Is the afferent pathway from the rectum impaired in children with chronic constipation and encopresis?

doi:10.1016/0016-5085(95)90326-7

Gastroenterology

Volume 109, Issue 2, August 1995, Pages 397-403

https://doi.org/10.1016/0016-5085(95)90326-7 Get rights and content

Abstract

$Background & Aims :$ Rectal sensations to balloon distention are impaired in children with chronic constipation and encopresis. The impairment of rectal sensation, which is often persistent and is related to nonrecovery, could be caused by a defect in the visceral afferent pathways. The aim of this study was to test whether the afferent pathway from the rectum is impaired in children with constipation and encopresis. $Methods :$ Fifteen healthy children and 15 children with constipation and encopresis were studied. Cerebral evoked potentials (EPs) were studied by averaging results of 100 rectal distentions, which used 10, 20, and 30 mL air. EPs were recorded from Cz′ to Fz. $Results :$ Two different types of EPs were recorded in each control subject and each child with constipation and encopresis. One EP had an early onset and showed multiple positive and negative peaks. The other EP had a much later onset and was triphasic. Early-onset EPs were recorded with significantly smaller distention volumes than the late-onset EPs. N1 and P2 latencies of the early-onset EPs and NI, PI, and NII latencies of the late-onset EPs were significantly prolonged in children with constipation and encopresis compared with controls. $Conclusions :$ The prolonged latencies suggest a defect in the afferent pathway from the rectum in children with chronic constipation and encopresis.

References (34)

P Meunier et al.
Rectoanal pressures and rectal sensitivity studies in chronic childhood constipation
Gastroenterology
(1979)
VA Loening-Baucke
Abnormal rectoanal function in children recovered from chronic constipation and encopresis
Gastroenterology
(1984)
V Loening-Baucke
Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis
J Pediatr
(1990)
V Loening-Baucke et al.
Cerebral evoked potentials after rectal stimulation
Electroencephalogr Clin Neurophysiol
(1991)
V Loening-Baucke et al.
Evaluation of the motor and sensory components of the pudendal nerve
Electroencephalogr Clin Neurophysiol
(1994)
V Loening-Baucke et al.
Cerebral potentials evoked by rectal distention in humans
Electroencephalogr Clin Neurophys
(1993)
EA Mayer et al.
Role of visceral afferent mechanisms in functional bowel disorders
Gastroenterology
(1990)
EA Mayer et al.
Basic and clinical aspects of visceral hyperalgesia
Gastroenterology
(1994)
W Jänig et al.
Functional properties of spinal visceral afferents supplying abdominal and pelvic organs, with special emphasis on visceral nociception
Prog Brain Res
(1986)
JC Goligher et al.
Sensibility of the rectum and colon: its role in the mechanism of anal continence
Lancet
(1951)

G Badr et al.

Cortical evoked potentials following stimulation of the urinary bladder in man

Electroencephalogr Clin Neurophysiol

(1982)

GG Badr et al.

Cortical evoked potentials obtained after stimulation of the lower urinary tract

J Urol

(1984)

MV Hansen et al.

Cerebral evoked potentials after stimulation of the posterior urethra in man

Electroencephalogr Clin Neurophysiol

(1990)

H Gänzer et al.

Cortical evoked potentials by stimulation of the vesicourethral junction: clinical value and neurophysiological considerations

J Urol

(1991)

Y Sarica et al.

Cerebral responses evoked by stimulation of the vesico-urethral junction in normal subjects

Electroencephalogr Clin Neurophysiol

(1986)

T Frieling et al.

Cerebral responses evoked by electrical stimulation of the esophagus in normal subjects

Gastroenterology

(1989)

DO Castell et al.

Cerebral electrical potentials evoked by balloon distention of the human esophagus

Gastroenterology

(1990)

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2018, Radiotherapy and Oncology
Citation Excerpt :
We found prolonged latencies of the CEPs elicited by rectal distensions suggesting that AC patients have abnormal afferent neural pathways from the rectum to the brain. Prolonged CEP latencies after rectal stimuli have previously been described in patients with fecal and urinary incontinence, constipated children, and constipated adults with rectal hyposensitivity [32,42–44]. This likely represents aberrant (mechano-) receptor function or abnormal propagation properties of the afferent pathways, likely due to damage of the peripheral nerves.
Sphincter-sparing radiotherapy or chemoradiation (RT/CRT) have become the standard treatments for most patients with anal cancer. Unfortunately, long-term survivors often suffer from severe bowel symptoms indicating sensory dysfunction. The aim of the present study was to characterize the sensory pathways of the brain–gut axis after radiotherapy for anal cancer.
Cortical evoked potentials (CEPs) were recorded during repeated, rapid balloon distensions of the rectum and anal canal in 13 patients with anal cancer treated with radiotherapy or chemoradiation and in 17 healthy volunteers. Latencies and amplitudes of rectal CEPs were compared between the groups. CEPs from both rectal and anal distensions were examined using single sweep spectral band analysis to determine the relative amplitude of five spectral bands as a proxy of neuronal processing.
Groups were comparable by age (62.4 ± 7.8 vs 58.9 ± 8.9, p < 0.32) and gender. Patients had a mean Wexner fecal incontinence score of 5.5 (±3.8) and median LARS Score of 29 (0–39). Rectal CEP latencies were prolonged in patients (F = 11.7; p < 0.001), whereas amplitudes were similar (F = 0.003; p = 0.96). Spectral analysis of CEPs from rectal distensions showed significant differences between groups in theta (4–8 Hz), alpha (8–12 Hz), beta (12–32 Hz) and gamma (32–70 Hz) bands (all p < 0.001) and CEPs from anal distensions showed significant differences in the alpha, beta and gamma bands (all p ≤ 0.002).
Patients treated with RT/CRT for anal cancer have impaired ano-rectal sensory pathways and abnormal cortical processing. This may play a central role for the pathogenesis of late proctopathy.
Anorectal manometry with and without ketamine for evaluation of defecation disorders in children
2015, Journal of Pediatric Surgery
Citation Excerpt :
In constipated children, there have been reports of abnormal manometry profile of up to two folds increase in thresholds of rectal sensation, critical volume and RAIR as it was observed in this series [9,11,25]. In contrast, the first rectal sensory threshold and the critical volume in healthy children have been reported to be lower being 17 ± 7.1 and 101 ± 39, respectively [26,27]. It has been suggested that a defect is present in the afferent neural pathway of the rectum in children who have chronic functional constipation.
Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children.
This was a prospective study of children who were investigated for symptoms of chronic constipation and soiling between April 2001 and April 2004. We studied 52 consecutive children who had awake ARCM, biofeedback training and endosonography (awake group) and 64 children who had ketamine anesthesia for ARCM and endosonography (ketamine group). We age matched 31 children who had awake anorectal studies with 27 who had ketamine anesthesia.
The children in awake and ketamine groups were comparable for age, duration of bowel symptoms and duration of laxative treatments. ARCM profile was comparable between the awake and the ketamine groups with regard to anal sphincter resting pressure, rectal capacity, amplitude of rectal contractions, frequency of rectal and IAS contractions and functional length of anal canal. Of 52 children who had awake ARCM, dyssynergia of the EAS muscles was observed in 22 (42%) and median squeeze pressure was 87 mm Hg (range 25–134). The anal sphincter resting pressure was non-obstructive and comparable to healthy normal children. Rectoanal inhibitory reflex was seen in all children excluding diagnosis of Hirschsprung disease.
Ketamine anesthesia does not affect quantitative or qualitative measurements of autonomic anorectal function and can be used reliably in children who will not tolerate the manometry while awake. Paradoxical contraction of the EAS can only be evaluated in the awake children and should be investigated further as the underlying cause of obstructive defecation in patients with chronic functional constipation and soiling.
Pathophysiology of chronic childhood constipation: Functional and morphological evaluation by anorectal manometry and endosonography and colonic transit study
2013, Journal of Pediatric Surgery
Chronic idiopathic constipation (IC) is a common problem in children. We hypothesised that hypertonicity and overactivity of the internal anal sphincter (IAS) contributed to childhood IC.
This was a prospective study of children who were admitted for investigation and treatment of chronic constipation at the gastrointestinal motility clinic in Guy's and St. Thomas’ Hospital, NHS Foundation Trust, London. All children had a colonic transit marker study followed by anorectal manometry and anal endosonography under ketamine anesthesia. We used a validated symptom severity (SS) score questionnaire for assessment of constipation and fecal incontinence on admission to hospital and during follow-up for 12 months. The SS score of 0 was the best and 65 the worst.
Of 92 children, 57 were male and median (range) age was 8.46 years (3.35–14.97). Duration of symptoms was 4.7 years (0.3–13). Soiling was present in 88 (96%) patients, delay in defecation of once every 2 to 3 days or less frequently in 86 (93%) and a palpable fecaloma (megarectum) on abdominal examination in 76 (83%). 42 children had ‘fecal impaction’ requiring disimpaction of stool from the rectum under general anesthesia and 50 had ‘no impaction’.
The median IAS resting pressure was within the normal range measuring 55 mm Hg (25–107) and median amplitude and frequency of the IAS contractions were 10 mm Hg (2.0–58) and 17 cycles per min (5.0–34), respectively. The median IAS thickness was 0.93 mm (0.5–2.0). There was no correlation between amplitude and frequency of anorectal contractions and anal sphincter resting pressure. The mean right colonic transit time was 8.55 (standard deviation ± 13.22) h, left colonic transit time was 11.51 h (± 13.21), rectosigmoid transit time was 25.91 h (± 18.89) and total colonic transit time was 45.97 h (± 17.69).
The anal sphincter resting pressure is normal in children with chronic IC. Increased frequency and amplitude of IAS contractions seen in these patients do not cause raised anal sphincter resting pressure or obstructive defecation. Further studies should be done to investigate the role of external anal sphincter dysfunction in pathophysiology of childhood constipation and fecal incontinence.
Anorectal functional abnormalities in Egyptian children with chronic functional constipation
2013, Arab Journal of Gastroenterology
Chronic functional constipation represents 95% of the cases of paediatric constipation. Epidemiologic data, pathophysiology and anorectal functional abnormalities vary greatly among different reports across different populations. The aim of this study was to evaluate these data in Egyptian children with chronic functional constipation.
This study included 150 children with chronic functional constipation (101 males, 49 females; mean age 6 ± 3.1 years); a control group of 50 age- and sex-matched healthy children were enrolled for standardisation of the manometry technique. A structured symptom questionnaire and clinical examination including digital rectal examination in addition to anorectal manometry were done for all included children. Defaecation dynamics were assessed in all children 5 years or older using anorectal manometry with integrated electromyogram of the external anal sphincter and the puborectalis muscle.
The maximal tolerable volume was significantly higher in the constipated children than in the control group (p = 0.03). No significant differences existed between constipated and control children regarding other anorectal manometric parameters. Abnormal defaecation dynamics were detected in 35 out of 95 tested patients (36.8%).
Increased maximal tolerable volume is the most striking manometric feature in Egyptian children with chronic functional constipation. Abnormal defaecation dynamics were detected in about one-third of the tested patients. Standardisation of the measurement techniques and obtaining normal ranges for anorectal manometric parameters for each laboratory are recommended.
Constipation Is Associated With Spina Bifida Occulta in Children
2008, Clinical Gastroenterology and Hepatology
Spina bifida occulta (SBO) is a common developmental variant. The aim of this study was to re-examine the possible association between SBO and constipation in children.
A total of 113 children with constipation underwent plain abdominal radiography, anorectal manometry, neurophysiologic study, electromyography testing, and colonic transit study. Eighty-six were diagnosed with functional constipation (FC) and 27 were diagnosed with nonretentive fecal incontinence (NRFI). The incidence of SBO in these children was compared with 226 sex- and age-matched controls. Twenty-four SBO children with either FC or NRFI also underwent individualized biofeedback training and electric stimulation therapy based on the investigation results.
The incidence of SBO in the FC and NRFI groups was 47.7% and 77.8%, respectively. Statistically, this is significantly higher than that of the control group (chi-square, 23.9%; P < .05). Compared with the FC or NRFI children without SBO, the FC and NRFI children with SBO had decreased vector volumes and electromyography amplitudes, increased rectal sensory thresholds, and prolonged latency of pudendo-anal reflex. All 24 children who underwent individualized biofeedback training and electrical stimulation treatment had sustained symptomatic improvement with less straining, fewer incomplete bowel movements, and less abdominal pain. The recovery rate was 79.2% (19 of 24).
Constipation in children is associated with increased incidence of SBO. Individualized biofeedback combined with electrical stimulation improves both the symptoms and the objective anorectal function measurements.
Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial
2007, Journal of Pediatric Surgery
Citation Excerpt :
Other stimulants, such as Movicol and sodium picosulfate, were given if a child did not pass bowel motion for 3 days or as additional bowel stimulants over weekends. At least 2 of the following 4 criteria should have been fulfilled for the definition of constipation and fecal soiling: stool frequency of less than 3 times per week; soiling frequency of 2 or more times per week; periodic passage of large amounts of stool at least once every 7 to 30 days; and presence of a palpable abdominal or rectal mass [21,22]. Patients were excluded from the study if they had an underlying anorectal anomaly or endocrine abnormality, neuropathic bowel, learning difficulties, and evidence of anal sphincter damage on endosonography or a low anal sphincter pressure of less than 30 mm Hg on manometry.
Myectomy of the internal anal sphincter (IAS) has been performed on some children after failure of medical treatment to treat idiopathic constipation. The aim of this study was to compare botulinum toxin injection with myectomy of the IAS in the treatment of chronic idiopathic constipation and soiling in children.
This was a double-blind randomized trial. Patients between 4 and 16 years old were included in the study if they had failed to respond to laxative treatment and anal dilatation for chronic idiopathic constipation. All study patients had anorectal manometry and anal endosonography under ketamine anesthesia. Outcome was measured using a validated symptom severity (SS) scoring system, with scores ranging from 0 to 65.
Of 42 children, 21 were randomized to the botulinum group and 21 were randomized to the myectomy group. At the 3-month follow-up, the median preoperative SS score improved from 34 (range = 19-47) to 20 (range = 2-43) in the botulinum group (P < .001) and from 31 (range = 18-49) to 19 (range = 3-47) in the myectomy group (P < .002). At the 12-month follow-up, the scores were 19 (range = 0-45) and 14.5 (range = 0-41) for the botulinum group and the myectomy group, respectively (P < .0001). There was no complication in both groups.
Botulinum toxin is equally effective as and less invasive than myectomy of the IAS for chronic idiopathic constipation and fecal incontinence in children.

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^☆: Supported by the Children's Miracle Network Telethon and grant M01-RR-00059 from the General Clinical Research Center Program, Division of Research Resources, National Institutes of Health.

^☆☆: Presented in part at the American Gastroenterological Association meeting in Boston, Massachusetts, May 19, 1993, and published in abstract form (Gastroenterology 1993;104:A544).

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Alimentary tractIs the afferent pathway from the rectum impaired in children with chronic constipation and encopresis?☆,☆☆

Abstract

Gastroenterology

Gastroenterology

J Pediatr

Electroencephalogr Clin Neurophysiol

Electroencephalogr Clin Neurophysiol

Electroencephalogr Clin Neurophys

Gastroenterology

Gastroenterology

Prog Brain Res

Lancet

Electroencephalogr Clin Neurophysiol

J Urol

Electroencephalogr Clin Neurophysiol

J Urol

Electroencephalogr Clin Neurophysiol

Gastroenterology

Gastroenterology

Alimentary tract
Is the afferent pathway from the rectum impaired in children with chronic constipation and encopresis?☆,☆☆