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Slow transit constipation in children
J M Hutson1, J McNamara, S Gibb
1Department of General Surgery and General Paediatrics, Royal Children's Hospital and, Murdoch Children's Research Institute, Parkville, Victoria, Australia. hutsonj@cryptic.rch.unimelb.edu.au
Insights
Pediatric slow transit constipation, a recently described condition, presents challenges in treatment-resistant cases. Identifying intestinal neuronal dysplasia may lead to new diagnostic criteria and therapies for this severe constipation.
Area of Science:
- Pediatric Gastroenterology
- Colorectal Surgery
- Neurogastroenterology
Background:
- Chronic constipation in children unresponsive to treatment poses a significant clinical challenge.
- Slow transit constipation (STC) is a recently identified condition in pediatrics characterized by delayed colonic transit.
- A subset of children with STC exhibit intestinal neuronal dysplasia (IND), an innervation abnormality linked to colonic dysfunction.
Purpose of the Study:
- To describe the clinical features and diagnostic findings of slow transit constipation in children.
- To explore the association between intestinal neuronal dysplasia and slow transit constipation.
- To highlight the need for improved understanding and management strategies for pediatric STC.
Main Methods:
- Review of clinical features in children with intractable constipation.
- Assessment of colonic transit using transit studies.
- Histopathological examination of rectal biopsies for intestinal neuronal dysplasia (IND) and colon muscle biopsies for nerve fiber analysis.
Main Results:
- Common STC features include delayed meconium passage, early-onset severe constipation, or treatment-resistant encopresis.
- Intestinal neuronal dysplasia type B, characterized by submucosal plexus hyperplasia, is identified in a proportion of STC patients.
- Reduced substance P-immunoreactive nerve fibers in the circular muscle were observed in colon biopsies.
Conclusions:
- Slow transit constipation represents a distinct entity in pediatric functional bowel disorders.
- Intestinal neuronal dysplasia is associated with colonic motility dysfunction in pediatric STC.
- Further research into the pathophysiology and neurobiology of STC is crucial for developing targeted therapies.
Abstract:
Patients with chronic constipation that fails to respond to treatment remain a challenge for paediatricians and surgeons. Ongoing work in our institution suggests that a number of children with intractable symptoms have slow transit constipation, which has only been described recently in paediatrics. Common features of slow transit are: delayed passage of the first meconium stool beyond 24 h of age, symptoms of severe constipation within a year, or treatment-resistant 'encopresis' at 2-3 years, soft stools despite infrequent bowel actions, and delay in colonic transit on a transit study. A proportion of children with slow transit constipation have an abnormality of intestinal innervation associated with the dysfunctional colonic motility, recognized as intestinal neuronal dysplasia (IND). Intestinal neuronal dysplasia type B, the most common variant of IND, is defined on rectal biopsy by hyperplasia of the submucosal plexus. On laparoscopic colon muscle biopsy, many specimens show reduced numbers of excitatory substance P-immunoreactive nerve fibres in the circular muscle. Functional markers of the nerves allow new diagnostic criteria to be developed which may also allow a more rational approach to treatment. The aetiology remains obscure and the optimal management poorly defined, although subtotal colectomy, proximal colostomy or appendicostomy (for antegrade enemas) have been tried. Once the anatomy and physiology of the colon in children with slow colonic transit is better understood, we will have defined not only a new form of constipation, but also will be able to consider new therapies.
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