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)

Intoxicación por leche magnesia en una paciente pediátrica con constipación crónica: a propósito de un caso / Milk of magnesia intoxication in a pediatric patient with chronic constipation: case report

Resumen Las intoxicaciones accidentales siguen siendo un problema importante que genera gran cantidad de casos de autopsia médico legal, sobre todo cuando ocurren en pacientes pediátricos donde se deben descartar otras causas de muerte y que no se trate de un homicidio. La intoxicación con leche magnesia es un diagnóstico poco frecuente por lo que se hace necesario conocer sus características, evolución y las alteraciones metabólicas por las que se produce la muerte. La hipermagnesemia constituye una condición iatrogénica, generalmente secundaria a la administración de fármacos que contienen magnesio, entre ellos laxantes en pacientes con estreñimiento crónico, en muchas ocasiones sin supervisión médica; que puede producir depresión respiratoria, hipotensión, paro cardiorrespiratorio y la muerte. El diagnóstico de intoxicación con leche magnesia es clínico y se correlaciona con la concentración de magnesio detectada en análisis de muestras de sangre. A continuación se presenta un caso de intoxicación por leche magnesia en una paciente en edad pediátrica con antecedente de parálisis cerebral infantil y constipación crónica que desarrolló una hipermagnesemia posterior a la administración de dicho laxante por parte de sus padres.

Abstract Accidental intoxications continue to be an important problem in the Forensic Pathology field, mostly when they occur in pediatric patients where it is necessary to dismiss other causes of death and to rule out homicide. Milk of magnesia intoxication is a rare diagnosis, therefore it is important to know it´s characteristics, evolution and the metabolic disorders that lead to death. Hypermagnesemia is an iatrogenic condition, usually caused by the administration of medications that contain magnesium, such as laxatives in patients with chronic constipation, without medical supervision; that can lead to respiratory distress, hypotension, cardiac arrest and death. The diagnosis of milk of magnesia intoxication is clinical and can be correlated to the levels of magnesium found in blood sample analysis. We present a case of milk of magnesia intoxication in a 6-year-old girl with cerebral palsy and chronic constipation that was given laxatives by her parents and developed a fatal hypermagnesemia.

Relação entre níveis de chumbo e cádmio no sangue e a prisão de ventre crônica refratária entre crianças iranianas / Relationship between lead and cadmium levels in blood and refractory chronic constipation among iranian children

ABSTRACT BACKGROUND: There is limited research examining reasons causing refractory chronic constipation (RCC) in children. The effects of lead (Pb) and cadmium (Cd) exposures on this condition have been even less clear. However, some related factors may contribute to evaluation of blood lead levels (BLLs) and blood cadmium levels (BCLs). OBJECTIVE: The present study aimed to examine the relationship between Pb and Cd exposures and RCC in children living in the city of Ahvaz, Khuzestan Province, in Southwestern Iran. METHODS: This study was performed on a total number of 48 children aged 2-13 years, including 36 medically-diagnosed RCC cases and 12 controls referring to a pediatric clinic in the city of Ahvaz. Their BLLs and BCLs were then determined using a graphite furnace atomic absorption spectrophotometer. The data from the researcher-designed questionnaire were also recoded and the related risk factors were analyzed through Spearman's correlation and logistic regression analysis. RESULTS: The findings revealed that the geometric means of Pb and Cd in blood samples in the control group were 58.95 µg/dL and 0.45 µg/dL; respectively. These values in the case group were equally 45.26 µg/dL and 0.26 µg/dL; respectively. A significant difference was additionally observed between BCLs in the case and control groups (P<0.01). All children in both groups also had BLLs greater than the permissible limit endorsed by the World Health Organization (WHO) (≤10 µg/dL). On the other hand, 8.3% of the individuals in the case group and 33.3% of those in the control group had BCLs higher than the acceptable range mentioned by WHO (≤0.5 µg/dL). CONCLUSION: Pb and Cd exposures due to environmental pollution and susceptibility to heavy metals may not be associated with RCC in children living in the city of Ahvaz. Although this research was the first one providing data on BLLs and BCLs in children with RCC, the findings could be useful for designing future epidemiologic studies.

RESUMO CONTEXTO: Há limitadas pesquisas que procuram razões que causem constipação crônica refratária (CCR) em crianças. Os efeitos das exposições de chumbo (Pb) e cádmio (Cd) nesta condição têm sido ainda menos claros. No entanto, alguns fatores relacionados podem contribuir para a avaliação dos níveis de Pb no sangue (NPbSs) e dos níveis de Cd no sangue (NCdSs). OBJETIVO: O presente estudo teve como objetivo examinar a relação entre as exposições de Pb e Cd e a CCR em crianças residentes na cidade de Ahvaz, província de Khuzestan, no Sudoeste do Irã. MÉTODOS: Este estudo foi realizado em um número total de 48 crianças de 2 a 13 anos, incluindo 36 casos de CCR diagnosticados clinicamente, e 12 controles encaminhados a uma clínica pediátrica na cidade de Ahvaz. Seus NPbSs e NCdSs foram então determinados usando um espectrógrafo de absorção atômica do forno de grafite. Os dados do questionário projetado pelo pesquisador também foram recodificados, e os fatores de risco relacionados foram analisados por meio da análise de correlação e regressão logística de Spearman. RESULTADOS: Os achados revelaram que as médias geométricas de Pb e Cd em amostras de sangue no grupo controle foram de 58,95 μg/dL e 0,45 μg/dL; respectivamente. Esses valores no grupo constipação foram igualmente 45,26 μg/dL e 0,26 μg/dL; respectivamente. Observou-se diferença significativa entre os NCdSs nos grupos de caso e controle (P<0,01). Todas as crianças de ambos os grupos também apresentaram NPbSs maiores do que o limite permitido endossado pela Organização Mundial da Saúde (OMS) (≤10 μg/dL). Por outro lado, 8,3% dos indivíduos no grupo de casos e 33,3% dos do grupo controle apresentaram NCdSs superiores à faixa aceitável mencionada pela OMS (≤0,5 μg/dL). CONCLUSÃO: As exposições de Pb e Cd por poluição ambiental e suscetibilidade a metais pesados podem não estar associadas à CCR em crianças residentes na cidade de Ahvaz. Embora esta pesquisa tenha sido a primeira a fornecer dados sobre NPbSs e NCdSs em crianças com CCR, os achados poderiam ser úteis para a concepção de futuros estudos epidemiológicos.

Lactobacillus reuteri DSM 17938 and Agave Inulin in Children with Cerebral Palsy and Chronic Constipation: A Double-Blind Randomized Placebo Controlled Clinical Trial.

The main objective was to assess the efficacy of a probiotic (Lactobacillus reuteri DSM 17938), a prebiotic (agave inulin), and a synbiotic on the stool characteristics in children with cerebral palsy and chronic constipation. Thirty-seven children with cerebral palsy and chronic constipation were included. The probiotic group received 1 × 108 colony forming unit (cfu) of L. reuteri DSM 17938 plus placebo, the prebiotic group received 4 g of agave inulin plus placebo, the synbiotic group received L. reuteri DSM 17938 plus agave inulin, and the placebo group received two placebos for 28 days. The probiotic group showed a significant decrease in stool pH (p = 0.014). Stool consistency improved in the prebiotic group (p = 0.008). The probiotic, prebiotic, and synbiotic groups showed a significant improvement in the history of excessive stool retention, the presence of fecal mass in the rectum, and the history of painful defecation. L. reuteri concentration in feces was higher in the probiotic group than in the placebo group (p = 0.001) and showed an inverse correlation with stool pH in the probiotic group (r = -0.762, p = 0.028). This study showed that the use of L. reuteri DSM 17938 and/or agave inulin improved the stool characteristics such as the history of painful defecation and the presence of fecal mass in the rectum against placebo in children with cerebral palsy and chronic constipation.

Chagasic megacolon in Venezuela - case report / Megacólon chagásico na Venezuela

ABSTRACT Chagasic megacolon is the second most frequent cause of manifestation of the digestive forms of Chagas disease (trypanosoma cruzi parasitosis), characterized by progressive pseudo-occlusive symptoms or chronic constipation, caused by an alteration in the functioning of the colonic wall musculature. In Venezuela, cases of chagasic disease reported in the past are referred to chagasic heart disease, this being the first documented case of chagasic megacolon. We broach herein a case of chagasic megacolon in which early diagnosis and prompt surgical treatment led to a successful outcome.

RESUMO O megacólon chagásico é a segunda causa mais frequente de manifestação das formas digestivas da doença de Chagas (parasitose do Trypanosoma cruzi), caracterizado por sintomas pseudo-oclusivos progressivos ou constipação crônica, causado por uma alteração no funcionamento da musculatura da parede do cólon. Na Venezuela, os casos da doença chagásica relatados no passado são referidos como doença cardíaca chagásica, sendo este o primeiro caso documentado de megacólon chagásico. Neste artigo, abordamos um caso de megacólon chagásico no qual o diagnóstico precoce e o tratamento cirúrgico imediato levaram a um resultado bem-sucedido.

Anal position index; can it predict pelvic organ disorders in adults? / O índice de posição anal pode prever doenças de órgãos pélvicos em adultos?

ABSTRACT Introduction: Anal position index is calculated with a simple formula, which is used to determine the exact position of anus in perineum. This index is currently used only in neonates and infants. Anteriorly displacement of anus is a common cause of chronic constipation. Here we assessed the association between anal position index with patients' characteristics, chronic constipation, rectum prolapse uterine prolapse, and number of delivery. Material and methods: This was a cross-sectional study performed in 2018 on 63 adult admitted to colorectal surgery clinic. Anus-forchuette, coccyx-forchuette and coccyx-scrotum and anal-scrotum were measure by a simple meter tape. Statistical Package for the Social Sciences (SPSS for Windows, ver. 18) was used for data analysis. Independent Student's t-test, correlation coefficient and ANOVA were used. Results: Sixty-three patients within age range of 22-75 years old were recruited. 48 were male (76.2%) and 15 females (23.8%). Twenty-nine (46%) had chronic constipation. The mean ± SD of the index with confidence interval of 95% was 0.5325 ± 0.11861 in males and 0.4510 ± 0.16803 in females. Also the mean of the index was 0.4616 ± 0.14007 in patients with chronic constipation and 0.5570 ± 0.11559 in patients without constipation. Discussion: Anal position index can be a prognostic factor to predict chronic constipation and pelvic floor anatomy disturbance in adults as well as pediatrics.

RESUMO Introdução: O índice de posição anal é calculado com uma fórmula simples, usada para determinar a posição exata do ânus no períneo. Atualmente, esse índice é usado apenas em neonatos e bebês. O deslocamento anterior do ânus é uma causa comum de constipação crônica. No presente estudo, avaliou-se a associação entre o índice de posição anal e as características dos pacientes, constipação crônica, prolapso uterino, prolapso do reto e número de partos. Material e Métodos: Este estudo transversal, realizado em 2018, incluiu 63 adultos admitidos na clínica de cirurgia colorretal. As distâncias ânus-frênulo dos lábios, cóccix-frênulo, cóccix-escroto e ânus-escroto foram medidas com uma fita métrica simples. O SPSS for Windows (v. 18) foi usado para análise dos dados. O teste t de Student para variáveis independentes, o coeficiente de correlação e o teste ANOVA foram usados. Resultados: Sessenta e três pacientes com idade entre 22 a 75 anos foram recrutados; 48 eram do sexo masculino (76,2%) e 15 do sexo feminino (23,8%). Destes, 29 (46%) apresentavam constipação crônica. A média ± DP do índice, com intervalo de confiança de 95%, foi de 0,5325 ± 0,11861 no sexo masculino e 0,4510 ± 0,16803 no sexo feminino. Além disso, a média do índice foi de 0,4616 ± 0,14007 em pacientes com constipação crônica e 0,5570 ± 0,11559 em pacientes sem constipação. Discussão: O índice de posição anal pode ser um fator prognóstico para predizer constipação crônica e alterações da anatomia do assoalho pélvico em pacientes adultos e pediátricos.

Scintigraphic evaluation of colonic transit in children with constipation using 67Ga-citrate.

The aim of this study was to assess the colonic transit in children and teenagers with chronic constipation. Twenty patients from 1.5 to 16 years old were included (mean age = 6.9 years). Chronic constipation etiologies were as follows: congenital megacolon in 6; surgical treatment in 5 (imperforate anus 2, hip dysplasia 1, sacral teratoma 1, and paraspinal neuroblastoma 1); idiopathic chronic constipation in 5; sacral myelomeningocele in 3; and intestinal duplication in 1. Static images on the anterior projection of the abdomen were performed 1, 6, 24, 48, and 72 h after the radiotracer oral administration. Doses were 3.7 MBq of 67Ga-citrate. The images were visually analyzed and classified by the observers as normal, diffuse slow transit, right slow transit, and left slow transit. Patients' dosimetric estimation was performed also. There were four cases of diffuse slow transit that responded well to the clinical treatment, 3 of them being chronic idiopathic constipation. From five patients with right slow transit, 4 were submitted to appendicostomy (Malone surgery) with good results. There were 11 cases of left slow transit (ten at the rectosigmoid level). Five of the 6 patients with congenital megacolon had left slow transit. Patients' dose estimation was 1.9 mSv to the whole body, 1.8 mSv to the ovaries, and 1.4 mSv to the testicular. This method is simple, safe, noninvasive, provides helpful functional information, and allows therapeutic decision regarding chronic constipation.

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.

Intestinal neuronal dysplasia type B: A still little known diagnosis for organic causes of intestinal chronic constipation.

Intestinal neuronal dysplasia type B (IND-B) is a controversial entity among the gastrointestinal neuromuscular disorders. It may occur alone or associated with other neuropathies, such as Hirschsprung's disease (HD). Chronic constipation is the most common clinical manifestation of patients. IND-B primarily affects young children and mimics HD, but has its own histopathologic features characterized mainly by hyperplasia of the submucosal nerve plexus. Thus, IND-B should be included in the differential diagnoses of organic causes of constipation. In recent years, an increasing number of cases of IND-B in adults have also been described, some presenting severe constipation since childhood and others with the onset of symptoms at adulthood. Despite the intense scientific research in the last decades, there are still knowledge gaps regarding definition, pathogenesis, diagnostic criteria and therapeutic possibilities for IND-B. However, in medical practice, we continue to encounter patients with severe constipation or intestinal obstruction who undergo to diagnostic investigation for HD and their rectal biopsies present hyperganglionosis in the submucosal nerve plexus and other features, consistent with the diagnosis of IND-B. This review critically discusses aspects related to the disease definitions, pathophysiology and genetics, epidemiology distribution, clinical presentation, diagnostic criteria and therapeutic possibilities of this still little-known organic cause of intestinal chronic constipation.

Diagnostic accuracy of barium enema findings in hirschsprung's disease / Acurácia do diagnóstico de achados do enema opaco na doença de hirschsprung

ABSTRACT Background: Hirschsprung's disease is the most common cause of pediatric intestinal obstruction. Contrast enema is used for evaluation of the patients with its diagnosis. Aim: To evaluate sensitivity, specificity, positive predictive value, and negative predictive value of radiologic findings for diagnosis of Hirschsprung in patients underwent barium enema. Methods: This cross sectional study was carried out in Imam Khomeini Hospital for one year starting from 2012, April. Sixty patients were enrolled. Inclusion criteria were: neonates with failure to pass meconium, abdominal distention, and refractory constipation who failed to respond with medical treatment. Transitional zone, delay in barium evacuation after 24 h, rectosigmoid index (maximum with of the rectum divided by maximum with of the sigmoid; abnormal if <1), and irregularity of mucosa (jejunization) were evaluated in barium enema. Biopsy was obtained at three locations apart above dentate line. PPV, NPV, specificity , and sensitivity was calculated for each finding. Results: Mean age of the cases with Hirschsprung's disease and without was 17.90±18.29 months and 17.8±18.34 months respectively (p=0.983). It was confirmed in 30 (M=20, F=10) of cases. Failure to pass meconium was found in 21(70%) cases. Sensitivity, specificity, PPV, and NPV were 90%, 80%, 81.8% and 88.8% respectively for transitional zone in barium enema. Sensitivity, specificity, PPV, and NPV were 76.7%, 83.3%, 78.1% and 82.1% respectively for rectosigmoid index .Sensitivity, specificity, PPV, and NPV were 46.7%, 100%, 100% and 65.2% respectively for irregular contraction detected in barium enema. Sensitivity, specificity, PPV, and NPV were 23.3%, 100%, 100% and 56.6% respectively for mucosal irregularity in barium enema. Conclusion: The most sensitive finding was transitional zone. The most specific findings were irregular contraction, mucosal irregularity, and followed by cobblestone appearance.

RESUMO Racional: A doença de Hirschsprung é a causa mais comum de obstrução intestinal pediátrica. Enema baritado é usado para a avaliação dos pacientes com o diagnóstico . Objetivo: Avaliar a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de achados radiológicos para diagnóstico de Hirschsprung em pacientes submetidos ao enema opaco. Métodos: Este estudo transversal foi realizado em Imam Khomeini Hospital por um ano a partir de abril de 2012. Sessenta pacientes foram incluídos. Os critérios de inclusão foram: recém-nascidos com insuficiência de passagem de mecônio, distensão abdominal, e constipação refratária sem resposta ao tratamento médico. Foram avaliadas no enema zona de transição, atraso na evacuação de bário após 24 h, índice retossigmoide (máximo do diâmetro do reto dividido pelo máximo do sigmóide; anormal se <1), e as irregularidades da mucosa (jejunização). Biópsia foi obtida em três localizações acima da linha dentada. VPP, VPN, especificidade e sensibilidade foram calculados para cada achado. Resultados: A idade média dos casos com a doença de Hirschsprung e sem foi 17,90±18,29 meses e 17,8±18,34 meses, respectivamente (p=0,983). Confirmou-se em 30 (M=20, F=10) dos casos. Falha no mecônio foi encontrada em 21 (70%) casos. Sensibilidade, especificidade, VPP e VPN foram de 90%, 80%, 81,8% e 88,8%, respectivamente, para a zona de transição no enema. Sensibilidade, especificidade, VPP e VPN foram 76,7%, 83,3%, 78,1% e 82,1%, respectivamente para o índice de retossigmoide. Sensitividade, especificidade, VPP e VPN foram 46,7%, 100%, 100% e 65,2%, respectivamente, para contração irregular detectada no enema baritado. Sensibilidade, especificidade, VPP e VPN foram de 23,3%, 100%, 100% e 56,6%, respectivamente, para a irregularidade da mucosa. Conclusão: O achado mais sensível foi zona de transição. Os achados mais específicos foram contração irregular, irregularidade da mucosa, e seguido por aparecimento de mucosa em forma de paralelepípedos.

[Chronic constipation]. / Constipación crónica.

Infant constipation is a common problem in pediatric practice and it constitutes approximately 25% of children's gastroenterologist consultations. An average prevalence of 8.9% in the pediatric population is described, but it varies as it is influenced by different dietary habits and definitions used in the studied populations. 90 to 95% of the cases have a functional cause, where the most important therapeutic measures are: Education to children and their parents, forming a stool pattern, a diet rich in fiber and the use of drugs for disimpaction treatment and maintenance. Finally, it is important to explain to parents that the treatment is usually long, due to frequent relapses. It is described that 25% of affected children will continue with symptoms into adulthood.

Constipación crónica / Chronic constipation

La constipación infantil es un problema frecuente en la consulta pediátrica y constituye aproximadamente un 25% de la consulta al gastroenterólogo infantil. Se describe una prevalencia media de 8,9% en población pediátrica, pero esta es variable, ya que está influenciada por los distintos hábitos dietéticos y definiciones usadas en las poblaciones estudiadas. Un 90-95% de los casos son de causa funcional, y en ellos las medidas terapéuticas más importantes son la educación del niño y sus padres, la formación de un hábito defecatorio, una dieta rica en fibra y el uso de medicamentos en tratamientos de desimpactación y mantenimiento. Por último, es importante explicar a los padres que el tratamiento habitualmente es prolongado, ya que son frecuentes las recaídas. Se describe además que un 25% de los niños afectados continuarán con síntomas hasta la adultez.

Infant constipation is a common problem in pediatric practice and it constitutes approximately 25% of children's gastroenterologist consultations. An average prevalence of 8.9% in the pediatric population is described, but it varies as it is influenced by different dietary habits and definitions used in the studied populations. 90 to 95% of the cases have a functional cause, where the most important therapeutic measures are: Education to children and their parents, forming a stool pattern, a diet rich in fiber and the use of drugs for disimpaction treatment and maintenance. Finally, it is important to explain to parents that the treatment is usually long, due to frequent relapses. It is described that 25% of affected children will continue with symptoms into adulthood.

Manejo del paciente con constipación / Managing the constipated patient

El estreñimiento es un problema común. La mayoría de las personas resolverá el problema por si mismo, sin embargo hay un porcentaje que no lo logran y requieren de ayuda médica. Sigue siendo un reto para el médico seleccionar quienes se beneficiarán de estudios para excluir enfermedad orgánica, de estudios específicos para evaluar el mecanismo fisiopatológico implicado, y cuál es el mejor tratamiento para cada paciente. En este capítulo se revisan los aspectos más relevantes para el manejo de pacientes con estreñimiento funcional.

Constipation is a common problem. Most people solve the problem by itself, but there is a percentage who do not succeed and require medical help. It remains a challenge for the physician to select those who will benefit from studies to exclude organic disease, specific studies to evaluate the physiological mechanism involved, and what is the best treatment for each patient. In this chapter we review the most relevant aspects for the management of patients with functional constipation.

Pediatric functional constipation treatment with Bifidobacterium-containing yogurt: a crossover, double-blind, controlled trial.

AIM: To evaluate the treatment of pediatric functional chronic intestinal constipation (FCIC) with a probiotic goat yogurt. METHODS: A crossover double-blind formula-controlled trial was carried out on 59 students (age range: 5-15 years) of a public school in Belo Horizonte, MG, Brazil, presenting a FCIC diagnostic, according to Roma III criteria. The students were randomized in two groups to receive a goat yogurt supplemented with 10(9) colony forming unit/mL Bifidobacterium longum (B. longum) (probiotic) daily or only the yogurt for a period of 5 wk (formula). Afterwards, the groups were intercrossed for another 5 wk. Defecation frequency, stool consistency and abdominal and defecation pain were assessed. RESULTS: Both treatment groups demonstrated improvement in defecation frequency compared to baseline. However, the group treated with probiotic showed most significant improvement in the first phase of the study. An inversion was observed after crossing over, resulting in a reduction in stool frequency when this group was treated by formula. Probiotic and formula improved stool consistency in the first phase of treatment, but the improvement obtained with probiotic was significantly higher (P = 0.03). In the second phase of treatment, the group initially treated with probiotic showed worsening stool consistency when using formula. However, the difference was not significant. A significant improvement in abdominal pain and defecation pain was observed with both probiotic and formula in the first phase of treatment, but again the improvement was more significant for the group treated with B. longum during phase I (P < 0.05). When all data of the crossover study were analyzed, significant differences were observed between probiotic yogurt and yogurt only for defecation frequency (P = 0.012), defecation pain (P = 0.046) and abdominal pain (P = 0.015). CONCLUSION: An improvement in defecation frequency and abdominal pain was observed using both supplemented and non-supplemented yogurt, but an additional improvement with B. longum supplementation was obtained.

Biofeedback treatment in chronically constipated patients with dyssynergic defecation / Biofeedback aplicado al tratamiento de pacientes con estreñimiento crónico debido a defecación disinérgica

The aim of this study was to evaluate the effects of electromyographic biofeedback training in chronically constipated patients with dyssynergic defecation. With this purpose, ten patients (4 males, 6 females) with dyssynergic defecation unresponsive to dietary corrections and fibre supplements were selected and enclosed in the study on the basis of fulfilled the Rome III criteria for this functional gastrointestinal disorder. The study was carried out following a series of defined phases: clinical and psychophysiological assessment prior to the treatment (4 weeks), EMG-biofeedback treatment (8 sessions, two per week) and follow-up (4 weeks) one month later. In all phases, four clinical variables were assessed through selfmonitoring (frequency of defecations per week, sensation of incomplete evacuation, difficulty evacuation level, and perianal pain at defecation); moreover, psychophysiological measures were obtained through electromyography (EMG) of the external anal sphincter. Results show significant improvements in psychophysiological measures (EMGactivity during straining to defecate and anismus index), as well as in clinical variables. Biofeedback's benefits were maintained at the follow-up period.

El objetivo de este estudio fue evaluar los efectos del entrenamiento en biofeedback-EMG en pacientes con estreñimiento crónico debido a defecación disinérgica. Con este propósito, 10 pacientes (4 varones, 6 mujeres) con defecación disinérgica que no respondían a correcciones dietéticas y suplementos de fibra, fueron seleccionados e incluidos en el estudio sobre la base de cumplir los criterios Roma III para el diagnóstico de este trastorno funcional gastrointestinal. El estudio se llevó a cabo a lo largo de una serie de fases definidas: evaluación psicofisiológica y clínica previa al tratamiento (4 semanas), tratamiento por medio de biofeedback-EMG (8 sesiones, a razón de dos sesiones semanales) y seguimiento (4 semanas) un mes más tarde. En todas las fases, cuatro variables clínicas fueron evaluadas a través de autorregistro (frecuencia de defecaciones semanales, sensación de evacuación incompleta, nivel de dificultad de la evacuación y dolor perianal en la defecación); además, se obtuvieron medidas psicofisiológicas a través de electromiografía (EMG) del esfínter anal externo. Los resultados muestran mejoras significativas en las medidas psicofisiológicas (actividad-EMG durante el esfuerzo para defecar e índice de anismus), así como en las variables clínicas. Los beneficios del biofeedback se mantuvieron en el período de seguimiento.

Síndrome de Currarino: informe de un caso / Currarino’s syndrome: a case report

El síndrome de Currarino es una enfermedad hereditaria rara. La forma completa se caracteriza por la presencia de una malformación ano-rectal (generalmente estenosis), masa presacra y defectos óseos del sacro. El signo más importante es la presencia de estreñimiento desde el nacimiento. Se presenta un paciente de 13 meses de edad que consultó por estreñimiento crónico severo en quien se encontró la presencia de hemisacro y meningocele anterior, ambos hallazgos compatibles con una forma leve del síndrome de Currarino. Se realizó un manejo conservador y se inició polietilenglicol oral (PEG®), con una excelente respuesta al tratamiento. Se hace la presentación del caso junto con la revisión de la literatura actual con el fin de dar a conocer al personal médico la presencia del síndrome, enfatizar en puntos importantes que generen sospecha de su presencia y las diferentes opciones terapéuticas para su manejo.

The Currarino’s syndrome is a rare inherited disorder. The complete form is characterized by the presence of ano-rectal malformation (usually stenosis), presacral mass and bone defects of the sacrum. The most important symptom is the presence of constipation since birth. A 13 month old patient with chronic and severe constipation is presented. Among the studies the presence of hemisacrum and anterior meningocele were found, both findings consistent with a mild form of Currarino’s syndrome. A conservative management with polietilenglycol oral (PEG®), was initiated with an excellent response to treatment. The presentation of the case with a review of current literature is given to the medical staff in order to publicize the syndrome, as well as to emphasize key points that create suspicion of their presence and the different therapeutic options for its approach.

Consumo de fibra dietética en un grupo de niños de la consulta externa del servicio de gastroenterología pediátrica del Hospital Infantil Club Noel de Cali, Colombia / Dietetic fiber in 22 children from the Hospital Infantil Club Noel of Cali, Colombia

Introducción: El estreñimiento crónico funcional (ECF) es causa importante de consulta en gastroenterología pediátrica. El papel de la fibra dietética en niños como agente causal de estreñimiento es tema de controversia. Objetivo: Informar el consumo de fibra dietética en 22 niños del Hospital Infantil Club Noel (HICN) de Cali, Colombia. Informe de casos: Se trata de 22 niños (3-13 años), de ambos géneros, que consultaron por primera vez al HICN de Cali, por diversas causas digestivas. Se realizó una historia clínica médica, y una entrevista nutricional por recordatorio de 24 horas. Se definió desnutrición aguda cuando el déficit para peso/talla (P/T) era >10% y sobrepeso cuando el exceso para P/T era >10%. El análisis químico de la fibra dietética se hizo con base en el Contenido de Fibra Dietética y Almidón Resistente en Alimentos y Productos Iberoamericanos del CYTED. Se dividieron según género, hábito intestinal y signos y síntomas; en niños con estreñimiento (n=9) y sin estreñimiento (n=13) (p=0.865, 95% IC -6.71 a 7.91). Conclusión: Los 22 niños del HICN de Cali, independiente de la presencia de estreñimiento, consumen 12.8±7.8 g de fibra dietaria al día, que son los recomendados por la mayoría de estudios descritos.

Introduction: Functional chronic constipation is an important cause of consultation in pediatric gastroenterology. The role of the dietetic fiber in children is controversial as a cause of the constipation. Objective: To report the dietetic fiber consumption in 22 children of the Hospital Infantil Club Noel (HICN) of Cali. Report of cases: Were included 22 children (3-13 years), both gender, from the HICN of Cali with digestive diagnoses for the first time. A medical clinical history was made, and one interviews nutritional by reminder of 24 hours. Acute undernourishment was defined when the deficit for weight/height (W/H) was >10% and overweight when the excess for W/H was >10%. The chemical analysis of the dietetic fiber was made following the Content of Dietetic Fiber and Resistant Starch in Foods and Latin American Products of the CYTED. The patients were divided according to gender, intestinal habit, signs and symptoms; in children with constipation (n=9) and without constipation (n=13) (p=0.865, 95% IC -6.71 to 7.91). Conclusion: The 22 children of the HICN of Cali, independent of the constipation presence, consume 12.8±7.8 grams of dietetic fiber to the day, an amount that is the recommended one by almost all of the consulted studies.