TOPICAL TREATMENT OF THE ANAL SPHINCTER FOR CHILDREN WITH FUNCTIONAL CONSTIPATION

HREM is the gold standard for esophageal motility disorders with a PPV 96%, sensitivity 100% and specificity 98%. This study compares the barium esophagogram results with HREM in pediatric patients. Methods : Observational, retrospective, test-retest concordance study. Pediatric patients that had a barium esophagram performed within 90 days of the HREM were included. Results : A total of 101 patients with a median age of 13.6 years, (54 females) were analyzed. The most frequent symptoms were dysphagia, followed by vomiting, regurgitation and weight loss (Table 1). 60 patients had abnormal esophagram. (Abnormal contractility 66%, esophageal dilatation 50% and esophageal outflow obstruction 75%) 81.4% of abnormal esophagrams were consistent with an abnormal HREM, sensitivity of 92.3% and specificity of 90% (p<0.005). Ouflow obstruction on esophagogram is significantly associated with an abnormal IRP on HREM (p p<0.005) accuracy of 88%, sensitivity of 80.9% and specificity of 84.7%. Abnormal Distal Contractile Integral (DCI) on HREM is significantly associated with abnormal contractility on esophagram 72% accuracy, 63% sensitivity and 71.6% specificity (p=0.000) and with esophageal dilatation 57.8% sensitivity, 76.4% specificity and 74% accuracy (p<0.005) (Table 3). We found a good concordance between tests with a Kappa index of 0.69 (p<0.005) 11 patients had abnormal esophagram and a normal HREM and 6 had normal esophagram and abnormal HREM (including 2 type II achalasia) Discussion: Different tools allow evaluation of esophageal anatomy and motility; the barium esophagram is useful, minimally invasive and inexpensive. It is a valuable test for structural and functional evaluation of the esophagus, we found a sensitivity of 92% and specificity of 90% for the diagnosis of motor disorders, similar finding reported by Ott DJ et al. with a sensitivity of 89% and specificity of 91% in adult patients with dysphagia. All esophagrams with contrast stasis had abnormal HREM. Outflow obstruction in esophagram was associated with an abnormal IRP and dysmotility in esophagram with an abnormal DCI. Halland et al. found that isolated tertiary waves on esophagogram in patients without dysphagia is rarely associated with significant motor disturbances, we had only one patient with isolated tertiary waves and had a normal HREM. However, we found that out of 17 patients with non-isolated tertiary waves 2 had normal HREM, and 13 had achalasia. Conclusion: This study determined a good concordance between barium esophagram and HREM. Abnormal findings on esophagogram dysmotility, dilatation, and contrast stasis are significantly associated with abnormal HREM. A normal esophagram does not rule out a major motility disorder.

Background: Adult data suggests that disorders of primary peristalsis are associated with higher percent time pH<4 in the esophagus suggesting that abnormal peristalsis is associated with poor acid clearance. There are no studies of secondary peristalsis and its relationship to microscopic or gross esophagitis. The goal of this study was to determine the relationship between functional luminal impaging probe (FLIP) parameters and the presence or absence of esophagitis.

Methods: We reviewed the esophageal biopsies and FLIP 2.0 tracings for 72 patients and each FLIP tracing was measured for esophagogastric junction (EGJ) distensibility, repetitive antegrade contractions presence, occlusive diameters, and repetitive antegrade contractions (RACs) frequency. These results were then compared between patients with and without microscopic esophagitis and with and without erosive esophagitis. Means were compared using t tests. Proportions were compared using Chi-Square analyses.

Results: 72 patients were included in the analysis. The mean age of patients was 14.2 + 6.5 years. Five (6.9%) patients had erosive esophagitis and 26 (36%) patients had microscopic esophagitis. Erosive esophagitis was strongly associated with disorders of secondary peristalsis as shown in the Table; in patients with erosive esophagitis, occlusive diameters were significantly higher than patients without erosive esophagitis signifying weaker peristalsis in patients with inflammation (Figure). When RAC presence and morphology was dichotomized into normal or abnormal RACs, there was a significant relationship between the presence of abnormal RACs and the presence of erosive esophagitis (p=0.04). In contrast, there was no relationship between any of the FLIP parameters and the presence of any microscopic esophagitis or the presence of > 15 eosinophils per high power field in the distal esophagus (p>0.3). There was no relationship of EGJ distensibility and the presence of erosive esophagitis or microscopic esophagitis (p>0.2).

Conclusions: Disorders of secondary peristalsis may be associated with erosive esophagitis, a relationship that is not seen with microscopic abnormalities. EGJ distensibility did not impact esophagitis risk.

Background: Functional constipation (FC) in children often involves difficulty relaxing the anal sphincter or pelvic floor, and therefore topical treatment to allow relaxation of the anal sphincter may be beneficial. Our objective is to describe outcomes and safety of children with FC treated with topical treatment.
Methods: We performed a retrospective review of children with FC treated with topical treatment of the anal sphincter using topical diltiazem, nifedipine, or nitroglycerin at our institution. We recorded baseline demographics, medical history, symptoms at baseline and follow up, and any reported side effects.
Results: We identified 103 patients who were prescribed topical treatment of the anal sphincter at our institution and excluded 46 with an organic cause of constipation (38 with Hirschsprung disease, 5 anorectal malformation, 2 inflammatory bowel disease, 1 tethered spinal cord), 11 with anal fissure, 2 with internal anal sphincter achalasia, and 15 patients with FC without follow up data. We included 29 patients (59% female, median age 7 years, range 1-21) in our study. 13 patients were treated with diltiazem (61% male, median age 7 years, range 3-12). Diltiazem was applied 2 times a day (range 1-2) for a median of 3 months (range 2 weeks-1.5 years) at follow up. At follow up, 3 had stopped diltiazem: 1 because of lack of improvement, 1 because of patient refusal, 1 after anal sphincter botulinum toxin injection. 7/13 reported improvement: 3 in fecal incontinence, 2 in constipation, and 1 in abdominal pain. As shown in Table 1, presence of specific constipation symptoms did not change after treatment with diltiazem. 1/13 reported flatulence as a side effect. At follow up, 8/13 patients continued diltiazem treatment. Only 1 patient, an 11-year-old female, was treated with nifedipine. Nifedipine was applied 2 times a day for 1 month before stopping because of lack of improvement. 15 patients were treated with nitroglycerin (73% female, median age 8 years, range 1-21). Nitroglycerin was applied 2 times a day (range 1-2) for a median of 1.5 months (range 1 week-12 months) at follow up. At follow up, 5 had stopped nitroglycerin: 3 because of side effects, 1 because of lack of improvement, 1 for unclear reasons. 4/15 reported improvement: 3 in abdominal pain and 2 in constipation. Presence of specific constipation symptoms did not change after treatment. 4/15 patients experienced side effects: rash (1), discoloration of anus (1), and burning sensation (1). At follow up, 3/15 patients continued nitroglycerin treatment.
Discussion: In the first study of topical treatment of the anal sphincter for children with functional constipation, we found that diltiazem and nitroglycerin were generally well-tolerated with only minor side effects reported. Up to half of children treated with these topical treatments reported benefit.