Dr. Jose Garza joined our group in 2013 and has been providing excellent care for children throughout the South with suspected motility disorders. Recently, he gave our group a fabulous update on what’s new in motility.  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

FLIP -How Distensible is the Esophagus

• Distensibility index less than 2 mm2/mmHg is considered abnormal.
• Normal FLIP (presence of RACs and normal Distensibility Index) can obviate need for high resolution esophageal manometry (HREM)
• FLIP during anesthesia can only be done with certain medications: versed, fentanyl and propofol (no gas)
• FLIP  is useful  in evaluating if symptoms after achalasia treatment, during achalasia treatment (dilatation or Heller), if symptoms after fundoplication, and if manometry uncertain

IB-Stim

• Good results in improving pain, sleep, nausea and function
• Could be a 1st line treatment though cost can be an issue
• Related posts: IB-Stim (Neuro-Stim) for Adolescents with Irritable Bowel, Auricular Stimulation Associated with Less Pain, Less Disability, and Better Sleep, Neuro-Stim for Refractory Cyclic Vomiting?

Unable to Belch ( (Retrograde Cricopharyngeus Dysfunction)

• Inability to burp can be due to retrograde cricopharyngeal dysfunction. Symptoms can include chest pain, gurgling noises, bloating
• HREM can show UES not relaxing/air trapping in esophagus after carbonated beverage challenge.
• Treatment: ENT can inject botox to UES. This is usually a one-time therapy which may help stop a learned behavior.
• Related JPGN article: Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry. Dorfman L, El-Chammas K, Mansi S, Graham K, Kaul A.

Sitz Markers

• Guideline published suggest single xray on day 5 (usually off treatment). Cleanout recommended (especially if impacted)
• Useful for non-retentive fecal soiling as well

Vibrating capsule

• Adult study showed efficacy for constipation
• Related post; Price Per Poop with Vibrating Capsule and New AGA Constipation Guidelines

Fecobionic

• Emerging technology to help provide more data on defecation dysfunction

Medications:

• Linaclotide effective in randomized controlled-trial of children (dose 72 mcg). In this study, 6-11 yr olds had better response and it is possible that a higher dosage would be more effective in adolescents. Safe profile -can cause diarrhea. Related post: Linaclotide -Now FDA-Approved for Children
• Gabapentin shown to have similar effectiveness as baclofen for chronic cough.
• Baclofen is being used more frequently as an adjunct with rumination. Related posts: Most Kids with Rumination Respond to Specialized Treatment, Baclofen for Rumination
• Prucalopride helps with esophageal peristalsis, upper GI symptoms  and with constipation. There was a negative pediatric study for treatment of constipation but the study enrolled a lot of younger patients (not likely helpful in overcoming withholding). Insurance coverage often precludes use in younger age group. Related post: Prucalopride -Not Better Than Placebo for Children with Constipation
• Mirtazapine has been helpful for chronic nausea. The typical starting dose in teens 15 mg at bedtime. (related posts: Mirtazapine for Functional Dyspepsia, Dreaded Nausea (2022) Plus Skills or Pills)

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