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Anorectal manometry with and without ketamine for evaluation of defecation disorders in children
A S Keshtgar1, M S Choudhry2, D Kufeji1
1Evelina London Children's Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, UK.
Insights
Ketamine anesthesia is a reliable option for pediatric anorectal manometry, yielding comparable results to awake assessments for most functions. However, evaluating external anal sphincter (EAS) dyssynergia requires awake assessment in children with constipation.
Area of Science:
- Pediatric Gastroenterology
- Physiology
- Anesthesiology
Background:
- Anorectal manometry (ARCM) is crucial for diagnosing pediatric constipation and incontinence.
- ARCM may be challenging in awake children due to discomfort.
- Ketamine anesthesia's impact on ARCM requires evaluation.
Purpose of the Study:
- To assess ketamine anesthesia's effect on ARCM in children.
- To compare manometry findings between awake and ketamine-anesthetized groups.
- To evaluate defecation dynamics and anal sphincter pressure in pediatric constipation.
Main Methods:
- Prospective study comparing awake ARCM (n=52) with ketamine-anesthetized ARCM (n=64).
- Age-matched subgroups analyzed (31 awake, 27 ketamine).
- Evaluated anal sphincter resting pressure, rectal capacity, and contraction dynamics.
Main Results:
- ARCM profiles were comparable between awake and ketamine groups.
- Key parameters like resting pressure, rectal capacity, and contraction frequency showed no significant differences.
- External anal sphincter (EAS) dyssynergia was only detectable in awake children (42%).
Conclusions:
- Ketamine anesthesia reliably assesses autonomic anorectal function in children.
- It is a viable alternative for children unable to tolerate awake ARCM.
- EAS dyssynergia evaluation necessitates awake assessment for obstructive defecation diagnosis.
Introduction:
Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children.
Methods:
This was a prospective study of children who were investigated for symptoms of chronic constipation and soiling between April 2001 and April 2004. We studied 52 consecutive children who had awake ARCM, biofeedback training and endosonography (awake group) and 64 children who had ketamine anesthesia for ARCM and endosonography (ketamine group). We age matched 31 children who had awake anorectal studies with 27 who had ketamine anesthesia.
Results:
The children in awake and ketamine groups were comparable for age, duration of bowel symptoms and duration of laxative treatments. ARCM profile was comparable between the awake and the ketamine groups with regard to anal sphincter resting pressure, rectal capacity, amplitude of rectal contractions, frequency of rectal and IAS contractions and functional length of anal canal. Of 52 children who had awake ARCM, dyssynergia of the EAS muscles was observed in 22 (42%) and median squeeze pressure was 87mm Hg (range 25-134). The anal sphincter resting pressure was non-obstructive and comparable to healthy normal children. Rectoanal inhibitory reflex was seen in all children excluding diagnosis of Hirschsprung disease.
Conclusions:
Ketamine anesthesia does not affect quantitative or qualitative measurements of autonomic anorectal function and can be used reliably in children who will not tolerate the manometry while awake. Paradoxical contraction of the EAS can only be evaluated in the awake children and should be investigated further as the underlying cause of obstructive defecation in patients with chronic functional constipation and soiling.
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