State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation

Abstract

Background: Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC. Methods: A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5–10 years. Results: The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer’s procedure) can be guided with a balloon expulsion test. Conclusion: Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.

Is Collaborative Care the Future of Medicine? Lessons Learned from the Care of Children with Colorectal Conditions

“…All providers need to agree on what is meant by a "failure of medical management" to understand how evaluate a patient's anal sphincters, pelvic floor, and colonic motility, and to know when to offer an intervention. Collaborative evaluation algorithms lead to more efficient and accurate diagnoses of underlying causes of constipation, allowing for targeted intervention strategies [54,55]. These interventions include pelvic floor physical therapy, botulinum toxin for internal and external anal sphincter dysfunction, antegrade access for colonic flushes, and surgical removal of a dysmotile colonic segment [56].…”

State of the Art Bowel Management for Pediatric Colorectal Problems: Hirschsprung Disease

“…Anorectal manometry (AMAN) in patients with HD depicts the defecation dynamics and allows for a diagnosis of pelvic floor dyssynergia which is managed with pelvic floor physiotherapy [ 20 , 63 ]. For further information on the management of this condition, please refer to a related manuscript on functional constipation [ 64 ].…”

The Risks of Phosphate Enemas in Toddlers: A Life-Threatening Unawareness

“…For this reason, at any age, it is mandatory to consider red flags and alarm signs suggestive of an organic condition. Medical history and a physical exam should include and evaluate the lumbosacral, perianal, and abdominal regions, and a high index of suspect for signs of spinal dysraphism, abdominal masses, malignant infiltration of the vertebrae or the spinal cord, infections such as spondylodiscitis, or the onset of a Guillain Barré syndrome should be considered [ 14 , 15 , 16 , 17 , 18 ]. As a rule, digital rectal examination should be avoided because it could be distressing for the child, except for the diagnosis of Hirschsprung’s disease where explosive stools, abdominal distension, and a history of recurrent enterocolitis are highly suggestive of the condition [ 19 ].…”