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Development of a multidisciplinary colorectal and pelvic health program: Program implementation and clinical impact.
Style, CC, Hsu, DM, Verla, MA, Mittal, AG, Austin, P, Seth, A, Dietrich, JE, Adeyemi-Fowode, OA, Bercaw-Pratt, JL, Chiou, EH, et al
Journal of pediatric surgery. 2020;(11):2397-2402
Abstract
INTRODUCTION Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation. METHODS This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation. RESULTS During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p < 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004). CONCLUSION The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care. LEVEL OF EVIDENCE IV.
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Content analysis of bowel protocols for the management of constipation in adult critically ill patients.
Dionne, JC, Johnstone, J, Smith, O, Rose, L, Oczkowski, S, Arabi, Y, Duan, EH, Lauzier, F, Alhazzani, W, Alam, N, et al
Journal of critical care. 2020;:98-104
Abstract
PURPOSE Alterations in bowel habits are common during critical illness, and bowel protocols are gaining acceptance. Our objective was to characterize bowel protocols in a cross-sectional analysis of ICUs. MATERIALS AND METHODS We engaged 44 adult ICUs and performed content analysis of bowel protocols, addressing initiation criteria, medications incorporated, medication escalation, discontinuation criteria, stool assessment methods, and protocol contraindications. RESULTS Bowel protocols operated in 33/44 ICUs (79.5%). The commonest medications were senna (81.0%) and bisacodyl (75.6%). Less common agents were sodium phosphate (45.9%), glycerin (43.2%), docusate sodium (43.2%), polyethylene glycol 3350 (37.8%), lactulose (29.7%), sodium citrate (16.2%), milk of magnesia (13.5%) and mineral oil (16.2%). Bowel protocols were activated by nurses (62.8%) based on initiation criteria [no bowel movement for 24-96 h (35.1%), opioid use (18.9%), "at risk for constipation" (13.5%), stool on digital rectal exam (10.8%), feeding initiation (10.8%), and ICU admission (8.1%)]. Laxative escalation criteria included time from last bowel movement (59.4%), opioid use (18.9%) and no stool on digital rectal exam (10.8%), while 15 (40.5%) included diarrhea as a discontinuation criterion. CONCLUSIONS Bowel protocols have variable initiation, escalation, and discontinuation criteria incorporating different classes of laxatives, reflecting unclear evidence about optimal bowel management strategies in ICU.
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Associations between physical activity and constipation in adult Americans: Results from the National Health and Nutrition Examination Survey.
Wilson, PB
Neurogastroenterology and motility. 2020;(5):e13789
Abstract
BACKGROUND There is mixed evidence that physical activity is associated with constipation on the population level. This analysis aimed to determine whether amount and types of physical activity are cross-sectionally associated with constipation. METHODS A total of 9963 adults from the 2007-2010 National Health and Nutrition Examination Survey (NHANES) were included. Constipation was defined based on low stool frequency (<3 stools/wk) and a hard/lumpy consistency (type 1 or 2 on the Bristol Stool Form Scale). Univariate logistic regression models evaluated associations between physical activity variables and constipation, while multivariate models were built to account for other variables (age, gender, education, race/ethnicity, relationship status, health status, body mass index, fiber intake, and moisture intake). KEY RESULTS Based on <3 stools/wk, 3.4% (95% CI, 2.8%-4.2%) of Americans were constipated, whereas 7.3% (95% CI, 6.7%-8.1%) were deemed constipated when using the hard/lumpy definition. Odds ratios (ORs) of experiencing < 3 stools/wk were 1.82 (95% CI, 1.11-2.97) for people engaging in no vigorous recreational activity (vs. any) and 1.41 (95% CI, 1.08-1.85) for those doing no moderate recreational activity (vs. any). Likewise, doing no moderate recreational activity was associated with slightly higher odds of hard/lumpy stools (OR = 1.23, 95% CI, 1.03-1.46). These associations were attenuated and insignificant in multivariate models (all ORs < 1.45). CONCLUSION On the population level, self-reported physical inactivity is not strongly associated with passing < 3 stools/wk or hard/lumpy stools. Better-designed prospective observational and intervention studies are needed to clarify how physical inactivity impacts different forms of constipation.
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Constipation in the elderly from Northern Sardinia is positively associated with depression, malnutrition and female gender.
Dore, MP, Pes, GM, Bibbò, S, Tedde, P, Bassotti, G
Scandinavian journal of gastroenterology. 2018;(7):797-802
Abstract
OBJECTIVES Constipation is a common complaint in older adults. The rise in life expectancy may amplify the problem and increase social expenditure. We investigated the major risk factors associated with constipation in a large sample of elderly. METHODS Outpatients from Northern Sardinia attending a Geriatric Unit between 2001 and 2014 were enrolled. Demographic and anthropometric data, income, education and self-reported bowel function were collected. The presence of constipation was adjusted for cognitive status, assessed by the Mini-Mental State Examination (MMSE) test; single and cumulative illness rating scale (CIRS); current or past symptomatic depression and anxiety measured by the Geriatric Depression Scale (GDS); nutritional status, evaluated using the Mini-Nutritional Assessment (MNA); type and number of different medications used. RESULTS 1328 elderly patients (mean age 77.7 ± 7.2 years) were enrolled. Constipation was present in 32.1%, more commonly in women (35.4% vs 28.3%) and increased with age. The multivariate analysis showed a significantly greater risk of constipation in patients with a risk of malnutrition (OR = 1.745, 95% CI: 1.043-2.022; p = .034), female gender (OR = 1.735, 95% CI: 1.068-2.820; p = .026) and depression (OR = 1.079, 95% CI: 1.022-1.140; p = .006). Other potential predisposing factors assessed such as MMSE, CIRS, body mass index, marital status, smoking habit, education, income and number of taken drugs did not show a statistically significant association. Aging was a risk for constipation also in patients free of medications. CONCLUSIONS Knowledge of risk factors associated with bowel alterations in elderly individuals may provide important clues for caregivers to prevent or reduce constipation.
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Sacral nerve stimulation for constipation and fecal incontinence in children: Long-term outcomes, patient benefit, and parent satisfaction.
Lu, PL, Koppen, IJN, Orsagh-Yentis, DK, Leonhart, K, Ambeba, EJ, Deans, KJ, Minneci, PC, Teich, S, Diefenbach, KA, Alpert, SA, et al
Neurogastroenterology and motility. 2018;(2)
Abstract
OBJECTIVE To evaluate the long-term efficacy of sacral nerve stimulation (SNS) in children with constipation and describe patient benefit and parent satisfaction. METHODS Using a prospective patient registry, we identified patients <21 years old with constipation treated with SNS for >2 years. We compared symptoms, medical treatment, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), and Fecal Incontinence Severity Index (FISI) before SNS and at follow-up. We contacted parents to administer the Glasgow Children's Benefit Inventory (GCBI) and a parent satisfaction questionnaire. KEY RESULTS We included 25 children (52% male, median age 10 years): 16 had functional constipation, six anorectal malformation, two tethered spinal cord, and one Hirschsprung's disease. Defecation frequency did not change after SNS but patients reporting fecal incontinence decreased from 72% to 20% (P<.01) and urinary incontinence decreased from 56% to 28% (P=.04). Patients using laxatives decreased from 64% to 44% (ns) and patients using antegrade enemas decreased from 48% to 20% (P=.03). GSS, most FIQL domains, and FISI were improved at follow-up. Six (24%) patients had complications requiring further surgery. Of the 16 parents contacted, 15 (94%) parents indicated positive health-related benefit and all would recommend SNS to other families. CONCLUSIONS & INFERENCES Sacral nerve stimulation is a promising and durable treatment for children with refractory constipation, and appears particularly effective in decreasing fecal incontinence. Although a quarter of patients experienced complications requiring additional surgery, nearly all parents reported health-related benefit. Future studies to identify predictors of treatment response and complications are needed.
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[Comparison of the effectiveness and safety of polyethylene glycol with and without electrolytes in the treatment of chronic constipation].
Llerena, E, Varea Calderón, V, Pujol Muncunill, G, Hernandez Hernandez, K, Sosa Giraldo, FJ, Suarez Fuentes, T, Martín de Carpi, J
Anales de pediatria (Barcelona, Spain : 2003). 2016;(1):34-40
Abstract
INTRODUCTION To compare the effectiveness and safety of polyethylene glycol with and without electrolytes (EL) over a 12 week period in treatment of chronic constipation in paediatrics. MATERIAL AND METHODS This was an observational, prospective, longitudinal, parallel group study, including 62 children with chronic constipation according to ROME III criteria and a history of faecal impaction. The children were divided into groups, one group of 30 received polyethylene glycol without EL (PEG) and 32 PEG with EL (PEG+EL) for at least 12 weeks. The main outcomes were the number of bowel movements at 6 and 12 weeks, and the presence of electrolyte disturbances at 6 weeks. RESULTS The mean weekly stool frequencies were similar in both groups at 6 and 12 weeks, with 5.4 and 4.6 stools per week in the PEG+EL and PEG groups, respectively at 12 weeks. After 6 weeks of treatment, 83% (25 of 30) of the PEG group had at least one electrolyte disturbance compared with 56% (18 of 32) in the PEG+EL group (P=.02). Hyponatraemia was found in 15% (5 of 32) vs. 36% (11 of 30) of PEG+EL and PEG groups, respectively (P=.05). None of the laboratory abnormalities were clinically relevant. CONCLUSIONS PEG formulations with or without EL have a quite similar effectiveness, safety and acceptability. PEG without EL produced more electrolyte abnormalities, but none of them were symptomatic.
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Is There an Association between Functional Constipation and Excessive Bodyweight in Children?
Koppen, IJ, Velasco-Benítez, CA, Benninga, MA, Di Lorenzo, C, Saps, M
The Journal of pediatrics. 2016;:178-82.e1
Abstract
OBJECTIVES To determine the prevalence of functional constipation, overweight, and obesity in a cross-sectional observational study among children in Colombia and to examine the association between functional constipation and excessive bodyweight in this population. STUDY DESIGN Demographics, anthropometric data, and questionnaires were collected from 2820 children between 8 and 18 years of age across 4 regions in Colombia. A Spanish translation of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version was used to determine the prevalence of functional constipation. Anthropometric measurements of weight, height, and body mass index (BMI) were obtained following World Health Organization guidelines; overweight was defined as a BMI z-score (adjusted for sex and age) between 1 and 2, obesity was defined as a BMI z-score >2. RESULTS A total of 368 children (13.0%) were found to have functional constipation, 542 children (19.2%) were overweight, and 188 children (6.7%) were obese. Functional constipation did not occur more frequently in children who were obese (14.9%) or overweight (13.1%) compared with children with normal weight (12.9%, P = .73). The prevalence of functional constipation, overweight, and obesity differed significantly between regions. Functional constipation and excessive bodyweight were significantly more common in children attending private schools compared with children attending public schools. CONCLUSIONS Functional constipation, overweight, and obesity are commonly observed in children in Colombia. No association between functional constipation and overweight or obesity was found.
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Quality of Colonoscopy and Spectrum of Lower Gastrointestinal Disease as Determined by Colonoscopy.
Rehman, KU, Qureshi, MO, Khokhar, N, Shafqat, F, Salih, M
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2015;(7):478-81
Abstract
OBJECTIVE To document the quality of colonoscopy practice and the pattern of colonic disease including polyp detection rate at Shifa International Hospital, Islamabad, Pakistan. STUDY DESIGN An observational study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, Pakistan, from May 2013 to June 2014. METHODOLOGY This retrospective study recorded demographics of patients, indications and quality indices of 505 colonoscopies performed during the study period. Preparation was done with low residue diet and polyethylene glycol. Conscious sedation was generally used. Quality indices studied were compared with guideline standard. RESULTS Out of 505 colonoscopy patients, 305 were males and 200 were females. The indications for colonoscopic examination were lower gastrointestinal bleeding (26.5%, n=134), screening for colorectal cancer (14.1%, n=71), chronic diarrhea (12.9%, n=65), abdominal pain (10.9%, n=55), anemia (9.1%, n=46), constipation (7.3%, n=37), hematochezia and diarrhea (6.3%, n=32), altered bowel habits (5.1%, n=26), weight loss (3.6%, n=18), colonic thickening on CT scan (3.0%, n=15) and others (1.2%, n=6). Bowel preparation was adequate (in 92%, n=465) cases. Cecal intubation rate was 88.71% (n=448). Endoscopic diagnoses were hemorrhoids (36.2%, n=183), normal (22%, n=111), polyps (11.3%, n=57), ulcerative colitis (8.7%, n=44), cancer (4%, n=20), diverticulosis (3.4%, n=17), infective colitis (2.6%, n=13), intestinal TB (2.6%, n=13), non-specific colitis (2.2%, n=11), proctitis (1.8%, n=9) and others (5.3%, n=27). CONCLUSION There is room for improvement in quality of colonoscopy, cecal intubation rate is slightly below the recommended standard and polyp detection rate is quite low however, it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence. Time to reach caecum and withdrawal time should clearly be documented in the notes which can help to evaluate quality of the procedure in a better way.
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Constipation in the Critically Ill Child: Frequency and Related Factors.
López, J, Botrán, M, García, A, González, R, Solana, MJ, Urbano, J, Fernández, SN, Sánchez, C, López-Herce, J
The Journal of pediatrics. 2015;(4):857-861.e1
Abstract
OBJECTIVE To analyze the incidence and factors associated with constipation in critically ill children. STUDY DESIGN We performed a prospective observational study that included children admitted to the pediatric intensive care unit for more than 3 days. Constipation was defined as more than 3 days without a bowel movement. Relationships between constipation and demographic data; clinical severity score; use of mechanical ventilation, use of vasoconstrictors, sedatives, and muscle relaxants; nutritional data; electrolyte disturbances; and clinical course were analyzed. RESULTS Constipation developed in 46.7% of the 150 patients studied (mean age, 34.3 ± 7.1 months). It was most common in postoperative, older, and higher-body-weight patients, and in those with fecal continence (P < .01). Compared with patients without constipation, patients with constipation had higher severity scores and more frequently received midazolam, fentanyl, muscle relaxants, and inotropic support (P < .05). Patients with constipation also started nutrition later and with a lower volume of nutrition (P < .01). There were no between-group differences in mortality or length of pediatric intensive care unit stay. In multivariate analysis, independent factors associated with constipation were body weight (OR, 1.08; 95% CI, 1.03-1.13), Pediatric Index of Mortality 2 score (OR, 1.05; 95% CI, 1.02-1.09), admission after surgery (OR, 7.64; 95% CI, 2.56-22.81), and treatment with vasoconstrictors (OR, 10.28; 95% CI, 3.53-29.93). CONCLUSION Constipation is common in critically ill children. Body weight, Pediatric Index of Mortality 2 clinical severity score, admission after surgery, and the need for vasoconstrictor therapy are major independent risk factors associated with constipation.
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[Efficacy, tolerance and safety of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children].
Infante Pina, D, Segarra Cantón, O, Vilalta Casas, R, Carnicer de la Pardina, J, López Liñán, MJ, Molera Busoms, C
Anales de pediatria (Barcelona, Spain : 2003). 2014;(5):278-84
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Abstract
OBJECTIVE To assess the renal safety of treatment with polyethylene glycol 3350 with electrolytes at 1, 3 and 6 months, its gastrointestinal tolerance and dose effectiveness. PATIENTS AND METHODS Three groups of 30 healthy patient aged 2-10 years (mean 6.2 years) who suffered functional constipation (Rome III criteria) with 1, 3 and 6 months of treatment were evaluated. Efficacy was evaluated by the change in the number of stools per week and stool consistency (Bristol scale). Urine screens, sodium and osmolality, were performed at the beginning and after 1, 3 and 6 months of treatment. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed on the one-month treatment group. RESULTS The mean dose was 0.37g/kg/day (range 0.18 to 0.8) titrated according to age, weight and response. The number of stools per week during treatment (2.4±0.64) showed a significant difference (P<.001) vs (6.21±1.5) after treatment. There was also a significant difference in the Bristol scale score (1.9±0.75 vs 4.9±1.1 [P<.001]). The mean sodium intake was 112mg (5mg/kg/day [range 4-12mg/kg/day]). The values of sodium and urine osmolality were normal in all groups with no statistical difference compared to normal control values (90 healthy children without treatment). NIRA values were normal in all patients. The hydrogen breath test was normal with a median of 7ppm. CONCLUSION There were no adverse renal biochemical parameters or gastrointestinal disorders. Tolerance and efficacy was shown to be optimal. Polyethylene glycol 3350 with electrolytes can be safely recommended for the treatment of functional constipation in children in the short and long term.