Effect of Colon Transection on Spontaneous and Meal‐Induced High‐Amplitude–Propagating Contractions in Children

Abstract

Background After Hirschsprung’s disease (HD) surgery, many children suffer fecal incontinence caused by increased number of high amplitude propagating contractions (HAPCs) propagating through the neorectum to the anal verge. The aim of this study was to determine whether children with HD have more HAPCs than children with colon transections for reasons other than HD. Methods We reviewed 500 colon manometries. Children (7.6±5.1 yrs; 275 male) with functional constipation (n=237; 7.4±5.0yrs; 126 male) and chronic abdominal pain (n=48; 9.8±5.8yrs; 25 male) served as controls compared to subjects with HD (n=56; 6.9±4.1yrs; 44 male) and colon transection for other reasons (n=24; 6.1±5.8yrs; 12 male). We excluded 139 subjects without HAPCs. We documented HAPCs during 1 h fasting and 1 h postprandial. Results are mean ± SD. Results During fasting, HD subjects had more HAPCs (2.2±3.4/h) vs. functional constipation (0.8±2.2/h, p=0.0004) and chronic pain (0.5±1.1/h, p=0.001), but not more than colon transection (1.9±3.2/h, p=1.0). HD showed more postprandial HAPCs (4.0±5.4/h) than functional constipation (1.5±2.5/h, p<0.0001) and chronic pain (0.9±1.6/h, p<0.0001), but not more than colon transection (2.4±3.0/h, p=0.6). There were more HAPCs fasting and post-prandial after colon transection (1.9 ± 3.2/h and 2.4±3.0/h) than functional constipation (0.8±2.2/h, p=0.3 and 1.5±2.5/h, p=1.0) and chronic pain (0.5±1.1/h, p=1.0 and 0.9±1.6, p=1.0). HD subjects were divided by chief complaint: fecal incontinence or constipation. HD subjects with incontinence (n=23) only had more HAPCs fasting (p=0.01) and post-prandial (p=0.01) than HD subjects with constipation (n=28) only. Conclusions Increased HAPCs followed colon transection, regardless of cause. HD subjects with incontinence had more HAPCs than subjects with colon transection for other reasons.

Sequential incremental doses of bisacodyl increase the diagnostic accuracy of colonic manometry

“…For instance, the maximum dose ranges between 5 and 10 mg and only a single intraluminal stimulation is usually suggested with only few studies reporting the use of either two doses or a single higher dose. 7,9,[15][16][17][18][19][20][21] In the present study, the additional higher dose of bisacodyl (0.4 mg/kg up to a maximum of 20 mg) significantly increased the number of HAPCs throughout the entire colon, improved the propagation of HAPCs toward the distal colon, and sharpened the morphology of pressure waves within HAPCs. This suggests that this higher dose may be more effective compared with lower doses in assessing the residual function of colonic motor activity and in discriminating between those patients with normal colonic motor activity from those with localized segmental abnormalities.…”

“…To date, there is a still considerable inconsistency regarding the dose of bisacodyl that should infused intraluminally during manometric recording. For instance, the maximum dose ranges between 5 and 10 mg and only a single intraluminal stimulation is usually suggested with only few studies reporting the use of either two doses or a single higher dose . In the present study, the additional higher dose of bisacodyl (0.4 mg/kg up to a maximum of 20 mg) significantly increased the number of HAPCs throughout the entire colon, improved the propagation of HAPCs toward the distal colon, and sharpened the morphology of pressure waves within HAPCs.…”

“…14 During the manometric recording, the bisacodyl dose appears to be standardized at 0.2 mg/kg; conversely, the suggested maximum dose is extremely variable ranging between 5 mg and 10 mg. 7,9,[15][16][17][18][19] To the best of our knowledge, provocation with only a single intraluminal dose is advocated with scarce data regarding either the use of repeated or higher doses. 20,21 In our center a dual sequential incremental dose regime was instituted in 2011 given clinical concerns over limited response to a single dose (0.2 mg/kg) regime, which may provide insufficient clarity to inform further management decisions including surgery and evidence that higher doses may be used to stimulate colonic contractions. 22 Therefore, in this retrospective study we aimed to explore whether an additional higher 'double dose' of bisacodyl increases the diagnostic yield and accuracy of CM and, theoretically, impact on decision making in the clinical management of patients with slow transit constipation (STC).…”

An ANMS‐NASPGHAN consensus document on anorectal and colonic manometry in children

“…A recent report highlighted the association between bisacodyl‐induced HAPC and anal canal relaxation (a “colo‐anal reflex”), with most contractions resulting in anal canal relaxation as HAPC reach the splenic flexure . After any type of colonic transection, CM has demonstrated that there is an increase in the number of HAPCs, probably due to the loss of a negative recto‐colonic feedback, with a higher frequency of propagated contractions occurring in those patients operated for Hirschsprung's disease compared to those undergoing surgery for other indications …”

“…35 After any type of colonic transection, CM has demonstrated that there is an increase in the number of HAPCs, probably due to the loss of a negative recto-colonic feedback, with a higher frequency of propagated contractions occurring in those patients operated for Hirschsprung's disease compared to those undergoing surgery for other indications. 36 It is obvious that interpretation of colon manometry studies requires experience and sub-specialty training. In the Guidelines for Training in Pediatric Gastroenterology by NASPGHAN published in 2013 it is stated that pediatric GI fellows should be exposed to this procedure but the numbers of studies required for the training were not specified.…”