Tag Archives: constipation

Rome IV -Pediatric Changes

Posted on by

What are the changes in Rome IV for children and adolescents?  JS Hyams, C DiLorenzo et al (Gastroenterol 2016; 150: 1456-68) provide a helpful review.

Key point:

The ‘dictum’ that there was “no evidence for organic disease” as an criteria for functional disorders has been dropped in favor of “after appropriate medical evaluation the symptoms cannot be attributed to another medical condition.”  This subtle change discourages excessive investigations.

The functional disorders covered in this article include

  • H1 Functional nausea and vomiting disorders: H1a -cyclic vomiting syndrome, H1b -functional nausea and vomiting (NEW), H1c -rumination syndrome, H1d -aerophagia
  • H2 Functional abdominal pain disorders: H2a -functional dyspepsia, H2b -irritable bowel syndrome, H2c -abdominal migraine, H2d -functional abdominal pain -not otherwise specified
  • H3 Functional defecation disorders: H3a -functional constipation, H3b -nonretentive fecal incontinence

Other points:

  • “There are no published data on the treatment of isolated functional nausea and isolated functional vomiting”
  • “We have eliminated the requirement of pain to fulfill the criteria for FD” [functional dyspepsia]
  • Criteria for cyclic vomiting and abdominal migraines now require only 2 episodes in a 6 month period
  • Criteria for functional constipation requires only 1 month rather than 2 months (this is true for H3b as well).  The authors endorsed the NASPGHAN expert guidelines which included “no role for routine use of an abdominal x-ray to diagnose FC.”  The guideline discourages testing for cow’s milk allergy, hypothyroidism, celiac disease and hypercalcemia in the absence of alarm symptoms.

In a separate article, MA Benninga, S Nurko et al (Gastroenterol 2016; 150: 1443-55) describe the functional disorders affecting infants and toddlers.

In my view, the article in this special edition that incorporates the most changes regards functional disorders of the biliary tree (FGBD) (PB Cotton et al Gastroenterol 2016; 150: 1420-29). This is mainly due to data showing that sphincterotomy is no better than sham treatment for patients with post-cholecystectomy pain.  “The concept of sphincter of Oddi dysfunction type III is discarded.”  In addition, for biliary pain/’gallbladder dyskinesia,’ the authors also acknowledge that the role of obtaining a gallbladder ejection fraction is “controversial.”  “Symptoms suggestive of FGBD often resolve spontaneously so that early intervention is unwarranted.”  Ultimately, the authors state that “treatment recommendations are not firmly evidence-based.”

Related blog posts:

Owl in Our Neighborhood

Owl in Our Neighborhood

538: Gut Science Week

Posted on by

While FiveThirtyEight garners a lot of attention for its political and sports forecasts, there are often health-related posts.  This week is devoted to Gut Science Week.

Here’s the link: Gut Science Week Introduction

Here’s an excerpt:

One of the major leaps forward in gut science began with an accidental shooting at a trading post on June 6, 1822. A fur trader named Alexis St. Martin took a bullet in the abdomen, leaving him with a hole ripped through his muscle, bone and internal organs…

His doctor, William Beaumont, could literally tie a bit of food on a string, shove it into St. Martin’s stomach through the hole, and pull it back out again. Using this one weird trick, Beaumont extracted samples of the man’s gastric juices. Over eight years and more than 200 awkwardly invasive experiments, St. Martin and Beaumont gave humanity its first real understanding of how digestion works.

Another post: Everybody is Constipated, Nobody is Constipated

Here’s an excerpt:

Doctors use diagnostic criteria for constipation, where patients have to experience two or more of six symptoms:

  1. Straining during at least 25 percent of defecations
  2. Lumpy or hard stools in at least 25 percent of defecations
  3. Sensation of incomplete evacuation in at least 25 percent of defecations
  4. Sense of obstruction in at least 25 percent of defecations
  5. Manual maneuvers needed to facilitate at least 25 percent of defecations
  6. Fewer than three defecations per week

And a video: What Your Poop Says About You — FiveThirtyEight

Gut Science Week --FiveThirtyEight

Gut Science Week –FiveThirtyEight

Torsion of Accessory Spleen

Posted on by

A case report (PM Guglietta et al. NEJM 2016; 374; 373-82) presents a 9 year-old girl who had repeated episodes of abdominal pain with associated nonbilious vomiting.  These pains started 5 years prior and were often sudden episodes of sharp pain on the left side or epigastric region and were associated with tachycardia.

AXR in Case Report

AXR in Case Report

Ultimately the diagnosis was established with a CT scan.  “Most persons with accessory spleens are asymptomatic, but abdominal pain can occur with torsion.”

While the case report is interesting, one aspect I did not like was the discussants justification of the delay of the diagnosis based on the presumption of constipation.  The radiologist even commented: “a moderate-to-abundant amount of stool distributed in the colon, particularly the ascending colon; these findings are consistent with the clinical history of constipation.”  This and other comments in the case study go against previous expert recommendations to avoid routine radiographs in the diagnosis of constipation and the finding of reviews which have not found a correlation between clinical symptoms and so-called fecal loading on abdominal radiographs.

Related blog posts:

Flamenco Beach

Flamenco Beach

 

Microbiome Predicts Constipation plus two

Posted on by

In brief:

G Parthasarathy et al. Gastroenterol 2016; 150: 367-79.  Mucosal and fecal microbiota samples were collected from 25 healthy women and 25 women with chronic constipation.  Key finding: The mucosal, but not fecal, microbiota profile were 94% predictive of constipation. The associated editorial (pg 300) provides a framework for understanding these findings and show the complexity of trying understand the interations between diet, motility and microbes.

S Fukudo et al. Gastroenterol 2016; 150: 358-66.  This prospective study of Ramosetron for 576 women with IBS-D.  Key finding: 50.7% of treatment patients reported global improvement compared with 32.0% of control patients.  Patients had less abdominal pain, less discomfort, and better stool consistency.  Ramosetron, a 5-HT3 antagonist, has not been reported to cause ischemic colitis (in contrast to alosetron).

In followup to a post earlier in the week, another worrisome study on the Zika virus in pregnancy from NEJM. Here’s an excerpt:

Fetal abnormalities were detected by Doppler ultrasonography in 12 of the 42 ZIKV-positive women (29%) and in none of the 16 ZIKV-negative women. Adverse findings included fetal deaths at 36 and 38 weeks of gestation (2 fetuses), in utero growth restriction with or without microcephaly (5 fetuses), ventricular calcifications or other central nervous system (CNS) lesions (7 fetuses), and abnormal amniotic fluid volume or cerebral or umbilical artery flow (7 fetuses).

Farjado, Puerto Rico

Farjado, Puerto Rico

“Simple Remedies for Constipation”

Posted on by

“Common sense is not so common” –Voltaire

A useful review of constipation management in the NY Times: Simple Remedies for Constipation

This review explains the role of diet and exercise in treatment of constipation.  The author notes that coffee helps many and that laxatives are safe. In addition, the idea of “autointoxication” due to infrequent bowel movements is debunked.

Here’s an excerpt:

Dr. Wald and others say that properly designed studies of these [stimulatory] laxatives have shown no harm to the colon when they are taken in recommended amounts.

Yet many doctors still warn – inappropriately, Dr. Wald says — against taking stimulatory laxatives for more than a few days. Indeed, the website FamilyDoctor.org states, “When these laxatives are taken for a long time, the bowel can lose its muscle tone and ‘forget’ how to push the stool out on its own.” Best to forget this outdated idea as long as you stick to the recommended dose if you must take these products.

Related blog posts:

Screen Shot 2016-02-09 at 8.56.54 PM

Do You Know the Best Way to Use Antegrade Enemas?

Posted on by

Currently, there is no best way to use antegrade enemas.  This is the obvious conclusion after reading a study by S Kuizenga-Wessel et al (JPGN 2016; 62: 71-9).  In this study, the authors reviewed 21 articles and also surveyed 23 physicians involved in the care of children who receive antegrade continence enemas (ACE). While the study provides a lot of details, the bottom-line is that there is wide variation in outcomes, definition of success, workup prior to institution of ACE, and irrigation solutions (16 out of 23 used saline).  The only areas of agreement seem to be the following:

  • use of ACE daily: 22 of 23
  • use of antibiotics with placement: 23/23 (though wide variation in specific regimen)
  • indications for ACE were largely in agreement, including constipation with fecal incontinence (21 of 23), anorectal malformations (22 of 23) and spinal abnormalities (23 of 23); however, only 8 of 23 considered due to functional non-retentive fecal incontinence as an acceptable indication

With regard to the type of enema, the vast majority of physicians (19 of 23) only add a stimulant to the solution after initial failure.  Though, one study (J Pediatr 2012; 161: 700-4) has reported “that subjects who use stimulants from the very beginning had significantly better outcomes.”

My take: Like of a lot areas in medicine and throughout pediatric gastroenterology, there is wide variation in clinical treatment approaches.  Variation in treatment is obvious in the use of ACE.  Collaborative work and consensus building in management would improve success; that is, after we define what success looks like.

In the same issue a link to “History of Pediatric Endoscopy” is provided.  This is a ~15 minute video with interviews with many pioneers/leaders in pediatric gastroenterology.

Related blog posts:

Golden Gate Bridge

Golden Gate Bridge

Early Study Shows That Relamorelin Impoves Constipation and Transit Time

Posted on by

An early study shows that Relamorelin relieves constipation & accelerates colonic transit in a placebo-controlled, randomized trial.  Abstract follows.

Relamorelin Relieves Constipation and Accelerates Colonic Transit in a Phase 2, Placebo-Controlled, Randomized Trial A Acosta et. Clin Gastroenterol Hepatol; December 2015Volume 13, Issue 13, Pages 2312–2319.e1. DOI: http://dx.doi.org/10.1016/j.cgh.2015.04.184

Abstract:

Background & Aims

Ghrelin receptors are located in the colon. Relamorelin is a pentapeptide selective agonist of ghrelin receptor 1a with gastric effects, but its effects in the colon are not known. We aimed to evaluate the effects of relamorelin on bowel movements (BMs) and gastrointestinal and colonic transit (CT) in patients with chronic constipation.

Methods

We performed a study of 48 female patients with chronic constipation who fulfilled the Rome III criteria and had 4 or fewer spontaneous BMs (SBMs)/wk. In a randomized (1:1), double-blind, parallel-group, placebo-controlled trial, the effects of relamorelin (100 μg/d, given subcutaneously) were tested during 14 days after a 14-day baseline, single-blind phase in which patients were given placebo at 2 Mayo Clinic sites. The participants’ mean age was 40.6 ± 1.5 y, with a mean body mass index of 25.7 ± 0.6 kg/m2, with 1.7 ± 0.1 SBM/wk, and a mean stool consistency of 1.2 ± 0.1 on the Bristol scale during this baseline period. The effect of treatment on transit was measured in 24 participants with colonic transit of less than 2.4 (geometric center at 24 h) during the baseline period. Gastric emptying, small-bowel transit, and CT were measured during the last 2 days that patients received relamorelin or placebo. Bowel function was determined from daily diaries kept by patients from days 1 through 28. Study end points were time to first BM, SBMs/wk, complete SBMs/wk, stool form, and ease of stool passage. Effects of relamorelin were assessed by analysis of covariance.

Results

Compared with placebo, relamorelin accelerated gastric emptying half-time (P = .027), small-bowel transit (P = .051), and CT at 32 hours (P = .040) and 48 hours (P = .017). Relamorelin increased the number of SBMs (P < .001) and accelerated the time to first BM after the first dose was given (P = .004) compared with placebo, but did not affect stool form. Adverse events associated with relamorelin included increased appetite, fatigue, and headache.

Conclusions

Relamorelin acts in the colon to significantly reduce symptoms of constipation and accelerate CT in patients with chronic constipation, compared with placebo. ClinicalTrial.Gov registration number: NCT01781104.

Lights at Life University

Lights at Life University

Improving ER Performance for Suspected Constipation

Posted on by

While the ultimate goal would be for most constipation to be prevented or managed by primary care physicians, the reality is that a lot of children are seen in the ER setting.  Particularly in the hospital setting, many practitioner’s have relied on abdominal xrays (AXRs) and this practice has been criticized previously (What’s Wrong with Ordering an AXR for Constipation in the …).

It is gratifying that efforts are underway to reverse this tendency.  A recent study (J Kurowski et al. J Pediatr 2015; 167: 706-10) document the effect that a 10 minute training session can have.

In this retrospective chart review, the researchers examined a 2 month baseline period and then a 2 month period after institution of a 10-min educational module for ER healthcare providers.  The module included the following:

  1. Rome III criteria for constipation  -at least 2 criteria weekly for >2 months:
    • ≤2 defecations in the toilet per week
    • at least 1 episode of fecal incontinence per week
    • history of retentive posturing or excessive volitional stool retention
    • history of painful or hard bowel movements
    • presence of a large fecal mass in the rectum
    • history of large stools which may obstruct toilet
  2. Review of the lack of utility of abdominal radiographs
  3. Use of rectal exam

Patients were identified who were discharged from the ER (without hospital admission)  with a diagnosis of constipation and with a chief complaint of abdominal pain.  In the baseline period, there were 105 patients and in the followup period, there were 91 patients.

Key findings:

  • Digital exams increased: 22.9% —>47.3%
  • AXR decreased: 69.5% –>26.4%

This study has numerous limitations; these include retrospective study and patient selection. Nevertheless, it makes several useful points.  If constipation is suspected, better care at a lower cost can be achieved by including a digital exam.  The authors note that “there is no strong evidence to support the utility of radiographs for this diagnosis [constipation] or even reliable standards to evaluate the normal stool burden across different ages.”

My take: The lessons from this study are applicable to primary care physicians and gastroenterologists as well as to ER physicians.  While this educational module is a good start, if I were designing a module, I would include information on irritable bowel syndrome which is often confused with isolated constipation.

Related blog posts:

Soiling Stinks!

Posted on by

The initial title of this post was too boring: “Documenting the Detrimental Effects of Fecal Incontinence on Quality of Life”

In perhaps one of the least surprising conclusions, the authors of a recent study (Kovacic K, et al. J Pediatr 2015; 166: 1482-7) have shown that “fecal incontinence significantly decreases quality of life compared with functional constipation alone in children.”  This multicenter prospective study surveyed families of 410 children (2-18 years).

Despite the obvious findings, I still think that the burden of fecal incontinence is underestimated by families and practitioners.  Here is an excerpt from this article’s discussion:

“Fecal incontinence impairs general functioning for children and their families…[it] is an insidious burden with substantial economic impact and adverse effects on quality of life…this effect increases as children approach adolescence…The devastating effect of fecal incontinence on quality of life and social functioning make it imperative that health professionals address defecation disorders proactively.  When aggressive and appropriate medical therapies are unable to provide a satisfactory outcome, then a multidisciplinary approach or a surgical option (e.g. cecostomy tube for antegrade enema) may be justified.”

Bottomline: Soiling stinks!  We need to keep working on this problem even if aggressive interventions are needed.

Related blog posts:

Not Letting Go of a Log

Not Letting Go of a Log -Can Lead to Problems

Refractory Constipation -Terrific Update

Posted on by

Recently I attended a terrific talk by my partner, Jose Garza.  This lecture provided a great deal of information on refractory constipation for both pediatricians and pediatric gastroenterologists alike.

Elements of the talk included diagnosis, pathophysiology and differential diagnosis.

Rome III Criteria -Helpful in Diagnosis of Constipation

Rome III Criteria -Helpful in Diagnosis of Constipation

JG1 pathophys

Is it Hirschsprung's Disease?

Is it Hirschsprung’s Disease?

Some of the more useful points.

  1. AXR should not be used to make diagnosis of constipation.
  2. Many refractory constipation patients are stooling fine and actually labeled as constipation instead of a functional abdominal pain disorder.  That is, they are complaining of stomach pain and have been erroneously told they are constipated (see point #1).
  3. Miralax remains a 1st line agent for constipation. In individuals with fecal soiling, if miralax is not working and they have had appropriate cleanout, then senna laxative may be helpful.
  4. Sitz markers are particularly helpful in proving stooling when teenager claims to not be stooling for a month and in proving functional fecal retention rather than nonretentive soiling.
  5. If good treatment is not working, then refer to neurogastroenterology.

Related blog posts:

JG3 -Help