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ORIGINAL ARTICLE
Year : 2012  |  Volume : 6  |  Issue : 1  |  Page : 22-25

Treatment of constipation in children based on anorectal manometery findings


Department of Pediatric Surgery, Hormozgan and Shiraz University of Medical Sciences and Iranian Legal Medicine Research Center, Shiraz, Iran

Date of Web Publication28-Aug-2012

Correspondence Address:
Mohammad Zarenezhad
MD, Iranian Legal Medicine Research Center, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.100205

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   Abstract 

Background: Constipation is a common symptom in children and manometery can be a useful diagnostic method in choosing suitable therapeutic methods for these patients.
Aim: The aim of this study was to assess the manometeric findings and determine its role in the management of children with constipation referred to our hospital.
Setting and Design: This was a descriptive cross-sectional study.
Materials and Methods : It was carried out on patients referred from September 2006 to December 2009 to the children hospital for performance of anorectal manometery because of constipation. They received their treatment according to findings at manometry (normal, absent, dilated, and retentive) with Botolinium toxin (BT) injection, surgery, enema, and medications, respectively. For each patient, variables such as age, sex, chief complaint, manometry result, food regimen, and treatment method were recorded. Symptom severity scale was assessed using a scored questionnaire.
Statistical Analysis: Data were analyzed using SPSS 17 and descriptive statistics, t-test, and χ2 .
Results: Seventy-one patients were included in our study. The mean age of the participants was 4.98 ΁ 1.43. Sixteen (22.5%) had acute and 55 (77.5%) had chronic constipation. Seventeen (25.4%) had a diagnosis of Hirschsprung's disease and 22 patients (31%) had retentive type constipation. Nineteen patients (28.8%) received pull through treatment and 27 (38%) received BT, while 34 (47.9%) received medical treatment. Mean symptom severity score after treatment was 3.88 and 4.59 in males and females, respectively. This difference was statistically significant (P
= 0.03). There was no statistically significant difference after treatment according to other variables.
Conclusions : In summary, our study results were comparable with studies that reported an effective role for manometry in diagnosis and planning the type of treatment in constipated children. and is a useful physiologic tool for measuring anorectal complex function.

Keywords: Children, constipation, Hirschsprung′s disease, manometry


How to cite this article:
Hosseini SM, Zarenezhad M, Hedjazi A, Khazdooz M, Falahi S. Treatment of constipation in children based on anorectal manometery findings. Ann Nigerian Med 2012;6:22-5

How to cite this URL:
Hosseini SM, Zarenezhad M, Hedjazi A, Khazdooz M, Falahi S. Treatment of constipation in children based on anorectal manometery findings. Ann Nigerian Med [serial online] 2012 [cited 2019 Oct 16];6:22-5. Available from: http://www.anmjournal.com/text.asp?2012/6/1/22/100205


   Introduction Top


Anorectal manometry plays its most significant clinical role for children who suffer from severe constipation, i.e., where the diagnosis of Hirschsprung's disease needs to be excluded. It is also useful in diagnosing other problems such as motor disorders combined with spinal anomalies and anal achalasia. [1]

In children with severe constipation, acute constipation, lack of fecal soiling precedence, decreased stool thickness, and when growth deficiency is observed on physical examination, or in cases of severe constipation despite an appropriate treatment program, a small rectal biopsy is needed. [1]

Regarding the significance or role of anorectal manometry in diagnosis and treatment of children who suffer from chronic constipation, this study deals with the analysis of the manometric findings in such children and its value in planning treatment for those who have been referred to our Children Hospital.


   Materials and Methods Top


This study is a cross-sectional descriptive study carried out in children suffering from chronic constipation who had been referred to Children Hospital for manometry from September 2006 to December 2009. After receiving written consent from the patients' parents, all patients underwent manometry using a water-perfused system (MEDIWATCH, UK), and subsequent treatment was planned based on manometric findings and the results were assessed using a scored questionnaire.

Based on the manometry, a normal reflex is when the tension increases in the rectum and then a relaxation of internal sphincter is observed after using rectal balloon with the volume of 0.5 cm³. If the tension increases but the internal sphincter does not relax, then there is no normal reflex (absent anorectal inhibitory reflex).

The patients were classified under four categories, based on their manometric results for treatment:

  1. Patients who had a normal reflex using a 5-10 cc balloon inflation.
  2. Patients who had a normal reflex using a more than 10-cc balloon inflation (dilated type).
  3. Patients who show sever over activity of external muscle when the balloon was filled and then the muscle relaxed (retentive type).
  4. Patients with no normal reflex and no increased tension in the internal sphincter using a 10-cc balloon (suspicious Hirschsprung's disease). [2],[3]
The patients with a dilated reflex were treated using enema and drugs, and retentive type patients with an increase in internal muscle tone were treated using Botolinium toxin (BT) and drugs, and where this was not successful, they were treated using rectal biopsy and pull through. [2],[3]

Manometry was performed using a black nelaton that was attached to a glove finger which was used to measure the tension by inflating the rectum with water at a rate of 0.5 cc/min. Variables such as age, sex, main complaint, manometry result, diet, treatment, and the level of symptoms were collected for all patients. The patients were assessed with regard to the level of symptoms, within 6 months to 2 years after treatment using an 8-point questionnaire. The score of this questionnaire varies from 0 to 36. Zero indicates the lowest level of symptoms and 36 indicates the highest level. [2],[3]

Statistical Analysis

The data were analyzed using SPSS 17. Descriptive statistics (mean, standard deviation, and frequency) was done and the statistical tests used were t-test and χ2 test.


   Results Top


A total of 71 patients were enrolled. The patient's age ranged from 3 to 11 years with average of 4.98 ± 1.43 years. The subjects included 34 (47.9%) male and 37 (52.1%) female subjects. Sixteen (22.5%) patients suffered from acute constipation and 55 (77.5%) patients suffered from chronic constipation. Eleven (15.5%) patients were reported to have delay in passing meconium.

Seventeen (25.4%) patients suffered from Hirschsprung's disease and 22 (31%) from retentive type constipation. In 43.6% of patients, abnormal rectum was observed. None of the patients showed megarectum.

Considering the patients' diet, 28 (39.4%) of subjects had excessive fiber intake and 6 subjects (8.5%) had excessive liquid consumption. 37 (52.1%) had normal diet and none of the subjects had a history of mental problems in their families.

On examinations, all patients showed normal sphincter tone and stenosis was not observed in any of the patients. A pull through method was used to treat 19 (28.8%) patients and BT was used for 27 (38%) patients while medication alone was used for 34 (47.9%) patients. After completing the treatment, the level of symptoms was investigated using a questionnaire and the lowest score was 1 and the highest was 8.

The levels of symptoms after treatment are compared based on various demographic variables in [Table 1]. The history, examination findings, and diagnosis are also compared. The mean of the symptoms score in patients with acute constipation was less than those with chronic constipation (P = 0.067).

The mean of symptoms score is significantly different between the patients with a positive history of delayed meconium defecation and those with no report of delay in meconium defecation (P = 0.676). The level of symptoms in patients has no significant statistical relationship with the final diagnosis of the patients and there was no difference between the patients suffering from Hirschsprung's disease and retentive type of constipation and other patients in this regard (P < 0.05).
Table 1: Mean symptom score after treatment, considering various demographic variables of patients

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With respect to the symptoms score between patients after treatment by pull through method, BT, medication, and other patients, there was no statistically significant difference between these groups regarding the level of their symptoms (P < 0.05). There was no difference in the level of symptoms after treatment of patients, based on their diet.


   Discussion Top


Based on the results obtained from this study, 25.4% suffered from Hirschsprung's disease and 31% suffered from retentive type constipation. Similar studies have been carried out on the role of manometry in diagnosis and treatment of patients who suffer from constipation. However, only some results obtained from those studies can be compared with the results of this study due to the relative differences between the method and difference in reporting of the results.

As our study indicates, the level of symptoms score after treatment was lower in male subjects and it was higher in those patients who were treated by BT. There was no significant relationship concerning other variables between the level of symptoms and variables such as (acute or chronic) constipation, report of delayed meconium defecation, different diets and different diagnoses, and other treatment (other than BT).

In this study, the level of symptoms was analyzed after treatment. In another study that analyzed the relationship between the manometric findings and the level of symptoms, a week prior to manometry, relatively similar results were reported and it revealed no relation between the level of symptoms and the results obtained from manometry. [4]

These results revealed that manometry is useful for diagnosis and treatment of patients who suffer from constipation. In a study by Noviello et al., among the total of 85 patients who were studied, Hirschsprung's disease was diagnosed in only 2 patients (2.4%) [5] compared to our study where 25.4% suffered from Hirschsprung's disease. However, the average age of the patients in both studies was different. Racial features may have affected the frequency of Hirschsprung's disease, or the standards of inclusion might have been different in these two studies. [6]

In patients who suffer from constipation, the rectal disorder with increase tension in the constricted anal sphincter makes manometry to become a useful tool in the diagnosis of these diseases. [7] Various studies show that manometry can positively impact on the diagnosis of organic and functional problems in children who suffer from chronic constipation. [5] However, some studies show that manometry is effective only as a diagnostic test in excluding the diagnosis of Hirschsprung's disease. [8]

In manometric studies on patients with chronic idiopathic constipation, anorectal motor disorders are observed. [9] It has been revealed that manometry has sensitivity, characteristic, and positive and negative indicative values of 0.1, 0.94, 0.77, and 1, respectively, in differential diagnosis of constipation. [10]

In general, our study supports the results of other studies that have reported an effective role for manometry in diagnosis and treatment of patients who suffer from constipation. However, as the level of symptoms is different based on the primary diagnoses, the assessment of the level of symptoms before and after treatment and comparison of these two values can undoubtedly be useful in finding the level of efficiency of different treatments on the level of symptoms. Constipation is generally a disease that originates from neurogenic dysfunction of bowel motility that some times cannot be measured, from absence of ganglion cells (classic Hirschsprung's) disease to normal pathologic finding with severe constipation (neurogenic dysfunction) which needs surgery. [2],[3] Therefore, manometery of the anorectum as a means of physiologic assessment in anorectal complex function is recommended for planning the treatment in the different types of constipation to achieve much better results.

 
   References Top

1.Loening-Baucke VA. Chronic constipation in children. Gastroenterology 1993;105:1557-64.  Back to cited text no. 1
[PUBMED]    
2.Hosseini SM, Foroutan HR, Bahador A, Khosravi MB, Geramizadeh B, Sabet B, et al. Role of rectal biopsy in predicting response to intrasphincteric botulinum toxin injection for obstructive symptoms after a pullthrough operation. Indian J Gastroenterol 2008;27:99-102.  Back to cited text no. 2
[PUBMED]    
3.Foroutan HR, Hosseini SM, Banani SA, Bahador A, Sabet B, Zeraatian S, et al. Comparison of botulinium toxin injection and posterior anorectal myectomy in treatment of internal anal sphincter achalasia. Indian J Gastroenterol 2008;27:62-5.  Back to cited text no. 3
[PUBMED]    
4.Borowitz S, Sutphen J, Ling W, Cox D. Lack of correlation of anorectal manometry with symptoms of chronic childhood constipation and encopresis. Dis Colon Rectum 1996;39:400-5.  Back to cited text no. 4
    
5.Noviello C, Cobellis G, Papparella A, Amici G, Martino A. Role of anorectal manometry in children with severe constipation. Colorectal Dis 2009;11:480-4.  Back to cited text no. 5
[PUBMED]    
6.Liu TT, Chen CL, Yi CH. Anorectal manometry in patients with chronic constipation: A single-center experience. Hepatogastroenterology 2008;55:426-9.  Back to cited text no. 6
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7.Czerwionka-Szaflarska M, Zielinska-Duda H, Mierzwa G, Drewa S. [The value of anorectal manometry as differentiated organic and functional disorders in children and youth with chronic constipation]. Pol Merkur Lekarski 2006;21:319-24.  Back to cited text no. 7
    
8.van Ginkel R, Buller HA, Boeckxstaens GE, van Der Plas RN, Taminiau JA, Benninga MA. The effect of anorectal manometry on the outcome of treatment in severe childhood constipation: A randomized, controlled trial. Pediatrics 2001;108:E9.  Back to cited text no. 8
    
9.Liu S, Zou K, Song J. A study of anorectal manometry in patients with chronic idiopathic constipation. J Tongji Med Univ 2000;20:351-2.  Back to cited text no. 9
[PUBMED]    
10.Bustorff-Silva JM, Costa-Pinto EA, Fukushima E. [Role of anorectal manometry in the differential diagnosis of chronic constipation in children]. J Pediatr (Rio J) 2000;76:227-32.  Back to cited text no. 10
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