Histological transitional zone pull-through in Hirschsprung disease. Postoperative functional results and current recommendations.

BACKGROUND: Surgeons create a neorectum to repair patients with Hirschsprung's disease (HD), which should be formed from a normoganglionic bowel. However, the neorectum is occasionally created with a transition zone (TZ) bowel. A neorectum created with a TZ has been postulated as a cause of postoperative enterocolitis or constipation. This study compares the incidence of enterocolitis and constipation in patients with TZ neorectum and normoganglionic bowel. METHODS: We conducted a retrospective review of patients with rectosigmoid HD who underwent primary pull-through. Patients were divided into normoganglionic neorectum (NNR) and TZ neorectum. The diagnosis was based on the final histopathologic report of the proximal margin. The incidence of enterocolitis and constipation was compared between these two groups. RESULTS: A total of 98 HD patients were analyzed. Seventy-one patients fulfilled the inclusion criteria. 65 (92%) had a NNR, and six patients (8%) had a TZ neorectum. From these patients, 42 (59%) presented with enterocolitis or constipation. However, there was no significant difference between both groups. CONCLUSION: The present study showed no difference in the incidence of enterocolitis or postoperative constipation in HD patients with normoganglionic or TZ neorectum. These results suggest that TZ neorectum does not cause postoperative obstructive symptoms.

INTRODUCCIÓN: Los cirujanos crean un neo-recto para tratar a los pacientes con enfermedad de Hirschsprung (EH), que debe formarse con intestino normogangliónico; sin embargo, en ocasiones el neo-recto se forma con intestino de la zona de transición. Se ha postulado que un neo-recto en zona de transición causa enterocolitis o estreñimiento postoperatorio. El objetivo de este estudio fue comparar la frecuencia de enterocolitis y estreñimiento en pacientes con neo-recto en zona de transición y con neo-recto normogangliónico. MÉTODOS: Se llevó a cabo una revisión retrospectiva de pacientes con EH recto sigmoideo que se sometieron a descenso primario. Los pacientes se dividieron en el grupo neo-recto normogangliónico y el grupo con neo-recto en zona de transición. El diagnóstico del neo-recto se estableció con el informe histopatológico definitivo del margen proximal. Se comparó la frecuencia de enterocolitis y estreñimiento entre estos dos grupos. RESULTADOS: Se analizó un total de 98 pacientes con EH, de los cuales 71 pacientes cumplieron los criterios de inclusión; 65 (92%) con neo-recto normogangliónico y seis (8%) con neo-recto en zona de transición. Posteriormente, 42 (59%) pacientes presentaron enterocolitis asociada a Hirschsprung (HAEC) o estreñimiento; sin embargo, no hubo diferencia significativa entre ambos grupos. CONCLUSIONES: El presente estudio no demostró una diferencia en la frecuencia de HAEC o estreñimiento postoperatorio en pacientes con EH con neo-recto normogangliónico o en zona de transición. Estos resultados sugieren que un neo-recto en zona de transición no causa síntomas obstructivos postoperatorios.

OCCULT AND SEMI-OCCULT CONSTIPATION IN CHILDREN WITH MONOSYMPTOMATIC OR NON MONOSYMPTOMATIC ENURESIS.

BACKGROUND: Functional constipation and enuresis frequently coexist. Constipation treatment often results in resolution or improvement of the enuresis. However, besides the classical presentation, patients can present with occult constipation (OC) diagnosed in complementary evaluation; in addition, semi-occult constipation (SOC) can be detected by means of a detailed questionnaire. OBJECTIVE: To quantify OC and SOC frequency in children with monosymptomatic or non monosymptomatic enuresis (MNE or NMNE). METHODS: Otherwise healthy children/adolescents, with enuresis refractory to behavioral therapy and denying constipation after simple questions, answered a structured bowel habit questionnaire and were submitted to a plain abdominal radiological exam. Constipation was classified considering the Boston diagnostic criteria (to allow diagnosis at initial stages), and fecal loading in the X-ray quantified ≥10 by the Barr score. Children with constipation received a standardized treatment (except 26 "pilot" children). RESULTS: Out of 81 children, 80 aged 9.34±2.07 years, 52.5% male, were diagnosed with constipation: 30 OC, 50 SOC; 63.75% had MNE, 36.25% NMNE (six NMNE without behavioral therapy). Demographic data and the Barr score were similar for OC and SOC, but SOC children experienced significantly more constipation complications (retentive fecal incontinence and/or recurrent abdominal pain). Not showing the Bristol Stool Scale (BSS) to 24 "pilot" children, or absence of constipation symptoms accompanying BSS predominantly type 3, in 13 children, did not significantly impact the detection of constipation by the Barr score. Children identifying BSS 3 or ≤2 had similar results. Twenty-eight children, with adequate follow-up after treatment, improved or recovered from constipation at 44 of their 52 follow-up visits. CONCLUSION: In patients with MNE or NMNE refractory to behavioral therapy, and who initially denied constipation after simple questions, a detailed questionnaire based on the Boston diagnostic criteria detected SOC in 61.7%, and the radiological Barr score revealed fecal loading (OC) in 37.0% of them.

Deep Endometriosis: the Involvement of Multiple Pelvic Compartments Is Associated with More Severe Pain Symptoms and Infertility.

Endometriosis can be classified into three phenotypes: superficial, ovarian, and deep. Deep endometriosis (DE) has been associated with more severe pain symptoms, although no large-scale studies have evaluated the association between pain intensity and infertility and the different compartments of the pelvis affected by superficial and DE. This retrospective study included 1116 women who underwent laparoscopy for endometriosis treatment at two referral centers between 2009 and 2019. For the evaluation of each symptom, patients were divided according to their visual analog scale score (< 7 and ≥ 7) and fertility status. On multiple logistic regression, severe dysmenorrhea and dyschezia were correlated with DE of the posterior compartment alone (odds ratio (OR) = 1.6, confidence interval (CI) 1.09-2.34, and p = 0.02 and OR = 2.09, CI 1.36-3.23, and p < 0.01, respectively) and in combination with other compartments. DE of the posterior and lateral compartments had the most consistent statistical power (OR = 3.55 for dysmenorrhea and OR = 4.4 for dyschezia). Infertility was associated with DE of the posterior compartment alone (OR = 1.6, CI 1.06-2.54, p = 0.04) and in combination with the anterior compartment (OR = 2.62, CI 1.29-5.29, p < 0.01), with the combination of posterior and anterior compartment having the highest OR value. Severe dyschezia and infertility were also correlated with the presence of multiple localizations of DE (p = 0.04 and p < 0.01). This study confirms the association between DE and severe pain symptoms as well as the influence of the number of DE compartments on the severity of symptoms and the chance of infertility.

[Toxic Megacolon: A rare complication of chronic constipation. Three Pediatric Cases]. / Megacolon Tóxico: Complicación infrecuente de la constipación crónica. A propósito de 3 casos pediátricos.

INTRODUCTION: Chronic constipation is a frequent pathology in the pediatric age that affects the quality of life of pa tients and their families. Its management is usually complex and long associated with poor adheren ce. Toxic megacolon is a serious, potentially lethal disease when chronic constipation is left untreated or poor adherence to treatment. OBJECTIVE: To report 3 pediatric cases of toxic megacolon as a com plication of poorly managed chronic constipation. CLINICAL CASES: Three males patients, aged 6 to 13 years, with a history of chronic constipation and poor adherence to treatment are discussed. They were admitted to the emergency department with clinical findings of toxic megacolon (intestinal dilation and signs of systemic toxicity). Given their condition, all patients required management in the critical patient unit (CPU) and early surgical intervention, undergoing ostomy. All presented fa vorable outcome, performing stoma reversal surgery between 8-24 months later. In all cases, organic cause of the constipation was ruled out. CONCLUSIONS: Toxic megacolon is an infrequent but highly morbid and potentially lethal disease. It requires a high index of suspicion as well as multidisciplinary medical-surgical management.

Complicated acute appendicitis in pediatric patients with "empacho" and abdominal manipulation history: Case series. / Apendicitis aguda complicada en pacientes pediátricos con antecedentes de "empacho" y manipulación abdominal: Serie de casos.

INTRODUCTION: According to Latin American popular culture, empacho is a gastrointestinal disease caused by ex cessive intake of cold or under-cooked food. Abdominal manipulation or sobada is one of the popular treatments used for empacho and consists of an abdominal massage, where the skin is rubbed and stretched, applying pressure on the abdomen. OBJECTIVES: To characterize clinical evolution and complications secondary to diagnostic delay in pediatric patients with acute appendicitis, with history of empacho and abdominal manipulation. PATIENTS AND METHOD: Descriptive, observational, How to cite this article: Andes pediatr. 2021;92(1):86-92. DOI: 10.32641/andespediatr.v92i1.3352 prospective study of pediatric patients with complicated acute appendicitis and history of abdominal manipulation, identified in the pediatric surgery room between November 2019 and June 2020 at the Mario Catarino Rivas Hospital. Descriptive statistics were used for analysis. RESULTS: 10 patients were studied, aged ranging from 6 to 16 years (median age 14 years). Half of them were from rural areas. The main symptoms that appeared before abdominal manipulation were vomiting, nausea, and loss of appetite, followed by sudden diarrhea or constipation, and increased pain intensity. Complications were gastrointestinal perforation (5/10), appendicular mass (3/10), intra-abdominal abscess (3/10), and gangrenous appendicitis (1/10). The median time between initial symptom and hospitalization was 60 hours [IQR, 33.0 - 72.0]. CONCLUSION: This study describes the influence of the empacho and its respective treatment on clinical deterioration due to the delay in diagnosis and treatment of acute appendicitis, resulting in different complications.

Tubular colonic duplication in an adult patient with long-standing history of constipation and tenesmus

Background Intestinal duplications are rare congenital developmental anomalies with an incidence of 0.005-0.025% of births. They are usually identified before 2 years of age and commonly affect the foregut or mid-/hindgut. However, it is very uncommon for these anomalies, to arise in the colon or present during adulthood. Case presentation Herein, we present a case of a 28-year-old woman with a long-standing history of constipation, tenesmus, and rectal prolapse. Colonoscopy results were normal. An abdominal computed tomography (CT) revealed a diffusely mildly dilated redundant colon, which was prominently stool-filled. The gastrografin enema showed ahaustral mucosal appearance of the sigmoid and descending colon with findings suggestive of tricompartmental pelvic floor prolapse, moderate-size anterior rectocele, and grade 2 sigmoidocele. A laparoscopic exploration was performed, revealing a tubular duplicated colon at the sigmoid level. A sigmoid resection rectopexy was performed. Pathologic examination supported the diagnosis. At 1-month follow-up, the patient was doing well without constipation or rectal prolapse. Conclusions Tubular colonic duplications are very rare in adults but should be considered in the differential diagnosis of chronic constipation refractory to medical therapy. Due to the non-specific manifestations of this entity, it is rather challenging to make an accurate diagnosis pre-operatively. Surgery remains the mainstay of treatment. Some reports suggest that carcinomas are more prone to develop in colonic/rectal duplications than in other GI tract duplications.

Constipação com obstrução à saída e incontinência fecal: o tratamento de reabilitação é o caminho? Mito ou realidade / Outlet obstructed constipation and fecal incontinence: is rehabilitation treatment the way? myth or reality

ABSTRACT Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

RESUMO A reabilitação do assoalho pélvico visa abordar alterações funcionais e anatômicas perineais, bem como disfunções mecânicas torácicas-abdominais que levam a doenças procto-urológicas como prisão de ventre, incontinência fecal e urinária e dor pélvica. Requerem uma abordagem multidimensional, com impacto significativo na qualidade de vida dos pacientes. Um protocolo clínico e instrumental exaustivo para avaliar os transtornos de defecação deve incluir avaliação clínica e instrumental, bem como diversos parâmetros clínicos/fisiátricos. Todos esses parâmetros devem ser considerados para reconhecer e definir qualquer fator potencial desempenhando um papel nos aspectos funcionais da incontinência, prisão de ventre e dor pélvica. Após tal avaliação, tendo identificado com precisão quaisquer alterações anatômicas e funcionais tóraco-abdomino-perineais, um programa de reabilitação pelvi-perineal pode ser realizado para corrigir as alterações acima mencionadas e obter melhora clínica. O sucesso do processo de reabilitação está ligado a diversos fatores, como uma avaliação cuidadosa do paciente, visando selecionar a terapia de reabilitação direcionada mais adequada e específica, além do trabalho árduo e escrupuloso do terapeuta, especialmente no que diz respeito ao estado emocional e psíquico do paciente e, finalmente, a conformidade do paciente em realizar a terapia em si, especialmente em casa. Esses fatores podem influenciar profundamente os resultados globais das terapias de reabilitação, que vão desde o sucesso "real" até o "mito" ilusório.

OUTLET OBSTRUCTED CONSTIPATION AND FECAL INCONTINENCE: IS REHABILITATION TREATMENT THE WAY? MYTH OR REALITY.

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

Association between abdominal pain and fecal impaction grade assessed through radiography in constipated patients at a pediatric emergency service. / Asociación entre el dolor abdominal y el grado de coproestasis mediante la evaluación radiográfica en pacientes estreñidos que acuden a los servicios de urgencias pediátricas.

INTRODUCTION AND AIM: Abdominal pain in children is a frequent cause of emergency room consultation. An important group of those patients presents with chronic constipation and fecal impaction. Plain abdominal x-ray is widely used for making a diagnosis and ruling out the need for surgical treatment. The present study examined the association between pain intensity and fecal impaction grade. MATERIALS AND METHODS: An analytic cross-sectional study was conducted that compared 2 radiographic scales to determine the association between the grade of fecal impaction observed and abdominal pain intensity in patients that sought medical attention at an emergency service within a 7-month period. The analysis was carried out by 2 different observers, utilizing 2 different radiographic scales to confirm their reproducibility. The degree of interobserver agreement was measured using the Kappa coefficient and the association between abdominal pain and fecal impaction grade was measured through the Spearman correlation coefficient. RESULTS: There was a significant association between pain intensity and the radiographic grade of fecal impaction (P<.05) for the radiographic scale by segments and its interobserver agreement was high, compared with the scale by percentage. CONCLUSIONS: Radiographic scales may be useful in the evaluation and treatment of patients with abdominal pain and constipation. The segmental scale showed less interobserver variability, suggesting its proposal as an alternative in the evaluation and follow-up of patients with chronic constipation.

Bowel Habits and the Association With Uremic Toxins in Non-Dialysis-Dependent Chronic Kidney Disease Patients.

OBJECTIVE: The aim of this study is to evaluate the association between bowel habits and microbial-derived uremic toxins p-cresyl sulfate (PCS) and indoxyl sulfate (IS) in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). DESIGN AND METHODS: This is a cross-sectional analysis including 43 nondiabetic NDD-CKD patients (58% men; 59.0 ± 13.5 years; estimated glomerular filtration rate, 21.3 ± 7.9 mL/min/1.73 m2). Bowel habit was assessed by the Bristol Stool Scale (BSS <3, characterized by hard consistency of stools and/or low frequency of evacuation and BSS ≥3, representing a more regular bowel habit) and by the Rome III criteria. PCS and IS (serum, free and total; urinary, total) were determined by high-performance liquid chromatography. Dietary intake was assessed by the 3-day food records. RESULTS: The frequency of constipation assessed by BSS and Rome III criteria was 33% (n = 14/43) and 35% (n = 15/43), respectively. The BSS <3 exhibited higher PCS, independent of renal function and dietary protein-fiber ratio (ß [95% confidence interval {CI}]: serum, total PCS = 1.54 [1.06-2.23], P = .02; serum free PCS = 1.40 [1.00-1.97], P = .05; urinary PCS = 1.78 [1.10-2.90], P < .02). According to the Rome III criteria, a tendency for a higher serum total PCS (ß [95% CI]: 1.39 [0.95-2.03 µmol/L], P = .09) and a significantly higher urinary PCS (ß [95% CI]: 1.80 [1.11-2.94 µmol/24 h], P = .02) was found in constipated participants. No effect of a compromised bowel habit (Rome III criteria or BSS) was found on IS. CONCLUSION: Constipation may lead to production of PCS in nondiabetic NDD-CKD patients.

Prevalencia y perfil epidemiológico de la constipación funcional en población adulta sana con los nuevos criterios ROMA IV / Epidemiologic profile and prevalence of functional constipation in adult based on the ROME IV criteria

Resumen Introducción: Los reportes extranjeros dan cuenta de la presencia de esta patología en cifras que varían entre 10 y 70%, con sólo un reporte nacional centrado en ancianos institucionalizados. Existen diferentes formas de evaluar la presencia de constipación; en nuestra experiencia utilizamos los nuevos criterios de ROMA IV que define como constipación funcional cuando se cumplen dos o más criterios. Objetivos: Determinar la prevalencia y el perfil epidemiológico de pacientes adultos sanos con constipación. Material y Método: Estudio de corte transversal realizado entre enero y marzo de 2018. Se incluyen mayores de 18 años que acceden a completar la encuesta. Se excluye aquellas personas con antecedentes quirúrgicos o mórbidos gastrointestinales. Se realiza encuesta aplicando los criterios de ROMA IV considerando aspectos demográficos. Se utiliza estadística descriptiva. Resultados: De 1.500 encuestas realizadas se seleccionan 1.223. Un 68,4% cumplían con dos o más criterios de constipación funcional, con diferencias estadísticamente significativas en el grupo de sexo femenino y en pacientes de mayor edad. El análisis específico de cada criterio de ROMA IV muestra que los síntomas más frecuentes fueron deposiciones duras, esfuerzo defecatorio excesivo y sensación de evacuación incompleta. Hubo diferencias estadísticamente significativas en mujeres en los ítems: menor frecuencia, deposiciones duras y esfuerzo defecatorio mientras que la mayor edad se asocia a evacuación incompleta. Las maniobras digitales fueron poco frecuentes. Conclusiones: La constipación es frecuente en la población adulta sana afectando, principalmente, a mujeres de mayor edad. Los síntomas más frecuentes fueron deposiciones duras, esfuerzo defecatorio y sensación de evacuación incompleta.

Introduction: The prevalence of this condition has been reported in foreign studies in around 10-70%, with only one national report focused in the institutionalized elderly. There are different diagnostic approaches to determine the presence of functional constipation, in our experience, we use the ROME IV diagnostic criteria, which requires the presence of two or more criteria for confirmation. Aim: To determine the prevalence and epidemiologic profile of healthy adults with constipation disorder. Materials and Method: Transversal cohort study between January-March 2018. Inclusion criteria are 18 years and above. We exclude patients with gastrointestinal medical or surgical comorbidities. Data are collected from a face-to-face survey based on the ROME IV criteria, considering demographic features. Descriptive statistics are used to analyze the results. Results: From a total of 1,500 questionnaire surveys, 1,223 are selected. Two or more criteria for functional constipation were present in 68.4%, with significant statistical differences in the female and elderly population. When analyzing each criterion separately, hard stools, straining and sensation of incomplete evacuation were the most common responses. In women, less frequency, hard stools and straining items showed significant statistical differences, whereas sensation of incomplete evacuation was the highlight in the elderly. Manual maneuvers to facilitate defecation was the less selected item. Conclusions: Functional constipation is a frequent condition seen in healthy adults. Older female population are particularly prone to it. Hard stools, straining, and incomplete evacuation sensation were the most common symptoms.

Effect of polyethylene glycol versus lactulose on abdominal pain in children occult constipation: a randomized controlled study: un estudio controlado aleatorio / Efecto del polietilenglicol versus lactulosa sobre el dolor abdominal en el estreñimiento oculto en niños

Introduction and aim: Functional abdominal pain (FAP) is one of the major gastrointestinal complaints in childhood. Studies have reported occult constipation (OC) as one of the leading causes of abdominal pain. Recent researches have proposed laxatives as potent therapeutic targets for abdominal pain in patients with OC. However, no study has compared effect of poly ethylene glycol (PEG) and lactulose on occult constipation. Materials and methods: 51 patients aged 4 to 18 years with abdominal pain who had OC (defined as fecal impaction in abdominal X ray) were studied. Demographic and clinical data including age, sex, body weight, height, abdominal pain duration, abdominal pain rate and fecal odor were registered. They were randomly assigned to receive PEG (1gr/kg) or Lactulose (1cc/kg) for at least two weeks. All patients were reevaluated by pain measurement scale after at least two weeks of treatment. Results: It is indicated that the efficacy of PEG for reducing abdominal pain in OC was 48% while it was 37% for Lactulose. This study indicated that this efficacy is not affected significantly by sex and fecal odor, however this efficacy is influenced by age, body weight, abdominal pain duration and abdominal pain rate for both PEG and Lactulose. Conclusion: It could be concluded that PEG is a more efficient drug for treating abdominal pain in occult constipation than Lactulose and its optimum effect can be achieved in elder patients with more severe abdominal pain.

Introducción y objetivo: El dolor abdominal funcional (FAP) es una de las principales molestias gastrointestinales en la infancia. Los estudios han informado que el estreñimiento oculto (OC) es una de las principales causas de dolor abdominal. Investigaciones recientes han propuesto laxantes como objetivos terapéuticos potentes para el dolor abdominal en pacientes con OC. Sin embargo, ningún estudio ha comparado el efecto del polietilenglicol (PEG) y la lactulosa sobre el estreñimiento oculto. Materiales y métodos: Se estudiaron 51 pacientes de 4 a 18 años con dolor abdominal que tenían OC (definida como impactación fecal en rayos X abdominales). Se registraron datos demográficos y clínicos que incluyen edad, sexo, peso corporal, altura, duración del dolor abdominal, tasa de dolor abdominal y olor fecal. Fueron asignados aleatoriamente para recibir PEG (1 gr/kg) o lactulosa (1 cc/kg) durante al menos dos semanas. Todos los pacientes fueron reevaluados por la escala de medición del dolor después de al menos dos semanas de tratamiento. Resultados: Se indica que la eficacia de PEG para reducir el dolor abdominal en OC fue del 48% mientras que fue del 37% para la lactulosa. Este estudio indicó que esta eficacia no se ve afectada significativamente por el sexo y el olor fecal, sin embargo, esta eficacia está influenciada por la edad, el peso corporal, la duración del dolor abdominal y la tasa de dolor abdominal tanto para PEG como para lactulosa. Conclusión: Se podría concluir que el PEG es un fármaco más eficaz para tratar el dolor abdominal en el estreñimiento oculto que la lactulosa y que su efecto óptimo se puede lograr en pacientes mayores con dolor abdominal más severo.Palabras clave: dolor abdominal, estreñimiento oculto, polietilenglicol, lactulosa.

Association between a constipation scoring system adapted for use in children and the dysfunctional voiding symptom score in children and adolescents with lower urinary tract symptoms.

INTRODUCTION: A presumed association between more severe lower urinary tract symptoms (LUTS) and more severe functional constipation (FC) remains unconfirmed. Because the Rome IV criteria do not quantify FC, an adult constipation scoring system was modified and adapted for use in children. OBJECTIVES: The objective of this study was to assess the correlation between FC severity as determined by the modified constipation scoring system and LUTS severity in children/adolescents and the correlation between this modified scoring system and the Rome IV criteria. STUDY DESIGN: This was a cross-sectional study including 5- to 17-year-old patients with LUTS, with or without FC. Patients with neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract were excluded. Girls with Dysfunctional Voiding Symptom Score (DVSS) ≥6 and boys with DVSS ≥9 were diagnosed with lower urinary tract dysfunction (LUTD). Patients with at least two positive Rome IV criteria were considered constipated. The severity of FC according to the adapted constipation scoring system was classified as mild for scores of 1-10, moderate for scores 11-20, and severe for scores 21-30. RESULTS: Of 128 patients with LUTS, 71 (55.5%) were female. Lower urinary tract dysfunction was detected in 107 patients (83.6%) and was more common in girls. Functional constipation was present in 80 patients (62.5%). Constipated children had higher constipation scores and DVSS, with both scores increasing with the severity of FC. Correlation was moderate between the constipation score and the DVSS (þ = 0.5, p < 0.001) and was strong between positivity for a greater number of Rome IV criteria and the constipation score (þ = 0.7, p < 0.001). Most of the constipated patients had mild or moderate FC, while in 30 non-constipated patients, the constipation score indicated mild FC. DISCUSSION: Patients from a specialist center are more likely to have more severe medical problems, and this may have influenced the correlation between the scores. The modifications made to the constipation scoring system require a future validation study. Nevertheless, this study provides new data on urinary dysfunction and its association with FC and highlights the need to investigate occult bowel symptoms that could affect the treatment of urinary dysfunction. CONCLUSION: The intensity of FC as measured by the modified constipation scoring system correlated with the severity of the urinary symptoms in children/adolescents with LUTS/LUTD. In constipated patients, there was a correlation between the modified constipation scoring system and the Rome IV criteria. In non-constipated patients, the constipation scoring system identified symptoms/signs of bowel dysfunction not picked up by the Rome IV criteria. Finally, constipation score modified for use in children and adolescents could be important for research purpose and particularly having a prognostic importance.

[Manometric characteristics in children with chronic constipation and acquired anorectal pathology]. / Características manométricas en niños con estreñimiento crónico ypatología anorrectal adquirida.

OBJECTIVE: To describe the anorectal manometry results in the pediatric population with chronic constipation and acquired anorectal disease. MATERIALS AND METHODS: We reviewed the records of children who were referred to the Motility and Pelvic Floor Laboratory of the Hospital San Jose Tecnologico de Monterrey between 2004-2016 for further evaluation with anorectal manometry and who presented acquired anorectal disease. RESULTS: We reviewed 170 records. The mean age was 7.18 ± 4.51 years old. The prevalence of anorectal disease was 73%. The symptoms more frequently presented were difficult evacuation (78%), painful defecation (67%), large and hard stool (50%) and fecal soiling (49%). 44% of patients with hypotonic external anal sphincter (EAS) presented with soiling and 74% of those had diminished critical volume. Significant manometric values (p<0.05) were EAS resting pressure, maximal squeeze pressure, and critical volume. 97.7% of those who underwent abdomino pelvic coordination evaluation had pelvic floor dyssynergia (anismus). CONCLUSIONS: Contrary to adult population, the manometric values in children with acquire anorectal pathology were within normal values except for the EAS resting pressure and critical volume that were diminished. This could suggest a different mechanism in the pediatric population. Pelvic floor dyssynergia could explain chronic constipation in these patients.

Gastrointestinal disorders in Down syndrome.

Down syndrome is the most common human chromosomal disorder. Among clinical findings, one constant concern is the high prevalence of gastrointestinal system alterations. The aim of this study was to determine the prevalence of gastrointestinal disorders at a Down syndrome outpatient clinic during a 10-year follow-up period. Data from medical files were retrospectively reviewed from 1,207 patients. Gastrointestinal changes occurred in 612 (50.7%). The most prevalent disorder was chronic intestinal constipation. Intestinal parasite occurred in 22% (mainly giardiasis), gastroesophageal reflux disease in 14%, digestive tract malformations occurred in 5%: 13 cases of duodenal atresia, 8 of imperforate anus, 4 annular pancreases, 2 congenital megacolon, 2 esophageal atresias, 2 esophageal compression by anomalous subclavian and 1 case of duodenal membrane. We had 38/1,207 (3.1%) patients with difficulty in sucking and only three with dysphagia that resolved before the second year of life. Peptic ulcer disease, celiac disease, and biliary lithiasis were less prevalent with 3% each. Awareness of the high prevalence of gastrointestinal disorders promotes outstanding clinical follow-up as well as adequate development and greater quality of life for patients with Down syndrome and their families.

Anorectal manometry in children with retentive fecal incontinence: What parameters should we evaluate? / Manometría anorrectal en niños con incontinencia fecal retentiva: ¿Qué parámetros debemos evaluar?

INTRODUCTION: Children with functional constipation frequently present with alterations in rectal compliance and the urge-to-defecate sensation that can be evaluated through anorectal manometry (ARM). In the present study, we evaluated the usefulness of the parameters obtained through ARM in children with retentive fecal incontinence (RFI). MATERIALS AND METHODS: Children with functional constipation, aged 4 to 17years, that underwent ARM were included in the study. RESULTS: Of the 35 children evaluated, 21 presented with functional constipation and 14 had functional constipation and RFI. The children with both constipation and RFI tolerated greater volumes of air insufflation for triggering the urge to defecate and reaching maximum tolerance of pain, compared with the children that did not have RFI. We identified the cutoff point of 135ml of air as the maximum tolerance sensation for distinguishing children with RFI. CONCLUSIONS: Maximum tolerance of pain was the most useful parameter for evaluating RFI in children with functional constipation.

Easy resolution of severe obstructive kidney injury.

Chronic constipation is a common diagnosis with a high prevalence in the elderly. Constipation affects the quality of life of sick individuals, bringing several clinical complications.

Constipation is associated with tension type headache in women.

Tension-type headaches (TTH) and irritable bowel syndrome (IBS) are comorbid diseases affecting, especially, women. One of the underlying mechanisms for both is autonomic dysfunction in the brain-gut axis. We aimed to evaluate the factors accompanying TTH and their relation to functional gastrointestinal disorders. METHODS: Women diagnosed with TTH were questioned about headache pattern and severity, and accompanying factors, as well as being screened for IBS according to the Rome III criteria. The participants were divided into two groups: constipation-dominant IBS (IBS-C) group and "others", with a total of 115 individuals included in the study. RESULTS: Of the 115 patients; 48 (41.8%) of the women had IBS-C criteria while 67 (58.2%) described mixed-type IBS or diarrhea-dominant IBS. There were no significant differences in terms of mean age (p = 0.290), body mass index (p = 0.212), visual analog scale (p = 0.965), duration of attacks (p = 0.692), and episodic/chronic type (p = 0.553). Osmophobia was seen in 43.5%; phonophobia in 68.7%, and photophobia in 47.0% of the patients, and only osmophobia was significantly associated in women in the IBS-C group (p = 0.001). CONCLUSION: In female patients with TTH, a higher level of constipation was detected. The relationship of these two diseases suggests that they may share common mechanisms. This is the first study showing the relationship of osmophobia with constipation.

Características manométricas en niños con estreñimiento crónico y patología anorrectal adquirida / Manometric characteristics in children with chronic constipation and acquired anorectal pathology

Objetivos: Describir los resultados de las manometrías anorrectales (MAR) en pacientes pediátricos con estreñimiento crónico y patología anorrectal adquirida. Materiales y métodos: Se revisaron los expedientes de pacientes pediátricos referidos entre 2004 y 2016 al Laboratorio de Motilidad Gastrointestinal del Hospital San José Tec de Monterrey para evaluación por manometría anorrectal y que presentaron patología anorrectal adquirida. Resultados: Se revisaron 170 expedientes. Edad 7,18 ± 4,51 años. La prevalencia de patología anorrectal (PA) fue de 73%. Síntomas con mayor incidencia: dificultad para evacuar (78%), dolor al evacuar (67%), heces duras (50%) e incontinencia fecal asociado (49%). El 44% de los pacientes con esfínter anal externo (EAE) hipotónico presentaron incontinencia y 74% estos últimos, presentaron menor volumen máximo tolerable (VMT). Los valores manométricos con mayor significancia: presión en reposo del EAE (promedio ± DE) 14,16 ± 10,19 en PA y de 26,08 ± 13,65 en SPA; presión en contracción del EAE 48,4 ± 34,1 en PA y 68,3 ± 37,7 en SPA; VMT 120,8 ± 60,4 en PA y de 173,2 ± 78,0 en SPA. El 97,97% de los pacientes en los que se evaluó la coordinación abdomino-pélvica tuvieron disinergia del piso pélvico. Conclusiones: A diferencia de la población adulta, los valores manométricos de niños con patología anorrectal se encontraron dentro de rangos normales excepto por el EAE y el VMT los cuales estuvieron disminuidos. Esto puede sugerir un mecanismo diferente en la población pediátrica. La disinergia del piso pélvico podría explicar el estreñimiento crónico en estos pacientes.

Objective: To describe the anorectal manometry results in the pediatric population with chronic constipation and acquired anorectal disease. Materials and methods: We reviewed the records of children who were referred to the Motility and Pelvic Floor Laboratory of the Hospital San Jose Tecnologico de Monterrey between 2004-2016 for further evaluation with anorectal manometry and who presented acquired anorectal disease. Results: We reviewed 170 records. The mean age was 7.18 ± 4.51 years old. The prevalence of anorectal disease was 73%. The symptoms more frequently presented were difficult evacuation (78%), painful defecation (67%), large and hard stool (50%) and fecal soiling (49%). 44% of patients with hypotonic external anal sphincter (EAS) presented with soiling and 74% of those had diminished critical volume. Significant manometric values (p<0.05) were EAS resting pressure, maximal squeeze pressure, and critical volume. 97.7% of those who underwent abdomino pelvic coordination evaluation had pelvic floor dyssynergia (anismus). Conclusions: Contrary to adult population, the manometric values in children with acquire anorectal pathology were within normal values except for the EAS resting pressure and critical volume that were diminished. This could suggest a different mechanism in the pediatric population. Pelvic floor dyssynergia could explain chronic constipation in these patients.

Quality of life of cancer patients living in Trinidad and Tobago.

PURPOSE: To determine quality of life (QoL) of cancer patients in The Republic of Trinidad and Tobago using the European Organization for Research and Treatment of Cancer Care Quality of Life Instrument (EORTC QLQ-C30) and examine relationships between QoL and socioeconomic and medical variables. METHOD: A cross-sectional study, consisting of 480 cancer patients being managed at the National Radiotherapy Centre, was conducted. One-way, multiple analysis of variance (MANOVA) with post hoc testing was used to analyze relationships between socioeconomic and medical variables and scales on the EORTC QLQ-C30. Stepwise linear regression was used to evaluate which independent variables contributed to the global QoL and function scores. RESULTS: Participants were of mean age 64.1 ± 12.1 years (males) and 56.7 ± 16.6 years (females). Mean values for global QoL and function scales were below 75. Persons in younger age groups had significantly better physical and cognitive function scores (p < 0.05). Males had higher emotional function scores than females (p < 0.05). Persons with higher income and education had better scores on all function scales, except social, and less symptoms (p < 0.05). Persons receiving chemotherapy had more nausea/vomiting, appetite loss, and constipation (p < 0.05). CONCLUSION: Age, income, education, and cancer treatment were factors most associated with scores on the EORTC QLQ-C30. Further research is required in this population to examine these variables in more depth and explore methods to improve QoL of cancer patients in this population.