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The Peña Colorectal Center answers frequently asked questions from patients and parents.
Answer: We believe not all children with constipation and anorectal malformation should be evaluated with motility tests.
Evaluation of colonic motility, sometimes using contrast enemas, rectal manometry, and colonic manometry, is not very accurate. For contrast enemas, patients are given an enema with a contrast material.Most children with anorectal malformations suffer from an abnormal colonic motility / movement of the colon. In fact, the overwhelming majority of patients suffer from slow motility / hypomotility, which translates into constipation. This is an incurable but manageable condition. Evaluation of motility only confirms the colon moves too slowly, but it does not help treat the condition. Therefore, we believe not all children with constipation and anorectal malformation should be evaluated with motility tests.
In addition, she doesn't expel her stools all the way out of her anus. She does not require special foods and we make sure that she has a very balanced diet. What can we do to "even out" the frequency of her bowel movements?
Answer: What you describe is a problem of constipation. Even when your daughter has many bowel movements in a day, she is still constipated because she does not empty her rectum completely. Give her foods you know have a laxative effect. If that is still not enough to help her empty her rectum completely, try a laxative. Keep her on a diet of three meals a day and maintain her diet, as regulated as possible, to try to decrease the number of bowel movements.If she does not respond to these measures, she will need an evaluation with an X-ray film and more aggressive treatment. Untreated constipation can lead to a dilated colon, which leads to more constipation, creating a vicious cycle. Eventually this can result in pseudo incontinence.
My daughter was born in 1982 with a high imperforate anus. She had a colostomy from her birth to 1984, when she had surgery to establish continuity of the anus. The surgery had no effect on her continence, and when she was 12 years old, the repair of the anus failed because it was made without a colostomy.Six months later, the last attempt at repair was not very successful, and she is still incontinent. She is having difficulty coping with the situation, does not want enemas, and has asked us to seek intervention.Graciloplasty with electrical stimulation has been proposed. What are the chances of success for this procedure, and has it been used successfully on people who have imperforate anus and several attempts at repair?
Answer: The concept of "high imperforate anus" in a female is a conflicting, controversial one. The great majority of female patients classified as having "high imperforate anus" in the past, in reality, suffered from a persistent cloaca. The urethra, vagina and rectum were fused together, opening in a single orifice in the perineum.Often, the rectal part was repaired, leaving the patient with a common opening for the vagina and urethra together. In such cases, the patients remained asymptomatic until puberty, when it became obvious that the vagina was still attached to the urethra and the patient needed another operation. Your daughter needs an examination under anesthesia to rule out that condition. Otherwise, there is no explanation for such a diagnosis as "high imperforate anus."Graciloplasty is an old operation and uses a long thigh muscle called the gracilis to surround the lower rectum. The patient is trained to try to contract that muscle to simulate the function of a new sphincter. That operation was abandoned because it didn't usually work.Recently, the procedure has been revived by a number of surgeons who believe that by connecting an electrical current to that new sphincter, it may develop a tone that will be able to prevent fecal incontinence. That procedure is known as dynamic graciloplasty.Skepticism remains, however, about the results of that treatment. First, the results presented by authors still report a significant number of patients in which the procedure doesn't work. Second, the long-term effects of such operations remain unknown. Patients undergoing this operation have a foreign body (electrical device), which can cause problems later in life.Keep in mind that bowel control depends on three factors:
Dynamic graciloplasty only addresses the sphincter problem, but not the other two conditions. If a patient has no sensation, a sphincter is usually useless. More important, perhaps, is the fact that there are two types of patients who suffer from fecal incontinence:
Creating a new functional sphincter without identifying the type of incontinence that the patient has, may have severe secondary effects. In a patient who suffers from constipation, the activation of the sphincter may hold the stool inside the rectum, but the deactivation (relaxation) of the sphincter doesn't mean that the patient will be able to empty the rectum and the patient may need an enema to empty the rectum. Using enemas, however, can keep patients completely clean without the need of a new sphincter.All these reasons argue for remaining cautiously skeptical about the results of graciloplasty.
The procedure has provided him with a wonderful quality of life. The irrigation is done with 1,000 milliliters of saline water and one pediatric Fleet" enema, which normally takes 20 minutes, and then he sits on the toilet for an hour until he is cleaned out.The problem is that sometimes the 1,000 milliliters with enema does not come out for hours, and he has horrible stomach cramps and throws up. Last week we had to go to the emergency room after the water did not come out for 36 hours, and his pain was unbearable. It did make its way through, finally. He had X-rays and barium enemas to see if there was a blockage or any other problems. There were none.We tried regulating his diet with bran and other laxative foods, but this made this situation worse. Our doctors say they have no idea why this is happening as everything looks fine. Is there any advice you can give us to help us to get the water through him quickly? We find if we do it faster than 20 minutes it just creates more cramping and does not solve the problem. We have tried adding mineral oil enemas with the regular enemas and I do not see a big improvement.
Answer: The Malone procedure only provides a different route for administration of the enema. Your main problem seems to be bowel management. When we implement the bowel management program, we do it over a period of one week by trial and error, seeing the patient and taking X-ray films every day.If you give an enema through the Malone orifice and the rectosigmoid is impacted (which may or may not be the case of your son), it is expected that the patient will have cramps and will not be able to evacuate. It is important first to remove the impaction in the colon, since the bowel management should start with a clean colon. The enema should only remove the amount of stool that has been produced for 24 hours.We cannot answer your question because we do not have enough information. When we implement the bowel management program, we see the patient everyday and also take an abdominal film, which we consider indispensable to interpret correctly the symptoms of the patient. The X-ray film will tell us if you are giving an enema to a child with a fecal impaction. In such case, we will indicate a program of disimpaction prior to the implementation of the bowel management program. On the other hand, the abdominal film may show an empty colon; in such case, we must consider the possibility of the enema producing an irritation of the colon. Our specific suggestion is to go through the entire bowel management all over again, to try to figure out the best way to keep your son clean, without inflicting pain.
Should we expect that our son will always need laxatives or will he eventually be able to do without them? Is there a typical age where they aren't needed? In my son's case, what part of his 60 percent chance of continence includes taking laxatives the rest of his life?
Answer: Most patients who need laxatives will need them for many years, although some patients, for reasons not clearly understood, may have less need for laxatives as time goes by. Perhaps these patients become sensitive to certain kinds of food and the patients themselves or family members learn what foods work, avoiding the need for laxatives.
The majority of patients, however, need higher and higher amounts of laxatives as time goes by. After all, a laxative is a stimulant medication and physiology studies show that when you take a stimulant, you will need higher and higher amounts to keep the stimulant working.
Laxatives are used because better alternatives are not available. The consequences of not taking a laxative when indicated are much worse than any potential secondary effects of the long-term use of laxatives.
A patient like your son, born with a rectoprostatic fistula type of defect, has a 60 percent chance of having voluntary bowel movements. However, if he suffers from constipation and does not receive adequate treatment (laxatives), the 60 percent chance may become 0 percent because he will suffer from fecal impaction and overflow pseudo-incontinence.
For example, given that the goal is one bowel movement a day, how do you achieve this with diet? In general, is it better to try to control the diet to manage his bowel movements, or just feed him like the rest of the family and add more prunes, sorbitol, or other laxatives?
Answer: There are very few tips to offer with regard to timing, quantity or combinations of food laxatives. Some foods do have a tendency to produce laxative effects, while others tend to have a constipating effect.
Most important, however, is what works for the individual. You will become the expert on your own child and will know exactly what type of food will provoke a laxative effect and how many hours after the ingestion of that particular type of food the effect will occur. It is a long process of trial and error.
The goal, as you mentioned, is to provoke one or two big bowel movements each day and nothing in between. Sometimes this is impossible to achieve. You have a better chance to achieve that goal if you give three meals per day and no snacks.
Every time we eat something, we produce a gastrocolic reflex, meaning that the colon moves. Therefore, try to give only three meals of the same quality and preferably at the same time of the day, every day.
We recommend that laxatives be given at a single, specific time every day. Again, those are our general recommendations. You have to learn about the individual way your child responds.
Constipation should usually be managed by giving laxative food and laxative medication, if necessary, and let the child otherwise eat freely. Put on the table what you know is laxative but don't try to make your child eat something. Let him eat whatever he wants from a variety of laxative foods and then give medication if that food is not enough.
Below is a very general list of laxative and constipating types of foods. Keep in mind, however, that every patient responds in a very different way.
Milk and dairy meals
Broiled or boiled meat (chicken, beef, fish
Answer: Milk and fats generally produce a laxative effect, but in some patients produce the opposite effect.
Answer: A sigmoid resection is indicated to reduce the amount of laxatives and sometimes to eliminate the use of laxatives, but is only recommended in patients who have demonstrated bowel control. Keep in mind it is much more difficult to treat a patient with fecal incontinence and diarrhea than fecal incontinence and constipation.
Removing the sigmoid in a patient who suffers from fecal incontinence, without the ability to have voluntary bowel movements, would be a mistake.
Patients suffering from fecal incontinence are subjected to our bowel management program, which keeps them clean and makes them socially accepted.
Removing the sigmoid colon in such patient could result in incapacity to form solid stool (diarrhea). The implementation of our bowel management program is much more difficult in a patient suffering from diarrhea.
Answer: The dosage of laxatives varies with the individual and needs to be adjusted by trial and error. Do not go by the instructions on the label if you are giving laxative medication to a patient born with imperforate anus. Work with your physician to determine the proper dosage.Both constipation and diarrhea are enemies of children with anorectal malformations. Patients with liquid stools cannot feel the stool coming out through the rectum because they have an abnormal sensitivity in the anorectal area. Therefore, diarrhea may produce incontinence to a child with borderline bowel control.Constipation, on the other hand, means retention of stool in the rectosigmoid, which leads to fecal impact and pseudo incontinence. This means that the patient behaves like being fecally incontinent, but when he is disimpacted and receives an adequate amount of laxatives he actually behaves like fecally continent child.
Answer: The main risk associated with the use of laxatives is the increase of laxative requirement as time goes by. But for a patient who needs laxatives, the risks of not taking laxatives are much worse and eventually the patient may need higher doses of laxatives because constipation produces a dilated colon and a dilated colon produces more constipation.Some concern had been expressed that using senna (Senokot) for many years could potentially cause cancer, but government-promoted research concluded long-term use of senna poses no such risk.Except for higher doses required in a patient as time goes by, we are unaware of other secondary effects. However, that does not answer your question. Actually, nobody can guarantee that laxatives are free of secondary effects on a long-term basis.
Answer: Enemas are not used to replace laxatives. Enemas are used in patients who have demonstrated that they suffer from fecal incontinence. A saline enema is the most natural way to clean the rectosigmoid, but many times it is not powerful enough to achieve its goal and phosphate, more salt or other substances are added. Laxatives are indicated in patients with a potential for bowel control that need help to improve the colon's motility. We never use a combination of laxatives and enemas.However, we respect very much the concept of "quality of life." Therefore, if a patient prefers to receive an enema, rather than taking laxatives, to treat constipation, we do not interfere with his or her desire. However, the overwhelming majority of patients prefer laxatives.
Working with a laboratory technician who weighed and measured samples and based on a normal saline of 0.9 percent, we determined the formula for home mixing should be one heaping teaspoon in one quart of water. Is this the recommended formula for use with children with anorectal malformations?
Answer: We recommend exactly one and a half teaspoons of salt in one liter (1000ml) of water. Putting excessive amounts of salt in the water of an enema may have serious negative consequences, such as seizures and coma. The safest saline solution is that one prepared by a pharmaceutical laboratory. It is called Normal Saline Solution (0.9 percent).
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