View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Groningen University of Groningen Treatment of fecal impaction in children using combined polyethylene glycol and sodium picosulphate Lamanna, Anthony; Dughetti, Lauren D.; Jordan-Ely, Julie A.; Dobson, Kyla M.; Dynan, Megan; Foo, Adeline; Kooiman, Louise M. P.; Murakami, Naomi; Fiuza, Kaic; Foroughi, Siavash Published in: BJGP open DOI: 10.1002/jgh3.12062 IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2018 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Lamanna, A., Dughetti, L. D., Jordan-Ely, J. A., Dobson, K. M., Dynan, M., Foo, A., ... Southwell, B. R. (2018). 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Download date: 13-11-2019 doi:10.1002/jgh3.12062 ORIGINAL ARTICLE Treatment of fecal impaction in children using combined polyethylene glycol and sodium picosulphate Anthony Lamanna,*,†1 Lauren D Dughetti,*,†1 Julie A Jordan-Ely,* Kyla M Dobson,* Megan Dynan,*,† Adeline Foo,*,† Louise M P Kooiman,*,‡ Naomi Murakami,*,§,¶ Kaic Fiuza,*,¶,k Siavash Foroughi,*,** Marcelo Leal,†† Suzanna Vidmar,*,‡‡ Anthony G Catto-Smith,†,††,§§ John M Hutson*,†,¶¶ and Bridget R Southwell*,†,¶¶ *Surgical Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia. †Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia. **Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia. ††Gastroenterology and Clinical Nutrition, Royal Children’s Hospital, Parkville, Victoria, Australia. ¶¶Department of Urology, Royal Children’s Hospital, ‡‡Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia. §RMIT University, Bundoora, Victoria kUniversity of South Australia, Adelaide, South Australia, Australia. §§Gastroenterology Department, Lady Cilento Children’s Hospital, Brisbane, Queensland, Australia, ‡University of Groningen, Groningen, The Netherlands and ¶Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, Brazil Key words Abstract chronic constipation, laxatives, macrogol, polyeth- Background and Aim: Polyethylene glycol (PEG) is the gold standard for fecal dis- ylene glycol, X-rays. impaction in constipation. A regimen of PEG combined with the stimulant laxative sodium picosulphate (SPS) produced fecal disimpaction in chronically constipated Accepted for publication 23 April 2018. children in the community, but it is unknown if it is effective for more severe consti- Correspondence pation. To determine the stool output and effect of a combined PEG and SPS regimen Dr Bridget R Southwell, Murdoch Children’s on fecaloma in children with severe constipation and impaction. ≥ Research Institute, Royal Children’s Hospital, Methods: Children with symptoms for a duration of 2 years, a palpable fecaloma, Parkville, 3052, Australia. and enlarged rectum on X-ray (rectal: pelvic ratio > 0.6) were recruited from a ter- Email: [email protected] tiary hospital. Daily diaries recorded laxative dose, stool frequency, volume, and consistency (Bristol stool scale, BSS). Abdominal X-rays were taken on day 1 and 1Co-first authors day 8, and stool loading was assessed using the Leech score. Laxative doses were Declaration of conflict of interest: None of the based on the child’s age. The dose of PEG with electrolytes taken was 2–8 sachets authors have pecuniary interests in Norgine (14.7 g/sachet) on days 1–2, reducing to 2–6 sachets on day 3. The SPS dose was (manufacturer of Movicol) or Boeringher 15–20 drops on days 2–3. (manufacturer of Dulcolax SPS drops) or received Results: Eighty-nine children (4–18 years) produced a large volume of soft stool funding from either company. The Movicol and (median/inter-quartile-range: 2.2/1.6–3.1 L) over 7 days. Stool volume on X-rays Dulcolax SPS drops were provided at a reduced decreased significantly in the colon (P < 0.001). Fecalomas resolved in 40 of 89 chil- price. dren, while 49 needed a second high dose. Rectal:pelvic ratios did not change. Financial support: This study was funded by the Conclusions: A combined high dose of PEG and SPS on days 1 and 2 was effective Australian National Health and Medical Research in removing the fecaloma in half of the children. Administering high doses for a lon- Council (NHMRC), Project Grant (1025726) ger period should be tested to provide outpatient disimpaction for severe fecalomas. 2012–2016 and was supported by the “Victorian Rectums remained flaccid after emptying. Government Operational Infrastructural Support Program” and the Senior Research Fellowship (BS, 607396). The trial was registered for clinical trial registration-ACTRN12612001009808. http:// www.anzctr.org.au/TrialSearch.aspx?searchTxt= ACTRN12612001009808.&isBasic=True. The study was presented to the Gastroenterology Society of Australia Annual meeting (Australian Gastro Week) in August 2017 and published in the abstracts of the Journal of Gastroenterology and Hepatology Volume 32, Issue S2, August 2017, Pages: 190–197, Version of Record online: 17 August 2017, DOI: 10.1111/jgh.13900. Data on symptom changes in subsets of the patients were presented at the American Gastroenterology 144 JGH Open: An open access journal of gastroenterology and hepatology 2 (2018) 144–151 © 2018 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. A Lamanna et al. Fecal impaction with polyethylene glycol and sodium picosulphate Association Annual meeting (Digestive Diseases Week, 2015 (Southwell BR, Dughetti LD, Jordan-Ely JA, Dobson KM, Stathopolous L, Leal MC, et al. Su2051 Combined Polyethylene Glycol and Sodium Picosulphate for Disimpaction in Children With Chronic Constipation and Palpable Faecaloma. Gastroenterology 2015;148 (4):S-585) and the Gastroenterology Society of Australia Annual Meeting (Australian Gastro Week) in 2016 (Jordan-Ely J, Dughetti L, Dobson K, Stathopoulos L, Lamanna A, Leal M, et al. Disimpaction for children with palpable faecalomas using polyethelene glycol and sodium picosulphate. J Gastroenterol Hepatol. 2016;31:178–9). Funding support: National Health and Medical Research Council Project Grant 1025726 2012-2015 Introduction Methods Chronic constipation is common in pediatrics, representing 3–5% of A total of 120 patients (4–18 years of age) from the community general outpatient visits and up to 25% of gastroenterology consulta- or those presenting to The Royal Children’s Hospital Emergency tions.1 The prevalence of constipation in children has been estimated Department with chronic constipation were enrolled. Patients to range between 1 and 30%.2,3 Treatments include dietary, pharma- were screened by history, and those who met the criteria were cological approaches (laxatives, prokinetics), behavioral therapy, assessed by a Pediatric Gastroenterologist (ML) for a palpable – and, in extreme cases, surgery.4 6 Fecal impaction is defined as fecaloma. If a fecaloma was present, they were X-rayed and accumulation of hard stool in the anorectum.7,8 Disimpaction, to then educated on how to do the disimpaction and the dose of remove the hard fecal mass, is required before commencing mainte- laxatives to take. Fecal disimpaction was performed by nance therapy for constipation. patients as the first step in a RCT testing another intervention. Polyethylene glycol (PEG) 3350 is an osmotic laxative that All patients underwent disimpaction followed by 3 weeks of draws water into the colon to soften the stool. It is an oxyethylene education on diet, stress, when to toilet, and toilet posture. polymer (H[OCH2CH2]3350OH) that cannot be absorbed or Patients completed a daily diary that was used to record laxa- metabolized by the body.9 PEG disimpacted 92% of children in tive volume taken, stool volume produced, stool frequency, randomized control trials (RCTs) and was significantly more and consistency measured with the Bristol stool scale (BSS). effective than a placebo.10,11 In these clinical trials, the maximum Study data were collected and managed using the REDCap high dose for each age (1.5 g/kg/day) was given for