A recent review (S Rajindrajith et al. JPGN 2021; 72: 794-801. Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management) provides a quick review of fecal incontinence in children but one part left me unsettled.

Under the section titled, “Clinical Evaluation,” the authors state the following:

“Digital examination of the rectum is not needed as general history and examination reveal the diagnosis in most cases; however, in case of diagnostic uncertainty, digital examination should be performed and can provide information about the integrity of the spincter complex…the presence of a large fecal mass helps to differentiate between constipation-associated FI [fecal incontinence] and FNRFI [functional nonretentive fecal incontinence].”

Of course, there are many situations in which a rectal exam should be deferred. But I think it is a big mistake to state in a leading pediatric GI journal that the default position is that a rectal exam is unnecessary. Here’s why:

1. A rectal exam is the best way to determine if a patient needs a ‘cleanout’ prior to a routine management plan.
2. A rectal exam can help avoid unnecessary hospitalizations. I have been made aware of patients in the inpatient setting who have been subjected to cleanouts when they did not need this. Unnecessary cleanouts for outpatients also happen. This can occur in children with irritable bowel syndrome who are having regular bowel movements and are told by practitioners that they are backed up due to flimsy evidence (like a normal abdominal xray).
3. A rectal exam does not add any additional costs to the evaluation. Later in this same review the authors describe many potential expensive investigations including colonic transit studies, anorectal or colonic manometry, and MRI of lower spine. Is it really a good idea to order any of these tests without completing a rectal exam first?
4. The article also reviews potential treatments beyond fiber and pharmacology including psychological interventions, transanal irrigation, botulinum toxin injection, antegrade continence enemas, bowel resection and neuromodulation. In my view, none of these should be undertaken prior to a rectal exam.

The review does state that guidelines recommend against using plain abdominal X-ray for evaluation for defecation disorders, noting that “the sensitivity and specificity are not sufficient to provide the required diagnostic accuracy.”

My take: I fundamentally disagree with the premise that a rectal exam is NOT part of the routine evaluation of children with defecation disorders.

Related blog posts:

• What’s Wrong with Ordering an AXR for Constipation in the ER …
• Improving ER Performance for Suspected Constipation | gutsandgrowth
• Soap Suds Enemas & ED Management of Impactions | gutsandgrowth
• Prucalopride -Not Better Than Placebo for Children with Constipation | gutsandgrowth
• Don’t Let the Chief of Staff Review This Constipation Study | gutsandgrowth
• Refractory Constipation -Terrific Update | gutsandgrowth
• Diagnosis and Misdiagnosis of Constipation
• Key to Reducing Unnecessary AXRs: Individualized Metrics | gutsandgrowth
• Diagnostic tests hardly ever help patients poop | gutsandgrowth
• Updated Pediatric Expert Constipation Guidelines | gutsandgrowth

Picture below from “Robert Is Here” Fruitstand (Homestead, FL)

Summary from AGA website: New AGA guidelines on the medical management of moderate-to-severe Crohn’s disease (see below for main takeaways). These guidelines are for adults.

Fulltext Guideline: JD Feuerstein et al. AGA Clinical Practice Guidelines on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn’s Disease. DOI:https://doi.org/10.1053/j.gastro.2021.04.022

Resources:

• Technical review
• Spotlight (infographic)
• Clinical decision support tool
• Commentary: Providing the Best Care for Patients with Crohn’s Disease: An Examination of the New AGA Clinical Practice Guideline on the Medical Management of Moderate to Severe Luminal and Fistulizing Crohn’s Disease

A good Sunday read: Full text: Mammalian enteral ventilation ameliorates respiratory failure (R Okabe et al. Med (2021), https://doi.org/10.1016/j.medj.2021.04.004) -thanks to a friend for forwarding the study.

Background: Several aquatic organisms such as loaches have evolved unique intestinal breathing mechanisms to survive under extensive hypoxia. Scientists hope that the approach could one day be used to treat people with low oxygen, without risking the lung damage that can be caused by mechanical ventilators. To date, it is highly controversial whether such capability can be adapted in mammalian species as another site for gas exchange. This study reports the advent of the intestinal breathing phenomenon in mammalians by exploiting EVA (enteral ventilation via anus).

This study showed that administration of oxygen-rich perfluorochemical liquid via the rectum could “increase oxygenation in several mammals including pigs. The level of arterial oxygenation, if scaled for human application, is likely sufficient to alleviate patients with severe respiratory failure. The administration of 200–400 mL PFD to pigs weighing 10–20 kg improved PaO₂ by 13 mm Hg (from 57.2 ± 13.5 to 70.8 ± 6.22 mm Hg) and SaO₂ by 7% (from 84% to 91%).”

NY Times review of this study: Breathing Through the Rectum Saves Oxygen-Starved Mice and Pigs

My take: It is good that this study was not published on April 1st! Perhaps, if this advances, this will be more work for our aerodigestive team.

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Some screenshots from a recent (5/19/21) ‘tweetorial’ on Magnet Safety:

More information on this topic from a previous Bowel Sounds Podcast with Bryan Rudolph (June 2020)

Also there’s a GIF (from Bryan Rudolph’s twitter feed):

Related blog posts:

• Outcome of Zen Magnets vs Consumer Product Safety Commission
• Hazardous Toys: Jarts and Magnets
• Today’s Children in Crisis: YOYO | gutsandgrowth
• NASPGHAN Statement on High-Powered Magnet Court Ruling
• Magnet ingestion -urgent removal needed | gutsandgrowth
• More on magnet ingestions | gutsandgrowth
• “Fatal attraction” | gutsandgrowth
• Button Battery Algorithm Link
• Magnetic Foreign Bodies –Still a Problem

Two recent studies show how infliximab improves outcomes in Crohn’s disease.

• P Bossuyt et al. Clin Gastroenterol Hepatol 2021; 19: 947-954. Infliximab Exposure Associates With Radiologic Evidence of Healing in Patients With Crohn’s Disease
• AAM Singer et al. Clin Gastroenterol Hepatol 2021; 19: 1071-1073. Factors Associated With Development of Perianal Fistulas in Pediatric Patients With Crohn’s Disease (see previous blog: Early Treatment with Anti-TNFs and Development of Perianal Fistulas)

The first study by Bossuyt et al was a substudy (n=36) of the TAILORIX trial. Key findings:

• At week 54 of treatment, 36.4% of patients had a radiologic response, 30.3% of patients were in remission, and 71% had endoscopic features of remission
• Radiologic remission correlated with infliximab trough level at week 14 (P = .049) when the infliximab trough level cut-off value was set at 7.8 μg/mL (area under the curve, 0.74; 75% sensitivity; 86% specificity; 90% negative predictive value; 57% positive predictive value)
• Radiologic response was also associated with continuous infliximab trough levels above 5.0 μg/mL at all time points) (P = .034)
• Among patients with both radiologic and endoscopic remission, the median infliximab trough level was 8.5
• In this study, one interesting finding was that only half of patients with endoscopic remission achieved radiologic remission, especially since the cohort had a short disease duration at the onset of treatment (median duration of 1.5 months)

In the second study by Singer et al with 208 pediatric patients with Crohn’s disease, all patients had baseline cross-sectional imaging. Key findings:

• 26% had perianal fistulas at baseline
• 14/136 (10%) developed perianal fistulas within 3 years
• Non-white race increased the risk of perianal fistula
• Non-penetrating perianal lesions (NPLs) increased the risk of perianal fistulas (20% in patients with NPLs vs. 4% in those without NPLs)
• Anti-TNF treatment was associated with a decreased risk of perianal fistulas (HR 0.11); this risk reduction was seen in patients with NPLs also (HR =0.14)

My take: Good infliximab levels correlate with better outcomes.

Related blog posts:

• Efficacy of Anti-TNF Agents for Internal Fistulas
• Video for Patients: Benefits and Risks of IBD Treatment
• Anti-TNF Therapy Associated with Reduced Surgical Resections
• RISK Study -CCFA 2017 Update
• Do Biologics Alter the Natural History of Crohn’s Disease in Children?
• Here’s the Proof That Proactive Drug Monitoring Improves Outcomes in Children with Crohn’s Disease
• Real-World Experience with Proactive Therapeutic Drug Monitoring in Inflammatory Bowel Disease
• Appropriate Proactive Therapeutic Drug Monitoring
• Briefly noted: Induction Infliximab Levels
• Is there good evidence for proactive therapeutic drug monitoring of anti-TNF therapy?
• Is Standard Infliximab Dose Too Low in Pediatrics?
• Can Therapeutic Drug Monitoring with Monotherapy Achieve Similar Results as Combination Therapy for IBD? | gutsandgrowth

And from The Onion: