JMJ van der Zande et al. J Pediatr Gastroenterol Nutr. 2026;82:980–987. Interrater reliability in pediatric high-resolution anorectal manometry recordings
This study analyzed the interpretation of 10 pediatric high-resolution anorectal manometry (HR-ARM) by 10 pediatric experts in neurogastroenterology, including one of my partners, Dr. Jose Garza.
Key findings:
There was only fair agreement among readings with regard to rectoanal inhibitory reflex (κ = 0.35), the bear down maneuver, and the final interpretation of the study either being normal or abnormal (κ = 0.50 and κ = 0.43, respectively).
There was excellent agreement with regard to assessment of the anal canal resting pressure, the squeeze pressure, as well as the squeeze duration
My take: This is a cautionary study indicating a high-rate of variability in the interpretation of key components of HR-ARM; the results are similar to a 2012 study of colonic manometry (see below). Thus, clinical context and supporting data (eg. histology) are quite important as well for clinical decision-making.
SO Larsen et al. J Pediatr Gastroenterol Nutr. 2026;82:425–433. Efficacy of low volume transanal irrigation in children with retentive fecal incontinence: A randomized controlled trial
Methods: Two-arm randomized controlled trial, including children (N=41) aged 4–14 suffering from retentive fecal incontinence. All included children were refractory to at least 2 months treatment with stool softening oral laxatives. Treatment duration was 6 weeks. The control group continued oral laxative therapy. The intervention group received low-volume transanal irrigation (L-TAI) as add-on.
Irrigations: “Irrigations were performed once daily with the Qufora IrriSedo MiniGo® Small system. According to the manufacturer the MiniGo® water pump contains 180 mL of water, with an estimated 20 mL residual water per use. Families were instructed to use 1 pump full of water to irrigate. If this did not result in defecation, they were instructed to refill and irrigate again.”
Key Findings:
In the intervention group, 75% were responders with 35% experiencing full response, while 33% in the control group were responders, with 4.8% experiencing full response
One limitation of this study, besides its sample size, is the type of laxative used prior to enrollment. Patients had been treated with PEG, magnesia or lactulose. These agents are not recommended for refractory constipation; high dose sennosides or bisacodyl have been recommended per recent position paper.
My take: Willie Sutton was a notorious bank robber who was famous for his quote (which he later denied) that he robbed banks “because that’s where the money is.” Similarly, for constipation, targeting treatment at the site of the “deposit” turns out to be an effective strategy. (I have no financial ties to the irrigation company.)
This was a case report of a 21 yo with chronic constipation and likely undiagnosed autism spectrum disorder hospitalized for severe fecal retention, unresponsive to nasogastric polyethylene glycol. He underwent a manual disimpaction but due to residual stool in more proximal colon, Neostigmine was administered with good results.
Methods: “The patient underwent manual disimpaction under general anesthesia with a large amount of hard stool removed from the rectum. He was noted to have ongoing abdominal distension with significant palpable stool more proximally. A trial of 1 mg intravenous (IV) neostigmine was given. This was done without anticholinergic co-administration due to his persistent tachycardia (HR ~ 120 s) and with close heart rate monitoring. Passive passage of stool occurred within 5 min of drug administration. Subsequently, neostigmine was titrated in additional 1 mg IV doses every 3–5 min. His heart rate remained above 90bpm. He received a total of four doses of neostigmine over 20 min. Each administration, combined with abdominal massage, produced large amounts of soft stool along with marked reduction in distension and palpable stool burden.
Before NG cleanout and disimpaction:
After NG cleanout and disimpaction/Neostigmine:
Pharmacokinetics:
” Neostigmine has been clinically utilized by anesthesiologists to reverse the effects of non-depolarizing neuromuscular blocking agents…In the gastrointestinal (GI) tract, the accumulation of acetylcholine in the neuromuscular junction of the small intestine and colon results in increased contractility and peristalsis, thus promoting defecation. Neostigmine is predominately administered intravenously with typical dose ranges from 0.03 to 0.07 mg/kg, up to maximum 5 mg. The peak effect typically occurs between 7 and 10 min, while the duration of action lasts approximately 55–75 min in adult patients…
Because of its cholinergic effects on the muscarinic receptors of the cardiac parasympathetic nervous system, neostigmine results in a significant decrease in heart rate. Therefore, when neostigmine is bolused to reverse non-depolarizing paralytics at the clinically appropriate dose (~3–5 mg IV), it is always co-administered with glycopyrrolate or atropine to prevent bradycardia at a 1:1 volume ratio.”
My take (borrowed from authors): “This case demonstrates that intravenous neostigmine can be a safe and effective adjunct to manual disimpaction in severe refractory constipation when administered in a monitored setting.”
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D Simon et al. J Pediatr Gastroenterol Nutr. 2026;82:407–414. Dolichocolon is common in pediatric gastroenterology patients with constipation and associated complaints
L Dorfman, A Kaul. J Pediatr Gastroenterol Nutr. 2026;82:320–322 Commentary. Dolichocolon in pediatric patients with constipation—The chicken or the egg?
Methods: In this retrospective study, a total of 155 contrast enemas were administered and then assessed for features of colonic redundancy consistent with dolichocolon (DC), based on a priori imaging (adult) criteria.
“DC was defined as: any portion of the sigmoid colon reaching above the iliac crest line (Type 1), and/or any portion of the transverse colon reaching below the iliac crestline with or without redundant flexures (Type 2)…We decided not to study Type 3 DC (i.e., redundant loops at the hepatic or splenic flexure, example shown in Figure 1A*) separately because that category was deemed to be arbitrary/imprecise.”
Key findings:
Consensus‐based identification (i.e., independent agreement among all three reviewers) of dolichocolon (DC) was observed in 74.1% of children under 2 years old and 88.6% of those aged 2–4 years presenting with constipation
The prevalence subsequently significantly decreased with age, with 68.8% in children aged 5–10 years and 47.6% in adolescents aged 11–17 years. “The pattern of decreasing prevalence of DC with age after 5 years is in contrast to findings in adult patients over 40 years with constipation, where DC frequency was found to increase significantly with age”
The vast majority (95.6%) of DC was Type 1; 3.5% was Type 2. 0.9% was both Type 1 and Type 2
The dashed line marks the iliac crest line [IC]; the gray arrow highlights the sigmoid colon reaching above the IC The blue arrow highlights the transverse colon falling below the IC
The editorial by Dorfman et al. notes that “dolichocolon has a long history in medical literature, but its exact role remains uncertain, presenting a classic “chicken or the egg” dilemma…Until more stringent pediatric-specific definitions and longitudinal evidence are acquired, clinicians should exercise caution in solely attributing symptoms to dolichocolon…While dolichocolon may play a role, it is unlikely to be the sole cause.”
My take: I had to read the article because I was not familiar with the term “dolichocolon.” The authors, though, summarize the key point: “the clinical relevance of this radiologic finding is not completely understood.” As a separate matter, a pediatric study on how a dolichocolon affects colonoscopy would be interesting; presumably, it would make it more difficult with longer duration and lower rates of TI intubation.
A Almallouhi et al. J Pediatr Gastroenterol Nutr. 2025 DOI: 10.1002/jpn3.70316. Clinical outcome of constipation as the presenting symptom in children with celiac disease
Background: “It is not clear if CeD prevalence is higher in children with refractory and chronic constipation or not.11–15 The current guidelines from the American Gastroenterological Association (AGA) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) do not consider constipation an indication for CeD testing in the absence of suggestive family history, growth, or developmental delay.”
Methods: This was a retrospective study (1994-2024) of children (<18 years) who presented with constipation and then diagnosed with celiac disease (CeD). There were 248 children with CeD, 177 (71%) had biopsy-confirmed CeD, and 56 (23%) were diagnosed with serology-only criteria
Key findings:
My take:
It is unclear if having constipation increases the risk of celiac disease
Many children with celiac disease also have functional disorders like irritable bowel and constipation that often continue despite a gluten-free diet
Methods: Single-center, retrospective study of children (4–21 years old, n=191) with biopsy-proven Celiac disease (CeD) who were evaluated for DGBI based on Rome IV criteria. Patients who were adherent to a GFD, demonstrated tissue transglutaminase immunoglobulin A (TTG IgA) decline, and had at least one visit 9–24-months after diagnosis with a pediatric gastroenterologist. For this study, sustained TTG IgA decline required at least two declining TTG IgA values, a 90% decline from baseline, or normalization of TTG IgA.
Key findings:
43% (n = 83) met Rome IV DGBI diagnostic criteria.
Functional constipation (27/83, 33%) and functional abdominal pain (24/83, 29%) were the most common DGBI
Abdominal pain, constipation, and vomiting at initial presentation as well as comorbid joint hypermobility, headaches, and chronic musculoskeletal pain increased risk of developing DGBI after serological decline
Discussion Points:
“The prevalence reported here is similar to a study of adults with CeD who were adherent to a GFD that reported over 50% met criteria for a functional gastrointestinal disorder19 and is higher than previously reported pediatric prevalence rates”
“The majority of patients who met DGBI criteria did so through having the persistence of the same gastrointestinal symptoms that were present at CeD diagnosis. This raises the question as to whether the symptoms at presentation were due to CeD, DGBI, or both”
“Clinicians could consider discussing that while symptoms related to CeD should improve on a GFD, some symptoms may persist, especially if they have an increased likelihood of having a comorbid DGBI. Such counseling may prevent the misattribution of persistent symptoms to ongoing gluten exposure and mitigate hypervigilance”
“Having complete villous blunting on diagnostic biopsy increased the likelihood of having a DGBI. Intuitively, it is possible that complete villous blunting can lead to greater nerve sensitization and subsequently higher rates of DGBI. It is also possible that complete villous blunting is slower to recover”
My take: Given the overlap of DGBI symptoms with CeD, diagnosing DGBI in patients with CeD can be challenging. However, DGBI is much more likely to contribute to lingering symptoms than refractory CeD.
As a practical matter, the high frequency of ongoing GI symptoms despite use of a GFD provides another drawback to relying on a no-biopsy diagnosis. A no-biopsy diagnosis introduces greater uncertainty in the diagnosis and does not allow for a histologic comparison if a subsequent evaluation is needed.
Background: The modified Bristol Stool Form Scale for Children (mBSFS-C) removes #3 and #5 from the Bristol Stool Form Scale (BSFS), leaving only one normal image and shortening the options from seven to five.
Methods: Pediatric gastroenterology providers (21 faculty, 11 fellows, 3 nurse practitioners) and 200 children/families rated the same 35 stool photographs, reflecting diverse stool forms, using both scales. The order of photograph presentation and scale use were randomized.
Modified Bristol Stool ScaleBristol Stool Chart
Key findings:
Of 1,225 provider ratings using the mBSFS-C, 90.0% agreed with the provider’s modal ratings vs 77.8% using the BSFS.
Of 7,000 child ratings using the mBSFS-C, 84.6% agreed with the children’s modal ratings vs 71.8% using the BSFS.
Using providers’ modal ratings as the reference, all mBSFS-C photograph modal ratings matched between children and providers (35/35 photographs) whereas only 86% (30/35 photographs) matched with the BSFS.
Discussion:
“Unique and new in this study is the direct head-to-head comparison of the 2 scales (BSFS, mBSFS-C) when used by pediatric gastroenterology providers and children. Both the BSFS and mBSFS-C demonstrated excellent reliability…modal rating agreement was significantly poorer for the BSFS than for the mBSFS-C.”
“Almost 20% of the time expert raters using the BSFS (vs. 8% with the mBSFS-C) deemed a stool to be a different clinical delineation than that selected by the majority of their peers.”
My take: The modified BSFS is easier and better. This study indicates it should be widely used for children but probably for adults too. As Dr. Lu’s editorial notes, “aren’t adults just big children?”
Methods: In three large cohorts, the Nurses’ Health Study (NHS), NHSII, and the Health Professional Follow-up Study (HPFS) (combined >95,000 participants), the authors identified chronic constipation based on repeatedly-measured self-reported constipation symptoms for ≥12 weeks in the past year.
Key Findings:
The top quintiles of alternate Mediterranean diet (aMED) and plant-based dietary index (PDI) were associated with 16% (9-22%) and 20% (14-27%) reduced risk for constipation. Vegetable and nut intake, which are enriched in aMED and PDI, were associated with decreased constipation risks.
A Western diet in the top quintile was associated with a 22% (11-33%) increased risk for constipation
My take: The results from this study are not surprising, but nice to see more data on the effects of diet on constipation. While this data focused on adults, it is clear that dietary patterns have a big role in the frequency of constipation in children too.
This was a cross-sectional observational study in pediatric IBD-patients (n=238) with 104 (43.6%) with Crohn disease (CD), 130 (54.6%) with ulcerative colitis (UC) and 4 (1.6%). Only patients who filled out the Rome IV questionnaire for FC, through dedicated symptom recall at the next clinic appointment or telephone recall, were finally enrolled in the study for subsequent analysis.
Key findings:
Forty-seven out of 238 (19.7%) had a functional constipation history before the IBD diagnosis. In the CD children the prevalence of constipation before the IBD diagnosis was 19/104 (18.2%) and in the UC patients was 28/130 (21.5%).
The difference in terms of endoscopic localization was statistically significant in UC patients presenting FC (p = 0.026) with a prevalence of proctitis and left side colitis (30% and 15%, respectively)
There was a delay in the diagnosis of patients with preceding constipation
Discussion Points:
The main limitations of the present study are certainly related to the retrospective nature and, therefore, the possibility of recall biases must be taken into account.
Rectal bleeding that persists despite stool softener therapy should be investigated
My take: While this study shows that constipation is fairly common prior to a diagnosis of IBD, many times a parent is told that their child is constipated on the basis of an xray or simply because the child complained of stomach pain. This likely increases the risk of recall bias. My guess is that a prospective study involving careful questioning at the time of the initial colonoscopy would yield a lower number of children who had constipation at the time of diagnosis.
Background: The Council of Pediatric Subspecialties (CoPS) created a list of 3 to 5 learning objectives that each subspecialty believes are the most important practical skills for the general pediatrician and recommends be included in general pediatrics, medicine-pediatrics, and other combined residency program curricula… The Subspecialty Perspectives on (pediatrics) Training (SPoT) action team within CoPS asked each subspecialty representative, most of whom were fellowship program directors at the time, in collaboration with their subspecialty colleagues, to provide a list of 3 to 5 practical learning objectives that should be expected of graduating pediatric residents and practicing general pediatricians in the evaluation and management of conditions related to their subspecialty.
Recommendations for Pediatric Gastroenterology:
My take: This article identifies four of the most important areas in pediatric gastroenterology. If I were to add a fifth, given the wide variety of problems in our field, it would be to know how to quickly reach out to a pediatric gastroenterologist when you need advice.
This article is worth a quick look to see if you have the essential knowledge in all pediatric subspecialty fields (Table 1). One of the most important that relates to pediatric gastroenterology is in the allergy section: “Identify the importance of avoiding indiscriminate testing for food allergy without an appropriate clinical history concerning for IgE mediated food allergy.”
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