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 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.     

Gastrointestinal transit time, frequency of defecation, and anorectal manometry in healthy and constipated children

Total gastrointestinal transit time (TGITT), frequency of defecation, and anorectal manometry were evaluated in 63 pediatric patients referred for chronic nonorganic constipation; in 39, segmental transit times of the right and left colon and rectum were also measured. TGITT was significantly longer in chronically constipated children than in matched normal controls. Although bowel frequency was highly significantly correlated with TGITT in patients with prolonged transit time, not all children with prolonged TGITT had reduced bowel frequency. Moreover, not all children with constipation had prolonged TGITT. In children with idiopathic chronic constipation, slowing of intestinal transit occurred most frequently at the level of the distal colon and rectum. Anorectal motility variables were not significantly different in children with functional chronic constipation and in normal children. Maximal resting and pressure and mean intrarectal distending volume causing threshold inhibition in constipated patients did not significantly differ from the control values. Therefore, anorectal manometry did not detect relevant motor abnormalities in constipated children.     

Revision anorectoplasty in the management of anorectal anomalies

Twelve patients who had a revision posterior sagittal anorectoplasty (PSARP) were evaluated by questionnaire. They were 11 months to 15 years old (median 5 years) at the time of revision surgery. All were born with an intermediate to high anorectal anomaly (ARM) and had ongoing problems of rectal prolapse (3), stenosis (1), faecal incontinence (9), or severe constipation (4). All but 1 had a huge megarectum with a poor anorectal angle and stool impaction, causing overflow incontinence. After revision surgery, marked improvement occurred in 7 and at least some improvement was achieved in the remaining 5. Previous severe constipation resolved in 2 and improved in another 2 children. The number of soiling episodes significantly decreased in 8 patients: while before surgery 8 had been wearing nappies all the time, only 2 use them postoperatively. The anorectal prolapse has resolved in 3 and sensation improved in 5, and as a group, there has been a reduced need for laxatives and rectal washouts. The favourable outcome of our patients confirms that PSARP is an excellent technique for revision surgery, and tapering of a secondary megarectum plus the formation of an anorectal angle can produce clinical improvement, even in more severe forms of ARM. Accepted: 7 February 2001     

Rectosigmoid ectasia associated with anorectal anomaly repair: experience with sigmoid anterior resection and endorectal pull-through.

PURPOSE: Surgical treatment of anorectal anomalies may be followed by severe constipation with or without overflow incontinence secondary to dilation and ectasia of the rectosigmoid. The aim of this study is to evaluate the efficacy of anterior resection and endorectal pull-through for the treatment of rectosigmoid ectasia secondary to posterior sagittal anorectoplasty (PSARP). MATERIAL AND METHOD: Seven patients with a history of PSARP presented with serious rectosigmoid ectasia and overflow incontinence of fecal impaction. Four were boys and 3 were girls aged from 16 months to 15 years. Preoperative diagnosis was based on physical examination, barium enema, MRI and rectal biopsy. Surgical treatment of the post-PSARP rectal ectasia was made by anterior resection of the ectatic segment of the sigmoid combined with pull-through of normal colon into the mucosectomized ectatic rectum. RESULTS: During a four-to ten-year follow-up period all of our patients had normal bowel movements. Postoperative barium enema radiography demonstrated a normal rectal caliber and manometry revealed normal anorectal motor function. CONCLUSIONS: The good postoperative results draw attention to the following. a) The aim of the surgical treatment of megarectum is to establish a neorectum with normal bowel. b) Resection of megasigmoid and pull-through of bowel with normal caliber into the mucosectomized ectatic rectum is an effective procedure in patients with post-PSARP rectosigmoid ectasia. c) The neorectum attains its reservoir function through a gradual process after resection and endorectal pull-through.     

不同型别的功能性便秘患儿肛门直肠测压对照研究

目的探讨功能性便秘（FC）患儿与健康儿童肛门直肠动力学差异,为其临床分型诊断及治疗提供依据。方法采用功能性胃肠病罗马Ⅲ诊断标准,收集2008年1月至2009年1月在第四军医大学唐都医院儿科门诊及住院的FC患儿为FC组。选取同期无消化系统症状,平日排便正常的健康儿童为正常对照组。采用不透光X线硫酸钡条测定结肠传输指数（TI）,依据TI将FC组分为出口梗阻型（OOC）亚组、慢传输型（STC）亚组和混合型（MIX）亚组。通过肛门直肠测压法分析FC各亚组与正常对照组肛门直肠动力学差异。结果研究期间FC组纳入25例,其中STC亚组10例,OOC亚组15例,未发现MIX患儿;正常对照组纳入10名。FC组与正常对照组肛门括约肌静息压差异无统计学意义（P＞0.05）。STC亚组肛门括约肌最大收缩压与正常对照组差异无统计学意义（P＞0.05）,OOC亚组肛门括约肌最大收缩压显著高于正常对照组及STC亚组（P＜0.05）。FC组直肠最低敏感量及最大耐受量均显著高于正常对照组（P均＜0.05）。STC亚组与OOC亚组直肠最低敏感量及最大耐受量差异均无统计学意义（P均＞0.05）。结论FC患儿存在明显的肛门直肠动力和感觉异常;OOC和STC患儿的肛门直肠动力学存在差异。肛门直肠测压检查对协助诊断FC有一定价值。     

结肠传输时间测定和直肠肛管测压在儿童便秘中的意义

目的　小儿便秘的病理生理基础目前尚不清楚,该文对结肠传输时间和直肠肛管测压在儿童便秘 中应用的意义进行初步探讨。方法　对28例便秘儿童(便秘组)和43例正常儿童(对照组)进行全胃肠传输时间 (TGITT)、左半结肠传输时间(LCTT)、右半结肠传输时间(RCTT)和直肠乙状结肠传输时间(RSTT)测定和直肠肛 管向量测压(包括肛管压力、向量容积和对称指数)。根据结肠传输时间是否超过对照组均值加两个标准差将28 例便秘儿童分为传输时间正常型便秘组和传输时间延长型便秘组。结果　便秘组儿童TGITT、LCTT和RSTT较对 照组均显著延长(92±56hvs29±8h,17±13hvs7±4h,62±29hvs13±6h)(P均<0.01),肛管最大收缩压显 著升高(216±44mmHgvs190±38mmHg)(P<0.05),对称指数显著降低(0.71±0.06vs0.84±0.08)(P< 0.05),两组RCTT正常。传输时间正常型便秘组和传输时间延长型便秘组儿童肛管最大压力、向量容积和对称指 数差异无显著意义。结论　便秘儿童的结肠传输功能和/或直肠肛管动力存在不同程度异常;无论结肠传输时间 正常与否,所有便秘患儿均应进行直肠肛管测压检查。     

Anorectal manometry results in defecation disorders.

Anorectal manometry and suction biopsy were carried out on 47 children with constipation or soiling, or both. Patients were divided into two groups. Group 1 (37 patients): functional faecal retention, group 2 (10 patients): functional faecal soiling without retention. Ganglion cells or normal acetylcholinesterase staining, or both, was demonstrated in all cases. Normal inhibition of internal sphincter could be achieved by rectal distension in all except 2 children with severe constipation. Resting sphincteric pressures, pressure responses, and conscious rectal sensitivity thresholds were similar in groups 1 and 2, but were increased compared with controls. In group 1 alone, the critical volume increased parallel with conscious rectal sensitivity threshold. Since the complete relaxation of internal sphincter occurs before conscious rectal sensation arises in children with soiling without retention, this may be an important factor, at least in some of the soilers.     

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。     

Investigations for incontinence and constipation after surgery for Hirschsprung's disease in children

Surgery for Hirschsprung's disease is associated with high rate of morbidity, in the form of either constipation or incontinence or a combination of the two. This study investigates the mechanisms responsible for incontinence and/or constipation following the pull-through operation for Hirschsprung's disease. There were 19 children (15 boys and 4 girls), who at the time of study; 16 had undergone Duhamel, 1 Rehbein, and 2 Soave operation. We classified patients according to their symptoms into 3 groups: Group A was incontinent of faeces; Group B was constipated and incontinent of faeces, and Group C was constipated only. The median age at referral was 6 years, and the median period after operation was 5 years. All patients were investigated by intestinal transit study, endoanal sonography and anorectal manometry. Group A had normal or rapid transit study, as opposed to Groups B and C, who had delayed-transit study. On endoanal sonography, all children had an intact internal and an external anal sphincter, below the level of pull-through operation. The anorectal manometry showed a significantly lower resting anal pressure in the incontinent Group A as compared to the constipated children with or without incontinence in Group B or C (38 mmHg versus 57 or 66 mmHg respectively). The rectal pressure was also significantly higher in children in Group A as compared to those in Group B or C (71 mmHg versus 42 or 36 mmHg). The ratio of rectal/anal pressure was higher in incontinent children in Group A, as compared to constipated children in Group B or C. Therefore, constipation can be caused by high anal resting pressure and a weak rectal peristalsis, while faecal incontinence can be secondary to poor compliance and elevated rectal pressure in the presence of normal or low anal sphincter resting pressure. Aperients are the mainstay of treatment of constipation, however, children with incontinence are more difficult to treat. We did not attempt to define the pattern of nerve plexus because of poor results of revision operation for residual hypoganglionic segment and intestinal neuronal dysplasia. Treatment of these children can become more rational, if furnished with detailed functional studies. We advocate investigation of the anorectal function at an early stage in symptomatic children after surgery for Hirschsprung's disease, and less invasive treatment should be considered before embarking on major surgery.     

Treatment of chronic functional constipation in children by administration of vegetable fiber (Dicoman 5)

Chronic functional constipation is a common clinical disorder in pediatric age. Thirteen children with functional constipation were treated by administration of vegetable fibres together with a toilet training program, for two months. In each patient anorectal manometry showed presence of inhibitory anal reflex and diagnosis of constipation was confirmed by a prolonged gastrointestinal transit time measured by radio-opaque markers. In all patients there was a significant improvement in both stool frequency and intestinal transit time; furthermore, a normalization of anorectal motility variables was observed at rectal manometry. No changes in the blood levels of nutritional parameters were seen in any patient. It is concluded that vegetable fibres represent an effective treatment of functional chronic constipation in children.     

Colonic transit times and behaviour profiles in children with defecation disorders.

AIMS: To evaluate children referred for defecation disorders using the child behavioural checklist (CBCL). METHODS: A total of 215 patients were divided into three groups: 135 (5-14 years of age) with paediatric constipation (PC), 56 (5-17 years) with functional non-retentive faecal soiling (FNRFS), and 24 (5-16 years) with recurrent abdominal pain (RAP). Behavioural scores were correlated with colonic transit time (CTT) and anorectal function parameters (manometry and EMG). RESULTS: No significant differences in the mean CBCL scores were found among the three patient groups. However, children with PC and FNRFS had significantly more behavioural problems than the Dutch normative sample, while children with RAP had scores within the normal range. No significant differences were found between CTT in the patient groups, with respect to the CBCL. Similarly, no significant difference existed between children able or unable to relax their pelvic floor muscles during defecation attempts and their behaviour profiles. CONCLUSION: There seems to be no relation between colonic/anorectal function and specific behavioural profiles. On the other hand, children with defecation disorders show more behavioural problems than do controls.     

Colonic transit times and behaviour profiles in children with defecation disorders

Aims: To evaluate children referred for defecation disorders using the child behavioural checklist (CBCL). Methods: A total of 215 patients were divided into three groups: 135 (5–14 years of age) with paediatric constipation (PC), 56 (5–17 years) with functional non-retentive faecal soiling (FNRFS), and 24 (5–16 years) with recurrent abdominal pain (RAP). Behavioural scores were correlated with colonic transit time (CTT) and anorectal function parameters (manometry and EMG). Results: No significant differences in the mean CBCL scores were found among the three patient groups. However, children with PC and FNRFS had significantly more behavioural problems than the Dutch normative sample, while children with RAP had scores within the normal range. No significant differences were found between CTT in the patient groups, with respect to the CBCL. Similarly, no significant difference existed between children able or unable to relax their pelvic floor muscles during defecation attempts and their behaviour profiles. Conclusion: There seems to be no relation between colonic/anorectal function and specific behavioural profiles. On the other hand, children with defecation disorders show more behavioural problems than do controls.     

经肛巨结肠根治术后患儿的肛肠功能评价

目的：经肛门巨结肠一期根治术近期效果好,但术后患儿的肛肠功能目前尚不十分清楚。该文旨在评估患儿术后的排便模式,结肠和肛门括约肌功能。方法：对58例经肛门巨结肠根治术后半年以上儿童进行随访,随访时间为15.8 月 (6～24 月)。并进行排便功能问卷调查、钡灌肠、结肠传输时间和肛门直肠测压检查。33例正常儿童作为对照。结果：大多数随访患儿排便正常,无任何临床症状。４例出现稀便便频,9例污便,5例便秘,3例小肠结肠炎。钡灌肠结果显示大多数随访患儿结肠形态恢复良好。全部病例术后直肠肛管角（度）较对照组显著开大,有症状组较无症状组显著开大。58例随访患儿的平均全胃肠、左半结肠和右半结肠传输时间较术前显著缩短,与对照组相比差异无显著性意义。直肠肛管反射5例阳性。便秘组的肛管最大静息压和最大收缩压明显高于无症状组和对照组。污便组向量容积和对称指数较对照组显著降低。便秘组对称指数显著高于对照组。结论：经肛门巨结肠根治术后大多数患儿排便功能、结肠功能和括约肌功能良好。少数病例排便功能障碍可能与术后乙状结肠曲减少或消失、“新直肠”储便功能代偿不全和拖出结肠致直肠肛管角开大、肛门括约肌痉挛失弛缓有关。［中国当代儿科杂志,2007,9（3）：188-192］     

以难治性便秘为主要表现的儿童结肠冗长症诊断及治疗进展CSCD

难治性便秘是指经保守治疗3个月无效的胃肠运动障碍性疾病,患儿常并发结肠冗长症。结肠冗长症表现为长期便秘和大量粪便潴留,进而造成肠道蠕动障碍,严重影响患儿生长发育及生活质量。通过灌肠造影可判断结肠定位及形态是否异常,结肠传输试验、肛门直肠测压、结肠测压、组织病理学检查可辅助诊断难治性便秘。目前,以难治性便秘为主要表现的结肠冗长症如长期保守治疗无效,应采取顺行节制性灌肠、骶神经刺激以及手术治疗。本文对以难治性便秘为主要表现的儿童结肠冗长症的诊断与治疗进展进行综述。     

Effects of herbal medicine Dai-Kenchu-to on anorectal function in children with severe constipation.

AIM: We administered the herbal medicine Dai-Kenchu-To (DKT) to children with severe chronic constipation or with severe constipation after surgery for anorectal malformations. We then objectively assessed the effect of DKT on anorectal function by manometric study in addition to using a clinical scoring system. PATIENTS AND METHODS: Ten children with severe chronic constipation and 5 children with severe constipation after surgery for anorectal malformations were assessed. These 15 children received 0.3 g/kg/day of DKT for periods ranging from 3 months to 1 year. We objectively assessed their bowel function, sphincter function and rectal reservoir function by anorectal manometry and clinical scoring. RESULTS: In 10 children with severe chronic constipation, the clinical score after administration of DKT (7.2 +/- 0.8) improved significantly compared with that before administration of DKT (4.6 +/- 2.9) (p < 0.02). The threshold sensation volume and the maximum tolerable volume after administration of DKT significantly (p < 0.05; p < 0.01) decreased (128 +/- 63 ml vs. 69 +/- 18 ml; 229 +/- 99 ml vs. 144 +/- 47 ml), and rectal compliance after administration of DKT also significantly (p < 0.05) decreased (12.4 +/- 10.9 ml/cmH(2)O vs. 4.7 +/- 3.9 ml/cmH(2)O). CONCLUSION: The present study demonstrated that DKT had a favorable clinical effect on severe constipation in children, and anorectal manometry showed an improvement in their rectal reservoir functions. It appears that the results were secondary to DKT-stimulated peristalsis of the intestine, which promoted regular bowel habits.     

Thickening of the internal anal sphincter in idiopathic constipation in children

Thickening of the internal anal sphincter (IAS) is observed in chronic idiopathic constipation (IC) and solitary rectal ulcer syndrome (SRUS), where it has been correlated with the presence and severity of rectal intussusception. Alternatively, thickened IAS may be a feature of the obstructed megarectum in a similar way to the hypertrophy of bladder neck seen in dyssynergic bladders. The aim of this study was to investigate the significance of thickening of the IAS in children with chronic IC and to determine any association between the thickened IAS and anorectal manometry findings and patient's symptoms. A total of 144 children were admitted for investigations and treatment of chronic IC and evaluated prospectively between April 2001 and April 2003. IAS thickness was measured by endosonography using B&K axial endosonic probe type 1850 with a 10-MHz rotating transducer. The thickness of IAS was measured at 3, 6, and 9 o'clock, and the mean value of the three measurements was used for analysis. Functional assessment was done by anorectal manometry pressure studies under ketamine anaesthesia. A validated symptom score (SS) was used to assess the severity of symptoms. The sum of SS ranged between 0 and 65. Spearman's rho two-tailed test was used to correlate the thickness of IAS with patients' symptoms and anorectal manometry findings. Results were expressed as median and range and p-value of less than 0.05 was considered significant. Of 144 children, 84 were boys, median age 8.1 years (range 3.1-15). Soiling was present in 137 (94%) patients, delay in defecation in 132 (91%), and a palpable megarectum on abdominal examination in 117 (80%). The median duration of symptoms and duration of laxative treatment were 4 years (range 0.3-14.5) and 3.3 years (0.2-13.5), respectively. The average severity score for soiling, delay in defecation, palpable megarectum, and the total SS were 8 (range 0-10), 5 (0-10), 2 (0-12), and 33 (11-51), respectively. The median thickness of IAS was 0.9 mm (range 0.3-2.8) and the median resting anal sphincter pressure was 54 mmHg (19-107). The median amplitudes of rectal and anal sphincter contraction were 3 mmHg (1-25) and 9 mmHg (1-35), respectively. The thickness of IAS correlated significantly with total symptom severity score (r=0.31, p=0.0001), soiling score (r=0.28, p=0.001), megarectum score on abdominal palpation (r=0.29, p=0.001), size of megarectum on manometry (r=0.36, p=0.0001), amplitude of rectal contraction (r=0.23, p=0.007), and age of patient (r=0.55, p=0.0001). There was also a significant correlation between the amplitude of rectal and anal sphincter contraction (r=0.32, p=0.0001). There was no correlation between thickness of IAS and resting anal sphincter pressure and amplitude of anal sphincter contraction on anorectal manometry study. A total of 24 children had myectomy of thickened and overactive IAS in addition to the medical treatment of their chronic IC. The histology examination of myectomy specimen with eosin and haematoxylin staining and histochemical acetylcholine esterase staining showed smooth muscle fibres and ganglion cells. Thickening of IAS correlates significantly with duration and severity of symptoms, size of megarectum, and amplitude of rectal contraction. The pathogenesis is secondary to the continuous presence of faeces in the rectum, resulting in chronic abnormal stimulus to the IAS, which leads to hypertrophic changes in the rectum wall and IAS.     

Outcome of functional constipation in childhood: a 10-year follow-up study

OBJECTIVES: To assess the outcome of patients presenting with functional constipation in childhood during a 10-year period and to determine any risk factors for developing persistent constipation throughout adolescence and adulthood. PATIENTS AND METHODS: 72 children (mean age 4 years; 40 boys) referred for constipation were included in a longitudinal set of observations. Initial workup included segmental colonic transit time and anorectal manometry; 45 of the 72 patients could be reevaluated 10 to 12 years later. RESULTS: 21 of 45 patients (46%; 95% confidence interval 29% to 67%) remained constipated at follow-up. Encopresis and recurrent abdominal pain were present in 25% and 56% of patients, respectively. Patients with anorectal dyssynergia remained more frequently constipated at follow-up than the others: 61% versus 29% (P < .05). CONCLUSION: Almost 50% of patients presenting with constipation during childhood remained constipated on long-term follow-up. Anorectal dyssynergia is associated with a worse prognosis.     

Rectal manometry in patients with isolated sacral agenesis

OBJECTIVE: The authors evaluated rectal manometry of children with sacral root abnormalities secondary to isolated sacral agenesis. METHODS: The anorectal manometric recordings of seven patients with isolated sacral agenesis (four with partial agenesis and three with complete agenesis) were retrospectively evaluated and compared with tracings from healthy control subjects. Characteristics of the internal anal sphincter (IAS), the rectoanal inhibitory reflex (RAIR), voluntary external anal squeeze pressure, and threshold of rectal sensation to distension were analyzed. Characteristics of the patients' neurologic function with attention to urinary and fecal continence were obtained by chart review. RESULTS: All seven patients had urinary and fecal incontinence. IAS resting pressure was the same in patients and control subjects. In the three patients with total sacral agenesis, IAS relaxation was more complete and lasted longer after balloon distention of the rectum. These patients also had significantly lower voluntary external anal squeeze pressure and blunted sensation of rectal distension. CONCLUSIONS: Abnormal parasympathetic innervation associated with sacral agenesis is associated with changes in anorectal function. Manometric findings suggest that there is modulation of the RAIR by extrinsic innervation, which may explain the fecal incontinence in these patients.     

Evaluation of dysfunction following reconstruction of an anorectal anomaly

To evaluate the utility of anorectal manometry (ARM) and magnetic resonance imaging (MRI) with an endocoil in the assessment of dysfunction in children with repaired anorectal anomalies (ARA), 15 patients aged 1 to 15 years with repaired ARAs and chronic faecal incontinence or constipation were prospectively recruited. They underwent clinical assessment using a modified Wingfield score (MWS). ARM and MRI with an endocoil and conventional external coil were carried out. The results of ARM alone, MRI alone, and a combination of ARM and MRI were correlated with the MWS. Manometric internal anal sphincter (IAS) scores determined from sphincter length and activity correlated with MWS (r = 0.56, P = 0.02); manometric scores of rectal peristaltic activity did not. Overall manometric score (IAS and rectal scores combined) showed a correlation with MWS (r = 0.55, P = 0.02). Endoanal MRI sphincter scores did not correlate with MWS, but the presence of a megarectum on MRI did (r = 0.44, P = 0.05). Overall MRI score did not correlate with MWS. Minor neurosacral anomalies were shown on MRI in 3 children who had poor functional scores. Combined manometric and MRI scores showed a correlation with MWS (r = 0.58, P = 0.01). ARM and MRI are potentially useful in the assessment of dysfunction of children with repaired ARAs. Both modalities require refinement and further assessment in the context of directing management.