Cara Mengukur Konstipasi

http://journals.lww.
com/jpgn/Fulltext/1996/10000/Colonic_Transit_Ti
me_in_Constipated_Children__Does.7.aspx
Colonic Transit Time in Constipated Children: Does Pediatric SlowTransit Constipation Exist?
Benninga, M. A.; Bller, H. A.; Tytgat, G. N. J.*; Akkermans, L. M. A.; Bossuyt, P. M.; Taminiau, J. A.
J. M.
Free Access
Article Outline
Author Information
Department of Pediatrics; *Department of Gastroenterology; Department of Surgery, University
Hospital, Utrecht; and Department of Clinical Epidemiology.
Address correspondence and reprint requests to Dr. M. Benninga, Department of Pediatrics,
Academical Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam.
Abstract
Summary: In adults, slow-transit constipation is a wellestablished form of constipation with abdominal
pain and an empty rectum on examination. Marker studies in these patients, mainly women, show a
markedly slowed transit time in all colonic segments. No studies in constipated children are available
that assess the existence of slowtransit constipation. In a prospective study, a total of 94 referred
constipated pediatric patients, 63 boys and 31 girls (median age, 8.0 years), underwent colonictransittime measurements using radioopaque markers to evaluate the pattern of transit. In addition,
orocecal-transittime measurements using the hydrogen breath (lactulose) test, anorectal manometry,
and behavior studies using the Child Behavior Checklist were performed in all children. Based on the
upper limit (mean + 2 SD) of total colonic transit time (CTT) in constipated children, we arbitrarily
separated patients into two groups. Children with CTTs >100 h were said to have pediatric slow-transit
constipation (PSTC), while patients with CTTs <100 h were said to have normal- or delayed-transit
constipation (NDTC). In 94 constipated children, PSTC was found in 24 children; in 70 children, total
CTT was <100 h (NDTC). Total and segmental CTTs were significantly prolonged in PSTC (median,
189 h; range, 104.4-384) versus NDTC (median, 46.8 h; range, 3.6-99.4) hours. No significant
differences were found in orocecal transit time. Significant clinical differences in children with PSTC
versus those with NDTC existed regarding nighttime soiling (71 vs. 11%); daytime soiling episodes
(14 vs. 7 each week, median), and nighttime soiling episodes (5 vs. 0 each week, median); absent
urge to defecate (33 vs. 14%); and palpable abdominal (71 vs. 39%) and/or rectal (71 vs. 13%)
masses. All manometric parameters were comparable in the two groups, except for a significantly
lower maximal squeeze pressure with PSTC. Using the Child Behavior Checklist, both groups differed
significantly from controls (26 and 43%, respectively), with no significant differences in behavior
problems found between the NDTC and the PSTC groups. In conclusion, based on objective marker
studies, our findings suggest the existence of pediatric slow-transit constipation. This entity can be
recognized by clinical features, most importantly nighttime soiling and a palpable rectal mass. The
probability of PSTC with both of these symptoms was 0.82; in the absence of these two symptoms, it
was 0.07. It is of interest that CTTs in PSTC are comparable with CTTs in adults with slow-transit
constipation, although the clinical presentation is clearly different. Further studies are needed to
investigate whether the prolonged CTT characterizes a distinct form of constipation in children or is an
epiphenomenon of the underlying constipation itself. The mechanisms responsible for the slow transit
in these children and the appropriate therapeutic approach need to be studied.
Colonic inertia or idiopathic slow-transit constipation is a syndrome characterized by severe,

longstanding constipation. In adults, this syndrome is almost entirely confined to women of
childbearing age (1-5). With radioopaque marker studies, these patients show a markedly slowed
colonic transit time (CTT) in all colonic segments (2,4,5). It is unknown whether a similar clinical entity
exists in children with constipation. Previous studies in children with idiopathic chronic constipation
showed that retardation of intestinal transit occurred most frequently in the distal colon and rectum,
compatible with an outlet obstruction (6,7). In a prospective study in children with constipation using
radioopaque markers, we investigated the presence of slow colonic transit in children. Based on their
CTTs, we analyzed differences among these patients in clinical symptoms and in orocecal transit time
(OCTT) using the hydrogen breath test, anorectal manometric measurements, and the Child Behavior
Checklist. This is the first study establishing the existence of slow-transit constipation in constipated
children.
Back to Top | Article Outline
PATIENTS AND METHODS

In a 14-month study period (May 1991 to June 1992), a group of otherwise healthy children was
referred to the outpatient clinic of a tertiary academic teaching hospital by school physicians, general
practitioners, pediatricians, and psychiatrists; the children had complaints of constipation with or
without encopresis, encopresis alone, or recurrent abdominal pain. To enter the study, the patients
had to fulfill at least two of the four following criteria of pediatric constipation: (a) two or fewer bowel
movements per week; (b) two or more soiling or encopresis episodes per week; (c) passage of very
large amounts of stool once every 7-30 days; and (d) a palpable abdominal or rectal
mass. Soiling was defined as the loss of loose stools and encopresis as the loss of formed stools. A
palpable rectal mass was defined as the presence of a firm and large fecal lump in the rectal ampulla.
Children with Hirschsprung's disease, spinal and anal anomalies, surgery of the colon, metabolic
diseases, and/or mental retardation and children on drugs other than laxatives were excluded.
Each child underwent a complete workup that included a detailed medical history and a thorough
physical, including digital and rectal examination. In addition, transit time studies, anorectal
manometry, and the Child Behavior Checklist were performed. The study was approved by the
hospital's Medical Ethical Committee. Written informed consent was obtained from patients and/or
their parents.
Healthy controls for the OCTT test and for the anorectal manometry were 39 and 15 healthy children,
respectively. They were recruited from siblings and friends of pediatric patients and of the medical
staff. Informed consent was obtained from the subjects and their parents.
Assessment of OCTT and CTT

Because of poor compliance in children regarding the intake of crude fiber, the measurement of OCTT
and CTT was performed on outpatients taking their normal diet. Any treatment with laxatives was
discontinued at least 4 days prior to the test. No subject had received antibiotics for at least 3 months
prior to the test (8). No enemas were given before the transit studies.
Colonic transit time

Total and segmental analysis of CTTs was done as described previously (9). In short, on 3 consecutive
days at 9:00 a.m., patients ingested a capsule with 20 radioopaque markers. Abdominal x-ray films
were obtained on days 4 and 7 at 9:00 a.m. Additional abdominal x-ray films were obtained on days
10, 13, and by day 16 if >20% of markers was still present. Abdominal x-ray films were obtained using
a high-kilovoltage fast-film technique to reduce radiation exposure (estimated surface exposure, 0.08
mrad per film).
Localization of markers on abdominal films relied on the identification of bony landmarks and gaseous
outlines as described by Arhan et al.(10). Markers were counted in the right, left, and rectosigmoid
regions, and mean segmental transit times were calculated according to a previously described
formula (9,10). The normal range for segmental transit times was based on the upper limits (mean + 2
SD) from a study by Arhan et al. in nonconstipated children (10).
Orocecal Transit Time

The method employed to study OCTT was as described by van der Klei-van Moorsel et al. (11). Studies
were performed after a low-fiber diet the day before and an overnight fast. End-expiratory breath
samples were taken before ingestion of 10 g of lactulose (20 ml of a 50% solution) and at 15-min
intervals thereafter, to a maximum of 240 min (12). At all time points, measurements included two
samples taken 1 min apart. The breath was collected in a 60-ml plastic syringe with a side hole and a
mouthpiece at the tip opening (11). The H2content of the expelled air was measured by the Hoekloos
Lactoscreen (11) and expressed in parts per million (ppm). The OCTT was defined as the period
between oral lactulose intake and a rise in hydrogen excretion to 10 ppm above basal values. The test
was terminated when this rise in hydrogen excretion was sustained for two subsequent time intervals.
H2 nonproducers were defined as children with a peak excess breath H 2 concentration <10 ppm
following lactulose.
Manometry
A five-lumen manometric anal probe of 4.8 mm outer diameter and 0.8 mm inner diameter was used
as described earlier (13). Two side holes spaced 3 cm apart were perfused with sterile water at a rate of
0.5 ml/min by a hydraulic infusion system (Arndorfer) (14). A rectal distending balloon with high
compliance was tied to the tip of the probe, 3 cm above the first side hole. Pressures were measured
by transducers in each perfusion line and connected to PC Polygraf HR preamplifiers (Synectics
Medical). The analog signals from the preamplifier were digitally converted and transmitted via a fiberopticcable to a personal computer.
Maximal anal resting tone and maximal squeeze pressure were measured by stationary pull-through
at a rate of 1 cm/min. The sensory threshold was defined as the smallest reproducible volume of
rectal distension sensed. Critical volume, the minimal amount of air required to produce the sensation
of a persistent (at least 1 min) urge to defecate, was determined by filling the rectal balloon stepwise
in increments of 30 ml at intervals of 30 s. Intraabdominal pressure was defined as the rise of
pressure during a defecation attempt. The defecation dynamicsi.e., the manometric profile obtained
by expelling the rectal balloonwere assessed during at least five simulated defecation trials.
Electromyography
Electrical activity of the external anal sphincter (EAS) was recorded by one reference and two
differential electrodes connected to a bioamplifier II and the PC Polygraf HR. Electrocardiogram
(ECG) pregelled disposable neonatal electrodes overlaying the subcutaneous part of the EAS were
used. The reference electrode was located on a thigh. Defecation dynamics were defined as normal if
integrated electromyography (EMG) of the EAS showed a decrease or no change during expulsion of
the balloon in at least two of five defecation attempts. Defecation dynamics were defined as abnormal
if manometric and myoelectrical increase occurred during bearing down in at least four of five
defecation attempts (15-17). The rectoanal inhibitory reflex was measured in response to balloon
distension to exclude short-segment Hirschsprung's disease. No sedation was used.
Child Behavior Checklist
A parent or parent proxy completed the Child Behavior Checklist (CBCL) (18) within 14 days of the
initial visit. The CBCL is an inventory for parents of children 4-16 years old. Normalized t scores for
the social competence scale, the internalization score, the externalization score, and the total
behavioral score are standardized for age and sex (19). The behavioral ratings were compared with the
behavioral ratings of the CBCL normative sample of nonreferred Dutch children (n = 2,076), all of
whom are profiled by age and sex (19).
Statistical Methods
Data were collected using an integrated patient database. Results were expressed using the median
and the range for continuous variables and percentages for discrete variables. Groups were
compared using the Wilcoxon signed-rank test for continuous variables and the 2 test for discrete
variables; exact p values were calculated for the latter. For all tests, a level of 0.05 was used for
significance. All patient characteristics with p > 0.20 in the univariate analysis were used to construct
a multivariate model to predict pediatric slow-transit constipation (PSTC). In a multivariate model,
differences between groups on a particular variable were assessed conditional on the presence of
other, potentially confounding variables. We retained those variables that discriminated between
PSTC and normal- or delayed-transit constipation (NDTC), using a forward, stepwise inclusion
strategy, with a level of 0.10 for inclusion.
RESULTS
Patients
In the 14-month study period, a total of 156 children was referred to the Pediatric Intestinal Motility
Unit for constipation and/or fecal incontinence and/or recurrent abdominal pain. Based on the
definition of pediatric constipation already defined, 94 children were enrolled in our study. In the 62
children not participating, the sole complaint was encopresis alone (n = 47) or recurrent abdominal
pain (n = 15).
Normal OCTT data were collected, using the breath hydrogen test, in 39 healthy children (5-14 years
old; average, 9.9; 18 boys and 21 girls). Controls for the manometric values came from 15 healthy
children (7-15 years old; average, 11; 10 boys and 5 girls).
Colonic Transit Time

Colonic transit time studies were performed in all constipated children. Based on the upper limit
(mean + 2 SD) of a previous study in 63 constipated children, we arbitrarily labeled patients with total
CTT >100 h as having PSTC (7). Patients with total CTT <100 h were considered to have NDTC; this
group contained patients with normal-transit constipation (<63 h) as well as patients with delayedtransit constipation (63-100 h). Further analysis of the NDTC group after separation into a group with
total CTT <63 h and one with total CTT between 63 and 100 h showed no significant clinical or
manometric differences. Similarly, those children with total CTTs between 63 and 100 h showed the
same significant differences compared with PSTC children as did the total NDTC group, allowing the
merge of these children.
Table 1 shows the transit time values. The median total CTT was 189.0 h (range, 104.4-384) in the
PSTC group and 46.8 h (range, 3.6-99.4) in the NDTC group. Of the 24 patients with PSTC, 13 (54%)
had significant slowing in transit in all segments, four (17%) had significant slowing in the
rectosigmoid only, four (17%) had significant slowing in the right colon and rectosigmoid segment, two
(8%) had significant slowing in the left and rectosigmoid segment, and the remaining one (4%) had
significant slowing in the left and right colonic segments. Of the 70 patients with NDTC, 37 (53%) had
transit within the normal range through all colonic segments; 21 of the remaining children had slowing
of markers in the rectosigmoid, based on the upperlimit values of the Arhan et al. study (20).
Table 1
Image Tools
Personal and Family History

As shown in Table 2, the PSTC group consisted of 24 patients, 17 boys and 7 girls, with a median
age of 8.0 years; the NDTC group consisted of 70 patients, 46 boys and 25 girls, also with a median
age 8.0 years. The 24 PSTC patients were all white. In the NDTC group, 63 children (90%) were
white, six were Asians from Surinam, and one was from Turkey.
Table 2
Image Tools
The age at which parents first recognized a bowel problem was, in the majority of children in both
groups, between 12 and 48 months (Table 2). The median duration of constipation was 56 months in
NDTC and 81 months in PSTC. In both groups, a preponderance of boys was seen. Furthermore,
there was a positive family history of constipation in 39% of patients in the two groups.
Bowel Function
As shown in Table 2, the mean number of bowel movements per week was almost similar in both
groups. Nine patients in the PSTC group and one in the NDTC group never had any normal bowel
movements, but exhibited daily fecal loss (soiling). In both groups, the frequency of loss of formed
stools (encopresis) was comparable. The presence and number of soiling episodes (day and night)
were significantly more frequent among PSTC patients. The periodic passage of a very large amount
of stool every 7-30 days was not significantly different in the two study groups. The consistency of the
stool was described as hard in more than half of the patients in the NDTC group, versus a minority in
the PSTC group. Consequently, pain during defecation was significantly more frequent in NDTC
patients. More than 30% of the PSTC patients never sensed any urge to defecate, versus 14% in the
NDTC group. Bloody stools were rarely observed, being found in only one PSTC patient (4%) and two
NDTC patients (3%).
Anorectal Symptoms and Physical Examination

All patients appeared healthy on physical examination. Abdominal and/or rectal masses were palpable
more often in the PSTC group. On rectal examination, the tone of the internal anal sphincter and
voluntary contraction of the external anal sphincter appeared normal in both groups. Anal fissures
were seen in no PSTC patients and in one NDTC patient; hemorrhoids were seen in no PSTC
patients and three NDTC patients.
Associated Symptoms
Patients in both groups complained of abdominal pain and poor appetite. Day and/or night urinary
incontinence was not significantly different between groups.
Multivariate Analysis
The following eleven variables were used in the multivariate analysis: age of toilet training,
dichotomized at 2.5 years; episodes of soiling during the day, dichotomized at 2; daytime soiling;
nighttime soiling; consistency of stool; pain during defecation; lack of urge to defecate; palpable
abdominal mass; palpable rectal mass; abdominal pain; and poor appetite. These variables were
used in the stepwise construction of a logistic-regression equation, taking slow-transit constipation, as
defined earlier, as the dependent variable. The following five variables were retained in the final
equation (Table 3): palpable rectal mass, nighttime soiling, poor appetite, abdominal pain, and pain
during defecation. Obviously, a rectal palpable mass and nighttime soiling are the most objective of
these variables. The proportions of children with PSTC and with a rectal palpable mass, nighttime
soiling, or both were 0.34, 0.39, and 0.82, respectively. Only 7% of the children without any of these
characteristics had PSTC.
Table 3
Image Tools
Onset of Constipation
Table 4 lists the events occurring at the onset of constipation as mentioned by the parents. No
obvious cause of constipation was found in the majority of patients.
Table 4
Image Tools
Treatment
No significant effect was observed by the parents when fiber content or fluid intake was changed in
these children. In the PSTC and NDTC groups, 75 and 56% of the patients, respectively, used
laxatives with inadequate results for long periods of time (mean, 3.7 years; range, 0.5-11), including
lactulose, mineral oil, and stimulant laxatives given by mouth or by enema. Withholding laxatives led
in all cases to an aggravation of constipation. Additional psychiatric treatment was given to 30% of the
children in each group. In the PSTC and NDTC groups, 6 (25%) and 31 (44%) patients, respectively,
were never treated for constipation.
Anorectal Manometry
In 26 children (17 with PSTC, 9 with NDTC) with enormous fecal retention, disimpaction with enemas
was performed daily during the week prior to manometry to assure that the rectal ampulla was free of
fecal material. The remaining patients required no enemas before manometry. Table 5 shows that all
manometric parameters were comparable between the two patient groups, except for a significantly
lower maximal squeeze pressure (p = 0.05) in PSTC children. The two patient groups required
significantly larger balloon volumes to provoke a rectal sensation (p = 0.02 and p = 0.03, respectively)
and to produce a rectoanal inhibitory reflex (p = 0.003 and p = 0.02, respectively) than did control
children. The defecation dynamics were abnormali.e., contraction instead of relaxation of the
external anal sphincter during defecation attempts in 67 and 60% of children with PSTC and NDTC,
respectivelyand were significantly different from those of controls (p < 0.001). All children exhibited
a rectoanal inhibitory reflex on balloon distension.
Table 5
Image Tools
Megarectum was considered when both the sensory threshold and critical volume exceeded upper
limit values (mean + 2 SD) of healthy controls (42 and 196 ml, respectively). Megarectum was found
in seven children (29%) with PSTC and eight children (11%) with NDTC; a rectal mass was palpable
in four of the children with PSTC and in one child with NDTC. Four children with PSTC with
megarectum had significantly slowed transit in all segments, one had a significant slowing in the
rectosigmoid only, one child had slowing of markers in the right colon and rectosigmoid area, and the
remaining one had a delay of transit in the left colon and rectosigmoid segment. In the NDTC group,
three patients had transit within the normal range through all colonic segments, four had slowing of
markers in the rectosigmoid, and one had slowed segmental transit in the left colon.
Orocecal Transit Time

The median OCTT in PSTC, NDTC, and controls was 52 min (range, 30-135), 60 min (range, 30-180),
and 60 min (range, 30-120), respectively. No significant difference in OCTT among the three groups
was found. Only one child (4%) in the PSTC group and four children (6%) in the NDTC group were
classified as H2 nonproducers, with breath H2 peaks <10 ppm above baseline values throughout the
3-h test. All healthy controls were H2 producers with breath H2 peaks of >10 ppm above baseline
values.
Child Behavior Checklist

On the Child Behavior Checklist, 26% of children with PSTC and 43% of children with NDTC had
scores in the clinical range for behavior problems. In both groups, the scores for behavior problems
differed significantly (p < 0.01) from the 10% abnormal clinical range found in healthy children. There
was no significant difference in clinical range for behavior problems between the PSTC and NDTC
groups.
DISCUSSION
Measuring colonic transit time with markers is a noninvasive and simple method with which to
document or confirm complaints of infrequent defecation. Different methods using radioopaque
markers have been described to assess total CTT (stool radiography) and/or segmental CTT
(abdominal radiography at different time points) (9,10,20-23). In adults, various patterns of prolonged colonic
transit have been identified (2,4,5). Consequently, slowing of markers can point to colonic dysfunction in
distinctive segments, as in right colonic stasis, hindgut dysfunction, outlet obstruction, and colonic
inertia or idiopathic slow-transit constipation (3,5,23,24). In adults, no clear limits have been agreed on to
define slow-transit constipation. Some authors named a marked decrease in transit of radioopaque
markers in all colonic segments colonic inertia, which is almost only found in young women (2-5). Only
Wald et al. divided adult constipated patients into those with normal transit (<70 h) and those with
slow transit (>70 h)(25).
Very few studies describing CTT have been performed in children. The studies of Arhan et al. (10) and
Bautista Casasnovas et al. (26) in healthy nonconstipated children found total CTTs of 29 4 h and
37.8 6.2 h, respectively. In constipated children, however, longer total CTTs, with a maximum of
100 h, were observed than in healthy children (7). It was suggested that slowing occurred mainly at the
level of the rectosigmoid, which was termed outlet obstruction (2,6,7). One study described segmental
CTT in constipated children with a mean total CTT of 60 h; in 5.4% of the constipated children, there
was a delay of markers in all segments (6).
Although no limits have been put forward in children, the 100-h cut-off proposed for pediatric slow
transit in this study was based on the upper limit of total CTT in constipated children as described by
Corazziari et al. (60.7 18.5) (7). This cut-off results in a clear separation of children with PSTC, who
have, on average, almost three times the total and segmental CTT of children with NDTC. In the
PSTC group, 54% showed significantly prolonged transit in all colonic segments, or colonic inertia.
The extremely long transit was due primarily to significant slowing in the rectosigmoid in only 17% of
children with PSTC. In the remaining patients, a significant decrease in transit occurred in at least two
of the three large bowel segments. Interestingly, total CTTs in adults with colonic inertia are
comparable with those in children with PSTC (5). However, a study evaluating the effect of fecal
disimpaction is necessary in children with prolonged CTTs to either confirm the existence of a distinct
form of pediatric slow constipation or prove that prolonged CTT is due to mechanical obstruction by
enormous fecal impaction in the distal colon. In the majority of children in the NDTC group (53%),
transit times within normal limits occurred in all colonic segments. In two thirds of the remaining
patients, slowing of markers occurred in the rectosigmoid, suggesting the presence of an outlet
obstruction. This latter finding corroborates the finding of outlet obstruction in several studies in
constipated adults and children (2,5-7).
Since it was not considered ethical to use barium enemas to evaluate the existence of megarectum in
children, we relied on anorectal manometry for this diagnosis (27-29), although there is some debate
regarding the solitary use of this technique in the diagnosis of megarectum. Verduron et al.
considered adult patients with maximal tolerable volumes exceeding the upper-limit values of controls
(320 ml for women, 440 ml for men) to have megarectum (30). However, no clear limits are available for
megarectum in pediatric literature. Therefore, we consider megarectum in children to be present when
patients have values of both the first conscious rectal sensation (sensory threshold) and maximal
tolerable volume (critical volume) exceeding the upper-limit values of healthy controls. In both of our
patient groups, megarectum was demonstrated in a minority of patients and was not associated with
distinctively recognizable clinical symptoms or colonic transit patterns, as shown in adults (30). These
results are different from those of earlier studies by Clayden, which suggested that a high percentage
of chronically constipated children have megarectum (31). In addition, a palpable rectal mass was
found in 30% of all children with megarectum, but the mass was not related to isolated prolonged
rectosigmoid transit time with normal right and left colon transit; this correlation was observed in only
one patient. In the PSTC group, more than half of the patients with megarectum demonstrated a
significant slowing of markers through all segments, or colonic inertia. In two patients with
megarectum, there was evidence of outlet obstruction. In contrast to these findings in children,
Verduron et al. stated that megarectum is always associated with an outlet obstruction in adults (30).
Despite its radiological exposure, we believe that the simplified Metcalf marker method is essential to
appraise constipation in children. Sometimes, however, although there are complaints of infrequent
defecation, marker studies are normal. Wald suggested psychosocial disturbances in adults with
similar findings; however, no similar studies in children are yet available (5).
This is the first study describing children with severe prolonged CTT, and it is not clear why this
phenomenon has not been previously identified. Slow-transit constipation in adults is almost
exclusively confined to young white women, whereas constipation and/or encopresis in children, as in
this study, is predominantly found in boys (3,4,32,33). A longer follow-up of these children is needed to
substantiate whether only the girls continue to have slow-transit constipation. In both groups, similar
ages at onset of symptoms were found, contradicting the suggestion that PSTC itself is the result of
constitutional or long-standing constipation (34). It is noteworthy, however, that one third of the patients
in both groups exhibited complaints before the end of the first year. Similar findings were reported by
Arhan et al., with the age of onset in 40% of constipated children in the first months of life (6).
On multivariate analysis, the three most important clinical features of PSTC are soiling, particularly at
night, poor appetite, and a palpable rectal mass. This fecaloma stretches the rectal wall and lowers or
even abolishes rectal sensitivity; 33% of the children with PSTC never sensed any urge to defecate.
The decreased sensitivity interferes with the conscious contraction of the external sphincter on
relaxation of the internal sphincter (35,36) and most likely causes the constant loss of mucus and liquid
feces. Although an important decrease in rectosigmoid motility occurs during sleep, minimizing the
loss of feces during the night in constipated children, the enormous rectal impaction in children with
PSTC, which is clearly more extreme than in children with NDTC, still induces frequent nighttime
soiling (37). In our experience, children with PSTC, in contrast to the majority of children with NDTC,
initially receive great relief of symptoms, especially soiling, from removal of the fecal impaction by
enemas.
Further analysis of soiling in the PSTC group revealed a constant loss of fecal material not only during
the night but also during the day. In the NDTC group, daytime soiling occurred, on average, five times
a week. In the PSTC group, this occurred 14 times a week and clearly interfered with school and other
social activities. Soiling is embarrassing in children and often leads to a physician being consulted.
Interestingly, encopresis, the loss of formed stools, is relatively rare, and its occurrence was not
significantly different between the two groupsmost likely because encopresis is more related to a
(conscious or unconscious) denial of control of defecation.
Surprisingly, on multivariate analysis, abdominal pain and pain during defecation were more
associated with NDTC. The pain during defecation is probably the result of more hard and solid stools
in children with NDTC, while the stools in children with PSTC are more clay-like and easier to pass.
The clinical presentation in adult slow-transit constipation differs from that in PSTC. Adults with slowtransit constipation pass about one stool weekly with the help of laxatives, and they are often greatly
troubled by abdominal pain, bloating, malaise, and nausea. Fecal incontinence, one of the important
features of constipation in children, is not described in adult slow-transit constipation, but it does occur
in adults with constipation and megacolon or megarectum (30,38,39). Other symptoms are urinary
incontinence, hesitancy, nocturia, and poor bladder emptying. Furthermore, women with slowtransit
constipation tend to have irregular painful menstruation and to have painful breasts and
galactorrhoea. On rectal examination an empty rectum is often found. In addition, adults with slowtransit constipation show on barium enema films a rectum of normal diameter and area and a colon of
normal diameter (40). We do not know if children with PSTC have a normal colon, since we did not
perform barium enema studies, since they pose an unethical radiation exposure in children. In adult
cases, decreased bowel movements and other symptoms are often first noticed around puberty and
slowly worsen; they are severe by the third decade.
In the majority of patients the cause of constipation is unknown; in contrast to general beliefs,
constipation is not due to failed toileting, change of schools, or birth of siblings. Sexual abuse has
been suggested as an important cause of constipation in adults (41). We did not find this in children,
although reliable information is often very difficult to obtain.
No significant differences were found in OCTT (using liquid lactulose) in children with PSTC or NDTC
or controls, suggesting no etiological role of the small bowel in the constipated children. However,
Vajro et al. showed differences in OCTT with lactulose in a liquid form versus OCTT with a standard
meal (42). Studies in adults suggested an accelerating effect of liquid lactulose due to an
unphysiological stimulation of peristalsis by the osmotic load of the unabsorbed disaccharide (43). This
stimulus of transit might explain the observed normal OCTT in constipated children in this study. The
importance of an enlarged rectum in small bowel transit is a matter of debate. Our study has shown
that patients with palpable rectal masses had no significant increased OCTT compared with those
with an empty rectum (data not shown). In contrast, Youle and Read found that prolonged intermittent
balloon distension of the rectum in healthy adults decreased small bowel transit (44). On the other
hand, Bannister et al. found a significant prolongation of small bowel transit time, irrespective of a full
or empty rectum, in young women with slow-transit constipation (45).
Manometric analysis revealed no difference in maximal anal resting tone between the two patient
groups and healthy controls. Maximal squeeze pressure in patients with NDTC was comparable with
earlier findings in similar patients and lower but not significantly different than in controls (46,47).
However, maximal squeeze pressure was significantly lower in PSTC patients than in NDTC patients
and controls and was most likely the result of the fecaloma. In accordance with other studies in
constipated children and adults, a higher volume was required in both groups to produce rectal
sensation and to elicit a rectoanal inhibitory reflex (48-53). The observed differences between PSTC and
NDTC in threshold of sensation and rectoanal inhibitory reflex were caused by the increased stretch
of the rectal wall in the PSTC children. Interestingly, high percentages of children in the PSTC and
NDTC groups, 67 and 60%, respectively, showed abnormal defecation dynamics; they closed the anal
canal by contracting rather than relaxing the external anal sphincter, puborectalis, and pelvic floor
muscles during defecation attempts. This finding confirms other studies in constipated children and
adults and underscores the possible etiological role of abnormal dynamics in constipation (15,53-55).
Therefore, the abnormal dynamics are now the subject of a large prospective randomized trial to
establish the therapeutic effect of biofeedback training in these children.
Using the CBCL, we found a significantly higher incidence of behavior problems in both groups than in
healthy normal children. These findings confirm the studies of Loening Baucke et al. (56) and Wald et
al. (15), who found behavior problems in 50 and 45% of children, respectively, with constipation and
encopresis. However, it needs to be confirmed whether long-standing constipation leads to behavioral
problems or vice versa.
In conclusion, on the basis of these results it seems appropriate to suggest the existence of pediatric
slow-transit constipation. Although, even in adults, no clear limits have been agreed on, we propose to
define PSTC only after using marker studies showing total CTTs >100 h. However, the measurement
of CTT using marker studies is only useful in complicated or unclear cases of constipation or
encopresis(57). Therefore, the marker method should be performed if initial dietary and laxative therapy
fails and in cases were the patient information is not reliable. In the majority of constipated children, a
good history including a stool diary and clinical examination is sufficient to distinguish between severe
long-standing constipation and milder forms. It is obvious that slow-transit constipation in children is
clinically different from slow-transit constipation in adults. It is, however, unclear if the pediatric
presentation evolves into the more clearly defined adult form. On clinical grounds, PSTC can be
expected in children with constipation who complain of nighttime soiling and who have an impressive
fecaloma on rectal examination with a probability of 0.82. Nighttime soiling is an important feature of
PSTC and should not only lead to consultation with a psychiatrist, as happened with many patients in
this study. The cause of the extremely slow transit is unknown. Only hypotheses can be put forward
regarding its etiology, such as congenital or acquired infection or motility disturbances. In the absence
of a causative factor, treatment is symptomatic. Many children with PSTC are initially relieved of
symptoms by removal of the fecaloma using enemas. However, further studies are needed to firmly
establish the existence of slow-transit constipation in children and to exclude the influence of
mechanical obstruction by scybala.
One study is currently being performed in our institution. Future studies should also examine whether
this is an isolated type of constipation, with its own definition, or merely a severe end of the
constipation spectrum. Furthermore, it should established whether children with PSTC require
different therapeutic regimens than children with normal- or delayed-transit constipation.
Acknowledgment: We are grateful to G. W. Akkerhuis of the Department of Child Psychiatry for
analysis of the Child Behavior Checklist. The study was financially supported by a major grant from
the Stichting Kinderpostzegels Nederland and from an endowment from Zyma Nederland (Importal).
REFERENCES
1. Lane WA. Chronic intestinal stasis. Br Med J 1909;1:1408-11.
Cited Here...
2. Martelli H, Devroede G, Arhan P, Duguay C. Mechanisms of idiopathic constipation: outlet
obstruction. Gastroenterology 1978;75:623-31.
Cited Here... | PubMed

3. Watier A, Devroede G, Duranceau A, et al. Constipation with colonic inertia: a manifestation of
systemic disease? Dig Dis Sci 1983;28:1025-33.
Cited Here... | PubMed | CrossRef
4. Preston DM, Lennard-Jones JE. Severe chronic constipation of young women: idiopathic slow
transit constipation. Gut 1986;27:41-8.
5. Wald A. Colonic transit and anorectal manometry in chronic idiopathic constipation. Arch Intern
Med1986;146:1713-6.
6. Arhan P, Devroede G, Jehannin B, et al. Idiopathic disorders of fecal continence in
children.Pediatrics 1983;71:774-9.
7. Corazziari E, Cucchiara S, Staiano A, et al. Gastrointestinal transit time, frequency of defecation,
and anorectal manometry in healthy and constipated children. J Pediatr 1985;106:379-82.
8. Gilat T, Ben Hur H, Gelman-Malachi E, Terdiman R, Peled Y. Alterations of the colonic flora and
their effect on the hydrogen breath test. Gut 1978;19:602-5.
9. Metcalf AM, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG. Simplified assessment
of segmental colonic transit. Gastroenterology 1987;92:40-7.
10. Arhan P, Devroede G, Jehannin B, et al. Segmental colonic transit time. Dis Colon
Rectum1981;24:625-9.
Cited Here... | View Full Text | PubMed | CrossRef
11. van der Klei-van Moorsel JM, Douwes AC, van Oeveren JP. New principle for estimation of
hydrogen in expired air. Eur J Pediatr 1984;141:221-4.
Cited Here...
12. Metz G, Gassull MA, Leeds AR, Blendis LM, Jenkins DJA. A simple method of measuring breath
hydrogen in carbohydrate malabsorption by end-expiratory sampling. Clin Sci Mol Med 1975;85:54655.
Cited Here...
13. Benninga MA, Wijers OB, vd Hoeven CWP, et al. Manometry, profilometry and endosonography:
normal physiology and anatomy of the anal canal in healthy children. J Pediatr Gastroenterol
Nutr1994;18:68-77.
14. Arndorfer RC, Steff JJ, Dodds WJ, Linehan JH, Hogan WJ. Improved infusion system for
intraluminal esophageal manometry. Gastroenterology 1977;73:23-7.
15. Wald A, Chandra R, Chiponis D, Gabel S. Anorectal function and continence mechanisms in
childhood encopresis. J Pediatr Gastroenterol Nutr 1986;5:346-51.
16. Loening Baucke VA, Anuras S. Anorectal manometry in healthy elderly subjects. J Am Geriatr
Soc1984;32:636-9.
17. Buser WD, Miner PB Jr. Delayed rectal sensation with fecal
incontinence. Gastroenterology1986;91:1186-91.
18. Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and Revised Child Behavior
Profile. Burlington, Vt: University of Vermont, Department of Child and Adolescent Psychiatry, 1983.
Cited Here...
19. Verhulst FC. Mental health in Dutch children [Thesis]. Rotterdam, 1985.
Cited Here...
20. Cummings JH, Wiggins HS. Transit through the gut measured by analysis of a single
stool. Gut1976;17:219-23.
21. Hinton JM, Lennard-Jones JE, Young AC. A new method for studying gut transit times using
radiopaque markers. Gut 1969;10:842-7.
Cited Here...
22. Martelli H, Devroede G, Arhan P, Duguay C, Dornic C, Faverdin C. Some parameters of large
bowel motility in normal man. Gastroenterology 1978;75:612-8.
23. Chaussaude S, Khyari A, Roche H, et al. Determination of total and segmental colonic transit time
in constipated patients. Dig Dis Sci 1989;34:1168-72.
Cited Here...
24. Ducrotte P, Rodomanska B, Weber J, et al. Colonic transit time of radiopaque markers and
rectoanal manometry in patients complaining of constipation. Dis Colon Rectum 1986;29:630-4.
25. Wald A, Hinds JP, Caruana J. Psychological and physiological characteristics of patients with
severe idiopathic constipation. Gastroenterology 1989;97:932-7.
26. Bautista Casasnovas A, Varela Cives R, Villanueva J, Castro-Gago M, Cadranel S, Tojo Sierra R.
Measurement of colonic transit time in children. J Pediatr Gastroenterol Nutr 1991;13:42-5.
27. Patriquin H, Martelli H, Devroede G. Barium enema in chronic constipation: is it meaningful?
Gastroenterology 1978;75:619-22.
28. Meunier P, Louis D, Jaubert de Beaujeu M. Physiologic investigation of primary chronic
constipation in children: comparison with the barium enema study. Gastroenterology 1984;87:1351-7.
29. Clayden GS. Is constipation in childhood a neurodevelopmental abnormality? In: Milla PJ,
ed.Disorders of gastrointestinal motility in childhood. Chichester: Wiley, 1988.
Cited Here...
30. Verduron A, Devroede G, Bouchoucha M, et al. Megarectum. Dig Dis Sci 1988;33:1164-74.
31. Clayden GS. Management of chronic constipation. Arch Dis Child 1992;67:340-4.
32. Davidson M, Kugler MM, Bauer CH. Diagnosis and management in children with severe and
protracted constipation and obstipation. J Pediatr 1963;62:261-75.
33. Hatch TF. Encopresis and constipation in children. Pediatr Clin North Am 1988;35:257-80.
34. Pettei MJ, Davidson M. Idiopathic constipation. In: Walker, Durie, Hamilton, et al., eds. Pediatric
Gastrointestinal diseases. Decker, 1991:818-29.
Cited Here...
35. Meunier P, Mollard P, Marechal JM. Physiopathology of megarectum: the association of
megarectum with encopresis. Gut 1976;17:224-7.
36. Read NW, Abouzekry L. Why do patients with fecal impaction have fecal
incontinence. Gut1986;27:283-7.
37. Davidson M, Sleisenger MH, Almy TP, Levine SZ. Studies of distal colonic motility in children. I.
Non-propulsive patterns in normal children. Pediatrics 1956;17:807-19.
38. Lane RHS, Todd IP. Idiopathic megacolon: a review of 42 cases. Br J Surg 1977;64:305-10.
39. Barnes PRH, Lennard-Jones JE, Hawley PR, Todd IP. Hirschsprung's disease and idiopathic
megacolon in adults and adolescents. Gut 1986;27:534-41.
Cited Here...
40. Preston DM, Lennard-Jones JE, Thomas BM. Towards a radiologic definition of idiopathic
megacolon. Gastrointest Radiol 1985;10:167-9.
41. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with
functional or organic gastrointestinal disorders. Ann Intern Med 1990;113:828-33.
42. Vajro P, Silano G, Longo D, Staiano A, Fontanella A. Orocecal transit time in healthy and
constipated children. Acta Paediatr Scand 1988;77:583-6.
43. Armbrecht U, Jensen J, Eden S, Stockbrgger R. Assessment of orocoecal transit time by means
of a Hydrogen (H2) breath test as compared with a radiologic control method. Scand J
Gastroenterol1986;21:669-77.
Cited Here...
44. Youle MS, Read NW. Effects of painless rectal distention on gastrointestinal transit of a solid
meal.Dig Dis Sci 1984;29:902-6.
45. Bannister JJ, Timms JM, Barfield L, Read NW. Physiological studies in young women with chronic
constipation. Int J Color Dis 1986.
Cited Here...
46. Benninga MA, Bller HA, Taminiau JAJM. Biofeedback training in chronic constipation. Arch Dis
Child 1993;68:126-9.
47. Loening Baucke VA. Abnormal rectoanal function in children recovered from chronic constipation
and encopresis. Gastroenterology 1984;87:1299-304.
48. Molnar D, Taitz LS, Urwin OM, Wales JKH. Anorectal manometry results in defecation
disorders.Arch Dis Child 1983;58:257-61.
49. Meunier P, Marechal JM, de Beaujeu J. Rectoanal pressures and rectal sensivity studies in
chronic childhood constipation. Gastroenterology 1979;77:330-6.
50. Shouler P, Keighley MRB. Changes in colorectal function in severe idiopathic chronic
constipation.Gastroenterology 1986;90:414-20.
51. Read NW, Timms JM, Barfield LJ, Donelly TC, Bannister JJ. Impairment of defecation in young
women with severe constipation. Gastroenterology 1986;90:53-60.
52. De Medici A, Badiali D, Corraziari E, Bausano G, Anzini F. Rectal sensitivity in chronic
constipation. Dig Dis Sci 1989;34:747-53.
53. Loening Baucke VA, Cruikshank BM. Abnormal defecation dynamics in chronically constipated
children with encopresis. J Pediatr 1986;108:562-6.
54. Preston DM. Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci 1985;30:413-8.
55. Turnbull GK, Lennard-Jones, Bartram CI. Failure of rectal expulsion as a cause of constipation:
why fiber and laxatives sometimes fail. Lancet 1986;1:767-9.
56. Loening Baucke VA, Cruikshank B, Savage C. Defecation and behavior profiles in encopretic
children. Pediatrics 1987;80:672-9.
57. Benninga MA, Bller HA, Staalman CR, et al. Defecation disorders in children, colonic transit time
versus the Barrscore. Eur J Pediatr 1995;154:277-84.
Cited Here...
Cited By:
This article has been cited 61 time(s).
Pediatric Surgery International
Functional constipation in children: the pediatric surgeon's perspective

Wester, T
Pediatric Surgery International, 29(9): 883-887.

10.1007/s00383-013-3354-0
CrossRef
Brazilian Journal of Medical and Biological Research
Gastric emptying of water in children with severe functional fecal retention

Fernandes, VPI; Lima, MCL; Camargo, EE; Collares, EF; Bustorff-Silva, JM; Lomazi, EA
Brazilian Journal of Medical and Biological Research, 46(3): 293-298.
10.1590/1414-431X20132448
CrossRef
Journal of Urology
Management of Functional Constipation in Children with Lower Urinary Tract Symptoms:

Report from the Standardization Committee of the International Children's Continence
Society
Burgers, RE; Mugie, SM; Chase, J; Cooper, CS; von Gontard, A; Rittig, CS; Homsy, Y; Bauer, SB;
Benninga, MA
Journal of Urology, 190(1): 29-36.
10.1016/j.juro.2013.01.001
CrossRef
Journal of Pediatric Surgery
Colonic manometry via appendicostomy shows reduced frequency, amplitude, and

length of propagating sequences in children with slow-transit constipation
Stanton, MP; Hutson, JM; Simpson, D; Oliver, MR; Southwell, BR; Dinning, P; Cook, I; Catto-Smith,
AG
Journal of Pediatric Surgery, 40(7): 1138-1145.
10.1016/j.jpedsurg.2005.03.047
CrossRef
J

Cara Mengukur Konstipasi

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Cara Mengukur Konstipasi

Caricato da

Copyright:

Formati disponibili

http://journals.lww.

Colonic inertia or idiopathic slow-transit constipation is a syndrome characterized by severe,

PATIENTS AND METHODS

Assessment of OCTT and CTT

Colonic transit time

Orocecal Transit Time

Child Behavior Checklist

Colonic Transit Time

Personal and Family History

Anorectal Symptoms and Physical Examination

Orocecal Transit Time

Child Behavior Checklist

Cited Here... | PubMed

Functional constipation in children: the pediatric surgeon's perspective

Pediatric Surgery International, 29(9): 883-887.

Gastric emptying of water in children with severe functional fecal retention

Management of Functional Constipation in Children with Lower Urinary Tract Symptoms:

Colonic manometry via appendicostomy shows reduced frequency, amplitude, and

Potrebbero piacerti anche