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Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence

Abstract

Purpose

There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children’s Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI.

Methods

Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS).

Results

Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung’s disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05).

Conclusions

Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.

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Funding

This work was funded by the Health Foundation for Innovation for Improvement grant [GIFTS 7639 CRM 2656, 2016]; PORTS Charity.

Author information

Correspondence to Eleni Athanasakos.

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Conflict of interest

The authors declare that we have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Written consent was obtained from each patient and/or their parent/guardian when undergoing their routine investigation at our service.

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Appendix

Appendix

The report for AHRAM includes a quantitative assessment of different parameters (Fig. 2) including the analysis of qualitative assessment of defaecation dynamics (push). For each manoeuvre period, the anal canal area was highlighted as an ‘area of interest’ using the e-sleeve box. This allowed the software to derive the maximum pressure recorded over this anal length at each point in time. Averages were then calculated automatically over the duration of the manoeuvre. The variables recorded together with their respective definitions are shown in Table

Table 4 Analysis parameters and definitions for paediatric use

4 which has been mostly adopted from our adult Gastrointestinal (GI) Physiology Unit protocol, with alterations made for paediatric use [18].

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Athanasakos, E., Dalton, S., McDowell, S. et al. Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence. Pediatr Surg Int 36, 295–303 (2020). https://doi.org/10.1007/s00383-019-04605-y

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Keywords

  • High-resolution anorectal manometry (HRAM)
  • Anorectal physiology
  • Chronic constipation
  • Faecal incontinence
  • Pathophysiology
  • Multidisciplinary team (MDT)