Very Recent Scientific Abstracts:

The abstracts which follow are narrowly focussed on issues and mechanisms pertinent to encopresis, enuresis, and toilet training. Scroll down to find each of the sections on Encopresis, Enuresis, and Toilet Training. In general, more recent articles are posted at the end of each section, but this is not always true if there appears to be a good fit with a prior article. The completeness of the updating of course is limited to the cited search terms and cited authors that I have used to this date with my subscribed literature retrieval service (Thomson Scientific).

My weekly computer updates received through 05/12/2008 have been reviewed for significant abstracts to post. The last posting(s) were made on 05/06/2008. I recently deleted some abstracts from 2004 and early 2005 in the Encopresis and Enuresis sections. This was truly painful, but the list was just getting too long.

This page receives my strong, personal attention. It is oriented toward professionals and not the general public.  Of couse, everyone is free to examine it and parents may find it interesting to see the latest research in the area of encopresis and enuresis.  RWC.

The antegrade continence enema successfully treats idiopathic slow-transit constipation

King,S.K., Sutcliffe,J.R., Southwell,B.R., Chait,P.G., Hutson,J.M.* Royal Childrens Hosp, Dept Gen Surg, Parkville, Vic 3052, Australia

Search Terms: slow-transit, constipation, low motility, malone, antegrade continence enema (ACE), encopresis, cecostomy, appendicostomy.

Background: Antegrade continence enemas (ACE) 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 ACE are less effective in patients with colonic dystomility. (c) 2005 Elsevier Inc. All rights reserved.

This group or researchers emphasize low motility as central for many cases of encopresis. Most authorities believe encopresis is due to stool retention or holding. There is a case to be made for encopresis being either low motility dominant or holding dominant or a mixture of the two. The surgical ACE procedure appears to be the treatment of choice for low transit disorders. I hardly view the use of suppositories and enemas in a programmed way to end encopresis as more drastic than this surgical approach! My protocol should used first and if not successful a specific low motility study should certainly be done before going to the ACE procedure. DrC.

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Treatment of childhood constipation by primary care physicians: Efficacy and predictors of outcome.

Borowitz,S.M.*, Cox,D.J., Kovatchev,B., Ritterband,L.M.,Sheen,J. Univ Virginia, Div Pediat Gastroenterol & Nutr, Dept. Pediat, Box 800386 HSC, Charlottesville, VA 22908 USA

Objective. Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are.
Methods. A total of 119 children who were between 2 and 7 years of age ( mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians ( 15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians.
Results. After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose ( 8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes ( 5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively.
Conclusion. Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic. (C) 2005 Elsevier Inc. All rights reserved.

No Comment! RWC

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Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children

Dupont,C.AU* - Leluyer,B.AU - Maamri,N.AU - Morali,A.AU - Joye,J.P.AU - Fiorini,J.M.AU - Abdelatif,A.AU - Baranes,C.AU - Benoit,S.AU - Benssoussan,A.AU - oussioux,J.L.AU - Boyer,P.AU - Brunet,E.AU - Delorme,J.AU - Francois-Cecchin,S.AU - ottrand,F.AU - Grassart,M.AU - Hadji,S.AU - Kalidjian,A.AU - Languepin,J.AU - Leissler,C.AU - Lejay,D.AU - Livon,D.AU - Lopez,J.P.AU - Mougenot,J.F.AU - Risse,J.C.AU - Rizk,C.AU - Roumaneix,D.AU - Schirrer,J.AU - Thoron,B.AU - Kalach,N. Hop St Vincent de Paul, Serv Neonatol, 74-82,Ave Denfert Rochereau, F-75674 Paris, France

Objectives: To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients.
Study Design: This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-control led, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (250HD(3)) were measured in blood before and after treatment (day 84) in a central laboratory.
Results: The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 5 1% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives.
Conclusion: This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

This is a significant study and appears to support the use of Miralax for safety, efficacy, and fewer side-effects over Lactulose. RWC

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Using the Internet to provide information prescriptions

Ritterband,L.M.*, Borowitz,S., Cox,D.J., Kovatchev,B., Walker,L.S., Lucas,V., & Sutphen,J. Univ Virginia Hlth Syst, Dept Psychiat Med, Ctr Behav, Med Res, POB 800223, Charlottesville, VA 22908 USA

Introduction. An information prescription is the provision of specific information to a patient on how to help manage a health problem. The Internet is being used increasingly as a source for information prescriptions, with clinicians directing patients to specific Web sites. As with any health care intervention, patients' lack of compliance is a barrier to the effectiveness of Web-based information prescriptions (WebIPs). WebIPs cannot be helpful if patients do not review the information prescribed for them.
Objective. The main objective of this study was to quantify the percentage of families who visit a Web site that was specifically prescribed by their physician. In addition, the use of an e-mail reminder was used to determine if it increases the likelihood that families will visit the prescribed Web site. Finally, barriers to accessing the prescribed Web site were identified.
Methods. Children were eligible if they presented to the pediatric gastroenterology clinic with chronic constipation and/or encopresis and their family had an active e-mail account and access to the Internet in their home. During their clinic visit, physicians instructed families to visit a Web site that provided educational information pertinent to their child's problem. Families were given a form with the Web-site address and a log-in identification number. Two days after their clinic visit, half of the families received an e-mail reminding them to visit the Web site. Families were contacted 1 week after their clinic visit to identify barriers to accessing the Web site.
Results. Eighty-three families participated in the study. Of the 83 families, 54 (65%) visited the prescribed Web site within 1 week of their clinic visit. Families who received e-mail reminders were significantly more likely to visit the Web site than families who did not receive an e-mail reminder (77% vs 53%). This difference could not be explained by the type or speed of Internet connection or how frequently they accessed the Internet or e-mail. The most common reasons that families cited for not accessing the Web site were "I forgot" and "I didn't have time." Few families cited technical reasons for not accessing the Web site.
Conclusions. Almost two thirds of the families given a WebIP logged on to the prescribed Web site. The probability that families would access the site was increased by 45% with an e-mail reminder. Clearly, e-mail prompts improve compliance to WebIPs. As content and treatment programs continue to proliferate on the Web, it is important to identify barriers and solutions to them to improve overall compliance.

This University of Virginia group is leading the way in researching the effects of internet-based interventions for encopresis and other problems. I stay in regular touch with them and have recently opened my own parent's forum for parent's who purchase the Clean Kid Manual. RWC

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Mental and somatic health in a non-clinical sample 10 years after a diagnosis of encopresis

Hulten,I., Jonsson,J., Jonsson,C.O., Address not available.

The aim of this study was to assess the relation between the diagnosis of encopresis at 8 and 10 years of age, and mental and somatic health 10 years later. The importance of type of encopresis (primary or secondary) at 8 years was also studied. Subjects were a non-clinical encopretic sample (N=73) and control subjects (N=75) [2]. Seven assessment variables from conscription surveys provided information about mental and somatic health status at 18 years of age. Former encopretics (n=66) did not differ significantly from the controls (n=67) at 18 years of age, although there were consistent, small negative differences. The boys who at 10 years of age had still been encopretic did not differ significantly at 18 years of age from the boys who at 10 years had recovered from encopresis, and the signs indicating the small differences varied. For former primary and secondary encopretic boys, there were two significant differences, the men in the secondary group being more often exempted from conscription than the primary group and the control cases. The results indicate that boys with non-clinical encopresis show only small, if any, mental and somatic disturbances at the beginning of adulthood. Comprehensive investigations of encopretic patients are recommended as important clinical problems, in addition to encopresis, might be present.

It was relatively resassuring to see no effects of encopresis at 18 y/o.

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Cecostomy in children with defecation disorders.

Mousa,H.M.*, Van Den Berg,M.M., Caniano,D.A., Hogan,M., Di Lorenzo,C., Hayes,J.
Childrens Hosp, Div Pediat Gastroenterol, 700 Childrens Dr,ED 426, Columbus, OH 43205 English

Search Terms: Antegrade enema, cecostomy, encopresis, fecal incontinence, Hirschsprung’s disease, imperforate anus, tethered spinal cord

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n =9), Hirschsprung's disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

I found it interesting that a significant sub-sample of these surgical cases was for encopresis, a functional disorder. Elsewhere it has been reported that when the cecostomy is closed the children can continue on a much improved basis. DrC.

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Effect of micturition on the external anal sphincter: Identification of the urethro-anal reflex

Shafik,A., El Sibai,F., Shafik,I., & Shafik,A.A. No address or source given.

Search terms: Enuresis, Encopresis, EMG, micturition, defecation, sphincter, EAS.

Background/Objective: A study on the response of the external anal sphincter (EAS) to the passage of urine through the urethra during micturition could not be found in the literature. We investigated the hypothesis that urine passage through the urethra effects EAS contraction to guard against possible flatus or stool leakage during micturition.
Methods: The study was performed in 23 healthy volunteers (age, 38.6 +/- 10.8 [SD] years; 14 men and 9 women). The EAS electromyogram (EMG) was performed during micturition by surface electrodes applied to the EAS. Also, the EAS EMG response to urethral stimulation by a catheter-mounted electrode was registered. The test was repeated after individual anesthetization of the EAS and urethra.
Results: The EAS EMG recorded a significant increase (P < 0.01) during micturition and on urethral stimulation at the bladder neck. Stimulation of the prostatic, membranous, or penile urethra produced no significant change in the EAS EMG. Urethral stimulation after individual EAS and urethral anesthetization did not cause any changes in the EAS EMG.
Conclusions: Urine passing through the urethra or urethral stimulation at the vesical neck produced an increase in the EAS EMG, which presumably denotes EAS contraction, which seems to guard against flatus or fecal leakage during micturition. EAS contraction on urethral stimulation is suggested to be mediated through a urethro-anal reflex. Further studies on this issue may potentially prove the diagnostic significance of this reflex in micturition and defecation disorders.

This finding identifies a new reflex arc between bowel and bladder sphincter function. This is very interesting in view of my clinical obversations and some limited earlier reports that there is some association between disorders of bladder and bowel control. A recent epidemiological study in Japan is reported by Kajiwara below toward the end of the ENURESIS section which presented findings on the concurrence of diurnal enuresis, nocturnal enuresis and encopresis and its developmental course. DrC.

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New insight into rectal function in pediatric defecation disorders: Disturbed rectal compliance is an essential mechanism in pediatric constipation

Voskuijl,W.P.,* Van Ginkel,R., Benninga,M.A., Hart,G.A., Taminiau,J.A.J.M., & Boeckxstaens, G.E.Univ Amsterdam, Acad Med Ctr, Dept Pediat Gastroenterol & Nutr, Dept Biostat & Gastroenterol, Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: constipation, megacolon, manometry, encopresis

Objective: To evaluate rectal sensitivity inpatients with pediatric constipation (PC) and nonretentive fecal soiling (FNRFS) using pressure-controlled distention (barostat).
Study design: Thresholds for rectal sensitivity (first sensation, urge to defecate, and pain), and rectal compliance were determined using a barostat.
Results: A total of 69 patients with PC (50 males; mean age, 10.9 +/- 2.2 years) and 19 patients with FNRFS (15 males; mean age, 10.0 +/- 1.9 years) were compared with 22 healthy volunteers (HVs) (11 males; mean age, 12.7 +/- 2.6 years). Sensitivity thresholds were not significantly different among the 3 groups. Rectal compliance was increased in 58% of the patients with PC (P < .0001 vs HVs). Rectal compliance did not differ between patients with FNRFS and HVs. Children with PC with abnormal rectal function required significantly larger rectal volumes at urge to defecate.
Conclusions: Increased compliance is the most prominent feature in patients with PC. Because of higher compliance in these children, larger stool volumes are required to reach the intrarectal pressure of the urge to defecate. Children with FNRFS have normal rectal function.

My clinical observations accord well with this "new insight" . Occasionally, I have to recommend to parents of children to use my voiding protocol on an every other day basis. This is because in my program, if the children do not transition properly to going on their own after daily trials on my protocol it is evident that there is not a sufficient "natural" urge stimulus available for them to respond to. I had reasoned some time ago that the urge sensations should be more salient with a two day accumulation of stool and that, accordingly, the children are more likely to "sense" the build up so that there is a potential Conditioned Stimulus available for being properly conditioned to release stool as occurs with the suppository or enema in my program which serve as Unconditioned Stimuli for a voiding reflex. The children in a sense tune up to their natural urge sensations by using the urge sensations associated with the suppositories or, if necessary, an enema which almost surely produces the voiding reflex (typically overcoming anismus which becomes less over trials as the child becomes less habitually defensive). As the Pavlovian process takes over the gentler urge of the glycerin suppository becomes adequate and then the childs natural urges to accumulating stool becomes sufficient. This then can proceed to daily evacuations eventually as the enlarged colon begins to shrink with more regular voidings and a lesser accumulation may become a sufficient trigger. Dr Whitehead with Dr. Marvin Schuster sometime ago noted the importance of sensory awareness for effective biofeedback interventions. RWC

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Longitudinal follow-up of children with functional nonretentive fecal incontinence

Voskuijl,W.P.,* Reitsma,J.B., van Ginkel,R., Buller,H.A., Taminiau,J.A.J.M., & Benninga,M.A. Univ Amsterdam, Acad Med Ctr, Dept Pediat Gastroenterol & Nutr, Meibergdreef 9,Room C2-312, NL-1105 AZ Amsterdam, Netherlands

Search Terms: CONSTIPATION, Encopresis, Non-retentive form

Background & Aims: Functional nonretentive fecal incontinence (FNRFI), incontinence in the absence of signs of fecal retention, is a frustrating phenomenon in children. No data on long-term outcome are available. The aim was to investigate the long-term outcome of FNRFI patients after intensive medical treatment.
Methods: Between 1990 and 1999, 119 patients (96 boys) with FNRFI were enrolled in 2 prospective, randomized trials investigating the effect of biofeedback training and/or laxative treatment. Follow-up (FU) was performed at 6 months, 1 year, and thereafter annually until September 2004. A standardized questionnaire was used to evaluate symptoms. Success was defined as a fecal incontinence frequency < 1 per 2 weeks.
Results: Median age (25th-75th percentiles) was 9.2 years (range, 7.9-11.6 years). A 90% FU was achieved at all stages of the study. After 2 years of intensive therapy, 33 of 112 (29.5%) patients were successfully treated. The cumulative success percentage after 7 years of FU was 80%. At the biologic ages of 12 and 18 years, 49.4% (40/81) and 15.5% (9/58), respectively, of the patients still had fecal incontinence. Duration of fecal incontinence, with 4 years of age as the starting age for fecal incontinence (when a child should be toilet trained), was not related to successful outcome or relapse. Relapse occurred in 37% of patients.
Conclusions: Only 29% of the patients with FNRFI were successfully treated after 2 years of intensive treatment. Despite recovery in the majority of patients beyond puberty, at age 18 years, 15% continued to have fecal incontinence.

This is a very important study which probably could not be done in our country with our fragmented and proprietary health care systems with less centralized record keeping, a highly mobile population, two working parents, single working parents, market beseiged individuals guarding their privacy, and the longer distances involved. I've had some limited success with email follow ups with parents, but have not analyzed that data as yet. Also, this study is important because the population of concern here has appeared to be very resistant to effective interventions. I am wondering if my protocol, which is so much more definitive in terms of a tight, well-timed conditioning process to a particular time of day, might not be more successful than all of the standard operant behavioral and other approaches that have been tried. I don't appear to get enough of this variety of encopresis to form an impression. The children coming in to my site are likely somewhat self-selected by reading the materials at my website that focus much more extensively on the retentive form of encopresis which is addressed by the Clean Kid Manual-III. RWC.

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February, 2006 NATURE CLINICAL PRACTICE GASTROENTEROLOGY & HEPATOLOGY (v3,2), Pp. 90-100. Posted on 02/27/2006.

Pathophysiology, diagnosis and current management of chronic constipation

A Wald, Univ Pittsburgh, Med Ctr, PUH, Mezzanine Level,C Wing,200 Lothrop St, Pittsburgh, PA 15213 USA

Search Terms: Constipation, Encopresis, Low Motility, Slow Transit, laxatives, megacolon

Chronic constipation is prevalent in Western countries and is a complaint that is commonly seen in clinical practice. Only a relatively small percentage of constipated patients seek medical evaluation and most can be managed satisfactorily with first-line, conservative therapy. In patients with severe, refractory constipation, additional studies of colonic and anorectal function
have clinical utility, as such patients are candidates for therapies not given to most constipated patients. This article reviews the modern principles and therapies used to manage chronic constipation of varying severities.

This review is included for its likely value as a comprehensive review of methods for treating Slow Transit disorders. It appears that he is emphasizing "first-line, conservative" therapies. I have reported on more esoteric research methods higher up on this page. RWC.

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Removal of tonic nitrergic inhibition is a potent stimulus for human proximal colonic propagating sequences

Dinning,P.G., Szczesniak,A., & Cook,I.J.* Univ New S Wales, St George Hosp, Dept Gastroenterol, Kogarah, NSW 2217, Australia

Search Terms: Motility, Slow Transit, mechanisms, Nitric Oxide, encopresis, IBS, chronic constipation

Propagating sequences (PS) are important in colonic propulsion and defecation, yet the triggers of these motor patterns are not understood. Nonadrenergic noncholinergic neurones are believed to modulate smooth muscle in the gastrointestinal tract via the ubiquitous inhibitory neurotransmitter nitric oxide (NO). In the mouse colon periods of quiescence correlate with an increase in the release of NO. We investigated the colonic response to NO synthase inhibition in the conscious human subject. Intravenous infusion of saline or N-G-monomethyl-L-arginine (L-NMMA; 3 or 6 mg kg(-1) h(-1)) occurred in random order in six healthy volunteers in whom a 5 m long nasocolonic manometry catheter was positioned such that 16 recording sites, at 7.5-cm intervals, spanned the terminal ileum and colon. L-NMMA infusion at 3 mg kg(-1) h(-1) but not 6 mg kg(-1) h(-1) significantly (P = 0.02) increased proximal colonic PS frequency (2.0+/- 1.9 vs 11.7 +/- 7.0 PS h(-1)) and non-propagating motor activity (5296 +/- 2750 vs 6362 +/- 1275 mmHg s). We conclude that blockade of NO synthesis has a stimulatory effect on the frequency of proximal colonic PS. This suggests removal of tonic nitrergic, inhibition of the colon might be a physiological stimulus for propagating activity.

This is an important demonstration of a basic mechanism involving a blockade of NO synthesis for motility in the GI Tract.

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The relevance of fecal soiling as an indicator of child sexual abuse: A preliminary analysis

Mellon,M.W.*, Whiteside,S.P., & Friedrich,W.N. Mayo Clin, Dept Psychiat & Psychol, 200 1st St SW, Rochester, MN 55905 USA

Search Terms: abuse, encopresis, sexual abuse, constipation, chronic constipation

Encopresis is typically characterized as resulting from chronic constipation with overflow soiling but has been portrayed as an indicator of sexual abuse. The predictive utility of fecal soiling as an indicator of sexual abuse status was examined. In a retrospective analysis of three comparison groups of 4-12 year olds, we studied 466 children documented and treated for sexual abuse; 429 psychiatrically referred children with externalizing problems and 641 normative children recruited from the community, with the latter two samples having abuse ruled out. Standardized parent report measures identified soiling status and sexual acting out behaviors. Multiple regression analysis was used to predict abuse status in each group. Reported soiling rates were 10.3% (abuse), 10.5% (psychiatric), and 2% (normative), respectively. The soiling rate in the abused group differed significantly from that of the normative group, but not from the psychiatric group. Similar rates of soiling were reported among abused children, with and without penetration, and the psychiatric sample. Rates of sexualized behavior were reported significantly more often by the abused group versus both the psychiatric and normative groups and were a better predictor of abuse status. The positive predictive value of soiling as an indicator of abuse was 45% versus 63% for sexual acting out. The psychiatric sample displayed
significantly more dysregulated behavior than the sexually abused sample. The predictive utility of fecal soiling as an indicator of sexual abuse in children is not supported. Soiling seems to represent one of many stress-induced dysregulated behaviors. Clinicians should assume the symptom of soiling is most likely related to the typical pathology and treat accordingly.

I receive occasional enquiries about the likelihood of sexual abuse based on the mere presence of encopresis. In the not too recent past there was often a rush to judgment based on symptomatology to prosecute for child sexual abuse. This public hysteria has lessened somewhat and courts now require independent and direct observations and evidence of sexual abuse. This study helps to reinforce a more reasoned, evidence-based review for the presence of sexual abuse. I have certainly seen many, many cases of encopresis which derive from such ordinary triggers as toilet training, starting school, stressful changes in the family, and bouts of constipation. Indeed, my sense is that the very distressed reactions to encopresis in and of itself are what may to lead to physical abuse, though not sexual abuse. The aura of anal intrusion with suppositories or enemas and a child’s strong reactions to this often leads to concerns by parents that this is a form of sexual abuse in its own right. The paradox of course is that the childrens’ very withholding and reflexive sphincter contractions against voiding are the cause of the disorder itself and of resisting the suppository or enema!! They don’t want anything to go in or out! The child’s eventual acceptance and desensitization to the application of the suppositories and enemas, properly done, likely generalizes and eases the reflexive resistance to voiding at the same time. The very fact that the child experiences success in voiding, clean clothes, pleasing his parents, and feels better physically and psychologically overtime will consolidate the learning to void more naturally. RWC.

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Urinary excretion of polyethylene glycol 3350 during colonoscopy preparation.

Rothfuss,K.S.*, Bode,J.C., Stange,E.F., & Parlesak,A. Robert Bosch Krankenhaus, Abt Gastroenterol Hepatol & Endokrinol, Auerbachstr 110, D-70376 Stuttgart, Germany

Search Terms: Miralax, PEG, encopresis.

Background: Whole gut lavage with a polyethylene glycol electrolyte solution (PEG) is a common bowel cleansing method for diagnostic and therapeutic colon interventions. Absorption of orally administered PEG from the gastrointestinal tract in healthy human beings is generally considered to be poor. In patients with inflammatory bowel disease (IBD), intestinal permeability and PEG absorption were previously reported to be higher than in normal subjects. In the current study, we investigated the absorption of PEG 3350 in patients undergoing routine gut lavage.
Methods and Results: Urine specimens were collected for 8 hours in 24 patients undergoing bowel cleansing with PEG 3350 for colonoscopy. The urinary excretion of PEG 3350, measured by size exclusion chromatography, ranged between 0.01 and 0.51% of the ingested amount, corresponding to 5.8 and 896 mg in absolute amounts, respectively. Mean PEG excretion in patients with impaired mucosa such as inflammation or ulceration of the intestine (0.24% +/- 0.19, n = 11) was not significantly higher (p = 0.173) compared to that in subjects with macroscopically normal intestinal mucosa (0.13% +/- 0.13, n =13).
Conclusion: The results indicate that intestinal absorption of PEG 3350 is higher than previously assumed and underlies a strong inter-individual variation. Inflammatory changes of the intestine do not necessarily lead to a significantly higher permeability of PEG.

This study runs counter to the general wisdom that PEG is not well-absorbed which has generally been considered a positive factor in terms of lessening potential side-effects. More research is clearly needed and possibly this finding will help to direct attention to looking for side-effects more closely. RWC.

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Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia

Chiarioni,G.,* Whitehead,W.E., Pezza,V., Morelli,A., & Bassotti,G. Univ Verona, Div Riabilitaz Gastroenterol, Azienda Osped Verona, Ctr Osped Clinicizzato, I-37067 Valeggio Sul Mincio, VR, Italy

Search Terms: Miralax, PEG, biofeedback, encopresis.

Background & Aims: Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education.
Methods: Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6-29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months.
Results: At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P <.001). Biofeedback's benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P <.01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months.
Conclusions: Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

Wonderful study contrasting a rational behavioral set of techniques (biofeedback) affecting physical function to specifically assist the proper concert of muscle groups by comparison to a laxative-mediated training with 5 counseling sessions to abet toileting efforts. The laxative use with education likely resembles standard practice by most physicians. Biofeedback requires more equipment and specialized training by its practitioners. Now if only I could persuade university programs to test my protocol as another treatment alternative with off-the-shelf preparations. My Clean Kid Manual would help to assure comparability across practitioners and parents in applying a treatment.

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An example of psychological adjustment in chronic illness: Hirschsprung's disease

Athanasakos,E.,* Starling,J., Ross,F., Nunn,K., & Cass,D. Royal London Hosp, Dept Paediat Surg, London E1 1BB, England

Search Terms: Hirschsprung's disease, encopresis, soiling, psychosocial outcomes, pull-through, surgery.

The aim of this study was to investigate the outcomes after definitive surgical correction for children with Hirschsprung's disease (HD) and the psychosocial impact of HD on the child and family. The total sample comprised 72 children with HD along with their families. The development of a condition-specific questionnaire measured the functional and psychosocial outcomes for children with HD with parental perception of their child's condition. Psychiatric
measures were also examined to assess psychiatric morbidity. The greatest functional problem after definitive surgery for HD was faecal soiling (76%). The principle findings of the study were that (1) HD did not have a significant impact on the child's rate of psychiatric morbidity and levels of hopefulness in comparison to the normal population, (2) surgical and psychosocial functioning improved with increasing age and, (3) families remain troubled about their future with HD and dealing with psychosocial difficulties related to the condition (such as distress because of faecal soiling). Specifically, faecal soiling was found to be physically, emotionally and psychosocially distressing complication. Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Despite the significant impairment of faecal continence, we found that children/young adults with HD have minimal psychiatric morbidity, yet experience condition-specific psychosocial problems (e.g. embarrassment and distress/discomfort). HD does not increase the rate of clinical psychiatric morbidity in children and families with HD, but does determine the context of their daily distress and concern.

Parents have many concerns about any kind of surgical intervention and this should help to allay their fears even if subsequent training/diet interventions do not work quickly. Again, this is where I would like to see either biofeedback in the abstract just above this one to be employed or my protocol used. I believe both would be more effective because of their specific, rational interventions than the usual use of laxatives or diet alone with urgings to toilet frequently. RWC.

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Psychological differences between children with and without soiling problems.

Joinson,C.*, Heron,J., Butler,U., & von Gontard,A. Avon Longitudinal Study Parents & Children, Dept Community Based Med, Unit Perinatal Paediat Epidemiol, 24 Tyndall Ave, Bristol BS8 1TQ, Avon, England.

Search Terms: Encopresis, Behavior, self-esteem, epidemiology.

OBJECTIVES. Previous studies, based on clinic samples, report that childhood soiling is associated with behavior problems and reduced self-esteem. This population-based study investigates the prevalence of psychological problems associated with childhood soiling.
METHODS. A total of 8242 children aged 7 - 8 years born to mothers in the United Kingdom - based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (
once a week or more), those who soil occasionally ( less than once a week), and those with no soiling problems ( controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events.
RESULTS. Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying ( as both perpetrator and victim) and antisocial activities compared with controls.
CONCLUSIONS. The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally.

No real surprises in the findings of more behavioral problems for encopretic children. The more interesting question for me is do these behavioral issues disapate with symptom remission when there are fewer demands or less tension associated with soiling? RWC.

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Does "stubbornness" have a role in pediatric constipation?

Burket,R.C.*, Cox,D.J., Tam,A.P., Ritterband,L., Borowitz,S., Sutphen,J., Stein,C.A., & Kovatchev,B. Univ Virginia, Hlth Sci Ctr, Box 801076, Charlottesville, VA 22908 USA

Search Terms: encopresis, constipation, stubbornness, toileting, behavior

The objective of this study was to determine if children with constipation are more stubborn, both in general and specifically regarding toileting behaviors, than children without constipation. A secondary objective was to determine if constipated children who are more stubborn are less likely to respond to routine therapeutic interventions than less stubborn constipated children. One hundred one children aged 2 to 6 years, who were first-time presenters (never received treatment) to their primary care physician (PCP) with constipation, were compared with 84 nonconstipated control children of similar age range. Comparison measures included general stubbornness and toilet-specific stubbornness (active resistance to participating in appropriate toileting behaviors). Measures of stubbornness were generated from retrospective questionnaires, prospective toileting diaries completed by the parents, and direct experimenter observations. The constipated children were treated by their PCP for 2 months and then reassessed. Constipated children were perceived by their parents to be significantly more stubborn than control children generally and specifically in terms of toileting. Some study evidence suggested that constipated children who continued to have difficulties after 2 months of treatment by their PCPs were perceived by their parents to have significantly more general stubbornness than constipated children who responded to treatment. Parent-perceived toilet-specific stubbornness significantly improved after successful treatment of the constipation by their PCP. The finding that constipated children had more parent-perceived stubbornness than children without constipation is notable because it may play a role in the development and/or maintenance of this bowel dysfunction as well as being an obstacle in treatment compliance.

The oft observed parental observation that their encopretic child is stubborn received some support in this University of Virginia study and may hinder treatment compliance because of refusal to cooperate. RWC

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April 2006 CLINICAL PEDIATRICS (v45, 3), Pp. 251-256. Posted on 06/05/2006

Variability in the management of childhood constipation

Focht,D.R. III*, Baker,R.C., Heubi,J.E., Moyer,M.S., Tripler Army Med Ctr, Dept Pediat, 1 Jarrett White Rd, Honolulu, HI 96859 USA

Search Terms: Miralax, PEG, Constipation, Encopresis

To assist primary care providers, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published clinical practice guidelines for management of childhood constipation. A cross-sectional survey of pediatricians from across the United States was conducted to assess pediatricians' constipation management strategies, whether pediatricians are familiar with the NASPGHAN constipation guidelines, and reasons pediatricians refer constipated patients to a pediatric gastroenterologist. Overall, 75% of pediatricians used polyethylene glycol without electrolytes to treat childhood constipation, 8% of pediatricians were aware NASPGHAN had published constipation guidelines, and parental pressure was just one reason pediatricians referred constipated patients to a pediatric gastroenterologist.

Doesn't look like much variability to me with 75 percent of pediatiricians using Miralax or its generic form. RWC.

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Colonic manometry as predictor of cecostomy success in children with defecation disorders.

van den Berg,M.M., Hogan,M., Caniano,D.A., Di Lorenzo,C., Benninga,M.A., & HM Mousa*, Childrens Hosp, Div Pediat Gastroenterol, Columbus, OH 43205 USA

Search Terms: ACE, manometry, Slow Transit, Encopresis, Constipation

Purpose: The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders.
Methods: Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n= 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical Success was defined as normal defecation frequency with no or occasional fecal incontinence.
Results: Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility.
Conclusion: Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.

The ACE procedure is a dramatic procedure to employ and it was used here for 13 patients with functional constipation. The importance of HAPC was confirmed and it was of relevance to see that responsiveness to bisacodyl is very promising if this procedure has to be implemented. RWC.

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April 2006, EUROPEAN JOURNAL OF PEDIATRIC SURGERY (v16, 2), Pp. 109-114. Posted on 06/05/2006

An external device for faecal incontinence

Hadidi,A.T. Univ Heidelberg, Dept Paediat Surg, Neuenheimer Feld 110, D-69120 Heidelberg, Germany

Search Terms: Encopresis, anal sphincter, device, anal plug

Aim: The aim of the study was to describe a simple external device that enables the incontinent patient to control the time, frequency and place of defecation. Principle: The device is based on the principle of a "ball & socket" valve. The "ball" is an inflatable silastic balloon while the "socket" is the anorectal junction. The device can be used with minor modifications in patients with terminal colostomy to make them continent and avoid the need for colostomy bags. Patients and Methods: The inflatable plug has been used successfully in eighteen incontinent children for a period ranging from six months to 8 years. The child decides the amount of air inside the inflatable plug that is comfortable and yet adequate to prevent soiling. This usually ranged between 10 to 25 cm of air.
Results and Complications: To date, the device has been manufactured manually. All the children tolerated the plug without discomfort. Deflation of the balloon occurred after 3 - 5 days of use due to defective manufacturing. None of the patients developed ischaemia of the bowel or skin excoriations.
Conclusion: This conservative, simple, inflatable plug enhances both qualitative and quantitative faecal continence in children with faecal soiling. An improvement in quality of life was also perceived by the patients and their parents. Better manufacturing may improve the results.

What a remarkable possibility for potential use if all else fails short of the ACE procedure! Clearly it needs to be tested more for complications and saftey in use. RWC

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Rectal hyposensitivity

Gladman,M.A., Lunniss,P.J., Scott,S.M., & Swash,M. No address listed.

Search Terms: Encopresis, Anorectal, Hyposensitivity, Rectal, Slow Transit, Constipation, Sensory, Biofeedback

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only '' apparent '' identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although ''sensory-retraining biofeedback '' appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

Many parents report that their encopretic children claim to have no awareness of the urge to "go". This observation tends to support that claim and "sensory-retraining biofeedback" would appear to be a rational treatment response. However, it is my contention that my protocol based on the Pavlovian conditioning paradigm accomplishes this same purpose by conditioning awareness of toileting urges to a degree where the child becomes aware of his/her ordinary urges and ties them into the necessary bodily responses associated with successful voiding. This can be seen in a stepwise fashion with my protocol when these children can only go with an enema and then find a gentle glycerin suppository sufficient before transitioning to going completely on their own. My procedure also associates and reinforces the appropriate precise behaviors for facillitating a successful and timely bowel movement. RWC.

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Pelvic Floor: Anatomy and function

Bharucha,A.E., Mayo Clin & Mayo Fdn, Coll Med, Clin Enter Neurosci Translat & Epidemiol Res Prog, Charlton 8-110,200 1st St SW, Rochester, MN 55905 USA

Search Terms: encopresis, sphincter, anal sphincter, pelvic floor, anatomy, chronic constipation.

The pelvic floor is a dome-shaped striated muscular sheet that encloses the bladder, uterus, and rectum, and, together with the anal sphincters, has an important role in regulating storage and evacuation of urine and stool. This article reviews the anatomy, nerve supply, pharmacology, and functions of the anal sphincters and the pelvic floor. The internal and external anal sphincters are primarily responsible for maintaining faecal continence at rest and when continence is threatened, respectively. Defecation is a somato-visceral reflex regulated by dual nerve supply (i.e. somatic and autonomic) to the anorectum. The net effects of sympathetic and cholinergic stimulation are to increase and reduce anal resting pressure, respectively. Faecal incontinence and functional defecatory disorders may result from structural changes and/or functional disturbances in the mechanisms of faecal continence and defecation.

This looks like an excellent teaching aid. DrC.

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Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children.

Brazzelli,M., Griffiths,P. No address listed.

Search Terms: Encopresis, Incontinence, Review, Biofeedback

Background: Faecal incontinence is a common and potentially distressing disorder of childhood.
Objectives: To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.
Search strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).
Selection criteria: Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.
Data collection and analysis: Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.
Main results: Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by
trials addressing the same comparisons.
Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children
(OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).
Authors' conclusions: There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

This is a meta-analytic study combining results from a variety of studies after conducting a thorough literature review. This methodology is controversial within the literature when it comes to making sweeping or specific conclusions.

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June 2006 CLINICAL PEDIATRICS (v45,5), Pp. 411-414. Posted on 08/23/2006.

Digital rectal examination and the primary care physicians: A lost art?

Safder,S., Rewalt,M., & Elitsur,Y.* Marshall Univ, Joan C Edwards Med Sch, Dept Pediat, Pediat Gastroenterol Div, 1600 Med Ctr Dr, Huntington, WV 25701 USA

Search Terms: CONSTIPATION, encopresis, Digital rectal examination

Digital rectal examination (DRE) in children is crucial to differentiate between simple (habitual) and complicated constipation. Previous experience suggests that primary care physicians (PCPs) avoid DRE in children with constipation before referral. We evaluated the rate of DRE performance by West Virginian PCPs in patients referred to our gastroenterology clinic. Data were collected from the physicians' referral letters and parental reports. We found that the vast majority (85%) of WV-PCPs do not perform DRE before referring their patients, resulting in missed diagnoses and treatment. We concluded that the lack of DRE in children with constipation may result in unnecessary referral to the specialist. To improve standard of care for children with constipation, an educational campaign for PCPs is clearly warranted.

A very similar study was done earlier by Gold, D.M., Levine J., Weinstein, T.A., Kessler, B.H., & Pettei, M.J. (1999). Frequency of digital rectal examination in children with chronic constipation. Archives of Pediatric and Adolescent Medicine, 153(4), 377-379 at the Schneider Childrens Hospital on Long Island, NY and cited in a couple of my publications (including the preface to my Clean Kid Manual-III which is on this website--see the home page). This study helps to document the intimidation of pediatricians that may have been fostered by a couple of influential articles which established the current dominant popular "top down" approach with oral agents in treating encopresis. Applications of enemas in treatment was described in those earlier articles as a form of "anal assault". Since that time articles have emphasized oral agents as a form of "gentle" treatment for encopresis. This bias is unfortunate and may bias against DRE's and the highly effective treatment protocol which I have established using suppositories and enemas when they are needed in a very structured and timed format to reestablish a proper voiding reflex. Parent and pediatricians have become very "stuck" when their standard "top down" treatment approach fails. Often they confuse my treatment as merely a "clean out" procedure and not part of a structured treatment program to end encopresis. RWC.

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Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE+e) followed by a double-blind comparison of PEG+e versus lactulose as maintenance therapy

Candy,D.C.A.,* Edwards,D., & Geraint,M., Royal W Sussex NHS Trust, Paediat Gastroenterol Serv, Chichester PO19 6SE, England

Search Terms: Encopresis, constipation, PEG, Lactulose

Objectives: To assess the efficacy of polyethylene glycol 3350 plus electrolytes (PEG + E; Movicol((R))) as oral monotherapy in the treatment of faecal impaction in children, and to compare PEG + E with lactulose as maintenance therapy in a randomised trial.
Patients and Methods: An initial open-label study of PEG + E in the inpatient treatment of faecal impaction (phase 1), followed by a randomised, double-blind comparison between PEG + E and lactulose for maintenance treatment of constipation over a 3-month period (phase 2) in children aged 2 to 11 years with a clinical diagnosis of faecal
impaction.
Results: Disimpaction on PEG + E was achieved in 58 (92%) of 63 of children (89% of 2-4 year olds and 94% of 5-11 year olds) without additional interventions. A maximum dose of 4 sachets (for 2-4 year olds) or 6 sachets (for 5 - 11 year olds) was required; median time to disimpaction was 6 days (range, 3-7 days). Seven children (23%) reimpacted whilst taking lactulose, whereas no children reimpacted while taking PEG + E (P = 0.011). The total incidence rate of adverse events seen was higher in the lactulose group (83%) than in the PEG + E group (64%).
Conclusions: PEG + E is safe and highly effective in the management of childhood constipation. It allows a single orally administered laxative to be used for disimpaction without recourse to invasive interventions. It is significantly more effective than lactulose as maintenance therapy, both in efficacy in treating constipation and efficacy in preventing the recurrence of faecal impaction.

This is an important comparison study for the traditional "top down" approach using the two major hypermolar agents for both "clean outs" and maintenance therapy. The advantage of PEG (Miralax) over Lactulose in such usage is supported here. RWC

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Gastrointestinal motility disorders: An update.

Lacy,B.E.,* &Weiser,K. Dartmouth Coll, Hitchcock Med Ctr, Div Gastroenterol & Hepatol, 1 Med Ctr Dr,Area 4C, Lebanon, NH 03756 USA

Search Terms: slow transit, motility, encopresis

Gastrointestinal motility disorders encompass a wide array of signs and symptoms that can occur anywhere throughout the luminal gastrointestinal tract. Motility disorders are often chronic in nature and dramatically affect patients' quality of life. These prevalent disorders cause a tremendous impact both to the individual patient and to society as a whole. Significant progress has been made over the last 5 years in understanding the etiology and pathophysiology of gastrointestinal motility disorders. This clinical update will focus on seven of the most common gastrointestinal motility disorders (achalasia, non-achalasia esophageal motility disorders, dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction, irritable bowel syndrome, and chronic constipation) with an emphasis on current treatment options and new therapeutic modalities.

See the abstracts at the beginning of this section on encopresis for the importance of slow-transit problems and their possible contribution to encopresis/chronic constipation. I’m looking forward to reading this as a general review on motility disorders. RWC.

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August, 2006 JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION (43, 2), 206-208. Posted on 08/28/2006.

Functional fecal soiling without constipation, organic cause or neuropsychiatric disorders?

Pakarinen,M.P.,* Koivusalo,A., & Rintala,R.J. Univ Helsinki, Childrens Hosp, Pediat Surg Sect,
Stenbackinkatu 11 PL281, Helsinki 00029, Finland

Search terms: encopresis, laxatives

Background: The aetiology of fecal incontinence in children has traditionally been attributed to idiopathic constipation, structural defects or neuropsychiatric disorders. We describe a new subgroup of otherwise healthy children who have fecal soiling without any underlying cause for the incontinence.
Methods: The hospital records of children with fecal incontinence were screened to detect patients without any history, signs or symptoms of constipation or an organic, neurological or psychiatric cause for the incontinence. Anorectal manometry findings were compared with those of age-matched children with idiopathic constipation and soiling.
Results: Eight boys and 5 girls were identified. The median age at diagnosis was 7.9 years. Soiling had lasted median of 4.1 years, occurred at least every other day in 9, at least once a week in 2 and occasionally in 2 and required change of underwear or use of protective pads. Abdominal x-ray and barium enema showed normal findings. Sacral x-ray and/or MRI of the spinal cord showed normal bony spine and spinal cord. Five children had coexisting night and/or
daytime wetting. Impaired rectal sensation was the only identifiable abnormality that was detected. The median volume required for the first sensation was 45 mL (range, 15-100 mL; normal, < 15 mL). Anorectal manometry alone was unable to differentiate patients with functional fecal soiling from those with idiopathic constipation associated soiling. The median follow-up time after the diagnosis was 9.1 months. Treatment of fecal soiling consisted of education, dietary modification or stimulatory laxatives to establish regular toileting routines. Treatment improved fecal continence in 6 out of 8 cases with follow-up longer than 6 months.
Conclusions: There is a small subgroup of children with fecal soiling who are otherwise healthy without constipation or any other underlying cause for the incontinence. These children seem to have isolated impairment of rectal sensation. In most, the prognosis is good with conservative treatment.

I have certainly had cases that might fit into this group of children just from parental histories. They have responded well to my program which appears to enhance sensory awareness via Pavlovian conditioning using immediate acting and pronounced UCS prompts. RWC

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A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence

Loening-Baucke,V.,* & Pashankar,D.S. Childrens Hosp Iowa, JCP 2555,200 Hawkins Dr, Iowa
City, IA 52242 USA

Search Terms: PEG, MOM, encopresis, constipation.

OBJECTIVE. Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes.
METHODS. Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical
adverse effects and blood tests.
RESULTS. Thirty- nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycoltreated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically
significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol.
CONCLUSIONS. In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

PEG or Miralax has moved far ahead in physician’s preferences for the use of a “top down” medication for treating encopresis. MOM (Milk of Magnesia) is an old standard. The compliance rate was higher for PEG which is likely one reason for the preference. What interested me was the low rate of recovery for PEG at 33% and MOM at 23% after one year!

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Evaluation and treatment of constipation in children: Summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Baker,S.S.*, Liptak,G.S., Colletti,R.B., Croffie,J.M., Di Lorenzo,C., Ector,W., Nurko,S. NASPGHAN, 1501 Bethlehem Pike,POB 6, Flourtown, PA 19031 USA

Search Terms: Encopresis, Motility, Chronic constipation, milk.

Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.

Go to http://www.naspghan.org/PDF/PositionPapers/constipation.guideline.2006.pdf for a complete copy of these guidelines. Some salient points from this source are:
1. Parental concerns about abnormal voiding are responsible for 3% of visits to Pediatricians and 25% of Pediatric Gastroenterology consultations.
2. The most common form of constipation is “functional” or non-organic in basis with retention or withholding.
3. Constipation is a delay or difficulty in defecation, present for 2 or more weeks and sufficient to cause significant distress to the patient. (Often the child is in denial and it is more evident that it is the parents who are in distress if soiling is present!—DrC.)!
4. 1.2 stools daily on the average at 4 y/o and later.
5. At least one digital (finger) anorectum examination is recommended.
6. “soiling…is not a willful and defiant maneuver.” (Pg. e6).
7. “The use of soap suds, tap water, and magnesium enemas is not recommended because of their potential toxicity.” (Pg. e7).
8. “The incidence of Hirschsprung disease is approximately 1 in 5000 live births.” (Pg. e10). “…in 8% to 20% of children, Hirschsprung disease remains unrecognized after the age of 3 years.” (Pg. e10).
9. “For children unresponsive to conventional medical and behavioral management consideration may be given to a time limited trial of cow’s milk-free diet.” (Pg. e11).
10. The guidelines indicate that the findings are too weak to support a definite recommendation for the use of fiber in treating constipation.

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Adult Hirschsprung's disease diagnosed during forensic autopsy

Chatelain,D.*, Manaouil,C., Marc,B., icard,J., Brevet,M., Montpellier,D., Defouilloy,C., & Jarde,O. Ctr Hosp Univ Amiens, Dept Pathol, Pl Victor Pauchet, F-80054 Amiens 01, France

Search Terms: Encopresis, Hirschsprung's disease, Adult, Megacolon, Forensic, autopsy

We report a case of fatal Hirschsprung's disease (HD) discovered at autopsy. A 20-year-old man collapsed at home. Emergency medical personnel found him in cardiac arrest and all resuscitative efforts failed. He had a past history of chronic constipation since infancy. Forensic autopsy revealed a megacolon full of gas and stools. Microscopic examination showed absence of ganglion cells in a short segment of the rectum and enterocolitis in the left and transverse colon. HD is rarely described in adults. In many cases, patients complained of constipation since infancy but the affection remained misdiagnosed. The relative good tolerance of the disease is usually
due to a short aganglionic bowel segment. Enterocolitis is a frequent and severe complication of HD in children but is rarely described in adults. This case suggests the importance of HD diagnosis in childhood in order to avoid fatal complications with forensic consequences.

This was a report on the death in a 20 year old due to short segment Hirschsprung’s disease, which was discovered only at autopsy. I suspect that this case may have a considerable impact on checking for short segment HD earlier in a difficult case of encopresis that resists treatment even beyond my protocol. RWC.

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December 2006 INTERNATIONAL JOURNAL OF COLORECTAL DISEASE (v21, 8), Pp. 826-833. Posted on 11/30/2006.

Colonic response to food in constipation.

Bouchoucha,M.,* Devroede,G., Faye,A., Le Toumelin,P., Arhan,P., & Arsac,M. Univ Paris 05, Hop Broussais, Lab Physiol Digest, 96,Rue Didot, F-75014 Paris, France

Search Terms: Encopresis, Transit, motility, constipation, obstruction.

Question: Is colonic response to food abnormal in constipation.
Methods: The colonic response to food was evaluated in 323 patients and 60 healthy subjects by following the movements of radiopaque markers after ingestion of a standard 1,000-cal test meal. Constipated patients were divided into four groups: one with a normal, and three with a delayed colorectal transit time. When the delay was found mainly in the ascending colon, the group was labeled as suffering from "colonic inertia". In "hindgut dysfunction", the delay was predominantly found in the descending colon, whereas the term "outlet obstruction" was reserved for constipated patients whose major site of delay was the rectosigmoid area. Colonic response to food was quantified by evaluating the variation of markers in a given abdominal region and the evolution of the geometric center on the entire plain film of the abdomen.
Results: Emptying of the caecum-ascending colon and filling of the rectosigmoid area characterize the colonic response to food in health