Carlo Di Lorenzo

Childhood constipation: evaluation and treatment.

Constipation is common in children. It is estimated that between 5% and 10% of pediatric patients have constipation and/or encopresis. Constipation is the second most referred condition in pediatric gastroenterology practices, accounting for up to 25% of all visits. In this article, a practical approach is laid out for those not familiar with constipation in children. Emphasis is placed on the evaluation and management options that are available to the treating practitioner. The diagnosis of constipation requires careful history taking and interpretation. Diagnostic tests are not often needed and are reserved for those who are severely affected. The daily bowel habits of children are extremely susceptible to any changes in routine environment. Constipation and subsequent fecal retention behavior often begins soon after a child has experienced a painful evacuation. Childhood constipation can be very difficult to treat. It often requires prolonged support by physicians and parents, explanation, medical treatment, and, most important, the childs cooperation.

Colonic motility after surgery for Hirschsprung's disease.

OBJECTIVE:Years after surgery for Hirschsprungs disease, many children continue to suffer from fecal incontinence or constipation. The purpose of the present investigation was to define the physiology underlying the persistent symptoms in children after surgery for Hirschsprungs disease, and to determine the outcome of interventions based on the results of the motility testing.METHODS:We studied 46 symptomatic patients (5.5 ± 3.3 yr old, 35 male) >10 months after surgery for Hirschsprungs disease. We performed a colonic manometry with a catheter placed with the tip in the proximal colon. We used a structured questionnaire and phone interview to follow up the patients an average of 34 months after the manometry.RESULTS:We identified four motility patterns: 1) high-amplitude propagating contractions (HAPCs) migrating through the neorectum to the anal sphincter, associated with fecal soiling (n = 18); 2) normal colonic manometry associated with fear of defecation and retentive posturing (n = 9); 3) absence of HAPCs or persistent simultaneous contractions over two or more recording sites (n = 15), associated with constipation (n = 13); and 4) normal colonic motility and a hypertensive internal anal sphincter (>80 mm Hg) (n = 4). We based treatment on results of the motility studies. There was improvement in global health (mean score, 3.9 ± 1.1 vs 2.8 ± 1.3 at the time of initial evaluation, p < 0.001) and emotional health (3.8 ± 1.1 vs 2.6 ± 1.1, p < 0.0001). Improvement in the number of bowel movements occurred in 72% of children. Resolution or decreased abdominal pain was reported in 80%.CONCLUSIONS:Colonic manometry clarifies the pathophysiology and directs treatment in symptomatic children after surgery for Hirschsprungs disease.

Rumination syndrome in adolescents.

OBJECTIVES To evaluate the clinical presentation and to assess the usefulness of antroduodenal manometry (ADM) and the results of multidisciplinary team management in 12 neurologically normal adolescents (9 girls) with rumination. STUDY DESIGN All patients had extensive investigations that ruled out other causes of their chronic symptoms. We performed ADM in all patients. A multidisciplinary approach was used for the nutritional and behavioral rehabilitation of these patients. RESULTS The median age at presentation was 14 years (range, 9-19 years), and the average duration of symptoms was 17 months. All patients complained of postprandial, effortless regurgitation, and the majority had weight loss and abdominal pain. Results of fasting ADM were normal in all. The postprandial ADM showed brief, simultaneous pressure increases at all recording sites, associated with regurgitation in 8 patients. No emesis was observed in the other 4 children during the study. Treatment included nutritional support in combination with antidepressants and anxiolytics (n = 6), cognitive therapy with biofeedback or relaxation techniques (n = 7), and pain management (n = 2). Resolution or improvement of symptoms was seen in 10 of the 12 patients, and successful transition to oral feedings was achieved in all during the follow-up period, which ranged from 5 to 36 months. CONCLUSIONS Rumination is a distinct functional gastrointestinal disorder of otherwise healthy children and adolescents, which can be diagnosed on the basis of clinical features. The ADM shows a characteristic pattern and rules out motility disorders that are often confused with rumination. A multidisciplinary team approach is associated with satisfactory recovery in most patients.

Quality of Life Outcomes in Congenital Chronic Intestinal Pseudo-Obstruction

The goal of this study was to assess the quality of life for children with chronic intestinal pseudoobstruction. We used a retrospective chart review to identify children with congenital chronic intestinal pseudoobstruction, then a structured telephone interview with parents that included the Child Health Questionnaire to gather information about the current status and quality of life for each patient and family. Children with chronic intestinal pseudo-obstruction had less freedom from pain, depression, and anxiety than healthy children or children with juvenile rheumatoid arthritis (P < 0.05 for all three parameters). Parents of children with chronic intestinal pseudo-obstruction had poorer emotional status than parents of healthy children or children with juvenile rheumatoid arthritis. The time required for parents to care for children with chronic intestinal pseudo-obstruction was greater than the time required to care for healthy children or children with juvenile rheumatoid arthritis (P < 0.01). In conclusion, the quality of life for children with chronic intestinal pseudo-obstruction lags behind that of healthy children and children with another chronic illness. Appropriate treatment of chronic pain may improve the quality of life for children with chronic intestinal pseudo-obstruction and their families. Moreover, attention to reducing each familys burden of time and emotional distress may help them cope better with their chronically ill child.

Colon Cleansing With Oral Sodium Phosphate in Adolescents: Dose, Efficacy, Acceptability, and Safety

BACKGROUND AND AIMS:Standardized bowel preparation in children and adolescents has not been established. Our aim was to compare two bowel preparation regimens and determine which was more effective, acceptable, and safer for children undergoing colonoscopy.METHODS:We compared the efficacy and acceptability of a 1-day regimen with oral sodium phosphate solution (NaP solution) (1 mL/kg/day, maximum 90 mL in two divided doses; regimen A) to our standard 3-day regimen magnesium citrate (4 mL/kg/day × 3 days, maximum 237 mL, followed by an enema the morning of colonoscopy; regimen B). After informed consent was obtained, 48 children were randomized (N = 25, 23, respectively). Weight, electrolytes, calcium, phosphorus, and magnesium were measured at screening and the day of the colonoscopy. Questionnaires were given to assess acceptability and adverse events. Endoscopists rated the quality of bowel preparation on a 4-level scale from excellent to poor.RESULTS:Median age and weight at screening were 14 yr, 53 kg, and 15 yr, 51 kg in regimen A and B, respectively. No statistical significance was observed in electrolytes, phosphorus, or adverse events apart from higher nausea intensity in regimen A (P= 0.012). Bowel cleansing was similar between groups (71% excellent or good). Subjects were more willing to repeat regimen A than B (77% vs 32%, respectively, P < 0.006). All 10 subjects who received regimen A and had prior colonoscopies using regimen B, preferred regimen A.CONCLUSIONS:In a selected group of otherwise healthy children and adolescents over 10.5 yr and above 34 kg, 1-day oral NaP solution was more acceptable than 3-day magnesium citrate with an enema, and both regimens were found to be safe and efficacious.

Function of Hollow Viscera in Children with Constipation and Voiding Difficulties

We wished to investigate the urodynamic characteristics and colonic motility in a group of children with severe chronic constipation and lower urinary tract symptoms. We performed colonic manometry using an endoscopically placed catheter. The urodynamic studies consisted of cystometry, electromyography of the external urethral sphincter, measurement of urinary flow rate, and urethral pressure profile. We found abnormal colonic motility in all patients. Findings included: absent gastrocolonic response (N = 8), absent high-amplitude propagated contractions (HAPCs) (N = 4), and abnormal propagation of HAPCs (N = 7). Urodynamic features were abnormal in 10 children. Findings included: uninhibited bladder contractions (N = 6), hypertonic bladder (N = 2), sphincter dyssynergy (N = 2), small capacity bladder (N = 1). In all children constipation improved, in three after a partial colectomy. Urinary symptoms persisted. We conclude that some children with severe constipation may have a neuropathy affecting both the colonic and lower urinary tracts systems. In this group of patients treatment of constipation does not result in resolution of urinary symptoms.

PEDIATRIC COLORECTAL DISORDERS

Approximately 5% of all visits to pediatricians and up to 30% of referrals to pediatric gastroenterologists involve children with a disorder of defecation. Abnormal stooling is invariably a source of great anxiety for parents and may be quite distressing for the affected child. Chronic fecal incontinence is particularly devastating for the child’s self esteem and for the parent-child interaction. One must remember that constipation and fecal incontinence are symptoms that can be caused by many different diseases. A plethora of organic disorders has been associated with constipation and/or fecal incontinence, but in the majority of cases children presenting with these symptoms suffer from functional constipation which may lead to fecal soiling. Childhood functional constipation differs significantly from constipation in adults. The diagnostic evaluation, differential diagnosis and treatment should be tailored to the pediatric population, because tests or therapies commonly used in adults may be unhelpful or even counterproductive in a constipated child (1).

Pediatric gastric and duodenal disorders.

Purpose of review This review provides a summary of new developments regarding common diseases affecting the stomach and duodenum in children. Recent findings Celiac disease seems to be more prevalent than previously thought in different areas of the world, including the United States. The value of different serologic screening tools and other noninvasive tests has been carefully assessed. HLA-DQ typing has been proposed as part of celiac disease screening testing for high-risk groups. The use of the newly defined pediatric Rome criteria is allowing recognition of nonulcer (or functional) dyspepsia as an entity that affects a sizable subset of children. Testing of gastric sensory and motor function is clarifying the pathophysiology of this condition in children and adolescents. Intriguing data are also emerging about the possible role of mucosal eosinophils and disaccharidase deficiencies in causing dyspeptic symptoms. Intrasphincteric injection of botulinum toxin A represents a novel technique to treat gastroparesis. In refractory cases, the use of a gastric electric stimulator has shown to be beneficial in idiopathic and diabetic gastroparesis. Progress has been made in understanding the epidemiology of Helicobacter pylori infection in developing countries and its role in causing a wide spectrum of symptoms in children. Several noninvasive methods for its diagnosis have been established. Summary Recent developments in the diagnosis and management of gastric and duodenal pathologic conditions are making a significant impact on pediatric clinical care. Future studies will likely continue to explore the use of minimally invasive testing and interventions in such conditions.

Tratamiento actual del estreñimiento infantil

El estreñimiento infantil es un problema mundial. Es una de las molestias más comunes que tienen que afrontar tanto los pediatras generales como los gastroenterólogos pediátricos. El tratamiento del estreñimiento crónico es problemático, a menudo exige un seguimiento a largo plazo y el uso de medicamentos. A pesar de su elevada frecuencia, se han realizado pocos ensayos aleatorizados para investigar la eficacia de las diferentes intervenciones utilizadas para tratar este proceso. En esta revisión comentaremos las opciones terapéuticas actuales para el estreñimiento infantil y abordaremos algunas de las preguntas planteadas más frecuentemente y los conceptos erróneos detectados entre los padres y los médicos.

Conditions Mimicking Gastroesophageal Reflux

Nissen fundoplication remains one of the three most common major surgical procedures performed in infants and children. However, despite its unquestioned value in preventing reflux and emesis, fundoplication is far from being an uncomplicated procedure. Dyspeptic symptoms such as fullness, early satiety, abdominal pain, or bloating may occur in up to 30% of patients who undergo surgery [4].