Electro-Neuromodulation for Colonic Disorders-Review of Meta-Analyses, Systematic Reviews, and RCTs.

BACKGROUND: In the last 20 years, studies have shown that large bowel function can be modified by neural stimulation. While still in its infancy, this area of research is beginning to show promise. METHODS: This overview brings together systematic reviews and meta-analyses of electrical stimulation used to treat colonic disorders (fecal incontinence, constipation, slow transit constipation [STC], irritable bowel syndrome [IBS-C], and spina bifida-neurogenic bowel). Different methods of electrical stimulation including through sacral nerves, paraspinal, transabdominal, and using electroacupuncture over the ankle or knee and direct stimulation of the bowel are reviewed. RESULTS AND DISCUSSION: Most evidence is low level (pilot and small cohort studies) but with more RCTs appearing. Sacral nerve stimulation (SNS) does improve urinary dysfunction and fecal incontinence but not constipation. It is expensive with high rates of reoperation. Transcutaneous stimulation with interferential current (IFC, alternating current at KHz frequency with 2 channels out of phase) does improve constipation and may provide benefit as an adjuvant to behavioral or exercise therapies. Acupuncture and electro-acupuncture (low/very low-level evidence) may have a benefit for constipation. CONCLUSION: SNS is effective but expensive and limited to extreme patients. Transcutaneous stimulation is noninvasive and cheap and IFC may be effective for constipation, but many parameters need to be optimized and higher level evidence provided from studies (sham, blinding, and larger patient numbers). The next 20 years should be exciting in the field as higher level studies are performed.

Treatment of fecal impaction in children using combined polyethylene glycol and sodium picosulphate.

BACKGROUND AND AIM: Polyethylene glycol (PEG) is the gold standard for fecal disimpaction in constipation. A regimen of PEG combined with the stimulant laxative sodium picosulphate (SPS) produced fecal disimpaction in chronically constipated children in the community, but it is unknown if it is effective for more severe constipation. To determine the stool output and effect of a combined PEG and SPS regimen on fecaloma in children with severe constipation and impaction. METHODS: Children with symptoms for a duration of ≥2 years, a palpable fecaloma, and enlarged rectum on X-ray (rectal: pelvic ratio > 0.6) were recruited from a tertiary hospital. Daily diaries recorded laxative dose, stool frequency, volume, and consistency (Bristol stool scale, BSS). Abdominal X-rays were taken on day 1 and day 8, and stool loading was assessed using the Leech score. Laxative doses were based on the child's age. The dose of PEG with electrolytes taken was 2-8 sachets (14.7 g/sachet) on days 1-2, reducing to 2-6 sachets on day 3. The SPS dose was 15-20 drops on days 2-3. RESULTS: Eighty-nine children (4-18 years) produced a large volume of soft stool (median/inter-quartile-range: 2.2/1.6-3.1 L) over 7 days. Stool volume on X-rays decreased significantly in the colon (P < 0.001). Fecalomas resolved in 40 of 89 children, while 49 needed a second high dose. Rectal:pelvic ratios did not change. CONCLUSIONS: A combined high dose of PEG and SPS on days 1 and 2 was effective in removing the fecaloma in half of the children. Administering high doses for a longer period should be tested to provide outpatient disimpaction for severe fecalomas. Rectums remained flaccid after emptying.

Short-Term Interferential Transabdominal Electrical Stimulation Did Not Change Oral-Rectal Transit Time in Piglets.

BACKGROUND: Transcutaneous electrical stimulation (TES) using interferential current (IFC) is a new therapeutic treatment for constipation. Clinical studies show that TES-IFC for 3-6 months improves colonic transit, but it is not clear if short-term stimulation affects transit or the effect requires longer to develop. The aim of this study was to determine if TES-IFC for only four days affects oral-rectal transit time in healthy pigs. METHODS: Twenty-two 4-5-week old large white female piglets had transit studies during week 4 and week 5 by placing a capsule containing 18 radiopaque plastic markers in the esophagus under anesthetic followed by x-rays at 6, 30, 54, and 78 hours. Animals were randomly assigned to active or control groups. The active group received TES for 30 min daily for four days. Interferential current was applied through four electrodes (4 × 4 cm), with two para-spinal just below the last rib and two on the belly at the same level. Stimulation was at 4000 Hz and 4080-4160 Hz with currents crossing through the abdominal cavity. RESULTS: Whole bowel transit times ranged from 7.7 to 72.2 hours, stomach transit from <1 to 63 hours, and bowel with rectum transit time from 5 to 53 hours. Transit times were the same for the control (median 28.4 hours) and TES-IFC (23.0 hours) groups in the prestimulation and stimulation weeks (control 23.0, TES-IFC 19.8 hours) with no change within or between groups. CONCLUSION: Four days of half-hour TES-IFC daily in healthy 5-week-old piglets did not change oral-rectal transit time.

Home-Based Transabdominal Interferential Electrical Stimulation for Six Months Improves Paediatric Slow Transit Constipation (STC).

BACKGROUND: Transcutaneous electrical stimulation (TES) for one to two months has produced some improvement in treatment-resistant slow-transit constipation (STC) in children. Optimal parameters for treatment are not known. It is possible that more improvement would occur with stimulation for longer. This study examined the effectiveness of stimulation for six months. METHODS: Children with STC confirmed by nuclear transit study (NTS) were enrolled prospectively. All had chronic constipation for greater than two years and had failed medical treatment. TES was performed for one hour/day for six months using the INF 4160 (Fuji Dynamics) portable stimulator and 4 cm × 4 cm electrodes near the belly button and on the back. Families kept bowel diaries and completed PEDSQLCore QOL (4.0) questionnaires before and at end of treatment. RESULTS: Sixty-two children (34 females; seven years, 2-16 year) with STC were studied. Defecation frequency increased in 57/62 (91%, mean ± SEM pre- 1.49 ± 0.20 vs. post- 3.25 ± 0.25 defecation/week, p < 0.0001) with the number with ≥3BA increasing from 6 to 37 (10-59%). Soiling frequency decreased from 4.8 to 1.1 days/week (p <0.001). Abdominal pain decreased from 1.7 to 0.3 days/week (<0.0001), and spontaneous urge to defecate improved. Quality of life (p < 0.01), mean transit index and gastric emptying on NTS improved (p < 0.005). CONCLUSION: Treatment-resistant STC responds to TES using interferential current across the abdomen when given daily for many months. Battery operated stimulators allowed stimulation at home for an hour each day. Stimulation for six months produced clinically significant improvement in defecation frequency, soiling, abdominal pain, urge to defecate, and quality of life in half of these chronic patients.

Home Transcutaneous Electrical Stimulation Therapy to Treat Children With Anorectal Retention: A Pilot Study.

AIM: As transcutaneous electrical stimulation (TES) increased defecation in children and adults with Slow-Transit Constipation (STC), we performed a pilot study to test if TES can improve symptoms (defecation and soiling) in children with chronic constipation without STC and transit delay in the anorectum. METHODS: Children with treatment-resistant constipation presenting to a tertiary hospital had gastrointestinal nuclear transit study (NTS) showing normal proximal colonic transit and anorectal holdup of tracer. TES was administered at home (1 hour/day for 3 months) using a battery-powered interferential stimulator, with four adhesive electrodes (4 × 4 cm) connected so currents cross within the lower abdomen at the level of S2-S4. Stimulation was added to existing laxatives. Daily continence diary, and quality-of-life questionnaires (PedsQL4.0) were compared before and after TES. RESULTS: Ten children (4 females: 5-10 years, mean 8 years) had holdup in the anorectum by NTS. Nine had <3 bowel motions (BM)/week. After three months TES, defecation frequency increased in 9/10 (mean 0.9-4.1 BM/week, p = 0.004), with 6/9 improved to ≥3 BM/week. Soiling reduced in 9/10 from 5.9 to 1.9 days/week with soiling, p = 0.004. Ten were on laxatives, and nine reduced/stopped laxative use. Quality-of-life improved to within the normal range. CONCLUSION: TES improved symptoms of constipation in >50% of children with treatment-resistant constipation with isolated holdup in the anorectum. Further studies (RCTs) are warranted in these children.

Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC).

Slow-transit constipation (STC) is a newly described subtype of intractable constipation in children which we originally identified with deficiency of substance P in axons supplying the proximal colonic muscle. When nuclear transit studies became available, the patients were found to have slow proximal colonic transit, and responded to antegrade enemas. Using the appendicostomy, we found that there was reduced frequency in propagating sequences throughout the colon. We began testing whether transcutaneous electrical stimulation (TES) could improve motility and symptoms, and over several trials have now shown that TES is remarkably effective in treating children with STC, with long-lasting effects. TES holds promise for treating STC, as well as a range of gastrointestinal motility disorders.

Transabdominal electrical stimulation increases colonic propagating pressure waves in paediatric slow transit constipation.

BACKGROUND AND AIMS: In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children. METHODS: Eight children (8-18 years) with confirmed STC had 24-h colonic manometry using a water-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas. They then received 12 sessions (20 min/3× per week) of IFC stimulation (2 paraspinal and 2 abdominal electrodes), applied at a comfortable intensity (<40 mA, carrier frequency 4 kHz, varying beat frequency 80-150 Hz). Colonic manometry was repeated 2 (n=6) and 7 (n=2) months after IFC. RESULTS: IFC significantly increased frequency of total PS/24h (mean ± SEM, pre 78 ± 34 vs post 210 ± 62, p=0.008, n=7), antegrade PS/24h (43 ± 16 vs 112 ± 20, p=0.01) and high amplitude PS (HAPS/24h, 5 ± 2:10 ± 3, p=0.04), with amplitude, velocity, or propagating distance unchanged. There was increased activity on waking and 4/8 ceased using antegrade continence enemas. CONCLUSIONS AND INFERENCES: Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2-7 months. IFC may provide a treatment for children with treatment-resistant STC.

The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation--a single-institution experience.

PURPOSE: Appendicostomy for antegrade continence enema is a minimally invasive surgical intervention that has helped many children with chronic constipation. At our institution, since 2006, transcutaneous electrical stimulation (TES) has been trialed to treat slow-transit constipation (STC) in children. This retrospective audit aimed to determine if TES use affected appendicostomy-formation rates and to monitor changes in practice. We hypothesized that appendicostomy rates have decreased for STC but not for other indications. METHODS: Appendicostomy-formation rate was determined for the 5 years before and after 2006. Children were identified as STC or non-STC from nuclear transit scintigraphy and patient records. RESULTS: Since 1999, 317 children were diagnosed with STC using nuclear transit scintigraphy with 121 during 2001 to 2005 (24.2/year) and 147 during 2006 to 2010 (29.4/year). Seventy-four children had appendicostomy formation. For 2001 to 2005, appendicostomy-formation rates for STC and non-STC children were similar: 5.4 per year (n = 27) and 4.8 per year (n = 24), respectively. For 2006 to 2010, appendicostomy-formation rates were 1.2 per year (n = 6) for STC and 3.2 per year (n = 16) for non-STC (χ(2), P = .04). CONCLUSION: Since 2006, appendicostomy-formation rates have significantly reduced in STC but not in non-STC children at our institute, coinciding with the introduction of TES as an alternative treatment for STC. Transcutaneous electrical stimulation has not been tested on non-STC children in this period.

Home transcutaneous electrical stimulation to treat children with slow-transit constipation.

PURPOSE: This study aimed to test the effectiveness of home transcutaneous electrical stimulation (TES) when patients with slow-transit constipation (STC) were trained by a naive clinician. METHODS: A surgeon was trained to teach the TES method to STC children who then self-administered at home (1 hour a day, 3-6 months) using a battery-powered interferential stimulator. Bowel diaries, PedsQL4.0 questionnaires, and radio-nuclear colonic transit studies were completed before and after treatment. RESULTS: Thirty-two children (16 female; mean age, 8.3 years; range, 3-17 years) self-administered 3 to 6 months of TES. Three did not return diaries. Group 1 (n = 13) started with less than 3 bowel actions per week, and group 2 (n = 16), with more than 3 bowel actions per week. Defecation frequency increased in 69% of group 1 (mean, 1.4-3.0 per week; P = .02). Soiling frequency decreased in 50% of group 2 (5.4-1.9 per week, P = .04). Of 13 patients, 7 improved with development of urge-initiated defecation. Abdominal pain decreased in 48% (1.6 episodes per week to 0.9 per week, P = .06). Stool consistency improved in 56%. There was significant improvement in child-reported and parent-reported PedsQL Scores. Colonic transit improved in 13 of 25 patients. CONCLUSION: Home TES provides a new treatment for STC children, with 50% of treatment-resistant patients benefited. Success requires clinician training and close patient contact. Transcutaneous electrical stimulation increased defecation and reduced soiling.

Long-term effects of transabdominal electrical stimulation in treating children with slow-transit constipation.

AIMS: Transcutaneous electrical stimulation (TES) was used to treat children with slow-transit constipation (STC) for 1 to 2 months in a randomized controlled trial during 2006 to 2008. We aimed to determine long-term outcomes, hypothesizing that TES produced sustained improvement. METHODS: Physiotherapists administered 1 to 2 months of TES to 39 children (20 minutes, 3 times a week). Fifteen continued to self-administer TES (30 minutes daily for more than 2 months). Mean long-term follow-up of 30 of 39 patients was conducted using questionnaire review 3.5 years (range 1.9-4.7 years) later. Outcomes were evaluated by confidence intervals or paired t test. RESULTS: Seventy-three percent of patients perceived improvement, lasting more than 2 years in 33% and less than 6 months in 25% to 33%. Defecation frequency improved in 30%. Stools got wetter in 62% after stimulation and then drier again. Soiling improved in 75% and abdominal pain in 59%. Laxative use stopped in 52%, and 43% with appendicostomies stopped washouts. Soiling/Holschneider continence score improved in 81% (P = .0002). Timed sits switched to urge-initiated defecations in 80% patients. Eighty percent of relapsed patients elected to have home stimulation. CONCLUSION: TES holds promise for STC children. Improvement occurred in two thirds of children, lasting more than 2 years in one third, whereas symptoms recurred after 6 months in one third of children.

Slow-transit constipation with concurrent upper gastrointestinal dysmotility and its response to transcutaneous electrical stimulation.

PURPOSE: Transcutaneous electrical stimulation (TES) speeds up colonic transit in children with slow-transit constipation (STC). This study examined if concurrent upper gastrointestinal dysmotility (UGD) affected response to TES. METHODS: Radio-nuclear transit studies (NTS) were performed before and after TES treatment of STC as part of a larger randomised controlled trial. UGD was defined as delayed gastric emptying and/or slow small bowel transit. Improvement was defined as increase of ≥1 Geometric Centre (median radiotracer position at each time [small bowel = 1, toilet = 6]). RESULTS: Forty-six subjects completed the trial, 34 had NTS after stimulation (21 M, 8-17 years, mean 11.3 years; symptoms >9 years). Active stimulation increased transit in >50% versus only 25% with sham (p = 0.04). Seventeen children also had UGD. In children with STC and either normal upper GI motility (NUGM) and UGD, NTS improved slightly after 1 month (57 vs. 60%; p = 0.9) and more after 2 months (88 vs. 40%; p = 0.07). However, mean transit rate significantly increased with NUGM, but not UGD (5.0 ± 0.2: 3.6 ± 0.6, p < 0.01). CONCLUSION: Transcutaneous electrical stimulation was beneficial for STC, with response weakly associated with UGD. As measured by NTS, STC children with NUGM responded slightly more, but with significantly greater increased transit compared to those with UGD. Higher numbers are needed to determine if the difference is important.

What is new in radiology and pathology of motility disorders in children?

Disorders affecting colorectal motility lead to significant morbidity in children with surgical conditions. Etiology is frequently unknown, which in turn makes treatment empiric and compromises outcome. A thorough understanding of the normal mechanisms of control and the ability to recognize and manage defects is an important goal for clinicians. This article reviews recent advances made in the investigation of children with colorectal motility disorders, including the role of transit studies (marker studies and scintigraphy), options for assessing anatomy (ultrasound, contrast enema, and sectional imaging) and the use of manometry, both anorectal and colonic. Current concepts in microscopic evaluation are outlined.

Daily transabdominal electrical stimulation at home increased defecation in children with slow-transit constipation: a pilot study.

PURPOSE: Transcutaneous electrical stimulation (TES) (3 sessions/wk) over the abdomen stimulated bowel functions in a randomized controlled trial. This pilot study assessed whether daily TES at home with a safe, portable machine would be possible and more efficacious than trial results. METHODS: Eleven patients (6 male/5 female; mean age, 14 years; range, 12-18 years) with slow-transit constipation who relapsed or responded poorly in the trial were recruited (11 +/- 5 months later). An EPM-IF-4160 (Fuji Dynamics, Hong Kong) portable machine (sine waveform, 4 kHz carrier frequency, 80-160 Hz beat frequency, intensity <33 mA) delivering interferential current (2 electrodes over epigastrium + 2 over kidneys) was applied 1 hour daily at home. Continence diaries were kept for 1 month before and 2 months during treatment. RESULTS: All children completed more than 1 month of treatment after baseline recording. Defecation increased in 9 of 11 children, and soiling decreased in 4 of 11 children. There was a significant increase in total episodes of defecation per week (mean +/- SD, 2.5 +/- 2.1 vs 6.7 +/- 4.4; P = .008) and a nonsignificant decrease in soiling (3.8 +/- 1.6 vs 1.1 +/- 0.5 episodes/wk, P = .1). Daily stimulation does not affect abdominal pain. No adverse events occurred. CONCLUSIONS: Daily TES at home is safe and significantly improved bowel function in children who did not respond to 3 times per week of TES. Home TES may be a novel treatment of intractable slow transit constipation, avoiding hospital visits.

Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation.

BACKGROUND: Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. METHODS: Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. RESULTS: Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. CONCLUSION: Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL.

Decreased colonic transit time after transcutaneous interferential electrical stimulation in children with slow transit constipation.

PURPOSE: Idiopathic slow transit constipation (STC) describes a clinical syndrome characterised by intractable constipation. It is diagnosed by demonstrating delayed colonic transit on nuclear transit studies (NTS). A possible new treatment is interferential therapy (IFT), which is a form of electrical stimulation that involves the transcutaneous application of electrical current. This study aimed to ascertain the effect of IFT on colonic transit time. METHODS: Children with STC diagnosed by NTS were randomised to receive either 12 real or placebo IFT sessions for a 4-week period. After a 2-month break, they all received 12 real IFT sessions-again for a 4-week period. A NTS was repeated 6 to 8 weeks after cessation of each treatment period where able. Geometric centres (GCs) of activity were calculated for all studies at 6, 24, 30, and 48 hours. Pretreatment and posttreatment GCs were compared by statistical parametric analysis (paired t test). RESULTS: Thirty-one pretreatment, 22 postreal IFT, and 8 postplacebo IFT studies were identified in 26 children (mean age, 12.7 years; 16 male). Colonic transit was significantly faster in children given real treatment when compared to their pretreatment NTS at 24 (mean CG, 2.39 vs 3.04; P < or = .0001), 30 (mean GC, 2.79 vs 3.47; P = .0039), and 48 (mean GC, 3.34 vs 4.32; P = .0001) hours. By contrast, those children who received placebo IFT had no significant change in colonic transit. CONCLUSIONS: Transcutaneous electrical stimulation with interferential therapy can significantly speed up colonic transit in children with slow transit constipation.

The antegrade continence enema successfully treats idiopathic slow-transit constipation.

BACKGROUND: Antegrade continence enemas (ACEs) are successful for constipation and/or fecal incontinence caused by anorectal malformations or spina bifida but have been thought to be less successful in the treatment for patients with colonic dysmotility. We studied the long-term efficacy of ACE in a large group of patients with idiopathic slow-transit constipation (STC). METHODS: We identified 56 children with an appendicostomy for ACE with radiologically proven STC. An independent investigator (SKK) performed confidential telephone interviews. RESULTS: We assessed 42 of 56 children (31 boys) of mean age 13.1 years (range, 6.9-25). Mean follow-up was at 48 months (range, 3-118). Mean symptom duration before appendicostomy was 7.5 years (range, 1.4-17.4). Indications for appendicostomy were soiling (29/42), inadequate stool evacuation (7/42), and recurrent hospital admissions for nasogastric washouts (6/42). Both quality of life (Templeton quality of life [P < .0001]) and continence (modified Holschneider continence score [P < .0001]) improved with ACE. Soiling frequency decreased in 32 of 42 (11/32 completely continent). Thirty-seven of 42 children had reduced abdominal pain severity (P < .0001) and frequency (P < .0001). Complications included granulation tissue (33/42), stomal infection (18/42), and washout leakage (16/42). Fifteen of 42 children ceased using the appendicostomy (7/15 symptoms resolved). Thirty-five of 42 families felt that their aspirations had been met. CONCLUSIONS: Antegrade continence enemas were successful in 34 (81%) of 42 children with STC, contradicting views that ACEs are less effective in patients with colonic dysmotility.

Pilot study using transcutaneous electrical stimulation (interferential current) to treat chronic treatment-resistant constipation and soiling in children.

BACKGROUND: Chronic constipation in children may have organic or behavioral causes. The purpose of the present study was to investigate the effect of treatment with transcutaneous electrical stimulation (using interferential current) in children with chronic treatment-resistant constipation with proven organic disorders. METHODS: Eight children (7-16 years) with at least 4 years of chronic treatment-resistant constipation and soiling, who had failed diet, laxative treatment and behavioral therapy were given 1 month of transcutaneous electrical stimulation. The three most severe cases had appendicostomies with antegrade washouts every 2-3 days to prevent impaction and reduce their soiling. Children and carers kept a daily diary of bowel habits, recording number of spontaneous defecations, episodes of soiling, use of bowel washouts and medications. Transcutaneous stimulation using interferential current was applied three times per week for 3-4 weeks using four surface electrodes, two to the paraspinal area of T9-10 to L2 and one to either side of the anterior abdominal wall beneath the costal margin. Diaries were recorded for 1 month before, during, and after stimulation and for 2 weeks 3 months later. RESULTS: Transcutaneous electrical stimulation using interferential current stopped soiling in 7/8 children and increased the frequency of spontaneous defecations in 5/8. Defecations remained high and soiling low for 3 months in 3/6 children (with data). CONCLUSIONS: These results suggest that transcutaneous electrical stimulation using interferential current has a beneficial effect for children with chronic treatment-resistant constipation. Further trials using larger series of patients are needed to confirm this benefit, to determine the ideal stimulation parameters and to investigate why electrical stimulation might be effective.