A F Flores

Use of colonic manometry to differentiate causes of intractable constipation in children

We evaluated colon manometry as a means of differentiating causes of intractable constipation in children. We studied pressure changes in the transverse, descending, and rectosigmoid colons of 23 children with intractable constipation. All patients had a history of less than one bowel movement per week for longer than 2 years without resolution after conventional medical management. The possibility of Hirschsprung disease was excluded in all. On the basis of pathologic and manometric studies of the upper gastrointestinal tract, 10 patients had a diagnosis of gastrointestinal neuropathy and two had a diagnosis of myopathy. The other 11 patients had functional fecal retention; this diagnosis was based on history and outcome of therapy. On the day of study we used endoscopy to place a manometry catheter into the transverse colon and recorded intraluminal pressure for longer than 4 hours. After obtaining a baseline recording, we gave the patient a meal to assess gastrocolonic response. Colonic contractions were recorded in 21 of 23 children. Children with functional fecal retention could be differentiated from those with neuropathy by examination of the postprandial record. After a meal children with functional fecal retention had (1) an increase in motility index (3.4 +/- 0.5 while fasting vs 9.1 +/- 1.3 postprandially; p less than 0.001), and (2) at least one high-amplitude propagated contraction (in 10 of 11 children). The patients with neuropathy had no high-amplitude propagated contractions (p less than 0.001 vs group with functional fecal retention) and motility index in these children did not increase significantly after a meal (2.7 +/- 1.0 while fasting vs 2.9 +/- 1.3 postprandially). The two children with hollow visceral myopathy had no contractions. We conclude that in children with severe chronic constipation the colonic results of manometry differentiate patients with functional fecal retention from those with neuropathy or myopathy of the colon.

Postviral gastroparesis : Presentation, treatment, and outcome

We describe the clinical features and long-term outcome of 11 children who had persistent gastroparesis after an acute viral illness, eight of whom tested positive for rotavirus. Gastric emptying was delayed in the 10 children evaluated with scintigraphy. Antroduodenal manometry confirmed postprandial antral hypomotility in 10 subjects. All children recovered within 6 to 24 months.

Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically fragile toddlers

Background In chronically ill children who refuse to eat, surgery to correct anatomic problems and behavioral treatments to overcome oral aversion often succeed. A few patients fail with standard treatments. The aims of the study were to: 1) investigate motility and gastric sensory abnormalities and 2) describe treatment that was individualized based on pathophysiology in children who failed surgery and behavioral treatments. Methods We studied 14 patients (age 1.5–6; mean 2.5; M/F: 7/7). All had a lifelong history of food aversion and retching or vomiting persisting after feeding therapy and fundoplication. All were fed through gastrostomy or gastro-jejunostomy tubes. We studied esophageal and antroduodenal manometry, and gastric volume threshold for retching. We identified when gastric antral contractions were associated with retching and pain. A multidisciplinary treatment program included a variable combination of continuous post-pyloric feedings, drugs to decrease visceral pain, drugs for motility disorders, and behavioral, cognitive, and family therapy. We interviewed parents 2–6 months following testing to evaluate symptoms, mode of feeding and emotional health. Results We found a motility disorder alone in 2, decreased threshold for retching alone in 5 and both motility and sensory abnormalities in 7. After treatment, 6 of 14 (43%) began eating orally and 80% had improved emotional health. Retching decreased from 15 episodes per day to an average of 1.4 per day (p <0.01). Conclusions Upper gastrointestinal motor and/or sensory disorders contributed to reduced quality of life for a majority of children and families with persistent feeding problems. A multidisciplinary approach improved symptoms and problems in these children

Colonic manometry in children with chronic intestinal pseudo-obstruction.

Pressure changes were evaluated in the transverse, descending, and rectosigmoid colon of 30 children with chronic intestinal pseudo-obstruction. Twenty two had severe lifelong constipation and eight had symptoms suggesting a motility disorder exclusively of the upper gastrointestinal tract. Based on prior antroduodenal manometry, 24 children were diagnosed as having a neuropathic and six a myopathic form of intestinal pseudo-obstruction. On the day of study, endoscopy was used to place a manometry catheter into the transverse colon and intraluminal pressure was recorded for more than four hours. After a baseline recording, we gave a meal to assess the gastrocolonic response. Colonic contractions were noted in 24 children. The six children with no colonic contractions had a hollow visceral myopathy and constipation. In the children with colonic contractions, fasting motility did not differentiate children with and without constipation. After the meal, in all eight children without constipation there was (1) an increase in motility index (3.2 (SEM 0.3) mm Hg/min basal v 8.4 (SEM 1.1) mm Hg/min postprandial; p < 0.001), and (2) at least one high amplitude propagated contraction (HAPC). In the 16 constipated children with colonic contractions the motility index did not significantly increase after the meal (2.1 (SEM 0.3) mm Hg/min basal v 3.1 (SEM 0.4) mm Hg/min postprandial) and 12 of them had no HAPCs (p < 0.01 v group without constipation). In summary, in children with a clinical diagnosis of chronic intestinal pseudo-obstruction, constipation is associated with absence of HAPCs, and the gastrocolonic response or with total absence of colonic contractions. It is concluded that studies of colonic manometry are feasible in children and may document discrete abnormalities in those with intestinal pseudo-obstruction with colonic involvement.

Effect of erythromycin on antroduodenal motility in children with chronic functional gastrointestinal symptoms

To evaluate the effects of erythromycin on antroduodenal motility in children with chronic functional gastrointestinal symptoms, we studied 35 consecutive subjects referred for diagnostic motility studies. We recorded fasting motility for >4 hr, then infused in random order either 1 or 3 mg/kg erythromycin intravenously over 1 hr and continued the study for another hour. Erythromycin induced phase III in 18 of 20 children who had phase III during fasting compared to only one of 15 who did not (P<0.001). The antral motility index increased after erythromycin (1596±323 vs 436±242 mm Hg/30 min before erythromycin,P<0.005) but the duodenal motility index did not change. The antral motility index was greater in children receiving 3 mg/kg than in those receiving 1 mg/kg (1968±391 vs 1226±285 mm Hg/30 min,P<0.01), but duodenal motility indices did not differ. Only one child receiving the lower dose erythromycin complained of abdominal pain, nausea, or vomiting vs 9 of 19 the children receiving the higher dose (P<0.02). In summary, in children with chronic functional gastrointestinal disorders, erythromycin rarely induced phase III in patients who did not have it during fasting. When different doses erythromycin are compared, 1 and 3 mg/kg are equally efficacious in inducing phase III episodes; the lower dose is associated with fewer side effects and the higher dose produces a higher antral motility index.

Bisacodyl and High-amplitude-propagating Colonic Contractions in Children

BACKGROUND The purpose of these studies was to determine the suitability of bisacodyl for stimulating high-amplitude-propagating contractions in pediatric studies of colonic manometry. METHODS Water-perfused manometry catheters were inserted into the right colon of children referred for evaluations related to defecation disorders. Colonic motility was measured in a 3-hour test session: an hour fasting, an hour after a meal, and 30 minutes after administration of a provocative agent. RESULTS Bisacodyl was superior to edrophonium as a stimulant for inducing high-amplitude-propagating contractions. Bisacodyl-induced high-amplitude-propagating contractions were similar in amplitude, duration, propagation velocity, and sites of origin and extinction to naturally occurring high-amplitude-propagating contractions. The effect of intrarectal bisacodyl was similar to that of intracecal bisacodyl, except for a delay of 10 minutes in onset. Bisacodyl induced high-amplitude-propagating contractions in all 28 children (22 with spontaneous high-amplitude-propagating contractions) without evidence of neuromuscular disease and in 2 of 9 children with a colonic neuromuscular disorder and no spontaneous high-amplitude-propagating contractions. CONCLUSIONS Bisacodyl-induced high-amplitude-propagating contractions were quantitatively and qualitatively similar to naturally occurring high-amplitude-propagating contractions. In selected cases, such as in children receiving total parenteral nutrition or restricted fluid intake, it may be possible to shorten diagnostic colonic manometry using bisacodyl rather than waiting for spontaneous high-amplitude-propagating contractions.

Antroduodenal Manometry in Children and Adults with Severe Nonulcer Dyspepsia

BACKGROUND Nonulcer dyspepsia is common in adults but has been recognized only recently in children. METHODS We compared signs, symptoms, and antroduodenal motility findings in 34 children and 35 adults with severe nonulcer dyspepsia. RESULTS Symptoms and signs were similar in the two groups. Ten children (29%) and one adult (3%) required tube feedings (p = 0.01). Abdominal surgery had been performed on 6 of 34 (18%) children and 18 of 35 adults (51%) (p < 0.01), without relief of symptoms. Esophageal manometry was abnormal in 5 of 23 (22%) children and 6 of 31 (19%) adults. Antroduodenal manometry was suggestive of neuropathy in 25 children and 26 adults and of myopathy in 3 children and 2 adults. Absence of phase 3 of the migrating motor complex was found in 4 children and 17 adults (p = 0.01). Antroduodenal manometry was normal in six children and seven adults. CONCLUSION Signs, symptoms, and discrete manometric abnormalities of childhood nonulcer dyspepsia resembled those of adult nonulcer dyspepsia. Manometric findings in nonulcer dyspepsia resembled those reported in chronic intestinal pseudo-obstruction, suggesting that these conditions are on a continuum of enteric neuromuscular diseases.

Chronic intestinal pseudoobstruction associated with fetal alcohol syndrome

Alcohol acts as a teratogen in the fetus,resulting in prenatal or postnatal growth failure,characteristic facial dysmorphic features, and centralnervous system dysfunction. The toxic effects of alcohol on the developing brain are well recognized,but gastrointestinal neuropathy has not been describedin fetal alcohol syndrome (FAS). Five children with FASpresented in infancy with signs and symptoms suggestive of chronic intestinal pseudoobstruction. Theywere not able to sustain adequate caloric intake bymouth, and all required prolonged special methods ofalimentation. We performed antroduodenal manometry in these children to determine whether theirsymptoms were associated with a gastrointestinalmotility disorder. All patients had abnormallypropagating phase III-like episodes during fasting(retrograde in four, simultaneous in two). Persistentclusters of stationary contractions were a prominentfeature in two patients. In utero neurotoxicity ofalcohol may not be limited to the central nervoussystem, but may also cause an enteric neuropathypresenting in infancy as chronic intestinalpseudoobstruction.

Colonic Motility in Children with Repaired Imperforate Anus

Following surgical correction of imperforateanus, voluntary bowel control is frequently poor becauseof abnormal anorectal function. Using colonic manometrywe investigated the role of colonic motility in the pathogenesis of fecal soiling inchildren following imperforate anus repair. Thirteenchildren with repaired imperforate anus and fecalsoiling underwent motility testing 2-12 years afteranoplasty. All had fecal incontinence unresponsive toconventional medical treatment. Colonic manometry wasperformed using water-perfused catheters. Anorectalmanometry was undertaken in 10 patients. Motility study results, treatment and outcomes were compared.All patients had high-amplitude propagating contractions(HAPCs) with an average of 80% propagation into theneorectum. There was no correlation between HAPC number or morphology and any variable. Internalanal sphincter resting pressure was low in 6/10patients. Relaxation of the internal anal sphincter waspresent in 6/10 children. Only 1 of 5 patients able to cooperate was capable of generating a normalmaximal squeeze pressure. Therapeutic regimens werechanged in 11 patients with clinical improvement infive. Fecal soiling in patients with repairedimperforate anus is a multifactorial problem includingpropagation of excessive numbers of HAPCs into theneorectum as well as internal anal sphincterdysfunction. Colonic manometry in conjunction withanorectal manometry aids in the understanding of thepathophysiology of fecal soiling and guides clinicalmanagement in children with repaired imperforateanus.

Does cisapride influence cardiac rhythm? Results of a United States multicenter, double-blind, placebo-controlled pediatric study.

Background Major concerns about serious cardiac side effects underlie the recent decision by the FDA and Janssen Pharmaceutica (Titusville, NJ) to make cisapride available only through a limited access program. Concerns have grown despite the fact that most instances of prolonged QTc and other ventricular arrhythmias occurred while the drug was used concomitantly with contraindicated drugs. This study sought to analyze electrocardiograms (ECGs) from a multicenter pediatric study and to identify abnormalities in QTc interval associated with cisapride use. Methods Children between 6 months and 4 years of age were enrolled if they manifested symptoms of gastroesophageal reflux not responding to medical therapy for at least 6 weeks. In 49 subjects, ECGs obtained before and after randomization to receive 0.2 mg/kg dose three times daily or placebo were reviewed independently and blindly by two pediatric cardiologists. Placebo and active drug groups were compared for QTc and for change in QTc from baseline values after 3 to 8 weeks of treatment. Results Mean QTc among patients taking the drug was 408 ± 18 ms. None was higher than 450 ms. Change between baseline and subsequent QTc at 3 to 8 weeks of treatment was 2 ± 20 ms. Conclusions In our study group of children without underlying cardiac disease or electrolyte imbalance, cisapride was found to have no significant effect on cardiac electrical function compared with placebo. These results are consistent with the drugs record of exceedingly infrequent cardiac events. Because the availability of this prokinetic is threatened, its safety and the safety and efficacy of alternative treatment options (including surgery) should be studied further.