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Published on: September 11, 2012
Pathophysiology of chronic childhood constipation: functional and morphological evaluation by anorectal manometry and
Alireza S Keshtgar1, Harry C Ward, Graham S Clayden
1Evelina Children Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom. ali.keshtgar@gstt.nhs.uk
Insights
Internal anal sphincter (IAS) overactivity does not cause chronic constipation in children. Studies show normal IAS resting pressure in pediatric patients, suggesting other factors may be involved in obstructive defecation.
Area of Science:
- Pediatric Gastroenterology
- Gastrointestinal Motility Disorders
- Colorectal Surgery
Background:
- Chronic idiopathic constipation (IC) is a prevalent condition affecting children.
- A hypothesis suggested that internal anal sphincter (IAS) hypertonicity and overactivity contribute to childhood IC.
Purpose of the Study:
- To investigate the role of internal anal sphincter (IAS) function in the pathophysiology of chronic idiopathic constipation (IC) in children.
- To determine if IAS hypertonicity or overactivity correlates with symptom severity or obstructive defecation in pediatric IC patients.
Main Methods:
- Prospective study of 92 children with chronic constipation at a pediatric gastrointestinal motility clinic.
- Utilized colonic transit marker studies, anorectal manometry, and anal endosonography under anesthesia.
- Assessed constipation and fecal incontinence using a validated symptom severity (SS) score over 12 months.
Main Results:
- Median IAS resting pressure was normal (55 mm Hg).
- IAS contraction amplitude and frequency did not correlate with resting pressure.
- Colonic transit times were significantly prolonged, particularly in the rectosigmoid region.
Conclusions:
- Childhood chronic idiopathic constipation is not caused by elevated internal anal sphincter (IAS) resting pressure.
- Increased IAS contraction frequency and amplitude do not lead to raised resting pressure or obstructive defecation.
- Further research is needed to explore the role of external anal sphincter dysfunction in pediatric constipation and fecal incontinence.
Background:
Chronic idiopathic constipation (IC) is a common problem in children. We hypothesised that hypertonicity and overactivity of the internal anal sphincter (IAS) contributed to childhood IC.
Method:
This was a prospective study of children who were admitted for investigation and treatment of chronic constipation at the gastrointestinal motility clinic in Guy's and St. Thomas' Hospital, NHS Foundation Trust, London. All children had a colonic transit marker study followed by anorectal manometry and anal endosonography under ketamine anesthesia. We used a validated symptom severity (SS) score questionnaire for assessment of constipation and fecal incontinence on admission to hospital and during follow-up for 12months. The SS score of 0 was the best and 65 the worst.
Results:
Of 92 children, 57 were male and median (range) age was 8.46years (3.35-14.97). Duration of symptoms was 4.7years (0.3-13). Soiling was present in 88 (96%) patients, delay in defecation of once every 2 to 3days or less frequently in 86 (93%) and a palpable fecaloma (megarectum) on abdominal examination in 76 (83%). 42 children had 'fecal impaction' requiring disimpaction of stool from the rectum under general anesthesia and 50 had 'no impaction'. The median IAS resting pressure was within the normal range measuring 55mm Hg (25-107) and median amplitude and frequency of the IAS contractions were 10mm Hg (2.0-58) and 17cycles per min (5.0-34), respectively. The median IAS thickness was 0.93mm (0.5-2.0). There was no correlation between amplitude and frequency of anorectal contractions and anal sphincter resting pressure. The mean right colonic transit time was 8.55 (standard deviation ±13.22) h, left colonic transit time was 11.51h (±13.21), rectosigmoid transit time was 25.91h (±18.89) and total colonic transit time was 45.97h (±17.69).
Conclusion:
The anal sphincter resting pressure is normal in children with chronic IC. Increased frequency and amplitude of IAS contractions seen in these patients do not cause raised anal sphincter resting pressure or obstructive defecation. Further studies should be done to investigate the role of external anal sphincter dysfunction in pathophysiology of childhood constipation and fecal incontinence.
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