The Colorectal Quiz Episode 8: Motility Disorders Part 1

Failure of medical management is defined as appropriate treatment with no appropriate response

Patients who cannot take treatment (e.g., kids with autism or other cognitive problems) are considered to have failed medical management

Patients with persistent symptoms or pain with treatment, or failure to grow, are considered to have failed medical management

Failure of retrograde enemas is considered failure of medical management

Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning is considered failure of medical management

General pediatricians typically prescribe osmotic laxatives (MiraLax, lactulose) and stimulant laxatives (Senna, bisacodyl), but there are other medications GI specialists use that pediatricians are not accustomed to prescribing

Initial evaluation includes history (triggers, stooling frequency, sensation of complete emptying), physical exam (abdominal distension, palpable stool, rectal exam), and diagnostic imaging (abdominal X-ray, water-soluble contrast enema)

Some children stool every day but don't completely evacuate

In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step is diagnostic studies including contrast enema to assess colonic dilation, redundancy, and ensure normal ratio

Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well

Colonic motility assessment is critical because in the past, colons or sigmoid colons were resected based on appearance, but patients had motility disorders and did not need resection

Many dilated colons will respond to treatment

Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy

Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum

High pressures on anorectal manometry may suggest underlying inability to relax, causing a functional obstruction

Patients with Hirschsprung disease have an absent rectoanal inhibitory reflex (RAIR)

Anorectal manometry provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate, comparing sensation to defecate with internal anal sphincter response

Doctor Levitt states he doesn't know how he survived without anorectal manometry testing

In the past, surgeons did not understand the major role the sphincter played in many patients