Functional nonretentive fecal incontinence: do enemas help?

OBJECTIVE: To assess the current treatment of functional nonretentive fecal incontinence, which consists of education, toilet training, and positive motivation. STUDY DESIGN: Patients, age 6 years and older, referred for fecal incontinence (FI) and diagnosed with functional nonretentive fecal incontinence were eligible candidates. Seventy-one children (76% boys, median age 9.3 years) were randomized to receive conventional therapy (control group) or conventional therapy in addition to daily enemas during 2 weeks. Treatment success was defined as <2 episodes of FI/month without use of enemas. RESULTS: At intake, the median FI frequency was 6.1 per week, whereas the median defecation frequency was 7.0 per week. At the end of the treatment period, the median number of FI episodes was significantly decreased in both groups: from 7.0 (IQR 4.0-11.5) to 1.0 (IQR 0.5-2.0) in the intervention group and from 6.0 (IQR 4.0-10) to 2.0 (IQR 0.5-3.5) in the control group. No statistical difference was found between the groups at the end of the treatment period (P = .08) nor during additional follow-up (average success rate 17% for both groups, P = .99). CONCLUSION: Temporarily application of additional rectal enemas did not significantly improve treatment success compared with conventional therapy alone.

Acupuncture as multi-targeted therapy for the multifactorial disease obesity: a complex neuro-endocrine-immune interplay.

The prevalence of obesity has reached pandemic dimensions. It is associated with multiple comorbidities and is becoming a clinical and public health threat. Obesity is a multifactorial disease with a complex pathophysiology and interplay of various systems. A strong interplay exists between the neuro-endocrine system, the immune system with systemic chronic low-grade inflammation, and microbiome dysbiosis that can lead to the development of obesity, which in turn can exacerbate each of these factors, hence creating a vicious cycle. The conventional treatment with lifestyle modifications such as diet, physical exercise, pharmacotherapy, and bariatric surgery does not always result in sufficient weight control thus paving the way for other strategies. As one such strategy, acupuncture is increasingly used worldwide to treat obesity. This narrative review outlines the evidence for this neuro-endocrine-immune interplay in the pathophysiology of obesity. Furthermore, the existing experimental and clinical evidence of acupuncture as a multi-targeted therapy for obesity is explained and future research perspectives are discussed.

The clinical effect of a new infant formula in term infants with constipation: a double-blind, randomized cross-over trial.

BACKGROUND: Nutrilon Omneo (new formula; NF) contains high concentration of sn-2 palmitic acid, a mixture of prebiotic oligosaccharides and partially hydrolyzed whey protein. It is hypothesized that NF positively affects stool characteristics in constipated infants. METHODS: Thirty-eight constipated infants, aged 3-20 weeks, were included and randomized to NF (n = 20) or a standard formula (SF; n = 18) in period 1 and crossed-over after 3 weeks to treatment period 2. Constipation was defined by at least one of the following symptoms: 1) defecation frequency < 3/week; 2) painful defecation; 3) abdominal or rectal palpable mass. RESULTS: Period 1 was completed by 35 infants. A significant increase in defecation frequency (NF: 3.5 pre versus 5.6/week post treatment; SF 3.6 pre versus 4.9/week post treatment) was found in both groups, but was not significantly different between the two formulas (p = 0.36). Improvement of hard stool consistency to soft stool consistency was found more often with NF than SF, but did not reach statistical significance (90% versus 50%; RR, 1.8; 95% CI, 0.9-3.5; p = 0.14). No difference was found in painful defecation or the presence of an abdominal or rectal mass between the two groups. Twenty-four infants completed period 2. Only stool consistency was significantly different between the two formulas (17% had soft stools on NF and hard stools on SF; no infants had soft stools on SF and hard stools on NF, McNemar test p = 0.046). CONCLUSION: The addition of a high concentration sn-2 palmitic acid, prebiotic oligosaccharides and partially hydrolyzed whey protein resulted in a strong tendency of softer stools in constipated infants, but not in a difference in defecation frequency. Formula transition to NF may be considered as treatment in constipated infants with hard stools.

Symptomatology, pathophysiology, diagnostic work-up, and treatment of Hirschsprung disease in infancy and childhood.

In the majority of infants and children with constipation, no obvious cause can be identified. A rare cause of constipation is Hirschsprung disease (HD). HD is characterized by the absence of ganglion cells from the anorectum for a variable length up to the duodenum. The extent of the aganglionic segment varies, but in most patients the lesion does not extend beyond the rectum and sigmoid colon. This review focuses on the passage of meconium, the recognition of HD, and new insights in its pathophysiology and genetics. The authors also provide a summary of the diagnostic evaluation and treatment of HD in infancy and childhood.

The Leech method for diagnosing constipation: intra- and interobserver variability and accuracy.

BACKGROUND: The data concerning the value of a plain abdominal radiograph in childhood constipation are inconsistent. Recently, positive results have been reported of a new radiographic scoring system, "the Leech method", for assessing faecal loading. OBJECTIVE: To assess intra- and interobserver variability and determine diagnostic accuracy of the Leech method in identifying children with functional constipation (FC). MATERIALS AND METHODS: A total of 89 children (median age 9.8 years) with functional gastrointestinal disorders were included in the study. Based on clinical parameters, 52 fulfilled the criteria for FC, six fulfilled the criteria for functional abdominal pain (FAP), and 31 for functional non-retentive faecal incontinence (FNRFI); the latter two groups provided the controls. To assess intra- and interobserver variability of the Leech method three scorers scored the same abdominal radiograph twice. A Leech score of 9 or more was considered as suggestive of constipation. ROC analysis was used to determine the diagnostic accuracy of the Leech method in separating patients with FC from control patients. RESULTS: Significant intraobserver variability was found between two scorers (P=0.005 and P<0.0001), whereas there was no systematic difference between the two scores of the other scorer (P=0.89). The scores between scorers differed systematically and displayed large variability. The area under the ROC curve was 0.68 (95% CI 0.58-0.80), indicating poor diagnostic accuracy. CONCLUSIONS: The Leech scoring method for assessing faecal loading on a plain abdominal radiograph is of limited value in the diagnosis of FC in children.

Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests.

OBJECTIVE: To compare the diagnostic accuracy of contrast enema (CE), anorectal manometry (ARM), and rectal suction biopsy (RSB) for the detection of Hirschsprung's disease (HD). STUDY DESIGN: Following a prospective protocol, infants suspected of HD underwent all 3 index tests. Children with positive results on 2 or more index tests or who continued to have severe bowel problems underwent a full thickness biopsy as reference standard. Clinical follow-up was the reference standard in all other children. RESULTS: Between 2000 and 2003, 111 consecutive patients (67 boys; median age, 5.3 months) in whom HD was suspected were enrolled. HD was found in 28 patients. RSB had the highest sensitivity (93%) and specificity (100%) rates, but values were not significantly different from CE (sensitivity, 76%; specificity, 97%) or from ARM (sensitivity, 83%; specificity, 93%). Inconclusive test results occurred in 8 infants with CE, in 15 infants with ARM because of agitation, and in 2 infants with RSB. CONCLUSION: RSB is the most accurate test for diagnosing HD, and it has the lowest rate of inconclusive test results.

Maturation of the rectoanal inhibitory reflex in very premature infants.

OBJECTIVE: To characterize anal sphincter function in very premature infants < or =30 weeks' postmenstrual age (PMA) and to evaluate the time of maturation of the rectoanal inhibitory reflex (RAIR) by using a sleeve catheter. STUDY DESIGN: Anorectal manometry was performed in 16 healthy neonates (nine girls) with a mean PMA of 29 weeks (range, 27-30 weeks) and a birth weight of 640 to 1590 g (median, 1220 g) with a micromanometric assembly (outer diameter, 2.0 mm). The assembly incorporated a 1.5-cm-long sleeve sensor for measurement of resting anal sphincter pressures and relaxation, and four side holes recorded anal and rectal pressures. Rectal distention was performed with direct air insufflation to elicit the RAIR. RESULTS: The mean anal sphincter pressure, rectal pressure, and anal sphincter oscillation frequency were 24.5+/-11.4 mm Hg, 6.5+/-4.8 mm Hg, and 11.1+/-2.3/min, respectively. A normal RAIR could be elicited in 13 (81%) infants studied. In two infants, the RAIR could not be elicited because of a low anal sphincter pressure of only 5 mm Hg. In the other child, no RAIR was seen despite the repeated insufflation of at least 5 mL of air. CONCLUSION: The majority (81%) of premature infants older than 26 weeks' PMA have normal anorectal pressures and a normal RAIR.