The Colorectal Quiz Episode 8: Motility Disorders Part 1

Hey there listeners, this is Rod from Cincinnati Children's. If you haven't already, download the Stay Current pediatric surgery app. The reason being is because if you're listening to this colorectal quiz, In the app, I'm gonna put X-ray images, coostograms, articles, whatever Doctor Fisher and Doctor Levitt are talking about, you can read along or look along with them in the app. So download it now, it's in the Apple App Store, it's in the Google Play Store, but until then, Enjoy the episode. If you've been listening to the colorectal quiz every week, then you know that the field of colorectal surgery can become multidisciplinary very quickly. That's why today we teamed up with our Peds GI colleagues to talk about motility disorder. A disease process that necessitates really good cooperation between GI and surgery to make sure that our patients are getting the best care. And today's also a special episode because I brought a friend along. Hi, I'm Amanda Jensen. I'm a pediatric surgery, colorectal subspecialty fellow at Cincinnati Children's Hospital. Amanda and I are going to walk you through this high yield discussion. On the diagnosis and management of motility disorder. So without further ado, this is the colorectal quiz. Welcome back, everyone. We're excited for you to join us again as we continue on our colorectal quizzes. That's Jason Frischer. He's a pediatric colorectal surgeon at Cincinnati Children's Hospital. Today, we are really excited to have some guests with us today. And from Cincinnati Children's Hospital, we have Doctor Khalib Graham. Doctor Khalib Graham is a pediatric gastroenterologist who specializes in Motility disorders. Oh yeah, so great you're here. Thank you for joining us and my good buddy, that's Doctor Mark Levitt at Children's National Hospital and partner in crime, Anil Darbari. Doctor Anil Darbari is also a gastroenterologist who specializes in motility disorders, and I've learned a ton, and now it's, nowadays, it's sort of funny because sometimes Anil says to me, I think the kid needs surgery, and I say to Anil, no, I think the kid needs more medical treatment, and that's the collaboration you're shooting for. The case that we have is that of a 10 year old boy with severe constipation. He presents with daily cramping, poor appetite, and soiling. He's been on multiple laxative regimens according to the family, and these have been tried with no success. What does it mean to failed medical management? Why do you need a gastroenterologist? Can a pediatrician take care of a patient like this? That's an excellent question, Mark, because defining failure of medical management is multifolded. The patient has appropriate treatment but no appropriate response. That is. Pretty clear cut, considered a failure. The patient cannot take treatment. So for example, kids with autism, other cognitive problems who really cannot take the medications that are prescribed, or the patient has persistent symptoms or pain with treatment, we would consider that as a failure of medical management or has failure to grow. We sometimes use retrograde enemas for these managements, and if that also So it doesn't work, I would consider that as a failure of medical management as well. In regards to quality of life, what is considered a failure of medical management? If a patient is very much reliant on rectal therapy or the retrograde enemas or having, continue having soiling and it's causing a, a, a significant effect on their, on their functioning as a young child, um, then that we also would Consider that a failure of medical management potentially. And that's assuming that they're on adequate doses for their bowel management. The other factor that comes into play is that most of the time we think about, uh, constipation medication at the general pediatrician level, you're thinking about your osmotic laxatives like MiraLax or lactulose, and then, and then you may think about your stimulant laxatives such as Senna or bisocodol. But there are probably other medications that the pediatrician is probably not used to prescribing and the GI doc is. So, here's a quick summary. So what you're saying in regards to quality of life is that the patient is relying on rectal enemas, however, still having soiling, or it is affecting their daily life and their function. Nice. OK, so next question. What do you include in your initial evaluation? So, always, anytime you see a patient and they're, they're, they're first coming to see me, you wanna get a really good history. That means trying to understand, you know, triggers, how often they're stooling, when they stool, do they feel like they're completely empty? Because some kids stool every day, but they don't completely evacuate. And then, of course, you always have to do a good physical exam. Looking at their abdomens, see if there's palpable stool. Are they? Significantly distended. A rectal exam many times is a very important part of the process. And then you wanna move on to diagnostic imaging, and abdominal X-ray, um, even potentially, uh, water-soluble contrast enemas. How do you like to, what, what's your first line of therapy, Anil, in a patient like this? How do you, how do you start treating them? If the appropriate treatments have been tried and uh they have failed. The first step in managing would be the diagnostic studies because there's a good, clear history. So in a patient with long standing constipation, where the appropriate treatments have been tried, often that's not true in routine functional constipation cases where the history is not very clear or the adherence to medical management is not very clear. So you would start with a contrast enema to see the degree of colonic dilatation and or redundancy and to make sure that the ratio is normal. Um, so here you have a contrast study. Um, you can see the images. If you're using the app, you can just see the images right away. Um, and Jason, you wanna just give me your feeling about what this image says to you, as if you're in an art museum looking up a beautiful picture, and how, what is it saying to you? It's saying that this is not a Monet, that is for certain. That being said, such a dad joke. You know, there's a few things. I agree with the contrast study, and it gives you a roadmap of the colon. I see stool in the distal rectum. What about the path of the sigmoid? Curvy, tortuous sigmoid colon, likely we would call. Redundant. What does that mean? I don't know, because there's probably a lot of people with redundant colons that stool perfectly normally, and we don't have imaging of it. And then when it comes to considering the dilation, is it the chicken or the egg, or was it dilated and redundant before, or did it happen because of maybe an outlet obstruction type pictures. So the contrast study is not a great predictor on how the patient is going to respond to medical or surgical management. You know, I have seen crazy looking colons that responded really nicely, and then alternatively, you can have colons that look totally normal on the contrast study, but they don't respond at all to treatment. So who needs a motility expert, particularly in the group of functional constipation patients. So the motility. utility of the colon becomes critical to how we end up taking care of these patients because Mark remembers not too long ago when we used to take out a colon or a sigmoid colon based on how it looked, and guess what, the patient had a motility disorder, they didn't need a resection. Many of these colons will listen to us, so to speak. They will respond to treatment. Here's Doctor Fisher with some more considerations regarding the contrast enema. We use water-soluble contrast, not barium. It helps us empty the colon, so it acts as a cleanout for the patient if they're going to start a new medical therapy. And lastly, it, it really helps the family and the child, if they're old enough to understand some of the anatomy, um, and some of the issues going on. So I really do think it's a great tool. So never forget that reviewing the diagnostic imaging with the family can really help them understand and ultimately build rapport. Alright, so let's reset a little bit, we have a 10 year old male, he has severe constipation with soiling, poor appetite, we got this contrast enema, he's very dilated, full of stool. The next step, say it with me now, anorectal manometry. The anorectal manometry showed an absent rare. And what Doctor Levitt means is RAIR or rectoanal inhibitory reflex. Basically when the rectum becomes distended with stool, the internal anal sphincter has to relax, this child doesn't have that response. Could, could we stop one second? That, that blows my mind, that with that contrast study, we see an absent rare. To better understand why Doctor Frischer's mind was so blown, let's just talk about why you even get anorectal manometry. To get a better understanding of the anal sphincters and also its relationship to the rectum, so you, you, you have a catheter that has a balloon tied to it. The catheter has sensors on it that are measuring pressure. And as you blow up the balloon, you can measure. Pressures and me and measure of responses, particularly how the internal anal sphincter responds. So, how do you interpret some of these results? High pressures may suggest that there may be some, some underlying issue going on with the inability to relax and essentially causing a, a functional obstruction. What about a patient who has Hirschprung disease? They would not have a rare. They would have an absent rare. So, what other information can we get from this anorectal manometry? You can also get information learning about defecation dynamics, so you can have patients bear down, you can have them squeeze and try to defecate, and then you can kind of compare when they have the sensation to defecate versus what their internal anal sphincter. is actually doing in response to that. So you actually get a whole bunch of information from a baseline standpoint as well as a functional standpoint. It's a very functional kind of test. And Doctor Levitt finds a lot of value in this test. I don't know how I survive without this test. I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played. In a lot of our patients. I think it's vital. So, I wanna, I wanna move along with this case, because it's gonna get very interesting now. The A man was done, and the a man showed an absent rare. It does get a lot more interesting, but unfortunately we're out of time for this week, so we gotta pick up next week. Before we get out of here, let's summarize. Our PSGI colleagues helped us to understand the diagnosis and management for patients with motility disorders, and it all starts in your clinic with a really good history, physical exam, really understand the nature of these patients with constipation. diarrhea, understand the bowel regimen that they were on previously from perhaps their pediatrician, maybe there are some medications that our GI colleagues are more comfortable with, you could try those as well, rectal enemas, things of that sort. Then you want to move on to imaging, you could start with a plain abdominal X-ray, sometimes that's helpful, but oftentimes you might have to move on to Contrast enema, that can be diagnostic and therapeutic. Based on that result, you may have to move on to anorectal manometry, which is critical when you have a conversation between GI and surgery and you're trying to determine, does this patient need a surgery, do they need a resection, because if they have motility disorder, that's a surgery that they do not need to have. So That concludes motility disorders part one. I know what you're thinking. Yes, we have a joke. There were 2 wind turbines in a field, in a wind field generating electricity, and they were having a conversation amongst themselves, these wind turbines. And one of them said to the other, hey, what kind of music do you like? And the other one said, come on, isn't it obvious? I'm a heavy metal fan. Terrible. It's terrible. Alright, so it's not open mic night at the Improv, but if you have a better joke, that you want Doctor Fishisher or Doctor Levitt to tell at the end of their colorectal quiz, you can leave a comment, if you're listening to this podcast in the Stay Current in pediatric surgery app. You could do a lot of things. I mean, you could look at the images, including the contrast enema, X-ray, things like that, while you're listening to the podcast. You can connect with other surgeons, you can leave this podcast entirely, watch a video on a PSARP, look up whatever you want about pediatric colorectal surgery in our app. You can download it now, it's in the Apple App Store, it's in the Google Play Store. You're gonna love it. But until then, I'm Rod from Cincinnati Children's, and remember, Knowledge should be free.