No-enema therapy for idiopathic constipation and encopresis.

Idiopathic constipation and encopresis of childhood are thought to occur when children volitionally withhold stool. Withholding may be prompted by social pressures or by episodes of painful defecation. Repetitive withholding may result in colonic dilatation and colorectal dysfunction. Therapy involves removal of impacted stool, stool softening, and behavioral therapy. The use of enemas in this therapy is widespread but may be counterproductive. A retrospective review of patients treated without enemas revealed 45 patients whose course could be followed for six months. Ninety-eight percent of these had successful initial cleanouts without enemas; 94% had continued success at six months. These results, comparable with other treatment programs, demonstrate that therapy without enemas is a reasonable alternative in the treatment of childhood constipation and encopresis.

A subacute rabbit model for hepatobiliary dysfunction during total parenteral nutrition.

Total parenteral nutrition (TPN) in children is associated with the complicating syndromes of cholestasis and cholelithiasis. The causes of these syndromes are not completely clear. Gastrointestinal hypomotility associated with enteral fasting may be involved in the pathogenesis of both syndromes. We compared weanling rabbits maintained solely on TPN with chow pair-fed and free-fed controls over a 10-day period. Gastrointestinal transit time, assessed with a solid marker technique, was significantly greater in the TPN-treated animals. No difference in intestinal or biliary bacterial flora was demonstrated by aerobic or anaerobic cultures. Gallbladder bile contained a higher percentage of lithocholic acid, unconjugated bilirubin, and total calcium in the TPN-treated animals. Markers of hepatic dysfunction were elevated in the serum of the TPN-treated animals. Mild steatosis and edema were the only histologic differences in the livers of the TPN-treated animals. We conclude that gastrointestinal hypomotility associated with enteral fasting plays a role in the pathophysiologic changes leading to TPN-associated hepatobiliary dysfunction. This dysfunction may be mediated by an increase in the absolute and relative concentrations of lithocholic acid in the bile of TPN-treated animals.

Observations of vitamin A toxicity in three patients with renal failure receiving parenteral alimentation.

Elevated serum retinol concentrations have been previously reported in patients with renal failure, although overt clinical toxicity has been described only rarely. We present three patients with renal failure receiving total parenteral nutrition (TPN) who developed biochemical and clinical findings of hypervitaminosis A. Improvement followed deletion of vitamin A from the TPN. These cases demonstrate that patients with renal failure may be at risk for symptomatic vitamin A toxicity if given TPN with standard retinol supplementation. Such patients should be carefully observed clinically and biochemically if supplementation is given.

Phenobarbital does not prevent total parenteral nutrition-associated cholestasis in noninfected neonates.

Cholestasis associated with total parenteral nutrition (TPN) is a serious complication of this therapy for which there is no known treatment other than beginning enteral feeds. Phenobarbital is commonly used in other cholestatic disease states, but its benefit in this syndrome has not been demonstrated. We conducted a retrospective review of phenobarbital use in neonates receiving concurrent TPN. Thirty-one noninfected neonates were studied. They were without evidence of intrinsic liver disease at the institution of exclusive TPN therapy. For the purposes of this study, TPN-associated cholestasis was defined as a serum bilirubin in excess of 3 mg/dl at postnatal age of 3 weeks or more. Fourteen of the study infants received phenobarbital therapy for neurologic indications. Sixty percent of the phenobarbital-treated infants developed TPN-associated cholestasis, as compared to 33% of the untreated patients. Phenobarbital therapy was not effective in preventing TPN-associated cholestasis.

Long-term external catheter biliary drainage for recurrent cholangitis after hepatoportoenterostomy.

An infant developed relapsing cholangitis following hepatoportoenterostomy for extrahepatic biliary atresia. The source of recurrent infection seemed to be an intrahepatic cyst. Short-term percutaneous cholangio-drainage of such cysts, resulting in eradication of infection, has been described. However, this child required continuous drainage because of persistence of infection in the reaccumulating bile. The insertion of a nephrostomy catheter and use of enterostomal appliances have allowed continuous uneventful biliary drainage for 15 months.