Diferencias en la duración del reflejo rectoanal inhibitorio en pacientes con constipación funcional refractaria y mielomeningocele / Differences in rectoanal inhibitory reflex duration between patients with refractory functional constipation and myelomeningocele

Introducción. Habitualmente, durante la manometría anorrectal, en lo correspondiente al reflejo rectoanal inhibitorio (RRAI) solo se pesquisa su presencia o ausencia. Estudios han reportado que su análisis detallado puede brindar datos de interés. Nuestra hipótesis es que la medición del RRAI puede dar información para reconocer causas orgánicas (médula anclada, lipoma, etc.) en pacientes en los que previamente se consideró como de causa funcional. Objetivos. Comparar la duración del reflejo rectoanal inhibitorio en la manometría anorrectal de pacientes con constipación funcional refractaria (CFR) y mielomeningocele (MMC). Población y métodos. Estudio observacional, transversal, analítico (2004-2019). Pacientes constipados crónicos con incontinencia fecal funcional y orgánica (mielomeningocele). Se les realizó manometría anorrectal con sistema de perfusión de agua y se midió la duración del RRAI con diferentes volúmenes (20, 40 y 60 cc). Grupo 1 (G1): 81 CFR. Grupo 2 (G2): 54 MMC. Se excluyeron pacientes con retraso madurativo, esfínter anal complaciente, agenesia sacra y aquellos no colaboradores. Resultados. Se incluyeron 135 sujetos (62 varones). La mediana de edad fue G1:9,57 años; G2: 9,63 años. Duración promedio G1 vs. G2 con 20 cc: 8,89 vs. 15,21 segundos; con 40 cc: 11.41 vs. 21,12 segundos; con 60 cc: 14,15 vs. 26,02 segundos. La diferencia de duración del RRAI entre ambos grupos con diferentes volúmenes fue estadísticamente significativa (p = 0,0001). Conclusión. La duración del RRAI aumenta a mayor volumen de insuflación del balón en ambas poblaciones. Pacientes con MMC tuvieron mayor duración del RRAI que aquellos con CFR. En los pacientes con RRAI prolongado, debe descartarse lesión medular.

Introduction. Usually, during anorectal manometry, only the presence or absence of rectoanal inhibitory reflex (RAIR) is investigated. Studies have reported that a detailed analysis may provide data of interest. Our hypothesis is that RAIR measurement may provide information to detect organic causes (tethered cord, lipoma, etc.) in patients in whom a functional cause had been previously considered. Objectives. To compare RAIR duration in anorectal manometry between patients with refractory functional constipation (RFC) and myelomeningocele (MMC). Population and methods. Observational, analytical, cross-sectional study (2004­2019). Patients with chronic constipation and functional and organic fecal incontinence (myelomeningocele). The anorectal manometry was performed with a water-perfused system, and the duration of RAIR was measured with different volumes (20, 40, and 60 cc). Group 1 (G1): 81 RFC. Group 2 (G2): 54 MMC. Patients with developmental delay, compliant anal sphincter, sacral agenesis and non-cooperative patients were excluded. Results. A total of 135 individuals were included (62 were male). Their median age was 9.57 years in G1 and 9.63 years in G2. Average duration in G1 versus G2 with 20 cc: 8.89 versus 15.21 seconds; 40 cc: 11.41 versus 21.12 seconds; 60 cc: 14.15 versus 26.02 seconds. The difference in RAIR duration with the varying volumes was statistically significant (p = 0.0001). Conclusion. RAIR duration was longer with increasing balloon inflation volumes in both populations. RAIR duration was longer in patients with MMC than in those with RFC. Spinal injury should be ruled out in patients with prolonged RAIR.

El consumo de dos kiwis diarios podría mejorar el hábito intestinal en personas con estreñimiento crónico / Daily consumption of two kiwifruits could improve bowel habits in people with chronic constipation

A partir del caso de una paciente con síndrome de intestino irritable a predominio de estreñimiento cuyos síntomas mejoraron con el consumo regular de kiwi, el médico de familia se planteó la pregunta de si el kiwi podría mejorar los síntomas asociados a constipación crónica en comparación con el tratamiento habitual. Tras realizar una búsqueda de estudios que analizaran los efectos del consumo de kiwi sobre el hábito intestinal, fueron seleccionados tres artículos que permiten concluir que el consumo de esta fruta tiene una eficacia superior al placebo y comparable al psyllium y las pasas de ciruela para mejorar los síntomas de personas con estreñimiento crónico. (AU)

Based on the case of a patient with constipation-predominant irritable bowel syndrome whose symptoms improved with regular consumption of kiwi, the family doctor wondered if kiwi could improve symptoms associated with chronic constipation compared to usual treatment. After conducting a search for studies that analyzed the effects of kiwi consumption on intestinal habit, three articles were selected that allow us to conclude that the consumption of this fruit has an efficacy superior to placebo and comparable to psyllium and plum raisins to improve the symptoms of people with chronic constipation. (AU)

Trastornos funcionales gastrointestinales. Cómo tratar sin medicar / Functional gastrointestinal disorders. How to manage them without medication

Los trastornos funcionales gastrointestinales (TFGI) se caracterizan por síntomas atribuibles al tracto gastrointestinal que no pueden ser explicados por anormalidades estructurales ni bioquímicas. Durante el primer año de vida, pueden generar mucho malestar en el lactante y preocupación en sus padres. Su diagnóstico se basa en criterios clínicos que expertos han determinado y en una historia clínica y un examen físico completo que descartan causas orgánicas. El objetivo de esta actualización es presentar estrategias para el manejo de los TFGI más frecuentes durante el primer año de vida: cólicos, regurgitaciones, disquecia y estreñimiento, bajo la visión de los nuevos conocimientos fisiopatológicos, que eviten los estudios y medicaciones innecesarias.

Functional gastrointestinal disorders (FGIDs) are characterized by symptoms attributable to the gastrointestinal tract that cannot be explained by the presence of structural or biochemical abnormalities. During the first year of life, FGIDs can cause great discomfort in infants and concern in their parents. The diagnosis of FGIDs is based on clinical criteria determined by experts and on a comprehensive case-taking process and physical exam to rule out organic causes. The objective of this update is to describe strategies for the management of the most frequent FGIDs during the first year of life: colics, regurgitations, dyschezia, and constipation, in light of new pathophysiological insights, to avoid unnecessary tests and medications.

Prevalence and predictors of functional evacuation disorder in patients with chronic constipation

Background: Functional evacuation disorder (FED) is the second most common cause of functional constipation (FC) after constipation-predominant irritable bowel syndrome. However, the data on FED is relatively scanty in our region. Hence, the present study was performed to evaluate the demographics of FED and to find out the predictors of FED in patients with chronic constipation. Methods: A total of 134 patients with chronic constipation diagnosed according to the Rome IV criteria who were referred for high-resolution anorectal manometry (HRAM) were retrospectively enrolled in the present study. All FC patients who underwent HRAM were asked to fill a questionnaire and underwent anorectal manometry and were submitted to the balloon expulsion test (BET). Results: The mean age of patients was 43.09 ± 9.32 years old, with a total of 76 (54%) males. The most common symptom was straining during defecation (87%) followed by incomplete evacuation (86%). The prevalence of FED, diagnosed by HRAM and by the BET was 39%. Patients with FED had a significantly higher percentage of straining and sensation of anorectal blockade compared with those without FED (96 versus 82%; p < 0.01; 81 versus 44%; p < 0.001, respectively). On the multivariate regression analysis, straining > 30 minutes (odds ratio [OR] = 3.63; p = 0.03), maximum squeeze pressure (OR = 1.05; p < 0.001), and balloon volume at maximal sensation (OR = 1.06; p < 0.001) were found to be significant independent predictors of FED. Conclusion: Prolonged straining and sensation of anorectal blockade were significant indicators of FED in patients with chronic constipation. (AU)

Pediatric Functional Constipation Questionnaire-Parent Report (PedFCQuest-PR): development and validation

Abstract Objective: Developing and validating a disease-specific instrument in the Brazilian Portuguese language to assess the Health-Related Quality of Life of children with functional constipation, applied to parents/caregivers. Methods: The process of developing the questionnaire was carried out in the following steps: items generation concerning functional constipation; elaboration of the preliminary questionnaire; assessment by health professionals; identifying problems or inconsistencies by the researchers; improvement of the questions; obtaining a final questionnaire named Pediatric Functional Constipation Questionnaire-Parent Form (PedFCQuest-PR) with 26 questions divided into four domains. Responses options use a Likert scale based on the events of the last four weeks. The process of validation was an observational, cross-sectional study in a sample of 87 parents/caregivers of children from 5 to 15 years of age diagnosed with Functional constipation according to the Rome IV Criteria. The questionnaire was applied simultaneously to the Pediatric Quality of Life Inventory 4.0 (PedsQL TM 4.0) as a control. Results: The questionnaire validation included 87 parents/caregivers. The children's median age was 8.2 years, with a long time of constipation symptoms associated with fecal incontinence in approximately two-thirds. Internal consistency reliability for the Total Scale Score of PedFC-Quest-PR by Coefficient Alpha of Cronbach score was 0.86. Convergent and divergent validity of PedFCQuest-PR was demonstrated by correlating the domains of both questionnaires. Conclusion: This study provides evidence that PedFCQuest-PR is a reliable instrument. The results showed a high degree of internal consistency and validity of the instrument for future applications.

Estreñimiento funcional en pediatría, diagnóstico y tratamiento / Functional constipation in pediatrics, diagnosis and treatment

El estreñimiento funcional es un motivo de consulta frecuente en pediatría, con una prevalencia del 3 %. El Grupo de Trabajo de Constipación del Comité de Gastroenterología de la Sociedad Argentina de Pediatría se reunió con el objetivo de actualizar el diagnóstico y tratamiento de la constipación funcional en pediatría.Se realizó una búsqueda de literatura para evaluar la calidad de la evidencia. Ante un paciente constipado, es fundamental una historia y examen clínico completos. Los Criterios de Roma IV establecen pautas que, habitualmente, permiten diagnosticar la constipación funcional y evitar estudios innecesarios. La realización de estudios diagnósticos solo se pondrá en consideración ante la presencia de respuesta refractaria al tratamiento médico o en los casos de signos de alarma (banderas rojas). El primer paso del tratamiento es la desimpactación (por vía oral o enemas), seguida del tratamiento dietético, de hábitos y laxantes (es de primera elección el polietilenglicol).

Functional constipation is a common disease and one of the most frequent reasons of visit in pediatric clinics with a 3 % of prevalence. The Constipation Working Group of the Gastroenterology Committee of the Sociedad Argentina de Pediatría met with the objective of updating the diagnosis and treatment of functional constipation in pediatrics.A literature search was performed to assess the quality of the evidence. In a constipated patient, a complete history and clinical examination is essential. The Rome IV Criteria establish guidelines that usually allow us to diagnose functional constipation, avoiding unnecessary studies. The performance of diagnostic studies will only be considered in the absence of response to medical treatment or in cases of alarm signs (red flags). The first step of treatment is disimpaction (orally or enemas), followed by dietary treatment, habits and laxatives, with polyethylene glycol being the first choice.

The real impact of colonic transit time and anorectal manometry in the diagnosis of adult patients with chronic constipation / O real impacto do tempo de trânsito cólico e da manometria anorretal no diagnóstico de pacientes adultos com constipação crônica

Abstract Introduction: Anorectal physiology tests are indicated for patients who have refractory symptoms of constipation, but the best sequence of investigation remains controversial. Objective: To evaluate the influence of colonic transit time and anorectal manometry in the diagnosis of chronic constipation in adults. Method: This was a study of adult patients with constipation at a private clinic in a city in southern Brazil, from January 1, 2009 to December 31, 2018. Those who showed warning signs were referred for colonoscopy and those with any anatomical alterations were excluded. The patients received 10 g of psyllium and those who remained symptomatic after three weeks were referred for functional assessment with colonic transit time (CTT). Those who presented outlet obstruction in the colonic transit time were referred to anorectal manometry. Results: Of the 889 adult patients surveyed, 227 were included. Of the 216 who completed the study, 167 responded to primary treatment. Forty-nine underwent CTT. In these, 16 had normal colonic transit time and 33 were altered. In those with altered colonic transit time, eight had a pattern of colonic inertia and 25 had an obstruction pattern. The 25 patients with an outlet obstruction pattern underwent anorectal manometry. Eighteen had signs of paradoxical contracture of the puborectal muscle (PPRC) and seven did not. Conclusion: This study concluded that anorectal physiology exams contribute to the diagnosis of constipation, often changing the behavior. These exams should be performed whenever the patient does not respond to hygienic changes and fiber replacement.

Resumo Introdução: Os exames de fisiologia anorretal estão indicados nos pacientes que mantém sintomas refratários de constipação, porém uma sequência desejada de investigação permanece contraditória. Objetivo: Avaliar a influência do tempo de trânsito colônico e da manometria anorretal no diagnóstico da constipação crônica de adultos. Método: Estudamos os pacientes adultos de uma clínica privada em uma cidade do sul do Brasil, no período de 01 de Janeiro de 2009 a 31 de Dezembro de 2018 apresentando constipação. Aqueles que apresentassem sinais de alerta, eram encaminhados a colonoscopia e com qualquer alteração anatômica eram excluídos. Foram prescritos 10 g de Psyllium e aqueles que permaneceram sintomáticos após três semanas foram encaminhados à avaliação funcional com tempo de trânsito colônico (TTC). Os que apresentavam obstrução de saída ao tempo de trânsito colônico foram encaminhados a manometria anorretal. Resultados: Dos 889 pacientes adultos levantados, 227 foram incluídos. Dos 216 que concluíram o estudo, 167 responderam ao tratamento primário. Quarenta e nove realizaram TTC. Nestes, 16 tiveram tempo de trânsito colônico normal e 33 alterado. Naqueles com tempo de trânsito colônico alterado: oito tinham padrão de inércia colônica e 25, padrão de obstrução de saída. Os 25 pacientes com padrão de obstrução de saída foram submetidos à manometria anorretal. Dezoito tinham sinais de Contratura Paradoxal do músculo Puborretal (CPPR) e sete não. Conclusão: Concluímos que os exames de fisiologia anorretal contribuem para o diagnóstico da constipação, muitas vezes alterando a conduta. Estes exames devem ser realizados sempre que o paciente não responder as alterações higienodietéticas e a reposição de fibras.

A experiência do médico examinador tem influência na avaliação do tônus anal em comparação à manometria anorretal? / Is the physician expertise in digital rectal examination of value in detecting anal tone in comparison to anorectal manometry?

ABSTRACT BACKGROUND: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient's complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient's management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient's history was blinded for the examiner's knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.

RESUMO CONTEXTO: Exame anorretal digital (EAD) faz parte do exame físico, também é essencial para a avaliação do cirurgião colorretal. Um bom EAD oferece informações preciosas relacionadas às queixas do paciente, que auxiliam na tomada de decisões. Sua realização é simples, rápida e minimamente invasiva. Em diversos centros ao redor do mundo, o toque retal ainda é o único método para avaliar o esfíncter anal antes do tratamento. Por outro lado, a manometria anorretal (MAR) é o principal método para avaliação funcional objetiva das pressões esfincterianas. A discrepância entre o EAD, dependendo do examinador para determinar o tônus esfincteriano em comparação à MAR motivou este estudo. OBJETIVO: Comparar o EAD com os parâmetros de pressão esfincteriana obtidos na MAR, dependendo da experiência dos examinadores. MÉTODOS: Trinta e seis pacientes consecutivos com queixas de incontinência fecal ou constipação crônica, do ambulatório de Fisiologia Anorretal da Faculdade de Medicina da Universidade de São Paulo, foram prospectivamente incluídos. Cada paciente foi submetido a MAR e EAD realizados por dois cirurgiões colorretais seniores e um júnior antes da MAR. A história dos pacientes propositalmente omitida dos examinadores, e os resultados de cada examinador foram cegos dos demais. Para o EAD, as pressões de repouso e contração foram classificadas por uma escala objetiva (EAD Scoring System), realizada pelos examinadores seniores e pelo júnior em todos os pacientes, que foi comparada com os parâmetros da MAR para a análise. ANÁLISE ESTATÍSTICA: A análise descritiva foi feita para todos os parâmetros. Para as pressões de repouso e contração, o índice Gamma foi utilizado para a comparação entre o EAD e a MAR, que variou de 0 a 1. Quanto mais próximo de 1 melhor a concordância entre os dois métodos de avaliação. RESULTADOS: A idade média foi de 48 anos e 55,5% dos pacientes eram do sexo feminino. A concordância das pressões anais de repouso entre a MAR e o EAD realizadas pelos examinadores seniores, proficientes, foi de 0,7 (IC 95%; 0,32-1,0), enquanto para o examinador júnior, menos experiente, foi de 0,52 (IC95%; 0,09-0,96). A concordância das pressões de contração foi de 0,96 (IC 95%; 0,87-1,0) para os examinadores seniores e de 0,52 (IC 95%; 0,16-0,89) para o júnior. CONCLUSÃO: Cirurgiões colorretais mais experientes, o EAD teve concordância mais significativa com a MAR, o que poderia levar a um manejo terapêutico mais adequado aos pacientes portadores de doença anorretais funcionais. A manometria anorretal permanece, portanto, como método de avaliação objetiva da função esfincteriana.

Propostas para aproximar os critérios de Roma para constipação intestinal em pediatria à prática diária / Proposals to approximate the pediatric rome constipation criteria to everyday practice

ABSTRACT BACKGROUND: Acceptance of the prevailing pediatric Rome constipation criteria, by primary care physician, is still low. Even for research purposes they have not been universally adopted. Thus, it has been indicated that some re-evaluation of these criteria would be welcome. OBJECTIVE: The authors aimed to look at the timing of diagnosis and the dietary treatment recommendations in the criteria, to make proposals trying to approximate them to everyday practice. METHODS: The literature cited in the Rome criteria was reviewed and the publications pertinent to the subject, searched by Medline up to January 2018, were included. RESULTS: An early diagnosis is fundamental to avoid evolution to bothersome complications and possibly to 'intractable' constipation, but the inclusion of two items of the criteria might hamper it. Thus, one constipation sign/symptom should suffice, usually the easily observable 'painful or hard bowel movements'. Details about dietary fiber recommendations are missing in the criteria, although its increase is usually the first approach in primary care, and overall the data about dietary fiber supplements point to beneficial effects. CONCLUSION: For diagnosis and treatment of pediatric constipation in primary care, one constipation sign/symptom should suffice. The recommended daily dietary fiber intake, according to the American Health Foundation, should be detailed as a treatment measure, and also for prevention, from weaning on.

RESUMO CONTEXTO: O emprego dos prevalecentes critérios de Roma para constipação em pediatria, no atendimento primário de saúde, ainda é baixo. Mesmo com finalidade de pesquisa, estes critérios não têm sido adotados universalmente. Assim, tem sido indicado que seria bem-vinda alguma revisão de tais critérios. OBJETIVO: Avaliar criticamente o 'timing' do diagnóstico e as recomendações dietéticas dos critérios, a fim de apresentar propostas que os aproximem da prática clínica diária. MÉTODOS: Foi revisada a literatura citada nos critérios de Roma e foram incluídas as publicações pertinentes ao assunto pesquisadas pela Medline até janeiro 2018. RESULTADOS: Diagnóstico precoce é fundamental, a fim de evitar evolução para complicações indesejáveis e possivelmente para constipação dita intratável, mas a necessidade de inclusão de dois itens - segundo os critérios - pode inviabilizá-lo. Assim, um sinal/sintoma seria suficiente, em geral a presença de 'evacuações dolorosas e/ou duras', facilmente observáveis. Ademais, nos critérios faltam detalhes quanto à recomendação sobre fibra alimentar, embora o seu incremento seja usualmente a primeira abordagem no atendimento primário, e no geral os dados sobre suplementos de fibra alimentar apontem para efeitos benéficos. CONCLUSÃO: Para diagnóstico de constipação em pediatria no atendimento primário, um sinal/sintoma de constipação deve ser suficiente. A ingestão diária de fibra alimentar, conforme a American Health Foundation, deve ser detalhada para o tratamento da constipação e também como medida preventiva desde o desmame.

Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria / Diagnóstico e tratamento da constipação crônica: atualização baseado nos critérios Roma IV

ABSTRACT The aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors' experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient.

RESUMO O objetivo deste trabalho foi avaliar os consensos de sociedade de especialistas e guidelines publicados sobre o diagnóstico e tratamento da constipação intestinal crônica em adultos, e confrontar com a experiência dos autores, a fim de padronizar condutas que auxiliem o raciocínio e a tomada de conduta do médico. Foi realizada busca na literatura científica, mais precisamente nas bases de dados eletrônicos Medline/Pubmed, Scielo, EMBASE and Cochrane, tendo sido utilizado os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Pode-se concluir que constipação crônica é condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. Identificar com precisão a fisiopatologia presente na constipação crônica funcional é complexo, requerendo a realização de testes funcionais nos casos refratários. O entendimento da motilidade intestinal e do mecanismo defecatório é importante para o manejo da constipação intestinal crônica funcional, sendo o tratamento cirúrgico indicado para casos selecionados, onde à abordagem medicamentosa não surtiu efeito. As informações contidas neste artigo de revisão devem ser submetidas à avaliação e à crítica do médico especialista responsável pela conduta a ser tomada, frente à sua realidade e ao estado clínico de cada paciente.

Score de Renzi para distúrbios evacuatórios - validação da versão portuguesa de acordo com a checklist COSMIN / Renzi score for obstructed defecation syndrome - validation of the portuguese version according to the cosmin checklist

ABSTRACT BACKGROUND: Recently, the Obstructed Defecation Syndrome score (ODS score) was developed and validated by Renzi to assess clinical staging and to allow evaluation and comparison of the efficacy of treatment of this disorder. OBJECTIVE: Our goal is to validate the Portuguese version of Renzi ODS score, according to the Consensus based Standards for the selection of the Health Measurement Instruments (COSMIN) checklist. METHODS: Following guidelines for cross-cultural validity, Renzi ODS score was translated into the Portuguese language. Then, a group of patients and healthy controls were invited to fill in the Renzi ODS score at baseline, after 2 weeks and 3 months, respectively. We assessed internal consistency, reliability and measurement error, content and construct validity, responsiveness and interpretability. RESULTS: A total of 113 individuals (77 patients; 36 healthy controls) completed the questionnaire. Seventy and 30 patients repeated the Renzi ODS score after 2 weeks and 3 months respectively. Factor analysis confirmed the unidimensionality of the scale. Cronbach's α coefficient of 0.77 supported item's homogeneity. Weighted quadratic kappa of 0.89 established test-retest reliability. The smallest detectable change at the individual level was 2.66 and at the group level was 0.30. Renzi ODS score and the total (-0.32) and physical (-0.43) SF-36 scores correlated negatively. Patient and control's groups significantly differed (11 points). The change score of Renzi ODS score between baseline and 3 months correlated negatively with the clinical evolution (-0.86). ROC analysis showed minimal important change of 2.00 with AUC 0.97. Neither floor nor ceiling effects were observed. CONCLUSION: This work validated the Portuguese version of Renzi ODS score. We can now use this reliable, responsive, and interpretable (at the group level) tool to evaluate Portuguese ODS patients.

RESUMO CONTEXTO: Recentemente, o Score de Distúrbios Evacuatórios (SDE) foi desenvolvido e validado por Renzi para avaliação e comparação da eficácia do tratamento dos doentes com esta patologia. Objetivo - O nosso objetivo é validar uma versão portuguesa do SDE de acordo com as orientações da checklist de COSMIN. MÉTODOS: O SDE foi traduzido para o português, cumprindo as orientações para validação cultural. Indivíduos com distúrbio evacuatório e controlos saudáveis foram convidados a responder ao SDE numa fase inicial, 2 semanas e 3 meses depois, respetivamente. Foi avaliada a consistência interna, confiabilidade, erro de medição, validade de conteúdo e constructo, responsividade e interpretabilidade. RESULTADOS: Foram entrevistados 113 indivíduos (77 doentes; 36 controlos saudáveis) na fase inicial. O SDE foi aplicado novamente aos 77 doentes, 2 semanas depois, e a 30 doentes, 3 meses depois. Relativamente à consistência interna, a análise fatorial confirmou a unidimensionalidade e o coeficiente α de Cronbach foi 0,77, suportando homogeneidade dos itens. O kappa quadrático ponderado de 0,89 estabeleceu a reprodutibilidade teste-reteste. Considerando o erro de medição, a mudança mínima detectável a nível individual foi 2,66 e a nível de grupo foi 0,30. A validade do constructo foi avaliada através do coeficiente de correlação de Spearman entre o SDE e o score total (-0,32) e físico (-0,43) do SF-36. Em termos de validação clínica, verificou-se uma diferença significativa de 11 pontos entre as médias dos doentes e controlos. A responsividade foi confirmada pelo coeficiente de correlação de -0,86 entre a mudança do score e a evolução clínica, avaliados após 3 meses. Através da curva ROC, a mudança mínima importante foi 2,00 e a AUC foi 0,97. Não foram observados efeito-chão efeito-tecto. CONCLUSÃO: Este projeto permitiu validar a versão portuguesa do SDE de Renzi. É possível agora utilizar esta ferramenta na avaliação de distúrbios evacuatórios em doentes falantes de língua portuguesa.

Anti-TTG entre crianças com constipação funcional crônica não responsivas após 6 semanas de tratamento da constipação / Anti-ttg among children with chronic functional constipation unresponsive to 6 weeks of treatment of constipation

ABSTRACT BACKGROUND Celiac disease is a glutten induced enteropathy. Some authors recommended screening celiac in children with constipation. There are studies to evaluate celiac disease in children with constipation. But most of them included children regardless to treatment failure. OBJECTIVE The aim of this study was to evaluate frequency of elevated anti TTG in children with constipation after failure to improve during 6 week of appropriate treatment of constipation. METHODS In this cross sectional study, 550 children with prolonged constipation were included. Place of study was Pediatric Gastroenterology clinic of Abuzar children's hospital. Prolonged constipation was defined as a constipation which failed to resolved after 6 weeks of appropriate treatment. Constipation was defined according to ROME III criteria. After parental agreement, 5 mL of blood was obtained. Serum anti TTG level was measure using ELISA method by Orientec kit. Anti TTG>10 was considered positive if IgA was normal. SPSS version 16.0 (Chicago, IL, USA) was used for data analysis. Chi square, t-test, and Mann Whitney test used for data analysis. RESULTS In this study 550 children (m=277, f=273) were included. Mean age of the cases was 6.8±2.9 year. Anti TTG antibody level was 5.8±2.8 unit/mL. Of these case, 42 (7.6%) had positive anti-TTG antibody. Celiac disease was confirmed in 40 cases after histopathology examination. CONCLUSION Anti-TTG was positive in 7.6% children with chronic constipation who failed to respond after 6 week of treatment. Another multicenter study with longer follow up period is recommended.

RESUMO CONTEXTO A doença celíaca é uma enteropatia glúten-induzida. Alguns autores recomendam a triagem de doença celíaca em crianças com constipação. Há estudos para avaliar a doença celíaca em crianças com constipação, mas a maioria inclue crianças independentemente do insucesso do tratamento. OBJETIVO O objetivo deste estudo foi avaliar a frequência de anti-TTG elevado em crianças com constipação após 6 semanas de tratamento adequado e sem sucesso. MÉTODOS Através de cruzamento seccional, 550 crianças com constipação prolongada foram incluídas. O local de estudo foi o ambulatório de Gastroenterologia Pediátrica do Hospital Infantil de Abuzar. Constipação prolongada foi definida como uma constipação, cuja resolução falhou após 6 semanas de tratamento adequado. Constipação foi definida de acordo com critérios de Roma III. Após o consentimento informado dos pais, obteve-se 5 mL de sangue. O nível de anti TTG no soro foi medido usando-se o método ELISA pelo Orientec kit. O anti-TTG >10 foi considerado positivo se IgA estivesse normal. Os dados foram analisados através de testes do Chi-quadrado, t-teste e teste de Mann Whitney utilizando-se o SPSS versão 16.0 (Chicago, IL, EUA). RESULTADOS Um total de 550 crianças (m=277, f=273) foi incluído neste estudo. A média de idade dos pacientes foi 6,8±2,9 anos. O nível de anticorpo anti-TTG foi de 5,8±2,8 unidades/mL. Do total, 42 (7,6%) indivíduos tinham anticorpos anti-TTG positivo. A doença celíaca foi confirmada em 40 casos após exame de histopatologia. CONCLUSÃO O Anti-TTG foi positivo em 7,6% crianças com constipação crônica que não conseguiram responder após 6 semanas de tratamento. Outro estudo multicêntrico, com acompanhamento mais longo período é recomendado.

Colonic Inertia: approach and treatment / Inércia Cólica: abordagem e tratamento

ABSTRACT Objective: Revision of the state of the art of the knowledge regarding pathophysiology, diagnosis and treatment of Colonic Inertia, which predominantly affects young women and has a significant socio-economic impact. Methods: A search was made in “colonic inertia”, “colon inertia” and “slow transit constipation” in PubMed database for articles of the last 5 years, in Portuguese or English with available abstract and full text. 59 articles and 2013 guidelines of the American Gastroenterological Association on constipation were included. Results: The pathophysiology is not completely elucidated and the reduction of the interstitial cells of Cajal is the most consistent histological finding. Diagnosis requires the exclusion of secondary causes of constipation and obstructed defecation syndrome, to which contribute several complementary diagnostic tests. Given the frequency of failure of the medical treatment, surgery is often the only possible option. Sacral nerve stimulation seems to be a promising therapeutical alternative. Conclusion: A deeper investigation of the pathophysiological mechanisms is fundamental to acquire a more global and integrated vision. Rigorous patient selection for each treatment and the discovery of new therapeutical targets may avoid the use of surgical therapies.

RESUMO Objetivo: Revisão do estado da arte do conhecimento da patofisiologia, diagnóstico e tratamento da Inércia Cólica, que afeta predominantemente mulheres jovens e tem um impacto socioeconómico significativo. Métodos: Pesquisou-se na base de dados PubMed por “colonic inertia”, “colon inertia” e “slow transit constipation” por artigos apenas dos últimos 5 anos, em português ou em inglês com resumo e texto completo disponíveis. Incluíram-se 59 artigos e as recomendações de 2013 da Associação Americana de Gastroenterologia para a obstipação. Resultados: A patofisiologia ainda não está completamente esclarecida, sendo que a redução das células intersticiais de Cajal constitui o achado histológico mais consistente. O diagnóstico requer a exclusão de causas secundárias de obstipação e de síndrome de obstrução defecatória, para o qual contribuem vários exames complementares de diagnóstico. Dada a frequência do insucesso do tratamento médico, a cirurgia é, muitas vezes, a única opção possível. A estimulação nervosa sagrada parece ser uma alternativa terapêutica promissora. Conclusão: É fundamental uma investigação mais profunda dos mecanismos patofisiológicos envolvidos para adquirir uma visão mais global e integrada. A seleção rigorosa de pacientes para cada tratamento e a descoberta de novos alvos terapêuticos poderão evitar a utilização de terapêuticas cirúrgicas.

Estudo descritivo dos exames de manometria anorretal realizados no laboratório de motilidade digestiva da Santa Casa de Misericórdia, Porto Alegre, Brasil / A descriptive study of anorectal manometry tests performed in the laboratory of digestive motility of Santa Casa de Misericórdia in Porto Alegre, Brazil

Introdução: A manometria anorretal é, atualmente, o padrão ouro, como método de diagnóstico laboratorial dos distúrbios evacuatórios. O objetivo do presente estudo é descrever uma experiência brasileira, da realização da manometria anorretal, valorizando-a como meio diagnóstico. Métodos: Estudo retrospectivo, com revisão dos laudos dos exames, no Laboratório de Motilidade Digestiva da Santa Casa de Misericórdia de Porto Alegre, Brasil. Foram incluídos os pacientes consecutivos, acima de 12 anos de idade, submetidos à manometria anorretal, entre março de 2003 e outubro de 2015. Resultados: No período, foram realizados 1319 exames, em pacientes com média de idade de 53,4±19,4 anos, sendo 70,7% do sexo feminino. A incontinência anal, com 62,4% dos exames, foi a principal indicação da manometria anorretal, a segunda foi constipação com 29,4% e por outros motivos em 8,2% dos pacientes. No período entre 2011 e 2015, houve um aumento significativo dos exames realizados por incontinência anal, em relação ao de 2003 até 2010. Conclusões: As duas principais indicações da manometria anorretal, no presente estudo e na literatura, são constipação e incontinência anal. O aumento significativo dos exames por incontinência anal, após 2011, sugere uma maior consciência dos médicos e pacientes em relação às possibilidades de diagnóstico e tratamento das disfunções evacuatórias. Este é o primeiro estudo brasileiro, que discute as indicações da manometria anorretal e as características dos pacientes encaminhados para o exame. Os autores sugerem a valorização da manometria anorretal como ferramenta de diagnóstico nas disfunções evacuatórias AU)

Introduction: Anorectal manometry is currently the gold standard for laboratory diagnosis of bowel disorders. The aim of the present study is to describe a Brazilian experience in performing anorectal manometry, valuing it as a diagnostic tool. Methods: A retrospective study, with review of test reports, in the Digestive Motility Laboratory of Santa Casa de Misericórdia, Porto Alegre, Brazil. We included consecutive patients, over 12 years of age, undergoing anorectal manometry from March 2003 to October 2015. Results: 1319 tests were performed in the studied period in patients with mean age of 53.4 ± 19.4, 70.7% of whom females. Anal incontinence, accounting for 62.4% of the tests, was the main indication for anorectal manometry, the second was constipation with 29.4%, and other reasons in 8.2% of the patients. In the 2011-2015 period there was a significant increase in the number of tests due to anal incontinence as compared to the 2003-2010 period. Conclusions: The two main indications for anorectal manometry in this study and in the literature are constipation and anal incontinence. The significant increase in the number of tests performed due to anal incontinence after 2011 suggests clinicians' and patients' greater awareness of the possibilities for diagnosis and treatment of bowel dysfunction. This is the first Brazilian study discussing the indications of anorectal manometry and the characteristics of the patients referred to the test. The authors suggest the use of anorectal manometry as a diagnostic tool in evacuation dysfunctions (AU)

Pediatrician's knowledge on the approach of functional constipation / Conhecimento do pediatra sobre o manejo da constipação intestinal funcional

Abstract Objective: To evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation. Methods: A descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013. Results: The majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated. Conclusions: Our results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.

Resumo Objetivo: Identificar o conhecimento do pediatra quanto ao manejo diagnóstico e terapêutico da criança com constipação intestinal funcional. Métodos: Estudo transversal descritivo com amostra constituída de médicos (n=297) entrevistados no 36º Congresso Brasileiro de Pediatria de 2013. Foi usado um questionário autoadministrado referente a um caso clínico hipotético de constipação intestinal. Resultados: Foi observada maior proporção de pediatras do sexo feminino, média de 44,1 anos, tempo de formação médio de 18,8 anos, 56,9% portadores de título de especialista pela Sociedade Brasileira de Pediatria. Exames complementares foram solicitados por 40,4%, a radiografia abdominal foi o mais requisitado (19,5%), seguido por enema opaco (10,4%), exames laboratoriais (9,8%), ultrassonografia de abdome (6,7%), colonoscopia (2,4%), manometria e biópsia (ambas 1,7%). Para o manejo foi sugerida a prescrição de lactulose (26,6%), óleo mineral (17,5%), polietilenoglicol (14,5%), suplemento de fibras (9,1%) e leite de magnésia (5,4%). Orientação alimentar (84,8%), desimpactação fecal (17,2%) e treinamento de toalete (19,5%) também foram indicadas. Conclusões: Evidencia-se uma discordância entre o manejo sugerido pelos pediatras e a conduta preconizada pela literatura disponível atualmente, uma vez que foram solicitados exames complementares desnecessários e não foi recomendada a orientação terapêutica considerada de primeira linha.

There is an agreement between constipation referred and that documented by objective criteria? / Existe concordância entre constipação referida e constatada por critérios objetivos?

Abstract Introduction Chronic constipation is the most common digestive complaint at the doctor's office, with high prevalence in the population. However, many patients - and even those physicians not so familiar with pelvic floor disorders-define and consider constipation based on intestinal functionality and stool consistency. But symptoms of incomplete defecation, digital maneuvers, abdominal discomfort, and straining should not be overlooked. Objectives To investigate the correlation between constipation referred and documented through objective criteria in patients admitted on a daytime-nursing ward basis at the Hospital Santa Marcelina, São Paulo. Methodology This is a prospective study of a random sample of patients admitted on a daytime-ward hospitalization basis at Santa Marcelina Hospital to perform minor surgical procedures not related to functional disorders of the gastrointestinal tract in the period from September 2014 to June 2015; the only exclusion criterion was "not agreed to participate in the interview conducted by students of medicine at Santa Marcelina Medical School". Results 102 patients were randomly analyzed in the period considered (51% female) with a mean overall age of 48.6 (19-82) years. Constipation has been reported spontaneously by 17.6% of participants and denied by 82.4%. With the implementation of the Cleveland Clinic's criteria for the diagnosis of constipation, the compliance with the referred symptomatology was 88.9%; the same value was found with the use of the Rome III criteria (Kappa = 0.665). In addition, a higher incidence of constipation was observed in female patients (p = 0.002). Conclusion A higher incidence of constipation was observed in female participants, with no statistical difference with respect to age. Furthermore, a substantial agreement was found between constipation referred and constipation documented through objective criteria.

Resumo Introdução A constipação intestinal crônica representa a queixa digestiva mais comum no consultório com elevada prevalência na população. No entanto, frequentemente, os pacientes e mesmo os médicos, não tão afeitos com os distúrbios do assoalho pélvico, definem e consideram constipação baseados na funcionalidade intestinal e consistência das fezes. Entretanto, os sintomas de defecação incompleta, manobras digitais, desconforto abdominal e esforço evacuatório não devem ser negligenciados. Objetivos Verificar a correlação entre constipação intestinal referida e constatada através de critérios objetivos em pacientes internados em regime de enfermaria dia no Hospital Santa Marcelina, São Paulo. Metodologia Estudo prospectivo de amostra aleatória de pacientes internados em enfermaria dia do Hospital Santa Marcelina para realização de cirurgias de pequeno porte e não relacionadas a distúrbios funcionais de trato gastrintestinal no período entre setembro de 2014 e junho de 2015, cujo único critério de exclusão foi o não consentimento em participar da entrevista realizada pelos alunos do curso de medicina da Faculdade Santa Marcelina. Resultados Foram analisados de forma aleatória 102 pacientes no período sendo 51% do sexo feminino e média de idade global de 48,6 anos (19-82 anos). A constipação foi referida de forma espontânea em 17,6% e negada em 82,4%. Ao se utilizar o critério da Cleveland Clinic para constatar constipação houve uma concordância com o sintoma referido fora de 88,9%, com mesmo valor ao se utilizar os critérios de Roma III (Kappa = 0,665). Além disso, verificou-se maior incidência de constipação intestinal nos pacientes do sexo feminino (p = 0,002). Conclusão Verificou-se maior incidência de constipação no sexo feminino sem diferença estatística baseado na idade. Além disso, constatou-se concordância substancial entre a constipação referida e a documentada através de critérios objetivos.

Risk Factors for Functional Constipation in Young Children Attending Daycare Centers

Our objective was to determine the risk factors associated with the development of functional constipation (FC) in young children attending daycare centers. A cross-sectional survey using a questionnaire based on the Rome III criteria was conducted in children aged 25 to 84 months from 3 randomly selected daycare centers in January 2016. The items in a questionnaire were statistically compared in the constipated and non-constipated groups. A total of 212 children were included and FC was found in 8.5%. Multivariate logistic regression analyses revealed that maternal history of constipation (odds ratio [OR] = 4.1, 95% Confidence Interval [CI] 1.2-13.9), history of painful defecation before age 1 (OR = 10.4, 95% CI 1.1-101.3), history of painful defecation during toilet training (OR = 28.9, 95% CI 1.9-423.8), no or difficult defecation at a daycare center (OR = 5,804.6, 95% CI 134.4-250,718.4), no meat consumption (OR = 10.1, 95% CI 1.2-88.1), and 500 mL or less of water intake per day (OR = 9.9, 95% CI 0.9-99.5) were powerful predictors of FC in young children (P < 0.05). Additionally, the constipated group was significantly associated with 2 hours or less of outdoor play activities per day, entry into daycare centers before 24 months age, 6 hours or more of attendance at a daycare center per day, breastfeeding for less than 6 months, 3 meals or less per day, and 3 or fewer servings of fruits and vegetables per day (P < 0.05). The findings of this study can guide parents, daycare teachers, and clinicians in prevention, early recognition and early intervention for the risk factors associated with FC in young children.

Risk Factors for Functional Constipation in Young Children Attending Daycare Centers

Our objective was to determine the risk factors associated with the development of functional constipation (FC) in young children attending daycare centers. A cross-sectional survey using a questionnaire based on the Rome III criteria was conducted in children aged 25 to 84 months from 3 randomly selected daycare centers in January 2016. The items in a questionnaire were statistically compared in the constipated and non-constipated groups. A total of 212 children were included and FC was found in 8.5%. Multivariate logistic regression analyses revealed that maternal history of constipation (odds ratio [OR] = 4.1, 95% Confidence Interval [CI] 1.2-13.9), history of painful defecation before age 1 (OR = 10.4, 95% CI 1.1-101.3), history of painful defecation during toilet training (OR = 28.9, 95% CI 1.9-423.8), no or difficult defecation at a daycare center (OR = 5,804.6, 95% CI 134.4-250,718.4), no meat consumption (OR = 10.1, 95% CI 1.2-88.1), and 500 mL or less of water intake per day (OR = 9.9, 95% CI 0.9-99.5) were powerful predictors of FC in young children (P < 0.05). Additionally, the constipated group was significantly associated with 2 hours or less of outdoor play activities per day, entry into daycare centers before 24 months age, 6 hours or more of attendance at a daycare center per day, breastfeeding for less than 6 months, 3 meals or less per day, and 3 or fewer servings of fruits and vegetables per day (P < 0.05). The findings of this study can guide parents, daycare teachers, and clinicians in prevention, early recognition and early intervention for the risk factors associated with FC in young children.

Manifestaciones imagenológicas y manométricas en pacientes con estreñimiento funcional / Imaging and manometric manifestations in patients with functional constipation

INTRODUCCIÓN: el estreñimiento es un síntoma o afección que puede comprometer la calidad de vida de los pacientes. Su prevalencia global varía entre 2 % y 28 %. OBJETIVO: evaluar la concordancia entre los resultados de los exámenes imagenológicos y la manometría anorrectal, en pacientes con sospecha de estreñimiento funcional. MÉTODOS: la muestra estuvo conformada por 37 pacientes, a los que se les realizó exámenes radiológicos de cecocolografía secuencial (o colon por ingestión), tiempo de tránsito colónico con marcadores radiopacos, defecografía y examen manométrico. Se calculó el índice de Kappa para determinar la concordancia. RESULTADOS: 62,2 % de los enfermos fueron del sexo femenino, la edad predominante estuvo entre 41 y 60 años (43,2 %), predominó el ciego móvil (54,2 %) como causa de estreñimiento. Se hicieron 14 estudios de tiempo de tránsito colónico con marcadores radiopacos, de ellos 28,6 % presentó un tiempo de tránsito lento. Se realizó defecografía a 4 pacientes y 3 presentaron disfunción del suelo pelviano. Se constató que 94,6 % de las pruebas imagenológicas y 78,4 % de las manometrías resultaron positivas (Kappa p= 0,006). CONCLUSIÓN: las técnicas imagenológicas que se investigaron son apropiadas para diagnosticar el estreñimiento funcional y la concordancia de dichas técnicas con la manometría anorrectal es adecuada.

INTRODUCTION: constipation is a symptom or condition that can compromise the quality of patient's life. Its global prevalence varies between 2 % and 28 %. OBJECTIVE: evaluate the correlation between the results of imaging tests and anorectal manometry in patients with suspected functional constipation. METHODS: the sample consisted of 37 patients, who underwent radiological examinations of sequential cecocolografía (colon or swallowed), colonic transit time with radiopaque markers, defecography and manometric examination. Kappa index was calculated to determine the correlation. RESULTS: 62.2 % of patients were female, the predominant age was between 41 and 60 years (43.2 %), mobile blind predominated (54.2 %) as a cause of constipation. 14 studies of colonic transit time with radiopaque markers, were made, 28.6 % of them presented a slow transit time. 4 patients underwent defecography and 3 had pelvic floor dysfunction. It was found that 94.6 % of imaging tests and 78.4 % of manometries were positive (Kappa p= 0.006). CONCLUSIONS: imaging techniques used in this study are suitable for diagnosing functional constipation and consistency of these techniques is suitable anorectal manometry.