Anal endosonography in children with chronic constipation

Background. Hypertrophy of the internal anal sphincter may be apparent in some children, but its significance has not yet been determined. Objective. To assess anal endosonographic findings in children with chronic constipation. Materials and methods. We performed anal endosonography in 46 children with chronic constipation and compared the results with values considered normal. Results. We did not find a significant relationship between age and thickness of the internal or external anal sphincters. The clinical response to medical management did not differ between patients with or without sphincter hypertrophy. Conclusions. Although we did not find a significant correlation between sphincter hypertrophy and constipation or age, further studies may clarify its place amongst other techniques which are used in the investigation of anorectal pathology. Received: 22 December 1997 Accepted: 15 June 1998     

儿童功能性便秘肛门直肠动力学分析

<正>功能性便秘(functional constipation,FC)是儿童消化系统较为常见的症候之一,以持续性或间断性排便困难,粪质坚硬而不伴有腹部不适或腹痛为主要表现。其发病机制仍不十分明确,治疗效果欠佳。目前国内外均有报道,直肠动力和感觉功能变化在很多FC患儿中均有异常,推测肛门直肠动力及感觉异常可能是FC产生的基础。为探讨FC发生与肛门直肠动力学异常之间的关系,本研究将30例FC患儿与30例健康儿童的肛门直肠动力学改变进行比较,报道如下。     

The impact of constipation on growth in children

The observation on the impact of constipation on nutritional and growth status in healthy children was never reported. During a 4-y period, we evaluated the consequence of constipation on growth in children. The enrolled children were aged between 1 and 15 y with constipation. Medical response of constipation to treatment was evaluated by the scoring of constipation symptoms. The correlation of therapeutic effect of constipation with growth status at 12 wk and 24 wk was statistically evaluated. About 2426 children (1284 boys, 1142 girls) with a mean age of 7.31 +/- 3.65 (range 1.1-14.9) y were enrolled. After 12-wk treatment, significant increase of z-scores of height-for-age, weight-for-age, and body mass index-for-age were all found in patients with good medical responses (1377 cases) than in those with poor medical responses (1049 cases). The 1049 patients with poor medical response received advanced medications; significant increase of z-scores of height-for-age, weight-for-age, and body mass index were also found in these patients. A marked increase of appetite was significantly correlated with better gain on height and weight after treatment. We conclude that chronic constipation may retard growth status in children, and a long-term medication for constipation in children appears beneficial to their growth status.     

小麦纤维素颗粒对功能性便秘患儿肛门直肠压力的影响

目的探讨小麦纤维素颗粒对学龄期功能性便秘患儿的疗效。方法选择2009年9月至2011年2月就诊的48例学龄期功能性便秘患儿,予小麦纤维素颗粒口服治疗3周,观察疗效;并于治疗前后检测直肠肛门压力。另选择10例健康正常儿童作为对照组观察。结果 48例功能性便秘患儿服用小麦纤维素颗粒后,43例便秘症状消失或改善,总有效率89.58%。48例便秘患儿治疗前的直肠感知阈值及直肠最大阈值明显高于正常对照儿童,差异有统计学意义(P<0.05);36例便秘患儿完成治疗前后直肠肛门测压检查,治疗前后的肛管静息压及肛管最大缩榨压差异无统计学意义(P>0.05);治疗后的直肠感知阈值较治疗前降低,直肠最大容量阈值也较治疗前明显降低,差异均有统计学意义(P<0.05)。结论小麦纤维素颗粒可降低肛门直肠压力,可用于学龄期儿童功能性便秘的治疗。     

儿童功能性便秘的X线排便造影表现及临床意义

目的 探讨功能性便秘儿童的X线排便造影表现及其对便秘分型和病因探讨的意义.方法 2000年6月～2007年2月将研究对象分为对照组和便秘组.对照组28例,男9例,女19例,平均年龄5岁.便秘组96例,男35例,女61例,平均年龄6.5岁,均符合儿童便秘罗马Ⅱ标准.对所有儿童进行钡剂X线排便造影检查,探讨其影像学表现.结果 X线排便造影显示耻骨直肠肌痉挛综合症21例:排便状态下直肠肛管角不开大,直肠后壁耻骨直肠肌压迹加深;肛门外括约肌痉挛9例:直肠肛管角正常开大,但会阴下降不明显,肛管前壁出现指状压迹;肠疝(包括小肠疝和结肠疝)10例:小肠或结肠下端疝入直肠膀胱陷凹,压迫直肠前壁;直肠黏膜脱垂和套叠8例:排便时肛管上方出现直肠黏膜影像;直肠前突3例:排便时直肠前壁向前方突出深度超过2 cm;会阴下降综合征3例:盆膈摆动幅度大,下降时超过2 cm;盆底痉挛综合征4例:表现为"鹅征".结论 功能性便秘儿童的X线排便造影表现因病因不同表现各异,多数类型具有典型影像学特点.X线排便造影可用于区分出121梗阻型便秘的病因与分型,方法简单易行,可作为儿童功能性便秘的常规检查项目.     

Gastrointestinal transit in children with chronic idiopathic constipation

Abstract  Chronic constipation in children is common and produces significant morbidity. Identification of the site of dysmotility in constipation may determine the cause and permit directed management. Scintigraphy differentiates constipated patients with anorectal hold-up from those with colonic slowing. Adults with colonic slowing demonstrate variation in the site of hold-up. However, in children with colonic slowing, variability in the site of hold-up has not been investigated. Purpose  The current study aimed to characterise colonic transit patterns in 64 children with chronic idiopathic constipation. Methods  Scintigraphic images were grouped visually by their transit patterns. Intra-observer variation was assessed. Scintigraphic data were analysed quantitatively. Results  Visual analysis of scintigraphy studies demonstrated normal transit (11/64), anorectal hold-up (7/64) and slow colonic transit (46/64). Transit characteristics in the slow transit group demonstrated three possible subgroups: pancolonic slowing (28/46), discrete hold-up in the transverse colon (10/46) and abnormal small and large bowel transit (8/46). Kappa testing demonstrated consistent characterisation (k = 0.79). Statistical analysis of scintigraphic data demonstrated highly significant differences from normal (P < 0.001) in the subgroups. Conclusion  Scintigraphy demonstrates three possible transit patterns in children with chronic constipation secondary to slow colonic transit.     

生物反馈治疗小儿功能性便秘的疗效研究

目的 评价生物反馈治疗盆底肌协调障碍引起的小儿功能性便秘的疗效.方法 对47例肛门直肠动力检查提示盆底肌协调障碍的功能性便秘患儿进行生物反馈治疗,每周2次,对完成3次及以上生物反馈治疗者进行了疗效分析.结果 共有27例患儿完成至少3次生物反馈治疗,其中男20例,女7例,年龄4～12岁[(6.7±2.2)岁],病程6个月～8年[(3.0±2.3)年].共完成5次生物反馈治疗者有16例,完成7次生物反馈治疗者8例.随着生物反馈治疗次数增加,直肠最大排便压力(mm Hg,1 mm Hg=0.133 kPa)增高,治疗前和治疗3、5、7次后依次为36.2±10.4,45.1±9.5,47.6±9.1,47.8±8.8(P<0.01),而肛门外括约肌肌电值逐渐下降,但差异无统计学意义.治疗后通过电话随访3个月至1年,根据排便症状改善情况进行疗效评定.27例患儿中治愈13例,显效8例,有效3例,无效2例,失访1例,总有效率88.9%(24/27).结论 生物反馈疗法可提高最大排便压力,能有效地治疗盆底肌协调障碍引起的儿童功能性便秘.     

Slow transit constipation in children

Patients with chronic constipation that fails to respond to treatment remain a challenge for paediatricians and surgeons. Ongoing work in our institution suggests that a number of children with intractable symptoms have slow transit constipation, which has only been described recently in paediatrics. Common features of slow transit are: delayed passage of the first meconium stool beyond 24 h of age, symptoms of severe constipation within a year, or treatment-resistant 'encopresis' at 2-3 years, soft stools despite infrequent bowel actions, and delay in colonic transit on a transit study. A proportion of children with slow transit constipation have an abnormality of intestinal innervation associated with the dysfunctional colonic motility, recognized as intestinal neuronal dysplasia (IND). Intestinal neuronal dysplasia type B, the most common variant of IND, is defined on rectal biopsy by hyperplasia of the submucosal plexus. On laparoscopic colon muscle biopsy, many specimens show reduced numbers of excitatory substance P-immunoreactive nerve fibres in the circular muscle. Functional markers of the nerves allow new diagnostic criteria to be developed which may also allow a more rational approach to treatment. The aetiology remains obscure and the optimal management poorly defined, although subtotal colectomy, proximal colostomy or appendicostomy (for antegrade enemas) have been tried. Once the anatomy and physiology of the colon in children with slow colonic transit is better understood, we will have defined not only a new form of constipation, but also will be able to consider new therapies.     

大龄儿童便秘的手术治疗

目的 了解手术治疗大龄儿童便秘的远期疗效.方法 回顾性分析14例大龄便秘儿童(年龄大于10岁)在我科手术治疗的临床资料,并对其进行随访.随访内容包括每日大便次数及大便性质.结果 14例患儿男9例.女5例.年龄10～18岁.平均12.8岁.术后病理诊断为先大性巨结肠症9例,IND2例、乙状结肠冗长2例、神经节细胞减少症1例.结肠部分切除、结肠肛管心形吻合10例,Soave手术3例,改良Rehbein手术1例.所有患儿术后均痊愈出院.无吻合口瘘、吻合口狭窄.1例IND在腹腔镜辅助下行结肠部分切除、结肠肛管心形吻合术,术后便秘复发,再次手术后大便轻度失禁.其余患儿术后随访2～12年.大便均成形,1日1次者7例.1日2次者3例,2日1次者3例,1日3次者1例.术后有4例发生肠炎,均经保守治疗后痊愈.结论引起大龄儿童便秘的原因多种多样.根据不同病因采用相应的手术方法 治疗大龄儿童便秘可取得满意的疗效.     

Encopresis and constipation in children

Chronic retentive constipation in children is common, often undertreated, and frequently resistant to standard treatment. A new understanding of abnormal defecation dynamics has evolved to complement the established medical behavior model of this condition. The primary care pediatrician is in an excellent position to facilitate prevention through counseling on normal bowel habits and early intervention. A comprehensive medical behavior intervention program can be supervised effectively by the pediatrician providing benefit to most patients. Those who are compliant with treatment and are resistant to intervention may benefit by extensive evaluation of anorectal dynamics and use of such teaching as biofeedback training.     

儿童功能性便秘相关检查的研究进展

功能性便秘(FC)是儿童时期的常见病、多发病。临床诊断除了要符合便秘的诊断标准,完善一般常规检查外,还需进一步行胃肠传输时间测定、肛门直肠测压及结肠镜等相关检查以除外其他原因造成的便秘。文章介绍几种便秘相关检查的最新研究进展,为临床医师提供一定的指导与借鉴。     

先天性肛门直肠畸形术后便秘合并巨结肠的临床特点及处理

目的 总结先天性肛门直肠畸形术后顽固性便秘合并巨结肠的临床特点和治疗效果.方法 回顾性分析2005年8月至2010年7月收治的顽固性便秘合并巨结肠23例临床资料,男10例,女13例.首次手术年龄3 d至6岁,术前诊断均为中低位肛门直肠畸形.23例患儿均以肛门成形术后便秘就诊.下消化道气钡造影显示下端结肠及直肠扩张,无移行段,排钡延迟.本次手术年龄1岁2个月至15岁8个月.均采用Soave巨结肠根治术.结果 术前见肛门外观大致正常13例,外观正常合并直肠尿道瘘1例,肛门开口位置前移6例,瘢痕回缩2例,肛门外口狭窄1例.术中进入盆腔后即为扩张肠管,系膜增生增厚,肠壁血管增生粗大.13例单纯经会阴手术,10例经腹会阴手术,其中1例同时回肠末端造瘘.9例巨结肠切除同时,再次行肛门成形术,1例巨结肠切除同时行前矢状入路直肠尿道瘘修补术.病理检查15例切除肠管远近段,可见神经节细胞者,8例肠管远端无神经节细胞者,23例均见肌层增生肥厚,肌纤维变性,肌层排列紊乱.二次术后随诊肛门功能李氏评分5～6分.结论 先天性肛门直肠畸形术后顽固性便秘往往并发巨结肠改变,影像显示为肠管局限性扩张、僵硬和动力紊乱.采取手术治疗,切除病变肠管,做必要的肛门解剖缺陷修复,术后效果良好.

Abstract：

Objective To summarize the experience of diagnosis and treatment of intractable constipation in children with repaired anorectal malformation.Methods Between August 2005 and July 2010,23 children with a history of anorectal malformation (ARM) repair were diagnosed with intractable constipation,and underwent surgical treatment at this center.The patients,including 10 boys and 13 girls,underwent primary surgeries to repair low or intermediate type of ARMs.Their ages at the primary surgery ranged from 3 days to 6 years old.Physical examinations found normal appearance of anus on 14 children including 1 with rectourethral fistula,anus antelocation on 6,cicatricial retraction of anus on 2,and anal stricture on 1.The positive barium enema revealed the dilated distal colon and rectum without transition zones,and delayed barium transit time.The patients' age at the second surgery ranged from 1 year and 2 months to 15 years and 8 months old.Results Dilated distal colon and rectum,with increased intestinal wall and mesentery thickness as well as proliferated blood vessels,was found during surgery on all patients.However,no transition zone was observed.To remove the dilated intestine,transanal Soave procedure was performed on 13 children,and the other 10 underwent abdomino-perineal Soave procedure including 1 had additional ileostomy.Besides the megacolon resection,9 patients also underwent anoplasty,and rectourethral fistula was also repaired on 1 patient.At the distal end of the removed intestine,pathological examination revealed ganglion cells in 15 patients,and no ganglion cells in 8 patients.Hypertrophy,degeneration and derangement of the intestinal smooth muscle cells were also observed.After reoperation,patients' anal function was graded as 5 or 6 according to Lizheng's anal function scoring criteria.Conclusions Intractable constipation after ARM repair is usually caused by acquired megacolon.It can be cured by megacolon resection.