in children causing less anxiety to the family.     

The diagnostic work up of growth failure in secondary health care; An evaluation of consensus guidelines

Background

As abnormal growth might be the first manifestation of undetected diseases, it is important to have accurate referral criteria and a proper diagnostic work-up. In the present paper we evaluate the diagnostic work-up in secondary health care according to existing consensus guidelines and study the frequency of underlying medical disorders.

Methods

Data on growth and additional diagnostic procedures were collected from medical records of new patients referred for short stature to the outpatient clinics of the general paediatric departments of two hospitals (Erasmus MC – Sophia Children's Hospital, Rotterdam and Spaarne Hospital, Haarlem) between January 1998 and December 2002. As the Dutch Consensus Guideline (DCG) is the only guideline addressing referral criteria as well as diagnostic work-up, the analyses were based on its seven auxological referral criteria to determine the characteristics of children who are incorrectly referred and the adequacy of workup of those who are referred.

Results

Twenty four percent of children older than 3 years were inappropriately referred (NCR). Of the correctly referred children 74–88% were short corrected for parental height, 40–61% had a height SDS <-2.5 and 21% showed height deflection (Δ HSDS < -0.25/yr or Δ HSDS < -1). In none of the children a complete detailed routine diagnostic work up was performed and in more than 30% no routine laboratory examination was done at all. Pathologic causes of short stature were found in 27 children (5%).

Conclusion

Existing guidelines for workup of children with suspected growth failure are poorly implemented. Although poorly implemented the DCG detects at least 5% pathologic causes of growth failure in children referred for short stature. New guidelines for referral are required with a better sensitivity and specificity, wherein distance to target height should get more attention. The general diagnostic work up for short stature should include testing for celiac disease in all children and for Turner syndrome in girls.     

Hirschsprung's Disease: a Clinical and Pathologic Study in Iranian Constipated Children

Objective

Hirschsprung''s disease (HD) is a complex disorder resulting from absence of ganglion cells in the bowel wall leading to functional obstruction and bowel dilatation proximal to the affected segment. The aim of our study was to evaluate rectal biopsies from constipated children in different age groups to see in which age it is more likely to encounter HD to avoid unnecessary rectal biopsy.

Methods

Records of all children with chronic constipation undergoing a rectal biopsy to exclude HD were obtained from the files of Children''s Medical Center in Tehran, Iran. A detailed retrospective demographic review, including age of beginning of signs and symptoms was made of all cases.

Findings

Totally, 172 biopsies were taken from 168 children in a five year period, of which 127 cases (75%) had HD. The mean age of constipated patients at biopsy was 39 months and the mean age of patients with proven HD was 18 months. Males were affected more than females. Congenital anomalies associated with HD were found in 9.6%. In 85 (91%) cases constipation had begun in neonatal period.

Conclusion

Our data supports previous studies that if constipation begins after the neonatal period, the child is unlikely to have HD. In neonates delay in meconium passage is the most important clinical sign of HD.     

Pathophysiology of chronic constipation in anorectal malformations. Long-term results and preliminary anatomical investigations.

Posterior sagittal anorectoplasty provides an optimal access to reconstruct the muscle complex in anorectal malformations. It gives much better results than the abdominoperineal pullthrough procedures performed before 1984. However, severe chronic constipation occurs postoperatively in about 10 % of the patients, which can only be treated by washouts. Clinical investigations of 578 patients treated from 1962 to 1984 and from 1985 to 1997 are presented here and both groups are compared to each other. In addition, a new continence score with special regard to chronic constipation and overflow incontinence was used to follow up 133 patients of the second group. The score distinguishes between children above and below the age of 3 years. To study the underlying reasons of severe chronic constipation in children with anorectal malformations, macro- and microanatomical investigations on 4 normal newborns, 3 neonatal piglets with imperforate anus and 25 rectal biopsies from the caecum were performed. The following reasons have been found to be probably responsible for postoperative constipation and overflow incontinence: 1. Malformations of the smooth and striated muscle fibres or connective tissue of the caecum; 2. Malformations of the intramural nerve plexus such as aganglionosis, hypoganglionosis or IND; 3. Malformations and/or iatrogenic lesions of the extramural nerve supply which runs anterior to the rectum and in front of the fascia of Denonvilliers, which can hardly be identified in neonates with imperforate anus. Therefore iatrogenic bladder injuries may occur after PSARP after extended mobilisation of the caecum. The macro- and microanatomical situation in the piglet with imperforate anus is totally different from the human newborn.     

Rectal localization of Burkitt's lymphoma]

BACKGROUND: Rectal tumors are rare in childhood and among them malignant tumors are even less common. Only eight cases of primary rectal lymphomas were reported in children, with various presenting signs and histology. Burkitt's lymphomas are among these cases. CASE REPORT: A five-year-old child presented with hematochezia and unusual constipation. The rectal examination showed a voluminous intra rectal mass. Radiographic and pathologic examinations led to the diagnostic of Burkitt's lymphoma with medullary involvement. Complete remission was obtained after initial chemotherapy but a local relapse occurred and the child died eight months later. CONCLUSION: Hematochezia associated with unusual constipation impose a rectal examination. Early diagnosis of a rectal tumor may allow patients survival.     

Factors responsible for persistence of childhood constipation

In this study 56% of children with chronic constipation and encopresis were unable to defecate rectal balloons. Most of them had an abnormal contraction of the external and sphincter during defecation trials. Eighty-six percent were still unable to defecate balloons 1 year later after having complied with a conventional treatment program. Only 14% of patients unable to defecate balloons had recovered by 1 year, whereas 64% of patients able to had recovered (p less than 0.02). Only 13% of patients unable to relax the external sphincter had recovered by 1 year, whereas 70% of those able to do so had recovered (p less than 0.01). In addition, none of the patients with an abdominal fecal mass present during the initial examination independent of ability or inability to defecate balloons had recovered (p less than 0.001). This study shows that abnormal defecation dynamics and the severity of constipation are predictors for persistence of chronic constipation and encopresis.