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Published on: November 9, 2016
Botulinum toxin injection for childhood constipation is safe and can be effective regardless of anal sphincter
Claire Zar-Kessler1, Braden Kuo2, Jaime Belkind-Gerson3
1Division of Pediatric Gastroenterology, Hepatology and Nutrition, Center for Neurointestinal Health, Massachusetts General Hospital for Children, 55 Fruit St., Boston, MA 02114.
Insights
Botulinum Toxin (BT) injections effectively treat severe childhood constipation, with over half experiencing relief for more than six months. Fecal incontinence may predict a poorer response to BT treatment.
Area of Science:
- Pediatric Gastroenterology
- Colorectal Surgery
Background:
- Childhood constipation is a prevalent condition.
- Internal anal sphincterotomy was previously used for hypertensive sphincters.
- Botulinum Toxin (BT) injections show recent promise for hypertensive/non-relaxing sphincters.
Purpose of the Study:
- To investigate the effectiveness of Botulinum Toxin (BT) injections for severe childhood constipation.
- To analyze BT response duration, symptom association, and efficacy in relation to sphincter dynamics.
- To compare outcomes based on anorectal manometry findings.
Main Methods:
- Retrospective study of 164 children with severe constipation unresponsive to medication.
- Anorectal manometry (ARM) was used to assess sphincter pressure and rectoanal inhibitory reflex (RAIR).
- Patients were grouped by normal/elevated sphincter pressure and normal/abnormal RAIR.
Main Results:
- 70% of 142 analyzed patients showed a positive response to BT, with 57% lasting over 6 months.
- Response rates were similar for normal (69%) and elevated (68%) sphincter pressures (p=0.87).
- Fecal incontinence prior to BT predicted a poorer response (p=0.02); fecal incontinence was the most common side effect, typically resolving within a week.
Conclusions:
- Botulinum Toxin (BT) is an effective treatment for chronic constipation in children.
- Children with pre-existing fecal incontinence may have a less favorable response to BT.
- BT offers prolonged benefit for many children, regardless of baseline sphincter dynamics, and is a viable option for intractable constipation.
Background:
Childhood constipation is common. Previously, internal anal sphincterotomy has been used for hypertensive/non-relaxing sphincters; however, recent benefit has been shown with Botulinum Toxin (BT) injections. The aim is to investigate BT, including response duration, symptom association and effectiveness in relation to sphincter dynamics.
Methods:
Retrospective study of 164 children receiving sphincter BT for severe constipation unresponsive to medication management. Charts reviewed for symptoms, anorectal manometry (ARM) findings and response defined by decreased pain or increased defecation. Patients were grouped: normal sphincter pressure (≤50 mmHg), elevated (>50 mmHg), normal and abnormal rectoanal inhibitory reflex (RAIR).
Results:
There were 142 analyzed and 124 completed ARMs; 98 (70%) had positive response with 57% lasting greater than 6 months. 36 had normal sphincter pressure with 24 (69%) responding. 88 had elevated pressure with 60 (68%) responding (p=0.87). 90 normal RAIRs with 64 (71%) responding. 34 abnormal RAIRs with 22 (64%) responding (p=0.41). With logistic regression, fecal incontinence prior to BT was a predictor of poor response (p= 0.02). The most common side effect was fecal incontinence typically resolving within week with equal frequency regardless of sphincter dynamics.
Conclusions:
BT is effective for children with chronic constipation. Patients with fecal incontinence are less likely to respond. More than half had prolonged beneficial response. Those with normal and abnormal sphincter dynamics had similar responses and without differences in side effects. Therefore, injection may be considered in patients with intractable constipation unresponsive to medication, regardless of anal sphincter dynamics.
Level Of Evidence:
Level III (Treatment Study: Retrospective comparative study).
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