Desale Yacob

Prevalence of pain-predominant functional gastrointestinal disorders and somatic symptoms in patients with anxiety or depressive disorders.

OBJECTIVE To determine whether children with symptoms of internalizing psychiatric disorders have a greater prevalence of pain-predominant functional gastrointestinal disorders (FGIDs) and migraine-like headaches. STUDY DESIGN Children and adolescents aged 6-18 years were recruited from a behavioral health center (n = 31) and a primary care center (n = 36). Subjects completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-based symptom inventory questionnaires to screen for internalizing psychiatric disorders, the Questionnaire on Pediatric Gastrointestinal Symptoms, and a somatic distress assessment interview. RESULTS Thirty-three subjects (19 of 31 from the behavioral health center and 14 of 36 from the primary care center) screened positive for symptoms of anxiety or depressive disorders. The remainder screened negative and served as controls. Pain-predominant FGIDs were more common in the group with symptoms of anxiety or depression compared with controls (prevalence, 51.5% vs 8.8%; P = .0002). Migraine headaches occurred in 57.6% of the subjects with internalizing psychiatric disorders vs 23.5% of the control group (P = .006). The prevalence of functional constipation did not differ significantly between the 2 groups. The data remained essentially unchanged when analyzed within each center of recruitment. CONCLUSION Youths with anxiety or depressive symptoms are more likely to suffer from pain-predominant FGIDs and migraine-like headaches, but not from functional constipation. The lack of an association between functional constipation and internalizing psychiatric symptoms suggests that FGIDs associated with pain may bear a specific relationship to emotional disorders.

Childhood constipation: finally something is moving!

Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.

Dexmedetomidine-ketamine sedation during upper gastrointestinal endoscopy and biopsy in a patient with Duchenne muscular dystrophy and egg allergy

Sedation during invasive procedures provides appropriate humanitarian care as well as facilitating the completion of procedure. Although generally safe and effective, adverse effects may occur especially in patients with co-morbid diseases. In many cases, given its rapid onset and offset, propofol is chosen to provide sedation during various invasive procedures. We present a nine-year-old, 45 kg child with Duchenne muscular dystrophy (DMD) who presented for esophagogastroduodenoscopy (EGD). Given the egg allergy, which was a relative contraindication to the use of propofol, and the potential risk of malignant hyperthermia due to DMD, a combination of dexmedetomidine and ketamine was used for procedural sedation. Dexmedetomidine was administered as a loading dose of 1 μg/kg along with a single bolus dose of ketamine (1 mg/kg). This was followed by a dexmedetomidine infusion at 0.5 μg/kg/hour. The patient tolerated the procedure well and was discharged to home. Previous reports regarding the use of dexmedetomidine and ketamine for procedural sedation are reviewed and the potential efficacy of this combination is discussed.

Surgical options for the management of severe functional constipation in children.

Purpose of review Constipation is a very common problem in pediatrics with both the severity of presentations and treatments varying across a broad spectrum. The majority of children with functional constipation are managed successfully without the need for specialized testing and surgical intervention. Those who present with intractable constipation, with or without fecal soiling, require referrals for motility testing that helps determine both medical and surgical management, and interventions. The literature was reviewed for publications on surgical approaches to children with severe constipation, including assessing the quality and levels of evidence and the use of objective measures to determine outcomes. Recent findings There is very little in the way of recent studies evaluating surgical indications or treatment approaches for functional constipation, apart from one systematic review and one recent expert review. Although the systematic review was published in the last year, most of the studies it analyzes are older. The vast majority of studies comprise level 4 and 5 evidence. Summary The indication for most surgical procedures is ‘failed’ medical management, yet no standardized definition for this exists. Many surgical procedures are proposed with little evidence to show outcomes. We recommend that the surgical evaluation and treatment of children with constipation needs to be protocolized and studied in a prospective manner using validated outcomes measures. Our centers current protocol is described.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation

BACKGROUND Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE IV.

Surgical decision-making in the management of children with intractable functional constipation: What are we doing and are we doing it right?

BACKGROUND Children with intractable functional constipation (FC) may eventually require surgery, often guided by motility testing. However, there are no evidence-based guidelines for the surgical management of intractable FC in children. AIM To assess the diagnostic and surgical approach of pediatric surgeons and pediatric gastroenterologists towards children with intractable FC. METHODS A survey was administered to physicians attending an international conference held simultaneously in Columbus (Ohio, USA) and Nijmegen (the Netherlands). The survey included 4 questions based on cases with anorectal and colonic manometry results. RESULTS 74 physicians completed the questionnaire. Anorectal manometry was used by 70%; 52% of them would consider anal sphincter botulinum toxin injections for anal achalasia and 21% would use this to treat dyssynergia. Colonic manometry was used by 38%; 57% of them reported to use this to guide surgical decision-making. The surgical approach varied considerably among responders answering the case questions based on motility test results; the most commonly chosen treatments were antegrade continence enemas and anal botulinum injections. CONCLUSION Surgical decision-making for children with intractable FC differs among physicians. There is a need for clinical guidelines regarding the role of anorectal and colonic manometry in surgical decision-making in children with intractable FC.

How to Deal with Pediatric Functional Gastrointestinal Disorders

Pain predominant functional gastrointestinal disorders (FGID) are common in the pediatric population and this review article is meant to explore the diagnostic and therapeutic approaches taking into account the most recent developments in the field.

Concerning our publication ‘Assessing colonic anatomy normal values based on air contrast enemas in children younger than 6 years’: reply to M. D. Levin

Dear Editors, First of all, we would like to kindly thank Dr. Levin for his interest in our work and the letter he wrote [1] concerning our publication in the journal Pediatric Radiology [2]. Here we provide a point-by-point response to the questions and concerns raised by Dr. Levin. We agree that it is uncertain whether the study population of children with intussusception is an accurate representation of the normal population. In the discussion of the article, we explained why we chose this approach:

Neuromodulation for Treatment of Pediatric Defecatory Disorders

Defecatory disorders are relatively common in children and can have a significant detrimental impact on a child’s quality of life. Treatment options for constipation and fecal incontinence refractory to conventional treatment are limited and often invasive. Neuromodulation is a promising treatment modality for this population. Evidence for the use of sacral neuromodulation to treat children with refractory constipation and fecal incontinence has been growing over the past decade, and there are reports of clinical response in children with a variety of underlying disorders, including functional constipation, anorectal malformation, and spinal cord abnormalities. However, sacral neuromodulation does require surgery and can be associated with certain known risks of complications, which may require additional procedures. Less invasive forms of neuromodulation, like abdominal transcutaneous electrical stimulation and posterior tibial nerve stimulation, have been used for children with defecatory disorders to a limited extent and with mixed results. In this chapter, we review current applications of neuromodulation for treatment of pediatric defecatory disorders and discuss potential future applications.

A comparison of Malone appendicostomy and cecostomy for antegrade access as adjuncts to a bowel management program for patients with functional constipation or fecal incontinence

BACKGROUND Appendicostomy and cecostomy are two approaches for antegrade enema access for children with severe constipation or fecal incontinence as adjuncts to a mechanical bowel management program. Each technique is associated with a unique set of complications. The purpose of our study was to report the rates of various complications associated with antegrade enema access techniques to help guide which option a clinician offers to their patients. METHODS We reviewed all patients in our Center who received an appendicostomy or cecostomy from 2014 to 2017 who were participants in our bowel management program. RESULTS 204 patients underwent an antegrade access procedure (150 appendicostomies and 54 cecostomies). Skin-level leakage (3% vs. 22%) and wound infections (7% vs. 28%) occurred less frequently in patients with appendicostomy compared to cecostomy. Nineteen (13%) appendicostomies required revision for stenosis, 4 (3%) for mucosal prolapse, and 1 (1%) for leakage. The rates of stenosis (33 vs. 12%) and wound infection (13 vs. 6%) were higher in patients who received a neoappendicostomy compared to an in situ appendicostomy. Intervention was needed in 19 (35%) cecostomy patients, 15 (28%) for an inability to flush or a dislodged tube, and 5 for major complications including intraperitoneal spillage in 4 (7%) and 1 (2%) for a tube misplaced in the ileum, all occurring in patients with a percutaneously placed cecostomy. One appendicostomy (1%) patient required laparoscopic revision after the appendicostomy detached from the skin. CONCLUSION Patients had a lower rate of minor and major complications after appendicostomy compared to cecostomy. The unique complication profile of each technique should be considered for patients needing these procedures as an adjunct to their care for constipation or fecal incontinence. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.