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Multidisciplinary Approach to Chronic Constipation Associated with Fecal Incontinence in Children

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Multidisciplinary Approach to Chronic Constipation Associated with Fecal Incontinence in Children GENERAL PAPERS MULTIDISCIPLINARY APPROACH TO CHRONIC CONSTIPATION ASSOCIATED WITH FECAL INCONTINENCE IN CHILDREN Claudia Olaru1, Smaranda Diaconescu1, Valeriu V. Lupu1, Nicoleta Gimiga1, Gabriela Paduraru1, Ancuta Ignat1, Radian A. Olaru2, Vasile Drug3, Marin Burlea1 1Department of Pediatrics, „Sf. Maria“ Children Emergency Hospital, „Gr. T. Popa“ University of Medicine and Pharmacy, Iasi 2„Gr. T. Popa“ University of Medicine and Pharmacy, Iasi 3Institute of Gastroenterology and Hepatology, „Gr. T. Popa“ University of Medicine and Pharmacy, Iasi ABSTRACT Constipation is a common symptom in clinical practice. Defi nition include abnormal transit diffi culty during def- ecation and abnormal stool consistency. Limited diagnostic methods and the many diseases that lead to symp- toms, leading to more cases of drug resistance. Treatment includes dietary and behavioral approaches, phar- macological therapy and surgery in carefully selected cases. Surgery is recommended in patients with severe constipation resistant to conservative treatment. Confi rmation of indication for surgical treatment requires co- lonic transit studies, defecation function and conducting anorectal manometry. Therefore, a close collaboration between pediatric gastroenterologists and surgeon pediatricians is essential for the careful preoperative evalu- ation and gastrointestinal function. Postoperative complications include intestinal obstruction, abdominal pain, fl atulence and diarrhea. The effectiveness of surgery and prevalence of postoperative complications are deter- mined by a careful preoperative evaluation of the gastrointestinal function. Keywords: organic constipation, encomprezis, surgical treatment, child Chronic constipation is a debilitating disease According to Rome III criteria (2006), chronic that is best managed through a multidisciplinary constipation is defi ned by: the presence of 2 or few- approach that includes pediatricians and gastroen- er bowel movements per week; at least 1 episode of terologists and usually consists of diet modifi ca- fecal incontinence per week; a history of adoption tion, cathartic agents, enemas and psychotherapy. of voluntary retention posts or excessive retention However, 40-50% of patients do not respond to of feces; diffi cult removal or disposal of faeces of medical treatments, so the surgery orientation has increased consistency; presence of faeces in the played an increasingly important role over the last rectum; removal of faeces of increased diameter. decade (1,2). In the past, the surgical approach was The diagnosis is supported in children aged 0-4 limited to the treatment of complications of consti- years if at least two criteria were present in at least pation and correction of anorectal anomalies. Re- 1 month and children over 4 years if at least two cently, this role has expanded and surgical treat- criteria were present at least 1 time per week for a ments now include: internal sphincter myomectomy minimum of 2 months. (1) and access for antegrade enemas by right cecosto- Intestinal fecal incontinence is the loss of con- my. For diagnostic accuracy, transanal rectal biopsy trol, resulting in involuntary passage of stool. This is practiced. (3-6) Corresponding author: Smaranda Diaconescu, „Gr. T. Popa“ University of Medicine and Pharmacy, 16 University Street, Iasi E-mail: [email protected] 14 REVISTA ROMÂNÅ DE PEDIATRIE – VOLUMUL LXIV, NR. 1, AN 2015 REVISTA ROMÂNÅ DE PEDIATRIE – VOLUMUL LXIV, NR. 1, AN 2015 15 can range from an occasional leakage of small Faecal incontinence is a devastating problem af- amounts of stool and passing gas up to a complete fecting approximately 25% of patients born with loss of control of stool. Faecal incontinence is esti- anorectal malformations (1), some patients who mated to affect between 0.8-4.1% of children in underwent surgery for Hirschsprung disease (2), Western societies. (7,8) Recent studies in Asia have patients who were born with pelvic tumors (3,4 ), shown that faecal incontinence is a signifi cant spina bifi da (5), sacral agenesis (6,18) and in pa- problem in Iran, South Korea and Sri Lanka, r ang- tients who had severe pelvic trauma. Children and ing from 2% to 7.8%. (9-11) A recent study from adults with faecal incontinence are often discrimi- Sri Lanka conducted on children aged 10-16 years nated against and can not have an active and pro- reported a higher prevalence of fecal incontinence ductive life. (19) in younger children (5.4%), while in adolescents a Children who underwent surgery for Hirschsprung much lower prevalence (<1%) was reported. (11) A disease have lost some of these components due to study from the Netherlands also noted that children surgery. They often develop postoperative consti- aged 5-6 years are more likely to develop faecal pation. Of these, a low percentage may suffer from incontinence than children aged 11-12 years (7). faecal incontinence as a sequela of surgery. Chil- Chronic constipation with faecal incontinence in dren with constipation after correction of anal im- order of the frequency of cases is associated to the perforation are included in this category. following categories of malformation: anorectal Children with recto-prostatic fi stula may devel- malformation, Hirschsprung’s disease, spina bifi da op in a percentage similar to voluntary bowel con- or agenesis of the sacrum. Until recently, faecal in- trol or they may be incontinent. In these cases it is continence and constipation were considered psy- necessary to attempt to make use of the toilet train- chiatric disorders and some of these children were ing. If this proves to be unsuccessful, the manage- directed to psychiatric clinics. In fact, 5.7% of chil- ment of bowel control should be implemented im- dren attending a psychiatric unit suffer from faecal mediately, so that the child can stay clean and avoid incontinence. (12) In previous studies the preva- the psychological sequelae lence of fecal incontinence was signifi cantly higher Other complications are represented by urinary in boys, with a ratio ranging from 3: 1 to 6: 1 against incontinence that occurs in male children with ano- girls. (7,11,13-17) rectal defects when they have a highly defective or Intestinal motility is one of the most complex absent sacrum or where the basic principles of sur- and sophisticated functions in the human body. The gery are not observed, signifi cantly damaging the colon absorbs water and acts as a reservoir. The liq- nerve endings during surgery. uid waste produced by the small intestine in the ce- Two surgical procedures have been described: cum, turns into solid stool in the descending and colon resection and access to perform retrograde sigmoid colon. To achieve fecal continence, three enemas. components are needed: rectal sensation, colonic According Lahr et al. (18), surgical treatment of motility and anal sphincter control. The patient’s constipation can be taken into account if several ability to maintain fecal continence vary depending criteria are met, including: 1) it must justify the se- on the type of anorectal malformation with which verity of surgical risk, 2) medical and psychologi- he/she was born. Major malformations are often ac- cal causes were excluded, 3) medical treatment companied by muscle atrophy, while small malfor- mations are usually associated with good muscle failed, and 4) diagnostic studies show anatomical function. or physiological abnormalities which can be cor- Anorectal defects associated with good progno- rected. sis are: ano-vestibular fi stula, perineal fi stula, rectal Surgical treatment is indicated in selected pa- atresia, recto-urethral fi stula and anal non-perfora- tients with chronic constipation resistant to pediat- tion without fi stula. ric treatment. Patients with constipation as a symp- Supervision of these children is needed to avoid tom of an organic disease of the digestive tract constipation, impaction and fecal incontinence. where surgery is a treatment of choice must be ex- Anorectal defects associated with a poor prog- cluded: slow transit constipation, rectocele, entero- nosis are: large cloaca with a common channel cel, rectal intussusception and rectal prolapse. largern than three centimeters and recto-vesical fi s- Preoperative evaluation should include: intesti- tula. nal transit time, anorectal manometry, antroduode- In children with anorectal malformations some nal manometry, anal sphincter electromyography or all of these essential components are missing. and defecography. 16 REVISTA ROMÂNÅ DE PEDIATRIE – VOLUMUL LXIV, NR. 1, AN 2015 Bowel management is indicated in patients with Sigmoid resection complications include leak- faecal incontinence after surgical repair of imperfo- age at the anastomosis level. This complication is rate anus or Hirschsprung disease. It is also used in similar to the complication that may arise after co- patients who present continence after surgery, but lon resections for other conditions. suffer from constipation (18). In patients with faecal incontinence, fair treat- Certain categories of patients may be candidates ment consists of a bowel management program by for resection of sigmoid. This procedure is indicat- administering enemas on a daily basis. Their rectal ed for those patients with a massive expansion of administration can be problematic in older chil- the rectosigmoid (Fig. 1). The goal of resection is dren. They tend to gain a degree of independence to reduce the amount of the laxatives that are need- and they do not want that the administering of en- ed to empty
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