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Manometric Tests of Anorectal Function in 90 Healthy Children Journal of Pediatric Surgery (2009) 44, 1786–1790 www.elsevier.com/locate/jpedsurg Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait Sunil Kumar⁎, Saleema Ramadan, Vipul Gupta, Safwat Helmy, Imran Atta, Ashraf Alkholy Department of Pediatric Surgery, Ibn Sina Hospital, P O Box 25427, Safat-13115, Kuwait, Kuwait Received 6 October 2008; revised 7 January 2009; accepted 7 January 2009 Key words: Abstract Rectoanal inhibitory Background/Purpose: Anorectal manometry is a noninvasive test used to evaluate conditions like slow- reflex, RAIR; transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative Resting pressure of anal results after Hirschsprung and anorectal malformations. This cross section study was designed to have canal, RP; normal manometric values of anorectal function in healthy children of different ages in Kuwait so that High-pressure zone, HPZ; control values are available for comparisons with various pathological states. Anal canal length, ACl Method: Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1—neonates up to 1 month, group 2—infants from 1 month to 1 year, and group 3—children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR). Result: Anorectal manometry was successfully done in all 90 children of different age groups with- out any complications. High-pressure zone or anal canal length was 1.67 ± 0.34 cm in neonates, 1.86 ± 0.6 cm in infants, and 3.03 ± 0.52 cm in children. Mean resting pressure of anal canal was 31.07 ± 10.9 mm Hg in neonates, 42.43 ± 8.9 mm Hg in infants, and 43.43 ± 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 ± 3.6, 14.0 ± 9.5, and 25.0 ± 11.6 mL was required for noenates, infants, and children, respectively. Conclusion: Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum. © 2009 Elsevier Inc. All rights reserved. Anorectal manometry offers a noninvasive diagnostic test results after definitive surgery for anorectal malformation for identifying dysfunction of the anorectum in children. It [3,4] and Hirschsprung disease [5,6]. However, there is a has been used commonly in clinical practice to diagnose lack of uniformity with regard to the methods of performance Hirschsprung disease [1,2] and to evaluate postoperative and interpretation of the tests. There is also a relative lack of normative data stratified for different pediatric age groups. ⁎ Corresponding author. Tel.: +965 24834794; fax: +965 24834864. This cross sectional study aims to measure anorectal E-mail address: [email protected] (S. Kumar). manometric parameters like length of high-pressure zone 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.01.008 Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City September 07, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. Manometric tests of anorectal function 1787 (HPZ) or anal canal length (ACL), resting pressure of anal digital converter, and information was transmitted via a canal (RP), and rectoanal inhibitory reflex (RAIR) in fiberoptic cable to a personal computer where data were children who have no symptoms pertaining to the gastro- collected and tracings were obtained on paper. Before each intestinal tract. study, a calibration of PolyGram was performed. 1.3. Manometric technique and measurements 1. Materials and methods Anorectal manometry was performed with the child in 1.1. Subjects supine position. Bowel preparation was done 2 hours before the study with glycerin suppository or enema (2 mL/kg). No sedative was given to any child. Distraction techniques and a From October 2007 to October 2008, 90 children (58 boys honey-coated pacifier were used in cases of young agitated and 32 girls) without any symptoms related to the lower children. All the tubings were connected before the gastrointestinal tract underwent anorectal manometry at Ibn beginning of the test, and calibration was performed before Sina Hospital, Kuwait. These children were either local the child was brought inside the room. A well-lubricated residents or immigrants from Asian, African, or Middle East anorectal catheter was introduced gently up to the 10 cm countries. They belonged to different social, ethnic, and mark so as to have the balloon placed high in the rectum. In cultural backgrounds and were studied in 3 age groups, with neonates with a small anal opening, the catheter was group 1 including neonates up to 1 month of age; group 2, introduced without a balloon. Live recording of the test infants from 1 month to 1 year; and group 3, children more was switched on once the child was quiet under a warm than 1 year. blanket with 1 parent beside the examination bed. The The research and Ethical Committee of Ibn Sina Hospital, catheter was withdrawn by stationary pull-through technique Kuwait, approved the study protocol, and a well-informed so as to pull a half centimeter every 60 seconds until all 4 written consent of the parents and children (when applicable) sensors (side holes) were out of anal verge. was obtained before each study. 1.4. Manometric ACL 1.2. Equipment The beginning of the anal canal was characterized by an Manometry was performed using a water perfused abrupt increase in the pressure of a particular channel of the 4-channel anorectal motility catheter (4.5-mm outer dia- catheter while it was being pulled by the stationary pull- meter) with 4 side openings placed spirally at 1-cm intervals through method. The end of the anal canal was identified (Fig. 1). The catheter tip was at a distance of 4.5 cm from the when the pressure of the same channel dropped to 0 and first side hole and had a port for a balloon of 250 mL the side hole appeared at the anal verge. Thus, total maximum capacity, which was to be inflated in the rectum. distance in centimeters traveled by 1 channel from the first All side holes were perfused with normal saline at rate of rise in the pressure until the anal verge (0 pressure) gave 0.5 mL/min (0.2 mL/min for neonates). Pressures were the ACL or HPZ. measured by pressure transducers situated in each perfusion line and connected to a PC through a PolyGram interface (Medtronic). The measured signals obtained from the Poly- 1.5. Resting pressure of the anal canal Gram net were converted into digital values by an analog- Although a particular channel was crossing the anal canal, 3 pressure segments were selected on the graph at 3 different levels, and the mean of these 3 readings was calculated as the resting pressure of that particular channel. Resting pressure of all channels was obtained in same manner, and the mean of all 4 channels was automatically calculated as the RP in millimeters of mercury. 1.6. Rectoanal inhibitory reflex The catheter was positioned in such a manner that the balloon was in the rectum and at least 1 channel was in the HPZ recording the baseline pressure. After 2 to 3 minutes of accommodation, RAIR was elicited with rapid inflation of the rectal balloon with a volume of air appropriate for age. Fig. 1 Anorectal manometry catheter with the balloon at the tip. Within 3 to 5 seconds, air was completely withdrawn from Downloaded from ClinicalKey.com at The Children's Mercy Hospital - Kansas City September 07, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. 1788 S. Kumar et al. Fig. 2 The RAIR (fall in the anal resting pressure of more than 5 mm Hg on air injection in rectal balloon is seen in lower tracings). the balloon. The initiation of the reflex was characterized by significance accepted at a P value less than .05. Results are an anal sphincter pressure drop of at least 5 mm Hg (Fig. 2). expressed as mean and SD or percentage. The initial volume used to demonstrate RAIR was 3, 10, and 20 mL in groups 1, 2, and 3, respectively. The threshold air volume required to stimulate RAIR was determined by 2. Results increasing the volume of air in a stepwise fashion. When the threshold volume required to stimulate the reflex had been determined, 3 further distensions were performed at 1-minute Of 90 children studied, there were equal numbers (30 intervals to document the presence of the RAIR. In neonates each) of neonates, infants, and children. Mean gestational with a small caliber anal opening, air was injected in the age of group 1 (neonates) was 37.4 ± 1.3 weeks (range, 34-39 rectum without using a balloon at the catheter tip. The weeks), whereas median age at the time of study was 6 days catheter was stabilized with a piece of tape at the level of (range, 3-28 days). Average weight of the neonates at the gluteal skin to avoid artifact owing to dislodgement at the time of study was 2.9 ± 0.7 kg (range, 1.9-4.7 kg). Group 2 time of inflation of balloon. Presence or absence of the reflex infants were aged 35 days to 16 months (mean age, 5.1 ± 4.2 was marked on the graph at different volumes of air injected.
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